THE IMPLEMENTATION OF DIRECT PAYMENTS FOR PEOPLE WHO USE CARE SERVICES 

Sheila Riddell, Centre for Research in Education Inclusion and Diversity, University of Edinburgh
Linda Ahlgren Centre for Research in Education Inclusion and Diversity, University of Edinburgh
Charlotte Pearson, Department of Urban Studies, University of Glasgow
Victoria Williams, Department of Urban Studies, University of Glasgow
Nick Watson, Strathclyde Centre for Disability Research, University of Glasgow
Hazel MacFarlane, Strathclyde Centre for Disability Research, University of Glasgow

COMMISSIONED BY THE SCOTTISH PARLIAMENT INFORMATION CENTRE FOR THE HEALTH COMMITTEE

CONTENTS

EXECUTIVE SUMMARY

REPORT

SECTION 1: BACKGROUND AND RESEARCH DESIGN

SECTION 2: UPTAKE OF DIRECT PAYMENTS IN SCOTLAND

SECTION 3: LOCAL AUTHORITY QUESTIONNAIRE SURVEY

SECTION 4: LOCAL AUTHORITY CASE STUDIES

SECTION 5: SUMMARY AND CONCLUSIONS

REFERENCES

APPENDIX: DIRECT PAYMENTS IN SCOTLAND SURVEY

EXECUTIVE SUMMARY

Main Findings

Two central arguments have been used to promote direct payments:

1. Direct payments have been promoted by the disability movement as a way of empowering disabled people
   
   
2. The Scottish government has seen direct payments as a way of delivering flexible, personalized and cost-efficient services, thus contributing to the modernization of welfare agenda.

• As a result of this twin rationalization, direct payments remains a contentious area of social policy.
  
• Take up in Scotland has been significantly lower than in England, and there are large differences in use of direct payments in different local authorities and for different user groups.
  
• Local authorities have not as yet shifted funds from traditional services into direct payments and there are anxieties that an increase in uptake of direct payments might destabilize existing provision.
  
• Training for front-line staff is patchy and social workers report a lack of knowledge and confidence.
  
• Local authorities have major anxieties about financial accountability issues and social workers feel the paperwork associated with direct payments is onerous.
  
• Social work staff also have concerns about how the local authority can guarantee a high quality of care since they have no control over personal assistants.
  
• Social workers often worry about users’ ability to cope with financial management.  However, service users believe that, whilst there are significant administrative demands, these are manageable with support.
  
• There is a growth in the number of people managing direct payments on behalf of others (e.g. parents of disabled children, children of frail older people).  Whilst these service users feel that direct payments provides opportunities for personalised services in their home, there are concerns about ownership of the payment.
  
• Local authority case studies illustrate the micro-cultures within particular settings which either inhibit or support the development of direct payments.

Introduction

Partly as a result of pressure from the disabled people’s movement, there has been a gradual move in Scotland, as elsewhere in the UK, towards forms of welfare which promote independent living, rather than more passive forms of welfare consumption.  Direct payments have been seen as a means of empowering disabled people by allowing direct control over the purchase of services to meet assessed needs.  However, since the implementation of the Community Care (Direct Payments) Act 1996, there has been differential use of direct payments by local authorities in Scotland, and, particularly at first, there was relatively low uptake of direct payments  in Scotland compared with parts of England (Witcher et al, 2000; Pearson, 2000; Riddell et al, 2005).  In 2001, there were only 207 direct payment users in Scotland, although this had increased to 1,438 by March 2005 (Scottish Executive, 2005). Certain groups, particularly people with learning difficulties, mental health problems and black and minority ethnic groups have been particularly poorly represented among direct payment users.  In addition, there have been significant differences between local authorities in the average size of packages, so that some local authorities which appear to be making quite extensive use of direct payments are spending a considerably lower proportion of their social care budget than others, which have fewer users but make larger payments on average (Scottish Executive, 2005).  Research carried out by team members (Priestley et al, forthcoming) has identified the local factors which appear to make a difference to the use of direct payments.  These include the nature and capacity of the local support organisation, the micro-politics of the local social work department and the political complexion of the local council.

The Community Care and Health (Scotland) Act 2002 places a duty on local authorities to offer direct payments to all client groups using community care services, and therefore has the potential to contribute to the promotion of direct payments in Scotland. Sufficient time has elapsed to allow an assessment of the early impact of this legislation. 

Research Aim and Objectives

Following the research specification, the over-arching aim of the research was to evaluate the implementation of direct payments policy in Scotland. 

The specific objectives of the research were to:

• examine whether there has been any significant change in uptake of direct payments since the Community Care and Health Act 2002 came into force.
• identify the extent to which people turn down the opportunity to receive direct payments
• identify the reasons why people choose not to take up direct payments
• identify differences in uptake between different client groups and explore whether there are specific reasons for these differences
• examine the experiences of those receiving direct payments in order to identify areas of good practice which facilitate their use and any difficulties encountered in using them
• identify barriers to effective implementation of the direct payments scheme by local authorities and support organisations.

Methods

The research used a progressive focussing strategy, starting with a very broad overview of the field, and gradually focusing down on the dynamics within three local authorities, highlighting the experiences of users, non-users and carers within specific local contexts.  The study was conducted in the following overlapping phases:

Phase 1: Analysis of official statistics

Scottish Executive statistics were obtained on use of direct payments from 2001 – 2005.  Secondary analysis of data was conducted by local authority, nature of client group, size of package and nature of support organisation.  National figures gathered by the Scottish Executive were used in this analysis.

Phase 2 : Survey of local authorities

A questionnaire was sent to all 32 local authorities in Scotland to identify what they consider to be the major facilitating and inhibiting factors in relation to the uptake of direct payments in relation to different user groups.  The extent of current or anticipated change following the implementation of the Community Care and Health (Scotland) Act 2002 was also investigated.  Specific factors to be explored were the role of the local support group, the contribution of the Scottish Executive, knowledge and awareness in local social work departments and the nature of local funding regimes (e.g. spot or block purchase arrangements).

Phase 3: Case studies of three local authorities

Case studies were conducted in three local authorities with different policies, practices and take-up rates in relation to direct payments. Within each local authority, the aim was to gather data from a range of perspectives including social work staff, finance officers, support organisations, users of direct payments and those who had opted not to use a direct payment. Interviews were semi-structured and the majority were tape-recorded and transcribed.

Interviews were designed to explore the critical factors within each local authority which have contributed to the development of direct payments.  The experiences of direct payment users were contrasted with the views of local authority personnel and support organisations. 

Interviews and focus groups with service providers and support organisations explored:

a) the extent to which the individual considers direct payments are currently in place
b) the benefits perceived for their particular area of practice or need
c) the disadvantages for their particular area of practice or need
d) perceived barriers to implementation
e) perceived drivers for implementation
f) details of any practice examples relevant to direct payment training requirements

Interviews and focus groups with direct payment users and non-users explored:

a) Initial access to their support; areas of help and hindrance (and the key agencies involved), supporting roles.
b) How payments are used (where appropriate) and their interaction with other day to day employment and/or social activities.
c) Views on how their support could be improved.

SUMMARY AND CONCLUSIONS

In the following section, we first summarise findings, before considering some emerging themes.

Policy background

• Direct payments are for self-directed community care and involve service users purchasing and managing for themselves some or all of the care they have been assessed as needing.
• They are intended to increase the flexibility, choice and control disabled people have over the care they receive.  They have been strongly promoted by disabled people as a means of achieving independent living.
• Since 1997, when the Community Care (Direct Payments) Act came into force in Scotland, England and Wales, local authorities have been permitted to make direct payments to 18 – 65 year olds.  There has been a gradual extension over time to older people, 16 and 17 year olds and parents of disabled children.  The Community Care and Health (Scotland) Act 2002, implemented from April 2003, made it mandatory of all community care service users to be offered a direct payment in place of a council-supplied service.
• Unlike England, Wales and Northern Ireland, carers in Scotland are not eligible to receive direct payments to meet their own needs.
• Direct payments have been described as a central part of the modernisation of welfare agenda, since they involve the services purchased should be user-focused and personalised.  They are also in line with earlier community care policy of developing a ‘mixed economy of care’.
• Early evaluations of direct payments in practice indicated that they might be more cost effective for the local authority.
• Concerns have been raised in the literature about the ability of some groups of disabled people, such as older people, to embrace the concept of becoming a purchaser rather than a passive consumer of services.
• Concerns have also been raised that personal assistants might have worse terms and conditions of employment than council workers or agency staff.
• This report focuses on Scottish data, and makes some statistical comparisons with the wider UK context.

Statistics on direct payments use in Scotland

• In Scotland, the number of people in receipt of direct payments has increased from 207 in 2001 to 1,438 in March 2005.
• Over 40 per cent of people who received a direct payment in 2005 were those aged 18-64 with physical disabilities.
• The value of payments has increased by nearly £11.6 million, from £2.1 million in 2001 to over £13.7 million in 2005.
• Almost a third of people who received direct payments in 2005 were aged over 65 or over, compared to over 7 per cent in 2001.
• There were major differences between local authorities in Scotland in their use of direct payments.  Fife had the largest number of users, but the City of Edinburgh contributed the greatest value overall, accounting for £2.5 million (almost a fifth of the total amount paid).
• Scotland has only half as many direct payments users as England, whether this is measured by rate per 10,000 population or as a proportion of people with long-term limiting illness or disability.

Findings from the local authority survey

• Just under half of local authorities appeared to have a designated post to oversee direct payments.  Local authorities with below median use were less likely to have such a post.
• Around half of local authorities, equally distributed between those with above and below median use, reported having a dedicated budget for direct payments. 
• Local authorities with above median use of direct payments had more ‘user led’ support organisations than local authorities with below median use. The above median group also appeared to see user involvement as more important in the development of direct payments.
• Local authorities with above median direct payment use regarded user involvement as a forum for service users to share information, whilst below median local authorities viewed user involvement as a means of gaining insight into the experiences of the service users. Both groups argued that a disadvantage with user involvement is that perspectives can be too narrow, failing to reflect the experiences of all potential service users.   Many local authorities with below median use felt that the expectations and hopes of service users were unrealistic and generally too high.
• Although local authorities identified similar facilitating and inhibiting factors, local authorities with above median use were more positive in their identification of facilitating factors, seeing these as critical, whilst local authorities with below median use were more definite in their identification of inhibiting factors.
• The most commonly cited aiding factors (identified by more than 90% of respondents) were demand from service users and carers; national legislation, policy and guidance; positive attitudes to direct payments amongst staff.
• The most commonly mentioned hindering factors (identified by about two thirds of respondents) were concern about managing direct payments among service users and carers and difficulties with the availability to work as personal assistants.
• Advantages of direct payments for the individual service user include choice, flexibility and control whereas disadvantages include problems with being an employer and managing the payment effectively.
• Advantages of direct payments for local authorities include more user involvement, fewer complaints and reduced contact with service users once care packages are established. Disadvantages of direct payments use for the local authorities included additional time demands, particularly in the early phases, cost constraints and complex administrative arrangements.  
• All local authorities expected an increase in direct payments use for all groups over the next five years.  Those with a lower starting point anticipated the largest increases.

Case studies: Local Authority 1

• Devolved care management and widespread use of spot contracting was felt to be helpful in allowing practitioners more flexibility in decision making over care packages and assessments for direct payments.
• Both practitioners and direct payment users relied heavily on the support organisation for information and advice.
• Practitioners generally welcomed the help given to them by the support organization.
• Direct payment users would have liked even more support than they were receiving.
• Practitioners were concerned that financial management might be too arduous a task for service users, but, with sufficient support, this did not appear to be the case.
• Practitioners and users thought that the monitoring practice was unsatisfactory.
• Practitioners were unhappy about being requested to undertake financial monitoring and users were aware of this.
• The proposal for the support organization to undertake financial monitoring was approved of by social workers and users, although there might be a conflict of interest for the support organization.
• Practitioners indicated that almost all users either received considerable support to manage the direct payment or had it managed for them.
• One social worker expressed concern that the disabled person might be isolated if their care was solely provided in the home.
• Family members managing direct payments on behalf of the disabled person tended to see it as ‘their’ package, raising questions about ownership and control. This clearly has broader implications for the independent living/social inclusion foundations of policy.
• Family members managing direct payments felt it gave them more autonomy in choosing personal assistants and controlling the quality of care.

Local Authority 2

• Whilst all groups recognized the potential of direct payments to give greater autonomy to some users, doubts were expressed at many different levels.
• Senior managers felt that new funds were needed from the Scottish Executive if the use of direct payments was to grow.  They believed that direct payments were likely to generate increased demand for council services. Demand for existing services was unlikely to decrease and these might become unsustainable given finite funds.
• The financial organization of direct payments through a separate cash limited budget appeared to limit the opportunities to promote direct payments as a mainstream policy option alongside other community care services.
• Practitioners were aware of budgetary constraints and found that requests for direct payments were ‘knocked back’ or else took a long time to be agreed.  They therefore felt that encouraging use of direct payments was a pointless exercise.
• There appeared to be mixed messages from senior staff and practitioners over the availability of training and information materials. All staff had access to a training manual and case study examples and it was emphasized by senior staff that training had been made available to all practice team leader. However, practitioners believed they had not received adequate training in how to process a direct payment.  They also felt the information they received from personal assistance advisers was partial, unclear and inaccurate.
• Practitioners believed that the paperwork involved in putting a direct payment in place was unduly cumbersome and contributed to their workload.
• Care managers felt that they had been disempowered by the policy, losing contact with the service user.
• Service users also felt that the paperwork was excessive.
• A key concern for both practitioners and the union was whether service users were able to act as responsible employers.
• Practitioners and the union representative were concerned about accountability for public money; the risk of abuse of ‘vulnerable adults’; the employment of unsuitable personal assistants who might harm other household members; the delivery of  substandard care; the practitioner’s loss of control; liability should something go wrong; service users’ ability to manage funds competently; unfair treatment of personal assistants.
• Senior managers believed the direct payments budget would increase as demand grew.  However, practitioners were reluctant to encourage prospective applicants because of a perception that funds were not available.  Service users were aware of a lack of enthusiasm for direct payments and believed the council did not want to make a success of the initiative.

Local Authority 3

• Local Authority 3 had a relatively high use of direct payments and was a pioneer of personalised services in Scotland.
• The relationship between the local authority and the support organisation had developed over a number of years and was mutually supportive.
• There was considerable expertise in the local authority in relation to direct payments, but a comprehensive training programme had yet to be extended to all social work staff.  As a result, some social workers lacked confidence in helping service users access direct payments.
• There were anxieties about the future impact of direct payments on existing services such as day centres.
• Social workers expressed anxiety about how they could ensure high quality care when responsibility for managing provision was handed over to the service user.
• There was general confusion about the status of disclosure checks on personal assistants and different views regarding whether these should be mandatory.
• Direct payment users reported mixed experience of social workers in terms of their knowledge and understanding of direct payments.
• Service users valued flexibility which direct payments offered, but felt that local authority systems were sometimes too controlling and limited potential creativity in the use of funds.
• Some social workers were concerned that direct payment users might receive an enhanced service, such as access to social activities, which traditional care packages would not allow.

Emerging themes

The status of direct payments in Scotland

It is evident from the review of policy and statistics that direct payments was initially adopted at a very slow pace by many Scottish local authorities.  In 2002 there were ten Scottish local authorities with no direct payment users despite the fact that enabling legislation had been passed in 1996.   By March 2005, all thirty two Scottish local authorities had at least one direct payment user, although in some local authorities numbers remained very low.  Per head of population, Scotland has only half the number of direct payment users compared with England, although in both countries there is considerable regional variation.  Some local authorities have been much more enthusiastic in their uptake of direct payments than others, with the City of Edinburgh Council being the largest local authority spender on direct payments, and Fife having the highest proportion of direct payment users (albeit with smaller average packages).  It is evident that west coast local authorities with traditional Labour administrations and significant concentrations of deprivation make less use of direct payments than others. Resistance to direct payments appears to be driven in part by a desire to defend collective approaches to welfare provision and to protect public sector jobs against ‘creeping privatisation’.  Direct payments policy may be seen to exemplify Scottish suspicion of some aspects of the modernisation of welfare. 

In Scotland, official government documents state that direct payments is one of a number of means of delivering improved and more individualised social services.  However, no member of the Scottish Parliament has strongly championed direct payments and local authorities have not been expected to meet any targets in relation to direct payments implementation.  There has also not been an equivalent in Scotland of the Direct Payments Development Fund (Hasler, 2006), under which £9 million of Department of Health money was invested over three years in improving take-up of direct payments by investing in support organisations.  In Scotland, a development organisation, Direct Payments Scotland, was funded until 2005 to support Scottish local authorities and support organisations in implementing direct payments and supporting users. 

Inequality of access by different user groups

The independent living movement emerged in the US in the 1960 and 1970s, with physically disabled students at the University of Berkeley being particularly active in demanding access to all aspect of ordinary living, with modern technology being seen as playing a crucial role in empowering disabled people.  The campaign for direct payments in the UK was inspired by the ideals of the independent living movement and it is interesting that to date the main beneficiaries of direct payments have been people with physical difficulties aged between 18 and 65, who still make up by far the largest group of direct payment users.    There are currently moves to equalize access to direct payments for other groups, including people with learning difficulties and mental health difficulties, older people and disabled children.  This raises questions about what it means to be ‘willing and able’ to manage a direct payment and how much support can be made available to those with fluctuating conditions or permanent cognitive impairments.  Questions also arise with regard to the ability of centres for independent living to represent effectively the interests of newer user groups such as frail older people.  Indeed, in the future older people are likely to make up the fastest growing group of direct payment users, raising major questions about the type of support and advocacy which will be needed

The influence of the disability movement

It has been argued that a key element in the promotion of direct payments is likely to be the advocacy of local groups of disabled people, who, as individuals, blaze policy trails and, collectively, provide support to others (Priestley, 1999).  In Scotland, findings from the local authority survey suggest that those with above median use of direct payments are more likely to have a user-led support organisation. 

The local authority case studies provide illustrations of the operation of user-led support organisations.   The most effective support organisations had developed productive working relationships with the local authority often over a considerable period of time.  They adopted an extremely important role in supporting service users and in providing information and guidance to social work staff.  There were continued debates about the extent to which they should retain an independent and arms-length relationship with the local authority.  Local Authority 1 provided an example of a support organisation taking over some of the work of the local authority in financial monitoring, whereas the support organisation in Local Authority 2 felt that undertaking monitoring on behalf of the local authority might compromise their ability to advocate for the disabled person. 

Direct payments and local cultures of welfare

The three Scottish local authorities provide contrasting models of the implementation of direct payments.  In Local Authority 1, there was a broad endorsement of the principle of direct payments, although the task of financial monitoring was seen as arduous by social workers and care managers, and it was being contracted out to the support organisation (see above).  In practice, direct payments were often being managed not by the disabled person, but by a family member, and there was sometimes a slippage in terms of ownership, with references to ‘my package’ by proxy managers.  Although it was felt that some disabled people benefited from more personalised services, many users were clearly not having full ownership of the process, and indeed for people with the most significant impairments financial management may not have been possible.  Nonetheless, the extensive use of direct payments by proxy managers was likely to have some impact on the potential of direct payments to reorientate social welfare provision to meet the needs of the disabled person. The alternative goal of direct payments, to foster a mixed economy of care within social welfare, would clearly be met regardless of whether the disabled person or the proxy manager was being empowered.

In Local Authority 2, with much higher levels of poverty and limiting long term illness and disability, direct payments were being pursued with much less enthusiasm.  Senior managers felt that their creaking budgets were unlikely to be able to meet the needs of the new social welfare service users generated by the promise of direct payments.  Whereas traditional local authority services had been off-putting to some potential users, the possibility of individually tailored services would be much more attractive and therefore more needs would be identified.  Senior managers believed that the designated direct payments budget would increase as a growing demand was demonstrated, however grass roots practitioners had absorbed the message that no new funds were available and therefore did not encourage people to consider a direct payment.  Practitioners also complained that their applications for direct payments were rarely approved, despite a large investment of time in the necessary paperwork, and this experience also dampened demand. For a period of time, social workers had refused to process direct payment applications on the advice of their union.

At senior management and grassroots level, there were serious doubts that service users had the financial competence to manage financial transactions, and there were fears that unsuitable individuals would be employed as personal assistants.  Overall, practitioners felt that direct payments threatened to deskill their work and make them loose contact with their ‘client’.  The support organisation believed that it had been given insufficient funds to meet user demand for support, and had taken a long time to reach a working agreement with the local authority.  Service users, for their part, believed that there was a shortage of both funding and support, and were therefore not encouraged to press their requests for direct payments.  Compared with Local Authority 1, where conditions seemed reasonably conducive to the development of direct payments, Local Authority 2 illustrates the profusion of barriers to direct payments development at organisational, financial, cultural and ideological levels.

Local Authority 3 appeared to have made the most progress in the development of direct payments.  With a strong user-led support organisation and commitment from social services, the difficulties in managing direct payments were recognised.  However, the benefits of allowing service users greater freedom to manage their own services were seen to outweigh the problems of loss of control over commissioning.  Even in this authority, however, it was recognised that a major expansion of direct payments would pose problems for some existing services, particularly those with high recurrent costs such as day centres.

The future development of direct payments in Scotland

The future of direct payments in Scotland is, of course, unwritten, and will depend on many factors including the future political composition of the Scottish Parliament.  There are signals from the Scottish Executive that development work on direct payments will continue over coming years.  The Scottish Consortium of Direct Payment Support Organisations is receiving support from the Executive to develop peer support amongst support organisations.  There has also been targeted investment in training for support which will be led by Lothian Centre for Integrated Living and it partners to help them operate more effectively.  The Scottish Personal Assistant Employers Network is also receiving support, and from 2007 Contact-a-Family, a voluntary organisation supporting families of disabled children, has been commissioned to deliver targeted training and support for disabled children’s service users.  In addition, a Consortium of Mental Health Organisations has been funded to deliver targeted training and support for mental health service users. Perhaps even more significant is the recognition in the 2006 Spending Review that direct payments inevitably require some additional funds to assist with start-up costs, even if they are cost neutral in the longer term.

Individualised budgets are being strongly promoted by the Westminster Government (DoH, 2005; Cabinet Office, 2005).  These would involve the aggregation of funds from a number of sources such as local authority direct payments, the Independent Living Fund, Attendance Allowance, Access to Work and Disability Living Allowance, providing the service user with even greater control over resources with far fewer bureaucratic constraints.  There would also be considerable administrative savings, since at the moment each stream of funding has separate assessment and monitoring procedures.  At the moment, whilst there is a commitment in Scotland to the delivery of personalised services, the extent to which this might involve individualised budgets is unclear.

References

Cabinet Office (2005) Improving the Life Chances of Disabled People London: The Stationery Office

Department of Health (2005) Independence, Well-being and Choice: Our Vision for the Future of Social Care for Adults in England London: The Stationery Office

Hasler, F. (2006) ‘The Direct Payments Development Fund’ in J. Leece and J. Bornat (eds) Developments in Direct Payments Bristol: Policy Press.

Pearson, C. (2000) ‘Money Talks?: Competing discourses in the implementation of direct payments’, Critical Social Policy,  20, 4.
Priestley, M., Jolly, D., Barnes, C., Mercer, G., Pearson, C., Williams, V. and Riddell, S. (forthcoming) ‘Explaining the uneven implementation of direct payments policy for disabled people in the UK: supply and demand in the context of devolution’, Journal of Social Work.

Riddell, S., Pearson, C., Jolly, D., Barnes, C., Priestley, M. and Mercer, G. (2005) ‘The development of direct payments in the UK: Implications for social justice’ Social Policy and Society, 4, 1, 75-87.

Scottish Executive (2002) Direct Payments Scotland 2005, Edinburgh: Scottish Executive National Statistics Publication, www.scotland.gov.uk/stats  

Witcher, S., Stalker, K. Roadburg, M. and Jones, C. (2000) Direct Payments: The Impact on Choice and Control for Disabled People, Edinburgh: Scottish Executive Central Research Unit.

SECTION 1: BACKGROUND AND RESEARCH DESIGN

Introduction

Partly as a result of pressure from the disabled people’s movement, there has been a gradual move in Scotland, as elsewhere in the UK, towards forms of welfare which promote independent living, rather than more passive forms of welfare consumption.  Direct payments have been seen as a means of empowering disabled people by allowing direct control over the purchase of services to meet assessed needs.  However, since the implementation of the Community Care (Direct Payments) Act 1996, there has been differential use of direct payments by local authorities in Scotland, and, particularly at first, there was relatively low uptake of direct payments  in Scotland compared with parts of England (Witcher et al, 2000; Pearson, 2000; Riddell et al, 2005).  In 2001, there were only 207 direct payment users in Scotland, although this had increased to 1,438 by March 2005 (Scottish Executive, 2005). Certain groups, particularly people with learning difficulties, mental health problems and black and minority ethnic groups have been particularly poorly represented among direct payment users.  In addition, there have been significant differences between local authorities in the average size of packages, so that some local authorities which appear to be making quite extensive use of direct payments are spending a considerably lower proportion of their social care budget than others, which have fewer users but make larger payments on average (Scottish Executive, 2005).  Research carried out by team members (Priestley et al, forthcoming) has identified the local factors which appear to make a difference to the use of direct payments.  These include the nature and capacity of the local support organisation, the micro-politics of the local social work department and the political complexion of the local council.

The Community Care and Health (Scotland) Act 2002 places a duty on local authorities to offer direct payments to all client groups using community care services, and therefore has the potential to contribute to the promotion of direct payments in Scotland.  Sufficient time has elapsed to allow an assessment of the early impact of this legislation.  

Research Aim and Objectives

Following the research specification, the over-arching aim of the research was to evaluate the implementation of direct payments policy in Scotland. 

The specific objectives of the research were to:

• examine whether there has been any significant change in uptake of direct payments since the Community Care and Health Act 2002 came into force.
• identify the extent to which people turn down the opportunity to receive direct payments
• identify the reasons why people choose not to take up direct payments
• identify differences in uptake between different client groups and explore whether there are specific reasons for these differences
• examine the experiences of those receiving direct payments in order to identify areas of good practice which facilitate their use and any difficulties encountered in using them
• identify barriers to effective implementation of the direct payments scheme by local authorities and support organisations.

Methods

The research used a progressive focussing strategy, starting with a very broad overview of the field, and gradually focusing down on the dynamics within three local authorities, highlighting the experiences of users, non-users and carers within specific local contexts.  The study was conducted in the following overlapping phases:

Phase 1: Analysis of official statistics

Scottish Executive statistics were obtained on use of direct payments from 2001 – 2005.  Secondary analysis of data was conducted by local authority, nature of client group, size of package and nature of support organisation.  National figures gathered by the Scottish Executive were used in this analysis.

Phase 2 : Survey of local authorities

A questionnaire was sent to all 32 local authorities in Scotland to identify what they consider to be the major facilitating and inhibiting factors in relation to the uptake of direct payments in relation to different user groups.  The extent of current or anticipated change following the implementation of the Community Care and Health (Scotland) Act 2002 was also investigated.  Specific factors to be explored were the role of the local support group, the contribution of the Scottish Executive, knowledge and awareness in local social work departments and the nature of local funding regimes (e.g. spot or block purchase arrangements).

Phase 3: Case studies of three local authorities

Case studies were conducted in three local authorities with different policies, practices and take-up rates in relation to direct payments. Each case study differed slightly in relation to the interviews and focus groups conducted and further details are given in Section 4.  Within each local authority, the aim was to gather data from a range of perspectives including social work staff, finance officers, support organisations, users of direct payments and those who had opted not to use a direct payment. Interviews were semi-structured and the majority were tape-recorded and transcribed.

Interviews were designed to explore the critical factors within each local authority which have contributed to the development of direct payments.  The experiences of direct payment users were contrasted with the views of local authority personnel and support organisations. 
Interviews and focus groups with service providers and support organisations explored:

a) the extent to which the individual considers direct payments are currently in place
b) the benefits perceived for their particular area of practice or need
c) the disadvantages for their particular area of practice or need
d) perceived barriers to implementation
e) perceived drivers for implementation
f) details of any practice examples relevant to direct payment training requirements

Interviews and focus groups with direct payment users and non-users explored:

a) Initial access to their support; areas of help and hindrance (and the key agencies involved), supporting roles.
b) How payments are used (where appropriate) and their interaction with other day to day employment and/or social activities.
c) Views on how their support could be improved.

Summary of research methods

Structure of the report

The report is structured as follows: Section 2 includes an analysis of official statistics collated by the Scottish executive on the use of direct payments in Scotland; Section 3 presents findings of the local authority survey and Section 4 focuses on local authority case studies.  In the final section we summarise findings and draw some conclusions about the current use of direct payments in Scotland and possibilities for the future.

SECTION 2: UPTAKE OF DIRECT PAYMENTS IN SCOTLAND

Introduction

In this section, we first present data on the uptake of direct payments in Scotland, drawing on information collected by the Scottish Executive from local authorities (Scottish Executive, 2005).  Subsequently, we make some cross-Border comparisons, examining the use of direct payments in different parts of the UK.

Direct Payments in Scotland: The Current Picture

Characteristics of users

Although direct payments have been available to people in Scotland since April 1997, early uptake was very slow and in 2001, there were only 207 users.  In March 2005, the number of direct payment users had increased to 1,438, a seven-fold increase. Figure 2.1 shows the number of users from 2001 – 2005, and the distribution by user group.  People with physical disabilities still predominate, in 2005 making up about sixty five per cent of all users.  It is also interesting to note that the majority of direct payment users with physical disabilities are 18-64 (see Figure 2.2 and Table 2.1)

Figure 2.1: Number of people receiving direct payments 2001-2005 by user group

Figure 2.2: Number of people receiving direct payments 2005 by user group and age
 

Table 2.1: Number of direct payments and value by age and client group, 2005

Whilst younger users still account for about seventy per cent per cent of the total, the proportion of users who are sixty five and over has steadily increased over time (Figure 2.3).  It is worth noting that from April 2005, eligibility was extended to older people aged sixty five and over assessed as needing care services due to frailty or old age, but this change was too late to be reflected in these figures.

Figure 2.3: Percentage of people receiving direct payments by age, 2001-2005
 

Value of direct payments

In addition to an increase in the number of users between 2001 and 2005, there has also been a marked increase in the value of direct payments, from £2.1 million in 2001 to £13.7 million in 2005 (see Figure 2.4).

Figure 2.4: Value of direct payments by user group, 2001-2005

 

Whilst the average value of a direct payment in 2005 was £9,500 per client, users with physical disability received the highest average payment (£10,300) and those with learning disabilities received the lowest (£7,600) (see Figure 2.5).

Figure 2.5: Average value of a direct payment by user group, 2005

 

The average value of a direct payment has fluctuated over time.  However, it is interesting to note that the average value per client in 2005 was £9,500, which is less than the average value per client in 2001 (£10,100).  This suggests that there has been an increase in smaller packages (see Figure 2.6 and Table 2.2).

Figure 2.6: Average value of a direct payment, 2001 – 2005
 

Table 2.2: Average value of direct payments by client group, 2001 – 2005

Use of direct payments by local authority

Whilst all local authorities made some direct payments in the year to 31st March 2005, Fife Council made the most payments (15 per cent of the Scotland total).  The City of Edinburgh had the greatest total value overall (£2.5 million, about a fifth of the total amount paid.  Inverclyde had only three direct payment users.  Figure 2.7 shows the number of direct payments users by local authority and user group. Angus made fewer direct payments than it had in the previous year, but all other local authorities made more. 

Figure 2.7: Number of people receiving direct payments in 2005 by local authority and user group

The average value of a payment increased in 20 out of the 32 local authorities, with Midlothian showing the biggest increase, from an average payment of £3,400 per client in 2004 to £13,100 in 2005.

Figure 2.8 illustrates the rate of clients per 10,000 population.  It is evident that smaller rural authorities tend to have a higher proportion of clients using direct payments, with Orkney having by far the highest proportion of direct payment users.  Of the city authorities, Edinburgh has the highest proportion of users.  Central belt authorities in the west, Glasgow and Dundee all have relatively low uptake. 

Figure 2.8: Rate of clients per 10,000 population by local authority
 

As noted in section 1, an aim of the study was to make some comparisons between the different countries within the UK to identify patterns in the uptake of direct payments in different parts and to explore the impact of a range of variables, including the political control of the local authority, the number of people reporting a long-term limiting illness in the 2001 census and the presence of a support organisation for disabled people wishing to make use of direct payments. All direct payments figures are based on publicly available statistics and statistical breakdowns available on February 18th 2004 (see Riddell et al, 2005 for further discussion). 

Table 2.3: Direct payment users in each country/province of the UK between 2000/1 and 2003: number and rate per thousand people with LLTID.

Notes

• Figures for Wales not available for 2000/1 and 2003
• LLTID refers to the percentage of people reporting a limiting long-term limiting illness or disability in the 2001 Census.  10.9 million people in the UK reported  LLTID with significant regional variations (London & South East: 15 %; Northeast England : 23 %)

Table 2.3 shows that in 2003, England had about twice the number of DP users relative to its population compared with Scotland, Northern Ireland and Wales, despite having the lowest proportion of people with long-tern illness or disability.  Nonetheless, there have been significant increases in use throughout the UK.

Summary

• In Scotland, the number of people in receipt of direct payments has increased from 207 in 2001 to 1,438 in March 2005.
• Over 40 per cent of people who received a direct payment in 2005 were those aged 18-64 with physical disabilities.
• The value of payments has increased by nearly £11.6 million, from £2.1 million in 2001 to over £13.7 million in 2005.
• Almost a third of people who received direct payments in 2005 were aged over 65 or over, compared to over 7 per cent in 2001.
• There were major differences between local authorities in Scotland in their use of direct payments.  Fife had the largest number of users, but the City of Edinburgh contributed the greatest value overall, accounting for £2.5 million (almost a fifth of the total amount paid).
• Scotland has only half as many direct payments users as England, whether this is measured by rate per 10,000 population or as a proportion of people with long-term limiting illness or disability.

SECTION 3: LOCAL AUTHORITY QUESTIONNAIRE SURVEY

Method

A questionnaire was devised which aimed to investigate the management of direct payments in Scottish local authorities and the factors promoting or inhibiting their development.  Questionnaires were sent off to all 32 local authorities. After three reminders we received responses from 23 local authorities, representing a response rate of 72%. Due to the small number of responses, we did not look for statistical difference but chose to express the analysis in proportions. The data were analysed according to rate of direct payment clients per 10,000 of population and comparisons were made between local authorities above and below median (see section 2, figure 2.8). The groups were as follows:

Above median: Orkney, Scottish Borders, Argyll and Bute, Clackmannashire, Fife, Highland and Dumfries and Galloway, Moray, Edinburgh, South Ayrshire, East Ayrshire, West Dunbartonshire, Stirling, Falkirk, Eilean Siar.

Below median: Angus, Midlothian, Shetland Islands, Aberdeen City, West Lothian, East Lothian, Aberdeenshire, Perth and Kinross, Glasgow, North Ayrshire, Dundee City, East Renfrewshire, East Dunbartonshire, Renfrewshire, North Ayrshire, North Lanarkshire, South Lanarkshire, Inverclyde.

Of respondents, 46% were in a designated post for direct payments and 54% were not. Local authorities that were below median were less likely to have a designated post for direct payment (36.4%) than local authorities above median (50%).

Financial arrangements within local authority

Around half (52%) of the local authorities reported having a generic budget for direct payment use. This was the case regardless of whether the local authority was above or below median direct payment use.

About half (47.8%) of the local authorities reported devolving budges to care managers for individual spot purchasing. Local authorities above median were slightly less likely to do so (41.7%) than local authorities below median (54.5%).

Support organisation and user involvement

Nearly all local authorities (83%) fund a support organisation. This figure was marginally larger for above median (83.3%) than below median (81.9%) local authorities. The size of the annual grant was less than £100,000 in the majority of local authorities. However, 16.7% of above median local authorities had a grant size of more than £150,000 compared to 9% of the local authorities below median.

Table 3.1: Size of annual grant to support organisations

The support organisation was “user led” in the majority of local authorities although slightly more so in above median local authorities (58%) than in below median local authorities (45.5%).

Table 3.2 Is the support organisation user led?

Generally local authorities appeared to focus on short-term as well as long-term contracts for the support organisations. Above median local authorities appear to focus slightly more on short-term contracts with a third reporting having contracts lasting less than two years compared to just above one quarter in the below median local authorities.

Table 3.3: Length of contract of support organisation

Local authorities above median appeared to regard user involvement as slightly more important for the development of direct payments (50%) than below median local authorities (36.4%).

Table 3.4 Importance of user involvement in development of direct payments

Participants were asked what advantages they saw in encouraging user involvement. Interestingly the majority of the local authorities with above median use of direct payments appeared to argue that the main benefit was that users were able to give feedback to each other and share experiences, whereas the majority of the local authorities below median seemed to argue that the main benefit was that users could inform the local authority and in that way influence the administration and the decision making processes.  Comments are listed in table 3.5 below.

Table 3.5: Advantages of user involvement

Participants were asked what they saw as the disadvantage of user involvement. One quarter of respondents argued that the user perspective might be too narrow, focusing too closely on the user’s interests and concerns, and failing to recognise that other people’s priorities might be different.  A quarter of respondents argued that service users had unrealistic expectations with regard to local authority resources, a view reported particularly by local authorities with below median use. Comments are listed in table 3.6 below.

Table 3.6 Disadvantages of user involvement

Factors facilitating development of direct payments

Respondents were provided with a list of factors and were asked to tick which of these applied in their particular context. They were asked to rate whether the factors were “helpful” (“unhelpful”), “important”, “critical” or “irrelevant”.

The main aiding factors which respondents believed had contributed to the growth of direct payments are listed in Table 3.7 below.

Table 3.7: Main aiding factors

Other factors perceived to be of critical importance included “National legislation, policy and guidance” (68%), “Training and support for front line staff” and “Effective direct payments support scheme” (57%), “Accessible information on direct payments for service users and carers” (52%) and “leadership within local authority”, Local political support for direct payments”, National support for direct payments”, “Availability of people to work as personal assistants” and “ Positive attitude to direct payments among staff” (48%). “Important” factors include “Demand from service users and carers for direct payments (57%) and “Strong voluntary sector” (52%).

Rarely mentioned aiding factors are listed in Table 3.8 below.

Table 3.8: Rarely mentioned aiding factors

“Ring fenced budget for direct payments” was considered irrelevant by 22% of respondents. The factors “National support for direct payments”, “Central government performance monitoring” and “Flexibility of commissioning strategy” were considered “irrelevant” by 9% of respondents.

Generally, local authorities with above and below median use of direct payments identified the same number of facilitating factors. However, some differences were found in ratings of the importance of aiding factors between above and below median local authorities:

• “Leadership within local authority” appeared to be regarded slightly higher as an aiding factor by local authorities above median (91.7%) than local authorities below median (81.8%).
•  “Local political support for direct payments” was regarded slightly higher by local authorities below median (63.6%) rating it as a critical aiding factor and only around a third of local authorities above median (33.3%).
• About two thirds of local authorities above median (66.7%) but only about half (45.5%) of local authorities below median rated “Effective direct payments support scheme” as a critical aiding factor.
• Nearly three quarters of local authorities below median (72.7%) rated “Training and support for front line staff” as a critical aiding factor, corresponding figure for above median local authorities was 41.7%.
• Nearly two thirds of local authorities below median (63.6%) considered “Accessible information on direct payments for service users and carers” a critical aiding factor. The corresponding figure for local authorities above median was 41.7%.
• Local authorities above median (58.3%) considered “Availability of people to work as personal assistants” as a critical aiding factor, this was true for only 36.4% of local authorities below median.
• “National legislation, policy and guidance” was rated as a critical aiding factor by 81.8% of local authorities below median but only by half of above median local authorities.

Overall, it appeared that local authorities with above median use placed considerable emphasis on the importance of the local and national policy context and on the involvement of a support organisation.  Local authorities with below median use saw training and support of frontline staff as a particularly important factor.

Factors inhibiting development of direct payments

The main inhibiting factors for the development of direct payments are listed in table 3.9 below.

Table 3.9 Main hindering factors

Other inhibiting factors are listed in table 3.10 below.

Table 3.10 Other hindering factors

Rarely mentioned are listed in table 3.11 below:

Table 3.11 Rarely mentioned hindering factors (Scotland)

Overall, a greater proportion of local authorities below median direct payments use identified inhibiting factors compared with local authorities above median. Cross tabulations revealed some differences in ratings between local authorities above and below median.

• Nearly three quarters of local authorities below median (72.7%) and just below 60% of local authorities above median considered “Concern about managing direct payments among service users and carers” a hindering factor.
• Around two thirds of local authorities below median (63.6%) and 41.7% above median considered “Difficulties with the availability of people to work as personal assistants” a hindering factor.
• Nearly two thirds of local authorities below median (63.6%) considered “Competing priorities for policy implementation” a hindering factor, but only one third of local authorities above median (33.3%).
• “National legislation, policy and guidance” was considered a hindering factor by 33.3% of local authorities above median but only 18.1% of those below median.
• “Inadequate training and support for front line staff” was considered a hindering factor by 41.7% of local authorities above median, but only by 27.2% of local authorities below median.
• Around a third of local authorities both above (33.3%) and below (27.2%) median considered “Lack of accessible information on direct payments for service users and carers” a hindering factor.
• “Resistance to direct payments among staff” was considered a hindering factor by 36.3% of local authorities below median but only 25% of local authorities above median.
• “Insufficient leadership within local authority” was considered a critical hindering factor by 25% of above median local authorities but only 9% of local authorities below median.
• Around two thirds of local authorities below median (63.6%) considered “Underdeveloped direct payment support scheme” to be a hindering factor, the corresponding figure for local authorities above median was around 42%.
• “Weak voluntary sector” was considered a hindering factor by 27.2% of local authorities below median but only 16.6% of those above median.
• “Lack of local political support for direct payments” was considered an important hindering factor by 25% of local authorities above median, 9% of local authorities below median considered this factor to be “unhelpful”.
• “Lack of national support for direct payments” was considered a hindering factor by 8.3% of local authorities above median and 9.1% below median.

Advantages and disadvantages of direct payment

Respondents were asked about the advantages of direct payments for the individual service user. Irrespective of whether the local authority was above or below median direct payment use, most respondents mentioned choice and /or flexibility (67%) and/or control (43%). Responses are listed in table 3.12.

Table 3.12: Advantages of direct payments for the individual service user

Respondents were asked to identify disadvantages of direct payments for the individual user. Irrespective of whether the local authority was above or below medium, frequently mentioned factors involved issues related to ownership of responsibility should any problems occur, liabilities of being an employee, care user being more vulnerable. Other issues involved amount of paperwork involved and difficulty recruiting staff. The responses are listed in table 3.13.

Table 3.13: Disadvantages of direct payments for the individual service user

Respondents were asked what advantages direct payments brought to the local authority. The most frequently mentioned factors involved were greater choice for customers; more user involvement and fewer complaints; reduced contact with management once care packages were established. The responses are listed in table 3.14 below.

Table 3.14 Advantages of direct payments for the local authority

Next respondents were asked about any disadvantages to the local authority in using direct payments. The main factors mentioned included financial and administrative issues such as lack of central funding and the amount of paperwork involved when monitoring budgets (see table 3.15 below).

Table 3.15 Disadvantages of direct payments for the local authority

Future development

Local authorities were asked about their predictions for direct payment use over the next five years. Around 90% of local authorities with both above and below median use anticipated an increase in direct payments. No local authority expected a decrease in direct payment use.

Table 3.16 Future use of direct payments

The anticipated difference in uptake of direct payments varied for different user groups. Around 90% of LAs below median anticipated an increase in use among adults with physical and/or sensory impairments. This was true for only 66.5% of local authorities with above median. One quarter of local authorities above median expected use in this group to stay the same.

Table 3.17: Anticipated differences in uptake by different use groups

Around three quarter of local authorities, both above and below median, anticipated an increase in direct payment use among adults with learning difficulties.

The anticipated difference in uptake of direct payments varied for different user groups, these are displayed in table 3.18.

Table 3.18: Anticipated difference in uptake of direct payments for different user groups

Some differences were found between local authorities with above and below median use of direct payments:

• Around 90% of LAs below median anticipated an increase in use of direct payments among adults with physical and/or sensory impairments. This was true for only 66.5% local authorities above median. One quarter of local authorities above median expected use in this group to stay the same.
• Three quarters of local authorities in the above median group but only two thirds of those below median anticipated an increase in direct payment use among adults with mental health difficulties.
• Nearly all local authorities expected an increase in direct payment use among children. Note that the only respondent that did not expect an increase represented a local authority above median and expected use to stay the same, thus direct payment use by this group is likely to be high already.

Summary

• Just under half of local authorities appeared to have a designated post to oversee direct payments.  Local authorities with below median use were less likely to have such a post.
• Around half of local authorities, equally distributed between those with above and below median use, reported having a dedicated budget for direct payments. 
• Local authorities with above median use of direct payments had more ‘user led’ support organisations than local authorities with below median use. The above median group also appeared to see user involvement as more important in the development of direct payments.
• Local authorities with above median direct payment use regarded user involvement as a forum for service users to share information, whilst below median local authorities viewed user involvement as a means of gaining insight into the experiences of the service users. Both groups argued that a disadvantage with user involvement is that perspectives can be too narrow, failing to reflect the experiences of all potential service users.   Many local authorities with below median use felt that the expectations and hopes of service users were unrealistic and generally too high.
• Although local authorities identified similar facilitating and inhibiting factors, local authorities with above median use were more positive in their identification of facilitating factors, seeing these as critical, whilst  local authorities with below median use were more definite in their identification of inhibiting factors.
• The most commonly cited aiding factors (identified by more than 90% of respondents) were demand from service users and carers; national legislation, policy and guidance; positive attitudes to direct payments amongst staff.
• The most commonly mentioned hindering factors (identified by about two thirds of respondents) were concern about managing direct payments among service users and carers and difficulties with the availability to work as personal assistants.
• Advantages of direct payments for the individual service user include choice, flexibility and control whereas disadvantages include problems with being an employer and managing the payment effectively.
• Advantages of direct payment for local authorities include more user involvement, fewer complaints and reduced contact with service users once care packages were established. Disadvantages of direct payments use for the local authorities included additional time demands, particularly in the early phases, cost constraints and complex administrative matters.  
• All local authorities expected an increase in direct payments use for all groups over the next five years.  Those with a lower starting point anticipated the largest increases.  Children and older people were identified as groups for whom particular increases were anticipated.