The role of relationships in the choices of older users of cash for care in England

This PhD thesis aims to contribute to a better understanding of how older users of long-term care make their choices regarding care; by exploring the nature of the relationships between older users of Direct Payments (DPs) and their carers, and how those relationships influence the choices and experiences (i.e. satisfaction with care) of users. This thesis used qualitative methods, including in-depth semi-structured interviews with twenty-four older users of DPs across three Local Authorities within greater London, supplemented by documentary reviews and interviews with nine care managers. The thesis found that relationships have an intrinsic value for many users as an outcome of care. These users mostly chose to employ a Personal Assistant (PA) and went on to develop deep and caring relationships. The choice to employ PAs was also partly motivated by a desire to ensure continuity of care from the same person. Those purchasing care from agencies seemed to attach less weight to the development of a deep caring relationship, and preferred to have more detached relationships with their paid carers. At the same time, a number of PA employers chose not to employ an existing acquaintance in order to keep the care relationship separate from friendship relationships. All users recognised that the relationship with the paid carer could also have an instrumental value, by allowing PA employers greater leeway in the definition of care tasks than users of agency staff. Reciprocal gift exchanges were reported by those hiring PAs, and were perceived by users as an important way of cementing the relationship and allowing users to receive care tailored to their needs and preferences. Reciprocal exchanges were mostly absent from those purchasing care from agencies. These findings are discussed in relation to rational choice theories underlining user choice policies in England, as well as to the concept of care as an experience good. Findings highlight the potential role of DPs to allow for a better matching of people with different preferences regarding care, as well as the importance of caring relationships and continuity of care as aspects of home care quality.