This document summarizes a presentation on consumer directed care and whether it provides more choice or voice for older people. It discusses the assumptions and benefits of consumer directed care, such as choice and control, but also notes risks like assumptions about choice and mechanisms for voice. It examines what choice and voice mean for different stakeholders and whether voice mechanisms can increase choice. The document concludes that choice alone is not enough and voice is important to have a say in services. It identifies implications for policy, research, and practice around supporting diversity in models of care and ensuring the voices of older people are heard.

1. Consumer Directed Care – More
Choice or Voice for Older People?
Carrie Hayter
PhD Candidate
Faculty of Education and Social Work
University of Sydney
Big Ideas on Ageing
ACH Group
Sir Keith Wilson Oration
South Australian Gerontology Conference
October 2013

2. Purpose
• Why consumer directed care?
– Different ideological perspectives
– Policy landscape in Australia
– Assumptions of consumer directed care
• What are the proposed benefits of consumer
directed care?
– Choice and control
– Flexibility and innovation
– Hearing the ‘voice’ of older people

3. Purpose
• What are the risks of consumer directed care?
– Assumptions and mechanisms for choice
– Assumptions and mechanisms for voice
• Implications
– Policy
– Research
– Practice

4. Methodology
• Literature review
– PhD research
• Historical perspective
– Lessons from reflecting on the history of aged
care policy in Australia
• Reflecting on policy and practice

5. What is Consumer Directed Care?
• Mechanisms to implement more personalised
or ‘self directed care’ (Cortis, Meagher, Chan,
Davidson & Fattore, 2013)
• Person centred care a form of Consumer
Directed Care?
• Primary mechanisms
– Individualised budgets
– Cash for Care

6. 8 August 2014
Case
Management &
Brokerage
Individualised
Budgets
(Budget Holder Model)
Consumer Directed Care 6
Cash for Care
(Carers
payment)
Consumer Directed Care in Aged Care
Australia
1980s 2011/2012

7. Consumer Directed Care in Australia
Disability policy
• Movement towards
individualised funding
through self managed
packages
– Victoria
– Western Australia
– National Disability Insurance
Scheme (NDIS)
• Features
– Employing own staff
Aged Care Policy
• Consumer Directed Care as
an individualised budget
model
• Features
– Budget holder model
– Older people and provider
‘co-produce’ outcomes

8. Assumptions of Consumer Directed
Care
• More ‘consumer’ choice and control will:
– Overcome welfare paternalism;
– Improve efficiency and effectiveness;
– Promote the well being and independence of
people with disabilities and older people;
– People will be active participants in their care
(Glendinning, 2008, Cortis et al, 2013)
• Assumption that ‘choice’ will give people more
‘voice’

9. The rise of the ‘consumer’
Economic perspectives
• Influence of neo-liberalism
• Older people as a
‘consumer’ or purchaser
within the marketplace
• Exercising economic power
within the marketplace
• ‘Consumers’ and producers
(Clarke et al, 2007)
• Focus on choice
Human rights perspectives
• Rise and influence of social
movements (eg disability
rights movements, mental
health service user
movement) (Barnes, 2009,
Beresford, 2009, Glendinning,
2009)
• Rigidity and inflexibility of
public services
• Service users as ‘citizens’
• Focuses on voice

10. The rise of the ‘consumer’
Challenges the ‘professional ‘
• Older people seen as
‘clients’
• Based on trust and
reciprocity between the
‘client’ and the
‘professional’
• Criticisms that clients were
passive recipients of care
• Professionals are self
interested and provide
limited choice.
Foucaultian notion of
‘governmentality’
• Questions whether service
users are active or passive
subjects (Harrison, 2012)
• Explores how the language
of ‘consumerism’ becomes
embedded in policy
discourse

11. What does having choice mean?

12. Choice and Stakeholders
Older people
Carers of older
people
Organisations
supporting older
people
Efficiency &
effectiveness
Respect
Having a break
Choice of staff,
voice of older
people
Federal
Government

13. Choice – A Political Concept?
Consumer as
Purchaser
Market mechanisms to
enact ‘consumer’ choice (eg
individualised budgets and
direct payments)
Choice and competition
(LeGrand, 2007)
Citizen
Role of State
Mechanisms to promote
service user voice
(Beresford, 2009, Barnes,
2009)
Social and
political rights
Economic
purchasing power

14. Risks of Consumer Directed Care
• Service Users
– Access to economic
resources can effect
ability to act as a
‘consumer’
(Glendinning, 2008, Le
Grand, 2007)
– Older people may not
be prepared to act as
‘consumers’ (Moffatt
et al 2011)
• Service Users
• Low take up of
individualised budgets
of older people
(Glendinning et al 2008,
Moran et al, 2013)
• Mixed evidence about
the benefits for older
people.
• Privatisation of care
(Glendinning, 2012)

15. Risks of Consumer Directed Care
• Workforce
– Move towards
contracting
– Service continuity and job
security
– Income security
– Quality and skills of
workforce (Cortis et al,
2013)
• Providers
– Market may not respond to
the interests of service
users (Glendinning, 2008)
– Appropriate supply of
providers and types of
services
– Administrative costs of
administering
individualised budgets
(Cortis et al, 2013,
Wilberforce et al, 2011)

16. Risks of Consumer Directed Care
• Government
– Access and equity
– Reduces cross
subsidisation of funding
a feature of block
funding
– Funding may not meet
all needs (Moran et al,
2013)
• Other
– Risks commodifying and
privatising social and
collective responsibilities
for care (Glendinning,
2009, pg 190)

17. Australia’s Aged Care System
• Mixed economy of care
• Hybrid system where informal supported by the formal
Managed Market
– Hybrid and Competitive Tendering and Contracting (Davidson,
2011/12)
• Limited choice and control for older people (Productivity
Commission, 2011)
• Power is vested in the provider
• Consumer Directed Care - Packaged Care
– Individualised budget holder model

18. Voice rather than choice?
“I am here to listen but not ask
questions”

19. What does having a ‘voice’ mean?
• Voice
– Having more say in
services
– Individual or collective
voice (Simmons et al,
2011)
– Voice can go beyond the
confines of choice
• Relationships
• Connections (Simmons et
al, 2011)
– Exit (Hirschman, 1970)
• Voice mechanisms
– Complaints
– Surveys
– Political activity through
voting or lobbying
– Participation in
representative bodies or
groups (Simmons et al,
2011)

20. The political spectrum of voice
Liberty -
Liberal prioritising of rights
minimum state interference
State fulfils basic needs
Source: Greener, 2008
Right wing Left wing
Liberty based on
prioritising of need
Increased reliance on self help
Individual
‘Active citizens’
Collective Interests

21. Can voice mechanisms increase
choice?
Neo-liberal economic
• Voice mechanisms (such as
complaints, and service user
forums) alone wont
encourage providers to
innovate (Le Grand, 2007)
• Voice mechanisms need to
be coupled with
competition. (Le Grand,
2007)
Human rights perspectives
• Creating structures to hear
and encourage the collective
and organised voice of service
users can change service
systems (Beresford, 2009,
Barnes, 2009).
• Acknowledge power
differences between users and
providers (Barnes 2009,
Beresford)
• Voice as exit (Hirschman,
1970) can promote choice

22. Voice mechanisms and Aged Care in
Australia
• Aged care system dominated by interests of professionals,
providers and government (Sax, 1990, Gibson, 1998)
– Older people seen but not heard
• Emergence of voice mechanisms in the late 1980s early
1990s
– User rights strategies through National Standards
– Limited awareness and impact on older people (Gibson, 1998,
House of Representatives Standing Committee on Community
Affairs, 1994)
– Consultative structures for older people in policy processes
(Howe, 1992)
– Impact on policy outcomes and changes?

23. Voice mechanisms and Aged Care in
Australia
• Organised voice of older people through
consumer groups
– Growing awareness of the ‘voice’ of older people
– Will this translate into changes in practice?
• Challenging staff attitudes to ageing
• Structures to hear the voices of older people (Barnes &
Bennett, 1998)
• Appropriate structures for different groups of older
people

24. Risks of voice mechanisms and
Consumer Directed Care
• Voice alone wont change behaviour of
providers (Le Grand, 2007)
– Aged care in Australia
• Providers may not ‘hear’ the voices of older
people
– Ignores power differences between older people
and providers (Ottmann et al, 2011).
• ‘Organised voice’ of older people
– Interests they represent

25. Benefits of voice mechanisms and
Consumer Directed Care
• Citizenship
– Individual and collective mechanisms (Simmons et al,
2011)
– Vehicle for politicising older people
• Opportunity for engagement
– Explore depth of feeling (Simmons et al, 2011)
– Collective or group response (Barnes & Bennett, 1998)
• Partnerships
– Older people and providers co-produce outcomes

26. Policy Implications of Choice and
Voice
• Risk of ‘one model’ of consumer directed care
– Will individualised budgets cater to the diversity of
older people?
• Mixed evidence of benefits of individualised budgets
for older people in the UK (Moran et al, 2013)
• Resources and support
– How are providers supported to manage and
adapt to changes?
• Diversity of policy responses to respond to the
diversity of older people

27. Policy Implications of Choice and
Voice
• Older people
– Engaged and politically active
– How to engage people who are vulnerable
because of physical health and or cognitive issues?
– Challenge stereotypes of ageism
– Provide appropriate political structures to ensure
the voices or organised voices of older people are
heard

28. Further Research
• Research on the perspectives of older people
– How different cohorts of older people respond to
individualised budgets
– Expectations of different cohorts of older people
– Older people from Culturally and Linguistically
Diverse (CALD) backgrounds and Aboriginal and
Torres Strait Islander people

29. Further Research
• Research on workers experience of consumer
directed models
– Limited research on the experiences of support
workers in consumer directed models

30. Conclusion
• Choice is not the only fruit
• Voice can be a mechanism for more ‘choice’
• Whose interests are we trading off in the
interests of choice as part of Consumer
Directed Care?
– Trade off conditions of workers will this have a
direct impact on quality of care?
– Preparing and supporting older people
– Engaging and supporting carers

31. Bibliography
Barnes, M. (2009). Authoritative Consumers or Experts by Experience? User Groups in Health and Social Care In
R. Simmons, Powell, M., & Greener, I., (Ed.), The Consumer in Public Services, Choice, Values and Difference, .
Bristol: The Policy Press
Barnes, M., & Bennett, G. (1998). Frail bodies, courageous voices: older people influencing community care.
Health & Social Care in the Community, 6(2), 102-111. doi: 10.1046/j.1365-2524.1998.00105.x
Boxall , K., Dowson, S., & Beresford, P. (2009) Selling Individual Budgets, Choice and Control: Local and Global
Influences on UK Social Care Policy for People with Learning Difficulties, Policy & Politics, 37(4), 499-515
Barnes, M., & Bennett, G. (1998). Frail bodies, courageous voices: older people influencing community care.
Health & Social Care in the Community, 6(2), 102-111. doi: 10.1046/j.1365-2524.1998.00105.x
Beresford, P. (2009). Differentiated Consumers? A Differentiated View from a Service User Perspective In R.
Simmons, Powell, M., & Greener, I., (Ed.), The Consumer in Public Services, Choice, Values and Difference
Clarke, Newman, J., Smith, N., Vidler, E., & Westermarland, L. (2007). Creating Citizen- Consumers, Changing
Publics and Changing Public Services. London Sage.
Clarke, J., Newman, J., & Westmarland, L. (2008). The Antagonisms of Choice: New Labour and the reform of
public services. Social Policy and Society, 7(02), 245-253. doi: doi:10.1017/S1474746407004198

32. Bibliography
Clarke, J., Smith, N., & Vidler, E. (2006). The Indeterminacy of Choice: Political, Policy and Organisational
Implications. Social Policy & Society, 5(3), 327–336.
Cortis, N., Meagher, G., Chan, S., Davidson, B., & Fattore, T. (2013). Building an Industry of Choice: Service Quality,
Workforce Capacity and Consumer-Centred Funding in Disability Care. Sydney Social Policy Research Centre
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options projects Canberra: Australian Government Publishing Service
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Individual Budgets Pilot Program York: Social Policy Research Unit
Glendinning, C. (2009). The Consumer in Social Care In R. Simmons, Powell, M., & Greener, I., (Ed.), The Consumer
in Public Services, Choice, Values and Difference Bristol The Policy Press
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doi:10.1017/S1474746407004204
Le Grand, J. (2007). Choice and
Moran, N., Glendinning, C., Wilberforce, M., Stevens, M., Nettens, N., Jones, K., Manthorpe, J., Knapp, M.,
Fernandez, J., Challis, D., & Jacobs, S. (2013) Older people’s experience of cash-for-care schemes: evidence from
the English Individual Budget pilot projects, Ageing and Society 33, pp 826-851

33. Bibliography
Ottmann, G., Laragy, C., Allen, J., & Feldman, P. (2011). Coproduction in Practice: Participatory Action Research
to Develop a Model of Community Aged Care. Systemic Practice and Action Research, 24(5), 413-427. doi:
10.1007/s11213-010-9181-5 http://dx.doi.org/10.1007/s11213-011-9192-x
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Australian Government
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I. Greener (Eds.), The Consumer in Public Services, Choice, Values and Difference Bristol The Policy Press.
Simmons, R., Birchall, J., & Prout, A. (2011). User Involvement in Public Services: ‘Choice about Voice’. Public
Policy and Administration, 27(1), 3-29. doi: 10.1177/0952076710384903
Wilberforce, M., Glendinning, C, Challis, D, Fernandex, J-L, Jacobs, S., Jones, K., Knapp, M, Manthorpe, J.,
Moran, N., Netten, A., & Stevens, M., (2011) ‘Implementing Consumer Choice in Long-Term Care: The Impact of
Individual Budgets on Social Care Providers in England’, Social Policy & Administration, 45 (5), 593-612

34. Contact Details
Carrie Hayter
Email: carriehayter@gmail.com
Linked in:http://au.linkedin.com/pub/carrie-
hayter/34/536/517/
Twitter @carriehayter