Micro-enterprise: care and support on a scale that’s “just right”?

This is a guest blog from researcher Catherine Needham of the University of Birmingham, who is launching the first research to look at whether size of provider organisation makes a difference to outcomes and cost-effectiveness. The summary is very readable and should be of interest to all care commissioners. Dr Needham writes:

It has long been evident that large-scale care provision on a time-and-task model has not been delivering care and support which is personalised and leads to valued outcomes. This week, a team from the University of Birmingham, of which I was a part, launched findings which solidify the evidence base about the benefits of micro-enterprise over larger providers.

Twenty-seven care organisations in England were included in the study, covering a range of sizes and functions, including day activities and support in the home. Interviews were done by academic researchers working alongside people with experience of local care services on a co-research model. Among the 143 people interviewed were owners, managers, members of staff, carers, and those receiving care services, including older and disabled people.

Findings show that micro-enterprises offer more personalised support than larger care services, and contribute to better outcomes (measured using ASCOT, the Adult Social Care Outcomes Toolkit). These benefits stem from micro-enterprises having greater continuity of staff, greater staff autonomy and greater accessibility of managers compared to larger organisations. The research also found that micro-enterprises offer good value for money: their hourly rates were on average lower than the larger comparator organisations, helped by low overheads.

The micro-enterprises in our sample talked about what had helped them to get started, and what barriers they faced in staying in business. Many had benefitted from local micro coordinators, part-funded by Community Catalysts, which helped them understand care sector regulation and funding.

To keep going the micro-enterprises had to market their services to potential users as they didn’t have a formal contract with the local authority in the way a large care companies did. Most people supported by micro-providers had a direct payment or were self-funding, and had found out about the provider through word-of-mouth or local advertising. The relatively low take-up of direct payments by older people highlights the need to provide alternative routes into micro-enterprise. Social workers, GPs and other care professionals need to be informed about micro-enterprises operating close-by so that they can match up people with support in their local communities.

Like most academic studies, the research answered many questions but generated others. In particular I was struck by how many people we spoke to in the research were concerned about the risks of letting micro-enterprises go into people’s homes, given that the micro-providers may not be regulated (if they don’t deliver residential or personal care) and probably won’t be on a local authority’s preferred provider list. This quote from a person who herself runs a micro-enterprise sums up this anxiety:

Micro services worry me, because they don’t have the accountability of council services, people who will challenge you. With more independent budgets coming in I’m worried that people will be vulnerable. Some of the people I’ve worked with have had problems with that in the past, although mainly with larger agencies. If [abusive] people like that worked for us they wouldn’t last long.

What’s intriguing about this quote is that the example of poor provision is from larger agencies, and the interviewee was very vehement that she (as a micro-enterprise) would never employ someone who was taking advantage of vulnerable people. In our study, the staff working for micro-enterprises were more thoroughly vetted, better supervised and stayed in post longer than they did in the larger organisations.

Let’s not try to make micro-enterprises adhere to inspection and regulation regimes that have been designed for large-scale provision and do not have a good track record of assuring care quality. Instead, let’s make sure people using services and their families have the power to choose and exit poor quality services, and develop local quality badges that don’t leave micro-enterprises suffocated by red-tape.

Dr Catherine Needham is a Reader in Public Management and Public Policy at the Health Services Management Centre, University of Birmingham. She tweets as @DrCNeedham . The full report and a video summary of the findings are available from http://www.birmingham.ac.uk/research/activity/micro-enterprises