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As part of the government's modernisation of health and social services, local authorities now have a duty to provide direct payments to older people who need care.¹

Recognising that direct payments have given younger disabled people control over their services, health secretary Alan Milburn pledged to oblige local authorities to offer older people the choice between receiving either directly provided services or a cash payment to buy their own care. Milburn says the intention is to "empower older people, their families and their carers in a way that has never been possible before".

The Community Care (Direct Payments) Act 1996 enabled local authorities to make cash payments instead of directly provided services. Initially, this excluded those aged 65 and over (unless they had started receiving payments before their 65th birthday), although the policy has since been extended to older people and a range of other user groups.

Direct payments is a policy that has been developed and promoted by disabled people themselves, and the growing body of literature in this area has begun to highlight a range of benefits.²

These include:

• People receiving direct payments can buy more responsive services than they would otherwise receive from the local authority.
• People have greater choice and control.
• Morale and mental or psychological well-being are improved.
• Individual users can make more creative use of resources than the local authority.
• Direct payments are cost-effective.

Although progress has been slow in some areas of the country, more people are receiving direct payments, and the act has been extended to older people, carers, disabled people aged 16 and 17 and the parents of disabled children. More recently, the Health and Social Care Act 2001 promises to signal a shift from a discretionary to a mandatory system, increasing the availability of direct payments further.

Against this background, Milburn's decision to make direct payments available to older people who want them is a major step forward. The move promises to offer older people the same choice and control enjoyed by other user groups.

However, turning the health secretary's pledges into reality is going to be more difficult than it may at first appear, and success is by no means guaranteed without a significant investment of time and resources. In particular, there are three key issues to consider.

First, a crucial feature of any successful direct payments scheme is the support services that are in place to help users take on new responsibilities. By using direct payments to hire their own staff, users become employers and incur new administrative, financial and legal responsibilities. This is likely to include accounting for all money received, recruiting staff, paying tax and national insurance, taking out appropriate insurance policies and managing personal assistants on a day-to-day basis. These are all complex tasks which will require direct payment recipients to develop new and often sophisticated skills. It is hardly surprisingly that users will need to gain access to appropriate support in order to ensure that they rise to the challenges that direct payments offer.

Although different arrangements are in place in different areas of the country, all support services should include access to information, advice and advocacy services, training and peer support. These services must equip people with the knowledge and skills they will need to manage their own direct payments package.

It is evident that such support is not always forthcoming. In some parts of the country there are few support arrangements, and some disabled people's organisations are struggling for funding. Elsewhere, support may be available only from front-line social workers, who often have heavy case loads and lack specialist knowledge about issues such as employment legislation or financial management. As a result, the need for dedicated funding for support mechanisms is a constant theme in much of the literature, and it is difficult to see how a major extension of direct payments will be possible without a substantial, ring-fenced injection of resources.

A second consideration is the attitudes of some social workers and their lack of training. For some workers, direct payments offer an exciting new way of working which allows them to empower service users and work with them rather than for them. For other practitioners, direct payments represent a threat to directly provided social services and a form of "privatisation by the back door".

Some are concerned about a policy that they fear could increase their already heavy workloads and create a demand that their departments cannot meet. Others simply lack knowledge about direct payments and have not received adequate training. Whereas those working with younger disabled people tend to be aware of direct payments, those working with older people and people with mental health problems or learning difficulties tend to be much less familiar with the concept. As a result, any attempt to promote direct payments among older people will need to be backed up by a concerted educational programme to win over those workers who are hostile to, or unaware of, direct payments.

Third, we know relatively little about how older people are likely to respond to direct payments. Although more research is being carried out, early studies suggest that older people can benefit from direct payments in the same way as younger disabled people, but that there may be specific barriers to overcome.

Many older people know little about direct payments and will need access to appropriate information in order to make informed choices about the services they want. Some may find the concept of direct payments alarming and will not want the financial management responsibilities. Others may be concerned about exploitation, and will be reluctant to advertise for and recruit their own staff. The evidence we have so far suggests that considerable effort will need to go into providing accessible information and support services so that older people feel able to take up the advantages that direct payments offer. More time may also be required as part of the assessment process so that older people can learn about direct payments and to think through the options available.

Overall, Milburn's announcement is good in theory, but weak on many of the practical and resource issues that could make or break his proposals. Although the government has pledged to work with older people's organisations, the task ahead will not be easy and probably will not be cheap either. With local authorities already struggling to meet the demands made upon them within their budgets, the danger is that direct payments might not necessarily be seen as a priority.

If we are not careful, there is a risk that too many older people will be set up to fail by being offered direct payments without the support to make their care packages work.

Jon Glasby is a lecturer at the University of Birmingham's health services management centre.

References

¹ Department of Health, Expanded Services and Increased Choices for Older People, DoH press release 2002/0324, July 2002

² J Glasby and R Littlechild, Social Work and Direct Payments, The Policy Press 2002