Market shaping and the supply of home care for older adults in England: a qualitative study

Abstract

Local authorities (LAs) in England have a duty to ensure that there is a wide variety of good quality home care services available for older adults who need them. However, workforce shortages, which are especially acute in rural areas, make this challenging. LAs are expected to participate in ‘market shaping’, collaborating closely with relevant partners to encourage and facilitate the whole home care market in their area. The aim of this thesis was to explore how LAs were approaching their market shaping duties and to examine differences between them and between rural and urban settings. Analysing 117 interviews, I identified three themes: care as a problem (as opposed to an enabler); care as quantity (with ‘problems’ and therefore, ‘solutions’ conceptualised in terms of quantity); and market shaping as maintaining dysfunction (with care rushed and unfulfilling and staff pressurised and leaving, creating more pressure for those remaining). There were exceptions to this where care provision departed from the industry standard model of care agencies contracting with LAs to deliver ‘time and task’ care. In some predominantly rural settings, LA staff had supported implementation of alternative models. The rural context initially helped reduced resistance from care agencies, many of whom could not deliver services in these settings. Applying Bourdieu’s concepts of field, capital and habitus I suggest that the structures of the home care field encourage care agencies and LA commissioners to engage in reproduction of field rules and regularities. However, some LAs implemented changes which departed from these rules. LA staff actions were key to disrupting expectations and practices associated with a gendered class- based habitus, which might have otherwise constrained carers’ access to sources of capital. This enabled paid carers to accumulate economic, social, cultural and symbolic capital in a way which facilitated personalised and fulfilling care delivery.