Making direct payments work for older people

The scope of the Community Care (Direct Payments) Act was extended to older people in February 2000. However, scepticism remains about older people's desire and ability to use direct payments. A new study examined the way older people use direct payments, how they make them work, and the role of local authority care managers and direct payments support services in making direct payments a real option for older people. The research was conducted in three local authority areas in England. It found that:

• Older people receiving direct payments reported feeling happier, more motivated and having an improved quality of life than before. There was a positive impact upon their social, emotional and physical health.
• Direct payments enabled Somali older people to employ personal assistants (PAs) who shared their language. Accountancy services dealing with banking and administrative requirements were essential in overcoming language and literacy barriers.
• Support services were crucial in enabling older people to use direct payments. The major difficulty lay in meeting audit and administrative demands, necessitating ongoing assistance from support services. Local authority funding does not always account for this.
• Most older people employed PAs. There was a call by older people for direct payments support services to maintain registers of assistants to ease the recruitment process.
• Some older people used PAs for social activities and/or alternatives to institutional respite care. They were rarely allocated hours for this in their direct payments packages, so they had to be 'creative' with their hours and fund additional costs themselves.
• Older people could probably derive more benefit from direct payments were it not sometimes assumed that older people have a restricted lifestyle.
• Older people experienced age discrimination when crossing the social services administrative boundary between 'adult' and 'older persons' services.
• Care managers are key to giving older people access to direct payments, but direct payments are yet to become part of the culture of care management. To make direct payments a mainstream option, care managers said they required sufficient knowledge, support from line managers, time to think and work creatively, and a clear understanding of the role of direct payments support services.
• The researchers recommend that funding of support services should reflect their value both to older people and to the local authority.

Background

The scope of the 1996 Community Care (Direct Payments) Act was extended to older people in February 2000, but take-up by older people has been slow. The Government has since placed a duty upon local authorities in England to offer direct payments to all those eligible for them. It has also signalled its commitment to increasing the number of older people using them.

This research examined 'what works' for older people on direct payments schemes in three local authority areas. Each area has a different type of direct payments scheme and/or support service.

Benefits older people derived from direct payments

I just feel keeping people in control gives them a better quality of life. (Helen, care manager)

This view about the benefits of direct payments for older people matched the views of the older people themselves in this study. Some care managers felt that direct payments had a preventative or delaying role with regard to residential care.

That direct payments enhanced people's choice, continuity and control of their support arrangements was an important issue for older people. They were able to create and manage their services to meet their own priorities.

One couple told us that direct payments had "revolutionised" their lives. Mrs Robinson had her "home ticking over so that it's comfortable" while Mr Robinson could now watch a football match on television in the evening without being put to bed before the end of the game.

It is like a magic door opening. It's meant that, well, I'm living a life now. (Mrs Young)

Such views were echoed by many older participants, who felt that they, rather than service providers, were now in control.

Direct payments also had a distinct 'added value' for older people in that they had a positive impact on their social, emotional and physical health. They felt happier, more relaxed, able to physically do more for themselves and go out more often. Direct payments gave older participants "a new lease of life" and greater freedom. Having control of what happened in their own homes was very important, as was the respect accorded to being employers.

Accessing culturally relevant services

Direct payments enabled Somali older women in this study to secure culturally relevant services where agencies were unable to provide Somali-speaking care assistants. Getting help with the shopping was particularly important, as the language barrier made it difficult for them to observe their cultural norms.

Sometimes I don't understand. I will choose some food that I don't eat. I get confused and end up eating something with alcohol or pork, which we should not eat, by mistake. (Mrs Osmani)

Having someone who can speak the same language was crucial in enabling the Somali women to be in control and determine what was done for them. They no longer had to rely solely upon family members for support, and their family relationships improved.

However, having access to an accountancy service through the direct payments support service to deal with the banking and administrative requirements was essential in overcoming the language and literacy barriers faced by the older women. None of the women spoke English and some experienced difficulties in dealing with bills and official letters. A link between Somali community workers and the direct payments support service helped to bridge the information gap between social services and the community, as well as give the older people access to direct payments.

Although it would be unwise to generalise too much, the research suggested that there are transferable lessons for local authorities and support services in overcoming barriers faced by other Black and minority ethnic groups in gaining access to social services and direct payments.

The importance of direct payments support services

Support in managing the financial and administrative demands was identified as crucial in making direct payments work for older people. Older people often felt overwhelmed by these demands, necessitating more intense and ongoing forms of support. However, local authority funding of direct payments support services did not always take this into account, leaving one support service providing assistance over and above its contractual agreement. Yet such support was essential.

It's just like a weight lifted. It would worry me. I've never kept books and accounts. (Mrs Fontwell)

Recruiting personal assistants was also an issue. Consequently, getting help with the wording of advertisements, advice and assistance when interviewing, and help with the drawing up of contracts of employment, were also valued. There was a call for support services to maintain registers of personal assistants. Having access to such a register was seen as a relatively safe means of recruiting assistants, though it was costly and time-consuming for support services to keep updated. To achieve this, they required sufficient flexibility in their funding by local authorities.

Some older people stressed how important it was that support services adapt to the specific concerns and requirements of older people and provide "a more personalised service". Many pointed to the importance of being able to access the support service quickly and easily, recommending a telephone duty system during office hours.

It's frightening when you're on your own and you've got no one to turn to. (Miss Turner)

In this sense, direct payments support services could take the strain off care management teams by providing instant access to information and support and releasing care managers from having to deal with day-to-day issues about service delivery.

Support services also provided useful training and information functions for care management teams, while working together with support services increased the confidence and knowledge base of care managers. These were particularly important functions, given the central role of care managers in giving older people access to direct payments.

The importance of having a good quality direct payments support service cannot be overstated. Adequate funding is key to ensuring the delivery of a quality service, responsive to the needs of different direct payments user groups.

Using direct payments for social activities

Direct payments fit with the policy agenda of promoting independence, quality of life and social inclusion. They empower older people to "live a normal life" by determining and meeting their personal and practical support needs on a daily basis. One participant, for example, used her personal assistant to enable her to pursue her love of the arts, from which she still got a "buzz", although she had to meet additional assistant costs, such as meals and petrol, herself.

Employing an assistant took a lot of work off my wife, and I'm not just sitting here like a cabbage. (Mr Clarke)

Taking control of his own support arrangements allowed Mr Clarke to go on a fishing trip, accompanied by his assistant, while his wife took a break from her caring role and went on holiday. Mr Clarke paid £100 for three nights away and 24 hour assistance, paying extra from his own pocket to cover the costs. He said this was much more enjoyable, and cheaper, than institutional respite care:

It's brilliant. It beats staying in an old people's home.

However, as he and others pointed out, it was otherwise difficult to creatively use direct payments, given the focus of 'personal care' and the lack of hours for social activities when it came to assessed needs. Creativity demanded forgoing some hours of assistance, "jiggling the money around" and paying for the extra costs themselves.

Age discrimination

Government policy initiatives such as Fair Access to Care Services and the National Framework for Older People aim to combat age discrimination. Yet older people in this study appeared to experience varying degrees of age discrimination when crossing the social services boundary between 'adult' and 'older persons' services.

Some older people felt disconcerted that they no longer had a named care manager and had to take "pot luck" with the duty system. They were also often "very frightened" that their hours would be reduced when they moved to older persons teams, and so avoided contacting social services even when they needed more hours.

Older people experienced a general shortfall in access to social and leisure facilities. Some were able to use their assistants to meet these needs, but those who had attended resource centres for disabled people found that they had to move to older people's day centres. Many felt that age thresholds were discriminatory.

Restrictions were also reported in securing funding for holidays with other disabled people. Instead, they were expected to use older people's respite facilities. Some were allowed a 'transitional period' vis--vis day centres or holiday funding, during which time they were supposed to adapt to their new situation. Or, as one care manager said of her client:

She's meant to be adapting to the life style of an older person. (Pat, a care manager)

Further discrimination was evident in that people aged 66 and over are excluded from applying to the Independent Living 93 Fund, neglecting the greater financial costs incurred by ageing and impairment.

Such policies and practices, together with the age-related assumptions of some social care professionals, reflect the ageist and fragmentary approach to social care work with older people, whereby services are designed and provided separately for older and disabled people and ageing is seen to equate with a reduced lifestyle.

The role of care managers

Demand for direct payments was related to the quality and accessibility of information available. Care managers were the most common source of information about direct payments for older people. However, some lacked sufficient knowledge to be able to offer direct payments to older people as a viable option.

I just don't understand it. It's not user friendly. Because I don't understand it, I don't think I can explain it. (Brenda, a care manager)

Direct payments were yet to become a part of care management culture, because mindsets were largely geared towards mainstream services. Care managers offered a number of reasons for this, including "the nature of the client group", tightening eligibility criteria, using traditional services was easier and quicker, and their belief that older people would not want to find their own employees and deal with the paperwork involved. Where direct payments were offered, it was often as a way of solving problems, for example, breakdown in relationships between clients and providers, or a paucity of local care provision.

Care managers were aware that the success of direct payments depended upon individuals having sufficient flexibility to determine their own daily routines. However, they faced tensions between adhering to local budgetary constraints and allocating sufficient hours to direct payments packages to enable social use as well as 'personal care'. Time and work pressures that could stifle more innovative practice compounded these tensions.

Care managers who had successfully implemented direct payments with older people gained a "massive sense of satisfaction" from empowering clients to be "able to do it themselves" and seeing "happier people" as a result. They pointed to key elements to their success:

• adequate training;
• a supportive line manager;
• permission to take time to think and work creatively;
• their own confidence and enthusiasm about the potential of direct payments and putting this across when presenting direct payments as an option to their clients;
• a clear understanding of the support offered by direct payments support services; and
• early referrals to support services.

Conclusions

The research suggested that direct payments were a positive option for older people, giving them greater choice and control and improving their quality of life and their emotional, physical and social health. Local authority care managers and direct payments support services play pivotal roles and are most effective when in concert with each other.

The researchers recommend that funding of support services should reflect their value both to older people and to the local authority. Older people could probably derive more benefit from direct payments were it not sometimes assumed that older people have a restricted lifestyle. Local authority adherence to government policy initiatives to tackle such age discrimination could perhaps take on board the more subtle mechanisms through which this ethos is perpetuated.

About the project

The researchers were Heather Clark and Helen Gough of University College Chichester, and Ann Macfarlane, an independent disability quality consultant. The research was conducted between January 2002 and June 2003 and examined how direct payments work for older people in three different local authority areas. Forty-one older people participated in in-depth interviews in their own homes and/or in group discussions, as did five senior managers, eleven team managers, thirty-two care managers, and ten direct payments support workers.