Scottish Government

Section 2: ASSESSMENT, PLANNING AND COSTING A DIRECT PAYMENTS PACKAGE

26. Section 1 gives guidance on the first stage of the direct payments journey to maximise a person's independence, whether direct payments are used to supply all the support that is needed, or as part of a mixed package of care. The first port of call for anyone receiving any care service is assessment. What is different about direct payments is not the assessment process but the means of delivering the care needed. Direct payments are an opportunity for service users and practitioners alike to think more innovatively about care and support, and this section gives guidance on ways in which service users and local authorities can get the best from the assessment they carry out together. This includes some essential pre-assessment work and/or training to enable potential direct payments recipients to think wider than the services they may be currently being offered, to what type of support is needed to meet their care needs as a whole person.

27. Section 1 also looks at the planning of direct payments and at the costing of the package. This is to ensure that there is sufficient money available for the user to get a service that the local authority is confident is of a sufficient standard.

Pre-Assessment

28. Before the assessment process begins, it is essential that individuals be given information about direct payments options. Local authorities should make the person, and their supporter or representative, aware of the possibility of receiving direct payments at an early stage to give as much time as possible to think about it. Direct payments information should be part of the leaflet provided by local authorities and their health board partners on single shared assessment and assessment of community care needs.

29. Individuals should be encouraged, as part of a self-assessment process, to consider for themselves what care assistance they might need. In some areas, self-assessment forms designed by user groups have been used to prompt people to think through the tasks with which they need assistance before their needs are assessed by the local authority. Local support organisations offer courses that can enable users to think of themselves, not as a 'passive' recipient of care, but as an 'active' citizen making decisions about how to best meet their care needs. Local authorities should fund this pre-assessment work.

30. It is already good practice for local authorities to involve carers wherever appropriate in the assessment of the person they care for. The Community Care and Health (Scotland) Act 2002, (the '2002 Act') now formally requires local authorities to take account of the contribution of carers who provide (or intend to provide) 'a substantial amount of care on a regular basis'.

Single shared assessment

31. To improve delivery of community care services, the Scottish Executive introduced single shared assessments ( SSA) which have been in operation for older people since April 2003 and for other community care groups since April 2004.

32. The emphasis here is on 'single', meaning that one professional carries out the assessment with the person, often with contributions from others, and that is shared with all those who have an interest to avoid the need for several professionals to undertake separate assessments. A holistic approach is essential in working out how best to meet a user's care needs and this will require both time and skill. The potential for review should be in-built from the outset to ensure continuity of care that is responsive to periods of changes and fluctuating needs.

33. Policy and practice guidance is contained in Circular CCD 8/2001: Guidance on Single Shared Assessment of Community Care Needs, ³ Circular CCD 8/2004: Guidance on Care Management in Community Care⁴ and The National Training Framework for Care Management (March 2006) ⁵ for trainers, managers and professionals.

34. From 2005 it has been a requirement that the SSA specifically discusses direct payments for self-directed care as an option for delivery of some or all of a person's care needs. So what makes direct payments different is not the assessment, but the way in which the agreed needs are to be met.

35. The expectation is that the local authority will also put users in touch with the local support organisations that they fund to help and support individuals exploring direct payments. The greater involvement the individual and a carer have in the assessment process and in decisions users take to use direct payments, the more likely it is that their direct payments will be a success for this person.

36. Direct payments give practitioners the opportunity to think more innovatively about how to support individuals to maximise their independence. Local authorities should consider how direct payments could assist people leaving hospital or residential accommodation. Local authorities may make direct payments available before the person leaves hospital or the care home to assist them during the transition from a hospital or a care home to their own home. A timely provision of direct payments may reduce the need for a more extensive provision of services in the future. It may also aid someone to regain their previous capability. Another key feature is that direct payments, if continued while someone is in hospital for a period of three months, may allow that individual to return home more quickly.

Informed consent

37. Eligible people who wish to receive direct payments must give their consent to do so, or if they lack the capacity to do so, consent can be given by an attorney or guardian. More detail is given in section 3.

Ability to manage direct payments

38. Throughout the setting up and managing of direct payments, the practitioner should consider what practical assistance the individual may need, which could be any of the following:

• advocacy help or encouragement to ask for what they need and/or take on a more active role in the assessment process and how care may be delivered afterwards;
• advocacy support to think through the implications of taking on direct payments and to consider whether this is what is wanted;
• expressing their choices and preferences between different types of support, for example, interpreters or other assistance may be required to communicate their views or preferences;
• being able to keep the necessary records;
• operation of PAYE through a pay rolling service;
• managing day-to day relationships with staff;
• appreciating and coping with the legal responsibilities that may arise if he or she becomes an employer;
• ensuring they get the support they have paid for; and/or
• managing direct payments on an ongoing basis even through periods of fluctuating or deteriorating condition.

39. Local authorities should ensure that they handle sensitively discussions about a person's ability to manage direct payments. Confidentiality needs to be ensured for users as well as their carers, family and other supporters. This is particularly important where the authority decides not to offer someone direct payments because it does not consider that, even with assistance, the individual will be able to manage them.

40. If the local authority concludes that someone would not be able to manage direct payments, it is good practice to discuss the reasons for the decision with the person, particularly if he or she disagrees and to put the reason in writing. Although the person may continue to be unhappy with the decision, the offer of an explanation is an important indication that the matter has been considered seriously. The authority should also make the individual aware that they can use the complaints procedure (see section 8) to challenge the local authority's decision not to offer direct payments.

Carers assessments

41. The 2002 Act gives local authorities a duty to inform carers providing 'a substantial amount of care on a regular basis' that they may be entitled to a carer's assessment. Where the carer requests an assessment, this is their ability to care, and it may be carried out separately, or combined with the assessment of the cared-for person.

42. It does not, however, give the carer an entitlement to Direct Payments in their own right. Its purpose is to clarify what the carer can do and what assistance they need in their caring role to be able to keep well.

43. What the local authority must do is take the carers assessment into account when making decisions about the support to be provided to the cared for person. Further information on this aspect can be found in guidance circular CCD 2/2003 Community Care and Health (Scotland) Act 2002 New Statutory Rights for Carers: Guidance in March 2003 ⁶.

Care/personal plans

44. A care plan describes how the assessed needs of an individual will be met and follows the assessment. It should be developed with the user and they should always be given a copy. If direct payments are to be used to fund part or all of the care plan, it is recommended that the direct payment agreement should be in the form of a contract between the local authority and the individual. This document should set out, in easy to understand language, the duties of the local authority as well as the individual.

45. A plan including a direct payments package should make clear for the benefit of both the user and the local authority:

• what the direct payments money may or may not be spent on;
• how much flexibility he or she has over how the money is spent;
• details of the type of variations to the package of support which the local authority would expect to be asked to approve in advance;
• what information and support the local authority will provide and where other support and information may be gathered. This would include information on support organisations, and when and how information on changes to a package will be provided;
• the information the individual will be expected to provide for audit purposes;
• any other conditions which the local authority has set.

46. Annex C to this guidance contains a checklist of what should be agreed/covered before direct payments start and which should be included in the agreement and care plan/personal plan.

Deciding how direct payments are to be used

47. Local authorities need to satisfy themselves that users are able to meet their assessed care needs, and should discuss exactly how users plan to do this prior to offering direct payments. Users can meet their needs by:

• contracting directly with service provider eg an agency/private provider/voluntary organisation (see section 4),
• employing staff to provide the services (see section 5);
• purchasing services from a local authority that does not have to be their own (see section 4); and/or
• other forms of support, for example, those used on a recovery journey after a period of mental illness (see sections 4 and 13).

48. By exploring innovative and creative options, it may be possible to identify alternatives that meet the individual's needs more effectively. For example, a combination of direct payments and local authority services may work best for some people. Or where the individual's needs fluctuate over time, it will be important to discuss in advance how the direct payments will be used to secure a package of assistance which varies according to need. Some flexibility over the way the money is spent will be necessary. The support purchased with a direct payment does not have to be the same as the service that the local authority would have arranged. What is important is that the support will meet the assessed needs of the person.

49. The 2003 Regulations prevent people from using direct payments to secure services from some family members. However, this is shortly to be modified by the Adult Support and Protection (Scotland) Bill (see annex A).

Costing a direct payments package

50. Direct payments must be sufficient to enable the recipient to secure support of a standard that will satisfy the local authority that the person's needs are being met. Local authorities should consider the arrangements which each individual proposes when deciding on the value of payments.

51. Each local authority decides on the amount of direct payments based on the support needed. The 1968 Act requires local authorities to make direct payments at a rate which is equal to the local authority's estimate of the reasonable cost, (based on the principles of best value in section 9) of the service users securing the provision of the preferred care assistance. This means that a direct payments package that purchases services from a service provider needs to take into account the service provider's range of hourly rates for day, night, weekend, bank and local holiday and emergency cover. Other types of packages, for example, those based on purchasing support from an independent sector care agency, will have slightly different cost elements, although these will tend to be more familiar to local authorities.

52. Many local authorities have set a maximum rate for standard agency care and if service users choose a more expensive rate they will be asked to pay the difference. This would not apply to care packages where a higher rate is needed to meet a more specialist need, for example, sign language.

53. The following is based on the assumption that payments will be used primarily to purchase personal assistance, with the user taking responsibility for employing their own workers directly.

Costing a Personal Assistant employer's package

54. A preference that many direct payments recipients have is to employ their own personal assistant ( PA). The following information is offered to enable the recipient, as prospective employer, to think through and resolve the costings.

55. Mandatory employments costs are:

• employers National Insurance (approx. 8.5%);
• holiday pay;
• sick pay & cover;
• maternity/paternity/adoption/dependents pay & cover; and
• fees for payroll and bookkeeping (average £1.50/week per PA).

56. In order to encourage good employment practice the following discretionary elements should be included where possible:

• training costs;
• employer's contribution to a pension scheme (optional 3-5%);
• emergency cover for staff absence (allowing for purchase of agency cover if needed);
• enhanced pay for Bank Holiday work (some schemes also offer enhancements for weekend work);
• protective clothing for PAs, for example gloves;
• administration - start up costs such as advertising and recruitment expenses, for example, travel expenses for prospective employees, formal appraisal of employees, public liability insurance
• employers liability insurance to protect employers and local authorities in the event that a PA employer is taken to a tribunal.

57. A critical element will be ensuring that PAs are sufficiently remunerated to wish to continue in that role.

58. Local authorities will need to discuss with the individual the arrangements that are planned to meet these costs. However, the local authority cannot be required to make direct payments to cover specific costs where there is a more cost-effective way of securing the service. Local authorities have discretion to decide whether to include an amount in the direct payments for costs, which they are not obliged to cover.

59. The local authority should give individuals as much notice as possible of the value of direct payments, and any contribution the person needs to make towards their care, before the payment begins or the level is changed.

Accessing a service user contribution

60. Section 87 of the 1968 Act enables the local authority to require the individual to make a financial contribution to the cost of any services they need to meet their assessed needs. Local authorities should refer to the Executive's circular No: SWSG l/97: Charging for Adult Non-residential Sector Care⁷ and CoSLA's guidance to local authorities on charging for non-residential care. In considering if an individual should make a financial contribution, local authorities should treat people who receive direct payments as they would treat them if the person was being charged for using the authorities equivalent services. Direct payments can therefore be made up of a combination of an individual's own contribution and a contribution from the local authority.

61. Local authorities are reminded that since 1 July 2002, people aged 65 and over, have been able to receive personal care services at home free of charge. Local authorities should refer to Executive circular CCD4/2002: Free Personal and Nursing Care ⁸, particularly Section 5: Payment Mechanisms. Where a person aged 65 or over chooses to receive direct payments to purchase this element of personal care at home the individual should not be asked for a contribution.

62. Those people receiving housing support services for services other than care or housing management. It should be noted that people in receipt of housing benefit and those receiving housing support services on a short-term basis (up to 2 years) will receive these services free of charge. Also people who receive housing support services previously funded from the Special Needs Allowance package will also receive direct payments free of charge. Details can be found in the Supporting People Charging and Financial Assessment guidance. ⁹

63. Under section 22(4) of the 1995 Act, local authorities have discretionary powers to charge contributions for children's services where the means of the family are sufficient.

Complaints about levels of direct payments

64. There may be cases where an individual thinks that the total value of the direct payments should be greater than the local authority proposes, and/or that his or her contribution should be less than the local authority proposes (see section 8). In such cases, the local authority is under no obligation to increase the amount offered. Nevertheless the local authority may decide to increase the amount enabling the person to secure his or her preferred service if it is satisfied that the benefits of doing so outweigh the costs. A consultative approach is encouraged towards reaching a decision about the level of direct payments. However, where a case cannot be resolved through discussion, the local authority should advise the individual that he or she might pursue the matter through the local authority's complaints procedure (see section 8).

65. While any complaint is being considered, the individual may choose to manage on the amount of direct payments being offered, without prejudice to the complaint that it is inadequate. Alternatively the person may choose to refuse to accept the direct payments, in which case the local authority must arrange the relevant services instead.