If you are receiving state funded adult social care you should expect to receive the best possible quality of care. But, how should that series of relationships between you, the funder of the care (the state) and the provider be organised to ensure you get that desired quality of care? This question is at the heart of changes in adult social care policy in England since the 1990s as the system has moved to a more mixed market of provision (away from state provided services), with the idea that the state can buy services in a competitive market that better ensures efficiency and quality.
Alongside this developed the policy of giving people who use the services more direct choice over what they have, most clearly crystallised in the policy of personal budgets to allow people to decide themselves what they want to buy, and something I have written about on here before.
These are fundamental changes in social care that have potential implications for services, communities and people using them, yet they are rarely given detailed exposure or debate in the mainstream public media, especially compared to the NHS.
When the changes are introduced they are usually done in a blanket fashion – i.e. this is now the policy for all groups of people using state funded social care. There is often little detailed debate as to whether or how the policy works best for specific groups like, say, older people, carers, or older people using home care services. Should we expect the operation of policies to always be the same and achieve the same effects for all the diverse groups of people using social care and their needs? So, there is little enough debate, amongst too narrow a group of people, and it is often too constrained.
This paper by Rodrigues and Glendinning (2014) takes up these debates in relation to older people who receive home care services. It begins with a very helpful recap of policy developments in terms of markets and personal budgets in adult social care in England. The paper then draws on two research projects to examine the implications of these policy developments for local home care service markets and for the experiences of older people using them.
As mentioned, there are two research projects reported in this paper. The first entailed interviews with senior managers in adult social care and focus groups with frontline staff in three local authorities in England.
In each, they explored the views and experiences of participants in supporting older people with managed personal budgets to exercise choice and shape the services they receive. They also interviewed 18 older people receiving home care services and using a managed personal budget to examine their experiences of exercising choice and control over the home care support they received.
The second study took place in three London local authorities and examined the experiences of older people who had recently taken their personal budget as a direct payment, their reasons for doing this and the outcomes. Twenty-four older people were interviewed, as well as relevant managers and commissioners in the local authorities.
In each of the local authorities the commissioners of services were moving from block contracts with providers of home care services (in which they are guaranteed a specific amount of work) to framework agreements (in which providers agree to work to certain prices and quality standards, but have no definite amount of work pre-specified). Whilst being seen by some as introducing helpful flexibility in to local systems, these arrangements also bought new risks (such as to providers of services as they no longer have a guaranteed income) and additional costs (for example, new roles and processes to broker access to the new market of providers).
Tensions were evident in terms of managing the balance of competition amongst providers, market stability and choice. The new arrangements presented opportunities and risks across the three parties of local authorities, providers and service users and managing the best balance could be challenging. If choice is exercised in certain directions, for example, does that mean that some providers collapse, thereby overall taking too much service capacity out of a local system too quickly?
Older people who had managed personal budgets reported having little scope to exercise choice and influence the service they received, but this was not always something that concerned them. Some people felt they did not have the information and/or capacity to manage a budget and exercise choice. However, people would have still appreciated more opportunities to be flexible over exactly how the time allocated to their home service was used.
Those who had opted to have a direct payment that they managed often did so after being dissatisfied with the process of local authority managed budgets, and reported more satisfaction and flexibility with their new arrangements.
Very important to the older people were the relational aspects of the direct care. They valued opportunities to get to know their regular care workers. This provides trust, valued social contact and, often, some more flexibility in support and care from their workers. Having more direct control over care budgets seemed to give more scope to develop these relational aspects. However, directly managing these resources did have some costs and sometimes led to considerable anxiety for the older people.
The authors concluded that:
There are suggestions of small increases in user agency and in opportunities for older people to receive more personalised home care, in which the quality of care-giving relationships can also be optimised. However, the [research] also presents early evidence of increases in risk and costs associated with the expansion of competition and choice, both for organisations providing home care services and for individual older service users.
The two research studies in this paper were both small, each covering three sites, which should make use hold the thought as to how representative they are of the wider experiences of these issues in adult social care in England. However, the authors acknowledge this and describe in detail their methods and the sites so that we can place the findings in to a context.
Keeping this caveat in mind, however, the paper raises some profound issues of detail concerning the operation of markets and personal budgets in the home care sector. The balancing factor against the research being smaller scale in terms of numbers of sites and people is the depth to which the researchers can delve. It is precisely these points of detail and their complex interplay that need wider debate about these policy moves, and how and to what extent they can and should operate in relation to specific client groups, needs and services.
Whilst there were positive experiences amongst some people who managed their own budgets and exercised choice, this approach had some costs and was not suitable or desirable for everyone. Then consider that more choice in the system can bring opportunities for providers, but also more risks in terms of no guarantee of business. Overarching this, the local authority has responsibility for market shaping (developing choice) but also for market oversight (managing the risks associated with service providers closing down).
This paper and others, including those linked above on the web site of the NIHR School for Social Care Research, are incrementally adding to our evidence about these highly complex processes and they ought to be understood and discussed as a collective body of knowledge.
Perhaps we also need to be asking if we have become too narrowly focused on the prescribed mechanisms (i.e. markets and personal budgets) and lost sight of what matters to people (e.g. valued relationships with regular care workers), and then how to make various mechanisms work to achieve this.
Ricardo Rodrigues & Caroline Glendinning (2014) Choice, Competition and Care – Developments in English Social Care and the Impacts on Providers and Older Users of Home Care Services. Social Policy and Administration. DOI: 10.1111/spol.12099 [Abstract]