Enabling access to direct payments: an exploration of care co-ordinators’ decision-making practices

Background: Increasing demands for the greater take-up of direct payments necessitates the willingness and ability of care co-ordinators to be able to meet this challenge. Aim: To consider how workers have responded to direct payments in practice and how they can enable or limit greater access. Method: The analysis presented here is primarily based on 20 in-depth interviews with care co-ordinators who took part in an evaluation of a national pilot to implement direct payments in mental health. Results: Three key responses were identified which mediated care co-ordinators' pursuit of direct payments as an option for clients: using selective criteria; incorporating it into a dominant framework (of ‘providing services’) and re-conceptualizing their role as enabling greater capacity for choice and control. In order to make sense of these responses it was necessary to examine their conflicting work context. Conclusions: Initiatives such as direct payments suggest the need to re-appraise the role of care co-ordinators and may require a significant shift in the focus of their practice. Whilst tensions inherent in their role may make this shift difficult, the analysis also suggests that it could lead to opportunities for putting into practice ideas about user empowerment which should be central to their practice