Archived decisions

Contact: Rea Mattocks Tel:01962 847200 email:[email protected]

1. Summary

1.1 This paper sets out the background to the Direct Payments Review, which was approved by Cabinet on 23 July 2007. It provides the results of the consultation and makes recommendations for future changes. The review of direct payments is a stage in the development of personalisation and self directed care. This report is presented to Cabinet as it affects both Adults and Children's Services and has implications for the Financial and Benefits team who are part of the County Treasurer's department.

2. Recommendations

2.1 The following decision is sought:

That cabinet approve the proposed changes to the Direct Payments scheme, including to introduce a self-assessment questionnaire, a support assessment tool, a risk assessment tool and the move towards outcome based care planning.

3. Background

3.1 In January 2007, the Direct Payments review was commissioned by the Hampshire County Council Adults and Children's Services departments to ensure that the Hampshire Direct Payments scheme still meets the needs of both departments.

3.2 The aim of the review was to ensure that the Hampshire Direct Payment scheme is simple for users to set-up and use, balanced with appropriate levels of control. The review sought to address the issues raised by the 2006 Internal Audit report. It also reviewed the scheme in the light of national direction to implement self-directed support. It is important to ensure that the scheme has a scaleable business process to cope with the expansion of scheme users.

3.3 In 1981, Hampshire County Council worked with service users to develop what we now know as Direct Payments. As the first county council to do this the County gained national recognition for demonstrating innovative thinking and valuing independent living. A Direct Payment is given to Service Users in lieu of a service provided or commissioned by the council. This enables them to exercise their right to purchase care from any third-party provider including individuals. Long-term residential care is excluded from the scheme. Service users get the benefit of increased choice of provider, more flexible care arrangements and often better value for money. Due to the direct contact with the supplier, service users have greater control over the quality of care they receive. Evidence is emerging nationally that better outcomes can be achieved for the same resource.

3.4 In December 2007, the Department of Health released a Concordat that called for local authorities to reform their Adult Social Care services to create a new high quality care system, which is fair, accessible and responsive to the individual needs of those who use services and their carers. The Leader has announced the setting up of a Hampshire Commission "Putting People First - Shaping your future, choosing your care". This will set Hampshire at the forefront of this key social care reform. Direct Payments are a key aspect of delivering personalised care, and the proposed changes outlined in this report are an important step towards delivering on this agenda. The findings from the Commission will play a part in the continuing development of Direct Payments and self directed care (personalisation).

3.5 A priority for this review has been to balance service users choice and independence, whilst ensuring that the process itself is sufficiently robust so that risks to the Council are adequately managed. Complexity and the monitoring process have been cited as potential barriers to the take-up of direct payments.

3.6 The number of Direct Payments users is a key national Performance Assessment Framework indicator for Adult Services. Historically, Adult Services has performed well. More recently, as a consequence of a change in the charging policy implemented in May 2005, there has been a reduction in the numbers of adults in receipt of a Direct Payment. At present, there are 882 adult service users who use a direct payment. The Commission for Social Care Inspection (CSCI) has identified increased uptake of Direct Payments as an area for improvement for Adult Services and is closely monitoring our progress in this area. Improvement against this indicator is likely to be a key factor in future star ratings.

3.7 Adult Services are forecast to spend £7.7 million on Direct Payments care packages and receive £0.7 million in service user contribution in 2007/08. This leads to a net cost of £7 million averaging a weekly payment of £188 for each service user. Children Services are predicting to spend £0.54 million on Direct Payments averaging £76 per week. 141 children with disabilities elect to take a Direct Payment in lieu of services.

4. Review findings

4.1 The review team set up a series of workshops and interviews with key stakeholders and a benchmarking exercise with other local authorities. The key findings from the workshops, interviews and the benchmarking exercise found that:

_ Hampshire needs to increase momentum in the effort to attract service users to Direct Payments.

_ Service users want to be involved in making improvements to the process and have given, and continue to give us feedback on what they would like changing and how.

_ Other authorities have a lighter touch in their approach to monitoring service user spend.

_ Other authorities are preparing for an outcomes-based approach to care management planning and monitoring in line with national guidance

_ User feedback indicates that the changes to the charging policy implemented in May 2005 has caused an overall reduction in the level of Direct Payment service users.

4.2 These findings informed a public consultation, carried out in accordance with the Hampshire Compact. The consultation process began in August 2007 and ran for 14 weeks. Over 400 people shared their views on self assessment, risk assessment, and outcome based planning.

4.3 The consultation resulted in a broad agreement that:

_ Self assessment of both finances and needs would be welcomed to help potential users assess the benefits to them of a direct payment. It would also help them prepare for the assessments. However, this was supported as a step before professional assessment, but not a replacement to it.

_ A risk assessment of what support users need to use direct payments would enable people to manage their money more effectively. This support could include an accountancy service and payroll service.

_ Care plans should be outcome based as should reviews and monitoring, which would lead to more flexibility in their frequency.

4.4 During the consultation there was a great deal of interest around self-reviewing. A number of service users suggested that they were in favour of self-review, particularly for more stable cases. They suggested that self-review would put them in control and help reduce the workload for care managers. It would also ensure that regular reviews take place. This is currently being looked at and a pilot, in Hampshire, in partnership with the Association of Directors of Adult Social Services, is being undertaken to establish how this could work in practice.

5. Proposed areas for change.

5.1 The findings from the review and the consultation have resulted in a number of key recommendations for updating the Hampshire scheme. A detailed case for change has been developed and is available on request. These are set out below.

5.2 Improved processes for service users.

5.2.1 The consultation looked at key areas which would ensure that the process of setting up and managing a Direct Payment was improved for service users. This covered self-directed assessment, use of a `support assessment tool' and the introduction of service user led reviews. Each of these elements is outlined in this section.

5.2.2 It is proposed that a form of self-directed assessment questionnaire is introduced. This would allow service users to assess their own needs and finances or carry out an assessment for someone else prior to the involvement of a professional for a full assessment. This will not replace assessments by professionals but will enable the person to be as fully involved in the process as possible from the outset and clearly fits in with the personalisation agenda.

5.2.3 It is proposed to introduce a `support assessment tool', to enable the care manager to assess and offer the right level of support to people choosing to take a Direct Payment. This will improve consistency in how much assistance service users are offered to manage their Direct Payments.

5.2.4 The consultation responses indicated that many service users wished to move towards service user led reviews. This would involve service users reporting on their level of health and wellbeing as a result of the direct payment.

5.3 Improved process governance.

5.3.1 It is proposed that the governance of the Direct Payment process is improved in a number of ways.

5.3.2 The introduction of a risk assessment tool with all service users will identify a more intensive monitoring regime for perceived high risk service users and reduce the time spent by the authority unnecessarily checking the bank details of low risk service users. This has been introduced to both support service users and to ensure that the system is robust enough for audit requirements. This is also in line with current CIPFA guidance which advises councils to take a light approach with due diligence.

5.3.3 The automatic referral of all users from the Contact Centre directly to the Financial Assessments and Benefits team will improve responsiveness to the service user and limit the loss of income from delayed referrals.

5.3.4 A new set of performance monitoring tools to record the quality and consistency of support being offered to service users on how to manage and use their Direct Payment.

5.4 To improve outcomes across all service users in Hampshire.

5.4.1 To ensure that outcomes are maximised for service users in Hampshire it is proposed that the Council move to outcome-based planning. This is in line with national policy on personalisation and Self Directed Servces. This would include a resource-allocation model for Direct Payments rather than the current model of an hourly rate.

5.4.2 The move to outcome based support planning and reviews will move the focus to how they can meet their identified needs. Currently we use an input based model. Inputs are what care is provided such as seven hours domiciliary care or two days a week day care. Service users have told us that care planning based on inputs reduces the flexibility they have to use their direct payments. An example of an outcome would be to overcome social isolation and have social contact and company (see table below to further illustrate the difference).

5.4.3 Outcome based care-planning means that people agree outcomes and can choose the way they achieve them. This gives them more flexibility with how they spend their Direct Payments to meet their needs. This is a key aspect of the Government's personalisation agenda.

Input	Outcomes
Domiciliary care	Personal cleanliness and clean environment
Day centre	Having social contact and company

6. Conclusion

6.1 Findings from this project for Direct Payments suggest that a number of issues need to be tackled. The recommendations apply to the set up and monitoring of direct payments for new and existing service users.

6.2 The approximate set up costs are £350,000 including training and IT costs, which will be resourced from the funding available to support the development of personalisation. The changes proposed in this report are also applicable to the wider self directed care project, which will provide benefits to a much wider number than current direct payment users.

6.3 The process will be managed to be at least budget neutral other than set up costs. Some efficiency savings may also accrue, depending on the impact of the growth in take up on the market. Direct payments nationally have produced modest efficiency savings.

6.4 The internal audit on Direct Payments carried out in 2006 resulted in 48 action points which were addressed in an action plan presented to the Governance Committee in April 2007. 32 actions were completed immediately and the remainder have been addressed in the review. We continue to monitor the progress against these action points.

6.5 This report covers the high level changes consulted on in 2007. A more detailed implementation plan will be developed once the outcomes of the review have been agreed. This will address learning and development, resources, detailed process redesign and timescales and ensure that all the issues raised by internal audit are actioned.

6.6 The changes proposed in this report will make the direct payments scheme easier to use, whilst providing a better framework for managing risk. It will also support the achievement of key performance indicators and sets important foundations for the wider development of personalised social care.

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1 Published works

2 Documents which disclose exempt or confidential information as defined in the Act

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