Who decides? How money for care reaches people in six countries

Most help that governments pay for reaches people in one of three ways. The state can buy a service and send it: a council home-care agency, a nursing home bed, a day centre. It can give the person a budget and let them direct how it is spent, with rules about what it can buy. Or it can pay cash and leave the rest to the household. The first is the oldest and still the most common. The second and third have spread over thirty years, and in several countries they are now how a large share of care is paid for. They change one thing above all: who decides what help a person gets, from whom, and when.

This briefing sets out where each model runs, how big it is, and what the evidence says it does. It is the first in a series on individual funding, the idea that money should follow the person.

Six systems, three answers

Australia has gone furthest with budgets. The National Disability Insurance Scheme, launched in 2013, gives each participant a plan with a funded budget; at 30 June 2026 it had 782,013 participants and spent $51 billion in the year. How much the person really decides depends on how the plan is managed. About three in ten participants manage all or part of their own plan; most use a registered plan manager who pays the bills on their behalf; the rest have the agency manage it and can use only registered providers. Since November 2025 older Australians receiving help at home get a Support at Home budget, set by assessment at one of eight levels between about $10,700 and $78,100 a year, spent through a provider they choose.

England pioneered direct payments in the 1990s: cash from the council, paid to the person, to arrange their own care. 117,655 people received them in 2024–25. They are falling, as a number and as a share: 24.5% of people on long-term support, down for the seventh year running, from a peak of about 130,000 in 2016–17. About a third of recipients use the money to employ their own personal assistants.

The Netherlands introduced the persoonsgebonden budget, or personal budget, in the 1990s. After growth and a series of fraud cases, a 2015 reform stopped paying the money to the budget holder: the social insurance bank now pays care providers directly on the holder's instruction. A sample at the time found 61% of claims insufficiently lawful; the reform cut fraud, and the number of budgets fell by about 30,000.

Germany offers a choice inside its long-term care insurance. A person assessed as needing care can take services, a cash allowance at a lower rate, or a mix. Most choose cash: in 2023, 2.69 million people took cash only and 570,000 a combination, against 173,000 who took services alone (867,000 more were in care homes). The cash is mostly spent on family carers.

The United States calls it self-direction. Medicaid programmes in every state now let people hire and manage their own care workers, often relatives, with a budget. About 1.52 million people self-directed in 2023, up 23% in four years.

Sweden gives people with the most severe disabilities a personal assistance allowance from the national social insurance agency, averaging about 138 hours a week. Recipients rose from about 6,100 in 1994 to 16,000 in 2010, then fell to about 13,300 by 2023 after a 2015 court ruling narrowed eligibility. In 2025 the agency reported that people linked to organised crime were working in all 62 of the largest assistance companies.

What the evidence says

The strongest evidence comes from the United States. Between 1998 and 2004 the Cash and Counseling demonstration randomly assigned people in Arkansas, Florida and New Jersey either to a budget they directed or to the usual agency services. Those who directed their own budgets reported large and significant reductions in unmet need and gains in satisfaction and quality of life; their unpaid carers reported less strain. In Arkansas nursing-home use fell by 18%. Spending on personal care went up, partly because people in the comparison group received less than they had been authorised.

England's two large evaluations point the same way, with a caveat. Personal health budgets, evaluated in 2012, improved care-related quality of life and wellbeing and were judged cost-effective. The earlier trial of individual budgets in social care, reported in 2008, found them cost-effective for most groups but not for older people, who on average reported feeling less happy with a budget than with conventional services. Discretion helps most people who want it and can use it; for some, especially in old age, it is a burden.

The record also shows what goes wrong. Spending grows when need that was hidden becomes visible: the NDIS grew by 10–22% a year before the government set an 8% target. Markets form unevenly: in the NDIS more than 154,000 unregistered providers were paid in a single quarter of 2022–23, but remote areas stay thin and 83% of providers always charge the maximum price. And where checks are weak, fraud follows, in the Netherlands, in Sweden and in Australia.

Who decides, in practice

Read side by side, the six systems differ less in whether the person decides than in how much. A budget run by a plan manager, a provider chosen from a list, an allowance paid to a provider on instruction: each moves the decision some of the way from the state to the person and keeps some of it back. The design questions are the same everywhere. Who sets the size of the budget? Who helps the person use it? What can it be spent on? Who checks? And what happens when it runs out?

The next piece in this series takes the first of those: who sets the budget, and what happens when an algorithm does.

Sources: NDIA quarterly report to 30 June 2026; NDIS Review (2023); Department of Health, Disability and Ageing, Support at Home funding classifications; NHS England adult social care activity and direct payments analysis 2024–25; Bijzonder Strafrecht on the 2015 PGB reform; German Federal Ministry of Health, long-term care insurance benefit recipients 2023; 2023 Self-Direction National Inventory (Acumen); Försäkringskassan statistics on personal assistance and 2025 report on organised crime; AcademyHealth synthesis of the Cash and Counseling demonstration and Dale and Brown (2006); IBSEN evaluation (University of York, 2008); PSSRU personal health budgets evaluation (2012).