In 2012, the Department of Health (DH) decided to test the extension of direct payments from community care to residential care. It invited councils to express interest in becoming pilot sites for direct payments in residential care and selected 20 pilot sites. In late 2013, DH commissioned the Policy Innovation Research Unit (PIRU) to conduct an independent evaluation of the pilots, now called ‘trailblazers’. This followed a scoping study conducted by PIRU in 2013.
The objectives of the evaluation were:
- To understand the different ways in which direct payments were being offered to residents of care homes and to examine the challenges arising from implementing direct payments for service users, carers, care home providers, and councils and their staff in trailblazer sites (process evaluation);
- To assess the impacts of direct payments in residential care on service users and their families, care home providers and the provider market, and councils and their staff (impact evaluation); and
- To examine, as far as possible, the relative costs and cost-effectiveness of different approaches to providing direct payments in residential care, for both service users and their families and local councils (economic evaluation).
This evaluation has a number of limitations principally as a result of the low uptake of direct payments by residents in care homes, which has limited our ability to collect interpretable quantitative data on outcomes and quality of life. However, the extensive number of interviews and the surveys support the following conclusions:
- Some service users and family members benefited from having a direct payment. In some of these cases, it offered a solution to a specific problem (e.g. self-funding service users who had become newly eligible for council funded residential care could remain in the same care home, although this typically incurred higher costs to the council or top-up payments by relatives). In other cases, service users previously holding direct payments in the community could continue to have control of their own budgets when entering residential care. However, the low uptake suggests that direct payments were not as attractive to service users and their families as had been expected, implying that potential benefits of direct payments were not self-evident to all prospective user groups.
- The effect of direct payments in residential care on people’s ability to exercise more choice and control over their services depended on the model of direct payments offered by councils and/or selected by service users and their families, and the funding arrangement underpinning each model. A direct payment covering the whole care home fee (i.e. representing a person’s entire personal budget) seemed easier to be set up for councils, but was less likely to offer service users greater choice (although some reported a greater sense of control). A part payment was more difficult to implement unless specific funding was available that could be deployed in addition to the care home fee. If such funding was available, then it would more likely increase user choice anyway without the need for a direct payment.
- The use of direct payments and their effects reflect differences in funding of residential care for different age groups. While older people (over 65 years) represented about three-quarters of all service users with a direct payment, they were less likely to experience increased user choice from having a direct payment, compared with younger adults. These differences appear to reflect underlying differences in funding available for younger and older people in residential care, with placements for people over the age of 65 years often attracting significantly less funding in relation to their needs than placements for younger people, allowing for less flexibility in the use of resources.
- The findings also suggest that the cost of implementing the scheme was high in relation to its modest outputs. Setting up direct payments typically took a significant amount of time and effort for council staff and providers, as well as for service users and/or their family members. While some of the problems encountered may have been ‘teething’ problems – expected in any relatively novel programme, the findings suggest that setting up and managing direct payments incur extra transaction costs, including costs for organising activities or services that are intrinsic rather than likely to reduce over time. It is at least conceivable that similar (or better) effects could be achieved by other means: some interviewees suggested that more personalised services could be achieved irrespective of a direct payment.