Direct Employment or Agency Care… That is the Question

A practical guide to choosing the right care model for your client

I am often asked by case managers and other partners how decisions are made regarding the use of agency care provision or direct employment. The answer isn’t a simple one, but if we refer back to the CQC fundamental standards and person-centred care, this should always be the starting point of any decision making.

We start with the individual, their needs, preferences, and capacity to make decisions about how their care is delivered. In many scenarios we find the people we are supporting are not clear on the options available to them. It can be overwhelming to navigate the different terminology used by providers when setting out their care offerings.

Informed decision making to reduce the unknown

For case managers, the provision of clear information and resources to aid decision making is key to supporting the client effectively. Local knowledge regarding care providers can be key, and helping our clients and their families navigate the CQC website can assist, not only with reviewing ratings and reports following inspection, but also with information about the different types of support that can be provided by the provider.

Integrated Care Boards (ICBs) play a significant role in shaping care models, particularly through the Personal Health Budget (PHB) framework. Where individuals have a PHB, direct employment of a personal assistant is a recognised and supported option. Some ICBs actively encourage this route as part of their commitment to personalised care. For clients who may feel daunted by the responsibilities that come with this model, organisations such as Bush & Co Care Solutions can take on the delegated employer role, managing the process on the client’s behalf, making direct employment a realistic and accessible option for far more people.

A changing landscape brings choice and greater control for families

Historically, for more complex or high-volume care packages, agency provision was often considered the safer and more comprehensive option; offering the perceived security of an established provider managing recruitment, compliance, and staffing arrangements. However, the landscape has changed considerably. With specialist care management support now available for direct employment, many of those barriers have been significantly reduced. Families and case managers can access the same level of oversight, governance, and contingency planning through a managed direct employment model, without sacrificing the consistency and personalisation that direct recruitment brings.

The goal is the right choice

That said, risk remains a central consideration in any decision around care provision, and it would be misleading to suggest that the barriers to direct employment have disappeared entirely. For some individuals, particularly those with highly complex or rapidly changing needs, the infrastructure and flexibility that an established agency can provide may still represent the most appropriate solution. The goal is never to favour one model over the other, but to ensure that the decision is led by the individual’s needs, circumstances, and the level of risk that can be safely and responsibly managed. In some scenarios, agency care remains not just a valid choice, but the right one.

Ultimately, the success of any care provision rests on getting the foundations right. When informed, thoughtful decisions are made at the outset, with the individual at the centre of that process, we create the conditions under which our clients can truly thrive. Whether that is through agency provision or direct employment, the quality of the decision making behind the model is just as important as the model itself.

Case Study: Supplementing Agency Care Through Direct Employment

A young client with complex care needs had been receiving overnight support through an established agency provider. Despite the agency’s best efforts, consistent staffing for the night shift proved difficult to maintain; leaving the family regularly facing last-minute cancellations and uncertainty about who would be providing care each night.

The impact on the family was significant. The client’s parents, already managing the demands of caring for a child with complex needs, found themselves exhausted and increasingly anxious about the reliability of the overnight provision. It was at this point that they approached Bush & Co Care Solutions to explore whether direct recruitment could offer a solution.

Working closely with the family, we recruited three dedicated care workers through direct employment to provide overnight support. Rather than replacing the agency entirely, the directly employed team worked alongside the existing provision; filling the gaps that had been causing such disruption to family life.

The results were transformative. With a consistent, familiar team in place overnight, the family reported an immediate improvement in their own wellbeing, and the client benefited from the stability and continuity that comes from being supported by the same trusted individuals. The agency continued to provide daytime support, and the two models worked complementarily to deliver a package of care that genuinely met the family’s needs.

This case illustrates that direct employment and agency care need not be an either/or decision. With the right support in place, the two models can work hand-in-hand to create a care package that is both robust and truly person-centred.

To discuss your client’s needs and explore the option of direct employment or a combined model of care support, contact us at care.enquiries@bushco.co.uk.