Questioning “choice”: A multinational metasynthesis of research on directly funded home‐care programs for older people

Abstract

In many developed contexts, home-care services have been overhauled with the intent of increasing control and flexibility for those using social and health services. This change is associated with providing funds directly to individuals, and sometimes their families and supports, to arrange at home-care assistance with the activities of daily living. Directly funded home-care programs, or "direct funding" (DF), are not value-neutral policy interventions, but complex and politicised tools for the enactment of care in contemporary times. In this qualitative metasynthesis, we consider 47 research articles published between 2009 and 2017 that explore various DF programs for older persons in the United Kingdom, Australia, and the United States to identify core concepts in the literature. We find that choice emerges as a central concern. We then assess the literature to explore the questions: How does the existing literature conceptualise choice, and the mechanisms through which choice is enhanced, in DF programs for older persons? How is choice, and the benefit of choice to older service users, understood in relevant studies? We argue that the concept of "choice" manifests as a normative goal with presumed benefits among the studies reviewed. Particularly when discussing DF for older people, however, it is essential to consider which mechanisms improve care outcomes, rather than focusing on which mechanisms increase choice writ large. In the case of DF, increased choice comes with increased legal responsibilities and often administrative tasks that many older people and their supports find burdensome. Furthermore, there is no evidence that choice over all elements of one's services is the mechanism that improves care experiences. We conclude by presenting alternative models of understanding care emerging from feminist and other critical scholarship to consider if we are, perhaps, asking the wrong questions about why DF is so often preferred over conventional home-care delivery.

Influences of service characteristics and older people’s attributes on outcomes from direct payments

“…Even so, no differences were detected in social care need-related outcomes between older and younger participants. Further analysis, excluding proxy responses, found no differences even in psychological wellbeing [ 26 – 28 ].…”

Decision‐making in home care package spending

“…It would appear that providers may still be grappling with the shift in power entailed in the principles of choice and control, as evidenced by limited use of strategies to support people to actually exercise choice and control, such as ensuring information is clear and user‐friendly, and genuine opportunities to tailor services 15 . Indeed, international research suggests that clarifying exactly what people would like increased choice about and the impacts of this on outcomes such as quality of care and quality of life remain to be understood 16 …”

Skill mix: The potential for personal assistants to undertake health‐related tasks for people with personal health budgets

“…Consumer-directed care is one of the many terms given to arrangements where state funds are passed to individuals who are enabled to organise their own care, rather than this being provided by care agencies. The international trend towards this approach is of interest especially in terms of the dynamic of worker/employer relationships and the extent to which such relationships are mediated by the funding body (Murphy & Kelly, 2019;O'Shea & Bindman, 2016;Woolham, Daly, Sparks, Ritters, & Steils, 2017).…”