Community Care (Direct Payments) Act 1996
PDF version The government has unveiled plans to extend direct payments to disabled adults, providing them with more choice and control over the state funding and services they receive.
Disabled people will receive direct payments in areas where currently they are not available by drawing together resources from different funding streams to better meet their needs.
The scheme will be trialled from late next year in eight trailblazer areas, which are yet to be chosen.
Right to control scheme
The plans, contained in Making Choice and Control a Reality for Disabled People, form the government response to the consultation on the right to control scheme.
Funding streams to be included in the pilot areas are Access to Work, Work Choice, the Independent Living Fund, Supporting People and the Disabled Facilities Grant. Community care for adults will also be included.
It means, for example, that a disabled person who needs support from a specialist disability employment programme will be able to decide how this is provided and who carries it out.
Disability living allowance, attendance allowance and employment support allowance will not be included.
Co-locating pilots
The Department for Work and Pensions (DWP) said it would be looking to co-locate right-to-control pilot sites and personal health budget pilots.
Minister for disabled people Jonathan Shaw said: "Disabled people are the experts in their own lives and that is why, through the Welfare Reform Act, we have put this legislation in place. This new scheme could have an impact on every area of disabled people's lives."
The DWP said individuals could choose to continue receiving the services arranged on their behalf or have a combination of the two options.
Related stories
Bill offers 'right to control' for disabled but tougher benefits regime
Pilots will cause unnecessary delay says National Council for Independent Living
Welfare reform white paper extends benefit conditions and choice for disabled
http://www.communitycare.co.uk/Articles/2009/12/09/113404/plans-to-exten...
The growing use of personal budgets and direct payments for social care may prove a way of quietly cutting services, a study published by Unison, the health service union, warns.
Labour has been pushing councils to introduce personal budgets and so-called direct payments, whereby individuals are given public money with which to buy social care.
All the political parties favour such services, which they say give people more choice and control. Recipients “use the money frugally and imaginatively”, according to Hilary Land, emeritus professor of social policy at Bristol University, and Susan Himmelweit of the Open University, the authors of the study.
There is also evidence that individuals receiving direct payments spend less than councils would if they provided the care.
But the study says there have been widespread variations in the amount local authorities give in direct payments.
Some have provided recipients with enough money to pay care staff above council rates, with others receiving less.
There have also been large variations in the amount spent supporting direct payments.
Given the forthcoming huge squeeze on public spending, “it will be easier for local authorities, and indirectly the government, to fail to raise direct payments and individual budgets in line with rising wages, than to cut services directly”, the study says.
This would push the problem of cuts in care onto recipients.
Personal budgets also raise problems for day centres and other forms of collective provision for the elderly, according to Professors Land and Himmelweit. “Some services directly provided or financed by local authorities may no longer be commercially viable on current funding,” they say. “Such collective forms of care bring benefits, including social contact, that it is difficult or impossible for individuals to produce through spending individual budgets on their own”.
Labour has set a target for 30 per cent of social care recipients to have a personal budget – which may nor may not involve a direct cash payment – by April next year.
As of April last year, only some 86,000 people from the 600,000 receiving social care in England were getting direct payments, with the payments accounting for about 4 per cent of the social care budget.
http://www.ft.com/cms/s/0/8a7b1114-5c6f-11df-93f6-00144feab49a.html
Yesterday’s coalition deal promises to break down barriers between health and social care and extends the roll-out of personal budgets to give people and their carers more control and purchasing power. But what factors affect the potential success of personal budgets and what is the role of frontline staff? We’ll be discussing this issues on the 8th of June. In the meantime, read more in our public interest seminar briefing paper…
http://opmnetwork.wordpress.com/2010/05/21/personalisation-seminar-brief...
The Personalisation toolkit is an on-line resource to support councils to begin to plan and deliver the transformation of their social care systems, as set out in Putting People First. Its main focus is on learning from the Individual Budget Pilot programme. As councils plan their transformation programmes, it is important, of course, to use these materials alongside others which focus on the other key priorities, including early intervention, prevention and efficiency.
Involving service users in shaping local services.
This study by Age Concern London brought commissioners and service users together to discuss how service users can be involved in shaping local services.
The project reflected on what's happening at the moment and how user involvement in commissioning could work in practice. It found that:
- The involvement of service users in shaping local services is still in its infancy.
- The definition of 'user involvement' varies from one-off consultations to equal partnerships.
- There are more good practice examples of user involvement in Social Care than in Health.
Summary
Download as PDF, 4 pages, 0.11 MB
Key points
- The involvement of service users in shaping and commissioning services is at an early stage. We are a long way from credible user involvement in World Class Commissioning.
- ‘User involvement’ can mean different things. It can represent a valued process with users as equal partners in reshaping services or be a manipulative one-off consultation, when users gradually realise they are being given bad news.
- Commissioners and their partners were frequently poorly placed to engage with user involvement in commissioning. Their skills, knowledge and practice of effective involvement were often limited. Even where they had knowledge, there were few drivers which pointed them towards service users and away from simply responding to organisational necessities.
- In most cases the facilitation of user involvement was handed down to voluntary organisations without acknowledging tensions between their provider and advocacy roles or taking into account variable user involvement within voluntary organisations themselves.
- There seemed to be two ideas within the same system. Individual service users were to have choice and control in line with Personalisation. Commissioners retained control over block contracts. It was difficult to see how one influenced the other.
- There were examples of better practice where service users were involved in shaping solutions, more often in Social Care rather than in Health.
- Even where good practice did not yet exist, there was often an honest acknowledgment of poor practice and a desire to improve.
- Change was not simply about shifting a few structures. Some of this was about trying out different approaches. But some of it was about believing it is possible.
The research
Samantha Mauger and Gordon Deuchars from Age Concern London, with independent consultants Stephanie Sexton and Silvia Schehrer
Background
A lot of social care public money is spent locally through commissioning. Officers buying in blocks of services where they can use their purchasing power to get the services they want, at a quality they want and at cheaper cost.
For years Governments have developed policies on choice and control for individual service users (e.g. Labour’s Personalisation Agenda; Conservative’s 1996 Direct Payments Act) built on ideas from disabled people before that. Policy language focuses on ‘World Class Commissioning’, but in fact this evidence shows that we are still a long way from ideas of choice and control and credible user involvement in the ways that services are commissioned.
This project was part of the Joseph Rowntree Foundation’s Independent Living programme. JRF had funded hundreds of projects over almost 30 years on the lives of different groups of service users. Although there were examples of good practice in achieving what people want, the system as a whole seemed slow to change in practice. The Independent Living programme focused on three important aspects of the Social Care system to see if a wider shift was possible. Those aspects were: people in residential care; bursting barriers to person-centred support in a range of services; and involving users in the ways that those services were commissioned in the first place. Age Concern London and London School of Economics separately succeeded in bids to undertake the work about user involvement in commissioning. These are the Findings from the Age Concern London project.
The project
The project, based in London, worked across six London local authorities and seven different user groups (ranging from mental health users to people living with HIV). The project team drew on the literature of user involvement and of commissioning in health and social care. User groups and commissioners in each of the local areas were asked about their experiences of working together in specific service areas, the extent to which their experiences were positive or negative, the limitations external factors had on aspirations (on all sides), what each group needed from the other and their own assessment of how involvement had (or had not) worked.
Service users experiences
1. Experiences of involvement
For service users there seemed to be three different service approaches to user involvement. Services
could be
- Open and willing
- Ostensibly open but not actually willing
- Not open
Users noted that, in practice, their local authority could adopt all three positions at the same time. This could make it incredibly complicated for users and for allies. In addition, the middle position (ostensibly open but not actually willing) can be particularly confusing.
Different user groups had different experiences of being involved in commissioning. Some had been involved with commissioners who had responded to what users wanted to a certain extent. Others reported that little or nothing had taken place. In one area, a group of people with learning difficulties had a stronger role – in another local area such a group did not exist or have a role.
2. The motivation for people to be involved
Service users said that there is a desire to get things done and to put something back. When it works there is mutual sense of feedback between the commissioner, service provider and user. But users also said that there is a need for some sort of action as a result of their contribution, and that feedback on what had changed as a result of their involvement was important.
3. The things that get in the way
For service users, all were keen and ready to be involved. There were lots of things that could get in the way: when commissioners refused to answer straightforward questions; the non participating silent majority in their own forums; involvement being a ‘tick-box’ exercise; a lack of clarity about the purpose of an event; officers working to a service-centred model rather than a user-defined agenda; jargon; anxiety about getting swamped; where the truth is not told and the lie is obvious; and where officers or users are focused on their own individual agendas rather than the common good.
We are grown ups and need to be informed about the realities rather than pretending this is really about choice and development. We can make sensible and useful contributions but it is important not to patronise us by pretence.” (Service user)
4. Funding and payment
Payment mattered to some: "It's an important principle (not necessarily about the amount) that our expertise is paid for." One indicator of involvement being taken seriously was when funding was available for users to be paid for their time and contribution.
5. Support workers
Support workers, trusted by users, could ensure that the link between staff and users in the group was managed well. However, support workers could also get in the way. In some boroughs, workers did not always work with users’ best interests in mind or (if employed by a voluntary organisation) there were conflicts of interest with a provider role.
Commissioners experiences
1. Background
Four of the six commissioner groups work in a local authority setting (one of these was moving towards joint commissioning teams). Two had a joint commissioning brief across their Primary Care Trust and Local Authority. The majority of commissioners interviewed were still trying to get to grips with their current role. Commissioners talked about the issues quite openly.
2. Experiences of involvement and commissioning
Commissioners reported that user involvement in commissioning was seen as useful in a number of different ways while also posing tensions and challenges.
A commissioner in one borough felt that user involvement had been very helpful in raising the particular profile of a particular service area locally and that this had led to councillors allocating more funding to that service.
User involvement was useful when councillors were willing to take time to attend meetings and valued what users were saying. Sometimes, however, it was merely seen as ‘a good thing’. Sometimes it was active manipulation; a way of legitimising unpopular decisions. There was no shared vision on what good user involvement in commissioning should look like. Many commissioners acknowledged that there was a lack of capacity, knowledge and skills around user involvement in their own and in partner organisations. It was also difficult to get the balance right in shaping services for present or future generations.
3. Partnership working of local authorities and primary care trusts
Generally commissioners were positive about the commitment of Local Authorities and Primary Care Trusts to user involvement but they thought health structures lagged behind local authorities.
One user group had been involved in tendering for the home care service and in a consultation exercise for GP services. Because the latter had no agreed framework and the purpose of involvement was unclear the users withdrew, as they had no confidence they could achieve anything.
4. User involvement – whose responsibility?
All bar one local authority relied heavily on voluntary organisations to facilitate user involvement in general (and in commissioning in particular). Commissioners did not acknowledge the potential tension between voluntary sector organisations as facilitators and as services providers. It was very unusual to see user-led organisations (rather than a conventional voluntary organisation) in the role of facilitator or lead advocate.
5. Who do we want?
Commissioners did not simply want to work with the usual individuals (and some groups were also hard to reach). However it was also important to work with people who had already become skilled and experienced. Commissioners were also aware that they could ‘cherry pick’ either the people who were involved or be selective about which comments fitted in with their own agenda.
6. Transfer of power
Commissioners appeared to struggle with sharing power and it was unclear how much power (if any) was really being transferred to users. Service users were also unsure about governance issues and what was expected of them. Sometimes technical issues in commissioning got in the way of transferring power; but sometimes it was a culture of decisions actually being made behind closed doors.
Although the perception on all sides was that practice remained quite poor, users and commissioners could also see the potential and some evidence on how user involvement in commissioning can (or could) make a difference.
Making it work
There were also shared and different perspectives between users and commissioners about what would make involvement in commissioning work better in practice.
1. Realities of involvement
Involvement needs to be resourced, people need to be willing to explore, make mistakes, discuss, make human contact, and be honest. Users need to be involved from the start, in sufficient numbers and throughout the process.
2. The need for honesty and feedback – what happened and what didn’t
Users especially wanted honesty about user involvement and about commissioning, feedback about what has and has not changed as a result (to learn from mistakes rather than hiding them). It needs to be a negotiated, open, fair and honest process.
3. Different stages and different contexts of commissioning
There is a need to spell out the different steps (from buying services now to planning for services in ten years time) and to involve service users in a way that can make a difference.
4. Involving others
Frontline staff and providers, care workers and those in direct contact with services users are likely to have a better understanding than commissioners about what people want and the texture of their lives. Their knowledge needs to be valued.
5. Ownership
If strategic commissioning is itself truly strategic, there needs to be ownership of user involvement by all (including and especially by public services).
Conclusion
The ways services are commissioned pose challenges and opportunities for commissioners as well as users. It is tempting simply to commission existing services. But the evidence from this project suggests that commissioners need to be visionary and experimental and to involve service users in this. The bad news is that we are starting from quite a low base in terms of credible user involvement. The good news is that developments favour people who are willing to take risks in trying out new approaches. It is difficult to argue against involving service users in shaping the services they use. The practical lessons (from ideas such as Direct Payments) show that it can pay dividends. The difficult part is moving beyond talking about why it’s not happening, to helping to make it happen.
About the project
The study, based in Age Concern London and employing two additional consultants, worked with service users in seven local organisations and commissioners in six inner or outer London local authority areas. The research team included a service user, a former commissioner and three others with policy or practice backgrounds. The team worked with a wide range of users, commissioners and associated organisations. The project involved a literature review and small group discussions about the current state of user involvement in commissioning. The researchers also acknowledged that the perspectives they were researching were also evident within their own team and discussed the implications of this in their approach and conclusions.
Patients will be offered more choice and control over their healthcare with the launch of the first direct payment scheme, Care Services Minister Paul Burstow announced today.
Eight Primary Care Trusts will begin to road test direct payments for personal health budgets. This will allow Primary Care Trusts to give the money for someone’s care directly to them, allowing individuals to decide how, where and from whom they receive their healthcare, in partnership with the local NHS.
Previously, personal health budgets could only be held by a Primary Care Trust or third party.
The cost of providing direct payments will come from existing funding within PCTs. Direct payments can be paid to patients in a number of ways, including monthly direct payments or a lump sum for a one off purchase such as a piece of equipment.
The scheme is designed to help individuals with a range of health conditions including people with diabetes, stroke, heart disease, end of life care and mental health conditions.
People can use their personal budgets in a number of ways. For example, one patient who suffers from chronic pain following removal of a spinal tumour uses her personal health budget for long term, extensive massage and hydrotherapy sessions to relieve chronic pain without the side effects of painkilling drugs, drowsiness and disorientation.
Another patient’s personal budget enabled him to spend his last few months at home with his daughter and grandchildren. The budget was used to provide flexible care while his daughter was at work, rather than the more traditional four times a day short visits.
Piloting direct payments is part of wider programme testing personal health budgets. More PCTs will be authorised to offer direct payments over the coming year. The pilot programme will inform decisions around how to proceed with wider, more general roll-out.
Care Services Minister Paul Burstow said:
“This is an important step towards putting patients at the heart of everything the NHS does.
“Direct payments have real potential to improve the lives of individuals with long-term health needs by putting treatment choices in their hands. That is why we are driving forward the commitment in the Coalition Agreement to extend access.
“There is strong evidence from the social care sector that direct payments help achieve better outcomes, and give people more choice and control over the care they receive. It also encourages a more preventative approach. It is a step away from the rigidity of the Primary Care Trusts deciding what services a patient will receive.
“Direct payments will not work for everyone or for all patient groups or services, but we want to identify whether, for whom and how they could offer an opportunity to help achieve the best health and wellbeing outcomes. That is why we are developing this pilot programme.
“It will stop healthcare from slipping back to the days of one-dimensional, like-it-or-lump-it services.”
Notes to editors
The authorised PCTs are:
To view the table that accompanys this release, please follow the link below;
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_117040
These pilots will run until 2012.
A personal health budget involves:
· An individual knowing how much money they can spend on their health care (their budget) before discussing and deciding what care and services they want.
· The PCT and the individual agreeing a care plan which sets out:
o what the individual’s health needs and desired outcomes are;
o the amount of money in their budget;
o how this money will be spent to meet the individuals needs/outcomes.
· Regular review of the care plan (at least once a year), and monitoring of how the money is spent. The money should meet the full cost of the agreed care plan.
The direct payment sites are all part of the Department of Health personal health budget pilot programme, which involves around seventy PCTs across England.
The cost of direct payments will be borne out of existing funding streams. In most cases PCTs are carving money out of the relevant condition specific budget. The evidence from social care suggests that personal budgets are cost neutral across the system.
http://nds.coi.gov.uk/clientmicrosite/Content/Detail.aspx?ClientId=46&Ne...
This document is to assist primary care trusts to meet the requirements of direct payments. It is written to reflect the requirements in the National Health Service (Direct Payments) Regulations 2010.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
Social workers are foisting direct payments on to adult social care users, a study in Essex has found.
The report found that nearly one in four direct payment users had not been offered the option of a council-managed personal budget by social workers and had been told direct payments was the new way to deliver adult care in the county.
However, many service users and carers felt more confident in managing direct payments as a result of the involvement of social workers, the Office for Public Management found.
The report was based on interviews with 21 service users and 25 relatives involved in helping direct payment users manage payments, and is part of a three-year study on direct payments commissioned by the council.
The study suggested that users were denied a choice because social workers were making judgements about who would benefit most from direct payments, as opposed to managed personal budgets, based on informal perceptions of need and vulnerability. Half of those who reported being denied a choice were relatives of adults with learning disabilities.
The study also found that in some cases frontline staff had tended to present support plans to families in terms of the number of hours of traditional care they could purchase, meaning they were not using direct payments in innovative ways.
Some service users and their relatives found social workers unable to explain the technicalities of how direct payments worked, which the report suggested could be down to a lack of clear guidance.
It called on the council to address the problem of social workers making implicit assumptions to avoid practitioners adopting a "gatekeeper role".
Jenny Owen, director of adult social services at Essex Council, said she expected some teething problems with such a big change as the transition to personalisation. She said: "Early on people didn't quite get the nuances of how you empower people and how you enable choices through personal budgets."
Owen said there had been changes to the training programme for frontline staff and ongoing support to correct the problems. She said the number of applications coming through for direct payments indicated this was having a positive effect.
Related articles
Community Care special report on the state of personalisation
Essex Cares combines private and public sector know-how
Councils weigh up future of in-house adult care services
http://www.communitycare.co.uk/Articles/2010/08/03/115034/social-workers...
Sub-topics of Self-directed support and personal budgets
Case studies
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Putting People First Case Studies
These case studies highlight emerging practice across the Putting People First (PPF) milestone areas as well as other key themes such as workforce development. The case studies were selected in consultation...
http://www.puttingpeoplefirst.org.uk/Topics/Browse/Milestones/SDSandpers...
Four in ten councils have missed a key target for the roll-out of personalisation, a survey has revealed.
By April all councils should have had a strategy for delivering information and advice about care and support choices in place. But only 60% had achieved this by June. In addition one in six councils were not at the planning stage for developing a strategy, the survey by advice provider Opportunity Links found.
By contrast, 12% had already started delivering universal information services ahead of a target to do so by October this year.
Stephen Burke, chief executive of charity and care advice provider Counsel and Care, said there was no excuse for the delays two-and-a-half years into the three-year social care transformation programme. "A lot of local authorities seem to be getting deflected by the need to make cuts and a lot of the building blocks to save money, through personalisation, have not been put in place," he said.
The Department of Health has set a number of milestones to chart councils' progress against the personalisation agenda.
As part of developing an information strategy councils should have analysed need, identified funding, engaged key partners and agreed a delivery model for the information service.
Local authority middle managers, who responded to the survey, blamed a lack of resources for the delays in implementation, with 40% citing this as the biggest barrier to implementation. More than 60% called for better practical guidance on implementing an information and advice strategy.
The ADASS and LGA survey conducted between January and March this year found 69% of councils were "very likely" to have an information strategy in place by April and 19% said they were "fairly likely" to do so.
Related articles
Regional disparities found in progress on personalisation
Special report: The state of personalisation
http://www.communitycare.co.uk/Articles/2010/08/05/115047/four-in-10-cou...
Foreword
The transformation of care and support could be greatly accelerated if there was a better understanding of how housing and communities fit into the picture. We know that the places where people live, their homes and neighbourhoods, make up a huge part of people’s experience and are central to well-being and requirements for care and support.
The purpose of the paper is to explore what personalisation looks like from the perspective of housing and communities, and to set this alongside the current focus on transforming care and support. It presents personalisation on a broad canvass providing a high level strategic overview. It accompanies another publication Housing, health and care1, which sets a common local context for action for partners involved in these service areas.
The paper illustrates ways in which this is already being tackled and sets out some practical steps that can be taken to embrace housing and communities within programmes for personalisation. It explores some paradigm shifts that need to take place in relation to governance, finance and the workforce. Using a question-led approach, it seeks to bring local authority strategic commissioners – of housing, adult social services, and housing support – together around a common understanding of the lead roles they need to play, and suggests some ways in which providers of
housing and of care and support might consciously reorganise their services around people’s aspirations.
The shift from block commissioning to individual purchasing power is providing funding silos rather than allowing money to follow the individual. And there is the ongoing challenge of coordinating revenue and capital funds to meet the changing aspirations of individuals and communities.
The paper is being published at an interesting time in British politics. We have a new Conservative- Liberal Democratic Coalition Government that is committed to Building the Big Society2 and many new faces in politics at the local as well as at the national level. This briefing paper is intended to assist:
Commissioners – local authority chief executives, strategic housing, adult social care and supporting people teams
Providers – mainstream and specialist housing providers
http://www.adass.org.uk/images/stories/Policy%20Networks/Housing%20Broch...
High Quality Care for All announced that from 2009 there will be a pilot, building on experience with individual budgets in social care, to test personal health budgets as a way of giving people greater control over the services they use. Over half the primary care trusts in England applied to become personal health budgets pilot sites. 73 primary care trusts, in 66 sites, have been awarded provisional pilot status. The pilot programme is now underway and will run for three years until 2012. This section contains news and information about personal health budgets, and links to other websites where you can find out more.
For more details http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/...
Individual budgets and direct payments Audit Commission guidance to appointed auditors
What is the issue?
The Department of Health (DH) ran 13 individual budgets pilot sites (external link) at local authorities in 2007/08. These pilots built on and extend previous more limited arrangements whereby authorities made direct payments (external link) to clients. Authorities need to have put in place arrangements to allocate, approve and assess individual budgets.
It is likely that, following the assessment of the trial, the DH will expand this programme of individual budgets. A number of stakeholders have expressed concerns that audit arrangements could undermine the purpose of the policy which is to empower individuals to use resources in a way that best meets their needs. However, the Commission is clear that the key issues are whether payments are made under lawful powers, in accordance with relevant statutory and professional guidance, and that proper arrangements are in place to ensure this, rather than simply how the payments are spent. Recognising the need for proper arrangements to ensure accountability for public money, audit work will therefore focus on the effectiveness of the arrangements that the audited body has in place to deliver value for money.
Where individual budgets or direct payments are significant, audit work is therefore likely to relate to the Code conclusion criterion on internal control to assess the authority's arrangements for managing individual budgets and how the authority is ensuring value for public money.
Who does it affect?
Single tier and county councils with social services responsibilities
What are individual budgets and direct payments?
As CIPFA (external link) states in 'Direct Payments and Individual Budgets: Managing the Finances':
Simply put, it is helpful to think of 'self-directed support' as an overarching term which encompasses a variety of tools to give disabled and older people greater levels of control over how their support needs are met. An Individual Budget is the amount of money that a local authority agrees to spend to meet an individual's needs and a Direct Payment is one way the person can choose to take that money in order to meet their needs. A trust or an appointed agent could also use an Individual Budget to arrange services on behalf of the person needing support.
A person could receive their individual budget as a direct payment. So what are the differences?
| Direct payments | Individual budgets |
|---|---|
| Direct payments use only social care money. | Individual budgets includes social care money and a number of other income streams - like community equipment and disabled facilities grants - which are brought together to give the individual a more joined-up package of support. |
|
Direct payments are a cash only payment in lieu of social care services. The money can only be spent on a narrow selection of traditional social care services (specified in the care plan). The focus is inputs rather than outcomes. |
Individual budgets give people a choice on how they receive their care package. It can be a cash direct payment, services commissioned by the local authority or broker who manage the budget on an individual's behalf, or a combination of both. Money can be spent on any product or service that achieves the outcomes specified in the care plan. It can also be spent on traditional social services (e.g. a care home placement). |
Why is it important?
Individual budgets are designed to provide individuals who currently receive services greater choice and control over their own support arrangements. DH has given a commitment to piloting individual budgets with a view to rolling them out nationally should they prove successful. The pilot project is a cross-government initiative led by DH but also working with DWP and CLG.
In December 2007, the Government announced in the Putting People First (external link) concordat that personal budgets would be rolled out nationally and become the norm for everyone eligible for help from social services in future, except in emergencies. Personal budgets are a form of individual budget that includes only social care funding. From 2008-09 all councils with social services responsibilities are actively implementing personal budgets.
The policy objective of the initiative is to empower individuals and therefore it is important that any audit work addresses the accountability for public money by the audited body rather than how the individuals have spent that money.
What should I do about it?
Auditors of the 13 individual budgets pilot sites will need to be aware of the pilot programme during 2007/08. Where individual budgets are material the auditor may wish to consider whether the authority has accounted for these properly as part of the opinion work. In giving the Code conclusion the auditor, when considering the criterion on internal control, may wish to consider the arrangements that the authority has in place to review, approve, allocate and monitor individual budgets.
While the individual budget pilot involved 13 councils, over 100 councils had already begun to implement personal budgets ahead of the policy announcement, as part of a voluntary initiative called In Control (external link). Therefore this guidance may also be relevant for auditors working with these councils.
Following the pilot, DH has published a personalisation toolkit (external link) reflecting learning and good practice from the pilot sites. DH guidance for pilot sites (Financial Monitoring and Review Guidance for IB Pilot Sites (external link)) emphasised that authorities should develop appropriate arrangements of their own. The guidance highlighted monitoring and review as an integral part of the individual budgets planning and evaluation process. The guidance refers to the need for pilot authorities to carry out an annual review, including assessing how the individual budget holder used their budget to achieve planned outcomes. CIPFA's Direct Payments and Individual Budgets: Managing the Finance (external link) includes guidance on financial issues such as:
- resource allocation systems
- [internal] auditing of individual budgets and direct payments
- risk management and financial monitoring
DH states that 'the main idea behind individual budgets is to put the person who is supported, or given services, in control of deciding what support or services they get', If payments are made under lawful powers and in accordance with relevant statutory and professional guidance and there are proper arrangements in place then how the payments are spent is not a focus for audit work.
Auditors should focus on the effectiveness of the authority's arrangements to review, approve, allocate and assess such monies. CIPFA recommends the following principles to local authorities for reviewing individual budgets:
- People have independence and choice but they also have responsibility. It is reasonable to ask people to account for how they have spent their Individual Budget money in achieving their support plan outcomes.
- Monitoring arrangements should be light touch and proportionate to the level of risk involved.
- Monitoring should be aligned as closely as possible with the review process so that information contributes to an understanding which can support people to make best use of the resources available to them.
- People should have flexibility to spend the resources allocated to meet their needs flexibly, and in ways which reflect their own priorities.
CIPFA also recommends that:
- Wherever possible, financial information should be collected alongside other information necessary to review the effectiveness of the existing support plan, how well it has been effected, and any changes in people's circumstances or needs. Councils should undertake a risk analysis to identify whether additional information should be collected and whether financial information alone will provide a reasonable indication of how well outcomes are being met or to indicate whether a person is at risk.
- Monitoring and review intervals should vary according to the level of risk involved. Reviews should occur more frequently where, for example, there may be a conflict of interest with the agent or family member, where there is evidence of poor financial history, or where the resource allocation system is large.
- It is acceptable for large amounts to be spent (for example on a holiday) if it meets the outcomes set out in the care plan.
In some circumstances, such as failure to manage the budget or excess accumulation of money, it may be appropriate for authorities to take back some control over the administration of the budget or claw back money.
In summary, where individual budgets or direct payments are significant, auditors should consider authorities' arrangements to:
- assess and monitor individual budgets
- ensure that payments are made in accordance with relevant statutory and professional guidance including CIPFA's guidance
Where can I find out more?
DH has a personalisation toolkit (external link) and more information is on the In Control (external link) website.
CIPFA has also updated its guidance on direct payments and published: Direct Payments and Individual Budgets: Managing the Finances in 2007 (external link). This publication covers key areas including:
- the relationship between the service user and the local authority
- resource allocation systems
- charging for self-directed care
- commissioning
- auditing individual budgets and direct payments (internal audit)
- risk management and financial monitoring
- review intervals
http://www.audit-commission.gov.uk/health/audit/methodology/Pages/indivi...
This review of local authority practice regarding the implementation of direct payments schemes sought to fill gaps in our understanding of how such schemes are managed.
Does the spirit of personalisation extend to councils allowing people to spend direct payments on sexual services? Vern Pitt examines a debate that has divided social workers
"The poor guy was all ready with his erection and not allowed to see it through," exclaims Tuppy Owens, founder of TLC Trusts, a website which puts disabled people in touch with sex workers. The "poor guy" in question was a disabled man in receipt of direct payments, which he intended to use, in part, to pay for sex, until the council declared that to be against the rules. He received a last-minute phone call while he was with a sex worker.
Owens says it's a typical situation she hears about from users of the site. "One minute they can buy sex and the next minute they are banned," she says. With the government's personalisation agenda driving increasing uptake of direct payments and personal budgets, this has the potential to become a bigger issue.
However, it appears not to be one recognised by councils, 97% of whom have no policy on the use of direct payments to pay for sex workers, according to a freedom of information request made by TLC Trusts. But it is clear that there is general opposition to the practice in councils, with 87% saying that they did not condone the payment of sex workers by disabled people in their care through direct payments.
Nevertheless most councils (53%) had a strategy that "explicitly empowered" disabled people to pursue their sexual aspirations, according to the survey, answered by 121 of the 206 relevant councils in Great Britain.
"A sexual relationship helps people to feel good about themselves, more attached and more secure," says Denise Knowles, sex therapist at Relate. "Even people's health can improve. Research has shown that immune systems are bolstered by a healthy sexual relationship," she adds.
Owens concedes that consensual long-term relationships are preferable but believes the use of sex workers can be an educative and confidence-building experience to reach this goal. She recounts the tale of one young man with an acquired brain injury who started a relationship with a woman whom he later married, only for her to leave with his money. She says that sex work has become part of his care package, organised by an occupational therapist, to teach him to be sexually self-reliant, increase his confidence and restore his faith in women.
Owens says councils are not engaged with the issue because they don't understand the nature of the work. "Actually councils and sex workers could work together, instead of councils' very childish refusal to engage in what is already happening," she says.
Regulations require councils to ensure direct payment users' support plans meet their eligible needs but not to prescribe how money is spent beyond this.
However, the issue of paying for sex brings two social work values into conflict - service user empowerment and the sense that prostitution is inherently exploitative. This conflict came alive in a recent debate on CareSpace, Community Care's discussion forum, about whether a man with learning disabilities should be allowed to spend his personal budget on paid sex in Amsterdam (see case study below).
"What social workers need to be sure about is that no one is being exploited, both the service user themselves and anyone they were buying sex from," says Ruth Cartwright, the British Association of Social Workers' joint manager for England.
Service users' own safety is also a consideration for councils, she adds, given that sex workers do not come with a regulator's stamp of approval.
Legality is another hurdle to be navigated. In the UK, paying for sex is not in itself illegal, but soliciting, kerb crawling and supporting the trafficking of women by paying for sex with them, all are. This puts professionals who want to help a client by organising a sex worker's visits in a difficult position because they may be breaking the law. This is most often the basis for council policies on the issue, which thereby prevent service users from buying sex.
There is also a broader legal framework to consider, however, in the shape of the Human Rights Act 1998. "We need to think about disabled people's rights to sexual relationships as a matter of human rights," says Liz Sayce, chief executive of disability network Radar. Owens agrees, arguing this means councils have a duty to provide assistance where necessary.
However, Neil Coyle, director of policy at Disability Alliance, says that while councils have a duty not to curtail people's rights, actively assisting in this area is another matter. "Public bodies don't exist to find people sexual partners," he says.
Councils are also wary of news stories about public money spent on prostitution.
"Councils are probably just terrified that it's going to get into the local paper and make them look silly," says Owens. "And it probably would because it's a great story."
Sayce warns that too wide a debate around the use of direct payments for sex could eclipse their real purpose - to promote choice and control for users more generally - undermine their image with the public and reduce their take-up, which she believes would hamper the equality of disabled people.
These issues illustrate the need for councils to draw up clear policies on whether and how far service users should be allowed, or enabled, to use direct payments or personal budgets on sex. This may not seem like a priority, but for service users who apply and the staff who work with them it could provide clarity and enable them to get on with achieving personalisation's wider aims.
Case Study: Green Light Given for the Red Light
I have a service user with a moderate learning disability who wants to have sex. He is 21 and has no real social network. He has had one girlfriend but she didn't want sex, and he was conscious of his disability insofar as he compares himself to others.
He mentioned to me that he heard that he could use his personal budget to go to Amsterdam with a carer, paying for sex through their licensed industry. Under personalisation this should theoretically be possible.
He has been to two different sexual health and sexual awareness courses and basically wants to try it.
Who says he can't do what he wants? We can't place restrictions on a young man who wants to experience the world.
Management hate the idea of him going to Amsterdam. They were aghast at what I proposed. But I did more research, built up a strong argument using outside sources, and now he's going.
Now he's using his personal budget, supported one-to-one by a family member (his brother) who knows exactly the purpose. I've conducted a capacity assessment and a best interest meeting has already been held. Management hate me for this but colleagues are supportive.
The bosses are petrified it's going to make the press and although I understand the rationale behind their concern, I personally think we should promote this even more.
He has calmed a bit since he's been told. He's planning to do more than just get his end away anyway - he's having a holiday (the first time he's ever left the country) which he's funding partially by himself.
The lesson I've taken from this is not to listen to management and their self-serving concerns, ignore expectations and ignore people's prejudicial belief that just because you have a learning disability, you don't need sex.
This social worker, known as AOGT, posted this story on CareSpace, prompting a vigorous debate about the rights and wrongs of the case. Join the debate
Related articles
Don't be so squeamish about sex
Social workers imposing direct payments on users
What future for the Independent Living Fund?
Community Care special report on the state of personalisation
http://www.communitycare.co.uk/Articles/2010/08/10/115069/service-users-...
Council set to cut support for users with moderate needs
Mithran Samuel
Monday 09 August 2010 14:24
People with moderate care needs would be excluded from support under plans to increase the eligibility threshold for care to substantial in Derbyshire.
The county council's plan, which has been issued for consultation, would save about £4m a year, is part of a package of measures issued last week to combat significant funding pressures across adult care over the next five years.
This is the first case of a council proposing to increase eligibility criteria since warnings were issued by local government leaders last month that such moves were on the cards.
Derbyshire is among a quarter of councils to set a moderate eligibility threshold for care under the fair access to care services guidance.
This applies to people who are unable to carry out several personal care tasks or family or work roles, while the substantial threshold applies to people who cannot carry out the majority of personal care tasks or family roles, or are at risk of abuse.
By raising criteria, Derbyshire would join the majority of councils (72%) in having a substantial threshold.
The plan have now gone out to consultation, alongside proposals for users to contribute from their own income and savings to personal budgets, which could net the council a further £8.7m a year.
This would involve people contributing £23.90 a week from their attendance or disability living allowance payments, or up to £200 a week from their savings if these exceed £50,000.
In a report to the council's cabinet last week, strategic director for adult care Bill Robertson warned that the council could face a cumulative overspend of over £90m in adult care over the next five years as a result of demographic pressures, the introduction of personalisation and government cuts.
Under a Freedom of Information request I submitted to the London Borough of Islington a request to identify the numbers and group by main disabling condition. With some 180,000 residents with in Islington, the enclosed information is both useful and suprising.
Additional information can be found at http://www.ic.nhs.uk/statistics-and-data-collections/social-care , http://www.whatdotheyknow.com/ and http://research.dwp.gov.uk/asd/
Kevin
http://www.citizensadvice.org.uk/index/campaigns/social_policy/consultat...
http://www.adviceguide.org.uk/index/your_family/family/community_care.htm
http://www.adviceguide.org.uk/index/life/benefits/payment_of_benefits_an...
http://www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/Directpaymen...
http://www.direct.gov.uk/en/CaringForSomeone/MoneyMatters/DG_10018531
http://www.direct.gov.uk/en/CaringForSomeone/MoneyMatters/DG_10018517
Abstract
This is the second PHBE interim report that focuses on the personal health budget implementation process. During the first wave of interviews for the first interim report, the focus was on exploring early experiences of implementation across the 20 in-depth pilot sites among project leads. This second interim report focuses on the views of a number of organisational representatives around the implementation of personal health budgets within the 20 in-depth sites.
Acevo convenes commission on the personalisation of public services
A group of leaders from the voluntary and public sectors have called for the creation of a powerful new Cabinet Office unit to oversee the personalisation of public services.
The Government has proposed giving people individual budgets to spend on their care as part of a reform of public services. The move could have huge implications for all service-providing organisations, including charities.
Chief executives body Acevo convened a Commission on Personalisation to consider the way forward. Its interim report, published this week, includes a series of recommendations that it says would lead to a "revolution in public service delivery".
The report urges ministers to set out a five-year timetable for the personalisation of services, to create a Cabinet Office personalisation delivery unit to oversee the transition and to legislate for a new "right to control", which would ensure people could choose the services they wanted.
It says local authorities should convene task forces to plan for the change, and urges trusts and foundations to prioritise funding to organisations that develop personalisation products, such as savings schemes that help people to manage their personal budgets.
Social entrepreneur Matthew Pike, who chaired the 14-person commission, told Third Sector the implications of personalisation for charities were profound.
"We have spoken to hundreds of organisations and many see this as liberating the third sector to serve the people it exists to serve," he said.
But a survey by the commission found that many charities were ignorant of personalisation and ill-prepared for change. Only 29 per cent said they were ready for personalisation and 11 per cent strongly desired it.
The report also acknowledges that many providers "might not have the capacity to respond to change".
The commission will present its final report to the Cabinet Office in autumn 2010.
http://www.thirdsector.co.uk/News/FinanceBulletin/967171/Sector-prepared...