Expert guide to direct payments, personal budgets and individual budgets
Direct payments and personal budgets are a central part of the personalisation agenda to give service users choice and control over their care and support.
What are direct payments?
Direct payments are cash payments given to service users in lieu of community care services they have been assessed as needing, and are intended to give users greater choice in their care. The payment must be sufficient to enable the service user to purchase services to meet their eligible needs, and must be spent on services that meet eligible needs.
Direct payments confer responsibilities on recipients to decide how their eligible needs are met, either by employing people, often known as personal assistants, or by commissioning services for themselves. Service users can get support in fulfilling these responsibilities from direct payment support services commissioned by local authorities, often from user-led organisations. Like community care services, direct payments are means-tested so their value is dependent on a person's income and assets as well as their eligible needs.
Direct payments are available across the UK and to all client groups, including carers, disabled children and people who lack mental capacity. However, they cannot be used to purchase residential care or services provided directly by local authorities.
What are personal budgets?
Personal budgets are an allocation of funding given to users after an assessment which should be sufficient to meet their assessed needs. Users can either take their personal budget as a direct payment, or – while still choosing how their care needs are met and by whom – leave councils with the responsibility to commission the services. Or they can take have some combination of the two.
One version of a council-managed personal budget is an individual service fund, under which the budget is held by a care provider but the service user can choose how some or all of it is spent. ISFs have been used to apply personal budgets to residential care.
As a result, they provide a potentially good option for people who do not want to take on the responsibilities of a direct payment. Personal budgets have been rolled out in England since 2008, with a target of providing every service user with one by 2013. In Scotland, where they are known as individual budgets, there are also plans to roll them out, under the country's self-directed support strategy, which is being turned into legislation.
What is the role of social care professionals?
Social workers and other care staff play a number of roles in the delivery of direct payments and personal budgets.
- Decision-making - helping service users decide whether a direct payment or council-managed personal budget is right for them.
- Assessment and resource allocation - assessing service users' needs, or supporting them to assess their own needs, and allocating a budget to meet them, based on a resource allocation system.
- Risk management and enablement - helping service users manage risks in their lives and regarding their care and support, and supporting them to take risks.
- Challenging the size of a personal budget - social workers may feel that a person's personal budget is insufficient to meet their needs, in which case they would take the case to a council funding panel.
- Support planning and brokerage - drawing up a support plan in partnership with the service user and their family, and providing information on or sourcing services to implement the support plan (brokerage). While these functions are often carried out by council social care staff, some argue that they are better provided by external, specialist organisations, including user-led organisations. There is also support for users and their families to lead the support planning process, with social workers only providing assistance where requested; this has been taken forward in councils including York.
- Review - keeping a service user's support needs under review to ensure they are successfully meeting people's needs.
How many people are using personal budgets and direct payments?
As of April 2011, 35% of eligible users and carers in England - 340,000 people - were using personal budgets, according to the Association of Directors of Adult Social Services. In a third of these cases, the recipient had taken their budget as a direct payment and in the rest the council was managing the personal budget.
In Scotland, 3,678 people were receiving a direct payment as of 31 March 2010, a 22% rise on the previous year. However, this figure is small compared with the 66,222 people receiving home care in the country at the same date.
In Wales, as of 31 March, 2010, 1% of older users of community-based services (552 people) and 9% of younger adult service users (1,908 people) were using direct payments.
Personal budgets for all by 2013
In its 2010 adult social care strategy, the UK government set an ambitious target of having all council-funded service users and carers on personal budgets, preferably as a direct payment, by April 2013.
The target has proved controversial with the Association of Directors of Adult Social Services warning that it has artifically driven councils to move people on to council-managed personal budgets without providing them with choice and control.
However, the government has shown no signs of dropping it.
Take-up across client groups
As the Welsh figures illustrate, direct payments have traditionally had a higher take-up among younger adults - notably people with learning or physical disabilities - than older people.
Figures for 2010-11 in England, from the NHS Information Centre, showed that 29% of older people were on personal budgets, compared with 41% of working-age adults with a learning disability and 35% of physically disabled adults of working-age. However, the figure was even lower for people with mental health problems of working-age, at 9%.
The figures reflect concerns that not enough has been done to make personal budgets work for older people, people with mental health problems and those with the most complex needs; these issues have been raised in a number of reports:-
- A March 2012 report by the Association of Directors of Adult Social Services on the care of older people, which called for a review into how personal budgets were being implemented for the client group;
- A November 2011 study by Alzheimer's Society, highlighting barriers to personal budget take-up for people with dementia;
- An October 2011 study from Sue Ryder Care and the think-tank Demos, which warned that the emphasis on personal budgets and direct payments risked excluding people with complex needs, for whom personalised care could better be delivered through other means.
Older people and people with mental health problems
There are ongoing efforts to boost take-up among people with mental health problems and older people:
- A research project has been set up to explore good practice in the delivery of personalised care to people with mental health problems.
- The Think Local Act Personal partnership, a sector coalition charged with supporting the implementation of personalisation in England, is focusing on how personal budgets can be better implemented for older people.
Learning in relation to supporting personal budgets for people with dementia has also been provided by the two-year Dementia Choices project, run by the Mental Health Foundation, which ended in March 2011.
Extending personal budgets
There are also initiatives to test how personal budgets would benefit homeless clients and to people who misuse substances.
In England, personal health budgets are being tested to give people with mental health problems or long-term conditions control over resources spent on their healthcare. These are due to be rolled out from October 2012, though concerns have been raised by mental health professionals and service users over their potential to improve outcomes.
The personal budgets concept is also being extended into other government funding streams used by disabled people through the Right to Control initiative, which is being tested in seven areas.
This is designed to give disabled people control over resources for their social care, employment support, housing support and equipment and adaptations, to enable them to shape how the money is used.
How successful have direct payments and personal budgets been?
A number of studies have shown significant benefits for service users from personal budgets and direct payments:
- The 2011 National Personal Budget Survey of 2,000 users and carers in England found that personal budgets were generally likely to have positive effects, with most users saying they had seen improvements in 10 out of 14 outcome areas from using personal budgets.
- A 2010 report by charity In Control found that 68% of service users said that their lives had improved since they started using a personal budget.
The National Personal Budget Survey found that outcomes were better where service users were informed about the value of their personal budget, fully involved in the support planning process, alongside family carers, relatively free of constraints and bureaucracy, and where they had a direct payment rather than a council-managed personal budget.
There are concerns that councils are looking to maintain control over resources by managing personal budgets themselves, rather than giving service users a direct payment, and denying service users genuine choice and control at the same time.
However, at the same time, there is recognition that managed personal budgets are the most appropriate options for many people who do not want the responsibilities of a direct payment, putting a premium on ensuring they deliver genuine choice and control.
Bureaucracy and the implementation of personal budgets
Despite the links between less bureaucracy and positive outcomes for service users, the implementation of personal budgets has been beset by excessive bureaucracy.
Three-quarters of adult social workers said there was more bureaucracy in their role as a result of personalisation, found Community Care and Unison's annual 2011 survey on personalisation.
Explanations put forward for the increase in bureaucracy include councils having multiple assessment processes, combining legally required professionals assessments with supported self-assessments.
The situation has sparked repeated calls for the processes involved in personal budgets to be simplified.