Open and Shut Case?

Since direct payments were introduced in 1997, more and more
people across the country are benefiting from the choice and
control which they bring. But direct payments can only be used
instead of social care services, so as health and social services
increasingly work together, what implications could direct payments
have for the NHS? What happens when health and social care are
working in integrated settings and where do direct payments fit
with the current partnership agenda?

In the future, could direct payments be used to promote greater
choice in the NHS (for example, for people wishing to obtain
counselling services in primary care, or for people needing
long-term physiotherapy)? And how might the NHS learn from direct
payments to encourage greater patient choice – now an NHS

Against this background, the National Centre for Independent
Living (NCIL) and the University of Birmingham’s Health Services
Management Centre (HSMC) ran a seminar in December 2004 for key
stakeholders to explore these issues in more detail. Hosted by the
Social Care Institute for Excellence, the seminar’s purpose was to
imagine what the world might look like if policy was changed in the
future so that direct payments could be used for health care.

At the seminar, participants broke down into groups and were
asked to answer one of the key questions above. The first group,
focusing on the partnership agenda, believed that it was
counter-productive to make payments for social care only, and
wanted to be able to make integrated health and social care
payments when working in integrated settings.

In particular, this group felt that the current situation was
complex and some people had received conflicting legal advice.
There was also considerable confusion among practitioners and
service users about the boundary between health and social care,
and anxiety about “breaking the rules” (without necessarily
understanding what “the rules” are).

As a result, there was a desire for greater clarity about the
legal situation and for government action to help integrated
services make direct payments to people with health and social care
needs. There was also a wish to consider direct payments not just
in health and social care, but also in housing and education.

The second group, exploring the possibility of direct payments
in health care, argued that direct payments should be extended to
those people already using them for their social care needs. This
was felt to be a pragmatic step and a useful way of “testing the
water” with a relatively small and discrete group of people, before
future debates about a wider extension.

Other areas for a future expansion of direct payments might
include continuing health care and long-term care as well as health
care equipment and palliative and terminal care. But if direct
payments were to be extended beyond this, there would be a range of
additional issues to consider, including:

  • Issues of supply: is there a sufficiently large market in
    health care to enable direct payment recipients to purchase the
    support they need?
  • Issues of cost: would a limited supply of suitably skilled
    workers lead to an increase in costs and is the NHS sufficiently
    sure of its unit costs to be able to compare its services against
    other ways of meeting needs?
  • Issues of equity: would better off people be able to “top up”
    their payment in order to purchase better services? (Some felt this
    objection was unsustainable as some already get different services
    by buying them privately.)

The final group looked at how the NHS could learn from direct
payments and encourage greater choice and control. Ideas included
the advent of new NHS case managers with access to financial
resources, so that decisions about funding are made as close as
possible to the individual, and using lessons from direct payment
support services – particularly the importance of peer support – to
help NHS patients make informed choices about their health

At the same time, direct payments raise very real questions
about expertise – who knows best about what people’s needs are and
how best to meet them: the professional or the individual
themselves with personal experience of living with their condition?
This is a key question that could be asked within health care: who
is the expert and how do practitioners and service users work
together to ensure that they use their respective skills and
knowledge to achieve the best outcomes for the individual?

Also direct payments have demonstrated the importance of
trusting people to make good decisions and supporting their right
to make such decisions (“good” or “bad”) as rational adults and as
citizens. Once again, this is a lesson that will be relevant for
the NHS as it takes forward current policies around patient choice
and work with people with long-term conditions.

Overall, participants recognised that the current system hinders
joint working and does not reflect the complexity of some people’s
needs and lives. As a result, there was support for further debate
and central guidance to help resolve these issues, and a desire to
extend direct payments outside social care.

As a first step there was a degree of consensus that there would
be immediate scope to extend direct payments to small and
relatively discrete areas of health care, providing a more holistic
response to people with multiple needs and piloting this new way of
working before future consideration of a wider extension.

However, beyond this, there was much less consensus about
whether direct payments could work in wider health services, and a
range of practical and conceptual issues. While some of these
involved very real concerns about issues of supply and demand,
others focused on common misunderstandings that have long since
been identified and challenged in social care settings. These
included fears about the ability of service users to design high
quality services that meet their needs effectively.

Overall, this suggests that the battle for hearts and minds that
took place in social care from the 1990s onwards may need to be
repeated in the NHS and in integrated health and social care
settings if service users are to experience greater choice and
control over their own services and lives. In particular, this will
need to draw on lessons from social care about the importance of
peer support and the way in which people who are expert in their
own lives and services can use this not only to design their own
support, but to also help others.

Training and Learning

The author has provided questions about this article to guide
discussion in teams. These can be viewed at and individuals’ learning from the
discussion can be registered on a free, password-protected training
log held on the site. This is a service from Community Care for all
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Some policy makers and practitioners are starting to question
the fact that people with both health and social care needs can
receive direct payments for the latter but not for the former. Yet
the NHS now emphasises issues such as “the expert patient”,
“long-term conditions” and greater “personalisation” of services –
all of which could benefit from the choice and control offered by
direct payments. This article reports key themes from a national
expert seminar held to explore the significance of direct payments
for health care.

Contact the Authors

BOXTEXT: Jon Glasby is head of health and social care partnerships
and a senior lecturer at the Health Services Management Centre,
University of Birmingham.
Frances Hasler is the former chief executive of the National Centre
for Independent Living and head of user and public involvement at
the Commission for Social Care Inspection.

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