What approaches have been used to implement direct payments within health systems, and how do various factors influence the effectiveness of these approaches in supporting personalisation, governance, and equitable access to care: A Rapid Evidence Summary
Background and Context
In Wales, people with complex health needs who qualify for Continuing NHS Healthcare (CHC) currently don’t have the option to receive direct payments to manage their care. This contrasts with social care, where direct payments have long been used to give people more choice and control. A new law passed in 2025 will change this, allowing direct payments for CHC from 2026. This report explores how direct payments have been introduced in other healthcare systems (particularly in England) and what lessons can be learned to help Wales introduce them successfully.
Aims
The aim of this study review was to understand:
- How direct payments have been introduced in healthcare systems
- What helps or hinders their success
- How they support personalisation, good governance, and fair access to care for everyone
Strategy/Method
The researchers looked at 8 academic studies and 16 reports from organisations, all published between 2010 and 2023. These included evidence from England and other high-income countries. The focus was on adults with ongoing or complex health needs. The review did not include evidence that focused only on social care or indirect funding models.
Findings/Outcomes
- Direct payments can offer people more freedom, choice, and flexibility in how their care is arranged
- They are often linked to better quality of life/wellbeing, greater independence, and a stronger sense of dignity
- Their success depends on good support systems, clear information, and staff who are properly trained
- Challenges include complicated processes, inconsistent access, and concerns about safety or misuse of funds
- People with strong support networks tend to benefit more, which raises questions about fairness and equal access
Impact – So What?
This review highlights that direct payments can work well in healthcare, but only if they are introduced with caution. When well supported, they can improve people’s lives by offering more choice and control. However, without the right systems in place, they may lead to increased stress or create inequalities. The findings will help shape how Wales introduces direct payments in a way that is fair, safe, and effective.
How Will the Research Be Used?
The Welsh Government will use this evidence to:
- Develop clear guidance and regulations for how direct payments will work in Continuing NHS Healthcare (CHC)
- To help design support systems to assist people in managing their care and handling the responsibilities that come with direct payments
- Help train staff across Wales and ensure consistent practices across the nation
How Will It Be of Benefit in the Real World?
Direct payments can help support people to live more independently and receive care that suits their lives. This is particularly valuable for those with long-term or complex health conditions. If done well, it can reduce pressure on services and lead to better outcomes for both individuals and their carers.
Key Findings
- Support is vital: People need help to manage their budgets, hire carers, and understand their options
- Training matters: Staff and personal assistants need proper training to deliver safe and high-quality care
- Information must be clear: People need straightforward guidance on how to manage their budget and what it can cover
- Equity concerns: Those living in rural areas or with fewer resources may face more barriers to accessing support
- Governance is key: Clear and strong processes/systems are needed to prevent misuse and ensure people are safe
Conclusion
Direct payments have the potential to transform healthcare by giving people more control over their care. However, they are not a quick fix or a simple solution. For them to work well in Wales, it’s important to learn from existing systems and build a strong foundation of support, good training, and clear guidance to make direct payments work for everyone.
Author: Beti-Jane Ingram, Public Partnership Group Member
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