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Essay: Privatisation of older adult social care in England and its impact in service delivery

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  • Privatisation of older adult social care in England and its impact in service delivery
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This dissertation aims to explore the existing literature from a variety of sources in respect of privatisation of social care provision for older or frail adults and a phenomenon of choice and control as it relates to social care provision. This dissertation will intend to identify and address the implications of privatisation and profit in social care. To complete this study this dissertation sets out three objectives at the beginning of the study.

1.2 The study objectives are to demonstrate

• An understanding of existing knowledge on privatisation of social care provision in England in relation to personalisation of care,
• To explore how privatisation of adult social care can be efficient and effective in promoting service user personalisation and
• To explore the potential impact of the reduced role of government in providing and regulating social provision in terms of cost, efficacy and quality of services.

The research approach adopted in order to address these objectives took the form of a desk-based review.

1.3 Significance of study:

This dissertation is motivated by the increasing role of private sector in social care services, and role of choice and control in the changing character of contemporary United Kingdom social care system, particularly in light of current fiscal containment pressures (Streeck and Thelen 2005 and Evans et al., 2012). This study is aimed at exploration of the impact of privatisation in the delivery of adult social care services. It highlights the need for both government and private service providers to address a personalised care delivery particularly in older adult care. The introduction of choice and competition has brought about a change in the organisation, management and character of the social care provision in the United Kingdom. On the one hand this has been debated as an implicit move towards a privatisation of risk (Hacker 2005). Privatisation of social care services with the aim of exposing organisations to market forces is perceived as an optimal means of dealing with the constraint of governments’ budgets. Gains in efficiency achieved through the transfer of ownership and management of state-owned enterprises into private hands are claimed in the literature to be the ultimate objective of privatisation reforms, as private enterprises operate more efficiently being driven by the ‘bottom line’ of profitability.

This research will set out set out a brief account of the policy context to date of the relationship between social care and the private sector providers. The research will then describe the methodology adopted for this review. Following this we set out the findings of the literature review. One thing that became apparent in the reading of the literature was the vast data surrounding many of the major themes in respect to this area of study. Therefore, the chapter of the findings sets out an account of the nature of this literature base, particularly in terms of methodology and theoretical and conceptual constructs. The findings will be examined according to the themes. In the discussion chapter this review will draw out the key points that comes out of the literature review and set out what i believe the major implications of this review are in terms of research, policy and practice. This review will then set out the major research questions which i believe need more evidence and further investigation. The final chapter summarises the review and makes a series of recommendations for future work in this field of older adult social care.

Chapter 2. Background literature

2.1 Introduction

The overall aim of this study is to explore privatisation of older adult social care in England and its impact in service delivery. Background literature conducted at an early stage of this research to evaluate the scope of the subject, and to critically evaluate the current literature base, and develop an initial framework. It explores four areas:

2.1.0 Older adult social care policy context

The history of adult social care in England is long and complex and is beyond the scope of this review. Over the last seventy years or so there have been many changes in how social care is organised and run, and who is involved in this (Lewis, 1995). The advent of ‘contract culture’, marketisation or privatisation in adult social care emerged in the 1980s. This was followed by a review of community care services by Sir Roy Griffiths in the late 1980s which led to the 1990 NHS and Community Care Act. Following this development, social workers were made ‘managers’, responsible of assessing individual need and arranging packages of care from a combination of private, public and charity services. This was consistent with the then conservative government’s political ideology of 1979 to 1997. As a result, social workers became ‘purchasers’ rather than providers. Much of the new social care funding that accompanied these changes was to be spent in the independent sector (Dickinson and Glasby 2011). From 1997 to 2007, under the new labour government this ethos remained, but with a growing emphasis on modernisation, portrayed as a ‘third way’ between the market-based ideology. Recent government policy emphasis personalisation where by social care service users have the greater choice and control in their care. For example, increasing role played by direct payments, social care service users receiving the cash equivalent of directly provided services with which to purchase or hire their own care staff.
2.1.1 Definition of privatisation in social care
Privatisation is a term that is used to convey a variety of ideas and covers a wide continuum of possibilities. However, in a broadest sense, privatisation can refer to the complete government withdrawal from the function, including the sale of government assets such as local authority run care homes or banks to private companies. In addition, privatisation of social care can include the use of vouchers to allow service users to “shop around” for services, as used (Nightingale and Pindus 1997). For the purposes of this study, this dissertation focuses on the most common form of privatization; contracting out services to private organisations. Private sector organisations can be for-profit or not-for-profit such as faith-based groups, foundations, social enterprises and charities. In researching the topic of privatisation of adult social care in the United Kingdom a lot of information could be found in abundance. Social care services are frequent objects of social policy reform as welfare state in England, as in the rest of the UK, and face increasing pressure on existing adult social care provision and anticipate growth in future demand (Anttonen, Baldock and Sipilä, 2003). In 1995 residential care expenditure for the older adults and chronically ill was just over £8 billion (Harrington and Pollock, 1998). According to Age Concern (2008) people live longer than ever before, and the rate of older people over 65 years whom Leadbeater et al., (2008) say are the largest group of recipients of social care in England, has been increasing gradually. Ageing population has brought about concerns in the delivery of social care and places substantial additional pressure on publicly provided social care. For example, in 2000, 16% of the population in the UK was over the age of 65. The World Health Organization (2008) has predicted that the world will have over 2 billion people living over the age of 60 years of age by 2050. The older people aged between 75-84 years were seen as the fastest growing age group in the world, growing at a rate 3.8% per year with one fifth of the older population envisaged to be eighty years and older by 2050 (United Nations, 2002). Adult social care, including care of an ageing population, is one of the big issues England face at present. The provision of adequate adult social care poses a significant public service challenge. Demand for care due to ageing population is rising while public spending is falling. On average, older people using social care services today have greater needs than their counterparts 10 or more years ago. The health status of older people has slightly deteriorated over the past decade, probably because of longer life expectancy. A report by (CHPI, 2016) highlights that around £24 billion is spent on adult social care in England every year, most of which is spent on older people receiving care either in their own homes or in a residential. In social care, the 1989 White Paper, Caring for People, emphasised the need to improve choice and deliver services that respond flexibly to individual needs (Means et al. 2003). Prior to the White Paper, social care services were predominantly funded, organised and directly delivered by local state-funded (‘in-house’) providers.
2.1.2 History of social care
Government provision for social care for older people in difficulty has a long history in England and across the United Kingdom. From the 1601 Elizabethan Poor Law with services funded through parish rates, and the reformed 1834 Poor Law Amendment Act, with its emphasis on social control as much care and compassion (Harris, 2005) to the 1948 National Assistance Act, which ended the Poor Law, and brought about the ‘Welfare State’. Since 1979 there has been a remarkable shift in social care provision. In 1979, 64% of care home beds were provided by local authorities and National Health Service (NHS). In 1993, 95% of domiciliary care was directly provided by local authorities. Laing and Buisson (2007) have found that in England, 78% of places in residential and nursing homes which have older people as their main clients were in the private sector. By 2012, only 11% of domiciliary care was provided by local authorities. This growing role for private sector involvement in social care provision, dictated by neoliberal ideology, has accompanied this shift. In trying to shape the relationships between public, private and voluntary sector bodies in the delivery of social care services, successive governments constructed the social care markets, starting with the rapid increase in the use of the residential care allowance for private care homes in the 1980s, the growth in outsourcing home care in the 1990s, and the closure and or sale of local authority care homes.
In the last 30 years or so the elderly social care system in the UK has undergone significant metamorphosis. The Community Care report by Griffith (1988), and the articulation of this into a solid policy base in the NHS and Community Care Act (1990), set the scene for the ensuing transformations in the delivery of social care services and remains the defining point in the development of today’s system. Griffith (1988) proposed a split between health and social care. Health boards remained responsible for acute and primary health care, but local authorities took responsibility for long term care. Local authorities were to be responsible for assessing and responding to the needs of individuals in their regional areas but their role as direct providers of care services was diminished. This was the beginning of what is now called the ‘mixed economy’ of social care services (Wistow et al 1994). The independent sector, including voluntary, charitable and private sector organisations, it was envisaged by Griffith, would take over the majority of social care provision. The cherished National Health Service (NHS) would remain state run and funded, but a new policy terrain of ‘social care’ was instigated (Glasby and Littlechild 2004; Lewis 2001).The adult social care sector has, however, experienced more intense rates of privatisation than the health care sector or any other social care sector, including care of the disabled or children.
2.1.3 Marketisation and personalisation in adult social care
According to the Department of Health, (2010) personalisation is process by which social care services are tailored to meet the needs of an individual and increase service user’s choice, louder voice, control and flexibility in accessing services. Glasby and Littlechild, (2009) puts choice and control over how money is spent, choice as to service user’s wish to control the money and if they do, how much control they wish to exert, as the fundamental principle of personalisation. Similarly, Bailey, Routledge and Sanderson (2013), say personalisation builds on person-centred care to focus on how people, including older people with dementia can have more choice and control over decisions affecting their lives, and be supported to be part of the community they live in.
Market mechanisms proliferation have become a general-purpose tool for public policy, including social care services. With the Health and Social Care Act 2012 (referred to here as ‘the Act’) the UK Government sought both to marketise (i.e. increase price-based competition between providers) and privatise (i.e. increase provision carried out by non-government providers). While the pro Act’s supporters argue that competition provides innovation, better management, and improved quality of care (Le Grand, 2013), its critics argue that competition exacerbates inequalities (Hunter, 2013) and service rationing (Lister, 2012), end comprehensive public-sector care service provision (Pollock and Price, 2011), and worsen democratic accountability (Davies, 2013). While the Act’s objectives fit most commonly accepted definitions of privatisation (Peedell,2011), Moody, (2011: 428-429) states that, in the future, “there will be no fully state-owned providers”. The number of government run




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