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.     

Care of Empowerment? A Disability Rights Perspective

This paper challenges the notion of "care", arguing that people who need support in their daily lives have been constructed as "dependent people". Instead, the author argues, if we want to empower people we must learn from the Independent Living Movement, from the people who struggled against segregation and insisted that access to personal assistance over which they have control is a civil rights issue. The paper takes issue with Clare Ungerson's perspective on the new direct payments legislation. This legislation is an important stage in the achievements of a civil rights movement and social researchers have a moral responsibility to collaborate with this movement in any work which they develop on issues which are not of mere academic interest but which concern people's rights to choice and control in their lives.     

Learning Experiences of Older Volunteers in a Community-based Social Program for People with Dementia

Abstract

This qualitative study aimed to explore older adults’ perspectives on volunteering in an activity-based social program for community-dwelling people with dementia called Stepping Stones. Semi-structured interviews were individually conducted with eight older adults who had volunteered in Stepping Stones. Interpretative phenomenological analysis was used to analyze interview data. Four themes related to learning experiences of older volunteers in Stepping Stones emerged. These themes include (a) self-growth and confidence in working with people with dementia; (b) understanding dementia, people with dementia, and needed support for people with dementia and their families; (c) desire not to develop dementia, while recognizing that anything can happen in old age; and (d) exercising person-centered approaches and taking on advocacy roles. Findings suggest that older volunteers gain feelings of personal growth and confidence in working with people with dementia, better understanding, and enhanced attitudes toward people with dementia through volunteering in an activity-based social program for people with dementia. Older adults will be able to fill the needs of community programs for people with dementia, while experiencing benefits from volunteering and learning in later life. Further research is needed to examine to what extent having previous dementia experiences make their experiences and learning different.     

Increasing Choice and Control for Older and Disabled People: A Critical Review of New Developments in England

This paper critically examines new policies currently being implemented in England aimed at increasing the choice and control that disabled and older people can exercise over the social care support and services they receive. The development of these policies, and their elaboration in three policy documents published during 2005, are summarized. The paper then discusses two issues underpinning these proposals: the role of quasi‐markets within publicly funded social care services; and the political and policy discourses of consumerism and choice within the welfare state. Despite powerful critiques of welfare consumerism, the paper argues that there are nevertheless very important reasons for taking choice seriously when considering how best to organize and deliver support and other services for disabled and older people. A policy discourse on consumerism, however, combined with the use of market mechanisms for implementing this, may be highly problematic as the means of creating opportunities for increased choice and, on its own, risks introducing new forms of disadvantage and social exclusion.     

Combining Work and Care: Carers' Decision-making in the Context of Competing Policy Pressures

Issues related to paid work and care are of global importance, reflecting the twin pressures of population ageing and efforts to increase labour market participation. Informal carers of sick, disabled or older people can experience tensions between policies aimed at support for care and support for employment. This article discusses a study of carers’ decision‐making around work and care, drawing on evidence from interviews with 80 working‐age carers in England. Carers are not homogeneous; their circumstances and needs differ reflecting age, gender, ethnicity, labour market participation, and the condition and/or needs of the person they support. This diversity is illustrated by contrasting rural and urban carers’ decisions and experiences about work and care. Key factors that impact on carers’ decisions are: current and anticipated financial need; the constraints arising from receipt of carers’ and other means‐tested income maintenance benefits; personal identity; job opportunities and scope for flexibility; social services provision; carers’ own health. Distance, travel times and transport are unique additional challenges for rural carers who (wish to) work. These difficulties are further intensified when they intersect with other factors such as the Carer's Allowance, the local labour market and social services provision. The findings are evaluated in terms of the adequacy of current government policy measures.     

Would Palliative Care Patients Benefit from Social Workers' Retaining the Traditional 'Casework' Role rather than Working as Care Managers? A Prospective Serial Qualitative Interview Study

Social workers have made a significant contribution to the developmentand delivery of palliative care. Both palliative care and socialwork are rapidly evolving but, given their changing contextsand increasing workloads, can they sustain compatibility? Advancesin treatment of life-threatening illness mean that people livelonger in a period of palliative care. Social work has undergoneradical change in the wake of the 1990 NHS and Community CareAct and subsequent local-authority modernizations, with socialworkers now given the role of care managers, rather than themore traditional ‘casework’ or therapeutic role.This paper aims to explore the current and potential role ofthe social worker in palliative care for people with cancerand other prolonged life-threatening illness. It draws uponevidence from a prospective qualitative, patient-centred researchstudy, which detailed the experiences of forty people with lungcancer and advanced cardiac failure, and their personal andprofessional carers (Murray et al., 2002). A total of two hundredand nineteen qualitative interviews were carried out. We found that social workers were conspicuous by their absencefrom the lives of these forty vulnerable adults, who were livingand dying in the community with many unmet needs which, potentially,could be met by social-work input. The study highlights sixareas of concern in which social-work assessment and interventioncould have impacted on dying patients’ quality of lifeand that of their carers: loss and dependency, family-centredissues, carers’ needs, practical tasks, emotional andspiritual struggles, and finally, support needs of staff. Theseareas are outlined to explore the territory which a social workermight inhabit if resources and policies permitted.     

Autonomy,Choice and Control for Older Users of Home Care Services: Current Developments in Swedish Eldercare

In Sweden, a policy shift towards more individualized eldercare, with an emphasis on consumer choice, has taken place. The aim of this study was to analyze the processes and practices of individualized eldercare, focusing on preconditions for older peoples’ choice and control. Data consist of qualitative interviews with users of home care services (n – 12) and staff (n – 12) and participant observations (n – 7) of meetings between staff and older people. The choice and control available to older users emerged as decisions about ‘what’ care and services, ‘who’ should provide the care and services, and ‘how’ the care and services should be performed. Three approaches to enable older people choice and control over their home care services were revealed: test and revise, services elaborated in close collaboration between users, care managers and home care staff; choices in the moment, users could choose services at each occasion; and quality improvement through competition, competing providers develop attractive services. The findings could guide policy makers in combining the strengths of these approaches to enable older people in need of support to become co-producers in designing, managing, as well as consuming, care and services. Future quantitative research is needed to achieve generalizable knowledge about the strengths and weaknesses of different ways to organize eldercare services.     

Promoting Personalization in Social Care Services for Older People

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Promoting personalization in social care services for older people

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Using Private Social Care Services in Finland: Free or Forced Choices for Older People?

ABSTRACT

Use of private social care services among older people is increasing in Finland. This study aims to understand why older people choose private care in a comprehensive tax-subsidized social care system and examines whether people choose private service as a free choice or a forced choice as well as what factors contribute toward making these choices. Data for this study (N = 1,436) were gathered in 2010 from people aged 75 and above living independently at home in two Finnish cities: Tampere and Jyväskylä. Data were analyzed with several quantitative tests: chi-squared tests, multinomial regression analysis, and qualitative content analysis (for the open-ended responses from the survey questionnaire). Findings reveal that people chose private services mostly because of the effortlessness involved in its use and of the need for additional services that are unavailable through municipality; for example, cleaning. Majority of the respondents performed a free choice to use private services. People who lived in a city center with a higher level of income and who needed more services were more likely to be constrained toward using private support. Major concern, due to diminishing public service provision, is about service accessibility of economically disadvantaged groups; therefore, more research is required to understand the effects of the growing care market in Finland.     

Raising the Quality of Home Care: A Study of Service Users' Views

Raising standards is one of the key objectives of the British government's Modernizing Agenda. The quality of life of vulnerable older people who are being maintained at home is fundamentally dependent on the quality of the home‐care services they receive, so raising standards of home care is clearly central to this agenda. This paper draws on a small‐scale study of service users and providers to examine the aspects of quality of home care of importance to older people, their experiences and barriers to improvement. Six key aspects of quality were investigated: reliability, continuity, flexibility, communication, staff attitudes and skills and knowledge. If performance indicators are to have the desired effect, more work needs to be done to ensure they reflect key aspects of quality from the user perspective. We identify potential areas for improvement in commissioning and organization but these all have resource implications that will need to be met if home care is to realize its full potential in maintaining and improving quality of life for older people.     

Living on the margins: older homeless adults in Toronto

A handful of scholars have acknowledged that, along side the traditional homeless, there are now older people who become homeless for the first time in old age. Few researchers, however, have systematically compared the recent older homeless with the chronic or traditional homeless. In the research presented here, we compare recent older homeless with long-term older homeless adults in Toronto according to their health and wealth, their housing history, and their use of health and social services. Findings indicate that people who become homeless for the first time at older ages have needs that are different from the lifetime elderly homeless and require different approaches to intervention.     

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.     

Compulsory intergenerational family solidarity shaping choices between work and care: Perceptions of informal female carers and local policymakers in Estonia

Estonians are obliged by law to provide maintenance for family members who are unable to cope by themselves. As a result, 80% of fragile older people receive informal care. Whether this is because the carers themselves feel solidarity and choose informal caring or because they lack alternatives is the question. We applied the cultural approach for explaining the construction of compulsory family solidarity in care provision to older people through the perceptions of informal carers and policy actors. Our interest is in how filial norms framed by individual responsibilities of care provision required by law can influence (i) informal carers’ perceptions concerning their choices between work and care and (ii) impact policy actors’ perceptions concerning eldercare service provision. Analysing the empirical data produced during focus groups with female carers and interviews with policy actors, we demonstrate the triple‐fold pressure to informal caregiving as an expression of compulsory family solidarity. Key Practitioner Message: ? The article demonstrates how the national Family Law Act constitutes a compulsory requirement of family solidarity in society; ? The compulsory family solidarity norm influences local‐level policymaking and inhibits the development of formal care services for older people; ? Informal carers’ choices between work and care are shaped by their personal filial norms, familialistic policymaking, and pressure exerted by older people.     

社会地位、生活境遇与焦虑

本文运用定量研究方法,探讨了人们的社会地位和遭受不公正对待的生活境遇在焦虑形成中的作用。研究表明,社会地位（包括客观地位和主观地位）和生活境遇对焦虑的产生具有明显的影响,社会地位低的群体和生活境遇中遭受过不公正对待的人,更易产生焦虑。这些由社会地位和生活境遇等因素导致的焦虑对于个体的影响是偏向消极的;在社会因素的持续作用下,具有焦虑特征的个体增多,焦虑有可能从个体的心理问题转化为社会的心理问题。     

Older Workers in Intergenerational Child Care

Thirty-four older workers in one of five intergenerational child care settings participated in a study exploring the effects of their participation in intergenerational child care programs. The purpose o the study was (1) to identify and describe a sample of older child care workers and (2) to identify characteristics of the older child care workers or the work experience which significantly impact on their lives. The older workers completed a written questionnaire, standardized life satisfaction scale, and interviews. The results suggest that participation in intergenerational child care programs supports the notion of generativity and enhances productive aging. Older workers reported increases in feeling needed, valued, and a sense of self-worth, and increased social contact. Over 90% of the older workers reported that their job expectations were met and that they felt the children had benefitted from their work. Positive changes in attitude about children's growth was positively related to the older workers' personal growth. Older workers also reported greater personal growth when they worked in excellent child care centers as compared to good or fair quality centers. Younger teachers reported positive changes in the classroom environment with the presence of older workers. These findings have implications for training older adults as child care workers and for social policy issues concerning older citizens' roles in our society.     

Living on an island: consequences of childhood abuse, attachment disruption and adversity in later life

This paper reports on a study which sought to obtain greater knowledge and understanding of the life circumstances of a group of people who had experienced adversity and abuse in childhood. A qualitative research strategy involving in-depth interviews with individuals was used to help achieve the study's aim. The study found that interviewees detailed multiple risks to their development during childhood and adolescence, including experiences of child abuse, being placed in care and major grief and loss experiences. Most had left home in their mid-teenage years and had little or no contact with their families of origin. Interviewees had very limited social networks and described difficulties in making and keeping friends. Many reported unstable and often violent personal relationships. As suggested by attachment theory, this study supports the notion of developmental continuities from adverse childhood experiences into later life, particularly in relation to personal and social relationships. Recommendations for a number of suitable methods of intervention and support are outlined.     

Driving outcomes: learning to drive,resilience and young people living in residential care

There are continuing concerns about the experiences offered to older adolescents being looked after (‘in care’) in the UK and, especially, to care leavers. Questions are asked about the limitations of State care compared with normal family life. This paper reports on an initiative to provide driving lessons to a group of six young men living in residential homes in one city. It links with resilience theory – how individuals can have relatively good outcomes despite early adversity. A qualitative study was undertaken to explore the effects of the initiative, including individual interviews with young men, heads of homes in which they lived and children's services managers. The overall results indicated that the initiative was very worthwhile. The lessons were a significant part of young people's lives. Possible effects on young people were divided into personal, instrumental and social. Benefits were reported from all parties concerning young people's self‐esteem and self‐confidence, as well as in forging close relationships with supportive adults. Driving would not be seen as a panacea for complex personal histories and structural problems, yet this small experiment suggests that driving lessons could be of disproportionate benefit and there is a moral obligation to provide them in any case.     

Social Inequality under a New Social Contract: Long-term Care in Japan

The 1990s saw the beginning of new developments in the social policy agenda of Japan. A combination of further cuts in social expenditure and increases in financial resources through various means has become inevitable in response to the increasing cost burden of an ageing society, the prolonged recession and changes in the Japanese family. In this context, “kaigo hoken” (long‐term care insurance) was introduced in 2000 to increase revenue and fill the gap vacated by the family. The scheme introduced a different concept to the public: that long‐term care was no longer “expected’’ from the family or “allocated” by the state, but has become part of a “social contract” based upon a system of mandatory contributions, uniform entitlements and consumer choice. This paper first explores the role of the new scheme in creating social inequalities among individuals (and families). A panel survey is used to highlight different patterns of care provision and the varying degree of financial pressure among different income groups. Second, based on qualitative research, the paper examines how the new scheme has transformed the relationship between older people and their families who have played a central role in this arena. The scheme has consequently divided “traditional” families and their liberal counterparts, as a result of care work being “commodified”. It is apparent that this scheme has not only responded to fill the existing care gap but may also help accelerate the changes that have been taking place for the last two decades.     

Social Welfare: Availability and Delivery of Services and Benefits for Children

It is contended that social welfare legislation is principally concerned with the allocation of resources of income, wealth, position and power. Australian legislation providing welfare services and benefits for children is assessed from this perspective. It is argued that the present legislation providing income support payments for young people accords excessive weight to the promotion of economic interests of the community such as the work ethic and fails to address the social and human needs of that population. It is also contended that the structure of the child welfare services legislation is overly concerned to cater to conservative forces in society who favour social control measures designed to protect their values and interests and who resist efforts to provide a network of non-coercive preventive services. Both areas of the law are criticized on the basis that they place excessive reliance on the notion that the family unit is capable of carrying the major responsibility for income support and service provision.