Direct Payments and care homes

One of the questions being considered for inclusion in next Spring’s social care White Paper is whether people should be able to use Direct Payments to pay for residential care, which at the moment is unlawful. The personalisation group of the White Paper engagement team is leading on this issue, so I’m very much writing about this with my own views, not in any way as co-lead of the prevention group.

My understanding of the rationale for excluding residential care users from Direct Payments, was that people may have been encouraged to buy the same old thing they were being offered before, which would not then amount to a radical change in the choice of provision out there. I’ve written a number of times about the ways in which the state and professionals have proved adept at assimilating the mechanisms of personalisation into their existing world view; I’m sure that having the option of transferring residential care users onto Direct Payments would have added to that problem.

I’m equally sure that the two-tier system which has resulted, with people who continue to use residential care excluded from one of the key aspects of personalisation cannot continue. It just doesn’t feel fair that I should lose a key route to choice and control when I move from receiving home care to a care home. However, I’m equally sure that opening up Direct Payments won’t by itself transform residential care. It will need to be part of re-thinking how care homes work. Community Care’s recent article on care provider Dimensions, which attempted to introduce more choice and control in one of its care homes, shows that addressing staff expectations and practice was more important than introducing an individual service fund approach to personal budgets.

It’s also worth noting that older people have been spending their own money on care homes for years, without the private care homes market establishing a reputation for forging ahead on choice, quality and value. As the Southern Cross debacle demonstrated, being an individual consumer of the product of an uncompetitive industry is not a very empowered place to be.

A colleague objected to a recent tweet in which I asked whether introducing Direct Payments for over and under 65s who use care homes would have very different connotations. He felt the suggestion was ageist and played to assumptions that older people don’t want choice and control, which of course they do. The difference I was interested in is not in the intended outcomes or in people’s ability to use Direct Payments. I think that personalisation within every care setting and for every age group is a given, and that, with the right support, there is no reason that Direct Payments shouldn’t become an equally important part of achieving choice and control for older people and their families, as for working age adults.

But if we’ve learnt one thing from the personalisation reforms, it’s that there’s no point in trying to reformat the demand for a service without also reformatting the supply. The market of care home provision for working age adults is nearly entirely used by people who are funded by the state, whereas the market for older people’s care homes is split between state-funded provision and privately purchased provision, with the latter the only area of growth in the market, whilst the former sees increasing numbers of providers go out of business as the margins become ever-more unworkable. It’s not unusual for one care home to house older people using their own money to buy care at one price, alongside people who are receiving care block-purchased by the council at a lower price. What would happen if the latter group suddenly became individual consumers, but with less money to spend than people who were already ‘self-funders’? 

Some of the most interesting developments in the use of Direct Payments seem to me to be those where people form small groups to purchase collectively. As a group you have much more chance to shape care, acting more like a commissioner than just an individual consumer. I’ve blogged below about what might have happened if a few thousand of Southern Cross’s users or their families had formed a user group, or even a buying co-operative. A group wielding that amount of purchasing power (Southern Cross’s users gave it and its shareholders around £600m per year to play with), might even opt to buy something very different from residential care, or to work with providers to create new kinds of support and accommodation.

I think there is a growing consensus that excluding care home users from Direct Payments is not sustainable. But I hope that the transition period is thought about very carefully and I suspect that introducing collective purchasing should be a part of that. And whatever happens to the way the money is managed, the kind of basic choice and control Dimensions, Anchor and others have started to introduce should be non-negotiable.