Cardiff pioneers autonomy in social care

“Wales has taken its own approach to people managing their own care. Direct payments for care have to be offered by local authorities in Wales but in practice have been taken up by a relatively small number of older people. A direct payment is available to people who have been assessed as needing community care and who qualify for help with the cost. It enables people to arrange care for themselves.”

“Gawd bless the NHS!” I’ve had occasion to say that over the years and now I must add in the IWA which, in its report Adding Life To Years quoted above, made me aware of the existence of Direct Payments for social care. These aim to concretise the rhetoric about care being self-directed, user-driven and empowering rather than imposed, inflexible and based on the whim of the provider – the opposite, in fact, to my forelock-tugging gratitude à la cartoonist Steve Bell’s urban peasantry.

I must tell my ninety-seven-year-old mother that she is at the cutting edge of developments in the delivery of social care in Wales. Not before time, is her likely response. Things bode well for the country’s ability to exploit creatively certain opportunities within U.K.-wide legislation – if the will remains strong. Cardiff in particular is seeing unique developments. Back in September 2010 I contributed a piece to ClickonWales (here) about the impact of discovering Direct Payments:

“No social worker has ever mentioned Direct Payments to me. Ever. Even though one of my (three) relatives is 95, one is a stroke victim and one, until his recent death, was dependent on a 23-year-old quadruple heart by-pass. Even though I was also a busy professional caring for a chronically ill child and coping myself with a physical disability. Even though it became clear that the forms of care that the Social Care Services could offer was not meeting my relatives’ needs or that there were problems within some of the care agencies themselves.”

My indignation was justified because social workers have an obligation to put the Direct Payments option to every person who is assessed as needing care. Under Direct Payments, money that might have gone to care agencies goes to the client who can employ ‘Personal Assistants’ directly and receive the care within much more flexible time-frames, which they can directly control. The legal obligation was set aside, I believe, because of a bias by social workers against the system. This was based on assumptions about the difficulty faced by clients in implementing it, particularly in sourcing suitable employees and managing the finances.

These employment and financial management issues were also identified by a Scottish Government report on self-directed support (Self-Directed Support – A National Strategy for Scotland – here) as the main reasons for low take-up of Direct Payments. However, due to some innovative developments that looks set to change – at least in Cardiff.

Direct Payments have been an option since 1996. However, a significant change in financial management issues occurred in Cardiff in 2011 when a Managed Banking system was developed by the Cardiff and Vale Coalition of Disabled People. This allows clients to choose to have all the financial elements of being an employer of Personal Assistants dealt with – previously clients were obliged to open a bank account. In April 2011 there were 190 Direct Payment clients on the Coalition’s books. Managed Banking came in as a pilot scheme in June and this number rose to 310 by October 2011. There are about 1800 adult domiciliary care service users in Cardiff.

In December 2011 Diverse Cymru was launched, a merger between the Coalition and Awetu, an organisation dealing with the mental health needs of black and minority ethnic people in Wales. This new body has an equality agenda and it is under the name of Diverse Cymru that Direct Payments are now facilitated on behalf of Cardiff Council. The Managed Banking scheme costs the client nothing which is unique – other providers run similar schemes but charge for them.

Diverse Cymru also provides a support service for clients in the recruiting and management of employees. Crucially, it recognises that care is delivered, very often, over long periods of time during which care needs change. It is not a question of putting responsibility into clients’ hands and then abandoning them with a once-and-forever arrangement. Diverse Cymru has worked with Cardiff Council over the last four years on developing the requirement for potential Direct Payments employees to be CRB-checked (not every Council insists on this). Diverse Cymru has also developed an AGORED-accredited training course for personal assistants .

My prediction is that, providing that clients are properly informed, the experience of Direct Payments in Cardiff so far will mean that the number taking advantage of it will increase dramatically in future. It remains to be seen how other Welsh councils will deal with Direct Payments.

It is important to note the context within which these developments in the delivery of social care are taking place. Cardiff Council recently reduced the number of care agencies with which it has a framework agreement from 56 to 11. As part of this exercise there has been a significant increase of Service Users who are now receiving Direct Payments to pay agencies who were not one of the 11 selected by Cardiff, as these users wished to maintain their existing arrangements.

Any growth in the uptake of Direct Payments has potential implications for care agencies who may fear a loss of business. This may not however be the case as Direct Payments clients will always need contingency cover which may come from an agency. Direct Payments clients may also choose a mixture of agency and personal assistant care.

The Welsh Government’s vision for social services is set out in its White Paper Sustainable Social Services for Wales: A Framework for Action, a precursor to a Social Services Bill for Wales in 2013. This will take account of the Welsh Government commitment to Citizen-Directed Support.  There is creating an opportunity to develop a Wales-based model, given that the Welsh Government’s Equality commitments have gone further than England in the enactment of certain parts of the 2010 Equality Act, as set out in the Equality Welsh Measure.

I have no doubt that Direct Payments are a sign of the social care times because they advance the user-directed agenda. Their great advantage is that they do away with the distressing lack of continuity of care which is a feature of many care agencies’ provision. They also dispense with the frustratingly low standard of training that so many agencies provide.

Instead, the clients can satisfy themselves of their employees’ skills before taking that person on. Care received from unskilled, harassed employees who resent the poor management they are getting from the agencies that employ them is experienced as a burden. It is terribly disempowering for all concerned.

My mother is now employing four personal assistants. It is early days and there are teething problems. However, she is much happier because she is spared the terrible randomness of past agency provision. The IWA’s report Adding Life To Years claims that:

“… as a society Wales is culturally attuned to the social solidarity and community empathy that will be needed to put together policies and programmes designed for the less well off and those in need of a public sector safety net.”

That is quite a claim and I hope not mere sentimentality. The future development of Direct Payments offers a simple test of this alleged cultural attunement.