Friend or Foe? Towards a Critical Assessment of Direct Payments

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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.