Direct payment budgets could be extended to people living in care settings to allow residents to make individual choices from healthcare services available to them, says David Janner-Klausner

Thegovernment's objective to provide citizens with a greater choice of services has been a driving force behind the system of direct payments. This allows people who are entitled to benefits in connection with a disability or special needs to receive a budget that they and their carers candecide how to spend, rather than receiving standardised benefits packages.This creates greater flexibility and a simpler regime for eligibility, which improves the relationship between the client and the service.

At the moment, residential care has several categories and payment streams, which raises an interesting question: how could direct payments be reconciled with a move into a care home?

Perhaps the most radical application of direct payments would be to scrap the local authority payment and the NHS component in facilitating residential care and replace them with an individual budget. There are myriad questions around this, not least whether the person entitled to the individual budget would be capable of managing it. The idea of an individual budget goes hand-in-hand with a plurality of providers and the ever more informed consumer. With many decisions being made under duress, a direct payment system may not work. It would be better to start by looking at the needs of the individual rather than looking at it purely as a system of funding. What does the person entering a care home want, and what do their families want?

I have been a volunteer at a care home for the past six years and have observed that there are basic services on offer, depending on the level of care needed and addressing physical needs and dementia in particular. Beyond that, there is a natural desire to personalise the experience people have. I hear repeated complaints that it takes too long to get a physiotherapist in after an old person has had a fall. Would we want individual budgets to provide a physiotherapist as soon as the treatment can be beneficial? Or is that something that should be part of the collective provision of service?

There are two key issues that can be highlighted when looking at this type of system. First, in an institutional setting where needs are often common and support is partly within a group context, there can be a contradiction between an individual budget and the net outcome. You would want to pool individual budgets to obtain a more rapid physiotherapy service, for example, as it is a very common need.

Second, assuming you have overcome the problem of preventing the individual budget from buying services that should be provided statutorily, you are still left with activities where it would be better for an institution to pool budgets - this would require serious engagement with residents and their families. You would also need to address issues arising from different residents 'importing' service providers into a care home. There will be co-ordination issues to iron out, including medication, food provision and any number of other areas where institutional policies interact with an individual's exercise of choice. It would not be impossible to solve these problems. However, the ideal answer would be to have a shared core of service in a care home, supplemented by a wide variety of other services provided at the instigation of residents. It just requires the institution to view itself differently; rather than providing total care, it would support commissioning by individuals and groups within the care home community.

For example, there are residents who would like regular massages. The home can broker the service, which is paid for through individual budgets. It may be worthwhile to train a staff member to provide the service in-house, or have a partnership agreement with a local practice. The care home would be responding to the advent of individual budgets by serving as a trusted broker or provider, offering residents easy access to diverse services - similar in a way to the service provided by a concierge in a high-quality hotel. This function would help overcome the weakness of the individual budget model because it requires a skilled customer to be most effective - a skill that some residents may be unable to acquire or exercise.

The intention of direct payments is to enable people with special needs to exercise greater control over their lives. However, in care homes, almost by definition, much of the capacity to exercise choice is taken away. Care homes ought to welcome a system that helps residents regain some of this capacity, and assists in making use of individual budgets effective for individual residents and the care home community as a whole.This way, the severance of ties care home residents often have with the outside world will become a notion of the past.