Direct payments were introduced in 1997 as a means of increasing the choice and control people have over the care they receive. However, take-up by people experiencing mental health problems has been slow. This project aimed to engage with service users and professionals to raise awareness about direct payments and their potential and to identify positive action to address the barriers to take-up. It also describes the process used to engage with stakeholders, including a national conference and recruiting service users from black and minority ethnic communities to facilitate focus groups.
Successful implementation of direct payments in mental health evidently relies on proactive managers who are clear about the task, knowledgeable and committed practitioners, and informed service users and carers who are interested in exploring the options of direct payments. The report identifies action for these three groups as well as for national policy-making.
Direct payments increase the choice and control that people have over the support they receive. The take-up of direct payments by people experiencing mental health problems has been extremely low in most parts of the country. This project, New Directions, was undertaken by the Health and Social Care Advisory Service and draws on a range of discussions with over 250 service users and staff in order to identify what needs to happen for direct payments to be successfully implemented:
- Service users, carers and professionals require straightforward, accurate and accessible information about direct payments which is specific to mental health.
- Both service users and professionals can be confused about the distinction to access to an assessment for receipt of direct payments and access to services, where the threshold may be much higher and based largely on clinical considerations. This can affect take-up.
- Mental health users require specific advocacy and practical support to facilitate access to and use of direct payments.
- The absence of a streamlined process integrated with the Care Programme Approach adds to the sense of direct payments being a burden rather than an opportunity.
- Ways to increase take-up by people from black and minority ethnic communities include developing resources and approaches, including outreach and direct support services specific to those communities.
- A change in the culture of mental health service provision is required. This would need a tangible commitment to promoting self-determination, evident in the way staff interact and support people experiencing mental distress.
- Introducing direct payments requires effective leadership to drive the process of implementation from national direction and guidance through to local leadership, at both a strategic and operational level.
- Fostering partnerships across organisations and supporting collaborative problem solving could facilitate learning about the implementation of direct payments.
- Introducing direct payments in a planned way requires thought as to how existing services can be reviewed, reconfigured and recommissioned.
- There is a need to review what direct payments cover in mental health: the distinction between health and social care in mental health is not an easy one, and arguably no longer relevant given the integration of health and social care to provide mental health services.
Local authorities now have a duty to offer direct payments to people who are eligible and to make payments to those who want them. Direct payments offer greater independence and flexibility in support arrangements and, for people from black and minority ethnic communities, this can mean improved access to culturally sensitive support. For people experiencing mental health problems direct payments can facilitate social inclusion, through providing support to access mainstream activities that are not stigmatising or mental health focused.
However, since the introduction of direct payments in 1997 their take-up by people experiencing mental health problems has been slow. At the end of September 2003, only five local authorities had ten or more mental health service users on direct payments and nearly two-thirds had no mental health service users using direct payments. The main aim of this project (‘New Directions’) was to engage with mental health service users, mental health professionals and managers in debate around common concerns in order to identify what needs to happen for direct payments to be successfully implemented. It built on an earlier study published in 2004 by HASCAS which had evaluated the introduction of direct payments in mental health in five national pilot sites.
“It’s all too difficult and complicated”
Service users and staff working in mental health services shared a lack of awareness and confusion about direct payments for people experiencing mental health problems, creating a sense that “it’s all too difficult and complicated”. They highlighted a number of issues.
For service users there was confusion with another government initiative to pay benefits directly into people’s bank accounts. Where people had heard of direct payments as a means of accessing social care there were concerns about the practicalities, particularly in relation to recruiting and employing staff, money management and excessive paperwork.
For staff working in mental health services there was a sense of being overwhelmed by government initiatives in mental health, a consequent lack of clarity as to where direct payments fitted and therefore what their role should be. As with service users, the absence of a streamlined process integrated with the Care Programme Approach added to the sense of direct payments being a burden rather than an opportunity.
There was also confusion about eligibility with an assumption being wrongly made that direct payments are only for physically disabled people or should only be offered to people whom care co-ordinators view as capable of managing the payment. There was also an underlying anxiety about the impact of direct payments on people’s jobs; this suggested the absence of a strategic and managed approach in introducing direct payments.
Information and support
The discussions highlight an urgent need to ensure access to straightforward accurate information which is specific to mental health and uses real life examples to demonstrate how direct payments can be accessed and used. Targeting specific groups and taking information to them was identified as essential; for example, targeting people before they leave hospital, outreach work with black and minority ethnic communities, as well as ensuring that the options are discussed with all potential recipients. Undertaking this work adequately would require resources and training being made available but is vital if take up for these communities is to be increased.
In addition, the existence of independent advocacy and support schemes - which can provide information, speak up on someone’s behalf and provide help with the practicalities - was identified as necessary for building confidence in accessing and using direct payments. There are many examples of where this is working well, for example the Independent Living Association in Essex. The voluntary sector was thought to have a central role in this respect, particularly for black and minority ethnic communities, with the Mellow Campaign and Equalities providing good examples of how this is working in practice.
Staff need to be clear what their role is in relation to direct payments and this needs to take account of the integration of health and social care to provide mental health services. There needs to be an investment in practice development which includes training and supervision with worked examples of direct payments and mental health. This should include sessions delivered by direct payment recipients, so staff can understand the impact of direct payments on peoples’ lives and how they can improve the available choices. This clarity of role would be further supported by processes which are effective and easy to use and are integrated with the requirements of the Care Programme Approach.
A different way of thinking
The policy on direct payments is different: unlike most other policies it has been driven by disabled people with a view to gaining greater independence and choice. This was made clear at the national conference:
“Direct payments have been framed in terms of support (not illness or incapacity); in terms of ensuring that people can have the kind and amount of support they need to live their lives as fully, as freely, and with as many choices and opportunities as they can. They can have more choice; they can have more control; because they can with help and independent guidance get the kind of support and assistance they need to live their lives.” (Professor Peter Beresford, Centre for Citizen Participation, Brunel University)
Many service users expressed a lack of confidence in services to understand this and therefore to implement direct payments successfully; for those from black and minority ethnic communities this was compounded by their experiences of institutional racism. Managers and staff alike identified both a focus on illness and diagnosis and the current emphasis on risk as restricting the vision and therefore opportunities for greater independence for people. Widespread implementation relies on an understanding of a ‘social model’ of mental ill-health which emphasises capacity and recovery. This has implications for organisations, their value base, how this is translated into action in the ways in which services are provided and their commitment to work with other organisations towards the goal of inclusion.
Implementing direct payments in mental health
The discussions suggest that successful implementation requires action on a number of different fronts by different players. It relies on proactive managers who are clear about what needs to be done, knowledgeable and committed practitioners and informed service users who are interested in exploring the options of direct payments and have access to an independent and appropriately funded direct payment support scheme. This needs to be fostered by a clear organisational direction and support for promoting an approach which increases people’s self–determination and by national guidance on implementing direct payments in mental health.
The importance of leadership at all levels was highlighted:
“It is the job of the manager to be the ‘plunger’ to unblock the blocks to change. Managers at all levels have to articulate the vision and the process.” (Leroy Lewis, South Essex NHS Partnership)
Team leaders were identified as central with the following suggestions for the action they should take: providing access to training and practice development, building a positive working relationship between the team and direct payment support schemes, and reflecting with the team on progress in relation to implementing direct payments. Supportive and enthusiastic senior managers were also identified as a key ingredient with the central role to play in ensuring a strategic approach and managing the changes in practice and service delivery which the introduction of direct payments, and the move to individualised commissioning, implies. The importance of director level support in demonstrating commitment to independent living, in general, and to direct payments, in particular, was also stressed.
The importance of a systematic approach
The need to adopt a strategic approach, managing the introduction of direct payments and supporting staff, users and carers through the process of change was a pervasive theme. The introduction of direct payments in mental health seem to be unplanned, ad hoc and opportunistic resulting in inequities in access. Enthusiastic care co-ordinators securing direct payments for individuals can give others the confidence to pursue direct payments for their clients and stimulate action form their managers. On its own, however, this is unlikely to be enough and attention need to be paid to the broader implications of introducing direct payments.
Other implications were also highlighted:
- Changes in practice will have to be underpinned in changes in service commissioning, for example moving away from block contracts to release money for direct payments. This has far-reaching implications which will need to be explored at both a local and national level;
- Making the whole system work and fit together needs attention, including the establishment of structures and processes which facilitate this. The development of a multi-agency Steering Group to spearhead the introduction of direct payments has been shown to have enormous value from previous work. This would need to link formally with existing multi-agency strategic groups which are responsible for reviewing and reshaping of mental health services, for example Local Implementation Teams or Partnership Boards.
Implications for policy
Whilst local authorities now have targets to meet to increase the number of people receiving direct payments, these on their own are unlikely to increase the take-up by people experiencing mental health problems. This study suggests that, in addition to a strategic approach at a local level, the definition of what direct payments can be used for in mental health needs reviewing in the light of the integration of health and social care in the provision of mental health services. Guidance is also needed on reviewing and decommissioning services as the introduction of direct payments provides an opportunity to reshape existing services, particularly day services.
About the project
This project was carried out by a team from the Health and Social Care Advisory Service. Four focus groups (120 participants) were held in Birmingham, Manchester, London and Maidstone (Kent). Their prime aim was to promote a dialogue with mental health professionals and service users about the potential of direct payments to offer choice and control to service users. Each focus group targeted a different group: service users (particularly those from black and minority ethnic communities); voluntary groups, self-help and advocacy groups; practitioners, particularly care co-ordinators and front-line workers; and senior managers.
Service users facilitated the focus groups with other service users, professionals and staff from direct payment support services sharing their experience and learning about direct payments during the focus groups. A national implementation event was held in May 2004 bringing together 150 participants to reflect on the key themes which had emerged from the focus groups and identify how the barriers to implementation could be addressed. Further information was obtained from structured telephone interviews with lead managers for direct payments from five local authorities, who have made progress in introducing direct payments for people with mental health problems (Essex, Leeds, Liverpool, Norfolk and West Sussex).
Additional information on HASCAS work on direct payments and mental health is available from: Health and Social Care Advisory Service, King’s Fund, 11-13 Cavendish Square, London, Tel: 0207 307 2892,