Background Direct payments (DPs) are cash-payments that eligible individuals can receive to purchase care services by themselves. DPs are central to current social care policy in England, but their advantages remain controversial. This controversy is partly due to their lack of historical visibility: DPs were deployed in stages, bundled with other policy instruments (first individual budgets, then personal budgets), and amidst increasing budgetary constraints. As a result, little unequivocal evidence is available about the effectiveness of DPs as an instrument for older people’s care. This study aims to partially fill that gap using data obtained during an early evaluation of DP’s that took place between 2005 and 07. Methods Semi-structured 81 face-to-face interviews with older people (and their proxies) using DPs are analyzed. DPs contribution to outcomes was measured using a standardized utility scale. Data on individual characteristics (dependency, informal support) and received services (types and amount of services) was also gathered. Multiple regression analyses were performed between measured outcome gains and individual and service characteristics. A Poisson log-functional form was selected to account for the low mean and positive skew of outcome gains. Results Levels of met need compared very favorably to average social care outcomes in the domains of social participation, control over daily living and safety, and user satisfaction was high. Benefit from DPs was particularly affected by the role and function of unpaid care and availability of recruitment support. The freedom to combine funded care packages with self-funded care enhanced the positive impact of the former. The ability to purchase care that deviated from standardized care inputs improved service benefits. Large discrepancies between total care input and that supported through DPs negatively affected outcomes. Conclusions The results offer clarity regarding the benefit derived from receiving DPs. They also clarify contested aspects of the policy such as the influence of unpaid care, types of care received, funding levels and the role of wider support arrangements. Tangible benefits may results from direct payments but those benefits are highly dependent on policy implementation practices. Implementation of DPs should pay special attention to the balance between DP funded care and unpaid care.

Direct payments have moved to the heart of the government's drive for increased user choice. At the same time, implementation has remained disappointing. This article explores the demand, supply and related factors associated with patterns of local variability in uptake and intensity of care package provision. Statistical analyses are conducted for key client groupspeople with physical disabilities, older people, people with learning disabilities and people who use mental health services -using data for England from 2000-01 to 2002-03. The results suggest that direct payments variability reflects a complex array of factors, both within and beyond the control of local public actors. In particular, while local policy preferences appear to shape the extent of direct payments growth, the results also demonstrate that understanding levels of activity requires attention to local circumstances. IntroductionRecently reinforced by the energy behind the government's 'choice' campaign, the policy of direct payments (user-controlled purchasing of social care) has been catapulted high up the social care agenda. As policy makers have adjusted and broadened the ambit of the direct payments approach, policy commentators have widened their descriptions of its contours and potential implications.While researchers have begun to elaborate more sophisticated explanations for the overall trajectory of developments, research on local patterns has been relatively limited, despite considerable variations in the introduction, take-up and level of direct payments. One purpose of this article is to chart those variations. A second is to apply statistical modelling to try to explicate socio-economic, political and policy process factors associated with these variations in England.

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