Norway and the UK’s direct payment systems face a similar dilemma: more local control risks growing inequality among service users, writes Karen Christensen as results from her comparative study of direct payments systems begin to come through
Direct payments in the UK and Norway’s “personal assistance” form only a small part of welfare provision, but they will have an increasing impact on care in the future. In England, 24,500 people received direct payments, while 1.7 million clients received social care services during 2004-5. In Norway, in 2003, 1,161 people received personal assistance, while 114,000 people received social care services. About 1,500 people currently receive personal assistance in Norway.
Government papers looking at the future for social services in both the UK and Norway agree on the limitations of the traditional way of organising home-based services for people with assistance needs. The local authority is the one in control of how many hours to give, which tasks are to be done, when they will be done and by whom.
Direct payments, on the other hand, empower people in terms of which, when and by whom, but the local authority still has the power to assess and decide the level of needs. Until now the majority of people using this alternative consist of physically disabled people.
Compared with the UK, particularly London, the Norwegian way of organising direct payments is more uniform. While there is a multitude of direct payments schemes across the UK, there are just a few in Norway.
The British arrangement is regulated by the Health and Social Care Act 2001 while the Norwegian one is regulated by the Social Services Act 2000 and the assessments and their detailed descriptions of the person’s needs for social services are a common starting point.
Once the British assessment is carried out people can choose between community services and direct payments. In Norway, this choice is made by the municipality. Also, in Norway there is a clear distinction between managing and employing personal assistants (PAs). Although everybody receiving personal assistance in principle should be able to manage this assistance, there are three possibilities as to who should have employer status: the local authority (64 per cent), the one and only existing co-operative run by disabled people in Norway – Uloba, (25 per cent), and the user (9 per cent). The co-operative is not an option for all Norwegians because not all municipalities have contracts with Uloba.
The British system is supposed to be based on individual choice, but local arrangements limit this. For instance, social workers can present the option of choosing direct payments in a way that limits this choice, by saying: “Do you really think you can manage to be an employer?”
Most London boroughs contract a non-profit direct payments organisation to provide support. But there are variations as to whether, for example, this organisation is rooted in the idea of the social model (the focus is on removing barriers that disabled people face instead of on their impairments) and on the extent to which the local authorities are taking an interest in this support. In some cases the entire support service is externalised.
Although the Norwegian municipalities have the power to choose who should be the employer, in practice they include the disabled person in this choice. Another practice is that the hours of assistance increase when people change from social services to personal assistance; research shows that the average increase is from 16 hours a week to 36. This is because people need a certain number of hours’ help if the aim is an independent daily life. And, if this argument is made by an organisation, it becomes even more powerful.
Also, it is important to mention that when Uloba takes over the employer role for a client, it seems to require higher payments per hour from the municipality compared with the sum municipalities themselves pay. This is due to, among other things, higher wages for the personal assistants.
Being a co-operative, Uloba has other functions besides its employer role. It is guided in its politics by its members, who are disabled people, and takes an interest in the relationships between disabled people and their PAs.
My study indicates that Norwegian disabled people who are members of Uloba are satisfied with the hours of help they receive, although they are afraid of losing them if negotiations for hours do not go well.
In Britain, this level of satisfaction is only reached by people who are severely disabled who are eligible for money from the Independent Living Fund, a charitable trust set up and funded by the government. My study also indicates that the level of PA wages is an issue for disabled British people, as many feel these are too low.
Pay is more regulated in Norway, where the majority of PAs are employed either by the municipality or Uloba. The British problem seems to be that the local authorities do not pay an adequate hourly rate and disabled people make the money they have go further by paying lower wages. Further, some agencies are taking part of the direct payments money by charging disabled people for their services.
Norwegian PAs find their job exciting, although temporary, and wish more people knew what their job entailed. The pay is not an issue. To a greater degree, British PAs are struggling to find ways, sometimes with their clients, to get higher wages – for example, by being employed directly by their clients instead of indirectly by agencies. Also, the British PAs represent, to a greater degree, a group of low-paid women who are used to working in the grey zones between unpaid and paid work, but who are attracted to this work by their commitment to welfare.
One of the main issues in Norway concerns the introduction of a legal right to personal assistance in order to reduce the differences in provision between municipalities. Norwegian people have no formal right to personal assistance, according to the Social Services Act, allowing municipalities to make their own decisions.
Critics say it is likely that this will not change much as long as municipalities have control over choosing the employer. On the contrary, in the UK, discussion is about individual budgets, bringing direct payments still closer to the character of a benefit (just money instead of money for services) and thus increasing the local differences further.
Perhaps the main political choice in both countries consists simply of either reducing local differences in how direct payments systems are run or allowing local variations to increase. And if the second route is chosen there is a risk of growing inequality among direct payments users.
Karen Christensen is a visiting research fellow at the Rehabilitation Resource Centre, City University, London, with a sabbatical year from her post at the University in Bergen, Norway.
Training and learning
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.
This article looks at direct payments from a Norwegian perspective by making some key comparisons with the UK. Although in Norway direct payments are organised more paternalistically the system still satisfies the needs of disabled people and their assistants. The evidence is drawn from a continuing qualitative comparative research project in London and Bergen.
ULOBA’s website in English:
Ministry of Health and Care Service, Norway,
National Centre for Independent Living,
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