What approaches have been used to implement direct payments within health systems, and how do various factors influence the effectiveness of these approaches in supporting personalisation, governance, and equitable access to care: A Rapid Evidence Summary

Continuing National Health Service Health Care (CHC) is a package of care for adults with significant primary health care needs who live in England or Wales. Currently, direct payments are not available for individuals receiving CHC in Wales. In contrast, in England, individuals in receipt of CHC can access direct payments as part of a broader system of Personal Health Budgets (PHBs), which offer choice and control over how their care is delivered. The Health and Social Care (Wales) Act 2025 includes provisions enabling the introduction of direct payments for CHC in Wales, with implementation anticipated in 2026, subject to the development of supporting regulations and guidance This review seeks to explore: what approaches have been used to implement direct payments within health systems, and how effective these approaches are in supporting personalisation, governance, and equitable access to care? Searches were conducted on bibliographic databases from 2012 onwards to build upon previous work. Important pre-2012 grey literature evidence was also considered. The review included evidence published from 2010 to 2023. The findings presented are based on the 8 review articles and 16 organisational reports, some of which cover both health and social care. The literature lacks clear definitions and consistent use of the terms related to direct payments and Personal Health Budgets (PHBs), often blurring the distinctions between different approaches. Where possible, findings have been drawn from the broader PHB literature, with relevant sections highlighted that directly address the implementation of direct payments. Many of the key elements for the successful implementation of direct payments are similar across the different models of PHB implementation and include: Robust support and referral systems, clear and accessible information for recipients (patients and families), comprehensive training and guidance for staff involved in implementation to enhance knowledge and attitudes. Policymakers should account for an initial adjustment period when assessing the impact of direct payments, as users and carers, as well as NHS staff, get used to any new arrangements and processes. Researchers should carefully consider the timing of data collection in evaluations of direct payments, as early-stage data may disproportionately reflect implementation challenges rather than long-term outcomes. Longer-term follow-up (minimum of nine months) is essential to capture the full impact of personalised care, allowing users time to adjust, build confidence, and develop sustainable routines that reflect the intended benefits. Funding statementThe authors and their Institutions were funded for this work by the Health and Care Research Wales Evidence Centre, itself funded by Health and Care Research Wales on behalf of Welsh Government.