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.     

Motivation and Commissioning: Perceived and Expressed Motivations of Care Home Providers

Commissioning of social care for older people has seen major changes since the early 1990s. Considerable responsibility now rests with local authority staff, whose views of care home providers’ motivations, their perceived strengths and weaknesses as service providers, will have a bearing on commissioning decisions. We examine commissioners’ views of provider motivations in eight English local authorities and compare their perceived motivations with providers’ expressed motives. Data were collected through semi‐structured face‐to‐face interviews with commissioners and care home providers. Providers are generally perceived by commissioners as highly altruistic, but also relatively financially motivated individuals. Further analysis revealed significantly different views towards profit‐maximizing, which commissioners perceive as very important, while providers consider it to be of little motivational value. Private sector providers are described by commissioners as significantly more motivated by personal income. Associations are found between commissioners’ perceptions of motivations and the nature of their relationships with providers. Perceptions of providers’ motivations appear important within the commissioning framework.     

The Role of Empowerment in Home Care Work

ABSTRACT

The home care industry experiences similar problems with the recruitment and retention of direct care workers (DCWs) as those faced by institutions, and it is important to identify strategies to help retain and grow this important workforce. The empowerment of DCWs has been shown to be an effective strategy for increasing job satisfaction and decreasing turnover in nursing homes but has not been studied in home care. Using Kanter’s organizational theory of empowerment, including structural empowerment (structure of opportunity, access to resources, access to information, and access to support) and psychological empowerment (meaning, competence, self-determination or autonomy, and impact) this study examined whether home care workers (HCWs) feel empowered in carrying out their jobs. An exploratory, qualitative study of 12 HCWs, recruited from two states in the United States, found high levels of both structural and psychological empowerment among research participants, as well as a number of disempowering aspects of their job. Findings suggest ways to support elements of the work that HCWs find empowering and decrease elements that contribute to job dissatisfaction and turnover.     

Home Care Services for Indigenous Population in Taiwan: Cultural and Socio-Structural Implications for Long-Term Care Policy

Taiwan faces the world’s top aging rate over the next 8 years, making long-term care a priority for all populations, including the 16 indigenous groups who live primarily in the mountains and have different cultural practices than mainstream Taiwanese people. To examine how home care services are coordinated, managed, and delivered to the indigenous populations, we interviewed 10 public care managers and analyzed the interview content to assess their work experiences with home care workers and indigenous users in 2016. The research revealed four findings: (1) Home care utilization patterns and attitudes were different between the rural indigenous and non-indigenous populations; (2) home care utilization was limited by cultural, economic, and language challenges; (3) home care workers faced cultural and socio-structural challenges; and (4) policy and service provisions were rigid, without the socio-structural flexibility needed to accommodate the indigenous culture. A more efficient model will require the collaboration of public care managers, home care workers, and indigenous families to create a fair-coordinated plan. As Taiwan launches the Ten-year Long-Term Care Plan 2.0, a one-stop service delivery center to integrate care options and provide services for people of indigenous backgrounds is a must.     

居家养老的国内外研究回顾

随着中国内地的人口老龄化,居家养老成为老年人照顾领域中备受关注的养老方式。笔者对中国的居家养老的研究进行文献综述,分析了居家养老的背景、概念、养老方式以及中国香港和台湾地区居家养老的具体措施,为中国内地的居家养老模式提出建设性的意见。     

Life Prolongation Technologies in Home Care for the Frail Elderly

The imporfation of life prolongation technology from acute and chronic care institutions to the home has given rise to a range of challenges for the practitioner engaged in the delivery of gerontological home care services. The prominent programmatic and training issues are identified in an ethical context and approaches to improving home care staff practice skills are offered.     

国内城市居家养老的研究综述

通过综合分析近十年来居家养老相关文献,本文总结出目前有关研究成果主要体现在产生根源、内涵界定、实施现状、问题及对策上,而其中对于居家养老内涵界定存在分歧,需要从重新明确养老模式的划分标准上来统一认识,对于居家养老方式的研究应跳出社区服务这个范围,认识到居家养老是作为家庭、社区、国家养老制度三者形成的合力,注重从整体上进行较为系统和全面的研究。     

国内城市居家养老的研究综述

通过综合分析近十年来居家养老相关文献,本文总结出目前有关研究成果主要体现在产生根源、内涵界定、实施现状、问题及对策上,而其中对于居家养老内涵界定存在分歧,需要从重新明确养老模式的划分标准上来统一认识,对于居家养老方式的研究应跳出社区服务这个范围,认识到居家养老是作为家庭、社区、国家养老制度三者形成的合力,注重从整体上进行较为系统和全面的研究。     

Reconciling Cash and Care: Home Care Charges and Benefit Checks in Social Services

Correspondence to Pete Alcock, Health and Community Studies, Sheffield Hallam University, Collegiate Cresent, Sheffield S10 2BP Summary This article contains the report of a small research projecton the development of welfare rights checks for home care clientsin social services departments. Welfare rights take-up activityhas become an important feature of provision by local authoritysocial services departments, frequently targeted on particulargroups of clients known to experience problems in claiming fullbenefit entitlement. Users of home care services are such aclient group. Take-up work with home care clients is also, however,a product of the impact of community care policy changes andof financial pressures on local authority social services. Thesehave resulted in the introduction of charges for home care servicesby many authorities, and the use of rebates from such chargesto protect low income service users. Welfare rights work hasthus become an important feature of the reconciliation of thesenew charging policies with the continued service needs of poorhome care clients. The research examined a successful take-upinitiative, linked to home care charges, in Sheffield and contrastedthis with similar activities in other authorities throughoutthe UK. The conclusion is reached that levels of non-take-upof social security benefits are particularly low amongst homecare clients and that benefit checks can secure significantadditional income for them, which may also have the indirecteffect of increasing the income to social services departmentsfrom the charges for home care services.     

Rethinking The Care‐Market Relationship In Care Provider Organisations

Care provider organisations are under pressure from funding bodies and regulatory procedures to narrowly construct care in ways that preclude its relational, emotional and social characteristics. This process of subjecting care to a managerialist‐market logic, however, creates tensions between the organisation and its key stakeholders: care recipients, care‐workers and unpaid carers. These tensions are significant and are likely to place organisations under pressure to develop a more holistic approach to care. In addressing this issue, this paper draws upon the concept of bounded emotionality to argue that it is feasible for organisations to be both instrumental and caring, and thereby be responsive to the needs of all of their stakeholders. The paper concludes by discussing some of the practical implications of organisations adopting a framework of bounded emotionality, and suggesting some directions for future research.     

English Local Authority Powers, Responsibilities and Guidelines for Managing the Care Home Closure Process

In England, the majority of older people living in care homesare publicly funded and the majority of publicly funded placesare purchased from the independent sector. While the sectoris subject to regulation, there is currently no statutory guidanceaimed specifically at how care home closures are managed. Thisarticle reviews the powers and responsibilities of councilsand the rights of residents during care home closures, beforedescribing the prevalence and content of existing council guidelines.Just over a third of councils in England responded to inquiriesand, of these, two-thirds reported having guidelines. This suggeststhat a considerable proportion of councils have no guidelinesin place. Existing guidelines also varied. Differences includedapproaches to allocating responsibilities and providing help,and assessment to self-funding residents. The large number ofarrangements and activities described suggest that some sortof plan or guidance is warranted to support the task of frontline care managers. At the national level, the variation foundin the guidelines combined with the lack of national guidancespecific to closures suggests that clarification of councils’legal responsibilities and powers during a care home closureis needed. Clarification of the role and responsibilities ofthe national regulatory body would also be useful.     

The Effects of Marketization of Long-term Care Services for Older Adults in Korea

To cope with the rapid increase in aging population, the South Korean government introduced new long-term care insurance in 2008 by using the market forces and mechanisms of competition and choice. The study explored the effect of the marketization of long-term care (LTC) services on the provision of services under the Korean long-term care insurance (LTCI) system. By adopting qualitative semi-structured in-depth interview methods, the experiences of 17 home visiting service provider managers were examined. The study results suggest that the marketization of LTC services faces several challenges. Some of the stakeholders in the field, such as home visiting service providers, care workers, and older clients, appear to employ unlawful activities or unprincipled behaviors to maximize their individual interests. The results also suggest that the unprincipled behavior, unlawful activities, and financial problems that service providers face contribute to low quality care services. Future studies should explore these issues using larger samples of service users and providers.     

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.     

Managing the Care Home Closure Process: Care Managers' Experiences and Views

This paper reports case study research that set out to identifywhat care managers do during independent care home closures.Little research has focused on the way in which care homes forolder people are closed in England, or what those involved thinkabout the process. This paper reports the activities and viewsof care managers directly involved in helping older people relocatefrom care homes that were closed by their owners. During suchclosures, residents and their families have no choice but tomove, usually to a deadline, and with little control over theprocess. Care managers have a responsibility to help arrangealternative care for those current residents who are publiclyfunded, and to offer information and support to those fundingtheir own care (the ‘self-funded’). Closure relatedactivities could involve considerable staff time. Care managementarrangements, including the organization of teams and provisionof needs assessments, varied across authorities. The care managersdescribed drawing on emotional counselling and inter-personalskills, as well as practitioner knowledge and experience, particularlywhen offering support and advice about finding appropriate newhomes. Tensions between aims, constraints on their actions andviews of good practice are identified.     

Lay Assessors and Care Home Inspections: Is There a Future?

This paper reports on research funded by the Nuffield Foundationexploring the role of lay assessors in the care home inspectionprocess in England and Wales. Lay people have been includedin many care home inspections for the past decade. Similar layinvolvement is included in other public service inspectionssuch as the Office for Standards in Education (OFSTED) inspectionsof schools. The Board of the short-lived National Care StandardsCommission (NCSC) controversially decided to dispense with suchlay involvement in the inspection process. The replacement body,the Commission for Social Care Inspection (CSCI), intends toinclude lay people in the inspections of support services inthe community but is hesitating about reintroducing them intocare home inspections. This research project was able to explorethe role taken by lay assessors in thirteen inspections of carehomes for older people and for adults with learning disabilities.The research concluded that lay assessors had a significantrole in communicating with residents and staff and observingcare home life. Their role was particularly important, as inspectorswere often so involved in paperwork and checking policy compliancewith the national minimum standards that they were often ableto spend little, if any, time talking to residents or staff.It is argued that there is considerable potential for a strengthenedrole of lay people in the care home inspection process.     

The Purchaser/Provider Split in Social Care: Is It Working?

This paper reviews the ideas of public choice theory that provided the rationale for introducing the purchaser/provider split and suggests that the notion of provider self-interest is as undifferentiated a concept as its rival: public ethos or duty. Using data from eighteen months' observation and interviewing in five local authorities, it then goes on to address the huge amount of work involved in separating purchasing from providing. We trace the changing understanding of the purpose of the split, problems of defining who is a purchaser and who a providers, problems of working the new relationship between purchasers and providers, and difficulties in developing the purchasing function.
We then seek to examine what are believed to be the main benefits of the purchaser/provider split, asking whether there is evidence that purchasers are doing a better job of identifying needs than providers, and whether there is evidence of competition involving multiple providers and multiple suppliers. Finally, we investigate whether there has been an increase in responsiveness, taking home care as an example. The paper concludes that while increased competition among suppliers has been one important factor in two authorities in securing a more responsive service, the evidence is equivocal as to whether the purchaser/provider split has been the key to securing competition.     

The Role of the Nursing Home Social Worker in Terminal Care

This study examines the role of the nursing home social worker in terminal care. Questionnaires were distributed to 60 social workers in 14 nursing homes in the greater Milwaukee area. The hypothesis was that the presence of policies/procedures governing terminal care would be related to a decreased amount of stress for social workers. This correlation was not supported by the survey results. Although 71% of respondents indicated no policies were available to them, only 32.6% of social workers reported that terminal care was a source of stress. In fact, 59% reported that the social worker's role in terminal care had not been discussed in the social services department of their facility. Comparative lack of stress for social workers may be related to the lack of perception that social workers play a significant role in the terminal care of residents.     

A New Look at Home Care and the Hospital Social Worker

Clinical, administrative and social action reasons for expanding social work services in hospital based home care programs are persuasive. Hospital departments of social work should consider carefully how they may expand services in home care and coordinate and integrate such activities with social work and discharge planning processes occurring throughout the hospital. It is necessary for social work leadership to be present on professional advisory, quality assurance and similar committees and to use these committees as arenas for expanding the social work role in home care.     

The Economic and Gender Consequences of South Africa's Home‐based Care Policy

South Africa's approach to care provision in the era of HIV/AIDS is home‐ and community‐based care, but in reality care for ill people in the home is provided on an unpaid basis, predominantly by women. But how much do they spend on this care work, in time and money? And what economic consequences does this policy have, particularly for poorer women? This article is based on findings from a study that focuses on unpaid care provision within the home for those in late‐stage HIV/AIDS in KwaZulu‐Natal, South Africa, and specifically on the costs of such provision. The findings show that female caregivers are bearing the bulk of the costs of care provision for ill people within the home on an unpaid basis. Home‐based care is cost‐effective for the provincial government but not for unpaid caregivers who are subsidizing the provincial economy. While hospital care for people with HIV/AIDS has been capped, home‐based care services have not been increased to a commensurate level. Unpaid caregivers and ill people within the home are largely disconnected from the health system. The analysis clearly shows that the home‐based care policy is not resulting in appropriate or sufficient support for these individuals in need and needs to be revised.     

End-of-Life Conversations and Hospice Placement: Association with Less Aggressive Care Desired in the Nursing Home

Education about end-of-life care and treatment options, communication between family and health care providers, and having advance directives and medical orders in place are important for older adults with chronic, progressive decline and end-stage disease who spend their last days in the nursing home. This study used retrospective data (6 months before death) of long-stay nursing home decedents (N?=?300) taken from electronic health records to capture the end-of-life experience. Findings showed for almost all decedents, Do Not Resuscitate and Do Not Intubate orders were in place, and just over one-half had Do Not Hospitalize and No Artificial Feeding orders in place. A small proportion had No Artificial Hydration or No Antibiotic orders in place. Overall, there was congruence between documented medical orders and treatment received. Findings showed that use of hospice and discussions about particular life-sustaining treatments each had significant associations with having less aggressive medical orders in place. These results can inform best practice development to promote high quality, person-directed, end-of-life care for nursing home residents.