‘Structural problems’ blocking take-up of direct payments in residential care, study suggests

“Structural problems” with how residential care is funded and delivered hampered the take-up of direct payments in pilot schemes across 20 English local authorities, according to a new research report.

The study, by the London School of Hygiene and Tropical Medicine (LSHTM) and the London School of Economics and Political Science (LSE), found a “lack of clarity” around the benefits direct payments would bring many service users.

When the pilot schemes ended in 2015, just 40 people, compared with a predicted 400, received a direct payment from their local authority. The schemes, announced in the 2012 care and support white paper, were intended as ‘trailblazers’ for the introduction of residential care direct payments across England in 2016. But the plans have now been shelved until at least 2020.

Unlike domiciliary care, where personal budgets have given people more ownership of the decision-making for the support they receive, direct payments in residential care were not underpinned by an “established positive narrative”, the report said. Direct payments also injected further uncertainty into care providers’ finances, by reducing the sums of money they were guaranteed from councils.

Uncertain benefits

Stefanie Ettelt, associate professor in health policy at the LSHTM and one of the study’s co-authors, said the study highlighted the difficulties in slotting direct payments within existing approaches to residential care.

“The absence of a coherent narrative [to support widening direct payments] is indicative of a number of fundamental problems,” she told Community Care.

The research, which drew on interviews with people leading the trailblazer projects, council and care home staff, along with service users and their families, identified a series of barriers towards implementation.

In many cases both council and care home staff, and service users and their families, were uncertain as to the benefits of direct payments. “High levels of care need can limit residents [such as those with dementia or severe learning disabilities] benefiting from the types of choice and control that direct payments can offer,” Ettelt said.

Some local authority workers felt uneasy about promoting direct payments, because they didn’t feel confident in answering detailed questions as to how they would work in practice. Councils found it tricky to decide how to implement the new system, which required them to pass whole care-cost sums over to service users, or negotiate with care providers as to how they could ‘split out’ elements of care.

Where the latter was possible, some residents, particularly older people, were left with limited options in terms of exercising meaningful choice, the study found. “Some homes had established relationships with volunteer groups and charities [that could facilitate daytime activities], often for younger adults with physical disabilities, while others had few or no support networks,” it said.

Financial risks

Care providers also said both ‘full’ and ‘part’ direct payments increased the financial risk they were exposed to.

In the case of full payments, they argued that service users and their families were more likely than local authorities to default on payments.

By accepting part-payments, meanwhile, they would be receiving a lower fee without necessarily making any savings. Many providers’ business models, the study noted, relied on pooling resources across residents – as highlighted by a recent by a recent Competition and Markets Authority (CMA) report, which found local authority resident fees were already on average 10% below costs.

Some care homes emerged as “gatekeepers”, the research found, with “many expressing concern about the potential impact of direct payments on finances if the scheme were to be rolled out”.

In some cases, family members were also reluctant to accept a direct payment because of the potential impact on overall standards of care if they began reducing the fee they paid to a home.

‘Make system fit for purpose’

Responding to the research findings, Margaret Willcox, president of the Association of Directors of Adult Social Services (ADASS), said it was important to bear in mind that direct payments were “never intended” to supersede all other methods of paying for care.

“They simply aim to support people who want greater choice and control over their financial planning,” Willcox said. “Making direct payments more widely available will enable this control to be offered to more people.”

Martin Green, chief executive of Care England, echoed Willcox’s endorsement of making direct payments more widely available and said that the government must work to make the system fit for purpose.

“If people have limited capacity, this should not be used as an excuse to deny them direct payments; rather, they should be offered independent advocacy to enable them to make informed choices,” Green added. Citing the CMA report, he blamed local authorities for trying to use direct payments to reduce “meagre funding levels” still further.

Meanwhile a Department of Health spokesperson said: “This research identifies poor take up of direct payments in residential care in the pilot areas and the barriers to implementation – but we know some people want this choice and control over their care and support.

“Next summer we will publish plans to reform social care – looking at the quality of care delivered, the funding of the system, and how it will be paid for – to ensure  that it is sustainable for the future – and we will consider the findings of the report in the context of the government’s wider reform programme.”