The Direct Payments (PB/PHB) Practioner Guide to Better Decisions



My recent blog that explored the need to have proper conversations on direct payments,  got a lot of hits. Obviously, this is a topic of interest, so I have given it a bit more thought to see what I, as a practitioner, would do in your shoes. If I was a member of a CCG/Team or Adult Social Care Team, how would I decide if what was asked for is appropriate? This is not a legal opinion; these are merely suggestions that may help me weigh up the decisions in your roles.

As I said in my previous post, I understand the pressures on staff via the government to reduce expenditure in our public services. Unless a major change happens in people's views this is not going to change. The main parties all want to reduce expenditure. This really doesn't help staff in these roles as the legislation for personalisation giving independence, choice and control, including the NHS Constitutional right to patients’ choice, and the Care Act all give people these legal rights. My personal view is that legislation trumps austerity. There have been no legislative laws brought in with regard to austerity, it is but a particular government’s wishes and views, however, I fully take on board this doesn't help either.

In my view, there has to be a balance between needs beings met and what a person thinks they are entitled to. For those in both Social Care and The NHS I would suggest the starting point to be look at the “Principles of Wellbeing” laid under section 1 of the Care Act. Yes, there is a legal definition for wellbeing, not just made-up service or name for feeling ‘good’. The principles give you an aim to work towards, as to how it benefits the person. The statutory guidance under the care Act is where you'll find further information on using wellbeing principles. They state that these should be used to justify or give reasoning behind the assessment process in the Care Act.  To date and I've asked plenty of times, I've never seen an assessment done with these principles. The New white paper on Social Care highlights that the Act is a good price of legislation it just isn't used how it's supposed to be and this point is one of the very ones the Government are the need to make decisions based on effects to life.

Below are two pictures I’ve created and used to help me and others understand the points above. The first is the explanation of needs under the Care Act and the graphics in the middle box that are assessed and identified as "needs". The outer box shows the wellbeing principles thus if a need is presented say the need for maintaining personal hygiene, this could  be shown as meeting the wellbeing principles of Dignity.

The following picture is the DST tool for NHS staff in a similar format. Can you see how many of the criteria are the same or similar to those of needs under social care (obviously adding on unpredictability, complexity and intensity)? I would therefore suggest that the same wellbeing principles could be used to firm up arguments. Obviously noting that when you do a NHS Personal Budget assessment you have to consider Social Care needs as well as required under the National Framework.

The above is just a first step in how better decisions can and should be made (remember this is statutory guidance).

The other decisions that often concern practioner is the benefit factor I.e. what benefit does the person derive from the expenditure, or more unsaid, is it likely that others might benefit too? To this I would add can the benefit be made in alternative manner, which is cheaper and more cost effective? The argument here being we can't all have what we want. It's got to be reasonable, whether you have a budget or not, want isn’t need. The other reasoning is how often the person is likely to benefit from it, and the additional costs involved (electric, water). When it comes to both, preservation of life and safeguarding must always be the main priority.

 Another factor to consider would be to evaluate the risk. Is there a potential mental or physical risk of potential harm if the item wasn’t available? Likewise, we can flip this and look at is the item or service help or make it likely to improve matters or maintain their needs or health?

One of the questions that gets thrown around when discussing budgets is regarding public accountability. So why not ask yourself this question, not as a practitioner, not as a recipient, but would you, as a member of the public, think in this circumstance that this is fair? Again, this is a practical decision, over want and need.

These questions are not out of thin air, but via what I know about some of the things accepted as allowable in the early days of budgets. For example, where the overall principles of get what you can, often even I questioned against whether it was a necessary expenditure or the need could have been met better and cheaper by alternative means. Having been through a number of these assessments, both social care and CCG, as budget holder myself and in advocating for others, I have used the above process to both justify to practioner and challenge users whether their requests were justified.

I hope this blog makes people think and have better conversations, in the end help both parties to come to a rational over the budget, and where independence, choice and control is not lost, whilst ensuring a fair and equitable system for direct payments can be retained.


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