Mixed Economy Of Care Research Articles

An evaluation of community care services for the elderly in Hong Kong

PurposeThis article analyses community care services (CCS) in terms of availability, awareness, accessibility, and acceptance (the Four A’s approach), untangles the deep-seated factors underlying the CCS and provides some short-term, medium-term, and long-term recommendations.Design/methodology/approachA literature review was conducted, including relevant government reports, consultation papers, Legislative Council papers and articles from academic journals from 1980 to the present.FindingsThe Four A’s approach shows that applicants to both centre-based services and home-based services endure lengthy waiting times because of the limited number of CCS. Furthermore, the awareness of day respite services is approximately 50 percent, which lags behind other CCS. Accessibility is contingent on a cross-district day respite service system and a lack of consistency between the quota and the proportion of older adults in the districts. Finally, the level of service provided by CCS is unsatisfactory due to inflexible service provision. Reviewing the brief history of long-term care services (LTC) reveals the deep-seated factors at the core of their heavy reliance on the subvention model, in contrast to the adoption of the ‘mixed economy of care’ by residential care services (RCS). An imbalance in budget allocation to RCS and CCS is also revealed.Originality/valueAlthough the principle of ‘ageing in place’ was introduced in 1977, the institutionalisation rate (6.8 percent) of older adults remains unexpectedly high in Hong Kong, even surpassing its Asian counterparts, whereas the usage rate of CCS hovers around 0.8 percent. Thus, how to implement policy concerning LTC services for older adults must be re-evaluated.

Value choices in a mixed economy of care: How politics shapes the implementation of complex social policies

AbstractWhile social and public policy studies recognize the diversity of actors and processes occurring in the implementation of policy and the organization of public service delivery, analysis of the role of value pluralism in implementation remains underdeveloped. This article contributes to a more nuanced understanding of the relationship between value pluralism and organizational responses to value conflict by exploring the effect of politics on the value choices of senior public servants involved in the design and implementation of Australia's National Disability Insurance Scheme. Our analysis shows that politics may play an essential role in facilitating implementation of a complex social policy that contains a number of incommensurable values because successful politics allows these incommensurable values to co‐exist and adaption to take place, thereby avoiding organizational dysfunction.

Social Work with Older Adults in the United States

This article examines ageing services in the United States, which are provided and financed through a mixed economy of care that includes government, the voluntary sector, and the private market. Because of substantial unmet needs, poorly coordinated systems, and social and economic disparities among older adults in the United States, social-work services have an important role to play in overcoming barriers to optimal functioning and emotional well-being in later life. Existing evidence suggests that the ability of social work to meet the needs of a growing ageing population is hampered by insufficient numbers of social workers with adequate training and competence in ageing. The article analyses and discusses recent advances in social work education in the United States designed to produce greater numbers of ageing-competent social work professionals, including initiatives in aging-related curriculum development, training, organisational development, and scholarship.

The limits of market-based reforms.

Every health and social care system around the world is concerned with how it can provide care in a way that ensures both high quality and cost-effective care for people. The English system is no exception and over the last few decades there has been increased interest in the use of markets within the context of health and social care [1]. Although local government in the UK has a longer track record of developing a market for care services (especially since the passage of the 1990 NHS and Community Care Act), a series of NHS reforms have followed suit, also drawing on market-based approaches (see [2,3]). The initial introduction of an internal market into the English NHS in the 1990s saw the separation of the functions of service delivery (provision) and the purchasing and planning of these (commissioning). The context has since developed and today commissioners are being asked to strengthen the market further and enable the diversification of provision in a mixed economy of care. The recent passage of the Health and Social Care Act 2012 requires commissioners to ensure good practice and promote and protect patient choice. The legislation seeks to make the NHS more responsive, efficient and accountable by putting clinicians at the forefront of commissioning and, most controversially, opening up the field of provision to encourage more entrants to the market and, ultimately, greater competition [4,5]. Thus, market-based competition is one of the main tools that are available to health care commissioners working within the NHS in England. These changes echo those which are going on in other parts of the globe as national governments seek to develop and extend markets in health and social care. Market based reforms have a central role within the English government’s plans for health and social care, however; they have not been warmly welcomed by all (to put it mildly). There has been considerable critique of the introduction and expansion of market-based reforms in health and social care [e.g. [6-8]]. Most recently there has been considerable debate about the Health and Social Care Act, generally and specifically in terms of the Section 75 regulations which on the face of it are concerned with ‘good procurement practice’, but which many feel open the NHS up to competition. Against this background the Health Services Management Centre at the University of Birmingham and the Nuffield Trust jointly convened a seminar to explore the ‘limits of market-based reforms’ in health and social care and the papers that comprise this supplement are a product of the presentations, discussions and debates from that day. Questions addressed during the day included: • What are the theories that have underpinned the study of commissioning? • What are the ways in which we can investigate commissioning? • What does it mean to do commissioning? • What is the evidence base for commissioning? • What is the future of commissioning? Ultimately, this seminar was particularly concerned with understanding what we know about the effectiveness of market-based reforms and from a variety of disciplinary and methodological perspectives.

Are Judicial Approaches to Adult Social Care at a Dead-End?

This article examines the limits of law to resolve or transform the contemporary dilemmas provoked by the provision of social care to adults in the UK. It juxtaposes the judgments in two cases, each of which interrogates the legal consequences of the mixed economy of care: the majority and minority opinions of the House of Lords in YL v Birmingham City Council (2007) and the Care Standards Tribunal decision in Alternative Futures v National Care Standards Commission (2002). We read the opinions/decisions as narratives that tell a variety of stories reconciling the different roles of law, the state, the family and the individual in the provision of care. Drawing upon David Scott’s concern with ‘the conceptual problem of political presents and with how reconstructed pasts and anticipated futures are thought out in relation to them’ (2004: 1), we seek to examine legal responses to the contractions and mutations of social welfare.

What are Children's Centres? The Development of CC Services, 2004–20081

AbstractChildren's centres are intended to be a mainstream, universal service. They began in 2004 and their origins are diverse. Some replaced various forms of local provision, most notably Sure Start programmes; others were established from scratch. Issues for exploratory empirical work have been identified from the guidance issued by central government. Using interview data from three urban local authorities, this article explores the nature of the ‘core offer’ that centres are expected to provide and the way in which they have pursued the goal of integrating staff and services. The article highlights the problems of balancing a focus on the child and on the parent; of reconciling childcare provision as part of the employability agenda and as a means to educational achievement for the child; of permitting local variation while achieving consistency; of the role of monitoring in relation to developing good practice; and of achieving integration in a mixed economy of care. We find that despite the greater specification of the core offer for children's centres compared to that for Sure Start, there are substantial differences between children's centres in terms of services, while the mixed economy of provision poses considerable challenges to the goal of integration.

Approaches to commissioning home care from the independent sector

PurposeThis paper is the sequel to the authors' earlier paper in this journal and aims to present the “future research” outlined in that paper.Design/methodology/approachThe approaches being employed by Welsh local authorities in commissioning home care from the independent sector are surveyed to see how a mixed economy of care is being implemented. The observed differences are analysed to see what can be learnt for the benefit of public sector managers concerned with the development of commissioning practices. Semi‐structured interviews have been performed with home care managers and commissioning officers in 13 (60 per cent) of the local, unitary authorities in Wales. Managers at independent home care providers have been interviewed also. The study has been ongoing since September 2004. For comparison, Barnet in England has been included because, unlike any Welsh authority, it has implemented 100 per cent outsourcing of home care. Croydon has been included as it has a good practice brokerage that has helped it to expand its provision from the independent sector.FindingsGreat diversity is seen in the approaches adopted by the Welsh local authorities when commissioning home care from the independent sector. They differ in the proportion of home care that is commissioned from the independent sector, what is commissioned, the number of independent providers and the contractual arrangements. These features are used to develop a taxonomy of home care strategies that reveals high levels of diversity. It is seen that in Wales there has been less political drive and compulsion to outsource home care than in England, but the natural desire to reduce costs in the face of a growing need for home care is now driving outsourcing in Wales.Practical implicationsThis paper provides guidance to public sector managers in local authorities seeking best practice in the commissioning of home care from the independent sector.Originality/valueThe existing literature contains little research into good practice in the commissioning of home care by local authorities from the independent sector. This paper is a timely contribution to addressing this shortfall.

Institutional Care for the Mentally Defective, 1914–1948: Diversity as a Response to Individual Needs and an Indication of Lack of Policy Coherence

Institutional Care for the Mentally Defective, 1914–1948: Diversity as a Response to Individual Needs and an Indication of Lack of Policy Coherence

Home care outsourcing strategy

This paper aims to help public sector managers that are formulating strategies for outsourcing home care from the independent sector. A review was performed of relevant literature on the outsourcing of home care and its political drivers in the U.K. This indicates that the future of home care services, taking into consideration outsourcing and how Best Value will be achieved, has not been researched widely. Therefore, an exploratory approach to research was adopted here using in-depth analysis of a small number of particularly informative local authorities and private providers selected by purposive/judgemental (extreme and critical case) sampling. Personal contact was deemed necessary in order to perform an intensive investigation to pursue in-depth information. The British Government's Best Value regime is driving local authorities towards increasing levels of outsourcing in the provision of home care. A local authority may choose to outsource all of its home care or maintain some in-house provision based on capacity or capabilities that are complementary to those provided by the independent sector. The 100 per cent outsourcing strategy places enabling demands on the local authority, whereas the alternative strategy requires decisions to be made on what should be outsourced. Across the authorities surveyed, six strategies for creating a mixed economy of care have been identified, with the mix being based on complementary capacity and/or capabilities. With Best Value driving authorities to consider lower-cost options, the outcome may be a reduction in the amount of complementary capacity provided in-house, in favour of strategies involving complementary capabilities that deliver the Best Value possible. Re-enablement is emerging as a common, complementary or core capability that is remaining in-house. Outsourcing also requires decisions to be made on the number of independent providers to be used and the type of contracts to be employed. This paper considers the decisions that have been made in the local authorities surveyed and critiques the alternative home care outsourcing strategies so derived. To date, the research has focused on Wales in general plus a few local authorities in England. The next stage will be to survey England in more detail along with other countries that are implementing substantial outsourcing of home care, such as Canada. This paper provides timely guidance to public sector and health care managers seeking Best Value in home care through outsourcing. Little has been found in the literature on strategies for outsourcing home care, yet such strategies are needed urgently in the U.K. to achieve Best Value. The World Health Organization stresses that strategies should be drawn up for providing support to patients and carers at community level in order to avoid costly institutional care.

Using a Whole System Approach to Service Development in Rehabilitation and Continuing Care Services

The past two decades have seen the final stages of the hospital closure programme of Victorian hospitals and a corresponding growth in the number of communitybased services with beds. A mixed economy of care has been encouraged, resulting in a wide range of rehabilitative and continuing-care provision across health, social services, voluntary and private sector providers (Department of Health, 2001; 2002). Correspondingly, the past decade has seen increasing pressure on acute in-patient units, resulting in occupancy rates over 100%, in some cases even as high as 123% (Ford et al, 1998; Sainsbury Centre for Mental Health, 1998). This pressure has been compounded by the considerable number of people who remain on acute wards because of the lack of suitable community alternatives (Fulop et al, 1996). Furthermore, the growth in community services has not always been within the locations where they have been required and as a result many people have been placed away from their local services, relatives and friends (Poole et al, 2002). There are now various pressures across the mental health system causing concern for service commissioners; these include over-occupancy of acute wards, difficulty in accessing low and medium secure facilities and escalating use of beds outside local services, often referred to as OATS (out of area treatments). The latter often results in finances being lost from services that could have been used to develop the capacity and capability of the local system, such as enhancing community mental health team resources to provide supported accommodation. Many commissioners are looking at their local nonacute services to determine whether they can function more effectively to relieve some of these pressures while also assisting in bringing people, and the associated funding, back to the local mental health system from where they came. One method of improving the effectiveness and efficiency of the mental health services of an area is through taking a whole systems approach to development. This paper presents data from three case studies where a whole systems approach to needs assessment and management has been undertaken. The client group concerned was adults with severe and enduring mental illness (non-organic) with rehabilitation or long-term continuing-care needs. None of the local services in these case studies was forensic in nature, although some of the residents came from such backgrounds. Providers included social services, the NHS, and voluntary and private sector organisations.

Appreciating Impact: Evaluating Small Voluntary Organizations in the United Kingdom

Within the mixed economy of care in the United Kingdom there are debates about the ways in which impact can be evaluated, in order to shape funding and policy decisions. One of the tensions evident in this debate is whether the evaluation approach should reflect the perspectives and goals of the voluntary organizations and their members, or whether evaluation should reflect the wider goals of the whole system of provision. The former runs the risk of being insular and self-congratulatory, while the latter may be inappropriate and dismissive of achievements. This paper explores this tension by reporting on a study that used Appreciative Inquiry to evaluate 10 small-scale not-for-profit schemes for older people. The data indicated some unexpected and long-term impacts that demonstrated the distinctiveness of the sector. Subsequently the findings were mapped on to the “impact grid” developed by Wilding and Lacey (2003). While this was straightforward at the levels of individuals and interorganizationally, it was more difficult at the sector/community level, suggesting that more work needs to be done to bring these two perspectives together.

Drawing the line: the boundaries of volunteering in the community care of older people.

Volunteers play a vital role in the current 'mixed economy of care', but have not attracted a proportionate level of interest from researchers. In this English study, 14 volunteer schemes formed the purposive sample. Semi-structured interviews were carried out with the organisers of each scheme, but it proved difficult to interview volunteers themselves, as organisers were reluctant to release names and addresses.

New Labour and the enabling state.

The notion of the 'enabling state' gained currency in the UK during the 1990s as an alternative to the 'providing' or the welfare state. It reflected the process of contracting out in the NHS and compulsory competitive tendering (CCT) in local government during the 1980s, but was also associated with developments during the 1990s in health, social care and education in particular. The creation of an internal market in the NHS and the associated purchaser-provider split appeared to transfer 'ownership' of services increasingly to the providers - hospitals, General Practitioners (GPs) and schools. The mixed economy of care that was stimulated by the 1990 NHS and Community Care Act appeared to offer local authorities the opportunity to enable non state providers to offer care services in the community. The new service charters were part of the enablement process because they offered users more opportunity to influence provision. This article examines how far service providers were enabled and assesses the extent to which new Labour's policies enhance or reject the 'enabling state' in favour of more direct provision.

Who volunteers?

The 1990 NHS and Community Care Act outlined an extended role for volunteers and voluntary organizations in the provision of services for disabled adults and older people. In broad terms, the Act assumed an untapped pool of volunteers, ready to contribute at little additional cost to the provision of care. More recent policy developments, including Millennium Volunteers (Scottish Office 1997) have made similar assumptions. For organizations which involve volunteers, the expectations of their increased use in service provision present considerable challenges, not least in attracting new recruits and retaining existing volunteers. The research presented in this paper builds on previous work to explore the current practice and organization of volunteering and to examine critically how far the reality matches the political rhetoric about the role of volunteers in the mixed economy of care. The paper begins with a critical review of recent policy and practice in volunteering to set the context which provided our key questions. The research methodology is briefly described and the findings from a survey of 117 active volunteers working with adults with learning difficulties, mental health problems and physical disabilities, and with older people in the North of Scotland are presented. The research examines the demography and personality profiles of the volunteers. It examines their perceptions of volunteering as these relate to motivation, recruitment, selection, training, support, rewards and reasons for leaving. Finally, it examines volunteers' perceptions of the organization of volunteering. The results are reviewed in relation to the policy assumptions about volunteering in the mixed economy of care.

Ageing and care of the elderly in a mixed economy of care: Challenges for nursing and nursing research

Ageing and care of the elderly in a mixed economy of care: Challenges for nursing and nursing research

Volunteers: Making a difference!

Reports on volunteering in Britain since 1976 suggest that 16–52% of adults in Britain participate annually in at least one voluntary activity, and that a ‘typical’ volunteer exists. However, the traditional volunteer profile (white, middle-class, middle-aged, educated woman) is being challenged by demographic and employment changes and recent shifts in government social policy. Further, demand for volunteer services is increasing as a result of the expectations of care in the community legislation and the increased role of volunteers in the provision of a mixed economy of care. In this paper we critically examine the ‘vision of volunteering’ in the light of what we can learn from recent research on volunteering.

Developing the Mixed Economy of Care in Sunderland

This Case Study sets out to show how one local personal social services authority, the city of Sunderland, approached the task of developing a mixed economy of social care through contracts and market management. It starts with an outline of the historic and policy background and the Sunderland context. It then explains how the task was given a strategic framework. The Case Study continues by setting out what Sunderland has done in achieving contracts for residential and nursing care and concludes with a brief review of how contracts are being developed for other social care services.

“An Inner Group of Willing People”: Volunteering in a Religious Context

In the age of “welfare pluralism”, volunteers are attracting increasing attention from academics and policy‐makers. This paper focuses on volunteering in the context of religious congregations. It is found to be similar in some ways to that in secular organizations but there are also significant differences including the impact of religious values on motivation, the fact that congregational volunteers are also “members”, and the special relationship with clergy. It is concluded that congregational volunteers can be important constituents of the “mixed economy of care”and “civil society”. However, long‐term care may be provided better by institutions which are less dependent on individual enthusiams.

FROM PROVIDING TO ENABLING: LOCAL AUTHORITIES AND THE MIXED ECONOMY OF SOCIAL CARE

Government policy seeks to introduce competition into the supply of social care through the separation of purchasing and providing responsibilities. A study of 24 local authority social service departments has explored the initial steps taken to prepare for the new enabling role, including the creation of a mixed economy of care. Very few were seeking to create a market in social care. Most argued that the inherent nature of social care rendered the introduction of service specifications and price mechanisms neither approriate nor feasible. Many authorities interpreted the enabling role in ways significantly different from that of the government. The study raises questions about the extent of local discretion in a context where the range of values and interests of implementing agencies may differ from those of the centre.

Implementing Caring for People? Draft guidance circulars from the Department of Health

Throughout the 1980s concern mounted over the provision of health and personal social services. As a result of inflation, an expansion in demand and technical advances, the increasingly expensive hospital services became more and more obviously threadbare, while the perceived failures of the community care movement were widely canvassed. As the decade ended the Government embarked on two bold initiatives aimed at increasing the efficiency, effectiveness and accountability of health and social care. These proposals, set out in the White Papers Caring for People (HMSO, 1989a) and Working for Patients (HMSO, 1989b), have now become law in the National Health Service and Community Care Act 1990. Another paper (pp. 641–645) somewhat critically reviews Caring for People from a psychiatric perspective (Holloway, 1990). At the heart of the ‘reforms’ is an attempt to create the conditions of a market. To achieve this a sharp distinction is to be drawn between the purchasers of care (Health Authorities, Local Social Services Authorities and Family Health Services Authorities) and service providers, with whom the purchasers will let contracts. It is envisaged that eventually a plethora of providers will compete within a “mixed economy of care”, becoming ever more efficient.