Direct payments in context: empowerment and quality of relationships

direct payments

Many countries across the world have developed different kinds of cash for care schemes; direct payments are the UK example. They are seen as offering more choice and control over care and support.

An increasing number of direct payments recipients directly employ Personal Assistants and Graham notes that that such arrangements involve new kinds of employment relationships. This article reports findings that some people with learning disabilities have found employing and managing PAs difficult. Graham aimed to explore these concerns in a context of ‘discourses of rights, the market, workforce concerns and (self-)regulation within the broader context of social care’ (p600).

The quality of relationships between care workers and service users has been identified as a key element in quality of care (Lewis and West, 2014; Lynch, 2007; Van Houdt et al, 2013). Personal qualities are also seen as important by some social care employers in the recruitment of social care workers. Furthermore, management and commissioning practices that make it difficult for care workers to develop good relationships and work to their values are linked with desires to leave social care work (Rubery et al, 2011). Graham’s article therefore addresses a topic of central importance in social care.

Graham notes the tensions in the development of personalisation, between the ideas of independent living proposed by the disability movement against the aims of responsibilisation and transferring risk to the individual, leading to reducing  state provision. Consequently, Graham highlights the ‘tension between the individual of neoliberalism and the collectivism of the activism at the heart of independent living’ (p600).

Graham notes that the UK approach to personalisation, like that in the USA, is highly regulated in relation to the allocation of public money, but allows great discretion to individuals employing PAs. In the UK, this has led to relationships in some ways resembling ‘master and servant’, when the focus is on practical tasks. However, the more informal, personal and emotional elements of these relationships, which are highly valued, create an inbuilt tension.  Roles can be blurred, suggesting a less polarised view of the transfer of power that has been identified with personalisation.

Carer with wheelchair user

Direct payments can create tensions with blurring of roles between employer and carer.


The small-scale qualitative study, on which Graham’s article draws, aimed to ‘explore understandings of ‘independence’, ‘choice’ and ‘control’ in the context of the discourses of empowerment at play in personalisation policy in England’ (p602). It focuses on people with learning disabilities who are direct payments employers in one city in England. The research involved unstructured interviews with:

  • Eight employers (people with learning disabilities who were in receipt of direct payments and employed a PA),
  • Three care managers and three family members, identified as supporters by six of the eight employers
  • Seven PAs working for each of the employers
  • Three professionals involved in developing support for people taking a direct payment

A grounded theory approach was adopted to identify key features of relationships between direct payment employers, supporters and PAs. It would have been useful to see more detail on the process of analysis, types of coding and how it was developed in order to evaluate the strength of the findings.

Three themes emerged from the analysis process:

  1. responsible employers
  2. the value of the ‘personal’
  3. a shift to the informal.

Responsible employers

Ensuring good working conditions was a concern of some employers in the research. However limited budgets and weak contracts have been identified in the literature as getting in the way of ensuring this. PAs are presented as employees whose employment requires them to support and educate their employers, which can create tensions. The relationships between PAs, employers and supporters are framed by discourses of independence, choice and control. At the same time, PAs use these discourses as part of the endeavour to ‘empower’ employers.

Graham suggests that the PA connects the individual with the community and supports the development of citizenship. These relationships are individualised and potentially isolated and unregulated, compared with relationships between individuals and service providers, although little exploration of the practice consequences of this has been made.

The value of the ‘personal’

Much of the debate about how PAs support their employers appears to centre on the question of how far personal or emotional supported should or can by separated from practical help. Participants in the study (including people with learning disabilities and PAs) appeared to value this personal aspect of the relationships more highly than the practical. This may lead to a greater experience of the tensions in these relationships, compared with employers with other kinds of needs.

The shift to the informal

Participants appeared to to have control over the support provided by PAs, thus embodying the altered hierarchy in relationships with paid workers envisaged in the development of personalisation. Graham notes that contracts tended to be generic, which created possibilities for blurred responsibilities, although this allowed for valuable flexibility in the kinds of support possible.

Concerns about how to maintain boundaries were evident, in, for example paying for drinks or meals, when supporting their employers’ leisure activities or limiting unpaid work, considering the context of the personal aspects of these relationships. By exceeding the employee-employer relationship, PAs could be seen as challenging the altered hierarchy. Alternatively, these tensions could arise because of a poor fit between market and the personal, emotional elements of these relationships.

Cup of tea

Employers greatly valued the personal and informal support from their carers.

Discussion and conclusion

Graham’s study has highlighted an important tension in the UK approach to personalisation. Transferring employment responsibilitiesand therefore power to disabled people can create a tension with the personal and emotional support valued by people with learning disabilities. Such tensions can create what might be seen as poor practice in traditional support relationships, for which increased regulation is being developed. Graham argues that this calls into question the consumerist model underpinning direct payments. However, it is important to note that these kinds of dilemmas also underpin traditional care services, in which the difficulties of maintaining professional boundaries have been acknowledged (e.g. O’Leary et al, 2013).


Primary reference

Graham, K. (2015), Cash payments in context: (self-), regulation in the new social relations of assistance, Disability & Society, 30, 4): 597–613.

Other references

Houdt S, Heyrman J, Vanhaecht K, Sermeus W, De Lepeleire J. (2013) An in-depth analysis of theoretical frameworks for the study of care coordination. International Journal of Integrated Care. 13(2). DOI:

Lewis. J. and West, A. (2014) Re-Shaping Social Care Services for Older People in England: Policy Development and the Problem of Achieving ‘Good Care’. Journal of Social Policy 43(01) 1-18. doi:10.1017/S0047279413000561

O’Leary, P., Tsui, M-S. and Ruch, G. (2013) The Boundaries of the Social Work Relationship Revisited: Towards a Connected, Inclusive and Dynamic Conceptualisation, British Journal of Social Work, 43(1),  135-153. doi: 10.1093/bjsw/bcr181

Rubery, J., Hebson, G., Grimshaw, D., Carroll, M., Smith, L., Marchington, L. and Ugarte, S. (2011), The Recruitment and Retention of a Care Workforce for Older People, University of Manchester: European Work and Employment Research Centre (EWERC), accessed 22/08/2016.

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Martin Stevens

Martin is a Senior Research Fellow at the Social Care Workforce Research Unit, where he has worked since 2004. He has led several research projects funded by the Department of Health and the NIHR School for Social Care Research. Projects include the National Individual Budgets Evaluation and a series of research projects on Adult Safeguarding. He currently chairs of the National Social Care Research Ethics Committee and also chairs the Social Services Research Group. Martin came into research after five years working in a residential service for people with learning disabilities, following a philosophy degree. His first research post was for Hampshire Social Services Department, where he stayed for 12 years, undertaking work on community care, child protection and learning disability services, amongst other topics. He completed his PhD during this period. His research interests include choice, personalisation, learning disabilities, adult safeguarding and interactionist perspectives

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