Direct payments: Answering frequently asked questions
Question 13. How do you introduce the idea of direct payments to service users? How does the assessment process work?
The care manager needs to be very clear about what direct payments are, who is eligible and what can be offered. This may well have implications for training, particularly where people's needs are more complex (see below).
Having confidence in your own knowledge and how the process works is essential, but the latter will differ across authorities, which can be confusing.
The local authority should think about developing information for staff and service users alike that is clear and accessible, about all aspects of direct payments, and ranges from assessment through to monitoring and review.
This information should address issues such as advocacy and the responsibilities of becoming an employer, and should reflect the Department of Health's Fair Access to Care Services (FACS), which covers the assessment of all adult users of social care, including older people. It says that assessments should include:
- sustaining social support and relationships
- sustaining family roles and other social responsibilities
- life and health including risk of abuse or neglect
- choice and control over day-to-day environment
- ability to carry out personal routines
- ability to take part in work, education or learning. (27)
The Department of Health 'Circular LAC (2002) 13 Fair Access to Care Services (FACS) guidance' (27) provides a framework for local authorities to use when making decisions on how they can provide support to adults of any age. They are required to be consistent in setting priorities that meet people's needs in order to promote independence and quality of life. The assessment for direct payments is the same as for other services. This means looking at the need for support and what social services sees as possible risks to the person's independence if they do not get a service.
According to suggestions made during the practice survey, care managers need to be relaxed and have more faith in the direct payment approach.
Care managers need to be flexible and move away from the traditional methods of doing things, always discussing the possibility of direct payments instead of deciding who it may or may not be suitable for.
Direct payments should be part of a person-centred community care assessment, which should offer the person a positive choice that needs to be fully explored before a decision is made.
It should also be remembered that just because someone does not want a direct payment at a particular time does not mean that the option should not be reconsidered at a later date.
The judgement as to whether someone is able to manage direct payments, and how much help is appropriate, can sometimes be difficult and will need to be made on an individual basis. Local authorities should consider what assistance would enable a prospective direct payments user to manage, rather than assuming that the person is unable to manage. (18)
The assessment may well require several sessions to complete. In addition, it may be a complex situation requiring the support of advocates, family members, interpreters, and staff from the support service, as well as the service user and care manager. However, this is no different to completing a traditional needs-led assessment.
Take the fear factor away by giving simple and clear information.
Part of the assessment relates to a person's ability to manage. The FACS guidance is very clear that, where necessary, support should be provided to facilitate this process, rather than seeing it as a problem or reason to exclude someone.
Support can come from a variety of sources, including family, friends and local support services that have been established to provide experience and expertise.
There is always the option of maintaining or contracting traditional services while this happens.
'The good practice guide for support workers and personal assistants working with disabled people with communication impairments' (28) discusses different methods of communicating and provides examples from service users that may be useful for the assessment process.
Methods vary from so-called 'low-tech' aids such as pictures or books, to 'hi-tech' equipment such as voice output communication aids. The guide goes on to provide some useful tips - for example:
- Slow down and listen.
- Pay attention to body language and facial expression.
- Don't be embarrassed if you don't understand at first.
- Treat the person with respect, in the same way you would want to be treated if in that position.
- Take time to find out how to communicate with the person.
- Check out that you have got it right.
When working with people with learning disabilities and those with mental health issues, make use of advocacy services and other recognised supportive approaches to ensure that they have equal access to direct payments.
For information on person-centred approaches and planning there are numerous websites and training materials available - for example:
- Person Centred Planning and Approaches
- British Institute of Learning Disabilities
- Valuing People Support Team
- North West Training and Development Team
- Circles Network
If a person has mental health problems, this also needs to be integrated with the care programme approach. Handling money is known to be a problem area for individuals with dementia and their carers, which often worsens as the condition progresses. However, progressive agencies offering dementia care and advice, such as Alzheimer Scotland Action on Dementia, advocate the making of plans while the person with dementia can understand and discuss matters. This would suggest some scope for involving people with dementia in considering cash payments instead of services, even if this has to be at the earliest stages of dementia. (23)
I had the ins and outs and pros and cons explained to me and was told all about the direct payments scheme. It was good because it took into account my social life as well as my personal needs.Direct payment service user
On the whole, people with learning difficulties need exactly the same sort of information, support and advice as other potential direct payments users - that is:
- support in accessing direct payments
- support in managing them, including payroll, managing staff, etc.
However, they may need this support provided in a different way (for example, written information may not be so useful or timescales for discussions and decisions may need to be longer). They also often have the hurdles of assumptions around consent and ability to manage a payment to overcome too. (24)
Andrew Holman (25) refers to several pointers in the successful assistance and management of direct payments for people with learning disabilities. He says that those who assist with direct payments should:
- show how this help maximises an individual's participation in decision-making about their direct payment
- recognise and respect the way in which an individual expresses himself or herself
- incorporate centrally, in the care plan, the ways in which someone makes their preference known in decisions made about the use of direct payments
- provide the service user with a range of opportunities and experiences in order to further facilitate informed choice
- document evidence that decisions about a direct payment are being made in this way, including evidence of outcomes and their desirability.
Care managers carry out joint visits with advisers from the support service during the initial stages.Croydon Direct Payments Support Service
Self-assessment is an important aspect of this process, and applicants should be able to identify their own needs. This can be facilitated through an advocate/family member/friend, and can be done in advance of meeting.
The process can also be facilitated by involvement from the direct payment support services (DPSS). DPSS are generally staffed by service users, and it can be helpful to have someone with first-hand experience to explain the process and deal with any concerns.
It was good as I had support to do my own self assessment in advance and felt well prepared and supported.Direct payments service user
In considering whether people's proposed arrangements will be adequate, local authorities should not be constrained by existing patterns of service provision. By exploring innovative and creative options, it may be possible for users to identify alternatives which both cost less and meet their needs more effectively. Where the user's needs fluctuate over time, it will be important to discuss in advance how the direct payments will be used to secure a package of assistance which varies according to need. (18)
One participant of a focus group, who was an Asian person and had mental health issues as well as physical impairments, commented that she was not allowed to have her advocate from the mental health advocacy group there in the assessment. This clearly breached accepted good practice and there was a general consensus that DP users must be given the option to have advocates present during the assessment.Direct payments service user
Assessments should include six main categories: (32)
- personal and social care
- health care
- education, leisure, employment
- transport and access.
The initial assessment as a couple was good - the social worker kept in contact and adjusted the requirement as my husband's condition deteriorated. We were both consulted and consent requested.Direct payments service user
Assessments should include plans to cover for emergencies/sickness and holiday cover. For some people, such as those with mental health problems, an advance directive can be put in place for times when they are feeling distressed or their mental health has fluctuated. This will enable the person to retain some control over their life and the response of others around them. For more information, contact National Centre for Independent Living (NCIL) and request a copy of 'Direct payments for mental health users/survivors: A guide to some key issues'.
Implementation relies on an understanding of a social model of mental health, which emphasises capacity and recovery. (24)
We are currently working with the local People First group to make all of our DP material accessible to people with learning disabilities. There is a section on having an assessment with the social worker and the importance of the person telling them about their needs. It also promotes self-advocacy and the involvement of the family or people close to the person during the time of assessment.Sandwell Ideal for All Ltd
Understand that independent living is so much more than having a shower and your bum wiped of a morning and half an hour back to bed. It's about socialising, working, housework whatever the disabled person wants.Direct payments service user
Remember that direct payments are not set in stone. Just because the assessment has been completed, it does not mean that that is the end of it. Flexibility is essential to take account of the changing needs of service users, carers and families.
For example, direct payments can now be used for short periods in residential care if it is agreed that that is what is needed, as well as providing an alternative to residential care or hospital admission.