Innovative use of Carers Direct Payments: ideas...

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1 Innovative use of Carers Direct Payments: ideas from good practice Carers Direct Payments are most often monetary payments offered to carers who have been assessed by their local authority as eligible for social care services. The aim is to support them in their caring role. Direct Payments enable carers to buy services themselves to meet their own needs instead of having the local authority arrange social care services for them. Local authorities currently give Direct Payments at their discretion they are not legally obliged to provide services to carers. The Government’s Care Bill aims to change this and give carers a legal right to services when they reach the eligibility threshold. Nonetheless, though some local authorities do not provide Carers Direct Payments, many local authorities have provided a Direct Payments service to carers since they were introduced with the Carers and Disabled Children Act 2000. In some localities, Direct Payments may also be provided to carers using NHS funding or from a pooled health and social care budget, applying different eligibility criteria. This report focuses on Carers Direct Payments for people who provide care to an adult. It aims to guide good practice and provide ideas for commissioners, carer’s leads and practitioners on facilitating the innovative use of regular and one-off Carers Direct Payments. By innovative, we mean using Direct Payments not simply to give carers a break from the person they care for, but to give them something with added value that makes extra difference to them personally as an individual, e.g. art classes, driving lessons, or assistance on holiday with the person they care for. The document draws upon a literature review, interviews and feedback from people involved in commissioning and delivering Carers Direct Payments, and feedback from carers. In theory, how innovative can Carers Direct Payments be? Department of Health (2009) Guidance on Direct Payments: for community care, services for carers and children’s services states that ‘Direct payments allow carers to purchase the services they are assessed as needing as carers to support them in their caring role and to maintain their own health and well-being.i There are few legal restrictions on what Carers Direct Payments may be used for: they may not be used for equipment or services that should be paid for by the Health Service, normal household bills, or (in most instances) services to meet the needs of the person the carer looks after. ii They may not be used to pay for personal care the Department of Health (2010) Carers and Personalisation: improving outcomes best practice guidance, recommends that support for carers in the form of short breaks should be included in service users’ personal budgets. iii The 2009 Guidance clearly encourages innovative use of Carers Direct Payments, giving the following examples of their use: purchasing ‘flexible respite care’ - having a break from their caring role by using one-off Direct Payments to pay a personal assistant to come on holiday with them and the person they care for; purchasing a washing machine so they do not have to go out to the launderette; taking horse riding

Transcript of Innovative use of Carers Direct Payments: ideas...

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Innovative use of Carers Direct Payments: ideas from good practice

Carers Direct Payments are most often monetary payments offered to carers who have

been assessed by their local authority as eligible for social care services. The aim is to

support them in their caring role. Direct Payments enable carers to buy services

themselves to meet their own needs instead of having the local authority arrange

social care services for them. Local authorities currently give Direct Payments at their

discretion – they are not legally obliged to provide services to carers. The

Government’s Care Bill aims to change this and give carers a legal right to services

when they reach the eligibility threshold. Nonetheless, though some local authorities

do not provide Carers Direct Payments, many local authorities have provided a Direct

Payments service to carers since they were introduced with the Carers and Disabled

Children Act 2000. In some localities, Direct Payments may also be provided to

carers using NHS funding or from a pooled health and social care budget, applying

different eligibility criteria.

This report focuses on Carers Direct Payments for people who provide care to an

adult. It aims to guide good practice and provide ideas for commissioners, carer’s

leads and practitioners on facilitating the innovative use of regular and one-off Carers

Direct Payments. By innovative, we mean using Direct Payments not simply to give

carers a break from the person they care for, but to give them something with added

value that makes extra difference to them personally as an individual, e.g. art classes,

driving lessons, or assistance on holiday with the person they care for. The document

draws upon a literature review, interviews and feedback from people involved in

commissioning and delivering Carers Direct Payments, and feedback from carers.

In theory, how innovative can Carers Direct Payments be?

Department of Health (2009) Guidance on Direct Payments: for community care,

services for carers and children’s services states that ‘Direct payments allow carers to

purchase the services they are assessed as needing as carers to support them in their

caring role and to maintain their own health and well-being.’i There are few legal

restrictions on what Carers Direct Payments may be used for: they may not be used

for equipment or services that should be paid for by the Health Service, normal

household bills, or (in most instances) services to meet the needs of the person the

carer looks after. ii

They may not be used to pay for personal care –the Department of

Health (2010) Carers and Personalisation: improving outcomes best practice

guidance, recommends that support for carers in the form of short breaks should be

included in service users’ personal budgets.iii

The 2009 Guidance clearly encourages innovative use of Carers Direct Payments,

giving the following examples of their use: purchasing ‘flexible respite care’ - having

a break from their caring role by using one-off Direct Payments to pay a personal

assistant to come on holiday with them and the person they care for; purchasing a

washing machine so they do not have to go out to the launderette; taking horse riding

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lessons to have a break and get some exercise; improving a path outside of the house

to the road to make it easier for someone in a wheelchair to get into a car to go out; and registering to do a charity trek.

The Department of Health Guidance states: ‘As a first principle, councils should aim

to leave choice in the hands of the individual, allowing people to address their own

needs as they consider best, while satisfying themselves that the agreed outcomes are

being achieved.’iv Councils may set reasonable conditions on the Direct Payments but

are asked in the Guidance to bear in mind that their purpose is to give people more

choice and control. The Guidance also states that councils should avoid setting up

disproportionately intensive monitoring processes.v Hence, in theory at least,

innovative use of Carers Direct Payments – use of Direct Payments for something

other than simply giving the service user and carer time away from one another - is

encouraged.

Are Carers Direct Payments being used innovatively? What benefit does innovative use of Direct Payment bring to carers?

Evidence suggests that giving carers the opportunity for a break can have a positive

impact on mental health: a 2001 study undertake in England found that 17% of carers

who had taken a break of more than a few hours suffered mental ill-health compared

to 36% of carers who did not have such a break since beginning their caring role.vi

There are pressing reasons for reducing carer stress. For example, carer stress is the

reason for admission to nursing or residential care in 38% of cases.vii

Research by the

Princess Royal Trust for Carers indicates that carers need time to carry out everyday

tasks and value short inexpensive holiday breaks to ‘recharge their batteries and

improve mental wellbeing.viii

The National Carers’ Strategy Demonstrator Sites

programme was an 18-month funded programme that started in 2009. As part of this

programme, 12 sites offered ‘breaks’ for carers. Some of the Carers Demonstrator

Sites included provision of short-term respite, sitting services or holidays and the

evaluation of the Sites indicated that breaks supported carers to continue caring and

prevented carer breakdown (and hence emergency admission to hospital or admission

to a care home) in some cases.ix

We can thus assume that using Direct Payments to

fund time away from the person cared-for could make a significant difference to

prevent carer stress and breakdown, but what difference does use of Direct Payments

in other ways make?

There is a great deal of published research on Direct Payments, but little specifically

on Direct Payments for carers of adults. Evidence on use of Carers Direct Payments is

included as part of the evaluation of the National Carers’ Strategy Demonstrator Sites

programme, however the evaluation does not clearly separate those which were given

as Direct Payments and those which are provided as services in its conclusions. There

is also a considerable amount of material published on Personal Budgets, including

many examples of innovative use, but examples tend to focus on Personal Budgets for

service users rather than carers. Hence in addition to undertaking a review of the

literature, we also we invited people who work with Carers Direct Payments to talk to

us about Direct Payments in their area, to discuss the impact of innovative Direct

Payments, the barriers, and what works for them in facilitating innovative use of

Carers Direct Payments. 12 people across eight localities – commissioners, managers

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and practitioners in voluntary sector organisations, local authorities and Clinical

Commissioning Groups (CCGs) - were interviewed. Several more people - carers and

people who work with carers - also reviewed or directly contributed feedback to this

document.

One-off Direct Payments

Carers Direct Payments may be a ‘one off’ payment, regular payments or payment of

a large sum in instalments, depending on the choice of the local authority. According

to a survey undertaken by ADASS, in 2011-12 just under half of the 51,191 carers in

receipt of a personal budget received their budget as a one-off Direct Payment.x Some

local authorities package Carers Direct Payments as ‘grants’. Some split them up with

different labels in order to apply different eligibility criteria or rules around what they

might be used for (e.g. ‘Short Break Grants’, and ‘Direct Payments’ being used for

anything else that may maintain the carers health and wellbeing).

Evidence suggests that many Carers Direct Payments have already been used in

creative ways. In 2010, as a one-off exercise, Hampshire County Council’s Adult

Services Department gave 826 carers a one-off Direct Payment of £200 to support

them in their caring role. Carers could spend the money however they felt would best

support themselves. The exercise was evaluated to find out how carers spent the

money and whether it made a difference to them in their caring role. 470 of the 826

carers choose to take part in the evaluation. The top two things that they spent the

money on were holidays and gardening. Other things that people spent it on included

equipment, leisure activities, utilities, driving lessons, education or a training course,

purchase of computers, car tax and MOT.

Less than 5% of respondents said that the money made no difference in supporting

them in their caring role. Over 95% said it made a difference and 45% said it made a

big difference. Feedback included:

‘The money has made a huge difference – I was able to pay for individual sessions at

the gym and have some ME time’

‘The money gave me the chance to go out for the day with my family and enjoy all the

things other families take for granted.”xi

Since 2004, Dudley Metropolitan Borough Council have been running a Carers Direct

Payment scheme, open to carers who cannot afford a break. In Dudley, Carers Direct

Payments are one-off payments of £300 available to give carers of adults a break’.

This is interpreted very widely - grants can be given for holidays, and short breaks

(with or without the cared for person), leisure activities and hobbies and equipment

for a hobby (including gardening), driving lessons etc. They may be used in

conjunction with support offered to a service user. For example, the Direct Payment

could be used to enable the carer to do something they would enjoy while the person

they care for has respite or sitting provision paid for out of their own budget.

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Dudley evaluated Direct Payments for a sample of their 450 Carers Direct Payment

recipients in November 2011. 47 of the carers who responded used their Direct

Payment for holidays and 22 for short breaks. 7 used them for day trips. Some people

in Dudley who used their Direct Payment to pay for a holiday or break away from the

person they care for found it difficult to get respite or alternative care for the person

they care for. Some experienced difficulty in reassuring the person they cared for that

they would be looked after in their absence. The presence of such barriers points

towards the importance of having flexibility in terms of options for carers to do

something else for rejuvenation if circumstances mean they cannot have a break from

the person they care for. An example from Hampshire illustrates the importance of

thinking outside the box:

“Trust is a major thing. We had a family where the carer didn’t want to leave her son

but she needed a break. They have gone away on holiday as a family. We gave her

money to pay her daughter to look after her brother on the holiday because that is

giving her a break and the reassurance that her son is looked after by a family

member. So they all have a family holiday together but she doesn’t deliver the care.

It’s about encouraging people to think outside the box rather than just putting

someone in residential care for a week.” Officer, Hampshire County Council

Eight of the Carers’ Strategy Demonstrator sites (Bath and NE Somerset, Bristol,

Derby, Lewisham, Liverpool, Nottinghamshire, Suffolk, and Sunderland) provided

one-off payments to help with or cover the cost of a holiday for the carer with or

without the person cared for. Carers and staff noted that funding holidays for both the

carer and person cared for enabled them to spend ‘quality time’ and made an

otherwise unaffordable break possible. Other sites offered breaks that were accessed

by the carer and person being cared for together (such as meals out with the person

cared for or with friends or family, as offered in the Sunderland, Bristol and Suffolk

sites). However, sometimes having ‘a break’ together can mean that carers do not

really get a break or indeed end up with more stress. Bearing this in mind, Cheshire

and Warrington Carers Centre try to build trust in respite services so that carers

became more able to feel that they can leave the person they care for with someone

else and have time away.

Bournemouth West Integrated Community Mental Health Team (CMHT) provide

one-off Direct Payments of approximately £300 to carers of people with severe and

enduring mental illness who are clients of the CMHT. Many carers use them for

breaks away or days out. Other uses have recently included horse riding lessons,

English lessons for a gentleman whose first language was Spanish, mobile phone

credit to enable a carer to maintain contact with the person they care for, and a

dressmaking course. An officer from the CHMT explained that even a one-off Direct

Payment can help prevent carer breakdown:

“One chap was really struggling to cope and we gave him a Direct Payment which

enabled him to go away. The person he cared for had to go to replacement care to

allow that to happen. I don’t think he would have been able to continue to provide the

support he was giving without having that break. Everybody has limits of what they

can deal with.” Officer, Bournemouth West Integrated CMHT

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Most carers who obtain Carers Direct Payments from Bournemouth Borough Council

also spend them on a holiday or short break. However, for some carers, having time

away with or without the person they care for is not an option because of frailty or

mental illness, and there may be a preference for very different things to enhance

wellbeing.

“We have a case at the moment where the carer wanted to get a laptop. She has been

having difficulty getting out to go shopping so she will use the laptop to shop. Her

husband has dementia and she doesn’t feel comfortable leaving him to go to the

market or shops. There are other services she could use to enable her to get out, but

she decided she wanted a laptop to shop online. Also her daughter is moving abroad

and she will then be able to Skype with her daughter and the grandchildren by using

that. So it's a creative way of actually improving their quality of life.” Debbie Hyde,

Bournemouth Borough Council

Other uses of Direct Payments from Bournemouth Borough Council recently have

included choir membership, refresher driving lessons, college courses and gym

memberships.

In Bristol, one of the types of one-off Direct Payments currently available is aimed at

carers who are supporting people that do not use social services. The reason they

might not use social services might be because the person cared for refuses social care

services or because the cared-for person is not eligible for them. This means that

people with only low moderate needs, self-funders, people with mental health

problems and no social care need, and Continuing Health Care clients currently may

be able to access Direct Payments in Bristol, whereas in many places in the country

they would not be able to access this form of support. To give an example, one

Continuing Health Care client towards the end of life received a Direct Payment to

enable him to go to church once a week. The funding from these Direct Payments

mainly comes from the NHS through a pooled budget. A recent example shows how a

Direct Payment might be used to keep a carer in employment:

“We had a lady who works full time and was in moderate need and had a one-off

Direct Payment. She was able to rent a ‘Just checking’ system, which is new assistive

technology, so she could stay in work and know her mum is ok.” Debbie Charman,

Bristol City Council

Another example from Bristol shows how a Direct Payment may help people

maintain relationships that have been affected by caring responsibilities:

“There is an elderly couple and the wife has moderate dementia but no social care

need and the husband was struggling. We gave them money to go on a steam train

trip because that was what they always used to do together. It enabled them to revisit

the things they used to do together before she got ill.” Debbie Charman, Bristol City

Council

In 2011-2012, in addition to holidays and short breaks, Direct payments were used in

Dudley for karate lessons, to attend concerts, meals out, attend football matches, go to

speedway meets, evenings out, exercise classes, health treatments, gardening

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equipment, pampering and shopping, fishing tackle and a fishing licence, new TVs

and computers, amongst other things.

‘Paid for 12 month Gym membership. The gym is only 2miles from dad's home, so I

can go after I’ve washed, dressed and fed father. An excellent way to use the grant

money.’xii

The 2012-13 scheme is currently being evaluated and carers giving feedback are

pointing out how the Direct Payments have given them the opportunities,

opportunities they otherwise would no longer have, of being looked after themselves

(e.g. through pampering or by being waited on at a restaurant), doing things they used

to enjoy (e.g. playing darts and pool), having some social contact (e.g. by having a

day out and the chance to converse with other people there, or by having the chance to

visit family and friends), or realising an inexpensive dream that was previously denied

to them because their caring responsibilities meant they could not afford it.

“All my life I have been a steam enthusiast. I loved them as a child and have always

wanted to go on this trip going over the Ribble Valley Viaduct. Both my wife and I

care for our son for twenty-five years so this trip was impossible. He died and now I

am the main carer for my wife. With caring all our lives money is very scarce so the

trip was still impossible. The money you sent helped us to realise this dream... We had

a wonderful day and gave a silent thank you to your office as we passed over this

wonderful Ribble Valley Viaduct structure. Many many thanks for this opportunity

you gave to me and my wife. We will remember this trip forever.” Carer, Dudley

Respondents are also highlighting the benefits upon their health or how these things

can keep them going. Several are also mentioning Direct Payments as bringing

something into their lives that is guilt-free or lessens feelings of guilt.

“Last year I bought a puppy Yorkshire terrier. The allowance covered the price of the

dog and some injections for her and I was able to get a bed and a dog carrier.

Because my husband suffers from depression and goes to a day centre twice a week, I

find myself very lonely. I have kept dogs before and thought she would be a kind of

company for me. It also gives me distraction from my circumstances and gets me out

for a walk each day. She is lovely company and a loyal little friend… the toll of caring

for someone often sucks the life out of you, leaving you unable to plan or arrange

anything for yourself/ so to receive something for yourself to use for yourself is like a

breath of fresh air to me and there is no guilty feeling of using house money just for

yourself. I am eternally grateful for this help.” Carer, Dudleyxiii

Over half of the Carers’ Strategy Demonstrator Sites (Bath and NE Somerset, Bristol,

Lewisham, Liverpool, Suffolk, Sunderland and Torbay) provided a Direct Payment

for the purchase of equipment or domestic goods that would enable the carer to do

something unconnected to their caring role (e.g. a computer for social networking

with friends and family, online shopping and leisure, or a bike). Staff in the Sites

noted that this enabled carers to choose something that met their individual needs (i.e.

rather than just choosing an existing service they could choose something

personalized to them). They felt that this can be a relatively cost-effective way of

meeting carers needs. Carers said this made new hobbies or leisure activities a

possibility for them. They appreciated the flexibility and choice that this option gave

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them.xiv

Carer Direct Payment Awards given by Telford and Wrekin Council usually range

from £100-£500, although higher amounts may be awarded. Money from the NHS in

a pooled budget is used to top up the Direct Payment Award budget if that pot runs

out. Direct Payments are most commonly used for breaks and relaxation therapies,

laptop computers, gym memberships and driving lessons, but some uses are more

unusual. The following example illustrates the importance of listening to the carer

about what will make a real difference to them and considering giving the go ahead

on something you would not usually give approval for.

“One social worker was working with a couple and they didn’t go out much. She went

out to do a bit of shopping but that was it. They didn’t socialize much at all. Her

partner was housebound. The social worker talked to them. They talked and talked

and she said ‘what I really would love is.. I sit her looking at this carpet day in and

day out and I’m ashamed to invite the neighbours in.’ This carpet was literally

threadbare. The social worker came back to me and said ‘what do you think?’ And I

said ‘well, if you can demonstrate that it will improve her wellbeing and quality of life

then I would go for it.’ And we did and I think the whole thing cost about £850. When

the social worker went back again and the lady had had neighbours in. She felt every

morning when she came down it was fresher, it looked lovely, it lifted her mood. It

tipped the balance of her wellbeing. For that particular carer, it was very relevant to

enhance that person’s quality of life.” Jill Tiernan, Telford and Wrekin Council

Other diverse examples of things Telford and Wrekin have given Direct Payments for

include sofas, flying lessons, French lessons, college courses, motorbike repairs to get

the carer back on the road, and hobby equipment.

Eight of the Carers’ Demonstrator Sites (Bath and NE Somerset, Bristol, Derby,

Lewisham, Liverpool, Suffolk, Sunderland and Torbay) gave one-off Direct Payments

for activities or courses to improve carers’ wellbeing. These were used in various

ways including alternative therapies, gym memberships, stress management courses

and pampering sessions, sometimes in conjunction with alternative care such as

sitting services. Carers said that therapies and gym memberships improved their

fitness and wellbeing. They said that using Direct Payments in this way promoted

relaxation and reduced their stress as well as facilitating weight loss. They also said it

increased their confidence and self esteem as well as providing an enjoyable

experience. Staff also noted that it reduced stress amongst carers, brought confidence,

gave carers a chance to relax and helped carers make positive lifestyle changes to

improve their health and wellbeing. xv

Cheshire and Warrington Carers Centre manage the Carers Personal Budget Project,

which currently funded by the Primary Care Trust. A multiagency panel, consisting of

staff from the Carers Centre, local authority and the CCG meet twice a month to make

decisions on awarding money for Personal Budgets. The money is most often

received as a Direct Payment of up to £500, which can be given in one lump or in

smaller chunks over a period of up to six months, depending on the request of the

carer and their circumstances. Some of the things carers have recently spent their

Direct Payment on include ballroom and Bollywood dancing, microlight lessons,

driving lessons, photography courses and weightwatchers.

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“We had someone who had microlight lessons. He was probably in his late 60s and

caring for his adult daughter and that's what he used to do when he was younger

before he had all of this responsibility. So it's the only time he had felt free. He’s up in

the air and nobody could get hold of him if they tried…

One lady joined Weightwatchers. The Direct Payment paid for her enrolment, the

books. She lost over two stone. She says she can fly up the stairs now. Its helped her

in her caring role as well but its making friends, having regular breaks, having

something else to focus on.” Steph Garner, Cheshire and Warrington Carers Centre

Regular Direct Payments

We do not have published evidence on what carers of adults currently spend regular

Direct Payments on across the UK. However, anecdotal evidence suggests that many

spend them on existing social care providers and services, using care agencies for

sitting/ ‘home based-respite’ or PA services so that either the person cared for or the

carer themselves can get out of the home. In other words, people are fitting into

existing ‘off the peg’ provider services. This is not ‘wrong’ or a problem: we know

that such services are very important to many carers and can help with emotional

wellbeing, reducing strain and giving peace of mind.xvi

Nonetheless there are strong reasons why local authorities should also consider how

they might better facilitate the more creative ways carers might use regular Direct

Payments to support them in their caring role and maintain their health and well-

being. One is that ‘alternative care’, such as use of sitting services and PAs, is not

acceptable to some. Feedback from carers in the National Carers’ Strategy

Demonstrator Sites indicated that those care for are sometimes reluctant to go

somewhere without their carer and it can be difficult or undesirable for carers to leave

the person they care for with someone else.

‘I got a greenhouse from the carers’ centre... It has helped me at a lot, but I don’t

know anything about breaks - I wouldn’t leave my husband with anyone. I would

rather be with him 24/7 and my son.’xvii

Another reason is that research shows that carers often have to give up things and put

their own lives on hold when they start caring for someone. The Survey of Carers in

Households found that in 2009-10, around two in five carers (42 per cent) said their

personal relationships, social life or leisure time had been affected because of the

assistance they provided. Those who had been affected in this way were asked an

unprompted question to establish the effects of caring. The most common effects were

having less time for leisure activities (69 per cent), being too tired to go out (32 per

cent), being unable to go on holiday (23 per cent) and the effect upon their own health

(20 per cent).

When asked about spending time doing social or leisure activities specifically, 25 per

cent of carers said they had less time with friends and 20 per cent had less time for

pastimes or hobbies because of their caring responsibilities.xviii

Recent research

undertaken by Carers UK between 2010 and 2011 has shown that 78% of carers have

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cut back on holidays and 74% have cut back on leisure activities as a result of

caring.xix

Carers UK’s State of Caring 2013 survey found that 74% of carers have cut

back on seeing friends and family in 2013.xx

Commissioned support services for carers do not always help mitigate this impact on

carers’ lives:

“I’ve found that not everyone wants to go to carers support groups for carers of

people with a particular condition. They don’t really want it rubbed in their face all

the time that they are a carer and this is the most they can expect in life. They don’t

always want any bit of leisure time that you can give them to be about caring.” Alison

Myers-Ward, Hampshire County Council.

‘Making it real for carers’, co produced by carers, tell us carers want to see in

practice:

“The space to be someone other than a carer.

Time to pursue my own hobbies and interests without worrying about the cared for

person.”xxi

If people are allowed to use them innovatively, Direct Payments can meet these

needs.

“There is often confusion [amongst practitioners) around what is a ‘carers service’.

It has to be something beneficial to the carer. Many people do carers assessments and

identify day services for the service user as a need for the carer as they think it will

give the carer a break. I say, that's ok, that can go in the support plan and personal

budget of the service user, but what does the carer get? What is specifically for them?

They may well only be able to use that time to try to catch up with the basic daily

things they are behind on, the housework, not do something that will really benefit

their wellbeing. Also, the clients may refuse services and the carers still need help

and are entitled to the assessments – they need something that is specifically for them.

Respite alone might slow the point at which crisis is reached but some innovative use

of Carers Direct Payments means the situation of carers can actually improve, e.g.

relationships. For example, give them back the things they have had to give up, the

things that people who aren’t carers have, such as the chance to learn new skills,

resume a hobby and the chance to be looked after or pampered themselves. Its fine to

put a need for respite on the form and in the service user’s resource allocation but

you also need to consider what can be put in place to actively improve the carers life,

not only give them a bit of time to tread water rather than drown.” Officer Hampshire

County Council

Only three of the eight organisations we spoke to provided regular Carers Direct

Payments. In Hampshire, regular Direct Payments may be given to eligible carers if it

is agreed at assessment that they will provide what carers need to support them in

their caring role. One-off Direct Payments for specific items or courses may

accompany regular Direct Payments - the frequency and amount is determined by the

carers assessment. An example from Hampshire shows that Direct Payments can

make a difference in carers’ aspirations as well as their wellbeing:

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“We have a carer who has had reiki training. We arranged a Direct Payment for her

because she wanted a break from her caring responsibilities. We said ‘how can we

make a difference for you?’ and she said, “Well I’ve always wanted to do reiki

course. I’ve never had time to do it.” We said ‘well how can we help you?’ and the

carer said “well I can’t afford it.” So we said ok. The service user, her partner, can

be left on his own. So the carer did this course and she practiced on her partner and I

think it helped their relationship. So he benefitted from her class as well. She did the

introductory year. Then she did another year as well to go on further. Her aim was

then that she might eventually be able to get a little bit of money by doing reiki, which

is brilliant. So it gave her a break and it gave her something to work towards for the

future and I think her wellbeing improved dramatically.” Officer, Hampshire County

Council

Bristol City Council has a similar arrangement to Hampshire with regards to regular

Direct Payments for carers. Carers in Bristol who are assessed to be in ‘critical’,

‘substantial’ or ‘exceptional’ need and are supporting people eligible for social

services can get a set amount as a Direct Payment per week, with the amount

determined by the carer’s level of need. Substantial need equates to £45 per week,

which is the value equivalent to a three hours sitting service. Critical need would

attract £60 per week, which is the value equivalent to four hours’ sitting service.

Carers and practitioners in Bristol are encouraged to think of things other than using a

sitting service if that is not what they need. For example, they might spend the money

on a gardener so they do not have the additional worry of being unable to keep the

garden up together as a result of their caring duties. In Devon, regular Direct

Payments are sometimes are used for facilitating specific hobbies, e.g. art classes, but

most carers choose to use them to buy domestic support, such as help with ironing

and cleaning.

At the Carers Demonstrator sites that offered regular or ‘one-off’ or payments to help

with the costs of support with practical activities in the home such as gardening,

cleaning, shopping and home repairs (Bristol, Lewisham and Suffolk), staff

commented that such practical help in everyday life was a priority for some carers

rather than having a break from caring. They said it makes carers lives easier and

reduces stress. There was a perception amongst carers that support to improve or

maintain their home environment has a positive impact and reduces stress and

anxiety.xxii

Ideas on what can help facilitate innovative use of Carers Direct Payments

Raising awareness of, and improving access to, carers DPs in the community

Recent research undertaken by SPRU on local authority practice relating to carers

involvement in personalisation (main findings due summer 2013) has found that

carers often decline the offer of their own assessment because they cannot see its

purpose having contributed to the service user assessment. This means people are

likely to be missing out on Carers Direct Payments they may be entitled to. As

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support in the form of short breaks is often technically under the control of the service

user, carers do not have equal control to the person they care for. The study suggests

that if carers do not take up the offer of a separate assessment, the carer’s needs

should be fully assessed during the service user assessment and documented

sufficiently for any additional carers’ funding to be allocated separately to them to

meet their needs as carers.xxiii

In Hampshire, the officer responsible for Carers Direct Payments attends service user

and carers forums, BME groups and user-led organisations’ meetings to tell them

about Direct Payments and other services available to carers, and raise awareness of

what a carers service is to combat the commonly-held assumption that it equates to

day services for the person cared for or respite in a care home.

“The community needs to be educated as to what a carers service is. Carers don’t

realise it is for them. They never think about themselves.” Officer, Hampshire County

Council

One suggestion was that carers should be notified as a matter of course that Direct

Payments might be available to them.

People told us that carers are often reticent with regards to taking up something for

themselves that is free, so some may require a deal of reassurance about Direct

Payments. Debbie Hyde, Bournemouth Borough Council, says,

“Carers are sometimes unsure – they say, can we really do that?”

Jill Tiernan of Telford and Wrekin Council adds,

“There is a cautiousness amongst carers. It’s like we are giving something for free

and people really struggle with that idea. Carers are a fantastic bunch of people and

are not used to getting something for nothing. People are humble. They don’t always

think of themselves, they think of the person they care for in the first instance, so when

you have something that is going to help them and its free, there is a cautiousness.”

In some areas, statutory authorities have linked up with voluntary organisations to

provide more access routes to Direct Payments. Telford and Wrekin Council have two

types of one-off Carers Direct payments. Any carer can apply for a ‘Short-term Break

Grant’ of £60 if they are registered with the Carers Centre (a voluntary organisation

who manage the grant on behalf of the Local Authority). Carers can also apply for

‘Direct Payment Award’ if they are eligible once they have had a carers assessment at

the Centre or via the Local Authority. Hence people need not have a relationship, or

prior relationship, with the council to get a service.

Similarly in Devon, in addition to Direct Payments that are given by the County

Council to carers assessed as eligible, one-off cash payments are provided through

Devon Carers, a voluntary organisation. The funding for this additional service is

provided by Northern, Eastern and Western Devon CCG and Devon County Council.

To obtain the cash payment, carers do not have to have any contact with the local

authority. They fill in a simple questionnaire that is based around known risk and

stress factors for carers and this determines the amount they will get. Carers can use

the money for any purpose. They are encouraged to use it for hobbies and outings to

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add value and enjoyment to time out. In Dudley, organisations who work with carers

can also submit applications for a carers Direct Payment to the local authority - it does

not have to be done by a social worker or other local authority employee. This means

that there is a strong awareness about Carers Direct Payments amongst groups and

organisations in the community and, again, people do not have to already be in touch

with social services themselves to find out about the service.

For some local authorities, awareness of carers Direct Payments is very high and this

means demand may be too great. Worcestershire County Council have given Carers

Direct Payments for almost 10 years. Currently, workers can apply for a maximum of

£200 per carer, per year. When applying, they need to explain how the requested use

of the payment will help the carer maintain their caring role and will mitigate against

the more negative impacts of caring. The majority of Carers Direct Payments are

spent on holidays taken either whilst the person cared for is in respite, or together

with the person. Other things they have been spent on include gym memberships,

relaxation therapies and hobbies or interests.

Worcestershire commission a voluntary organisation to provide information, advice

and support to carers and as part of this, if relevant, Carers are informed about carers

assessments and the Carers Direct Payment. Because demand is so great,

Worcestershire have had to restrict access to Carers Direct Payments. Eligibility is

controlled by a carers assessment, developed by Worcestershire and based on Fair

Access to Care Services (FACS) guidance. Carers Direct Payments are only granted

where it is demonstrated that the caring role would be at critical or substantial risk of

breaking down if the identified outcome that the Direct Payment aims to achieve was

not met.

Having a clear message on what they can be used for and providing inspiration to carers.

People we spoke to stressed the need to have a clear message to carers about what

Direct Payments can be used for. However, they were keen that if examples were

used to promote innovative use of Direct Payments, they should be present as ideas

for inspiration rather than as a set menu.

Dudley have a short but clear message that they use to tell people what their Carers

Direct Payments are for without being too prescriptive: “Grants may be used for

holidays, breaks, days out and a variety of leisure activities. Carers do not need to be

too specific. Grants must be used on an activity which the carer does. They can be

used to have a break with the cared for person but may not be used to fund formal or

informal ‘respite’.”

Other organisations have used particular devices to try and inspire people to use their

Direct Payments innovatively.

“I started a scrapbook with letters and photos and that kind of thing to show other

carers what they might like to do and pictures on the wall as well so that when people

come into the office people get a feel of how its benefitted other people.” Steph

Garner, Cheshire and Warrington Carers Centre

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Last year, Telford and Wrekin Council produced a ‘Carers Passport’ which included

the information about Direct Payments alongside information about free carers events

and activities, such as pampering days, and discounted mainstream leisure activities

and courses.

“The Passport was an attempt to try and get that information out to people. We found

locally that people need inspiring. We would ask ‘well what do you think you would

like the money for?’ and the carer would say ‘well I don’t know, I can’t think’. So we

say ‘in an ideal world, what would make a difference to you?’ And they would say

‘Well I’d like more respite for Joe’. So we would say ‘well we can look at that

through other means, but this is money for you to help you continue in your carer’s

role, to improve your quality of life or improve your wellbeing’ and try to inspire

them. So the Passport was for carers to inspire people on what they could do.” Jill

Tiernan, Telford and Wrekin Council

Educating councils, partners and practitioners on the purpose of carers DPs and giving carers the control.

Practitioners we spoke to agreed that local authorities, voluntary organisations and

health services needed to gain greater understanding that a Carers Direct Payment is

not for respite services or replacement care for the person cared for, but something

specifically for the carer.

“I think local authorities have to agree to let go a bit and trust the carer and stop

thinking that carers need [social] 'services' - on the whole they don't, although the

person they look after certainly might. It is also about everyone understanding the

difference between respite/PA support, etc. funded through a service user's Direct

Payment to meet the outcome of carer support, and giving the carer a Direct Payment

of their own for them to spend on something that they identify will give them a break

and lead to feelings of well being.” Christine Rowley, Dudley.

Some also said that it is a challenge to stop social worker and care manager

practitioners perceiving Carers Direct Payments as something that would diminish

their budget for service users - their priority. When asked what would help encourage

innovative use of Carers Direct Payments across the county, having money for carers’

services in a separate budget to money for service users was mentioned.

“We’ve got separate budgets so we can monitor if the money has been used, and if not

why? It helps practitioners because we, the Carers Unit, hold the budget and our

team is responsible for the monitoring and control of that. It’s not up to practitioners

to think ‘oh, we need to protect our budget’. The budget is there and our team will tell

you if it’s not being used or otherwise. If it’s needed, its needed, they shouldn’t need

to try to hold back on spending. However, the assessed need must come from the

worker, and not applied for simply because the carer has asked for it” Alex Daniel,

Worcestershire County Council

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However, it was mooted that ring-fencing budgets for Carers Direct Payments alone

might not necessarily enable practitioners to feel more comfortable in giving carers

cash payments to spend on well-being.

“When you have a family carer who is doing all the laundry and housework for an

elderly relative who won’t accept anyone else doing it, we could actually give the

carer some money to get a cleaner for their own home. Staff really struggle about the

idea of giving people money for that because as far as practitioners are concerned,

the social care budget is not to go on cleaning. And I say ‘no, its fine, its not for the

service user, it’s for the carer’. It's a big thing to move the mindset on that. It takes a

real shift in possibilities.” Debby Hyde, Bournemouth Borough Council

Some interviewees suggested that what helps, or what would help across the country,

is training or educating frontline practitioners about what Carers Direct Payments can

and cannot be used for, challenging cultures of control and changing tendencies to

focus on only social care services.

“I think it would really help to give practitioners more training and more guidance.

As practitioners we need to know what we can and can’t use them for and know the

process for setting them up. We are not experts in Direct Payments. I think it’s almost

a fear to a certain point. With commissioned services we have always got that control

over delivering it. You always have to be realistic with carers around expectations -

Direct Payments seem like a blank cheque but there isn’t a lot of funding there. We

don’t want to be going out to carers making promises that we can’t deliver.” Karen-

Lisa Palmer, Hampshire County Council

“There isn’t necessarily a great deal of knowledge about the possibilities for Carers

Direct Payments. I think having case studies more available would give practitioners

and carers more knowledge about the breadth of what they can actually do. We need

examples of what people have done and what difference it has made to them, because

it is often simple personalised solutions that will have the biggest impact. Its not

necessarily being ‘innovative’ or ‘creative’, it’s just doing things differently.” Sophie

Smeeton, Devon County Council

“We need to change the mindset that everything has got to be the classic type of care.

We need to consider the carer’s interests and the life they have had prior to caring –

we need to ask what things they liked to do when they could do it. Did they draw?

Travel? Did they like to follow sports? What was their recreation at home?” Alison

Myers-Ward, Hampshire County Council

Having leadership, through a dedicated team, a lead or through carers’ champions

who can give prompting, guidance, support, and help with processes, seems to help

encourage innovative use of Carers Direct Payments in some local authorities.

“We have a carers’ unit team and we work with the people who do the carers’

assessments. We regularly update them on the services that are out there and on how

the carers assessment process works. We are trying to embed carers into every stream

of work and it helps because they think of it outside of the service user work. It helps

them to recognise carers as individuals. It helps that we have dedicated people to do

that work - not to do the assessments for them- but we support them in the process

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and in awareness. We work with them to use the services available appropriately.

We’ve gone beyond the stage of having to remind them that there is money in the

budget to apply for. Having done all of that work over the years, we are now in a

good position where we have workers in teams that are more like carers’ specialists

and know the carers services out there, such as training, information, Direct

Payments and breaks and that helps.” Alex Daniel, Worcestershire County Council

“Across the Council, practitioners are understanding it more and being more

innovative and creative because they think ‘ooh we can do this’, you don’t just have

to pay for somebody to come and sit. We are getting more realisation of what people

can do with the money. We have a network of carers’ champions across the Council

and we have regular meetings and send out guidelines. It’s communicating with them

and getting the message out by word of mouth through the carers’ champions. Word

of mouth is always better. Because I look at all of the carers assessments, I can go

back to practitioners and say ‘maybe, have you thought about…’ and they say ‘oh,

can we really do that?’ and that’s another way of kind of giving people permission to

think creatively.” Debbie Charman, Bristol City Council.

Where voluntary organisations do carers assessments on behalf of local authorities,

they also need encouragement to support carers in ‘thinking outside the box’.

“I have done quite a lot of work with the voluntary sector, enabling them to be more

creative as well. And they are now comfortable in feeling that they can encourage

carers to be creative, rather than ‘you can have £500’ for a holiday’, knowing that

there is the flexibility to be much more person-focused and personalised.” Debbie

Charman, Bristol City Council.

Supporting carers to be innovative and overcome barriers in a person-centred way

Having initial person-centred support at the assessment stage was identified as

important. It should be not just filling in a form but sitting down with the person and

taking time to work out what sort of break would help them the most and identify any

barriers specific to that individual. Sometimes using a tool can help in looking at the

carer holistically as a person rather than just in the context of the person cared-for.

“Carers don’t like to have to fill in a form and put down what their level of needs are.

They need to talk it through with someone really. It’s quite rare that you have

someone who comes in and says ‘I want driving lessons’ or ‘I want to do this’. A lot

of the carers we see caring, for example, an elderly husband, tend to really not know

what to do with a Direct Payment and people that have been in the caring role quite a

few years who haven’t had that change in routine don’t tend to know what to do. So

it’s about unpicking that at the appointment. It's a supportive process. It’s usually an

hour with the carer. We get the application done and its basically like an informal

chat… We are using the Carers Trust Pilot Caring Star as our model, which helps in

identifying things such as social needs. Usually by the end of that appointment we

have a general idea of what they want to do. The support appointment gives people

the opportunity to think about something else other than caring and you usually find if

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you haven’t got something down by the end of the appointment, when you ring them to

let them know if the funding panel have awarded them the money they will have had

the chance to think about it.” Steph Garner, Cheshire and Warrington Carers Centre.

Interviewees identified practitioner and conversation skills as key to enabling carers

to think ‘outside the box’ and use Direct Payments creatively. Observation at the

person’s home, and focusing on the carer as a person rather than just looking that

them in the context of their role as carer can help in drawing out potential ways in

which carers might use Direct Payments in an innovative way that really makes a

difference to them.

“When I do a carer’s assessment I always look not just at what the carer does for the

person but also try to build upon their interests and the things that they like to do. I

spent some time working with a carers’ support group when I was a student social

worker and lots of carers highlighted that sometimes they feel left out. As

practitioners we don’t always listen to their view - we put in things like sitting

services and respite services but that is more for the client. I worked with an elderly

couple where the husband had advanced dementia. Because of the nature of his

dementia he was very agitated and very possessive about his wife so if she went out of

the room he would get very upset. I spent a long time with her and managed to draw

the conversation out from the paintings in the room. I noticed them and was able to

approach that as a subject. I said ‘Aren’t they good’ and we were able to start from

that. And it turned out that the carer actually painted a lot of these paintings. In her

words, painting was like a relief. She had been able to escape from things when she

was painting. She said she really missed her art. So I said ‘what if we can find a way

so you can take part in art again?’.

There is a lot of research about the benefit of art therapy so that’s what we talked

about, and how to get her escape. She wanted to go to an art group, but because of

his advanced dementia and his following her, and because of her own health

problems and the stress it might cause she was too worried about leaving him. We

looked at a plan B for what could give her that escape. So I worked with the care

agency to commission a sitting service. We usually engage them so the carer can go

out for a couple of hours but in this case I said to the carer that she didn’t need to

leave the home - so I was able to build trust up with the sitting service. In time, I was

able to get her a Direct Payment of £100, a one-off, for her to purchase art materials.

Now she could go and paint in the garden or in the lounge without her husband

following her and she had the reassurance that this person was there with her

husband - if her husband could see her, he was settled. I went and did a review about

four weeks afterwards and the feedback was that she really benefitted from it.

I always look at ways to engage the carer to try to look at their interests and steer it

away from their caring role as such to make them feel valued as a person They are

not just a carer, they are a wife, they have a life as well, they are a person in their

own right. We’ve all got our different interests and values. This is what I try to draw

out.” Karen-Lisa Palmer, Hampshire County Council

Sometimes carers need extra time to think and some inspiration.

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“I think some of it is trying to help practitioners think outside the box of what might

benefit carers because people have for so long thought ‘respite - the cared-for person

can go into a home and the carer will stay at home on their own’. It can be hard to

change that way of thinking and also for carers to think that they are getting money

from the state that is not means-tested and it’s for their own health and wellbeing. We

talk to carers about the money that is available and might give pointers like ‘these are

the kinds of things that people have done before’ and give carers time so they don’t

have to make that decision there and then on what break they would like the money

for. They have time to think about what really might make a difference. Carers tend to

be so in the moment with the stress of caring that they almost can’t think past that and

they need time to think what they could benefit from.” Emma Moody, Bristol CCG

Sometimes the barriers carers face with regards to having a break or ‘me time’ need

drawing out. To overcome them may mean practical support has to be offered,

resources in the community need to be identified and utilised, and staff need to think

outside the box themselves.

“It is a struggle to get carers to think that they can have something for themselves. A

lot of carers, certainly the carers I experience, mainly older people, they have a lot of

gratitude for anything that comes their way and are almost like ‘I dare not ask’. I find

people will usually accept a sitting service and they might say ‘well I want to go out

with friends or do something without feeling in any way that I am disloyal to the

person I care for. I want to do interesting things, like go sailing, but I don’t want to

feel that my loved one is sat there and can’t go out.’ Often it is so interrelated. The

carer is stricken with conscience that ‘I don’t want to do it if my loved one can’t do

it’. So when I look at something for the carer, I also look at the loved one to make

sure they have something to do.” Alison Myers-Ward, Hampshire County Council

“We do have a few people who still don’t know what to do and we would have a

follow-up appointment to look at their hobbies and interests and things like that. We

would look at if they have additional things that are barriers - e.g. if they are too

stressed to cope with organising taxis - that we could help with and overcome so they

can have a break. We may need to look at resources available in the community such

as a voluntary sitting service that is free. It’s not just about taking a break, it’s

making sure everything else is in place so they can take a break and know that

everything will be ok. There are other barriers. For example, we have had carers

being unable to go on holiday because they had no one to go with - so we put them in

touch and they went on holiday together and that worked out really well. Having the

confidence to go and do something unknown is a barrier. We usually say do little

things slowly. ” Steph Garner, Cheshire and Warrington Carers Centre

Being flexible about payments

Carers Direct Payments may be a ‘one off’ payment, regular payments or payment of

a large sum in instalments, depending on the choice of the local authority. Department

of Health (2009) Guidance on Direct Payments: for community care, services for

carers and children’s services asks that councils bear in mind in the circumstances of

potential recipients in determining frequency of payments. A survey undertake in

2012 by Carers Trust suggested that only a small number of local authorities are

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flexible with regards to the frequency of payments to carers and give carers the

choice.xxiv

Though the Department of Health Guidance states that people may ‘bank’

any spare money, and that this may be particularly useful where people have long-

term and fluctuating conditions, the Carers Trust survey found that many councils

have rules in place prohibiting build up of contingency funds, and thus limiting

choice.xxv

In Hampshire, payments are arranged according to the outcomes of the carers

assessment: they are paid in the way that will enable the carer to meet their outcomes.

They are most commonly regular payments. The Council does not prohibit build up of

contingency funds up to six weeks.

“What we find is most carers don’t attend their own health appointments. This is not

good and should not be happening. So we say, if you know you have an appointment

two or three weeks down the road it’s ok to put some by so that you can get someone

to help the person you care for while you go for your hospital appointment, or if you

need emergency cover. If you are looking at thousands of pounds built up, then we

would reassess and probably need to take some back because they are not using it to

meet outcomes. Saving £50 here, £100 there is fine, but you, the carer, do need to let

us know- we need to document it on the support plan to show that there is a need

there to accumulate.” Officer, Hampshire County Council

In Devon, carers can build up seven weeks’ of their Direct Payment in their account

before the local authority will check if there is a problem or a previously unidentified

need.

In Bristol, regular payments may be adjusted if the carer would prefer to have some of

the total money they would get in a year as a lump sum to enable them to acquire a

particular item that would really help them.

“If the thing a carer with a substantial need would benefit most from now is, for

example, a bed or a mattress, we could give them a one off payment of £500 and then

do the calculations so the Regular Direct Payment would kick in 11 weeks later after

that – so that the total for the year equates to £45 per week. We have just supported a

carer who has very bad sciatica who didn’t have a bath in her bathroom and was

desperate to have a bath. We got the local voluntary sector home repair agency to do

the work at a very discounted rate and gave her a one-off payment to pay for the bath.

Then we made the calculation for the ongoing Direct Payment so that will continue in

due course for her to spend on a sitting service or whatever else she needs at that

time. All she wanted was this bath.” Debbie Charman, Bristol City Council

Some carers find regular Direct Payments stressful because of the record keeping

required, so having one-offs available may be important.

“A lot of Direct Payments scare carers because of the record-keeping. One-off Direct

Payments are good because it’s just a matter of being able to show the evidence on

what you sent it on if asked. When asked about Direct Payments a lot of carers say

‘Oh no, I can’t possibly think about that at the moment, its too stressful. I find that a

one-off Direct Payment is easier for them to accept.” Karen-Lisa Palmer, Hampshire

County Council

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Alternatively, introducing a pre-paid card system may help carers find regular Direct

Payments more attractive, enabling local authorities to easily keep track of spending

and removing that burden from the carer. Devon County Council has recently

introduced such a system:

“We have just introduced a pre-paid VISA debit card to make it easier and I think

that should make a difference because obviously we are not asking people to set up a

bank account. It is pre-loaded with the Direct Payment and people can spend that

flexibly whenever they want. It also means the authority can see what the spend is. It

means the carers don’t have to send in evidence of what they spend. It reduces a lot of

the paperwork and makes the initial offer of a Direct Payment a lot easier because

you are not asking them to do something. So it makes the process a bit easier for

carers.” Sophie Smeeton, Devon County Council

Being flexible on who and what Direct Payments can be used for

Evaluation of the Carers Strategy Demonstrator sites showed the importance of giving

carers choice and being flexible to meet carers’ individual needs to enhance their

wellbeing. In the sites, carers’ ‘breaks’, delivered through a Direct Payment or in

some instances as commissioned services, could take the form of training, courses,

leisure, goods, holidays with the person cared for, employment support, help with

gardening and domestic jobs etc., as well as alternative care such as sitting services

and short breaks for the carer. Evaluation found that these personalised ‘breaks’

achieved positive outcomes and gave carers time for themselves. Staff highlighted

the benefits of increased choice, control and meeting of individual needs, which came

with flexibility with particular regard to the varied types of breaks carers could choose

or identify for themselves, and the flexible eligibility criteria applied (the services

were not restricted to those caring for a person with a community care assessment of

‘critical’ or ‘substantial’ need). Research undertaken by Carers Trust indicates that there are differences amongst

local authorities on what carers can use Direct Payments for and some specifications

may prevent carers from experiencing flexibility and choice.xxvi

20 of the 52 local

authorities who took part in the Carers Trust survey said that carers cannot use their

Direct Payment to purchase alcohol, tobacco and gambling.xxvii

These restrictions

have been imposed by the council’s themselves, not the Department of Health. It

understandable that many local authorities are risk adverse in this way, it means going

to Bingo, going to the races, going to the pub, having a glass of wine with a meal,

activities that may be enjoyed by the wider population, are all activities that may be

denied to many carers.

The people we spoke to in this study said alcohol, tobacco and gambling were rarely

mentioned in requests for Direct Payments, if at all. Some prohibited their use and

some did not (though it was clear that if gambling and alcoholism was a problem for

the person concerned and the Direct Payment would therefore not enhance wellbeing,

the request would be declined).

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“In Dudley, carers decide what will give them a break. It’s what personalisation is all

about. We have such no restrictions. These carers are all adults! If going to Bingo

meets their outcomes and then who I am to say they can’t go? It will give them the

social contact that they want - who could argue with that? ” Christine Rowley,

Dudley Metropolitan Borough Council

“If something came up, we would look at it on an individual basis. Carers know what

will give them a break.” Debbie Hyde, Bournemouth Borough Council

Local authorities can currently specify their own eligibility criteria for carers services.

Carers usually have to complete a carers assessment and meet a specified level of

need, which may vary according to which local authority runs the scheme. Additional

criteria can include things such as proof of financial need, requiring the cared for

person to also have critical or substantial needs as well as the carer, or only giving a

Direct Payment if the person cared for has declined services. In some localities, Direct

Payments may be packaged as a range of different ‘grants’ for different types of

support, e.g. short breaks, help with domestic tasks and leisure activities, each with its

own different eligibility criteria. In contrast, in Dudley there is one Direct Payments

grant that can be used for any type of carers’ service, which, arguably, may prevent

confusion, at least amongst carers.

Pooling budgets

In some of the organisations we spoke to, the NHS and social care services funded

one-off Carers Direct Payments through a pooled budget using a Section 75

Agreement. A commissioner working in Bristol CCG, explained that, by breaking

down the barriers between health and social care using this budget, more carers can be

supported - carers in need who are not in receipt of social care services. Because

people do not have to be eligible for social care services to get a Direct Payment it

makes it easier for practitioners to feel they can promote Direct Payments, and their

innovative use, to carers.

“One of the biggest benefits is breaking down the barriers between health and social

care. Once people are totally health-funded (under Continuing HealthCare) social

care no longer have a responsibility for the service users/patients care. Health has

then traditionally focused on the patient, and the carer can remain in need but no one

is actually supporting them. The Integrated Carers Team and the money we have

allocated have really allowed us to support this group of carers effectively. Rather

than passing people between health and social care we can say ‘we are responsible’

for supporting carers and the money is there to support them. Before it might have

been felt ‘well I don’t want to raise expectations and carry out an assessment because

if the carer is not at the critical or substantial level of need, they won’t get anything.’

Now it doesn’t matter whatever the level of need, as long as there is some caring

going on and it is affecting their quality of life, we are able to provide something. So

it is always going to be a good thing. So when practitioners recognize a need,

something can be done now, and that has made a big difference to how practitioners

approach carers assessments.” Emma Moody, Bristol CCG

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Evaluating the service

People we spoke to talked about the need for more case studies to help both carers

and practitioners gain knowledge about the scope and benefits of Carers Direct

Payments, and hence use them innovatively. It was suggested that more evaluation

would help provide such case studies. Evaluation has also led to continued investment

in innovative Carers Direct Payments in some local authorities.

“Crucially we devised that really simple evaluation form which produced fantastic

feedback ... so our budget was then doubled to allow about 450-500 Direct Payments

a year. Carers like it, staff like being able to give the carers ' a treat' - often when they

cannot do much else (perhaps because of the person looked after refusing help). It

keeps on delivering great outcomes. So maybe that is what people need to do, get that

that evidence of how well it works.” Christine Rowley, Dudley Metropolitan Borough

Council

It was suggested that it can be difficult for social workers and care managers to

understand Carers Direct Payments because they are so used to having to work within

strict limits in relation to expenditure on social care services. Arguably, better

evidence for the preventative benefits of Carers Direct Payments would help to win

hearts and minds of practitioners and commissioners and help them feel able to

encourage innovative use of Direct Payments. However, such evidence is difficult to

obtain.

“The trouble we have is how we gather the actual evidence on how we have sustained

the caring role to demonstrate to commissioners that investment in the service is

needed. We have recently developed a feedback form to go out to carers which will

hopefully capture how its gone in terms of sustaining people in their caring role in

key areas such as health and wellbeing, relationships and things. Obviously we need

to word it in more carer-friendly language. We need some more evidence because all

we get from workers is ‘ it benefitted them and they want it again’ and a few

comments like ‘it recharged the batteries’.” Alex Daniel, Worcestershire County

Council

“We’ve got some research to back it up, but people still say ‘well how do you know

that it prevents the situation from breaking down?’ At the moment we can’t really say

that X amounts of investment now equates to X amount of continuing caring at home.

There is research out there but it’s quite patchy.” Debbie Hyde, Bournemouth

Borough Council

Clearly, whilst anecdotal and qualitative evidence is sometimes gathered, further

research to quantify and cost out any preventative benefits of Carers Direct Payments

is needed. One piece of work along those lines is currently in progress: Bristol CCG

and Bristol City Council Adults and Children’s Services have commissioned the

University of the West of England (UWE) to evaluate their carers’ breaks services,

which includes their one-off Direct Payment service.

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“We thought it was best to have it evaluated externally rather than trying to do it

ourselves. UWE are looking at the breaks and how they improve quality of life for

carers and also the economic impact on the health and social care system. Everybody

says it is a very good idea to give carers’ breaks but nobody has quantified what that

actually means and demonstrated the impact that breaks can have on the health and

social care system. UWE are working with a company who do a lot of the evaluations

with the National Institute for Health and Care Excellence (NICE) and they are

looking at the breaks and the value based on feedback from carers to try and attribute

costs to it. It is quite an extensive evaluation and there is a lot of national interest in it

as well because it hasn’t really been looked at previously.” Emma Moody, Bristol

CCG

The findings from this evaluation should be available end of 2013 or early 2014.

Rachel Dittrich

29 August 2013

This mini project is part of the Social Care Evidence in Practice (SCEiP) project

funded by London School of Economics and Political Science's Higher Education

Innovation Fund. The author would like to thank the carers who gave permission for

their stories to be used, the professionals who consented to be interviewed or

reviewed this report and mentors Laura Clohessy and George Julian. Particular thanks

are due to Gary Spencer-Humphrey for his help and inspiration.

i Department of Health (2009), Guidance on Direct Payments Guidance on Direct

Payments: For community care, services for carers and children’s services, p.75.

London: Department of Health.

http://www.cambridgeshire.gov.uk/NR/rdonlyres/A2CC66B2-DB2C-40C7-92E9-

3C971D78565C/0/dh_121131.pdf. ii Gheera, M. (2012), Direct payments and personal budgets for social care.

http://panet.org.uk/wp-content/uploads/2012/11/SN037351.pdf. iii

Department of Health (2010), Carers and personalisation: improving outcomes.

London: Department of Health.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213806

/dh_122383.pdf. iv

Department of Health (2009), Guidance on Direct Payments Guidance on Direct

Payments: For community care, services for carers and children’s services, p.11.

London: Department of Health.

http://www.cambridgeshire.gov.uk/NR/rdonlyres/A2CC66B2-DB2C-40C7-92E9-

3C971D78565C/0/dh_121131.pdf. v Department of Health (2009), Guidance on Direct Payments Guidance on Direct

Payments: For community care, services for carers and children’s services, p.33.

London: Department of Health.

http://www.cambridgeshire.gov.uk/NR/rdonlyres/A2CC66B2-DB2C-40C7-92E9-

3C971D78565C/0/dh_121131.pdf

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vi

Singleton, N. et al. (2002), Mental Health of Carers. London: Office for National

Statistics, The Stationery Office. vii

Bebbington, A., Darton, A., Netten, A . (2001), Care Homes for Older People:

Volume 2. Admissions, needs and outcomes. University of Kent, Personal Social

Services Research Unit. viii

Princess Royal Trust for Carers (2011), Any Breakthrough for Carers? Glasgow:

The Princess Royal Trust for Carers and Crossroads Care. ix

Yeandle, S. and Wigfield, A. (eds.) (2011), New approaches to supporting carers’

health and well-being: evidence from the National Carers’ Strategy Demonstrator

Sites Programme, p.108-110. University of Leeds.

http://circle.leeds.ac.uk/files/2012/08/new-approaches-report-jan-12.pdf. x ADASS (2012), Personal Budgets Survey March 2012.

http://www.adass.org.uk/images/stories/Policy%20Networks/Resources/Key%20Doc

uments/PersonalBudgetsSurveyMarch2012.pdf. xi

Johnston, T. (2010), Hampshire County Council DP Carers One-Offs 2009/10

Evaluation project. Unpublished. xii

Rowley, C. (2012), Carers Direct Payments – feedback report 2011-2012.

Unpublished. xiii

Corespondence with Christine Rowley, Dudley Metropolitan Borough Council. xiv

Yeandle, S. and Wigfield, A. (eds.) (2011), New approaches to supporting carers’

health and well-being: evidence from the National Carers’ Strategy Demonstrator

Sites Programme, p.91. University of Leeds.

http://circle.leeds.ac.uk/files/2012/08/new-approaches-report-jan-12.pdf. xv

Yeandle, S. and Wigfield, A. (eds.) (2011), New approaches to supporting carers’

health and well-being: evidence from the National Carers’ Strategy Demonstrator

Sites Programme, p.91. University of Leeds

http://circle.leeds.ac.uk/files/2012/08/new-approaches-report-jan-12.pdf. xvi

Victor, E. (2009), A systematic review if interventions for carers in the UK:

outcomes and explanatory evidence, p.102-103. Essex: the Princess Royal Trust for

Carers. http://static.carers.org/files/systematic-review-15-jan-3840.pdf and Yeandle,

Y. and Wigfield, A. (eds.) (2011), New approaches to supporting carers’ health and

well-being: evidence from the National Carers’ Strategy Demonstrator Sites

Programme, p.91. University of Leeds http://circle.leeds.ac.uk/files/2012/08/new-

approaches-report-jan-12.pdf. xvii

Yeandle, S. and Wigfield, A. (eds.) (2011), New approaches to supporting carers’

health and well-being: evidence from the National Carers’ Strategy Demonstrator

Sites Programme, p.90. University of Leeds

http://circle.leeds.ac.uk/files/2012/08/new-approaches-report-jan-12.pdf. xviii

HM Government, Health and Social Care Information Centre (2010), Survey of

Carers in Households – England, 2009-10.

http://www.hscic.gov.uk/pubs/carersurvey0910. xix

Carers UK (2011), The cost of caring: how money worries are pushing carers to

breaking point.

http://www.carersuk.org/media/k2/attachments/The_Cost_of_Caring_1.pdf. xx

Carers UK (2013), The State of Caring 2013.

http://www.carersuk.org/media/k2/attachments/State_of_caring_report_PDF_version.

pdf.

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xxi

think local act personal (2013), Making it real for carers, p.7.

http://www.thinklocalactpersonal.org.uk/_library/MIRcarers_FINAL_13_August_201

3.pdf. xxii

Yeandle, S. and Wigfield, A. (eds.) (2011), New approaches to supporting carers’

health and well-being: evidence from the National Carers’ Strategy Demonstrator

Sites Programme, p.91. University of Leeds

http://circle.leeds.ac.uk/files/2012/08/new-approaches-report-jan-12.pdf. xxiii

Glendinning, C., Mitchell, W. and Brooks, J. (2013), Carers and Personalisation:

Discussion Paper for the Department of Health. Working Paper No.DH 2576. xxiv

Carers Trust (2012), Progressing Personalisation: a review of personal budgets

and direct payments for carers, p.5.

http://www.carers.org/sites/default/files/progressing_personalisation.pdf. xxv

Carers Trust (2012), Progressing Personalisation: a review of personal budgets

and direct payments for carers, p.5.

http://www.carers.org/sites/default/files/progressing_personalisation.pdf. xxvi

Carers Trust (2012), Progressing Personalisation: a review of personal budgets

and direct payments for carers, p.13.

http://www.carers.org/sites/default/files/progressing_personalisation.pdf. xxvii

Carers Trust (2012), Progressing Personalisation: a review of personal budgets

and direct payments for carers, p.11.

http://www.carers.org/sites/default/files/progressing_personalisation.pdf.