Direct payments and mental capacity in EnglandWhat’s happening in practice?Dr Marcus Jepson, University of BristolDr Anne Laybourne, Mental Health Foundation

Project team:Eva Cyhlarova, Mental Health FoundationToby Williamson, Mental Health FoundationVal Williams, University of Bristol

Our area of interest

The interface between:Direct Payments

andThe Mental Capacity Act

What we’ve called:Indirect Payments

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What we did

Outcomes of the indirect payment• High levels of satisfaction: it DOES work, both

for people with learning disabilities and people with dementia

• Person-centred outcomes

He needed to live where people knew him, where he knew people,

where he felt safe and secure – where he’d grown up.

Decision point 1: capacity• Practitioners were familiar with

the ‘language’ of the MCA • Application of the ideas: e.g. what

are they assessing capacity about?

• Assuming capacity

• Some expressed concern about what is being assessed:consent or ability to manage?

Decision point 1: capacity• Capacity assessment from the perspective of

the suitable people

[a social worker] visited him, but I can’t remember for what reason

Decision point 2: best interests

Two levels of best interests decisions.

a) The decision about whether to take up an indirect paymentb) The decisions about spending the money (decisions made by the suitable person)

Decision point 2: best interests

• Well understood by practitioners:

...best interests ...it varies from person to person. What I may feel is in someone’s best interests may not be. So you’ve got to rely on a wider range of people, who would then maybe give you a more holistic picture than you know what the person’s abilities are, where they can go

Decision point 2: best interests• Suitable people: understood in a more general context

…we will always be acting in somebody’s best interest, so although there then became an Act that made it a duty to do that, all I’d ever done was act in his best interests. So it wasn’t a new concept for me.

Decision point 3: who can be the suitable person?

• Little formal guidance for practitioners, reliance on professional judgment about suitability

• No suitable person?

So I think [identifying a SP] is relying too much on our judgment, rather than something

[tangible]

If you can't find a suitable person then [indirect payments] is not an

appropriate option, is it?

Why do people become ‘suitable people’?

1. Suitable people see indirect payments as the only real option available. For them:– it is a decision taken to avoid (inappropriate)

alternative services

– Or a decision brought about because of limitations on what can purchase

I felt so awful every time I left her, because she was put to bed at half-past three. And my mum was a head teacher – a highly intelligent person, and an author of Maths books.

One of the things that puts me off…how they make these rules about what you can and can’t use the money for

3. Suitable people with professional backgrounds

Mum…she works it very, very well. She's spot on every time. She sticks to the support plan. But

then her husband runs a business and she does the accounts for him

I think the concern that I have is the amount of stress she is under…the biggest problem, he’s not a particularly well

man himself. He’s got heart problems….

Experiences of suitable people

• The indirect payment meets their needs, as well as the needs of the PB user

• Lack of meaningful ongoing support – left to get on with it!

• Reviews are primarily about financial aspects

Next steps• 4-page findings summary• Resource for practitioners and suitable people:

including case studies From June 2013: Mental Health Foundation, Bristol University, SSCR websites. E-/print copies to participants

•Journal articles of detailed findingsTarget = BJSW / SW practice / Health & Social Care in community.

Contact

Eva CyhlarovaThe Mental Health Foundation Colechurch House1 London Bridge WalkLondon SE1 2SXecyhlarova@mentalhealth.org.uk