Rethinking Community Care in the 21st Century: The Perspective for Marketisation of Social Care

The agenda for marketisation of social care revisited familiar themes around the enhanced involvement of users in service delivery, upholding choice and control, increasing accountability and developing these by integrating a role for self-organisation and independent living within services. The modernisation of the social care market, drawing on the principle of provider/purchaser split (NHS and Community care Act (DoH 1990), managerialism in welfare services and best value cost effectiveness, provided a focus for delivering social care. Both the Conservative/Liberal Democrats government and New Labour administrations have pursued these ideologies. It also has included the privatisation of care for older people, raising the issue whether the for-profit sector in indeed likely to be the best option for good quality care, especially for frail older people.

A key feature of marketisation policy is about breaking down large-scale organisations providing social care and using competition to enable exit or choice by service users. The ideological position is to increase flexibility in the social care market as this would bring about equilibrium of demand and supply in the market. Individuals and groups at different positions on the political spectrum have promoted the idea of users’ rights to exercise choice in their use of public services. Progressive self-help movements have argued for choice as a means of promoting market-based solutions and curbing the power of the state (Clarke et al 2000; Leadbeater 2004; Cameron 2010; Ugwumadu 2011).

Marketisation significantly centred on issues of cost efficiency, consumerism, and responsibilities and cost savings, whereby the allocation of cash for care rather than services raised concerns as to the accountability of government monies.  Marketisation policy clearly presents significant opportunity for delivering personalisation of services through direct payments and individual budgets model and related support structure in the future social care market (Leadbeater 2004; Hasler 2006). According to Zarb and Nadash (1994) and Hasler (2000, 2006), they argued that direct payments is around 40% cheaper than direct provision. New Labour government assured in its positioning of direct payments and individual budgets as part of a wider marketisation of social care, established initially through the 1990 Community Care Act. This framed the market as an instrument for accessing choice and diversity in social care provision through the development of local care markets (Hasler 2006; DoH 2008).

The central doctrines for the Conservatives/Liberal Democrats government and  New Labour government’ agenda are: a focus on managerialism not policy and on performance appraisal and efficiency; the disaggregating of public bureaucracies into agencies which deal with each other on a user-pay basis; the use of quasi-markets and contracting out to foster competition; cost-cutting; and a style of management which emphasises, amongst other things, out-put targets, limited-term contract, monetary incentives and freedom to manage (Hood 1991; Osborne and Gaebler 1992; Leadbeater 2004; Cameron 2010). These ideological policy frameworks are fundamental principles behind the Big Society’s agenda to enhance the welfare systems. The Big Society project is claimed to offer the opportunity to deliver the personalisation agenda and to maintain cost effective social care.

However, many people would disagree with this position on the grounds illuminated below. For example, changes in delivering personal social services are accompanied by an increasing tendency to define home care intervention in terms of narrow tasks. This has resulted in complaints of unmet needs and lack of opportunities for more generalised social interaction between carers and service users (Sale and Leason 2004; Ugwumadu 2011). The continuous changes within social services’ policy and practice have influenced social work practice and social care delivery. According to Morris (1993a) and Glendinning et al (2002, 2009), changes in policy meant that social workers were no longer in a position to uphold social work ethical practice, but had to participate in a policy that deprived users of their rights and choices, as outlined in the National Health Services and Community Care Act (DoH 1990).

It is also possible to see the Community Care (Direct Payments) Act (DoH 1996 a & b), and the Carers and Disabled Children Act (DoH 20001 b) as an attempt by government to promote a distorted and flawed notion of empowerment by exit, shifting responsibilities to users. The aim was to control and reduce an escalation of public expenditure. In such a service, Leece (2000) claimed that it would be left to local authority social services departments to balance the books and reconcile the very real demand for direct payments with already stringent budget constraints. Pearson (2004a, b and 2006) noted the contradiction and tension between the legislation and practice.

The Conservatives/Liberal Democrats government has largely intensified the marketisation approach as the basis of their broader modernisation programme in social care with its increasing focus on personalisation services. The Big Society project and Personalisation of services are very potent but, highly contested and ambiguous idea that could be as influential as a privatisation was in the 1980s and 1990s in reshaping public provision.

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