Worlds Apart?
Public, Private and Non-Profit Sector
Providers of Domiciliary Care for Older
Persons in Ireland
FORTHCOMING in Journal of Aging Studies, 21(3), 2007
Dr. Virpi Timonen, Social Policy and Ageing Research Centre, School
of Social Work and Social Policy, Trinity College Dublin, Ireland.
Martha Doyle, Social Policy and Ageing Research Centre, School of
Social Work and Social Policy, Trinity College Dublin, Ireland
Shortened running title: Worlds Apart?
Corresponding Author: Dr. Virpi Timonen, School of Social Work
and Social Policy, Trinity College Dublin, Dublin 2, Ireland
Tel. direct line: + 353 1 896 2950, Fax: + 353 1 671 2262,
E-mail: timonenv@tcd.ie
First submitted: 16 June 2006
Revised version submitted: 5 September 2006
Current word count: 7,410 incl. all referencing
Abstract
Domiciliary care of older persons is changing rapidly in Ireland. The
most significant recent changes are the emergence of private
home-care companies, the introduction of a new policy instrument
(cash-for-care) and the professionalisation of the non-profit
(formerly voluntary) sector providers. This research project set out
to explore the central differences and commonalities between care
work in the public, private and non-profit sectors. Sixty-three care
workers across the three sectors participated in semi-structured
interviews and focus groups. The content of these was analysed
under six different themes. Separate interviews were conducted
with middle-managers involved in the recruitment, training and
supervision of care workers. Several salient differences between the
three sectors were discovered, most importantly with regard to
social protection, composition of the care workforce, and flexibility
in work tasks; all of these in turn have implications for the quality
of employment and quality of care.
Key words:
Community care, elder care employment, migrant/non-national
workers, home care workforce, long-term care services.
2
Introduction
Although much anecdotal evidence is presented in the Irish media
on the lessening capacity of family members and friends to provide
support to ageing relatives, such informal care continues to play a
pivotal role in Ireland. Centrality of informal care notwithstanding,
the demand for formal care services in Ireland is increasing as a
result of population ageing, increased affluence, lack of availability
of extensive informal care to some older persons, and policy
changes1. This article does not investigate the demand for
community care services or the informal provision of services.
Rather, the focus lies on the supply side of formal domiciliary care
for older persons. Extensive interviews and focus groups were used
to gain an insight into the nature of care work carried out by public,
non-profit and private sector care workers, their terms and
conditions of employment, the reasons for entering the home care
The Medical Card was granted to all residents aged 70 and over in 2001. While
the Medical Card does not entitle holders to receive all types of home care
services free of charge, it has changed attitudes towards receiving services and
many older persons are also under the impression that home care is one of the
new entitlements. This, together with the strong preference among older persons
for living in their own homes (Garavan, Winder and McGee 2001) and the
availability of home care packages in some areas (Timonen 2004), has
contributed to increased demand for home care services.
1
3
sector, factors that contribute to or diminish their job satisfaction,
their relationships with the care recipients and their suggestions for
improvements.
Three important and inter-linked changes have taken place on the
supply side of domiciliary care in Ireland over the last decade:
(1) Restructuring of the Non-Profit Home Care Sector
The non-profit sector has a long history of care service provision in
Ireland. Originally, these care services and providers were purely
voluntary (i.e. unsalaried), in many cases established and run by
the religious orders, receiving token funding on a discretionary
basis from the State (see Lundström and McKeown 1994;
Donoghue, Anheiser and Salamon 1999). The State has provided
financial assistance to the non-profit sector since 1953. While this
(at times sporadic) funding stream has in most instances not been
sufficient to cover all costs, the majority of the non-profit providers
are heavily reliant on this money for their continued survival. Since
2000, major changes have taken place in the terms and conditions
of both managers and workers in this sector, and as a result all
4
carers in this sector are now paid a wage and some have gained the
right to limited occupational social entitlements. The role of
religious orders is now minimal in the running of these
organizations: while some boards of non-profit home care
organizations have religious representatives, they are usually in a
small minority.
(2) Emergence of the Private and Public Home Care Sectors
In contrast to the long history of non-profit sector provision of
domiciliary services to older persons, both public and private sector
provision/employment in this area is a very recent development.
The introduction of public sector care workers (health care
assistants) delivering personal care to community-dwelling older
persons in the early 1990’s was intended to ease the workload of
public health nurses. The private home care sector is also a new
phenomenon: the first private home care organisation was
established in the late 1980s, and approximately a dozen private
companies have entered the market in the last decade.
(3) Introduction of Cash-for-Care
5
In common with a large number of countries, Ireland has recently
adopted a cash-for-care policy titled Home Care Packages
(Timonen, Convery and Cahill 2006). This is government funding
that is used to purchase domiciliary care services from non-profit
and private sector providers. Home care packages were envisaged
to complement, not replace, the provision of services via the nonprofit sector. However, the rate at which they have been introduced
and expanded suggests that in some areas they may be replacing
rather than complementing the work of the non-profit sector.
Private providers are particularly attractive to home care package
coordinators because unlike most of the non-profit organizations
they offer 24-hour care seven days a week and provide care
workers who work in a dual capacity (i.e. offer both personal and
domestic care).
(4) Other features of the institutional and economic
landscape
Shortage of the low-cost (to care recipients) public long-term care
beds, pressure on acute hospitals and the high costs and variable
quality of institutional care have also led to increased policy focus
6
on domiciliary care, which is (only partly correctly) perceived as a
relatively inexpensive form of care. Ireland has also witnessed a
steady increase in female employment participation rates over the
last thirty years; O’ Connell (1998) estimates that between 1981
and 1998 the number of women in the Irish labour market
increased by more than two-thirds, similarly the Central Statistics
Office estimates that female labour market participation rates
increased from 35.7 per cent in 1994 to 49.4 per cent in 2004 (CSO
2005). The changing position of women within Irish society and the
consequent reduced capacity of some women to provide informal
care is contributing to an increased reliance on formal care services
(Timonen and McMenamin 2002).
Diagram 1 illustrates the structure of the supply side of domiciliary
care in Ireland at present.
[Insert Diagram 1 here]
Several questions arise from these three supply-side developments.
Most crucially: does the distribution of care work and workers
7
across the three sectors matter from the point of view of care
recipients, care policy and care workers themselves? What
implications does this new care mix have for the State’s role in the
delivery and monitoring of domiciliary care? Does the expansion of
the care workforce have an impact on the recruitment, calibre and
training of its workers? Are these three sectors diverging (i.e.
specialising in types of care work where they have a comparative
advantage), or is there convergence (i.e. a significant overlap in the
services they provide), for example do the public-sector care
workers fit into the ‘medical model’ of care, and private and nonprofit sector carers into the ‘social model’ of care?
Key Research Questions and Hypotheses
This study represents the first attempt, in the Irish context, to gain
an understanding of the differences and similarities in public,
private and non-profit sector domiciliary care work with older
persons. The research set out to gather evidence to support or
undermine the assumption that private, public and non-profit sector
care work(ers) are radically different in a number of ways. Prior to
8
the interviews, it was hypothesised that significant differences
between public, private and non-profit sector care work(ers) would
emerge along the following dimensions:
1. The work tasks performed by private sector workers were
assumed to be more diverse and more loosely defined. It was
also assumed that greater flexibility in work tasks and
working patterns is expected from private sector workers
than from either the public or non-profit sector workers.
2. The terms and conditions of private sector care workers
were assumed to be less favourable and less desirable than
those of their counterparts in the non-profit and public
sectors. We expected this to manifest itself in lower levels of
remuneration, weaker social rights (pension, sick pay etc.),
and also in the graver concerns with the quality of their
employment voiced by private sector care workers.
3. The recruitment pathways and the geographical spread
of care workers and clients were assumed to be different.
9
As most non-profit home help organisations have their roots
in local parishes and started out as “good neighbour”
organisations, it was assumed that the geographical area
from which these employers draw their care workers and
clients is small and local. As private sector companies were
assumed to be more profit and market-oriented expecting
greater flexibility from their workers, it was hypothesised that
they draw on a large geographical area, both for their clients
and for workers.
4. The composition and management of the care
workforce was assumed to be somewhat different. The
private sector is hypothesised to draw on a more diverse pool
of care workers, and, due to the lack of a regulatory regime,
the private and non-profit sectors were assumed to have
looser standards regarding staff qualifications and monitoring
than the public sector.
5. The motivations for entering the field of domiciliary care
were assumed to differ somewhat between private and public
10
sector workers. Whereas the degree of flexibility coupled with
the part-time nature of the work were assumed to have been
major attractions for all workers, the wish to become engaged
in work that would benefit their local community was
assumed to feature more prominently in the interviews with
non-profit sector workers.
6. The perceived quality of the carer-client relationship was
also assumed to vary somewhat between the private sector
on the one hand and public and non-profit sectors on the
other hand, largely due to the factors outlined above (i.e. the
lower perceived quality of employment, geographical distance
and the lesser significance placed on community involvement
in determining the choice of employment among private
sector workers).
Design and Methods
Given that the research methods used in this project were
qualitative and that non-probability sampling methods were used to
11
select a small proportion of the total care workforce in Dublin, it
was clearly not possible to test these hypotheses in the sense of
deriving findings that would be completely representative of the
public, non-profit and private care sectors. However, it was possible
to establish certain basic facts for the public and non-profit care
workforce as a whole, since uniform terms and conditions apply to
the former and are fairly uniform in the latter. Quantitative
methods were rejected as they do not yield themselves to exploring
complex areas such as the work motivation and accounts of carerclient relationships, and also because no baseline data or databases
exist for care workers that could be used for the purposes of
questionnaire design and sampling. It is worth stressing that our
work represents the first attempt, in the Irish context, to outline
the similarities, differences, and interactions between the three
“worlds” of formal domiciliary care for older persons, and as such
started from a very low knowledge base. While the findings are not
generalisable in their entirety, they act as a reliable guide to
understanding some of the salient differences and similarities
between private, non-profit and public sector care work, and enable
12
us to move to the next level in theorising and gathering data on
domiciliary care.
Semi-structured interviews and focus groups were conducted
between September 2005 and February 2006 with two main groups
of informants, namely the care workers and their managers. Health
services administrators (public sector), directors and managers of
private and non-profit agencies were interviewed to gain a picture
of the operating principles and characteristics of the three sectors
from the point of view of middle managers, and to act as conduits
to the care workers. The aim was to recruit 20 care workers from
the public, private and non-profit sectors, yielding a total of 63 care
worker interviews. The number of individuals consulted in the
course of the interviews and focus groups is as follows:
Interviews with Care workers
Public sector (Health Care Assistants)
20
Private sector (Private sector Care Workers)
23
Non-profit sector (Home Helps)
20
13
Interviews with managers of care workers
Public sector
(Directors: public health nursing, services for older people)
212
Private Sector (Directors of private agencies/companies)
11
Non-profit Sector (Home Help Organisers)
21
In common with all research, this study has certain limitations. In
the absence of registers of care workers, convenience sampling was
used to recruit care workers. Across the three sectors managers
acted as gatekeepers, informing carers of the tenets of the research
and subsequently imparting the names of interested persons:
selection bias is obviously inherent in this approach. Interviews with
the informants also hinted at the existence of a large informal grey
labour market of care (i.e. paid workers (largely non-Irish) who
have no affiliation to public, non-profit or private organisations but
There are eight local health organisation (LHO) areas in Dublin. The interviews
at the public sector level covered all of the LHO areas. For the non-profit
organisation level interviews, seven LHO areas were represented. For the private
sector agencies, all available and consenting directors (and one assistant
director) were interviewed, representing at least three quarters of all such
operators in the capital.
2
14
are operating as independent entities outside the tax net). For
now, it was not possible to investigate this possibly very significant
and growing grey labour market. Moreover, carer-client
relationships from the perspective of the client were not explored:
this would constitute a separate study which was not feasible within
this project’s time frame. The discussion contained in this article is
mindful of these limitations.
Results
Work tasks
The work tasks performed by private sector workers were assumed
to be more diverse and more loosely defined than those of public or
non-profit workers, and this diversity was assumed to translate into
greater flexibility in work tasks and working patterns. Table 1 below
shows that the typical duties, work times and number of clients do
indeed vary between the three sectors. The general pattern is
towards greater variability and flexibility in the private sector, in
contrast to the considerably more closely delineated tasks and
working times confined to the “office hours” in the public sector,
and to a lesser extent in the non-profit sector.
15
[Insert Table 1 here]
The three sectors are distinct in their niches and comparative
advantages: while the non-profit sector specialises in providing
domestic help during the day-time (although in practice this often
veers in the direction of personal care as client develops personal
care needs) and the public sector focuses on personal care (also
during day-time, in short bursts of typically 30-60 minutes per
client per day), the private sector is carving a niche in more
flexible, night-time, round-the-clock but also companionship-type
services. Live-in care work (at present offered only by the private
sector) can be seen as having both attractive and unattractive
features from the perspective of the care workers. The choice
(where it is a genuine choice) to work as a live-in carer can be
construed as a manifestation of the greater flexibility available in
the private sector. Home carers in the public and non-profit sector
also have considerable opportunity to choose their own hours, but
the option of engaging in live-in care, night-time care work or
otherwise irregular hours is not available to them. Overall, public
16
sector home carers have the largest number of clients, which can
lead to a certain amount of work pressure and unrealistic
expectations on the part of managers and trainers:
‘[they] are idealistic in their expectations of how much time we can
spend with clients’.
More flexibility is required from private sector care workers than
from their public/non-profit sector counterparts in terms of the
range and combination of care duties. Whereas the public sector
workers carry out personal care duties exclusively3 and most nonprofit sector workers are focused on domestic work (cleaning,
shopping etc.), carers in the private sector are usually expected to
combine personal and domestic care.
An attractive feature of private sector care work is the insistence on
the part of some agencies that care be delivered in minimum blocks
of two to three hours. Working in longer blocks is less stressful and
Home care assistants are structurally and historically linked to nursing, which
appears to enhance their self-perception and many of them are keen to portray
themselves as para-medical and contrast this to the role of home helps.
3
17
gives an opportunity to engage socially with the client (naturally,
this comes at a cost and, outside the fully state-funded home care
packages, would seem to be available only to wealthy clients).
Many workers in the non-profit and public sectors viewed this
practice of spending more than one hour with a single client as a
luxury. Some non-profit sector workers expressed the wish for
more paid companionship time, stating that home helps offer the
companionship (unpaid) in many cases anyway and this should be
formally acknowledged.
While most workers within the private sector can exercise choice
regarding the package of work they put together this is arguably
the case for more skilled and experienced workers. The flexibility
expected of a private home care worker may also be influenced by
one’s nationality. A number of non-Irish workers interviewed
indicated that they cannot be too selective about the clients they
take on. In some instances this may mean travelling a considerable
distance for a two-hour care block. Two non-Irish workers believed
that they have frequently been asked to do more than the standard
18
duties of a carer and engage in an excessive amount of domestic
work.
Terms and conditions of employment
Table 2 summarises the key terms and conditions of care workers
in the public, private and non-profit sectors. This summary
indicates that our assumption regarding lower levels of
remuneration and weaker social rights in the private sector is
correct. However, there is divergence within the private sector
between providers who operate as an “agency” (treating their
workers as self-employed) and those who function as a company,
employing the care workers directly (the former are currently in the
clear majority). The terms and conditions of carers operating in the
company mode are preferable and their contracts are more secure.
While their employment contract is also usually part-time, they do
pay tax and social security contributions via the employer, are
insured by their organisation and are entitled to holiday pay.
Among the 19 agency care workers interviewed, only three were
registered as self-employed.
19
[Insert Table 2 here]
The typical hourly rate for a private home care worker is close to
the minimum wage. However, rates of pay are variable, and some
private sector providers grade the rates according to the nature of
the work, so that more demanding care tasks and work during antisocial hours carry a higher pay. Aside from the sacrifice of personal
freedom, live-in work pays relatively well: interviewees cited pretax incomes of between €650 and €1,200 per week.4 Some of the
agency directors acknowledged that the care workers complain
about the low rate of pay, but also argued for the importance of
keeping the service affordable to clients, even if it is at the cost of
lower wages to the workers.
Many non-profit sector home care workers expressed satisfaction
with the recent improvement in their wages. While practices
regarding social rights vary considerably between the non-profit
organizations, most do not offer holiday or sick pay, and have not
In contrast, low-wage care (or other semi-skilled or unskilled) sector
employment during regular working hours and within the 40-hours per week
bracket yields only around €300-400 per week.
4
20
implemented the recommendations regarding pension provisions.
Some non-profit sector carers stated that they had been offered
voluntary occupational (employee-financed) pensions, but these
were not perceived to be attractive, particularly for the older
workers who would not have sufficient time to accumulate a
pension in this way.
Both in the private and non-profit sectors, care work is
characterised by precariousness. Death of a client or a change in
the care arrangement of a client (such as a move into institutional
care) can have significant impact on the security of home carers’
work. In such eventualities a home carer’s hours can be
substantially reduced or in extreme cases there may be a short
period of unemployment as they wait to be assigned a new client.
One private sector company had taken a step towards remedying
this problem by making some of its employees salaried. However,
such a move is generally only possible in large organizations, where
consistent demand for service affords more security.
21
Recruitment pathways and the geographical spread of
workers and clients
As we hypothesised, the labour market for private sector providers
is less localised than for the public and non-profit sector. Whereas
the non-profit sector organisations recruit workers almost
exclusively from their immediate surrounding areas, the private
agencies tend to draw on a larger and more disparate geographical
area both for their workers and for their clients (see Table 3 below).
Paradoxically, the private sector also eschews any travel
allowances, which are available in the other two sectors. Many nonprofit sector managers saw their organisation’s local character as a
distinct advantage:
“beauty of the home help service is that it has evolved to suit each
area”.
[Insert Table 3 here]
Composition and management of the care workforce
22
According to our third hypothesis, the composition of the care
workforce is more diverse in the private than in the public and nonprofit sectors. This was found to be the case. The reasons for this
lie in the localized nature of the public and non-profit sector
operations, and in the nature of work tasks expected. Furthermore,
the lack of regulation of the private and non-profit domiciliary care
sectors also facilitates more flexibility with regard to qualifications,
training and monitoring, which many of the managers make use of.
As Table 4 below illustrates, while the proportion of females in the
workforce is very similar across the three sectors (generally 95-100
per cent), the proportion of non-Irish workers varies greatly. The
presence of non-Irish workers is at the moment slight in the public
sector, incipient in the non-profit sector and considerably higher in
the private sector. Some agencies employ almost exclusively nonIrish workers. Agencies that employ large numbers of non-Irish
tend to draw on workers from a fairly small number of countries:
the countries most frequently mentioned were Poland, South Africa,
Nigeria and the Philippines. Currently this cohort of non-Irish
23
workers is for the most part skilled, predominantly female, with
previous experience in the care sector. There was some evidence,
however, that an increasing number of unskilled migrant workers
seeking employment in the care-field are completing short two-five
day training courses as a means of entering the care sector. If
demand for care workers increases in the future, it seems likely
that an increasing number of these low-skilled non-Irish workers
will enter the care sector. The impact that this may have on the
quality of care services warrants attention.
The age range was fairly similar between the sectors, although the
largest proportion of older workers is found in the non-profit sector,
for the simple reason that this is the longest-established sector and
also the least focused on personal care, and hence is physically less
demanding than care work in the private or public sectors. Other
groups that featured across the three sectors are lone parents for
whom flexible part-time work is preferable. Many of the care
workers both in the private and non-profit sectors have
characteristics that lead to marginalisation in society and relegation
to entry-level jobs.
24
Practices regarding qualifications, training requirements, reference
and security checks vary widely in the non-profit and private
sectors. While all the private agency care managers interviewed
insisted that carers are required to have certain minimum training
qualifications, the extent to which this is enforced was found to be
dubious in some instances. Background and reference checks are
not thorough in all cases. The non-profit organisations’ reliance on
local contacts and word-of-mouth were argued result in the hiring
of individuals suited to care work, but clearly such informal
arrangements are not the best possible protection against
unsuitable workers entering employment.
The private sector care managers displayed a distinct lack of
inclination to pay for the further training of their workforce. The
principle of internalising the costs of training is so ingrained among
the workers targeting private sector employment that many
undertake to complete and pay for (in some cases rather
expensive) training courses before they approach the private sector
companies. Several managers of private sector companies stated
25
that they require prospective workers to complete such a course
before their job application can be considered. This can be seen as
an attempt by the private sector manager to ensure a certain
degree of quality among their workforce and therefore in the care
work provided: however, in the absence of national accreditation
such training courses do not in any way act as guarantees of good
quality care. Indeed it is possible that some dubious training
companies have sprung up, incentivised by the private sector
requirement to present a “diploma” in elder care work.
[insert Table 4 here]
Motivations
Contrary to the hypothesis stated at the outset, there do not
appear to be major differences between the sectors in the
motivations for entering care work, as Table 5 shows. While
altruism may have played a considerably larger role in the nonprofit sector in the past when the workers in this sector were
genuine (unpaid) volunteers, the role of this motive in the balance
26
is arguably no different from the public and private sectors at
present (indeed, as the discussion above has shown, the hourly pay
for day-time work is at present highest in the non-profit sector).
The flexibility of the job was also an advantage particularly for
those with children or those pursuing other jobs or study. For some
private sector workers, the ability to earn a relatively high wage is
an important attraction. As explained above, live-in work in
particular attracts a wage that is far higher than that yielded by
similar work during regular daytime hours. It also appears very
likely that in many cases private sector care workers who are liable
to make arrangements for paying their taxes do not in fact do so:
understandably, the informants were reluctant to elaborate in detail
on this point. In such instances social security benefits can continue
to be claimed.
[Insert table 5 about here]
The non-profit sector managers interviewed acknowledged that the
pay is relatively good in comparison with the rates in the past, and
as a result does attract more workers: in most areas organisers
27
have a waiting list of people wanting to work. However, an
interviewee stated that the improvement in pay
“has done something to the service…you now need to be more
astute [about the people you hire]”.
The non-profit sector was characterised as “paid but still vocational”
by one home help manager; many workers in the non-profit sector
entered employment when pay was very modest, and for this
reason it is reasonable to assume that for this cohort of non-profit
sector workers, considerations other than money must have played
a significant role in their original decision to take up this role.
Quality of the carer-client relationship
Several non-profit sector care workers characterised care work as a
vocation, and described long-standing and close relationships with
clients. The fact that many of the non-profit sector workers have
been employed in the sector for as long as 20-30 years is likely to
have a positive impact on the client-carer relationships, particularly
28
as carers in this sector tend to operate within a small geographical
area. According to one non-profit sector manager “For many,
[working as a home help] is a family tradition” as two or even three
generations of the same family may have worked in home help.
Many non-profit sector workers recounted examples of going
beyond the call of duty (for instance inviting clients to stay in their
home over Christmas) and explained that ‘when you go home you
continue thinking about them [the clients]’. This type of closeness
is rarely evident in the private and public sectors, although it is
likely that the primary reasons for this are geographical distance
and shorter duration of the relationship, rather than lack of
affection.
[Insert Table 6 here]
A number of the non-profit sector workers outlined that
companionship is a very important part of their job since many of
their clients are isolated or depressed and greatly anticipate the
home help’s visit. They all said that they enjoyed their work, that it
was challenging at times, especially when dealing with death, but
29
that it was a rewarding job and the level of appreciation they get
from families makes it worthwhile: “you get back all you give”.
A number of the directors delivering domiciliary care in the private
sector emphasized that they invest considerable effort in the quality
of the carer-client relationship, (e.g. by devoting a lot of time to
matching clients with suitable carers). The director of one
organisation believed that part of what they are selling is
companionship, “particularly for ladies living alone”. In this agency,
the application form for carers is five pages long and contains
information on the carer’s hobbies, interests and the type of service
they would like to give. This information is then cross-checked on
the computer with potential clients to achieve a good match.
Another director stressed the importance of hiring care workers
who are “not nurses, not cleaners, but someone who is like a family
member”. However, such extensive attention to matching clients
and carers is somewhat exceptional: although all agencies and
organizations in the non-profit sector stressed the importance of
the right match, this was often arrived at on the basis of a
30
telephone call or left to the discretion of the carer who paid the first
visit to the client’s home.
The quality of the client-carer relationship from the perspective of
the private home care workers varied. Many of the care workers
interviewed applied the standards of informal (family) care to their
formal care work. Two private sector carers stated:
“you need to think that this could be my mum…you need to have
that attitude to be a carer”
“The majority of carers are not in the job for the money, cause in
fairness it’s not the best paid job in world, a lot are there cause
they really enjoy what they do”.
By and large the relationship described between client and the
private home care workers was close and companionate, with five
of these carers comparing their relationship to that with a parent or
grandparent. Various levels of professional distance were practised
by the carers, with some preferring to maintain strictly business-
31
like relationships, and others offering their home phone numbers
for use in emergencies. The need to draw boundaries was also
evident from the interviews with carers in the non-profit sector:
‘Sometimes a client will get cranky with the carer ….sometimes the
client will treat the carer as a cleaner, and that’s when you give the
client the name of cleaning firm’.
Relationships with the client’s family in some instances were
problematic, with families expecting the carer to take on additional
domestic tasks and “get value for money”. These difficulties
seemed to arise more often for the non-Irish private home carers,
one African carer interviewed stated that
‘the relatives make life so difficult for you, they make you feel like a
nobody, they make you feel like a housekeeper, which is very, very
bad… it can be very discouraging’ [our emphasis]
In conclusion, it is not possible to etch out fundamental variations
in the client-carer relationships between the three sectors, and the
32
slight differences that can be detected are related to the nature of
employment contract first entered to and the level of care needs in
the clientele: non-profit sector workers who entered the sector
originally as unpaid volunteers and carry out domestic work in the
homes of clients with relatively low levels of care needs have more
scope for forming closer, longer-term relationships. Almost all
carers across the three sectors intimated that they had positive
relationships with their clients and the desire to care for a person in
need was an essential motivating factor in their job; as one career
concluded, ‘a lot [of carers]…enjoy their work, are doing a really
good job and the people [clients] are happy with them’. We found
this sentiment to be common among the majority of carers across
the public, non-profit and private sectors.
Conclusions
This study investigated six possible differences between care
provision and care work in the public, non-profit and private sectors
in Dublin, Ireland. The study focused on (1) the work tasks
performed by the carers; (2) the terms and conditions of care
workers; (3) the recruitment pathways and geographical spread of
33
the care workforce; (4) composition of the care workforce; (5)
motivations for entering care work; and (6) the quality of the
client-carer relationship.
The study was able to identify a number of important and policyrelevant differences between public, non-profit and private sector
care work and workers. The three main differences relate to (A)
social protection, (B) composition of the care staff and (C) flexibility
in work tasks and mobility. Of these salient differences, (A) and (C)
are of particularly great policy relevance as (A) has a powerful
impact on the short and long-term social security of care workers
and consequently on the attractiveness of care work, and as (C)
relates to the content and timing of services for clients. The private
sector is currently the most flexible provider, but this comes at the
expense of lower hourly wages and social security among the
workers. While the terms and conditions of workers are better in
the non-profit, and especially the public sector, most of these
providers continue to operate during ‘office hours’ only, and are
more inclined to insert their workers into clearly-defined roles
where less flexibility is evident. However, across all three sectors,
34
the social protection offered to carers is precarious in comparison
with the protection afforded to public and civil servants, and
employment contracts across the sectors are typically part-time and
afford little security.
While we argue that the three provider sectors do differ in a
number of important ways, we also acknowledge that a certain
amount of intra-sector variation exists in the case of the non-profit
and private sectors, and especially the latter. Intra-sector variation
in the non-profit sector is largely a reflection of the way the
organisations have evolved in tandem with the changing State
funding streams. While some
organisations have embraced the cash-for-care model by restructuring and re-training a proportion of their care staff to work
as dual-capacity carers and deliver care at weekends and
evenings/nights, others have not, and continue to offer only
domestic care via a largely untrained workforce. Carers working in
these organisations may potentially be disadvantaged in the future
since it appears that public funding to organisations that offer a
more limited service may gradually be reduced.
35
Intra-sector variation within the for-profit sector was generally a
reflection of whether or not the company had established itself as
an agency – essentially matching carers with clients, or a company
– placing, directly employing and supervising carers. Carers
employed in the former generally tended to have more precarious
work contracts and lower (or no) social security benefits.
There is a paucity of research on the comparative performance of
the for-profit and non-profit home care sectors. However, recent
research in England by Netten, Sandhu and Francis (2006) found
that certain variables which tended to be more characteristic of
public domiciliary providers than private sector providers were
closely associated with higher service quality. They found that
older, more experienced workers, with secure employment
contracts and higher wages provided a better quality service.
Furthermore, providers that had low staff turnover and few
recruitment difficulties tended to be associated with delivery of
higher quality services. While we cannot assume that these results
are directly transferable to the Irish context, we can assert that
36
these variables are more characteristic of the Irish public and nonprofit sectors than the private sector.
The results of this study indicate that there are three “worlds” of
formal domiciliary care in operation in Ireland. Public policies have
served to foster the divergence of these worlds, and the planned
expansion of the cash-for-care programme is likely to lead to a
growth in the absolute and relative size of the private sector. In the
light of such growth, public policies and regulation are urgently
needed to safeguard the rights of the care workforce and to monitor
the quality of care delivered by formal domiciliary service providers
in Ireland.
References
CSO. 2005. Statistical Yearbook of Ireland. Dublin, Central
Statistics Office.
37
Donoghue, F., H.K. Anheiser, and L.M. Salamon. 1999. Uncovering
the Non-Profit Sector in Ireland, It’s Economic Value and
Significance. Johns Hopkins University/National College of Ireland.
Garavan Rebecca, Rachel Winder and Hannah M. McGee. 2001.
Health and Social Services for Older People (HeSSOP). Dublin:
National Council for Ageing and Older People, Report No. 64.
Lundström, Francesca and Kieran McKeown. 1994. Home Help
Services for Elderly People in Ireland. Dublin: National Council for
the Elderly.
Netten, A. Sandhu, J. and Francis, J. (2006) Home care workers
and quality of care. Paper Presented at the XVI ISA World Congress
of Sociology 24 June to 29th July, Durban, South Africa.
O'Connell, P.J (1999) Astonishing success: Economic growth and
the labour market in Ireland. Employment and Training Papers 44.
International Labor Organisation
38
Timonen, V. and I. McMenamin. 2002. “Future of Care Services in
Ireland: Old Answers to New Challenges?” Social Policy &
Administration 36(1): 20-35.
Timonen, Virpi. 2004. Evaluation of Homecare Grant Schemes in
the NAHB and ECAHB. Dublin: Eastern Regional Health Authority.
Timonen Virpi., Janet Convery and Suzanne Cahill. 2006. “Care
revolutions in the making? A comparison of cash-for-care
programmes in four European countries” Ageing and Society 26(3):
455-74.
Acknowledgements
We wish to acknowledge the contribution of David Prendergast in organizing and
conducting some of the interviews and focus groups, and also warmly thank all
those who agreed to be interviewed and supplied us with primary data including
administrative records.
39
Diagram 1
The Three Sectors, Primary Focus and Care Worker Titles
SECTOR
Public
Primary
FOCUS
Personal
Care
Personal Care
& Domestic Work
Domestic
Work
Health Care
Assistant
Private Agency
Care Worker
Home Help
CARE
WORKER
Private
40
Non-Profit
Table 1: Working hours, tasks and number of clients
Care sector and
worker
Typical hours of
work
Typical work
tasks
Typical number
and type of
client
PUBLIC
Health Care
Assistant
Typically ca. 20
hours per week,
although some
work up to 39
hours per week
(daytime).
PRIVATE
Agency Care
Worker
Great variation
from 10 hours a
week, to live in
care for several
consecutive
weeks. Both day
and night work.
Personal care.
Typically work in
Work tasks
dual role
relatively clearly
delivering
defined. Not
personal and
allowed to
domestic care,
perform any
although some
medical care.
work in one
Majority of
capacity only.
workers never do Many agencies
any housework.
also offer
companionship.
Domestic care is
usually an
adjunct to the
core service of
companionate or
personal care.
15-25, although
Variable, typically
can be as many
a maximum of 3
as 30. People
to 4 clients, can
with personal
be a little as 1
care needs. Care
client. Needs vary
typically delivered from extensive
in short bursts of personal care to
ca. 30 minutes.
companionship.
41
NON-PROFIT
Home Help
Variable, but
average of ca.
10-15 hours per
week (daytime).
Predominantly
light domestic
work (cleaning,
shopping,
errands) and
companionship.
In practice line
between
housework and
personal care
often crossed. As
a result, many
end up working in
dual capacity.
Typically 3-6
clients, although
can be as many
as a dozen. Some
clients only need
domestic care,
but many clients
also receive
personal care
(mostly from
other sources).
Table 2 : Employers, terms and conditions, unionisation
Care sector
and worker
PUBLIC
Health Care
assistant
Employed by a
public sector
subsidiary,
managed by Public
Health Nurses.
PRIVATE
NON-PROFIT
Home Care Worker Home Help
Terms and
conditions in
brief
In principle similar
to public sector
employees; in
practice
implementation
inconsistent.
€12.70 highest
point on salary
scale. Little
security in terms
of duration, many
temporary
contracts.
Unionisation
Estimated 80-90%
members of
SIPTU.
Rates of pay can
vary considerably
depending on day
and care task,
average wages
slightly above
minimum wage
(€8 - €8.50). Poor
social rights for
those in agency
mode (no sick
leave, holiday
pay). Those in
company mode
have better rights
(e.g. holiday pay).
Unionisation rate
close to 0 %
Employer
5
Two different
types: “agencies”
treat staff as selfemployed,
“companies” treat
staff as direct
employees.
However, they still have a non-profit agenda.
42
Home help
organisations:
originally purely
voluntary/charitable,
now often limited
companies with
increasing structural
resemblance to
private sector
companies5.
Pay and benefits
increasingly similar
to public sector
workers’. Highest
point on salary scale
€14.60 per hour.
However, no
obligation to grant
workers pensions
and occupational
social security
rights.
Estimated 50 %
unionised (SIPTU).
Table 3: Recruitment pathways and geographical spread of
workers
Care sector
and worker
Recruitment
pathway
Geographical
spread
PUBLIC
Health Care
Assistant
Formal recruitment
channels in
compliance with
public service
regulations. In
practice often
referrals via local
connections.
Workers and
clients drawn from
the locality.
Workers usually
live within a short
distance of clients.
Small travel
allowances
available to cover
cost of travel
where applicable.
43
PRIVATE
Agency Care
Worker
Advertising in
commercial media
e.g. Golden Pages.
Those seeking
employment in
this sector are
often very proactive in seeking
out agencies and
sending
speculative
applications. Word
of mouth is also
important.
Workers and
clients in most
cases drawn from
a large area (often
city-wide).
Workers usually
travel to work by
bus or car. No
travel allowances
available in most
cases.
NON-PROFIT
Home Help
Usually by word of
mouth and
connections in the
local community.
Workers and
clients drawn from
the locality.
Workers usually
live within a short
walk of client.
Some
organisations offer
travel allowances.
Table 4: Care workforce composition, duration of
employment, level of training and supervision
Care sector
and worker
Female/Male
Breakdown
National/
Non-Irish
Breakdown
Training
Requirements
PUBLIC
Health Care
Assistant
95-100 % female.
Mostly nationals,
with a very small
non-Irish presence.
PRIVATE
Agency Care
Worker
95-100 %
female.
Varies across
agencies, but
considerably
higher than in
public/non-profit,
some employ
almost
exclusively nonIrish workers.
Fairly uniform levels Expected to have
of training required completed selffor entering role.
financed training
Receive additional
or gained work
training for free
experience before
without loss of
entering
income.
employment.
Directors
unwilling to
finance this
training.
44
NON-PROFIT
Home Help
95-100 %
female. Male
presence was
stronger prior to
systematic
taxation of home
helps’ income.
Mostly nationals,
with a small nonIrish presence.
Usually expected
to have some
prior experience
of formal or
informal care
work. Availability
of additional
training varies
between
organisations,
usually selffinanced (loss of
income while
training).
Table 5: Motivations for entering care work
Care sector and
worker
Central reasons
for entering
care work
PUBLIC
Health Care
Assistant
Perception of
health care
assistant role as
superior to other
home care roles.
Flexibility.
45
PRIVATE
Agency Care
Worker
Practical
(flexibility of work
and financial),
Altruistic, Change
from nursing
home work,
Financial.
NON-PROFIT
Home Help
Flexibility and
considerable
amount of control
over hours. Pay
perceived as
relatively good.
Table 6: The Carer-Client Relationship
Care sector and
worker
Perceived
relationship
PUBLIC
Health Care
Assistant
Relatively large
number of clients
and short
duration of visits
leaves less time
for building
relationships.
Relationships
nonetheless
generally close
and
companionate.
46
PRIVATE
Agency Care
Worker
Generally close
and
companionate,
though in some
instances
professional and
distant.
NON-PROFIT
Home Help
Many entered
work before
improvement in
pay hence
motivation could
be construed as
non-monetary;
also tend to work
for longer periods
with lower
dependency
clients in their
own locality and
hence more scope
for developing
relationships.