The title of Ettelt and colleagues’ 2018 article ‘Explaining low uptake of direct payments in residential care’, is a spoiler for the result of their national evaluation of the Governments ‘trailblazer’ programme. As only 40 care home residents had taken up direct payments by the end of the evaluation, falling far short of the 400 anticipated in an earlier scoping study (Ettelt 2013), it was not able to provide robust evidence about their value.
Direct payments are a ‘cash for care’ scheme, where people with care and support needs are given a cash budget with which to organise and purchase care and support services and, along with the subsequent personalisation agenda, were developed after a long campaign by the disability movement (Stevens et al., 2011). Their goal was to increase autonomy and control. At the same time, government policy (influenced by neoliberal ideas: Davies, 2015) has aimed to reduce the role of the state, restricting expenditure on social and welfare services, and transferring risk and responsibility to individuals (Stevens et al., 2017). Such a tension has resulted in long-term underfunding of adult social care (Beresford et al., 2018), particularly since the financial crash of 2008, at a time of increasing demand (Lewis and West, 2014).
Back in 2012, the Government initiated a pilot programme to test direct payments in residential care and participating local councils were ‘pilot sites’. When the Government extended its commitment in 2016, to introduce direct payments in residential care across England, the pilot sites became ‘trailblazers’, although national implementation has since been postponed.
The paper by Ettelt and colleagues reports an analysis of semi-structured interviews with trailblazer project leads (n=26), professional and frontline staff (n=41), service users (n=10), and family members or advocates (n=25). Interviews were analysed using the ‘framework’ approach, which generates themes and allows for analysis across different perspectives
Ettelt and colleagues’ findings focused on setting up the programme and barriers to implementation.
Setting up the trailblazer programme
Direct payments for care home residents were initially implemented in three ways. First, direct payments were used to pay the full care home fee. Second, part of the care home fee was allocated to the resident to purchase flexible kinds of services. Third, extra payments were made to the individual on top of the council contribution to the care home fee. This third approach represented a cost to authorities and so was phased out before the end of the evaluation. Two approaches were used to calculate the amount of the direct payment. First was to allocate resources on the basis of assessed need, before considering care home fees, however the need to actually be able to pay the care home fee made this approach problematic. More popular was an approach based on local care home fees, which was favoured by care home owners and managers as it maximised the chances of the full fee being paid.
Barriers to implementation
Ettelt and colleagues reported three main barriers to implementing direct payments (described below).
Lack of clarity about the benefits of direct payments
It was felt that the high level of needs of many care home residents may have meant they would be less able to use the direct payment to exercise choice and control. Service users and family members were often happy with their care and could not see the benefit of taking up the offer. In addition, it was hard to employ personal assistants (the most common use of direct payments in the community) in care homes, as this was thought to be too costly and difficult to implement.
The availability of the supply of services for which direct payments could be used
It was difficult to show what extra or optional services would be available for care home residents from within the care home or in the community. Also, accessing optional services was only really possible for people for whom part of their budget was already allocated for day time activities – mainly people with learning disabilities or physical disabilities.
Potential financial impact of direct payments
Implementing direct payments in residential care was intended to be ‘cost neutral’, which could mean that some of the money used by the council to pay care home fees might be used for other services. Consequently, all kinds of direct payments were perceived to represent a financial risk to care home providers, because of the possibility that service users would not pay their fees, or that a reduced fee would be paid, and the rest would be paid to other providers or individual care workers. Some larger care home providers felt they may be able to absorb some of these deficits, however.
Ettelt and colleagues concluded that professional resistance and structural problems in social care provision were part of the explanation for the low take-up of direct payments in residential care, echoing the two narratives identified by Fernandez and colleagues (2007) as underpinning low take-up of direct payments in the community. ‘Cherry picking’ residents seen as able to manage and use direct payments, and working with providers (who often had concerns about the scheme) to offer the scheme, is likely to have limited take-up. The absence of evidence about the benefits of direct payment also made it hard for council staff to promote take-up with service users and their families. Ettelt and colleagues argue that the barriers identified in the study may make it more difficult than expected to implement the scheme by the new 2020 target date. Also, it is hard to see how implementing direct payments will improve day-to-day relationships between care workers and care home residents, which as Lewis and West (2014) argue is critical to improving the quality of residential care.
Strengths and limitations
The research had a clear aim – exploring barriers to implementing direct payments in residential care. A qualitative approach was appropriate because the aim was to understand and explore barriers, rather than provide evidence about their prevalence. A wide range of perspectives were included in the study, which were needed to explore this complex topic. However, there was no discussion of the possibility that project leads and professionals might have felt restricted in their responses to a government-funded evaluation team. Full details of recruitment and obtaining consent are available in the full report of the evaluation (Ettelt et al., 2017), although not given in the paper. Additional information on the approach to coding, theme development and highlighting any contradictory findings would have helped establish their validity. However, the research has produced findings clearly in line with the research aim and appropriate to the methods used.
Implications for practice
The study suggests that working closely with providers, having a good knowledge of local care home and community provision, and making benefits to services users and families as clear as possible are required to implement direct payments in residential care. However, the findings also raise questions about the ultimate value of offering direct payments in residential care, which should prompt national and local debate.
Conflicts of interest
Ettelt S, Williams L, Perkins M, et al. (2018). Explaining low uptake of direct payments in residential care: findings from the evaluation of the Direct Payments in Residential Care Trailblazers (PDF). Journal of Social Policy 47(3) 505-522.
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Ettelt S, Wittenberg R, Williams L, et al. (2017). Evaluation of Direct Payments in Residential Care Trailblazers. Final report (PDF). London: Policy Innovation Research Unit.
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