The provision of benefits and cash allowances to care users, which are designed to encourage care users to employ their own care workers directly, are not unique to the UK. Similar systems have developed in many welfare states and have been named, by the present author, as part of a process of the ‘commodification’ of care (Ungerson, 1997a). It is the purpose of this chapter to use some recent cross-national research to unpick some of the implications of these systems for various dimensions of the ‘employment’ relationship and to begin to understand how and why different funding and regulatory regimes for various schemes of ‘cash for care’ are likely to have differential impacts on the employment relationship between care user and care giver. The chapter also considers the way in which different systems impact on the working conditions of the care giver.

Early work on the development of direct payments in relation to disabled people tended to argue that the employment by care users of their own care workers was in itself a form of empowerment (Morris, 1993). This argument had at its core an assumption that the ability to hire and fire one's own labour would transform the relationship between care user and care giver: it would undermine professionalised definitions of ‘need’ and the professionalised construction of the appropriate response to that defined need. Instead, within a ‘direct payments’ context, disabled care users would themselves be able to articulate and act upon their self-perceptions of need, and manage their own care arrangements such that these arrangements accurately responded to their needs. This literature was therefore concerned with the rights and empowerment of the employer. There was some concern expressed about the difficulties that some care users may encounter in managing the employment relationship, particularly where it was necessary to ensure a paper trail for tax and social security purposes and to pay national insurance contributions from what amounted to rather limited amounts of money (Kestenbaum, 1996). Later critiques developed, which noted that there was a possibility that these forms of employment could result in the exploitation of low-paid and relatively unskilled casualised labour (Ungerson, 1997b), although, in the light of some empirical evidence, this view was later tempered by the understanding that care workers employed by care users in receipt of direct payments were also able to bring their employment to an end when it no longer suited them or they could find other forms of employment (Ungerson, 1999).