Section Four: The Mechanisms
4.1. Individual budgets and direct payments
In order to provide greater clarity on the range of options for directing support, we propose to use the following terminology to differentiate between emerging tools and legislative provisions.
Individual budgets are an indicative allocation of funding given to users after an assessment for support. The assessment of the budget should be through a transparent process that demonstrates compliance with community care and other legislation. Where there has been a joint assessment, the budget may include money for health and educational/training needs. Individuals have a choice on how the budget is processed.
Individual budgets provide greater clarity about the financial contribution to meeting their needs. The individual budget may combine a collection of funding streams, to support the delivery of agreed outcomes. In practice, this has included Supporting People19,Independent Living Fund ( ILF)20, and Access to Work21.
The implementation of SDS should be genuinely personalised and the funding streams it brings together, and makes available for users to make decisions about, should include ALL that are relevant to each individual - for social services, education, housing, employment and health.
Direct payments are defined in legislation and are payments in lieu of services provided directly to eligible individuals assessed as being in need of community care services. Any arrangement whereby the council allocates the budget to an individual - or to third party to manage on behalf of the individual - is a direct payment. Direct payments can be used to purchase services from a provider, including from the council, or it can be used to employ a personal assistant ( PA).
An individual service fund or trust can be used to commission the service directly with providers. The contract for such an arrangement is in effect the same as a spot purchase, albeit with a focus on delivering the agreed outcomes in the individual's support plan. Inclusion Glasgow did some early work on the development of individual service funds and provides examples of a contract used to commission support in this way.
People may opt to leave councils with the responsibility to commission the services. Or they can have some combination.
What is crucial in the implementation of self-directed support is that all options are given equal weight, preventing some existing attitudes and practice that limit access to direct payments. The drive to increase the uptake of direct payments needs to be sustained, and Individual Budget pilots show this can be achieved. Information from discussion with most local authorities suggested that there is still significant scope to increase the numbers of direct payment recipients, and many areas have strategies and policies in place for doing so.
In some areas, development of personalisation programmes or self-directed support projects have been disconnected with direct payments activity. Apart from missing out on the opportunities to harness the knowledge and expertise of teams promoting direct payments, this separate focus risks diminishing the drive for real choice for citizens.
Some of the barriers to direct payments will apply equally to other uses of individual budgets, and implementation of this strategy will need to address issues such as flexibility in how budgets can be spent. Local authorities generally found existing Scottish Government and The Chartered Institute of Public Finance and Accountancy ( CIPFA) Scotland guidance helpful in relation to direct payments, and these should continue to be applied.
Using the budget flexibly
An issue of significant debate is the balance between innovation in meeting outcomes and accountability for the use of public funds. The need for financial prudence was often raised in discussions with staff at all levels in local authorities. These discussions revealed quite polarised views on what purchases should and shouldn't be permitted.
Stories that may attract unwelcome media attention travel faster than those that aim to promote SDS. The purchase of holidays abroad, a caravan for short breaks, and golf club memberships were cited by some as innovative and open minded approaches and by others as abuse of public funds.
An area attracting greater consensus on the flexible use of direct payments was respite. Indeed this was identified as the most likely service to enable short term growth in direct payments. The City of Edinburgh Council has published a leaflet 22 to encourage new short breaks opportunities for older people through direct payments.
The Homer and Gilder evaluation of the benefits of direct payments includes a number of personal stories highlighting the positive outcomes that flexible use of direct payments has brought.
In Control Scotland 23, and other organisations, have worked with a number of councils in Scotland to pilot their system of self assessment and resource allocation. A review of such a pilot in North Lanarkshire 24 found people had used their individual budgets for a wide range of purposes:
- People to help (Support worker, employment of live-in carer, personal assistants)
- Cleaning and laundry
- Equipment ( e.g. computer, iPod)
- Transport (Travel to/from college, taxis, electric scooter)
- Education (Courses e.g. film making)
- Access to leisure (Museums, exhibitions, cinema, music, entertainment, clubs, shopping)
- Improving health (Gym membership, acupuncture, physio at home)
- Social life and seeing friends.
No person using individual budgets in North Lanarkshire reported a negative impact of their individual budget on any area of their life. In most areas of life, people reported highly encouraging levels of positive impact that are similar to information collected from almost 50 adults in two English counties.
It is too early to identify how the range of SDS options deliver more flexible outcomes than direct payments. The earlier discussion on the unnecessary separation of the 2 mechanisms needs to be borne in mind, since the shift from process-focused to outcomes-focused support planning and review should in itself drive up autonomy and control.
Systems and processes to measure and monitor progress, locally and nationally, need to be reviewed to take account of self-directed support.
Reducing bureaucracy and cutting red tape
The shift to self-directed support, and thereby the promotion of independent living, should aim to reduce the multiple business processes associated with current activity to bring together different funding streams. It should be possible to achieve efficiency savings by streamlining some overlapping activity of the agencies involved.
There may also be opportunities to give the citizen a single entry point into funding for independent living, and current activity to streamline ILF processes should be built upon.
A deterrent to direct payments for some individuals has been the prospect of onerous processes to manage resources and account for the budget. The Edinburgh card can make money management more straightforward for individuals and families. It is a VISA card which direct payment budgets are paid into, and from which payments are made to providers.
Carers also have concerns about the expectations on them to manage budgets. In agreeing to opt for a direct payment of an individual budget, it is important that:
- assumptions are not made about the carer's contribution, rather this is jointly agreed through the process of carer assessment and support planning
- assumptions are not made that the carer will administer and manage the SDS
- a combination of arranged services and SDS are made available, as necessary
- DP set up time is kept to a minimum
- contingency planning is in place to address any breakdown in SDS arrangements
- larger packages of care and support factor in adequate management costs
- carers are supported in any employment and administrative activities
- adequate support and advocacy is in place to support people to manage, drawing on the experience of those who direct their own support.
Short Breaks SDS project
The numbers of people using flexible breaks in the Scottish Borders has increased yearly. Despite this the number of people with mental health needs using a flexible form of break remained low.
Most people taking a break continue to take this in a care home; for young adults this means travelling out of the Borders - and this journey can be difficult for some people.
There can be difficulties in providing robust, individualised packages of support for people with high support needs wanting a flexible break, and arranging a flexible break can be time consuming and complex for client, carer, care manager and provider.
The project aims to:
Increase the number of breaks that are flexible and individualised - and in particular increase the number of breaks for people with mental health issues
Provide a range of different models and support arrangements including alternatives for people who traditionally take a break within a care home.
Explore joint funding arrangements.
Update on what has been achieved to date
The number of flexible individualised breaks in 2009/10 increased by 96 weeks from the previous year. Most of these breaks have been purchased through a direct payment and there has been funding from social work, ILF and NHS. Examples of how people have taken a break are featured in the personal stories section below.
Following promotion and information about short breaks there was an increase over one year from 1 person to 9 people with mental health needs using a direct payment for their short break and an overall increase in people taking breaks including people arranging their break with a 'virtual' budget e.g. to a local hotel. An independent evaluation is being undertaken based on talking points outcomes.
Accessible self catering accommodation has been developed in the east and west of the Borders through partnership with two RSLs. People using the accommodation can take a break on their own or with family, friends and/or paid carers and the support is arranged as required. Margaret Blackwood Housing Association adapted a flat for short breaks use and Berwickshire Housing Association has built an accessible house in Duns which became available this month. This type of accommodation has been used by people who want an alternative to a care home and require regular breaks within their local community. The break can assist people to develop or regain skills and confidence - and can be part of a plan for young people to move from the family home.
The involvement of local providers has been crucial to achieve the robust, individualised packages that are required for most people using this accommodation and developing a partnership approach between providers is part of this approach.
The carebreaks website has been updated and will shortly be launched. This will provide local information including availability and booking information for the self catering accommodation mentioned above, with links to information and breaks nationally for example through Shared Care's website.
Support has been provided to individuals and care managers through increasing capacity in the short breaks development worker post. However, the success of the short breaks approach in meeting individual's needs has encouraged care managers themselves to directly promote and support flexible approaches.
Further work includes
A resource allocation system has been developed and will be piloted through the SDS project.
Reprovisioning a care home for older people and providing an alternative short breaks approach
The growth of self-directed support should lead to greater equity of provision, and whilst local authorities will continue to apply different resource allocation formulae, their focus on outcomes and clarity about available resources should aid those who move to another area, for example in order to live or work in another area.
Equally, there is a need for clarity about the contribution of personal income to meeting agreed outcomes, and the need for clarity in how charging policies will relate to developments in SDS.
The Scottish Government should work with COSLA and the Independent Living movement on simplifying Charging Policy to make this more compatible with the outcomes associated with self-directed support.
The issue of waiting lists for direct payments will also need to be addressed in taking forward a strategy for self-directed support. Some people who are currently on waiting lists have been refused a direct payment because of a lack of available resources. Some receive a commissioned service, others receive no support. Generally, demand for social work services has exceeded available budgets
As implementation of self-directed support progresses, the impact on waiting lists for delivering agreed support plans will need to be considered, with a view to working towards a clear target. As a matter of priority, people on current waiting lists should have the opportunity to undertake supported assessment, and to explore the range of options for directing their support.
4.2. PA workforce
The PA is workforce is a significant contributor to social care provision, within SDS users, yet is arguably the least developed. Currently, the majority of people use a direct payment to employ a Personal Assistant ( PA). Over 51% either employ only a PA or a PA and another service 25. This sector therefore has a key role to contribute to increasing the uptake of Direct Payments as a key option of self directed support. Evidence suggests that the employment of PAs does not impact on the recruitment and retention of workers in other areas of social care. Despite both employers and PAs valuing the training that a PA receives, nearly half of PAs do not receive any training. Providing training of PAs is a key to being a good employer, SPAEN have a role to ensure that employers promote best practice. Most PAs would like to access training but there are a number of barriers including availability and accessibility, there is no dedicated support service for PAs.
Local Authorities, Support Organisations, Providers and the third sector could all have a role in ensuring that PAs can access training. Training should be provided in a co-produced manner that ensures a balance between developing skills of a PA, whilst an individual has their own requirements met.
The PA workforce is unique within the Social Care workforce, in that it is not regulated by the Care Commission. This offers individuals additional flexibility and responsibility that some people prefer. However this is perceived as being unfair by some organisations that believe there is more risk to individuals using a PA, although there is no clear evidence of this. The regulation of individual PAs as a service is not proposed. The routes to ensuring adequate protection of individuals should be through effective inspection of social work services to ensure due processes for establishing they are following their duty of care. However, as SDS grows there may be new models of support, and providers may offer PA banks, taking on the employer responsibilities but giving individuals more control over their support. These would be regulated services, and only self-employed individuals would not be expected to register as such.
Whilst the current workforce is stable, recruiting suitable individuals provides direct payment recipients with some difficulties. Appropriate support is also important during the recruitment process to ensure a better experience for the individual and help resolve any concerns. Common concerns exist about the requirement to become an employer to the PA. There are gaps in support with regards to employment advice. For a significant number of direct payment recipients, there needs to be an attitudinal shift towards providing training for their PAs and embracing their responsibilities as an employer. It is vital that local authorities and NHS Boards fund the DP recipient to be a responsible employer and factor in elements of good practice such as training and indemnity insurance. Whilst direct payments are mostly used to employ PAs, there is often no relationship between a DP rate, PA wages and an annual uplift for the direct payment rate. As a result over time it becomes more difficult to recruit and retain PAs at a competitive rate.
The aim of a Scottish Government / SPAEN project was to raise the awareness of Social Work staff and NHS professionals of the benefits of Self Directed Support while focusing particularly on what needs to be in place for recipients who become employers running their own support package.
This was achieved by providing a framework of training that linked National Guidance on Self Directed Support, Local Authority policies and procedures and Community Care Assessment, incorporating sessions surrounding recruitment and retention of Personal Assistant staff and how the documents mentioned previously impinge upon and impact from an employment law perspective on the service user's contracts of employment. Following consultation, it was noted that each authority had its own unique interpretation of the National Guidance and three key areas were identified that would benefit from training to increase the skills and knowledge base of front line Social Work and Community Health professionals. Armed with this information the following plan was produced recognising that each authority required a customised package to take account of an authority's guidance, policies and procedures. To date the training has been delivered to 361 Social Workers in 12 local authority's over 32 sessions with bookings through to February 2011. We have also delivered to one Area Health authority and have 4 bookings with another:-
1 SDS Start Up Requirements - Employment Law Considerations
- look at the assessment process and the early stages of setting up the SDS package and what responsibilities come by making the commitment to managing the SDS package.
- emphasis on the need for a structured process to be in place providing a clear and transparent audit trail that establishes the boundaries of ownership and responsibility of the employer, thereby safeguarding the Local Authority from being cited as the employer
- potential discrimination issues
- where gender exemptions can be used.
2 Basic Employment Law
- issues which have historically caused the most problems for social work staff contacting SPAEN: namely, contracts, dealing with absenteeism and grievance and disciplinary issues
- what should be in place and what safeguards are out there to deal with these issues.
- raises the question: how to ensure a person (with or without support) is 'willing and able' (not capacity) to take on the employer role and how this is established (compulsory Coaching & Development?)
- clearly define the roles of the interested parties in the triangular relationship with the person centre to all decisions
3 Employment Law in Relation to Self Directed Support
- understanding the anomalies and contradictions that can arise between SDS and employment legislation.
- developing an awareness of how these differences might be overcome (best value, thinking outside the box, not always by providing more funding)
- how Local Authorities and Support Organisations can work in partnership to ensure people are supported through the transition of being a community care service user to become the manager of their own SDS package
- overview of problematic issues that re-occur needlessly
- Judicial Review
- look at the problem prevention strategy approach
Participants through training achieved an understanding of:-
- The policy context, including the key concepts underpinning self directed support, direct payments, and independent living
- The relevant legislation, eligibility criteria and permitted uses of direct payments
- The role of the Independent Living Fund
- The role of support services
- The Scottish Government's guidance on self directed support
- The difference between self directed support, direct payments and Individual Budgets
- How implementing effective self directed support can meet a variety of national and local policy objectives
- Best value, qualitative and quantitative assessment
- Judicial processes
- Where to get additional advice and information
As a result of the project closer links have been developed between SPAEN and Social Work Departments and three NHS Boards. There are a number of authorities with whom SPAEN regularly share information and conduct problem solving sessions. This highlights the need for joint working which could have benefits nationally.
The Self Directed Support Implementation Group with other organisations should consider the support provision needed for PAs.
The Scottish Government should co-ordinate work that ensures a system of support is provided to individuals, suitable training for PAs and proportionate local authority monitoring to ensure that individuals are aware of their responsibilities.
The Scottish Government should work with local authorities and support services to ensure PA employers can be assisted to proactively to comply with employment law, social service workforce regulatory requirements/Codes of Practice and best practice.
In addition to these specific recommendations, implementation of the strategy will need to consider how to develop a competitive PA workforce sector that provides a real alternative, whilst offering choice and flexibility to individuals.