Since the 1990’s many advanced welfare states have moved away from the delivery of home care services and towards alternative ‘cash-for-care’ schemes. This move towards self-directed care has formed the heart of the Government’s personalisation agenda and has become emblematic of Labour’s restructuring of the relationship between the citizen and the state in respect of welfare services and support. More recently the Government has also contemplated the potential of personal health budgets, which would permit individuals to buy their own health care.

 
Direct payments and personal budgets are viewed by many as a panacea for delivering greater choice for social care users, while at the same time containing the costs of long term care and chimes with private and third sectors expansion in developing markets in care services. Self-directed support heralds a significant shift in service provision, but also necessitates establishing a culture, support structures and processes to support it.
 
This new paradigmatic shift in social care has prompted concern and questions across the health and social care arena. Self directed support per se is a relatively new concept and as yet the long term implications and potential benefits/disadvantages have yet to be fully explored. The move to extend this form of self-directed support to people, who were previously not considered suitable, also merits greater attention. In particular there is a significant absence of research examining the potential challenges and consequences for people with dementia.
 
With the ageing of the UK population and the demand for all forms of personal long-term care in the UK expected to rise, it is imperative policy-makers have a clear understanding of the effect and consequences of extending direct payments to older people. This is particularly pertinent with regard to people with dementia given the specific issues and challenges in respect of consent, mental capacity and safeguarding. While there seems to be broad support for the proposal to extend direct payments to people with dementia from health and social care professionals, and third sector bodies and user groups, there must be clearer evidence, information and support on how self-directed support can work more generally for people with dementia and their families.
 
Until relatively recently, few people with dementia were eligible for direct payments. According to a NAO report in 2007 (http://www.nao.org.uk/publications/0607/support_for_people_with_dement.aspx), this was partly due to barriers within the system and the inherent complexities embedded within it.  Implicit within this are the attitudes and culture of social care professionals, who are considered by some to be reluctant to explore how direct payments can work for people who lack capacity. It is not only a question of education and training to support professionals, but how the system can be adapted and modified to respond to the needs of this specific cohort of users.
 
If we are to impose such a radical vision for social care, it will also be necessary to engender a sea change in thinking amongst older people and their families. As a SCIE report (2004) pointed out, it cannot be assumed that older people and their families will automatically consider autonomy, choice and control an attractive proposition.
 
There are also a number of wider questions that need to be addressed, namely: How would direct payments need to be adapted to be suitable for use by individuals with dementia? What are the barriers and challenges that hamper individuals with dementia using direct payments? And what criteria would need to be adopted to facilitate people with dementia using direct payments? Unless we answer such questions we are in danger of following a path with no real understanding of just where it may lead…
 
Sally-Marie Bamford