The position in mid-1994

Has the implementation of community care meant more choice for
users or are they still at the mercy of social services department
timetable? Jane Lewis discusses new research.

Borough A Nine-to-five in-house home care only. In the process
of reviewing domiciliary care to address the issue of weekend and
evening care by in-house providers and the possibility of
purchasing care from independent providers. Borough B Some evening
and weekend home care. Little independent provision, but changes to
employment conditions have resulted in relatively flexible in-house
provision. Borough c Small amount of evening and weekend home are
purchased from the independent sector. In-house providers, who are
working to capacity under current resourcing, offer little
flexibility, but review is being considered. Borough D Substantial
evening and weekend provision for new and highly dependent clients.
Large block contract for domiciliary care with an independent
supplier; little flexibility in-house. County Virtually all clients
who need it get evening and weekend home care. neven pattern of
independent provision; very flexible in-house service.

The problem of the client who wishes to be put to bed at 10pm,
but who instead gets put to bed by someone from social services at
5pm, is familiar. The community care policy promised users greater
choice, so it is worth asking whether such an apparently simple
problem has now been resolved in the user’s favour.

A research team from the London School of Economics has been
observing the implementation of community care in five local
authorities, four London boroughs and a county, over the past two
years. One of the issues looked at was whether users in these
authorities are more likely to receive a flexible and responsive
home care service, and to explain why this is or is not the
case.

The official guidance saw the new market in social care and the
purchaser/provider split as the key to providing more choice and
flexible services. The NHS and Community Care Act and guidance made
it clear that choice did not mean the exercise of preferences by
users. Local authorities had to assess need and determine
eligibility for services. Choice was defined in terms of a range of
providers from which to choose. The idea of making services
needs-led was therefore not the same as making them user-led.

But the government was convinced that a wider range of suppliers
from the independent and public sector, together with curbing the
perceived self-interest and/or inefficiency of public providers,
would ensure that services met users’ needs. It was believed that
competition and the new leverage exercised by purchasers would
force a change in provider practices.

The evidence we have is not clear-cut and raises the concern
that a sledgehammer – in the form of the purchaser/provider split –
may have been used to crack a nut.

Clearly, it is not possible to generalise about a client’s
chances of being put to bed when she or he wishes. Furthermore, in
borough D and the county, where clients are most likely to have
their wishes met, the relationship between the achievement of a
flexible service and the introduction of market principles is not
clear-cut either.

In the county, the service is flexible because of the changes
that have been made by in-house providers. After a 1988 report by
the Social Services Inspectorate, the authority moved towards
creating a home care service.

The calibre of managers appears to have been high, budgets were
devolved to provider-managers and the service was flexible. These
changes in in-house provision required an external ‘push’, but this
came from the SSI rather than from market competition in the first
instance. The threat of ‘externalisation’, to which members were
committed at the beginning of the 1990s, provided further important
impetus to promoting in-house flexibility. In addition the threat
of competition from independent suppliers has been significant.
Service level agreements exist between in-house providers of home
care and purchasers, but the initiative to develop them was taken
by the providers.

So, in this case, while the threat of market competition played
a significant role, flexibility has nevertheless been achieved
in-house.

In the case of borough D, the availability of evening and
weekend care, at least for new and highly dependent clients, is due
to direct provision by the independent sector. At the beginning of
1994, this authority decided to tender for a large block
domiciliary care contract. Unlike the county, the threat of
competition has had no effect as yet on patterns of provision by
the in-house home care service.

In borough B, where the client may have some success, and
borough C, where in the short-term there is relatively little
chance of success, the patterns are just as confused. Borough B
established an early and firm purchaser/provider split, but has
little by way of independent domiciliary care provision and was
recently disappointed by the paucity of interest from domiciliary
agencies in registering with the social services department.
However, it does have relatively flexible in-house providers, whose
contractual conditions of employment have been substantially
modified. A group consisting of both purchasers and providers
prompted change in the home care service.

Borough C has only recently established a purchaser/provider
split. It has only a few independent sector domiciliary care
providers and little flexibility in-house.

Nevertheless, it is in borough A, which has only fully
implemented its new assessment procedures, where the client stands
virtually no chance of success. This would seem to indicate that
the community care changes are significant, but which changes?

Competition from independent providers seems to be significant.
In the county, threat of competition was a spur to changes in
in-house provision; in borough D evening and weekend care has
deliberately been commissioned with special transitional grant
monies from independent providers to fill the gap. However,
external provision is not necessarily a panacea. The company
employed by borough D has experienced some difficulty in meeting
users’ wishes. It has proved difficult for a small company with
limited staff to put a high percentage of clients to bed within the
same hour. Indeed, there tends to be an absence of stable
independent domiciliary care provision and there is concern on the
part of authorities about the quality of services going to
vulnerable people at home.

In borough B, the social services committee turned down social
services’ plan to tender for an intensive home care service, saying
it wanted the highly skilled work to be carried out in-house, with
only the less intensive work going out to tender because of the
risk to clients. The experience of borough D shows that it is not
easy to secure flexible, high quality domiciliary care from the
independent sector; quality is generally acknowledged by economists
to be the Achilles heel of markets.

It is more difficult to come to clear conclusions about the role
of internal purchaser/provider splits. Many would stress the
importance of the cultural shift implicit in linking care
management and commissioning to create a much higher awareness of
user needs.

This link is especially important in the context of the
government’s 85 per cent rule, which has promoted purchasing from
already existing independent home owners, and which alone would not
be sufficient to prevent the replacement of one monopoly supplier
by another. Forty years of traditional local authority hierarchies
failed to promote change, and on that ground alone, many would
argue that the shakeup inside social services is thereby
justified.

There are two caveats. It is too crude to assume that providers
are self-interested in the sense of self-promoting and/or
inefficient. As a senior officer of borough C pointed out, a degree
of self-interest may in any case be necessary for survival. The
case of the county shows that providers may, under the right
conditions, take the initiative to improve their service. In
borough B, change was achieved by providers co-operating with
purchasers; and in borough C, they are also anxious to change, but
arguably the hiatus in social services while purchasers find their
feet has delayed the improvements they wish to see.
Purchaser-provider alliances are important.

Second, our research authorities have put huge effort into
restructuring their departments and everywhere this has been
accompanied by a formalisation of procedures and a flowering of
forms. For example, in the county an oft-repeated complaint from
front-line workers and some senior officers was about the large
number of forms that must be filled out to access home care.

These consisted of forms needed to conduct a needs-led
assessment (including financial assessment), forms to complete the
purchasing-related paperwork, and forms to fill in details required
by the providers. In other words, conducting a needs-led assessment
is considerably more labour intensive than responding to a simple
service request. The burden of increased bureaucracy on front-line
workers is hard to over-estimate.

There is an additional concern we would raise in relation to
attempts to hold down provider posts in a competitive climate. It
is not inconceivable that a client might be put to bed at 10pm by
the same worker who had previously come at 5pm, but whose new
contract gives her little by way of holiday or pension
entitlements, no overtime pay, and possibly a reduced hourly wage
rate. The trade-offs between the welfare of the user and of the
paid carer in the new system require further investigation.

Jane Lewis is professor of social policy, London School of
Economics.