Long-term care. Unknown quantities.

A small study of nursing home owners, managers, residents and relatives found effective management depended on strong leadership skills, high bed occupancy, enthusiastic staff and low staff turnover. Funding problems were a key issue for homes, creating massive insecurity for residents, relatives and staff. There was a feeling that nursing homes could be used more effectively by the NHS, but there were concerns about capacity and competence. The viability of homes would be improved by annual block booking by the NHS. This would also facilitate the development of intermediate care. A national development programme for nursing home managers is needed.

Bridging the gap: using direct payments to purchase integrated care.

This paper reports on a study of disabled people with receiving Direct Payments who were able to purchase assistance in ways that cross conventional boundaries between 'health' and 'social' services. Indeed, most of the Direct Payment recipients used the term 'personal care' to describe a range of help that extended right across this conventional divide. Nevertheless, most of the users reported purchasing help with aspects of health care through their Direct Payments, including physiotherapy, management of incontinence, chiropody, changing dressings and sustaining tissue viability. They chose to purchase this help from their personal assistants (PAs) because statutory services were not available, had been withdrawn, or because they were able to retain greater independence and control over their lives compared with receiving conventional services. Many Direct Payment users wanted more opportunities to purchase a range of health-related services, although this also raised questions about training, supervision and the professionalisation of flexible personal assistance. The paper concludes that health purchasers may need to consider contributing to Direct Payments in acknowledgement of the health care which such schemes are currently providing.

New kinds of care, new kinds of relationships: how purchasing services affects relationships in giving and receiving personal assistance.

This paper draws on interviews with users of direct payments and focus group discussions with the personal assistants (PAs) who assist them with personal and daily living activities. It discusses the benefits and the drawbacks of directly employing such assistance, from the perspectives of both the purchasers and the providers of these services. The paper shows that direct payments can enable disabled people to purchase a much wider range of flexible help, better continuity, greater control and an enhanced quality of life, compared with conventional services. PAs also valued the trust and close relationships they developed with their employers. However, these benefits were much less marked when direct payment users recruited and employed personal assistants through care agencies. On the other hand, both direct payment users and PAs also sometimes experienced difficulties in managing the relationships between them. Some of these problems could be alleviated by changes in the support provided by direct payment schemes themselves; other difficulties were more intractable and arose from the nature of the work and the close relationships which it entailed. The paper recommends a number of measures which could reduce the risks and vulnerability of both disabled direct payment users and personal assistants, without reducing the enhanced quality of life which direct payments can confer.