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Social Care Research 56 - September 1994 Current policies in community care aim to make much greater use of independent organisations in service delivery. One aim is to develop more choice for the service user. A recent study of voluntary and private organisations in three localities suggests that achieving greater choice is a more complex matter than merely providing greater numbers. The study, by Marilyn Taylor, Joan Langan and Paul Hoggett at the University of Bristol, found that:
Introduction Current policies are designed to transfer much of the delivery of community care to independent (private and voluntary) organisations. If this transfer of provision is to offer real choices to service users, policy-makers and purchasers need to be able to make sense of the growing range of organisations in the independent sectors and the impact such a transfer is likely to have on them. They also need to ensure that their policies support existing organisations and encourage new ones to enter the community care field. Distinctions within the independent sectors The study found a considerable variety of organisations in the three localities studied, suggesting that traditional distinctions between voluntary and private sectors are too simplistic. Other key dimensions in understanding this variety were size of organisation, and whether an organisation was run by or for users (see Figure 1).
The difference in values held by private and voluntary sectors was less extreme than popular stereotype suggests. Although examples were given of private sector providers who were concerned only with the 'bottom line', those in the study were as likely to be motivated by the desire to give a caring service and to promote independence as by profit. There were some differences between the voluntary and private sectors. Voluntary organisations were likely to engage in a wider range of activities than private care firms and, particularly, to engage in advocacy and campaigning activities. They were also more likely to be working alongside a range of other organisations (although this may change as new policies develop). However, an equally important distinction was that between organisations providing services for others (which includes private organisations and many voluntary organisations) and those run by service users or by and for carers. User- and community-based organisations often emphasised values of mutual support or developing a collective voice. Private organisations were more likely to stress individual customer care, while voluntary organisations providing services to others had a range of approaches to user empowerment. The third important distinguishing characteristic was size. Smaller private organisations in the study thought that the real danger to caring values lay in the entry of big corporate firms into the caring sector. The characteristics often attributed to independent organisations - flexibility, closeness to the consumer, autonomy and so on - were more likely to be found in small organisations or those organised on a decentralised basis than in larger organisations where ownership and management had become separated from service provision. Smaller and decentralised organisations and community and user-based organisations were more likely to have participatory approaches to management. Overlaps and networks The boundaries between statutory, voluntary and private sectors are becoming increasingly blurred. Voluntary agencies may be set up by public sector workers and often draw people from the statutory and private sectors into their management groups or as volunteers. Private and voluntary organisations may receive public funds and employ people from a public or voluntary sector background. Individual service users often gain support from a variety of providers in more than one sector. Local agencies studied often existed as part of an interdependent network. The disappearance of any one part of this network affected the capacity of others to carry out their work effectively. Pressures to conform Organisations in the study identified many pressures which affected their ability to provide care. Regulations, quality and training
Many organisations welcomed inspections and some gave evidence of improvements which had been made as a result. But inappropriate or excessive regulations can turn residential and nursing homes into formal institutions, with closed doors (because of fire regulations), official notices and no-go areas.
A woman with profound learning disabilities in one private home lost her purpose in life after being told that she could no longer sit in the kitchen with staff. To her, the kitchen was the centre of the home's life, as in many families. Inappropriate regulations may also serve to squeeze out the flexibility which a wide range of independent organisations are delivering. The costs of implementing standards fall disproportionately upon small organisations, as do the costs of implementing training. The quality standard BS5750 was popular amongst some care homes but it is expensive to achieve and others in the study questioned what exactly it measured as it deals with consistency and systems rather than outcomes. Becoming more business-like A number of organisations had reviewed their operations, tightened up on procedures or, in the voluntary sector, brought in new directors or management committee members with commercial, legal or financial experience. But there was concern at the weight of responsibility which many unpaid management committee members and trustees were having to bear. Some existing management committee members had resigned due to worries about legal liability. Others had been edged out in order to tighten up on management - they had retired, become a 'friend' of the organisation or moved into fundraising and social committees. The need for more 'professional' trustees also conflicted with the aspirations of many organisations, who saw it as part of their purpose to involve users or people from the local community. Many organisations commented on the increase in administration which had resulted from recent legislation. This had the effect of reducing job satisfaction for some managers who now had little time for contact with service users or staff and of reducing the commitment of volunteers whose primary interest was in face-to-face work. Growth
There were many pressures on small organisations to grow and become more
formalised. One was the need for economies of scale in a competitive market, especially the case amongst care homes. Smaller organisations felt they faced a choice to grow or get squeezed out of the market by larger, more competitive firms. But pressures to expand and diversify also came from inside. Some smaller voluntary organisations were weighing up opportunities to expand against their desire to maintain participatory and collective ways of working, which they feared they would lose if they grew. But they also found it very difficult to get the core funding which growth, or even survival in a more and more pressured environment, demands.
We can't provide a service unless it is well-managed; otherwise it will fray round the edges. But funders will only pay for face-to-face work. Funding Many organisations were experiencing serious financial difficulties and commented upon the unwillingness of purchasers to provide funds other than for direct services. Funds for development costs were extremely difficult to come by. Organisations also expressed fears for the future of services and activities that complement and support mainstream provision. Such services may prevent a crisis by providing support long before people come to official notice - but they are unlikely to be defined as priorities by hard-pressed authorities. Conclusions If community care in the future is to draw on the range of resources and motivations that the voluntary and private sectors provide, this is going to need more than an increase in the number of organisations competing to provide the same services. The researchers conclude that effective community care in the future is also going to require: Investment The survey suggests that investment will be needed in development, in new and emerging organisations, in the core management and infrastructure services on which services depend, and in innovatory services and structures. Support will also be needed for the advocacy that will allow service users to make informed choices and to take control over purchasing decisions. However, it is not easy to see where the necessary investment will come from. Social service departments are facing further upheaval with local government reorganisation, and independent organisations feared that this will mean further losses to already tight budgets. Recognition is needed from central government of the importance of investing in development and providing the space at local level to create flexible and imaginative patterns of care. Knowledge Purchasing policies need to be based on a clear and comprehensive picture of who operates in any locality, what they do and, especially, how they fit together. New ways of delivering services How can voluntary and private organisations maintain the strengths of 'simplicity' as they grow? Solutions are likely to be found in the development of networks, coalitions and new organisational forms which can give smaller organisations access to economies of scale, where necessary. Larger organisations as well as government have an important role to play in supporting small, local and user-based groups and creating autonomy at local level. More appropriate regulation Finding a balance between quality care and over-standardisation in a field which inevitably carries risks is not easy. A balance needs to be found between unacceptable risk and an acceptable quality of life and service users need to be involved in defining that balance. Some of the resources now going into regulation and standards could usefully be shared with carer and user-based organisations to allow them to specify the standards they feel they need. About the study The study was carried out by Marilyn Taylor, Joan Langan and Paul Hoggett of the School for Advanced Urban Studies, University of Bristol. The study was based in three areas of the country. It involved a postal survey of over 250 organisations, local interviews with key people and case-studies of 33 organisations. Further information For further information on this study contact Marilyn Taylor or Joan Langan, School for Policy Studies, University of Bristol, Rodney Lodge, Grange Road, Bristol BS8 4EA. Further results from the study will be published in journal articles and the professional press. |
