Abstract

Objectives and methods: Local authorities in England are committed to promoting independence and well-being among adults in the local population. Under the Care Act 2014, councils with social services responsibilities must ensure they take into account individuals’ personal opinions in relation to their life and their care. One mechanism for promoting such autonomy and control is the use of direct payments, which have been available for people living in the community for many years. Direct payments are defined as monetary payments made to individuals to meet some or all of their eligible care and support needs.

In 2012, the Department of Health decided to accept a recommendation by the Law Commission to extend direct payments to residential care on the grounds of widening equality for people living in nursing and care homes. A small number of local authorities in England have been piloting the programme since 2013. It has become known as ‘Direct Payment in Residential Care Trailblazers’ because the DH envisaged rolling out the initiative across England from April 2016. The government has now delayed implementation until 2020.

The Policy Innovation Research Unit (PIRU) has been conducting an independent evaluation of the programme since 2013. The objectives of the evaluation are to understand the different ways in which direct payments are delivered to residents of care homes and the challenges surrounding implementation; to assess the impact of the scheme on service users, their families and other stakeholders; and to examine the relative costs and cost-effectiveness of different direct payment models, if possible.

We will report on progress of the trailblazer sites, and the findings from the following methods of data collection: a self-completed survey of service users and family members, a survey of local authorities regarding administration costs, interviews with local authority representatives and providers, interviews with service users, family members, care home managers and social workers, and an online survey of care home providers.

Findings: Three ‘models’ of such mechanisms have been developed in the trailblazers. These consist of either a full payment covering the whole care home fee; part payment to fund day activities/services; or extra payments direct to the care home, used to fund one-off activities. The initial findings suggest that the costs and benefits of the programme are variable, depending on the model deployed by the local authority. The model in which a direct payment covers the full care home fee seems easier to set up for councils and care homes, but is less likely to offer service users and family members greater choice of services within the care home.

However, the take-up of direct payments has been far lower than expected, with only around 30 in place when the trailblazer programme formally ended. As a result, the number of completed questionnaires received and interviews conducted with service users and family members with a direct payment have also remained low. The available evidence suggests that there have been challenges associated with setting up direct payments, and many local authority and care home staff expressed doubts about whether direct payments are the best way to promote choice and control for care home residents. There were also concerns about whether they might adversely affect the financial viability of care homes. However, some providers said that personalising activities could be one of the most beneficial uses for direct payments, particularly for residents with learning and physical disabilities, and most service users who have received direct payments in residential care or their family members were satisfied with them.