Why is direct payments uptake so low?

Eleven years after the introduction of direct payments – and despite successive governments’ attempts to promote them – few people eligible to use them do so.

To understand the continuing variation in the take-up in local authorities and between service user groups, the Department of Health commissioned a study, which was published in May.

It reveals that the attitude of local politicians, managers and staff is a strong predictor of successful implementation of direct payments, as is the use of a ring-fenced budget. Key factors believed to inhibit wider take-up of direct payments include concern about the ability of people to manage a payment, resistance to direct payments among local authority staff and a lack of personal assistants.

But aspects of the government’s agenda for modernising adult social care have also caused problems for those charged with implementing direct payments locally. Conflicting attitudes towards the use of Criminal Records Bureau checks and issues of protection acted as a brake on the uptake of direct payments especially with some groups who were considered more vulnerable to abuse.

More fundamentally, fluctuating eligibility under the Fair Access to Care (FACS) criteria has proved a demoralising block to the expansion of direct payments in some areas. Indeed the white paper, Our Health, Our Care, Our Say, acknowledges the geographical variations in service provision that have arisen through applying FACS criteria.

Another factor is partnership arrangements between health and social care agencies. These have rarely been designed to accommodate the use of direct payments for the social component of a person’s care, while the role of the health service in promoting direct payments is either unclear or undermined by poor knowledge.

However, some of the more successful authorities are making efforts to encourage collaboration through multi-disciplinary representation on direct payments working groups, running joint training or paying for support schemes from joint finance. The lead officer for direct payments in one authority says: “Direct payments work well in integrated teams as the knowledge base is growing among professionals other than social workers. Sometimes there is a more enthusiastic response from other disciplinesthey are less caught up in tradition.”

Compromising free care

There are no immediate plans to extend direct payments to meet health needs, on the grounds that this would compromise the founding principle of the NHS that care should be free at the point of need. But the sustainability of this dichotomy is under serious consideration and for as long as it exists it will continue to pose challenges to the implementation of direct payments, particularly within the context of integrated care settings where the distinction between what constitutes a health or social care need can be artificial for providers and users alike.

There is also a lack of perceived fit between the Supporting People programme and direct payments and an apparent confusion between funding for housing support and the option of using direct payments.

Even where these conflicts have been resolved, there remains a question of equity of access to direct payments for different groups of service users. The perception of direct payments as being for younger disabled people can mean that the needs of other care groups are neglected in local strategies: common issues need to be addressed if older people, people with learning disabilities, people with mental health needs and people from ethnic ­minorities are to have better access to direct payments.

It is clear that some local support groups do not have the expertise or ability to sustain the support required to work with some individuals or groups (particularly people with mental health needs or a learning disability). Good, targeted support, often using the Direct Payments Development Fund, is associated with improved rates of take-up among these groups.

In one London borough that has been more successful in promoting direct payments among ethnic minorities, care managers found that the payments were helpful for engaging people who had previously been reluctant to accept support. Key to this was an outreach approach whereby workers from independent organisations, such as Age Concern which employed someone to liaise with the Bangladeshi community, could be involved in the initial assessment, alongside social services. Service users there were particularly appreciative of this advocacy role.

Councils surveyed were frustrated at the difficulties in promoting direct payments to staff working with specific care groups, who exhibit lack of awareness not just about how direct payments might be used but also the fact that they should be routinely offered as an option to people eligible to use them. Also, the study found a widespread belief among front-line staff that direct payments were “not appropriate” for most of their clients, and also some protectiveness towards clients by some care managers.

A care management team in one authority believed that most people with learning disabilities, mental health problems or older people lacked the capacity to manage a payment, while those who had capacity invariably needed help from their families. One care manager suggested that “a lot of people don’t want the bother because they need to know that they’ve got to manage it, we are not going to do it for them”.

Need for “champions”

Colleagues concurred, deciding whether to raise the issue of a direct payment according to each person’s situation rather than offering one as a matter of routine: the older, more infirm and dependent the client, the less likely they were to mention direct payments. As a consequence, few older people requiring help at home were using a direct payment rather than the authority’s contracted domiciliary care service, even though this service was regarded as being poor.

The study suggests that by far the most effective way to remedy this situation is to assign direct payments “champions” for each of the care groups and ensure that success stories are shared with care managers. In one authority, a direct payments champion working in learning disability services encouraged care managers to use direct payments creatively and flexibly by showing them how pooled support can work: “I have a guy doing that he gets his 10 hours and his personal assistant has introduced him to three other guys and they go out together with one PA. They tend to just chuck in all their hours and use it creatively like that.”

Ministers have spread the message that direct payments will remain a key vehicle for delivering individual budgets. For this to happen, the issues that underpin the postcode and client group lottery on direct payments uptake must be addressed.

Good Practice

● Senior managers need to ensure local policies and procedures on direct payments are clear and understood by front-line staff.
● Staff should be more aware about what direct payments can be used for, who is eligible to use them, and how they can be accessed.
● Front-line staff require help and managerial support to balance their duties and responsibilities with regard to the social care modernisation agenda.
● Training should involve people who use direct payments, and should focus on flexible care management practice and the potential to achieve positive outcomes.
● Local protocols should be drawn up and the role of health staff in promoting direct payments clarified to overcome problems associated with local partnership arrangements.
● The form and function of local support and advocacy organisations should be reviewed by commissioners of direct payment support services to ensure that they are addressing the needs of all eligible care groups.
● Consideration should be given to separate direct payment “champions” for different groups of service users with low levels of take-up.

Paul Swift is research fellow at the Foundation for People with Learning Disabilities

Further information
Direct payment survey reports
Our Health, Our Care, Our Say
Fair Access to Care Services guidance 

This article appeared in the 6 September issue under the headline “Champions can leap hurdles2

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