The Contributions of Health Care Management to Grand Health Care Challenges

Jennifer L. Hefner, Ingrid M. Nembhard, Jennifer L. Hefner, Ingrid M. Nembhard

• Publisher: Emerald Publishing Limited
• Year: 2021
• Print ISBN: 9781801178013
• eBook ISBN: 9781801178020
• Topic: Business
• Subtopic: Management
• Index: Business

The 20th volume of Advances in Health Care Management showcases how health care management research helps to further understand grand challenges in health care: what they are, why they exist, the consequences that they have, and what can be done to address them. Grand challenges are large, unresolved problems. "Grand health care challenges" include current events such as the COVID-19 pandemic, and ongoing challenges related to the quadruple aim of health care: improving the health of populations, reducing the cost of healthcare, improving patient care experiences, and improving the experience of working in health care. The book demonstrates that these challenges are amenable to organizational and managerial solutions, and therefore health care management research has many important lessons to contribute.

For this volume, The Contributions of Health Care Management to Grand Health Care Challenges, we define health care management as the planning, direction, and coordination of health services and the management of health care professionals. Included chapters consider five grand challenges facing the health care sector: (1) caring for vulnerable populations; (2) maintaining the health care workforce; (3) translating innovation into practice; (4) sustaining organizations; and (5) navigating pandemics. Each challenge is discussed in its own section and addressed by two chapters that offer different perspectives and approaches to the challenge. Across chapters a variety of methodologies are used including ethnographic case studies, survey data analysis, interviews, literature review, and informed commentary. Together, the chapters in this volume synthesize current information in the field, direct future research efforts, and generate actionable insights for managers and policymakers.

SECTION 1

THE CHALLENGE OF CARING FOR VULNERABLE POPULATIONS

Emergent Homecare Models Are Shaping Care in England: An Ethnographic Study of Four Distinct Homecare Models

Karla Zimpel-Leal

Abstract

This chapter addresses the grand challenge of an aging society and the subsequent growing demand for in-home care for the elderly – often referred to as homecare. It examines how emergent homecare models in England differ from the “time and task” model and how they are shaping the care market. These models offer new approaches regarding what, how, and when care is delivered at home. Homecare providers face rising demand driven not only by population aging but also by market demand for personalized care, choice, continuity of care, and real-time availability. The landscape presents an opportunity for innovative models to become established, by offering a more inducing service design and value propositions that respond to customers' needs. Using the “business model canvas” to guide data collection, this study presents an ethnographic case analysis of four homecare organizations with distinct emergent homecare models. The study includes 14 months of field observation and 33 in-depth interviews. It finds that providers are becoming increasingly aware of evolving customer needs, establishing models such as the “uberization,” “community-based,” “live-in,” and “preventative” described in the chapter. These models are becoming more pervasive and are mostly market-driven; however, some of their innovations are market shaping. The major innovations are in their value propositions, partnership arrangements, and customer segments. Their value propositions focus on well-being outcomes, including choice and personalization for care users; their workforces are perceived to be a major stakeholder segment, and their networks of partners offer access to complementary services, investments, and specialist knowledge.

Keywords: Emergent homecare models; homecare; care market; market shaping; business model canvas; value proposition

Introduction

Nine out of ten older adults prefer to live independently at home as opposed to residential care (UKHCA, 2019). Our aging population is creating new demands for technologies, products, and services, including new homecare models. Homecare, sometimes termed domiciliary care, is a growing and vital employment and business sector in England that supports and assists individuals with health and care needs to manage activities of daily living that they cannot manage unaided. Growing demand for homecare is occurring in tandem with government policies to minimize social care costs and maximize the utilization of the care workforce (Charlesworth et al., 2018). The last decade has seen the birth of numerous organizations offering new (“emergent”) models (for-profit and not-for-profit). These models offer diverse approaches to care provided at home ranging from unique different organizing style (i.e. community-based model) to the introduction of technologies to support care delivery (i.e. preventative model).

The UK Industrial Strategy is a long-term government plan to boost productivity and earnings in the United Kingdom by addressing a series of grand challenges (HM, 2017). It offers a recent example of a policy aiming to tackle the challenges of an aging society. Focusing especially on the needs commonly experienced by older people for support with mobility, care, and housing, the strategy argues the need to ensure innovative models and new technologies, services, and products are in place to address an aging society grand challenge. Furthermore, it claims that innovation in age-related products and services not only can make a significant difference to UK productivity and the well-being of individuals but can also find a growing global market.

A new generation of innovative organizations, particularly in homecare and other aspects of social care, thus has the potential to thrive in an expanding market. The Care Act 2014 is a legislation that outlines local authorities' duties in relation to assessing people's needs and their eligibility for publicly funded care and support. The Act focuses on personalization, well-being, and prevention, and it can be seen as a driver for actors in the care market to revaluate social care and the provision of care in general. Despite recent attention to care models that attempt to address the well-being of an aging population and the care workforce, the focus of care providers has been described by analysts as based predominantly on a “time and task” model (Bottery, 2018), which prioritizes standardized procedures and amount of time spent on care over meeting the needs of individual people (Nice, 2015).

The impact of emergent homecare models is relatively unexplored in the academic literature. A few exceptions include Low, Yap, and Brodaty (2011) which evaluated the outcomes of case-managed, consumer-directed homecare, and Sawyer (2005) that looked at commissioning and providing homecare on the basis of outcomes. In particular, very few analyses adopt a business model view or examine how different components of organizations interrelate. This chapter considers these issues to contribute to the grand challenge of an aging society. The main research question is: how have emergent homecare models shaped the care market in England in the last decade? The chapter's other objectives are to: (1) identify examples of emergent homecare models in England and (2) assess how these differ from the “time and task” homecare model.

To understand these emergent homecare models, inspiration is drawn from scholars who have combined a business model perspective (Amit & Zott, 2010; Chesbrough, 2010; Osterwalder & Pigneur, 2010) with insights from market shaping concepts (Jaworski, Kohli, & Sahay, 2000) as a way of generating theory (Nenonen, Storbacka, & Windahl, 2019). This approach enables us to understand if emergent homecare providers can act as market shapers, how they generate value creation from their business models within a market, and how this impacts a larger system of relevant stakeholders within adult social care (ASC).

The chapter is organized as follows. First, a market overview of the homecare market in England is presented, describing market shaping and an overview of the time and task model. The next section describes the study methods, including principles of selection and the analytical framework adopted. The findings are then presented, with four types of emergent homecare models discussed, each using a case study example. The discussion and conclusions then consider how these new homecare business models differ from the time and task, how they have emerged, and their implications for the wider care market.

Homecare Market

Homecare is a subsector of the wider ASC sector in the United Kingdom, which involves the provision of services for personal care and practical assistance for people over 18 years old who need extra support. In England, the delivery of ASC services is the responsibility of local authorities (Gray & Birrell, 2013). Homecare refers to a range of care and support interventions delivered to people in their own home: domestic tasks, shopping, housework, personal care, social activities, rehabilitation, recovery, and support for people who are at the end of life. It can be preventative, providing companionship, engagement, or early intervention to avoid a deterioration in health and well-being and/or to prevent admission to residential care or rehabilitative, for example, following illness or injury (Bennett, Honeyman, & Bottery, 2008). Care and support are provided to people who need homecare in two main ways: through services provided in the care market (which comprises private, public, and voluntary sectors) and through support offered by family members and friends (mostly unpaid). In 2017/2018, the market research agency Mintel estimated that the market value of homecare in the United Kingdom had reached a 5-year high, at £85 billion. It claimed that informal care was continuing to account for the majority (78%) of its total market value in 2017/2018 and was “worth” £66.4 billion, much more than the care purchased by local authorities (£13.14 billion), offered by the independent sector (£2.3 billion) or the National Health Service (NHS), which is the government-funded medical and health-care services provided to everyone living in the United Kingdom (£3.15 billion) (Cone, 2018; HM, 2017).

The homecare market in England is highly fragmented on the supply side. The independent sector (commercial and not-for-profit employers supplying 78% of the workforce in 2018) delivers both state-funded and privately purchased care, with some care providers specializing in one funding model, and others a mix of both (Skills for Care, 2019). The privately purchased homecare sector is expected to grow in real terms (as the population ages) and as the share of all homecare services delivered. This is due to tighter financial means testing of persons assessed as needing support by local authorities, and a greater awareness of the role of homecare as the preferred alternative to residential care (UKHCA, 2019). Most business activity in the independent sector is derived from local authorities, although the ability to win local authority business at a time when many social services departments are reducing the number of suppliers remains a critical barrier to market entry. Independent providers serving the state-funded market have experienced reductions in the prices local authorities will pay with impacts on profitability, with some struggling to survive in a high-cost, low-profit climate (Cone, 2018).

There is a major trend for larger providers to move their business to the privately funded market, which is seen as more buoyant with higher fees than state-funded care (LaingBuisson, 2020). In 2019, ASC in England (all types) comprised around 18,500 organizations and a workforce of some 1.49 million people (Skills for Care, 2019). Of these organizations, 9,100 were regulated providers of domiciliary care registered with the Care Quality Commission (CQC), the regulator for health and social care in England since April 2009. Possibly, many more – around one-third – are not registered (Holmes, 2016). Registered services must meet a common set of requirements that focus on safety and quality, with regulation intended to be proportionate and based on risk. Health and social care providers are audited under a set of compliance criteria. Homecare providers must vet homecare workers before engaging them by taking up references and carrying out Disclosure and Barring Service (DBS) checks on potential employees.

On the demand and purchasing side, homecare is either commissioned and paid for by local authorities, often (since the 2000s) via personal budgets (Yeandle & Stiell, 2007) or direct payments (introduced in 1997 for nonelderly disabled people and for older people from 2000) allocated to individuals following a care assessment, or privately purchased by individuals who pay for and arrange their own care, called self-funders (Bolton & Townson, 2018). More recently, care policy in England, under The Care Act (2014), aims to improve personalization and puts local authorities on duty to fulfill social care outcomes. Thus, shifting discourses of accountability from the state to the individual can be observed by the introduction of direct payments. Direct payments are a funding choice in personal budgets that involve cash payments given to service users and are intended to give users greater choice in their care (AgeUK, 2018). State-funded care is arranged and provided in a care package based on an individual assessment by local authorities that commission it largely from their preferred providers (Glasby & Littlechild, 2016). People receiving direct payments will choose providers who they feel will best meet their individual needs, which makes them similar to self-funders. Homecare for older people in England is commissioned through local authorities working predominantly with independent providers of care. Commissioners operate in a market model, planning and procuring homecare services for local populations (Davies et al., 2020). Commissioning practice typically involves assessing local needs, overseeing procurement of services and developing service specifications as part of a competitive contracting process.

There are 351,680 people receiving local authority purchased domiciliary care services in England, 156,155 receiving direct payments, and a further estimated 70,000 self-funded service users (UKHCA, 2019). The state-funded market is considered a quasimarket where budget-restricted public purchasers represent a diverse public and purchase services on their behalf from both nonprofit and profit-seeking providers (Bode, Gardin, & Nyssens, 2011). This differs from a fully competitive market in its lack of effective competition among providers, high transaction costs, and weak incentives to act as representatives of users' needs.

The self-funded market is more likely to act as a traditional competitive marketplace, where consumers choose services that best meet their needs and expectations of quality, service, and price. Here, the relationship between service users and care providers can take the form of longer care visits, consistency of care workers and the ability to build relationships over time, highly trai...

Table of contents

• Cover
• Advances in Health Care Management
• Title
• Copyright
• Contents
• Contributors Biographies
• List of Reviewers
• Preface
• SECTION 1: THE CHALLENGE OF CARING FOR VULNERABLE POPULATIONS
• SECTION 2: THE CHALLENGE OF MAINTAINING THE WORKFORCE – RETENTION AND EQUITY
• SECTION 3: THE CHALLENGES OF TRANSLATING INNOVATION INTO PRACTICE
• SECTION 4: THE CHALLENGE OF ORGANIZATIONAL SUSTAINABILITY
• SECTION 5: THE CHALLENGE OF PANDEMICS FOR PATIENTS, WORKERS, AND PRACTICES – LESSONS FROM COVID-19
• Index