Direct payments: Answering frequently asked questions

Question 03. Who can get them? What can they be used for?

Initially, people aged 18-65 who were assessed as needing community care services were eligible. Direct payments were then extended to older disabled people in 2000.

Since April 2001, direct payments have been available to carers, parents of disabled children and disabled young people aged 16 or 17 years old.

Everyone who is eligible has to consent to direct payment and be able to manage it, with support if required (see Question 13 on assessment and Question 14 on consent).

There are many examples of how direct payments have transformed users' lives, giving them more independence, flexibility and choice.

I now work full-time and my PA [personal assistant] complements, supports and enables me to live a full life. In the past, using an agency, I had no control who came to my house, when, what they did or anything. Now I have control, choice and the right to live my life the way I choose.

Direct payment service user

Payments can be made for day-to-day things such as dressing, cooking, driving, bathing children, support to facilitate discharge from hospital. They can also be used for social activities - visiting friends, evening classes and college courses, gardening - as well as for assistance to access training and employment.

One of the most exciting aspects of direct payments is their adaptability. Service users can use them to organise their care in a whole range of new and more effective ways. Indeed, local authorities are encouraged to explore innovative and creative options for meeting people's needs. The possibilities seem almost endless. (10)

Flexibility is an essential part of direct payments, and they can also be used as part of a combined package. For example, part of a care package can be provided through direct services, such as a day centre, while other parts can be through direct payments, enabling someone to live independently and choose their own support.

For the most part, direct payments are used to employ personal assistants, although this is slowly beginning to change.

A 56-year-old man with early-onset dementia has a very short concentration span requiring almost constant stimulation, which he seeks out from his wife, the main carer. The situation is likely to breakdown if the wife does not receive regular breaks and the husband does not receive regular stimulation. He also requires support to maintain links and regular contact with his family, but he is finding it difficult to remember how to use the train to reach them. Traditionally he would have been provided with three hours of domiciliary home care each week, plus two days a week at a day centre. The approximate cost of this service would have been £600 per month. He now receives a direct payment of £200 per month, and his wife receives a carer's direct payment of £55 a month. This is how they meet their eligible assessed needs: He now has a Sky satellite TV subscription that costs £40 per month. He can watch sport and football, which holds his concentration and which he enjoys immensely. This facility is available seven days a week. He now has a sports club membership and goes to the gym with a personal assistant every week. He also goes swimming when he can. The cost of the PA is £100 a month and the sports club membership costs £28 a month. His wife receives a carer's direct payment to fund her membership as they enjoy swimming together. He uses £150 a year to fund transport obtained through the community volunteer transport service, to travel with his wife to Center Parcs to stay with his family for holidays. He also pays the community volunteer transport service, so he can travel with his wife to stay with their family in London whenever possible. He uses part of the money to pay for a taxi every month to attend, with his wife, a club for people with early-onset dementia and their carers. His wife pays for half the cost of the taxi from a carer's direct payment she receives in her own right.

Example supplied by Essex Direct Payments development manager

A man with a diagnosis of severe and enduring mental illness and alcohol dependency had recently been through rehab. He was engaging very well with services but wished to move to another area. He had been paying off rent arrears, accrued during the time when he was not managing particularly well, but the area he wished to move to would not accommodate him until the debt was cleared. It was the opinion of the care team that an early move would be beneficial to him and his long-term prognosis. Direct Payments agreed to clear the remaining debt.

Example provided by Essex Direct Payments development manager

One of the key areas for concern since the inception of direct payments has been about who can be paid for providing care and support.

It is clear and understandable that many people would be more comfortable employing family members and friends, and the legislation supports this to a degree. However, it is only in exceptional circumstances that service users can pay relatives who live with them:

Some councils say they are confused over the rules governing how individuals can use their direct payments to pay close relatives. We're reminding councils that there is no legal restriction on individuals using their direct payment to pay close relatives who don't live with them.

Due to us changing the law last April, in exceptional circumstances, people can also use their direct payment to pay a relative who lives with them, if they and their local council decide this is the only satisfactory way of meeting their care needs.

Dr Stephen Ladyman, former Minister for Community, Department of Health, 26 January 2004

To date, the majority of direct payments have been made to people who have a physical impairment. However, with the right support, people with mental health issues and/or learning disabilities and older people can also manage them.

The following are examples of developments and innovations across England and Wales that have enabled direct payments to be made:

We have money from the Direct Payments Development Fund to run a 'support network' project aimed at building on the 'circles of support' model and applying it to DP users.

Independent Living, Norfolk

Our advocacy service is involved on many occasions, and we have a worker identified within the support service to provide the extra support that may be needed by people with learning difficulties. Referrals can be made to us and some care managers involve us at an early stage for this group.

Independent Choices, Northamptonshire

Older people receiving direct payments reported feeling happier, more motivated and having an improved quality of life than before. There was a positive impact upon their social, emotional and physical health. (11)

We tend to involve family members and friends more with this group. They like to feel that they are supported by someone they know. Social workers assume that older people do not want the hassle. I know that older people like direct payments as it gives them so much dignity, choice, respect and control. They like joint visits. Some use DPs for overnight stays, short-term care and many other ways in which they need part-time support without losing their pride! The 'older person's forum' meets monthly to discuss any concerns, issues they may have.

Gateshead LA

We were struggling with older people and direct payments, so we brought in what we call an 'inclusion broker' [who speaks on behalf of older people]. They were also responsible for all paper work that deals with direct payments and recruitment of personal assistants. If you have someone to work in partnership with the person, it seems to work much better. After we brought in the 'inclusion broker', referrals trebled within four months.

Tameside LA

We have advance directives for when people have crises and are not able to mange their schemes themselves - they will nominate someone to take over at such times. We use advocates - fewer problems around getting consent. Many of the issues are about being prepared for when people's situations change - e.g. so that there are instructions for workers on what to do when the user has a crisis. Preparation and planning is the key - having people with power of attorney lined up to take over when the user is unable to be in control themselves. The problems for mental health are around risk assessment: practitioners are concerned that care will be provided by people who are not trained and supervised to both recognise and respond appropriately to crisis situations. We're tackling that with training, training and more training. Having mental health service users take part in training has been very effective and gives the most powerful message.

Essex LA

Sarah was bright and organised, although she lived with serious mental health problems. She had had services from the staff at one independent home care agency for eight years, but a change in the boundary meant she no longer came within their contracted remit. Direct payments were an alternative way for her to purchase care, originally with the intention of preventing a change in provider. In fact, that provider could not continue anyway, so she used the money to buy care, designed to her personal specification, from another provider. But the really impressive thing was the therapeutic impact of using direct payments for Sarah. She felt more in control and it increased her self-esteem. Because she felt too vulnerable to interview and employ someone directly, she used an agency. The direct payments support team at Mount Pleasant were excellent, superb in fact. They met Sarah and answered all her questions.

Contributed by Hertfordshire Mental Health Trust

A person with learning difficulties employs a personal assistant to help them plan and organise their weekly diary and read, understand and reply to official communications, and another one to assist with managing their finances. The first supporter worker assists them in supervising the second worker, giving some independence in this work. The disabled person works as a trainer to introduce independent living skills to other disabled people and professionals. The personal assistance supports them in doing this work.

Example supplied by NCIL

Direct payments can also be used for some equipment. For up-to-date information and advice, check the website of Integrating Community Equipment Services.

Link: ICES - Integrating Community Equipment Services.

ICES states that:

"If certain conditions are satisfied, a local authority must make a direct payment up to the reasonable cost of securing the provision of the service or equipment."(10)

Joe wanted a new sit-down shower with additional features. In order to get the model of his choice, he was given a direct payment to cover up to the amount the local authority deemed reasonable. He then paid the remainder himself.

Contributed by NCIL

Certain groups are not eligible under the legislation:

For more information, check Department of Health direct payments guidance.

There are also restrictions about using direct payments for health rather than social care needs. According to the Department of Health:

Whilst the Department of Health is unable to comment on individual cases, direct payments made under the Health and Social Care Act 2001 relate only to certain local authority social services. This means that, where an individual has an identified health need which falls to the NHS, that part of any 'care' package cannot be delivered as a direct payment within the meaning of the legislation, including where a local authority is acting under a partnership arrangement pursuant to section 31 of the Health Act 1999. This statement is not, nor is it intended to be, a comprehensive description of the legal position concerning direct payments, and councils are advised to take their own legal advice on this issue. (13)