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.