councils (30).
2 The number of local authorities that responded from each English region was as follows: East (6); East Midlands (7), London (27), North East (9), North West (17), South East (13), South West (7), West Midlands (11), Yorkshire and the Humber (12).
3 Nationally, the proportion of local authorities receiving DPDF awards over the two rounds were: unitary authorities (77%), London boroughs (64%) shire counties (68%) and metropolitan districts (83%).
12. FACTORS AIDING AND HINDERING THE IMPLEMENTATION OF DIRECT PAYMENTS
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Conclusions
Pace of growth
There is little doubt that take-up of direct payments has increased markedly since the introduction of the 1996 Community Care (Direct Payments) Act, yet it is also clear that implementation varies considerably across the UK and between service user groups. As we have shown from the survey, take-up – and policy development generally – has been considerably stronger in England than in Scotland, Wales or Northern Ireland. (Official figures for the period to March 2005 support this finding, suggesting that the number of recipients per thousand adult population in England is approximately double the number elsewhere in the UK.) This raises questions about the impact of devolved governance on equity and social justice for people supported by social care services and their carers across the UK (Priestley et al. 2006).The higher response rate to the survey among local authorities in England may also be symptomatic of greater readiness and resourcing for policy development. Local capacity for implementation in many English authorities has been
underpinned by the Direct Payments Development Fund established by the Department of Health. Reports from the National Centre for Independent Living suggest that this Fund may have had a positive impact on overall numbers of direct payments users and on the extension to specific ‘new’ user groups – 70% of development funding was targeted at specific user groups (Hasler 2006) –
although a fuller evaluation of this initiative has not yet been completed. There are also signs of increased policy responsiveness in Scotland: supplementary survey work conducted for the Scottish Parliament in early 2006 indicates that Scottish authorities are now in a much stronger position to monitor and report on direct payments than was the case in 2005.
People with physical impairments continue to be the largest group in receipt of direct payments, mirroring the historic prominence of this group in advocating policy reform prior to 1997 and the later extension to some other groups. However, there is substantial evidence of change, with particular increases in the rolling out of direct payments to older people, and to parents of disabled children. But such growth needs to be seen in context: uptake remains very low compared to the overall pool of potential recipients.
There has also been a shift in the dynamics of implementation. While the development of direct payments was strongly associated with local user-led support organisations in the early years, this relationship is becoming less pronounced, with increased diversity in types of support organisation and in new user groups. The historical legacy of early activism and policy development remains most evident for people with physical disability or sensory impairment, with greater take-up of direct payments persisting in those local authorities or regions particularly associated with pioneering schemes prior to implementation
New dynamics have emerged, a good example being the influence of In Control – initially strong in North West England, but now nationwide – with its support for person-centred planning and direct payments for people with learning disabilities. Making direct payments available to people with learning disabilities requires investment in intensive and ongoing support using methods such as
user-controlled or family-led independent living trusts (Williams 2006; Gramlich et al. 2002; Leece 2003) and these systems of support are still in very short supply (Luckhurst 2006). It is also relevant that people with learning disabilities continue to receive low-level access to the kind of individualised services that direct
payments could be used to purchase, such as supported self-employment (Ridley et al. 2005). People with learning disabilities are now at the forefront of the general policy swing towards individual budgets and there is likely to be an increasing focus on the role of direct payments within schemes being developed to support people to work out their own life plans and support services (Williams 2006).
Data on the growth of direct payments and the timing of policy developments suggest that central government initiatives have had considerable impact on implementation. Prima facie, the shift to mandatory duties, the provision of development funding in England, and the introduction of performance targets and indicators appears to coincide with increased provision of direct payments, particularly where implementation was lagging (Fernandez et al. 2007; Priestley et al. 2006).
On the other hand, there appear to be limits to the impact of central drivers. In comparison with other groups, the number of direct payments recipients identified as mental health service users remains very low. This has partly been attributed to the episodic nature of some mental health experiences and the recruitment or retention of appropriate staff (Spandler and Vick 2004), but recent explanations also point to the impact of uncertainties among staff about roles and responsibilities and accountabilities in the wake of local service reorganisation to integrate health and social services, workload pressures (including the extent to which work is dominated by crisis response), often compounded by the view that direct payments are more demanding on care coordinators’ time (Spandler and Vick 2005). The recent Department of Health guide to action aims to alleviate such dilemmas in England and underline the necessity for progress despite ongoing work pressures (Department of Health 2006a), while a Care Services Improvement Partnership toolkit provides local councils and their partners with the means to make an assessment of their current situation and develop an action plan to support direct payments implementation (Care Services Improvement Partnership 2006).