The risk of users’ choice: exploring the case of direct payments in German social care

Abstract

In this article, we explore the risks associated with direct payments to users enabling them to purchase social care. These payments are intended to enable people with disabilities to make choices and increase their autonomy. However, there is little evidence in the existing literature about the risks involved in direct payments as seen by service users. In this paper, we draw on data from a qualitative study of direct payments for people with disabilities in a federal state of Germany. We interviewed 37 individuals involved in direct payment schemes including individuals receiving payments, care assistants, members of organisations providing care and the administrative officers of the local authorities between December 2011 and January 2014. In this article, we use a governmentality perspective to explore how individuals who received the payments saw and sought to manage the risks associated with the scheme. We found that while users reported that direct payments reduced the risk associated with being directly dependent on the care providers and hence increased their desired self-determination, they identified new risks linked to their liability for the transferred money, problems associated with their liquidity and cash flow, challenges presented by budget cuts, and sanctions resulting from violation of norms of ‘appropriate use’ and the difficulties of negotiating with the funders. To manage these perceived risks users indicated that they had subjected themselves to a new way of active self-control and self-management, normalising their behaviour. We note that risk to service users has been neglected in policy design and should be acknowledged more explicitly.

Keywords:

• user choice
• risk
• direct payments
• disability
• care
• governmentality
• Germany

Acknowledgements

We would like to acknowledge the helpful comments on previous versions of the manuscript by Barbara Junne, Monika Müller, Tobias Scheytt, Kim Soin and two anonymous reviewers. We would also like to thank the editor for his careful and insightful comments. All remaining errors and omissions are our own.