Friend or Foe? Towards a Critical Assessment of Direct Payments

Abstract

Direct payments enable individuals to purchase their own care rather than have directly provided services. This article unpacks the complexities involved in the implementation of direct payments by addressing the need to reconcile the strong evidence of their benefits with emerging concerns about the wider consequences of their implementation. One practice that highlights the conflicts at the heart of direct payments is the employment of personal assistants. While directly employing personal assistants offers maximum benefit for recipients, it also produces the strongest concerns. Therefore, an understanding of the context of direct payments, specifically the practice of employing personal assistants, is used to explore these complexities in greater depth. The discussion concludes by arguing for a more critical awareness of the wider context in which direct payments are being developed in order to understand how this context can open up or limit opportunities for greater self-determination. It suggests a number of factors that need to be addressed to ensure that direct payments continue to be a progressive strategy. These include reconciling conflicting ideologies such as those advocating individual choice and/or collective provision; the need for political action to secure adequate resources; and the development of alternative strategies such as cooperatives to address the collective needs of direct payment recipients and workers.

Direct Payments in England: Factors Linked to Variations in Local Provision

“…Second, it is only relatively recently that a belief has grown that the policy can be cost-effective, although the evidence used to promote that argument goes back further (Zarb and Nadash, 1994;Dawson, 2000). Third, the policy appeals across the political spectrum (Spandler, 2004). Conservative commentators can applaud its market-like characteristics, while for New Labour the policy resonates neatly with the broader thrust of the choice in public services campaign.…”

“…Information exchange, system organisation inflexibilities, concomitant 'excessive bureaucracy' and a lack of management leadership are portrayed as keys to understanding 'poor performance' (Commission for Social Care Inspection, 2004a). Other commentators have tended to emphasise wider resource constraints, process complexities, local party political traditions, surfeits of social movement activism and conflicts between the interests of workers, carers and users as the central disabling factors (Glendinning et al, 2000a;Barnes et al, 2004;Spandler, 2004;Riddell et al, 2005).…”

In(ter)dependent lives

“…The day-to-day life experiences with cash-for-care rather reveal a practice of interdependence, because the specific ways in which the relationships with the PAs work are crucial, the negotiations with the local authorities, support organizations (whether non-profit or profit-based) and accountants are crucial, and furthermore the recruitment and choice of PAs depends on the labour market for PAs. As pointed out by the few critical investigations of cash-for-care, PA work is low-status work, low-paid and often with insecure working conditions (Spandler 2004;Ungerson 1997). This can be crucial to the ideas for extending these cash-forcare systems in the future.…”

“…But this is generally ignored for one or two reasons. Within the new social politics directed at disabled people, this is ignored because of an ideological individualism, having the slogan of more individual choice (Spandler 2004). Within the disability movement it is disregarded because disabled people fear that this will veil the major difference between interdependence of non-disabled people and the forced dependence of disabled people (Kittay 1999;cited in Shakespeare 2006, 146).…”

Implementing the Community Care (Direct Payments) Act: Will the Supply of Personal Assistants meet the Demand and at what Price?

“…The discussion has been joined from a range of different perspectives (Spandler, 2004). Several interrelated themes and overlapping strands to the debate have emerged.…”