A blog entry by Catherine Needham,
Sustainable Care Co-Investigator

In February 2020 we finished a three year project about care markets. Six months later, after sign-off procedures and development of accompanying resources, the project was published. That six months was the most traumatic and turbulent of any period in recent history. The Covid-19 pandemic swept through care homes, resulting in 30,500 excess deaths between 28th December 2019 and 19th June 2020. Domiciliary care had a greater proportional increase in excess deaths than care homes for the same period. Thousands of people have faced isolation and distress as day services have closed and many older people been confined to their homes. Do any of the things we knew in February 2020 still hold true?

Catherine Needham

Professor Catherine Needham

Our project looked at how local authorities are undertaking their legal duty to ‘shape’ the care market, a duty given to them by the Care Act 2014. You can see an animation of the findings here. We identified the fragility of care markets, and the difficulties that local authorities have in shaping them effectively. Public service austerity, uncertainty over long term care funding, rising demand and workforce shortage have made it difficult to effectively shape markets. It’s not clear in social care, as in other sectors, that the state is very good at shaping markets – partly because public servants don’t always have the right skills and resources, but also because markets are shaped by a multiplicity of factors many of them outside the control of government.

In our case study sites, we found four different types of market shaping (shown in the image below). Some local authorities are drifting between them over time, often without purposively choosing one approach over another.

Care markets diagram

The two models that we found most effective at market shaping were the ones where local authorities opted for what we called the low control approach, letting communities and providers shape the service. These were the ‘open market’ model, which frees up individuals to purchase their own care, with an emphasis on user choice and control; and the ‘partnership’ model that requires local authorities to build long term relationships and share risk with providers and communities.

Both types of provision are needed in local care markets. Open markets already exist in many areas but are fragile and need active local authority facilitation to work effectively.  Partnership models are essential for long-term investment, but are underdeveloped and need to be built up in an iterative way to grow trust, enable providers, service users, families and communities to adapt, and to facilitate joint working with health and housing.

The Covid-19 pandemic has further highlighted the importance of trust and good communication between local authorities and the market. The issues and the local response has been variable between local authorities. Forthcoming research by Lizzie Ward, Mo Ray, Denise Tanner and a wider team as part of a project on self-funders of care found that in one local authority site, market management became easier during the Covid crisis, as it necessitated daily dialogue between local authorities and providers. This suggests a shift to the partnership quadrant of market shaping.

However the long-term stability required for effective partnerships has clearly been lacking during the pandemic. The crisis has put further pressure on the care market, with care homes facing high vacancy rates in spring and summer, although recovering into the autumn. Ward et al found that some family carers have been resistant to their loved ones going into a care home, even for respite, because of risk of infection but also because of limits on visiting and a fear of not being able to see the person.

The many people who purchase care themselves via the open market model (including self-funders and people with direct payments) have found things difficult during the pandemic. People with direct payments were not always able to get accurate information on what was allowed and how they could access PPE for personal assistants. Ward et al found that some self-funders were getting more missed or late care visits, as agencies worked to manage staff shortages and deploy staff differently. This open market quadrant is the one that is most consistent with the Care Act’s ambition of maximising individual choice and control, but it requires facilitation and good information flows, both of which were put under extreme pressure by the pandemic.

The recommendations of our research are as relevant now as they were in February: the sector needs a period of certainty for local authorities, providers and crucially people who have care needs now or are planning for old age. Some of this has to come from a new national funding settlement, which Boris Johnson yet again hinted at in his 2020 conference speak mentioning the ‘magic of averages’. But some of it also needs to come from a reimagining of what care is for and what lives people want to lead. The death toll and distress of Covid-19 have been so far beyond what many of us could have imagined earlier this year. None of us will be the same for it. So let’s lift our sights beyond models of care and actuarial magic to think differently about what is possible.

Catherine Needham

Shifting Shapes: how can local care markets support personalised outcomes? is funded by the National Institute for Health Research (NIHR) Policy Research Programme. The full report is available here. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Ward et al’s research report and other resources on self-funders are available here. See also: Ward, L., Ray, M. and Tanner, D. (2020) Understanding the social care crisis in England through older people’s lived experiences. In In P. Urban and L. Ward (eds.) Care Ethics, Democratic Citizenship and the State. Palgrave Macmillan, Cham, Switzerland, https://link.springer.com/chapter/10.1007/978-3-030-41437-5_11

Catherine leads the team researching ‘Comparing UK Care Systems: prospects, developments and differentiation in the 4 UK nations’ for the Sustainable Care research programme. Find out more about this research here.

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