Advancing Direct Payment Reforms in Ontario and Scotland

Over the last several decades, there has been an increased interest in cash-for-care programs internationally. Important among these reforms has been the emergence of direct payments (DPs), which are cash payments given directly to individuals so that they can purchase their own community care services. In the mid-1990s, both Ontario and Scotland implemented early direct payment programs with the explicit goals of providing greater choice and control over social services to adults with disabilities. Since then, however, the programs have diverged considerably. In Scotland, negative public perceptions resulted in DPs conversion into a program option embedded within the Self-Directed Support program. In Ontario, DPs have never been required by law and have instead expanded through multiple distinct programs funded through different government ministries. This paper compares the evolution of DPs in these two jurisdictions in order to better understand the actors and mechanisms that contributed to this divergence. Using the 3-I framework, we explore the ideas, interests and institutions that have shaped these reforms into their current structures. Our analysis offers several insights for other jurisdictions considering expanding direct payment reforms. These include recognizing: 1) policy conversion as a tool for managing negative perceptions of a reform, 2) policy levers for encouraging compliance among administering authorities, 3) divisions between health and social care as limiting possible expansion of the reform, and 4) program evaluations as justification for the reform's expansion. Les programmes de cheques services suscitent un interet croissant dans le monde depuis quelques decennies. Au nombre de ces reformes, une tendance importante a ete l’emergence de paiements directs, qui sont des paiements en especes verses directement aux beneficiaires pour qu’ils achetent eux-memes leurs services de soins communautaires. Au milieu des annees 1990, l’Ontario et l’Ecosse ont tous deux mis en place de tels programmes de maniere pionniere, avec comme but explicite d’offrir plus de choix et de controle sur les services sociaux aux adultes handicapes. Depuis, cependant, ces deux programmes ont diverge considerablement. En Ecosse, une reaction negative de l’opinion publique a conduit a transformer les paiements directs en une option au sein du programme Self-Directed Support (soutien auto-administre). En Ontario, les paiements directs n’ont jamais ete mis en place legalement et se sont developpes a travers divers programmes finances par des ministeres differents. Cet article compare l’evolution des paiements directs dans ces deux entites politiques afin de mieux comprendre les acteurs et les mecanismes ayant contribue a cette divergence. Suivant le concept 3-I, nous explorons les idees, les interets et les institutions ayant faconne ces reformes dans leur etat actuel. Notre analyse fournit des indications aux autres entites tentees par des reformes de paiements directs, entre autres : 1) la conversion de politique comme un outil de gestion des perceptions negatives d’une reforme, 2) les leviers politiques pour ameliorer l’adhesion des autorites administrative, 3) les limites potentiellement apportees a la reforme par la separation entre le sanitaire et le social et, 4) les evaluations de programmes comme une justification de l’expansion de la reforme.