Expert guide on direct payments, personal budgets and individual budgets
Direct payments, personal budgets and, to a lesser extent, individual budgets are at the core of the government's aim of personalising adult social care services around the needs of users. Through the Putting People First initiative, councils will be expected to significantly increase the number of people receiving direct payments and roll out a system of personal budgets for all users of adult social care, from 2008-11. In the long-term all users should have a personal budget from which to pay for their social care services, apart from in emergencies.
Putting People First is the culmination of a policy process that began in 2005, with the adult social care green paper, Independence, Well-being and Choice, and was developed through the 2006 health and social care white paper Our Health, Our Care, Our Say.
Latest articles on direct payments, personal budgets and individual budgets
Care services minister Ivan Lewis and the Department of Health are driving the Putting People First initiative, but scepticism remains among practitioners and social care leaders about the impact of personalisation on social workers' roles, on levels of risk carried by service users and about whether councils will be adequately resourced to deliver reform.
So what exactly are direct payments, personal budgets and individual budgets?
Direct payments are cash payments given to service users in lieu of community care services they have been assessed as needing, and are intended to give users greater choice in their care. The payment must be sufficient to enable the service user to purchase services to meet their needs, and must be spent on services that users need.
Like commissioned care, they are means-tested so assume that, in many cases, people will contribute to the cost of their care.
Direct payments confer responsibilities on recipients to employ people or commission services for themselves. They take on all the responsibilities of an employer, such as payroll, meeting minimum wage and other legislative requirements and establishing contracts of employment.
Some of these services can be contracted out and many councils have commissioned support organisations to help service users handle these responsibilities.
Personal budgets are an allocation of funding given to users after an assessment which should be sufficient to meet their assessed needs. Users can either take their personal budget as a direct payment, or - while still choosing how their care needs are met and by whom - leave councils with the responsibility to commission the services. Or they can take have some combination of the two.
As a result, they provide a potentially good option for people who do not want to take on the responsibilities of a direct payment.
Individual budgets differ from personal budgets in covering a multitude of funding streams, besides adult social care: Supporting People, Disabled Facilities Grant, Independent Living Funds, Access to Work and community equipment services.
The government has only called for the roll-out of personal budgets - not individual budgets. The latter were piloted in 13 areas until the end of last year and an evaluation on the pilots is due out this summer.
Background
Direct payments were introduced by the Community Care (Direct Payments) Act 1996 and came into being in April 1997 for adults of working age. They were extended to older people in 2000.
Since April 2001 direct payments have been available to carers, parents of disabled children and 16- and 17-year-old service users. Availability has also been extended to people with short-term needs, like those recovering from an operation, and to Children Act services to help disabled parents.
In April 2003, regulations came into force requiring councils to offer direct payments to all people using community care services. They do not apply to long-term residential care or services directly provided by councils, while they cannot be given to an agent to manage services on behalf of a person who lacks capacity.
Individual budgets were first mooted in January 2005 in a paper by the Prime Minister's Strategy Unit, and seen as a way of personalising services.
However, at the time a similar idea was already being piloted by the In Control Programme, which was set up in 2003 by Mencap and the Department of Health’s Valuing People Support Team and initially targeted at people with learning difficulties.
In Control is based on allocating a budget to an individual, on a self-assessment of their care needs, and enables them to choose the best mix of services and/or cash to suit their needs or wishes.
Individual budgets were taken forward in the March 2005 adult green paper and in November of that year the Department of Health announced they would be piloted in 13 councils.
The pilots are geographically spread, with some covering a wide range of client groups and others covering just one or two. The pilots are receiving support from a team from the DH’s Care Services Improvement Partnership and people who have been involved with the In Control scheme.
The pilots are also being evaluated by a team from the Personal Social Services Research Unit, York University’s social policy research unit and King’s College London’s social care workforce research unit.
At a Community Care conference in April 2008, Zoe Porter, deputy national programme manager for personalisation at CSIP, said the pilots had been a success but there had been significant challenges bringing funding streams together and in relation to older people's and mental health services.
She said the culture of older people's services had created a barrier as had the problem of mental health funding, with NHS cash excluded from individual budgets.
Take-up
Take-up of direct payments has risen significantly in recent years but still remains low as a proportion of people receiving services.
As of March 31, 2007, 40,600 adults in England were receiving a direct payment, up from 32,000 in 2006 and 22,100 in 2005. In Scotland, 2291 people received direct payments in 2006-7, up from 1829 in 2005-6.
The Commission for Social Care Inspection said that in 2005-6, direct payments constituted just 6% of net expenditure on social care services in the community.
Relatively low take-up has been explained in two ways – the reluctance of local authorities to promote direct payments and bureaucratic barriers they place in the way of take-up; and reluctance on the part of service users to take them up due to the real or perceived burdens they bring.
On the latter point, the introduction of individual and personal budgets has been designed to reduce people’s reluctance to take control of their care by lowering the demands in terms of employing and managing people.
However, a 2004 report by the Commission for Social Care Inspection found many barriers originated from councils including:
• Lack of information for service users.
• Low staff awareness of direct payments and what they are trying to achieve.
• Patronising attitudes on the part of staff about the ability of people to manage a direct payment.
• Inadequate or patchy advocacy or support services for direct payment users.
• Unnecessary and bureaucratic paperwork.
There is no doubt councils are getting better on direct payments but the step change in take up demanded by government and independent living activists has not happened yet.
Cost
One potential reason for this is the cost of direct payments. A report by the Audit Commission in May 2006 found direct payments were a net cost for each of 10 councils studied.
While savings were made through service users taking responsibility from care managers for finding and administering care, the research found that these were more than offset by the costs of supporting users and providing training to staff.
It suggested that the only way councils could save money was by making the value of direct payments lower than the price of an equivalent level of commissioned care. However, in practice this may not penalise service users because they may be able to buy in services at a cheaper cost than councils by using smaller agencies or family and friends.
When councils commission providers they typically have to pay a premium to cover management and infrastructure costs.
However, research from the In Control programme has suggested that giving users control over their own care can save money overall.
Risk
Another key issue in the direct payments debate is around risk. Independent living activists have long argued that to have true independence, service users should be able to employ who they want to care for them.
Adult protection campaigners, while admitting the importance of independence, have argued that people employed as personal assistants should face the same employment checks as others to ensure users’ safety.
Currently there are no plans to force direct payment users to submit those who they employ to checks. The government resisted attempts to impose checks through the Safeguarding Vulnerable Groups Act 2006, which will create a vetting and barring scheme for people working with adults and children in October 2009.
The vetting and barring scheme will apply to England, Wales and Northern Ireland, but different arrangements apply in Scotland, under the Protection of Vulnerable Groups (Scotland) Act 2007. This specifies that councils have the right to withdraw a direct payment from a service user if they do not employ only staff who have undergone an enhanced disclosure check.
People hired by directly direct payment users will also not be covered by service regulation so will not be liable to assessment by CSCI or its successor body the Care Quality Commission.
The debate in the rest of the UK is unlikely to die in a hurry. At the Association of Directors of Adult Social Services spring seminar in April 2008, CSCI chief inspector Paul Snell warned that personalisation would create new safeguarding challenges and direct payment recipients would need to receive the same level of support as others receiving council-commissioned care.
A study by Skills for Care, published in June 2008, found that almost half of a sample of direct payment users did not carry out CRB checks when hiring personal assistants they did not know, while 46% failed to seek references.
At the same time, the General Social Care Council announced it would consult on whether personal assistants should be registered, along with domiciliary care staff, when the social care register is opened up to this group, which is expected in 2008.
This would provide the first element of regulation of personal assistants, though it is unclear as yet whether making it compulsory for service users to employ registered PA is on the agenda.
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