Managing the pressures placed on local authority social care practitioners in the drive towards more personalised services has been anecdotally debated over the last decade.  The challenge of delivering personalisation where a person lacks capacity in relation to their social or health care needs, creates confusion and anxiety amongst many.

The take-up of direct payments and personal budgets by user groups viewed as ‘vulnerable’ or ‘unable to manage’ their own needs has been the subject of some debate.  Several studies (Newbeggin, with Lowe, 2005; Kinnaird & Fearnley, 2010; Wittenberg et al, 2015) suggest that they can improve overall outcomes where they have been successfully established.

Guidance issued by the Department of Health in 2009 (DH, 2009) aimed to create a process whereby a person assessed as lacking capacity can still access personalised options such as direct payments and personal budgets.

This paper, published in Health and Social Care in the community earlier this year (2016), reports the findings of a qualitative study conducted in 2011/2 focusing on the practice in six local authorities in relation to ‘indirect payments’.  Here, a close family member or friend receives a direct payment on behalf of the person lacking capacity.  This is used to arrange and deliver an appropriate support package.  The process should then be monitored by the Local Authority to ensure the persons ‘best interests’ are met.

Methods

The study used an interview-based design, drawing on the experience of a self-selected cohort comprising sixty-seven social work practitioners and eighteen recipients of ‘indirect payments’ of behalf of someone else.

The participants were in six LA areas and represented a diverse purposive sample of geographic and demographic area profiles. The LA identified possible participants who were then contacted by the research team and invited to participate. Indirect payment recipients were all recruited via the practitioners identified by the LA’s.

Semi-structured interviewing enabled the identification of thematic data.  Coding methodology was applied to categorise the findings from the interview process.

Findings

The thematic findings of the paper are arranged around five key decision points within the process of establishing an ‘indirect payment’.

• The decision to take up an indirect payment – at what point does the authority identify that making a direct payment to a person who is suitable to manage the payment on behalf of someone else?
• Deciding that a person lacks capacity – who is best placed to undertake the capacity assessment and what are the specifics of the question being considered?
• Is an indirect payment in the person’s best interest? While many of the aspects of this process may be considered to be a best interests decision, this paper focuses on whether personalised funding is considered to be best interests and supports the delivery of personalised outcomes.
• Deciding who the suitable person will be – this is a key issue as it appears that family are the usual choice and not everyone has this level of support.
• Deciding how the payment will be used – a focus on the support, planning and monitoring processes.

Several key points are highlighted in relation to different perceptions of professionals and family members.  Information sharing is noted as one of the areas that required attention in the practice being examined for the purposes of this study.

As with other areas of mental capacity assessment and practice, the conflation of several decisions was identified in the study.  Practitioners commonly confused the capacity to consent to a payment. with the capacity to manage a payment or support package.  Key aspects which created difficulties included record keeping, monitoring and liaising with the LA in relation to financial arrangements and ensuring an individual’s needs are being met.

While the paper focuses on assessment of capacity leading to best interest decision making, what it doesn’t do is recognise that each of the decisions highlighted are separate capacity issues. The importance of the principles of the Act should be kept central through any MCA process and whilst the authors do highlight the sequence of the process (assessment – decision making) this does need to be more specific to be fully aligned with the current understandings and case law precedents for decision specific, time specific decision making.

Discussion

The authors acknowledge their sample was not representative based on self-selection, size and the potential bias of those choosing to respond (or not) to the invitation to participate. It is also the case that the study itself was undertaken in 2011/12.  It may well represent practice that has since moved on and a legal framework that continues to evolve.  This may also have an impact on its application to current practice.

Despite these limitations what this paper does highlight is some of the issues that practitioners continue to grapple with in relation to working with at times seemingly competing public sector agendas.

The paper itself sets out a critical perspective to the use of indirect payments.  The practice of supporting a family member or friend to manage a direct payment on someone’s behalf may well be contributing to a two-tiered system.  Those who have family or close friends receive one level or service whereas those who are isolated with no family or friends will have what is provided and have no access to a more personalised support option.

Conclusion

While reinforcing themes that are already well established in terms of the challenges of working in a personalised way with those who are unable to decide for themselves, this paper offers little new information or knowledge to inform practice in this area. It does raise some interesting and important questions but unfortunately does not offer further discussion or suggestions. Its usefulness to practice is limited to being a reminder of how we could be doing more to make sure a person’s best interest are kept in focus.

 

Links

Primary paper

Jepson M, Laybourne A, Williams V, Cyhlarova E, Willimason T, Robotham D. Indirect payments: when the Mental Capacity Act interacts with the personalisation agenda. Health and Social Care in the Community (2016) 24 (5), 623-630.

Other references

• Department of Health (2009) Guidance on Direct Payments: For Community Care, Services for Carers and Children’s Services. Department of Health, London.
• Kinnaird, L. & Fearnley, K (2010) Lets Get Personal – personalisation and dementia. Alzheimer Scotland.
• Newbegging, K., with Lowe, J (2005) Implementing direct payments in mental health. Joseph Rowntree Foundation. [Accessed 15/12/16]
• Wittenberg et al (2015) Evaluation of Direct Payments in Residential Care Trailblazers: Second Interim Report. London: PIRU. [Accessed 12/11/16]

Image credits

• peasap, CC BY 2.0
• Ken Teegardin, CC BY 2.0;
• Transformer18, CC BY 2.0