Personalisation and direct payments: empowerment or abandonment of vulnerable people?

The debate in brief

Personalisation -- the principle that people who use social care should have choice and control over the support they receive -- has been the dominant policy framework in English adult social care for nearly two decades. Its most concrete expression is the direct payment: a cash sum given to an eligible individual in place of council-arranged services, allowing them to purchase their own care and support. The policy has its roots in the disability rights movement, which fought for decades for the right of disabled people to control their own lives rather than having services imposed on them. But as personalisation has been implemented at scale, through years of austerity and with inadequate support infrastructure, a gap has opened between the liberating vision and the messy, often isolating reality. For some people, direct payments are genuinely transformative. For others, they represent a transfer of risk and administrative burden from the state to individuals who are ill-equipped to manage it.

Quick takeaways

The arguments

The case for personalisation and direct payments

The case begins with rights, not efficiency. For decades, disabled people in the UK had no meaningful choice about their care. Services were arranged by local authorities, delivered at times and in ways that suited the provider, and changed or withdrawn without consultation. The Independent Living movement, led by disabled people themselves, argued that this was not care but control -- and that genuine support meant giving people the resources and the freedom to decide for themselves what help they needed, from whom, and when.

Direct payments, first legislated through the Community Care (Direct Payments) Act 1996 after years of campaigning, were the concrete expression of this principle. For the first time, disabled people could employ their own personal assistants, choose their own providers, and structure their support around their own lives rather than institutional timetables. The evidence from early adopters was overwhelmingly positive. Research by the Personal Social Services Research Unit (PSSRU) at the University of Kent found that direct payment recipients reported greater satisfaction, more control over their daily lives, and better outcomes than people receiving equivalent council-arranged services.

The empowerment case remains powerful. A person who employs their own personal assistant can choose someone who speaks their language, understands their culture, shares their interests, and is available at the times that suit them. They can sack a worker who is incompetent or unkind. They are an employer, not a passive recipient. For many disabled people and older adults, this shift in power -- from being done to, to being in charge -- is not a marginal improvement but a fundamental change in the quality of their lives.

The economic case, while secondary to the rights case, also has evidence behind it. In Control, the social enterprise that developed the individual budget model, published research showing that self-directed support could achieve equivalent or better outcomes at equivalent or lower cost, because people making their own decisions tend to spend more efficiently than bureaucracies making decisions on their behalf.

The case that personalisation has failed in practice

The critique is not that choice and control are bad ideas. It is that implementing them through individual cash budgets, in a context of savage austerity and a collapsing care market, has produced outcomes that the disability rights pioneers would not recognise.

The most immediate problem is administrative burden. Managing a direct payment requires the recipient -- or someone acting on their behalf -- to recruit, employ, and manage personal assistants, handle payroll and tax, maintain records for audit, navigate employment law, manage sickness and holiday cover, and account for every penny to the local authority. For a confident, organised, well-supported person, this is manageable. For someone with a learning disability, dementia, significant mental health difficulties, or simply no experience of being an employer, it can be overwhelming.

Research by the National Audit Office (NAO) in 2016 found that many local authorities were offering direct payments without adequate support services to help people use them. Support organisations -- which help with payroll, recruitment, employment law, and managing the budget -- were underfunded and unevenly distributed. In some areas, robust support existed; in others, people were handed a budget and left to manage alone.

The austerity context is critical. Between 2010 and the early 2020s, local authority spending on adult social care was severely squeezed in real terms -- councils' overall spending power fell by around 29% during the austerity decade, according to the National Audit Office, with adult social care absorbing much of the pressure. Personal budgets shrank as councils cut eligibility thresholds and reduced the hourly rates they would pay. A person given a direct payment nominally has "choice and control," but if the budget is too small to purchase adequate care at a rate that anyone is willing to work for, the choice is illusory. Several studies, including research by the University of York's Social Policy Research Unit, found that many direct payment recipients were unable to recruit personal assistants because the rates offered were at or below the national minimum wage once employment costs were factored in.

The result, for some people, is not empowerment but abandonment: a notional budget, no available workers, no support organisation, and full personal responsibility for making it work.

The market problem

Personalisation assumes a functioning care market in which individuals can exercise meaningful choice. In much of England, that market does not exist. Domiciliary care providers have been closing at record rates, driven by inadequate fees, recruitment crises, and rising costs. In rural areas and areas of high deprivation, there may be no providers to choose between. The Competition and Markets Authority's 2017 care homes market study found that the market was not functioning well for local authority-funded residents, and the situation has worsened since.

For people using direct payments to employ personal assistants directly, the recruitment challenge is equally severe. Social care had a vacancy rate of approximately 8.3% in 2023/24, among the highest of any sector -- around three times the wider economy rate. People competing to recruit personal assistants at direct payment rates are competing against supermarkets, warehouses, and hospitality -- all of which may pay more, offer more predictable hours, and require less emotional labour.

The personalisation model works best where there is a diverse, accessible supply of services and workers. In many parts of England, that supply has been eroded to the point where individual choice is a theoretical right with no practical content.

The evidence

The evidence on personalisation is extensive but contested. The IBSEN (Individual Budgets Evaluation Network) study, published in 2008, was the largest evaluation of individual budgets at the time. It was conducted by a consortium including the Social Policy Research Unit at the University of York, the Personal Social Services Research Unit (PSSRU) at the Universities of Kent, Manchester and LSE, and the Social Care Workforce Research Unit at King's College London. It found that individual budgets were associated with higher psychological wellbeing for some groups (particularly physically disabled adults and people with mental health conditions) but not for others (particularly older people, who often found the process stressful and did not want the responsibility of managing a budget).

Subsequent research has broadly confirmed this pattern. A 2018 systematic review published in the Journal of Social Policy found that direct payments were associated with greater satisfaction and perceived control, particularly for working-age disabled adults, but that the evidence for improved outcomes for older people and people with cognitive impairments was weak or mixed. The review noted that satisfaction was strongly linked to the availability of support services: people with access to good support organisations reported much better experiences than those without.

The Think Local Act Personal (TLAP) partnership, which brings together sector bodies to support personalisation, has published evidence showing that when personal budgets are adequate, when support services are available, and when individuals have genuine choice of provider, personalisation delivers on its promise. The problem, TLAP's own research acknowledges, is that these conditions frequently do not hold.

On the cost-effectiveness question, the evidence is genuinely mixed. Some studies have found that direct payments are more cost-effective than council-arranged services; others have found no significant difference. The NAO's 2016 report concluded that the Department of Health had no evidence that personalisation was achieving either better outcomes or better value for money at a system level.

Skills for Care workforce data consistently highlights the recruitment and retention challenge. The social care workforce has approximately 131,000 vacancies in England, and turnover rates above 25%. These figures represent the structural constraint within which personalisation must operate: choice is meaningless without supply.

Current context

The government's adult social care reform programme, building on the 2021 white paper "People at the Heart of Care" and carried forward with modifications by the current administration, continues to affirm personalisation as a core principle. The Care Act 2014 remains the legislative framework, requiring local authorities to offer personal budgets and direct payments. The proposed care cap and fair cost of care reforms, delayed multiple times, would, if implemented, affect the resources available for personal budgets.

The social care workforce crisis has intensified. The 2024/25 Skills for Care data shows that vacancy rates remain stubbornly high, and the sector continues to lose workers to better-paid industries. The government's workforce strategy, published in 2025, promises investment in training, career development, and improved pay, but progress has been slow and the sector remains sceptical about whether the scale of investment will match the scale of the problem.

There is growing interest in "managed personal budgets" as a middle ground -- where the local authority or a third party manages the budget on the person's behalf, with the person retaining choice over how the money is spent without the administrative burden of managing it directly. This model is less empowering than a full direct payment but more accessible for people who cannot or do not want to be employers. Uptake has been growing, though data collection on the different forms of personal budget remains inconsistent.

The disability rights movement remains broadly supportive of personalisation in principle but increasingly critical of its implementation. Disability Rights UK, Inclusion London, and other user-led organisations have called for higher personal budget allocations, better support infrastructure, and an end to the use of personalisation as a mechanism for cutting costs while shifting responsibility to individuals.

Last updated: April 2026

What this means for charities

Charities in social care and disability occupy multiple roles in the personalisation landscape. Some are service providers, competing for direct payment holders' custom. Some are support organisations, helping people manage their budgets. Some are advocacy bodies, campaigning for better implementation. Some are all three, which creates its own tensions.

For provider charities, personalisation means adapting to a model where the "commissioner" is the individual, not the local authority. This requires flexibility, responsiveness, and a willingness to be held to account by the people you serve. Charities that have genuinely embraced this -- offering person-centred, flexible services that respond to what individuals want rather than what the organisation finds convenient to deliver -- have often thrived under personalisation. Those that have tried to maintain institutional models of service delivery have struggled.

For support organisations, the challenge is sustainability. Many direct payment support services are funded by local authorities, and when councils cut budgets, support services are among the first to go. This is false economy -- a support service that costs a few hundred pounds per person per year prevents far more expensive problems -- but it is a pattern that has recurred across the country.

For advocacy organisations, the message should be clear: personalisation has not failed as a principle. It has been undermined by austerity, inadequate implementation, and a care market that does not function. Charities should be advocating for higher personal budget allocations, statutory requirements for support services, fair pay for care workers, and accountability for outcomes -- not a return to paternalistic, one-size-fits-all council-arranged services.

Common questions

What is the difference between a direct payment and a personal budget?

A personal budget is the total sum that a local authority calculates a person is entitled to for their care and support. A direct payment is one way of receiving that budget -- as cash, to spend directly. Alternatively, the council can arrange services to the value of the budget (a "council-managed" budget), or a third party can manage it on the person's behalf (a "managed personal budget"). The Care Act 2014 requires councils to offer all three options.

Who benefits most from direct payments?

The evidence consistently shows that working-age physically disabled adults benefit most, particularly those with stable conditions, good cognitive function, and access to support services. These are the people closest to the Independent Living movement's original constituency. Older people, people with learning disabilities, and people with fluctuating mental health conditions often find direct payments more difficult to manage, though with good support many still prefer them to council-arranged services.

Are direct payment rates adequate?

In many areas, no. Local authorities set the hourly rates for direct payments, and these have not kept pace with the cost of employing a personal assistant at or above the national living wage once employer costs (national insurance, pension contributions, holiday pay, insurance) are factored in. Research by the University of York found that in some areas, direct payment rates were effectively below minimum wage for the people being employed, making recruitment extremely difficult.

What happens if someone cannot manage a direct payment?

They can opt for a council-managed personal budget, where the council arranges services on their behalf, or a managed personal budget administered by a third party such as a support organisation or charity. In theory, the person retains choice and control over how the budget is spent; in practice, the degree of genuine choice varies significantly depending on local provision.

Has personalisation saved money?

There is no robust evidence that personalisation has delivered system-level savings. The NAO's 2016 report found that the Department of Health could not demonstrate that personalisation was achieving better value for money. Some individual studies have found that direct payments are more cost-effective than equivalent council-arranged services, but the system-wide picture is unclear, partly because data collection has been inconsistent.

What is the disability rights movement's position?

Broadly supportive of personalisation as a principle -- it was their idea -- but increasingly frustrated by implementation. Disability Rights UK, Inclusion London, and other user-led organisations argue that personalisation has been compromised by inadequate funding, a broken care market, and the withdrawal of the support infrastructure that makes self-directed support workable. Their position is not to abandon personalisation but to fund it properly and hold local authorities accountable for genuine, not nominal, choice and control.

Key sources and further reading

• IBSEN: Evaluation of the Individual Budgets Pilot Programme -- Individual Budgets Evaluation Network (University of York, PSSRU, King's College London), 2008. The largest early evaluation of individual budgets, finding varied experiences across different user groups.

• Care Act 2014: Statutory Guidance -- Department of Health and Social Care. The legal framework for personal budgets, direct payments, and the duty to offer choice and control.

• Personalised Care and Support Planning -- Think Local Act Personal (TLAP). Practice guidance and evidence on implementing personalisation effectively, including the conditions required for success.

• Personalisation in Social Care -- National Audit Office, 2016. Critical assessment of whether personalisation was achieving better outcomes or better value for money, finding insufficient evidence for either.

• The State of the Adult Social Care Sector and Workforce in England -- Skills for Care, annual. Comprehensive data on the care workforce, including vacancy rates, pay, turnover, and the recruitment challenges that constrain personalisation.

• Independent Living Strategy -- Disability Rights UK, updated regularly. The disability rights perspective on personalisation, direct payments, and what is needed for genuine choice and control.

• People at the Heart of Care: Adult Social Care Reform -- DHSC, 2021. The white paper setting out the government's reform agenda, affirming personalisation while acknowledging implementation challenges.

• Care Homes Market Study -- Competition and Markets Authority, 2017. Analysis of whether the care market is functioning, with findings relevant to the question of whether personalisation can work in a broken market.