Big Business in a Thin Market: Understanding the Privatization of Residential Care for Children and Youth in Sweden

This article analyzes the transformation of Swedish residential care for children from a regionally coordinated, public social service system into a thin, but highly profitable, national spot market in which large corporations have a growing presence. Marketization and privatization are theorized as complex processes, through which the institutional structure and logics of this small, but significant, social policy field changed profoundly. Using official documents, register data, media reports and existing research, three consecutive phases in the development of the children's home market are identified since the early 1980s. Change was driven on one hand by policies inspired by New Public Management, which shifted public authority horizontally to the private sector, and vertically to local authorities (funding) and to the state (regulation). On the other hand were the responses of local authorities and private actors to the changing incentives that policy shifts entailed. During the first two phases, both the proportion and size of for‐profit providers increased, and the model of family‐like care was replaced by a professional model. Cutting across the trend of privatization in the third phase was establishment of a parallel system of homes for unaccompanied refugee children – mostly in public ownership. Similarities with privatization in the English system of children's care homes are noted. By showing how the Swedish market for residential care has been created by policy and by actors’ responses to those reforms, the article provides a foundation for thinking through how the predictable, significant and well‐documented problems of such care markets might be addressed.     

Residential Care for Elderly People: Characteristics of Patients Admitted To Residential and Nursing Home Care from Hospital

Correspondence to Mr W. Power, Department of Social Work, Kingston General Hospital, Hull HU3 IUR Summary Fifty consecutive admissions to residential and nursing homecare from hospital were examined and the results discussed.Patient profile fitted the general pattern expected of frailelderly people with high dependency needs. There was a noticeableshift towards placements in private establishments but onlyabout half the patients were likely to have satisfied criteriafor local authority placement or require nursing home care.Breakdown in care-giver arrangements was found to be a majorreason for entry to care. Apart from a significant number ofwheelchair users going into nursing homes, there were no sharpdivisions between the residential care and nursing homes groups.     

Dependency and its Relationship to the Assessment of Care Needs of Elderly People

Correspondence to Dr Ian Gibbs, Social Policy Research Unit, Department of Social Policy and Social Work, University of York, Heslington, York, YO1 5DD Summary A number of previous studies of old people in residential homeshave suggested that a substantial minority are not in need ofthat form of care. The rapid growth in the number of peoplein private homes, supported by social security payments andentering without any independent assessment, has led to concernthat many more people enter residential homes without needingto be there. Social workers were employed in four areas to assess the needsof residents newly admitted to homes in the independent sectorand over eighty per cent were found to be in need of residentialcare. It is suggested that the measures of dependency used toindicate need in some previous studies fail to take into accountthe complex factors involved in deciding whether a person needsresidential care.     

Resilience of Young People in Residential Care

Children and young people in residential care may have experienced or may experience various difficult, life-threatening events, such as neglect, abuse, or violence and maltreatment known as adversities. Despite this, some of them are able to function and even prosper and this has been attributed to the development of resilience. In this qualitative empirical study, we focus on the under-researched area of how young people in care reflect on and cope with such adversities. The exploratory research comprised of semi-structured interviews with young people in two different care settings – re-education centres and children’s homes. The results showed that the sample of 34 young people had experienced 73 adversities prior to leaving residential care and that half of them were not able to resolve some of these adversities. It was found that methods for dealing with adversity change during time spent in care and that a combination of various individual strategies, adaptation and accepting support are effective. The findings also indicate that the development of resilience may vary according to type of residential care setting specifically, whether these facilities allow the development of multiple individual strategies for dealing with adversities, or whether they provide social support. The article discusses implications for future research and practice in residential care.     

Private Children's Homes

Summary The paper provides survey and intensive research material onthe private children's homes sector. It is shown that this sectoris currently in decline. Private homes are found to be shelteringchildren with long and complex care histories and to adopt adistinctive residential style. Although private homes providevaluable long term continuity, they are less likely to offerthe same range of community services as do residential settingsmanaged by the local authority and voluntary child care agencies.     

Long-Term Care of Older Adults in Malta: Influencing Factors and Their Social Impacts Amid The International Financial Crisis

ABSTRACT

This article explores recent changes in long-term care (LTC) for older persons in Malta, resulting from restructuring or other contextual factors related to the international financial crisis. The ageing population continues to grow, while traditional ways of providing care for the ageing population are progressively dwindling. Waiting lists for residential care have grown longer, although public-private partnerships have served to shorten these lists to some degree. Community care services are not keeping pace with need, and the frail elderly wishing to remain in their own homes often cannot do so without significant assistance from other sources.

Service recipients fall into four groups: those affording private residential care; those granted a government-subsidized residential bed; those cared for at home by relatives; and those similarly cared for by nonfamily live-in caregivers with (or without) input from family members. Existent data are reviewed and analyzed along with a focus group of 30 stakeholders to explore this topic further. Future recommendations are made and consequences are explored as caregiving options move away from the responsibility of the traditional family system toward greater pressure on state-provided care, use of expensive private care, and waiting lists to secure services.     

Nursing Homes in England and their Capacity to Provide Rehabilitation and Intermediate Care Services

The numbers of older people living in residential and nursing home care in the UK have risen exponentially since the early 1980s when the closure of long–stay geriatric wards and changes in social security funding of care home places led to a rapid expansion of the care home industry. While the implementation of the 1990 National Health Service (NHS) and Community Care Act shifted the responsibility for the commissioning and funding of these services to local authority social services departments, the provision of most health services (such as general practitioner care, physiotherapy and specialist nursing services) to nursing home residents remains the responsibility of community–based NHS practitioners. Recently, the attention of policy–makers in the UK has been focused on the need to improve the throughput of the acute sector. Older people who have received treatment but are not yet able to return to their own homes are to be transferred into intermediate care facilities, often by using nursing home beds, with the aim of supporting short–term rehabilitation outside of the acute sector. This paper presents evidence from a study of health service provision to older people living in nursing homes in England. It examines whether nursing homes have the capacity to fulfil the rehabilitation and intermediate care function envisaged by policy–makers. It concludes that shortfalls in the provision of NHS services to nursing homes and difficulties faced by nursing homes in paying for health services themselves may hinder the rehabilitation potential of intermediate care placements in nursing homes.     

Educational success for children in public care: advice from a group of high achievers

ABSTRACT Research over the past 20 years has consistently shown that children in public care fall behind at school, seldom achieve good qualifications, and are much less likely than their peers to go on to further or higher education. However, a small minority of looked‐after children do well academically. This paper examines the opinions of 38 high‐achieving young people who spent at least a year in residential or foster care on what they think are the best ways to enhance the educational experience of looked‐after children. An evaluation of four key questions from a semistructured interview highlighted the importance of foster carers, residential workers, social workers and teachers in providing support and encouragement for academic achievement. On the other hand, many of these individuals emphasized their dislike of being ‘singled out’ by the teacher. A third of the participants believed that negative stereotypes and low expectations of children in care among professionals and care providers were major obstacles to their educational success. Over half the sample reported that in many children’s homes basic necessities such as books, a desk and a quiet place to do homework were lacking. In addition their opportunity to engage in outside interests and hobbies was severely limited. By contrast, for these individuals foster care had provided better opportunities. On entering higher education the majority of the participants had faced severe problems. They stressed the need for continuing financial support and adequate year‐round accommodation, because, unlike most students, these care leavers usually have no parental home to return to during university vacations. A third of participants also felt a strong desire for a ‘guardian angel’ to support and encourage them during their time at university. The paper concludes that the views of these thoughtful and resilient individuals should be taken very seriously and translated into improvements in policy and practice. Official guidance now highlights the importance of education for looked‐after children, but changing attitudes and priorities at ground level presents a major challenge.     

Will Direct Payments Make Adult Residential Care more Personalized? Views and Experiences of Social Care Staff in the Direct Payments in Residential Care Trailblazers

Direct payments, i.e. cash payments made directly to the individual in lieu of social care services, have become an established option in council‐funded domiciliary care as a means to better personalize care and support. As part of its agenda to modernize social care, the Government tested their use in long‐term residential care in 18 trailblazing councils in England. This article presents findings from the independent evaluation of this initiative, using interviews with project leads seconded to the programme in all participating councils, and with council and care home staff involved in implementing direct payments in residential care in five sites. Interviews were conducted between September 2014 and November 2015. They explored professionals' views and experiences of personalization in residential care and their thoughts on the potential contribution of direct payments to promoting personalization. Whilst there was agreement that good care takes personal preferences into account and that many care homes could provide a more personalized service, doubts were voiced about whether direct payments were an appropriate mechanism to achieve this aim. This was seen as particularly pertinent in relation to residents with very high care needs and limited capacity to exercise choice and control. Interviewees also identified a number of risks and challenges to implementation, including financial risks to care homes. The findings from these interviews suggest that the contribution of direct payments to personalizing residential care may be more modest than expected.     

Foster and Residential Care Practices Compared

Correspondence to Dr Matthew Colton, Department of Social and Administrative Studies, Barnett House, Wellington Square, Oxford OX1 2ER Summary This paper reports what is, remarkably, the first systematic,in-depth, comparative study of foster and residential care practices.The overall research objectives were: (1) to delineate and comparecare practice in special foster homes (i.e., homes accommodatingchildren traditionally considered too old or disturbed for fosterplacement) and Children's Homes for older children in localauthority care; and (2) if possible, ascertain whether the responsesmanifested by children in such settings can be related to thecare practices they experience. The approach adopted was essentially sociological. A lengthyperiod of field-work in two local authorities featured the useof a range of research instruments and included the collectionof data on the following: the management of recurrent–mainlydaily–social events; children's community contacts; theprovision of physical amenities; the controls and sanctionsused by caretakers vis-à-vis children; the roles of caretakersand their behaviour and attitudes towards children; and thecharacteristics of children, their behaviour towards caretakers,perceptions of their social environments and progress duringplacement. Quantitative methods were used in data analysis becausethey provide a useful guide to the import of observed differencesbetween foster homes and Children's Homes. Care practice in the foster homes was, overall, significantlymore child-oriented than in the Children's Homes. Moreover,the responses of residential children appeared to fall shortof offering justification for the ways that the lives of suchchildren seemed to differ from those of foster children.     

Deregulation,workplace, and women: Nurses in private health care in India

The paper examines the growth of private health care in India in the context of its regulatory provisions and questions the work and employment conditions of female care workers (nurses) employed there. Nurses constitute 80% of the total workers in each nursing home/hospital. In the wake of increased demand for private health care since mid‐1990s, insertion of technology and investment is inducing transformation of nursing homes into multi‐ and super‐speciality hospitals resulting in changes in work organization of nurses. This has led to demand for larger numbers of workers. Employers gain by the segmentation in the nursing labor market, paying low wages. Workers face widespread social discrimination, long working hours, and high work intensity. The deplorable situation of a significant section of workers employed in this sector indicates state failure to control the private health sector. Lack of effective standards of work impacts nature of work of the workforce employed in various levels in the healthcare system.     

在公平与效率之间:对北京市养老资源的空间分析

基于网络采集的养老机构数据和第六次全国人口普查数据，以公共设施区位理论为框架，使用空间分析方法，本文对北京市养老资源的分布模式进行了研究。研究发现，在乡镇/街道层面，整体上公办养老资源分布相对均衡，呈现正的空间依赖，民办养老资源则局部呈现负的空间相关性特征。空间回归分析表明，尽管两者布局均受到辖域内服务对象绝对数量这一因素的影响，但民办养老资源分布对老年人口密度这一指标更为敏感。不同类型的养老资源分散与集聚的空间模式，体现了公共设施供给问题上效率与公平原则之间的对比关系，这是行政与市场力量形塑的结果。     

Cash versus Child Care Services in Finland

In 1985 the Finnish Parliament passed a law which stipulated that all children under age three were to be guaranteed a day care place as from the beginning of the 1990s. The law was made possible by a political compromise in which the agrarian Centre Party won the backing it needed to push through a system of state subsidies for the home care of children. As an alternative to a day care place, parents were now given the option of taking a child home care allowance and using that allowance either for purposes of looking after their child themselves or for paying for a private place. Measured in terms of the number of users, the child home care allowance was a hugely successful innovation. Most parents of small children have used the allowance for at least some period of time. This was due above all to the size of the allowance compared with other social benefits. However, following cutbacks in allowance expenditure of more than 20 per cent from 1995, the use of home care allowances declined at almost the same rate as the allowances were reduced. This brought significant short-term savings to the Government and to local authorities, but in the longer term other costs have been rising. There has even been a sharp, unexpected decline in the birth rate. The case of Finland goes to show that, even in a country where wage-earning motherhood has become firmly established, income transfers through family policy can have a very significant influence on the numbers opting temporarily for homemaking.     

Contested Housing Landscapes? Social Inclusion,Deinstitutionalisation and Housing Policy in Australia

Deinstitutionalisation is represented as a major step toward social inclusion through the resettlement of disabled people residing in segregated large‐scale institutions into community‐based homes. By promoting the right to live in ordinary community residential settings, deinstitutionalisation fundamentally changes both the support services and housing arrangements of former institutional residents. In Australia, as in many western countries, debates on community care have tended to focus on the location and nature of non‐housing supports for people leaving dependent care. This focus, however, overlooks the fact that deinstitutionalisation involves a radical rehousing of people in care. This paper explores the character and implications of deinstitutionalisation in Australia as a rehousing process. It is based on a recent national research project that has examined the housing futures of people with intellectual disabilities who have been, or will be, deinstitutionalised. The paper considers the increasingly divergent socio‐political perspectives that have emerged in recent discussions about social inclusion, institutional reform and independent living and their implications for housing and community care policies.     

Settling In and Moving On: Transience and Older People in Care Homes

This paper reports on a study which examined the experiences of 46 older people who moved into nursing and residential care homes, interviewing them at four points, from before the move to up to six months afterwards. A key finding was that older people were actively involved in the process of settling into homes and forming new friendships. Participant data also indicated that these older people had often experienced many moves in recent years, as their need for care had changed, and following them through after their inclusion in the study indicated that, for some, there were more moves to come. These data place the debates about assessment, and the identified problem of "misplacement" in a different light. The problem is not simply one of improving assessment techniques so that needs and provision can be matched more accurately, but it may mean accepting that the needs of older people are likely to change over time. The question then is whether we can develop services and forms of provision which ensure that care moves to older people, rather than older people having to move to care.     

Choice,Competition and Care – Developments in English Social Care and the Impacts on Providers and Older Users of Home Care Services

This article critically examines recent changes in markets for home (domiciliary) care services in England. During the 1990s, the introduction of competition between private (for‐profit and charitable) organizations and local authority providers of long‐term care services aimed to create a ‘mixed economy’ of supply. More recently, care markets have undergone further reforms through the introduction of direct payments and personal budgets. Underpinned by discourses of user choice, these mechanisms aim to offer older people increased control over the public resources for their care, thereby introducing further competitive pressures within local care markets. The article presents early evidence of these changes on:

• The commissioning and contracting of home care services by local authorities and individual older people.
• The experiences and outcomes for individual older people using home care services.

Drawing on evidence from two recent empirical studies, the article describes how the new emphasis on choice and competition is being operationalized within six local care markets. There are suggestions of small increases in user agency and in opportunities for older people to receive more personalized home care, in which the quality of care‐giving relationships can also be optimized. However, the article also presents early evidence of increases in risk and costs associated with the expansion of competition and choice, both for organizations providing home care services and for individual older service users.     

Continuing to Pay: the Consequences for Family Caregivers of an Older Person's Admission to a Care Home

This paper aims to discuss the reasons why caregiving in the community had ended for a sample of dependent older people, two-thirds of whom had dementia. Comparisons are made between the situation of a spouse caring for a partner and a daughter or son caring for a parent in a separate household. Spouses in the study had often sustained a greater burden before caregiving collapsedthan had daughters or sons. They were less likely, however, to have had support from the home care service. When caregiving in the community ended and the dependent older person entered a care home, family caregivers themselves often had a financial price to pay. Currently spouses have a legalliability to contribute to a partner's care costs. The implementation of this liability depended on individual local authority policies and the views of the individual social worker doing the financial assessment. Because of the UK's means-testing rules, daughters and sons were often penalizedbecause a parent's assets that they might have inherited had to be used to meet the care home costs. Resentment at being disinherited was related to the daughter's or son's family situation. Those with children or grandchildren themselves were far more likely to be angry than those without children.     

A Good Death for Residents of Long-Term Care

Abstract

Little research has been done on the topic of end-of-life care in long-term care settings to identify important themes regarding end-of-life care structures, processes, and outcomes. This study utilized data gathered in a stratified, random sample of 437 family members of residents who died in 31 nursing homes (NHs) and 199 residential care/assisted living facilities. Structural components of care including staffing adequacy, training, and consistence as well as facility environment and size were important factors for family members interviewed. “Being there” and manner of care delivery (e.g., staff attitudes/empathy) were major elements in the process of care. These factors were mentioned more than direct care, Hospice, or resident preferences. Family members identified themes of [dying at] home and being comfortable and clean as important outcomes of care. These identified structural components, processes, and outcomes have implications for the role of social workers in these settings despite that social work support is notably absent in these findings.     

Experiences of Young Indian Girls Transiting out of Residential Care Homes

Leaving the residential care home is one of the most significant occurrence in the life of every care‐leaver. It encompasses vast changes which has a long term impact on the care‐leavers future. This study captures the lived experiences of twenty‐four young Indian girls who have left care in the past four years. It addresses their journey of moving out of care at two levels — their preparation to leave care and their present experience. The primary focus of the study is to explore the interpretation and meanings attributed by these girls to the phenomena of transition out of care; identifying the uniqueness and commonalities that emerges from their experiences. The results exposes a plethora of emotions and episodes the girls have encountered at each step of their path. It also emphasises on the role played by multiple environmental factors — support network (friends, peer group, family, social workers, etc.), residential care home, state and other social processes — operating at different systemic levels, highlighting the interface between the ‘self’ and the ‘environment’, based on the Ecological Framework.     

Policy transfer,social pedagogy and children's residential care in England

Much concern has been expressed about the quality of care and poor outcomes for looked‐after children (‘children in care’) in England, especially regarding residential homes. This paper builds on a recent evaluation of the piloting of the continental European model of social pedagogy (SP) in English residential care. It does three things: it considers the theoretical social policy literature on policy transfer and its implications; discusses European residential care for children and the discipline of SP; and reflects on these debates and the situation of children's residential care in England. The paper concludes that there are some major hurdles to a widespread implementation of SP in England. This particularly concerns the differing social, professional and political context of children's residential services across neighbouring countries.