The Community Care (Direct Payments) Act 1996 introduced direct payments, allowing some disabled people to purchase the provision of their own support. In 1997, a pilot project was established in Norfolk, to consider the implementation of direct payments in a largely rural county. The Joseph Rowntree Foundation supported the pilot scheme by funding a researcher to assist with an evaluation of the project. The research found that:

• The introduction of direct payments is complex. Within a social services department it requires practical operational changes, a shift in approach to the concepts of risk and control, and a challenge to the culture of direct service provision. 
• In order to make the scheme practicable and workable, disabled people need to be involved in the introduction and operation of any scheme which affects their lives, including those related to direct payments. 
• Direct payments are a cost-effective means of service delivery when compared with similar support costs from in-house service provision and agency support. They can provide a positive alternative to direct services for some disabled people.
• Social workers are the 'gatekeepers' to direct payments. Most people became aware of direct payments through their social worker. 
• Good practice in this area is only developed when social service departments, and social workers in particular, begin from an assumption of disabled people's competence rather than incompetence when assessing the concepts of 'willing and able'. 
• Rural location and low population density did not seem to affect the uptake of direct payments. 

Background
The Community Care (Direct Payments) Act 1996 gave local authorities the power to make direct payments to some individuals in lieu of community care services provided under the National Health Service and Community Care Act 1990. 

Norfolk, like many other counties, had operated a third party scheme through the Independent Living Project (Norfolk). This scheme had acted as a broker for services; when the Act was introduced 48 people were receiving a service through this means. 

On 1 April 1998 the Norfolk Direct Payments Pilot project was launched. This adopted an innovative approach in that the scheme applied to all adults aged 18-64 who were assessed as eligible for specified community care services. The project provided three options for people receiving direct payments which offered differing levels of support and involved the partnership between an organisation of disabled people (the Norfolk Coalition of Disabled People), an organisation for disabled people (the Independent Living Project Norfolk) and a social services department (SSD). 

Consultation and user involvement
The drive for the implementation of the direct payments pilot project came initially from within the SSD, because of the need to transfer disabled employers from the previous third-party scheme to conform to the provisions of the Act. Disabled people were not actively engaged in the initial debates about the establishment of a direct payment scheme; this necessitated a further period of consultation. The consultation was very successful and disabled people became involved in each stage of the process of planning and in the operation of the scheme. There was a spirit of co-operation and of active participation. Disabled people were not passive recipients of a scheme devised and managed by service providers. They came to understand the constraints imposed upon and within the SSD and sought to work within these. Social services staff also developed a greater understanding of issues pertinent to disabled people. Working in partnership was itself a learning experience for all those involved and had lessons both for direct payments and other areas. 

Commitment of senior staff
The commitment of senior members of staff was highly significant. People within the finance section, contracts department and research department of SSD all gave time and resources to the scheme. Staff within these units had little experience of working with disabled people at the outset but the changes in approach were manifest. The creation of a new post (Direct Payments Officer), dedicated to direct payments and to overseeing the introduction of the scheme at a managerial level within the department, was pivotal to the success of the project. All staff working with adults aged 18-64 were required to attend training in policies and procedures relating to direct payments prior to the start of the scheme.

The Direct Payments Officer established a helpline within the department for staff; this provided an effective two-way communication system between those implementing the scheme and those putting it into practice. Commenting, the Direct Payments Officer said he: 

"... would strongly recommend it as a way of cutting through some of the complexities ... and also as a way of the SSD lead person keeping an ear to the ground on issues."

Support for people in receipt of direct payments
Within the scheme people could choose to receive as much or as little support as they required. Some wished to manage their own affairs entirely, others sought advice and support whilst operating their direct payments themselves, whereas more wished to delegate payroll management to a third party. To give people these options, Norfolk SSD entered into different service contracts with two support agencies: the Norfolk Coalition of Disabled People and the Independent Living Project (Norfolk). People using the scheme felt very well supported, but the existence of two support agencies led to an unnecessary duplication of tasks and costs. One support agency, controlled and managed by disabled people, would arguably be the most effective means of offering support and Norfolk SSD subsequently put this support function out to tender.

Recipients of direct payments 
There was no typical direct payments recipient. Age, gender, sexual orientation, family structure, income and employment, and family background differed enormously. 

Recipients were not people who would have naturally socialised together. The common factor was that they wished to have more control over their daily lives, including the arrangements for their support.

"Just because I use a remote control to turn my telly over doesn't mean I don't turn it over myself. Just because I don't paint the walls but I've chosen the colour. ... It's under my control. ... it sounds obsessive sometimes ... I go on and on about having control ... I've made all the choices."

Some disabled employers sought to gain independence from statutory services and contracted agencies. Changes in staff and rotas within agencies and SSD services sometimes meant that there was little opportunity to form relationships; the disabled person could feel like a task to be done rather than an individual:

"With social services home care I felt like they came in, 'did me' and then went off and 'did' someone else and I was beholden to them. With direct payments I'm the boss and the employee has a different approach to me as I'm paying them rather than someone else sending them to help a hopeless person."

Some sought independence from their families (in particular from their parents) whilst others wanted to maintain the mutual dependence of family members upon one another. There was a sense from some disabled employers and from some personal assistants that there was a mutual support between them, which could stretch beyond the immediate employer/personal assistant relationship. Employers felt they were contributing to the welfare and income of their personal assistants in exchange for their support in domiciliary tasks. One was not dependent on the other but rather they were interdependent. Indeed, the children, and on occasion grandchildren, of personal assistants became part of extended social networks for some disabled people. 

The uptake of direct payments
The uptake of direct payments was initially slow as staff within the social services department and disabled people came to understand the processes. 

"I don't think they [social workers] are quite as clued in as they could be about what it means to us. ... What is good for the spirit is good for the body. ... I think sometimes that gets neglected ... sometimes they are so busy looking after our bodies - making sure we're safe and secure and that we've got food on our plates - that they don't realise that the spirit is being neglected ... achieving something ... that's important."

After two years, there were 75 people in receipt of direct payments; approximately 15 per cent of those eligible for direct payments in Norfolk. Eight people had left the scheme during the two years, usually due to a change in life circumstances, for example divorce or moving house. 

For most people, direct payments were a positive alternative to direct service provision or services provided by agencies contracted by the SSD. Disabled people said the positive aspects included:

• Employing whom they choose;
• Determining the hours of employment;
• Determining the tasks they require the personal assistant to undertake; 
• The flexibility of the employment relationship, which allows them to vary their routines and activities with more ease;
• The level of support offered in their role as employers;
• Decreased involvement with professional agencies.

Although the scheme was open to all adults aged 18-64, including people with learning difficulties and users of mental health services, only two people who did not receive their support from teams working with people with physical impairments joined the scheme. The project is now recruiting an advocacy worker to help to address this imbalance. (The researchers have devised a checklist to aid social workers' assessments; this is included in the full report.) 

Norfolk is a county with both urban and rural wards. A mapping of the locations of people in receipt of direct payments shows no apparent correlation between the uptake of direct payments and sparsely populated or rural wards.

Recruiting personal assistants
Personal assistants were recruited through advertisement, informal networks and from the agencies which had provided a service to the employer before they joined the pilot project. The scheme brought some new personal assistants into the market who might otherwise not have entered this form of employment. 

"And Lisa said 'Well, I know someone who wants work 'cos she's got children' and so she's now home when she leaves off - for her children ... if one can't make it they phone the other one so we all work in." 

Most disabled employers had little difficulty in finding staff although there were isolated examples of unsuitable personal assistants who had been employed temporarily. A trial period was seen to be very significant:

"I interview them, I give them a month's trial and see if they work in fine with me."

Risks of abuse by personal assistants
Some disabled employers were concerned that they, vulnerable adults or children with whom they lived could be victims of abuse if they employed an unsuitable personal assistant. The latter raised questions about potential child protection issues for disabled parents and for the SSD. Some employers on the direct payments scheme in Norfolk asked their employee to provide their own statement from the Criminal Records Office (which costs approximately £10 to obtain). There was no evidence of abuse within the pilot project.

Financial matters
Direct payments were a cost-effective means of service delivery when compared with similar support costs from in-house service provision and agency support, although there were many hidden costs within social services and other agencies at the beginning of a scheme. The financial monitoring of direct payments is best undertaken within the social services department rather than contracted out to another organisation. Since direct payments are in lieu of community care services, the local authority may still claim charges for services. Some recipients were confused when asked to pay charges. 

Conclusion
The evaluation concludes that a direct payment scheme which involves disabled people from its inception and throughout its operation can provide a very positive alternative to direct service provision and one which empowers disabled people to live their lives as they choose, with no additional cost to the social services department.

About the study
The research took the form of qualitative interviews with disabled people who received direct payments, personal assistants employed through the pilot project, operational and support staff within social services and key people within the two support organisations. Questionnaires were sent to all disabled employers and the documentation of the project was reviewed. The full report, written to inform disabled people and their advocates, staff within social services departments and in voluntary organisations, follows the process of implementation and draws conclusions and recommendations for others those wishing to become involved with direct payments. 

How to get further information
The full report, Independent successes: Implementing direct payments by Carol Dawson, is published for the Foundation by YPS (ISBN 1 84263 011 3, price £14.95). 

Click on the 'order report' icon in the left margin to order online.