Direct Payments Strategy for Children’s and Adult Social Care 2023 to 2028

Executive Summary

This Strategy and Delivery Plan confirm the Surrey County Council Adult Social Care and Children with Disabilities commitment to improving outcomes, services, and support for individuals and families that choose to have a direct payment to self-manage their care and support needs. It was co-produced with the support of Surrey Coalition of Disabled People, people in receipt of direct payments, people working in the system, service providers, voluntary sector organisations and representative groups such as Sight for Surrey and Family Voice Surrey.

The strategy looks at how the model of providing direct payments can change and develop to provide an improved system so that people are better able to fulfil their aspirations. An important part of the co-production was to learn lessons from what works well and explore how this can be built on, and to identify gaps and/or changes in the support required to increase people's experience of managing a direct payment and encourage a higher uptake.

Introduction

This strategy covers people that have been assessed as being eligible for social care and support. It covers people who are aged 18+ as well as families of children with disabilities. It should be read in conjunction with other strategies which provide more detail in certain areas, for example:

• Accommodation with Care and Support Strategy
• Older People's Strategy
• Commissioning strategies for people with learning disabilities and/or autism and people with mental health needs
• Direct Payments Policy for Disabled Children and Young People

This strategy is for the next 5 years, 2023 to 2028. As such it does not contain the detail of how the strategy's vision will be achieved. A Strategy Action Plan will be developed setting out how the actions will be achieved. Much of this action planning will be done through establishing a direct payments programme board, in conjunction with Surrey Coalition of Disabled People, People who use direct payments and other key partners.

What are direct payments?

Direct payments and Personal Budgets are local social care payments for people who:

1. have been assessed as needing help from social services and
2. who would like to arrange and pay for their own care and support services instead of receiving them directly from the local authority

Direct payments offer families and individuals greater choice and control over their care and support and are our preferred approach to meeting individual's care and support needs.

For Adult Social Care funded individuals, direct payments can be used to purchase Community Services Provision, including for example:

• Accommodation with care and support
• Home Based Care
• Respite and short breaks
• Community services such as outreach services and supported employment
• Transport to access support services

However, direct payments cannot be used to purchase:

• Nursing care
• Residential care homes

Direct payments are mostly used by children and families to purchase Educational Teaching Support, support from Personal Assistants and Respite, whereas they are used by adults to purchase a wide range of solutions to enable them to live in the most independent and rewarding way.

A history of direct payments is shown in Appendix one.

The Vision

Surrey Community Vision 2030

We want Surrey to be a uniquely special place where everyone has a great start in life, people live healthy and fulfilling lives, are enabled to achieve their full potential and contribute to their community and where no one is left behind.

Social Care Vision

To promote people's independence and wellbeing, through personalised care and support that focuses upon their strengths, the outcomes they want to achieve and enables choice and control.

We want Surrey to be a place that offers opportunities for people to live healthy and fulfilling lives, where people's contributions to their local communities are welcomed, supported and valued, and no one is left behind. These opportunities should extend to all disabled people in Surrey. All organisations involved in developing and implementing this strategy are committed to ensuring that the vision and aims will be delivered in full for disabled people.

Why do we need a strategy?

Direct payments have been around since 1997 and there is national guidance available that indicates how local authorities should provide and manage direct payments. However, there is no standard framework for delivering direct payments, rather the national guidance is subject to local interpretation. As a result, the application of many aspects of providing direct payments, including how the value of a direct payment should be calculated, whether external user-led support should be commissioned and how their use should be monitored, is inconsistent across authorities.

• We are aware that while there is internal guidance for staff, this doesn't ensure all staff have a full understanding of how the system should work
• We have heard from families, young people, adults and family carers that there are challenges with understanding the benefits of a direct payment and what it can be used for and with accessing appropriate support in managing a direct payment

We are committed to bringing the right people together to address these barriers and to use our resources effectively to deliver the support that people need.

This strategy has been co-designed with users of services, their carers, practitioners and providers; it presents the steps that the Council will take to facilitate access and promote uptake of its direct payments offer.

To be successful a better understanding of our direct payment system is required; objective scrutiny to identify how the current system can be improved and a willingness to make some bold decisions in the way that direct payments are offered to better support the improvement of people's physical and mental health.

These are not quick things to deliver, the strategy will need to be embedded in our organisation and the wider community so that it is sustained and can be built on. But we know that with focussed leadership across the system, we can achieve the culture change required for a larger number of families and children, young people and adults in Surrey to use direct payments to exercise increased choice and control in how they achieve their outcomes.

Our strategy is here to focus the action of all partners across Surrey who have committed to work together to make the changes we need to see.

Direct payments vision

Initially, an internal Surrey Council 'One Council' group comprising Adult Social Care and Children, Families, Life-Long Learning and Culture Directorates was established in 2020 to review the approach to direct payments. This group was established primarily based on an aspiration to deliver the following Vision:

Direct payments become widely used by individuals, families and carers to arrange their own care and support, helping them live the life they wish to live.

Direct payments in Surrey

Adult Social Care

The vast majority of individuals that are eligible for funded care and support choose to be supported by directly commissioned services, that means the support service is identified and paid for, in part or in full by the council. There are around 21,000 adults receiving funded care and support of whom around 8,300 have the option to choose a direct payment to source their own care and support. Currently around 2,300 do so, giving a take up of direct payments of around 27%.

As might be expected, there are different take up rates for direct payments across the adult social care categories of care. Looking at our data, the highest number of users by client category is adults with a learning disability at around a third of our direct payments take up, followed by adults with a physical disability at nearly a third. The lowest level of take up is in our mental health service with around 5% of individuals using a direct payments.

Children, Families, Life-Long Learning and Culture

The total number of families supported by the Children with Disabilities team is 634, with 546 some 86% choosing a direct payment. This highlights the importance of having a good provider market for families.

Pre-paid accounts

To support the roll out of direct payments, Surrey Council has invested in the provision of a pre-paid account banking system. A pre-paid account is essentially a bank account that is used to manage the financial element of having a direct payment, for example it allows the council to make payments into the account and for the individuals and families with the account to manage and organise payments to care providers and other services funded with the direct payment.

Looking at our information on the number of pre-paid accounts, we found that out of a 2,800 individuals and families that have chosen a direct payment, some 90% use the pre-paid account to manage the financial payments.

Local provider market

In order for the direct payments offer to be successful, it is important that people with a direct payment can purchase services to meet their care and support needs, thus requiring a vibrant provider market that supports individuals and families. Looking at the data we have, a significant number of individuals with a direct payment are choosing to employ people as Personal Assistants, around 40% of adults with a direct payments, commonly this is to provide personal and domestic care. This proportion of employing a personal assistant is even higher for families of children with disabilities.

The council recognises that there is little regulation over the cost of care that direct payments users might be charged and has engaged with the market to advise that we expect providers to not only provide support to individuals with a direct payment but charge the same fee that we have agreed with them if they are an approved council provider.

The local Personal Assistant market

Personal assistants usually support individuals in their own home or to go out in the community. They are commonly employed directly by the person with a direct payment but might be self-employed. Each Personal Assistant might work with 1 individual or with a number of different people.

The Personal Assistant market in Surrey needs development: there are currently too few options to ensure compatibility between direct payment clients and available Personal Assistants.

Work is being undertaken to address this, including refreshing the recommended level of pay and recruitment drives. In addition, the Care Act national guidance suggests that local authorities utilize external user-led organisations to support the rollout of direct payments. Accordingly, we have commissioned Surrey Independent Living Charity, to provide independent support for delivery of the Council's direct payments offer.

They provide the following:

• Personal Assistant Support Service – this service is designed to connect individuals and families seeking a personal assistant with someone working as, or wishing to work as, a personal assistant
• Independent living advisors offer individuals and families specialist advice on all aspects of employing a personal assistant - specifically support with advice on employment, recruitment, payroll, training and insurance
• Peer support - to help individuals and families who are considering the use of a direct payment to understand the benefits in terms of choice and control over their lives and therefore achieve greater independence. It involves individuals in receipt of direct payments sharing their knowledge, experience and practical help

Personal health budgets

Surrey Health Integrated Commissioning Boards are also seeking to increase the number of people who can exercise greater choice and control over their care. Surrey County Council and Surrey Heartlands Integrated Care Board are working to align their work with a long-term ambition to integrate the offer. Currently people access to personal health budgets in relation to care and support provided under section 117 of the Mental Health Act, Continuing Healthcare and the wheelchair service.

Additionally, there is a well-established initiative to promote personal health budgets for adult carers in Surrey. These are one-off payments of up to £300 released following the carer's consultation with their GP to support additional expenditure that will enable the carer to manage their caring role and protect their own health and well-being. One example of their use is to purchase a washing machine, when otherwise they would need to use a launderette or hand wash clothes adding to the time and drain to their resources.

The future context

Social care reforms

On 7 September 2021, government set out its new plan for adult social care reform in England. This included a lifetime cap on the amount anyone in England will need to spend on their personal care, alongside a more generous means-test for local authority financial support.

The proposed reforms also indicated that people might have the option to choose to have a direct payment to contribute towards the cost of residential and nursing care, which it can be expected would lead to a significant increase in the number of people or their authorised person requesting a direct payment. Furthermore, given that the people who would become eligible for adult social care as a result of the lifetime cap and the more generous means-test are currently managing their own care and support our expectation is that the majority will choose to receive the council funding as a direct payment.

In November 2022, it was announced that the introduction of the reforms would be significantly postponed. However, work to establish a robust direct payments system with clear and streamlined processes and procedures and which promotes equity of access and increased uptake will ensure Surrey is better placed to respond to future changes to regulation and guidance that might be forthcoming.

Digital and technology

There are a wide range of individuals that have direct payments, the vast majority utilising modern technology to manage and organise their care and support arrangements and payments online. As new technology emerges, which can improve access to local provision and/or help to manage direct payments, we will seek to ensure that its use can be accommodated. Furthermore, we will seek to work in partnership with / be integral part of such projects. One example is the Tribe Project in North West Surrey, which seeks to connect micro enterprises and other community assets into the system of care and support.

Introduction to our strategy

Co-production and engagement

'Co-production is an approach where people, family members, carers, organisations and commissioners work together in an equal way, sharing influence, skills and experience to design, deliver and monitor services and projects. Co-production acknowledges that people who use social care and health services (and their families) have knowledge and experience that can be used to help make services better, not only for themselves but for other people who need them, which could be any one of us at some time in our lives.'. Co-Production Network, Think Local, Act Personal.

Engagement means involving people, as individuals, communities or organisations, in policy and service decisions that affect them. There are different degrees of engagement. These are not hierarchical in the sense of one being of more importance or value than another and all may be of equal value in different contexts.

Our approach to Co-production and engagement

A clear message in the development of this strategy is that the delivery of our vision requires improved strength-based and relationship-based practice, a vibrant provider and personal assistant market across Surrey, and the establishment of stream-lined procedures.

The internal 'One Council' Group considered the findings of a brief review carried out by Social Care Institute for Excellence which raised some concerns about the way direct payments were being offered and managed in Surrey and highlighted the need to develop a strategy. It agreed that further exploration of the issues, as part of a wider engagement process, was needed to determine what the key issue are to inform the production of a Direct Payments Strategy.

Following early consultation with Surrey Coalition of Disabled People, it was agreed that we should move from engagement and consultation to co-production as the method of exploring the issues further. Consequently, in June 2021, We Coproduce CIC, a social consultancy trading as a social enterprise, were approached to provide guidance and challenge to the co-design partners to develop a responsive, inclusive, participatory and representative process. We Coproduce were asked to help upskill some Adult and Children's' Social Care staff, so that local staff could embed coproduction and co-design it is ongoing work.

The aims and ambitions of the co-production work In July 2021, an eight-month plan was agreed, with agreed aims and ambitions:

Aims for the co-production work:

• To ensure that the strategy would be coproduced through grass-roots conversations
• To include many different and diverse voices to recognise that experience of the current offer is not uniform
• To ensure that practitioners' experience informed the strategy
• Having a clear vision for direct payments
• To identify strategy themes and headings by April 2022

Agreed ambitions of the strategy:

• Finding the right model for Surrey
• Fairness and accessibility - equalising access to direct payments
• Improving the overall administration, systems and delivery of direct payments
• Identifying and removing barriers to direct payments and/or care and support
• Building relationships and improving outcomes
• Raising awareness and understanding of direct payments
• Communicating the benefits of direct payments

It was agreed that it would be key, in order to achieve the aims, to engage with the following groups:

• People currently using direct payments and carers
• People using adult social care services but not receiving a direct payment
• People not receiving adult social care service but may likely need to in the future
• Carers and Personal Assistants
• People receiving Special Educational Needs and Disabilities
• Local authority staff and local providers

A report of the co-production work can be found as appendix two.

Findings: What needs to be improved

The co-production work identified some high-level themes that need to be considered in further detail to improve the direct payments system in Surrey. These have been framed below as six objectives and indicate key components that form the skeleton of an improvement plan.

Objective 1: Ensuring there is clear, accurate and accessible information

• Who can have a direct payment
• How to arrange a direct payment
• What a direct payment can and can't be spent on
• How flexible the direct payment can be
• What services and service providers are available

Objective 2: Ensuring quality support from social care practitioners through workforce development

• Assessments and reviews are strength based and outcomes focused
• Full involvement of customers in producing their support plan, which recognises that direct payments might be used flexibly to achieve the outcome(s) identified
• Staff are informed and up to date on direct payments policy
• Direct payments are offered as one way to deploy a personal budget, with a clear outline of their benefits and dis-benefits, and with full involvement of carers where appropriate to inform decision making regarding whether or not to use direct payments.
• Conversations about direct payments are designed to allay anxiety and fear
• Shared/supported decision-making approaches are used to arrive at the support plan

Objective 3: Ensuring equitable access and support in establishing a direct payment

• People have support to set up and manage a direct payment
• Advice and guidance on employment responsibilities if choosing to recruit a Personal Assistant(s)
• People have support employing and managing Personal Assistants
• Access to independent support and advocacy to assist with issues and problems

Objective 4: Ensure streamlined systems and administration

• The process to set up a direct payment is timely and as simple as possible
• Financial information and support is consistent, accurate and up to date
• Progress in establishing the direct payment is communicated in a timely and respectful manner
• People have access to support with negotiating rates, contracting and accountancy
• All information about local providers is available online and in a range of other formats
• Payments are not automatically reclaimed when not used but discussed alongside review of outcomes, acknowledging that underspend might be due to external/unforeseen circumstance and/or the customer might have a clear plan for how they will be used instead to meet the outcomes agreed in the support plan
• When payments are to be reclaimed, following discussion with the customer, this is clearly communicated in writing.
• Ensuring our systems align with those for Personal Health Budgets

Objective 5: Developing the provider market

• Reviewing the services available in order to identify and address gaps
• Ensuring equity geographically across Surrey and for different population groups, for example for different age groups and ethnicities
• Working with voluntary sector and community interest groups to grow local support
• Growing the number of Personal Assistants available across Surrey with a focus on equitable access across Surrey, for example across different age groups and ethnicities
• Ensuring fair and reasonable rates are used to determine an individuals direct payment budget whether care providers or Personal Assistants are identified as the most appropriate sources of care and support

Objective 6: The development of a direct payments communications plan

• Online and printed information is up to date, accessible and accurate
• Surrey Council staff are able to implement policy confidently and appropriately
• All parties understand their respective roles and responsibilities and the importance of the users experience is reinforced

Our action plan

What will we do?

The objectives and their key components, identified from the themes that arose from the co-design work form the basis of workstreams that will support delivery of the strategy. The action plan for each of these will be further developed in conjunction with the Core Group; elements identified to date are as follows:

Objective 1: Ensure there is clear, accurate and accessible information

Activities will include:

• Updated literature – clear and concise, for example what direct payments can or can't be used for. Different age-appropriate information.
• New resident facing web pages.
• Interactive features – link to external sources such as Skills for Care as well as the use of vlogs and video clips.
• Shared council and public available literature

Objective 2: Ensure quality support from social care practitioners

Activities will include:

• Ongoing training for all staff
• A review of the team structures supporting direct payments
• Awareness of residents' fears and concerns
• Review assessments and review processes for direct payments

Objective 3: Ensure equitable access and support in establishing a direct payment

Activities will include:

• Review existing support arrangements
• Fit for purpose assessment
• Consider the establishment of a Direct Payments Stakeholder Board
• Consider Single Point of Access
• Staff support
• Consider whether an Individual Supported Fund offer should be developed in Surrey to enable a greater proportion of people who may not opt for full direct payments are able exercise choice and control

Objective 4: Ensure streamlined systems and administration

Activities will include:

• Revisited policy on surplus financial arrangements
• Review of how the council provides, resources and manages our direct payments offer, including looking at the use of council resources as well as external organisations or setting up a dedicated direct payments team which includes experts by experience
• The review will be informed by looking at how other local authorities offer and manage direct payments

Objective 5: Develop the Provider Market

Activities will include:

• Further engagement with care and support providers, including home based care agencies, day care services and learning and skills providers.
• Personal Assistant market activity to promote the role
• Review of Personal Assistant pay levels
• Training offer through Surrey Skills Academy
• Review the Tribe Project App

Objective 6: Develop a direct payments communications plan

Activities will include:

• Identifying the different groups that need improved communications.
• How best to engage and communicate with different groups.
• Ensuring that communication is kept up to date

The action plan for each workstream will identify what activities will be carried out, what resources will be involved and when the activity will start and end.

There will be a new governance structure to oversee the delivery of the action plan and we propose that this will include individuals, family members and carers who have a direct payment.

Evaluation and impact

Work to address the findings of Social Care Institute for Excellence review into the council's direct payments offer has fallen into two phases to date:

• Phase one was led in large part by the internal 'One Council' group comprising Adult Social Care, the Children with Disabilities team and Children with Special Education Needs. It sought to secure greater understanding of some of the issues raised by Social Care Institute for Excellence and the experiences of social care practitioners. An external reference group supported this.
• Phase two was characterised by the co-design work that developed this strategy

Governance proposal

The publishing of this strategy marks phase three and with that we are seeking to establish a collaborative approach to progressing the action plan. To this end, we are proposing that the One Council Board is replaced by a Steering Committee, comprising representatives of the front-line council teams, representatives of independent providers, representatives of individuals who use or are considering whether to use direct payment to purchase care and health colleagues who are themselves considering how best to develop their direct payment offer.

We also propose the establishment of a reference group to secure input from a larger number of people most affected by the work we do to improve the offer, ensuring they meaningfully shape our action planning.

Therefore, we think that there will be a high-level Direct Payment Steering Committee which has representation from people that have a particular interest in direct payments as well as people that have a direct payment.

Sitting below the Steering Committee we anticipate setting up around six groups that that focus on the six objectives mentioned earlier. Each group would report into the Steering Committee.

Terms of reference for the new partnership structures will be developed in the first quarter of the new strategy.

Appendices

Appendix 1: History of direct payments

Prior to direct payments, there was an Independent Living Fund (ILF) which helped people with disabilities live an independent life in the community rather than in residential care. ILFs were set up in 1988 to provide financial support to disabled people with high support needs.

This funding could be used to:

• employ a carer or personal assistant to provide personal and domestic care
• pay a care agency to provide personal care and help with domestic duties

The ILF approach was permanently closed in June 2015 and the responsibility for supporting ILF recipients in England was passed to local authorities. In the years leading up to the end of the ILF scheme, individuals were transferred to local authorities and the funding was reviewed and paid as a direct payment.

Direct payments were established by the Community Care (Direct Payments) Act (1996) which came into force in April 1997 and was initially available only to a specific subsection of people qualifying for social care. The Act gave local authorities in Britain and Northern Ireland, the powers to make cash payments to disabled people. Initially, this was confined to people under age 65 years with physical and sensory impairments, learning difficulties and mental health problems. It was later amended to include older people, 16- and 17-year-olds, parents of disabled children and in England, Wales and Northern Ireland only, carers. This gave local authorities and health and social services trusts, the option of whether to allocate direct payments or maintain existing models of service provision. This led to an uneven development of direct payments across the UK with particularly poor uptake in Scotland.

The Carers and Disabled Children Act (2000) allowed parents of disabled children in England and Wales to receive direct payments, and 16- and 17-year-olds to receive them in their own right. Changes set out in the Health and Social Care Act (2001) which came into effect in 2003, sought to challenge this pattern by setting in place a mandatory duty on all local authorities to offer direct payments to all eligible people requesting one.

Appendix 2: Report of the Co-design work: Methodology and emerging themes

The gathering of experiences and insights was facilitated through micro-community work and conversations with people in receipt of direct payments, people working in the system, service providers, voluntary sector organisations. Methods of engagement included:

• 6 Core Community Group meetings with 22 people involved
• 13 one to one interviews
• 10 conversations with groups and organisations with 75 people involved
• 4 discussions at existing meetings with 38 people involved
• Surveys with 86 people responding
• 2 Surrey County Council staff sessions
• 2 case studies

With the addition of informal conversations, the overall number of people involved in the engagement is over 230 individuals. Many of the people who had one to one interviews, commented on the importance of having an independent organisation conducting the interviews. It became clear that this was underpinned by a general fear and anxiety caused when communicating with Surrey County Council.

The overall picture highlighted the following positives:

• Peer support being received
• Voluntary sector support and Training
• Choice of providers and use (but not always and usually limited)

The main narrative from the research was that of a system that is difficult to work with, where the decisions do not routinely reflect individual choice and control, instead commonly remaining with SCC staff. This is illustrated by the following:

Randomness in the system and its rules:

• Confusion, frustration, and anxiety about doing the wrong thing. The danger and worry of 'getting it wrong'
• Discrepancies. Being told one thing then something different by another party

Low respect and poor attitudes:

• Disappointingly poor relationships between recipients and operational staff.

A disjointed and hard-to-work-with system:

• A widespread feeling that more support in navigating the system is needed
• Lack of independent support to broker services and advise when there are problems

These key highlights serve to form three broad themes which provided the focus for further discussion and inquiry.

What the survey told us

The survey provided a more targeted approach to identify challenges with the current system. Interestingly, the themes from the one-to-one interviews and group conversations were also reflected in the survey responses, which is summarised as follows:

What people would like to know about direct payments

• Eligibility criteria
• What they are
• What the purpose is
• How to apply

Experience of direct payments

Reasons for not taking a direct payment when offered one:

• Process looked too complicated

People's thoughts on why they haven't been offered a direct payment:

• Not eligible/not disabled enough
• Too young
• Surrey staff do not know about them
• No one has ever mentioned them
• Self funder

Perceptions of direct payments:

• Excellent, good, reliable, easy
• Can be stressful to manage/overwhelming/a lot of work
• SCC taking a long time to listen to the individual
• Information overload
• Direct payment card takes away choice and is seen as a security risk
• Difficult to administer, restrictive, limited
• Difficult to find skilled providers/cultural carers
• Hard to find carers to work for the hourly rate/not enough funding
• Gives more choice
• Should be more flexible
• Beneficial to wellbeing
• Can be wonderful but mostly hard work and less than satisfactory
• Terrible that we have money we can't use as the services are not available
• Personal Assistant rates need to be reviewed
• Treated in a negative way by the Council
• Not told about Surrey Independent Living Charity
• Mistrust and accusations from finance team instead of support
• Language barrier for those where English is not their first language

Ideas - how direct payments could be made better:

• More support to manage a direct payment
• Made simpler and easy to understand
• More support for administration, finance and employment
• More flexible
• Finance staff need to be more approachable
• Offered to everyone
• More information for parents and carers
• More publicity
• New reconciliation system will make things easier
• Less bureaucratic
• Money to be used for costs as well as Personal Assistant hours
• Support to find Personal Assistants
• More person focused
• Guidance on tax
• More help for people with second language skills
• Publicise the benefits of having a direct payment

What the engagement and Core Community Group told us

The engagement and Core Community Group made up of representatives from several local support groups, staff from adults and children's services and individuals with a direct payment; provided rich insight into the main issues and a wealth of ideas and possible solutions, including:

• Checking and refreshing of direct payments guidance
• Appropriate contracting of voluntary sector for independent support and brokerage
• Stakeholder sharing forums
• Introduce values-based approaches and frameworks into everyday practice, for example shared decision making - in support planning which fits with Strength Based Principles and co-production with the individual
• Upskilling council staff to implement policy confidently and assist them in making the right judgements – shared learning forums, refresher training from voluntary sector
• Expert by Experience Direct Payments Panel
• Working with families in an inclusive way – with flexible options
• Accessible information and formats

Easy read version

Easy read version of the draft Direct Payments Strategy for Children's and Adult Social Care 2023 to 2028 (PDF).

This plan explains how we will get better at helping people who use direct payments. A direct payment is money we give to you to pay for your support.