Breaking the mould: new trajectories in the domiciliary care of older
people in Ireland
Martha Doyle, Virpi Timonen
School of Social Work and Social Policy, Trinity College Dublin, Ireland.
Key words: welfare mix, welfare pluralism, care regimes, quasi-markets, cash-for-care
Running title: Breaking the mould
Accepted for publication May 2, 2007
2
Abstract
This article reviews the development of domiciliary care services for older people in Ireland
over the last decade. It reveals three central developments, namely (1) the first steps, in the
Irish context, towards a quasi-market; (2) the introduction of cash-for care and the subsequent
notable segmentation of care tasks between the three sectors; and (3) a rapidly increasing
reliance on for-profit private home care providers. The article concludes that while the Irish
social care regime is still anchored in important ways in the primacy of informal (family) care
and the subsidiarity principle, it has broken path-dependency by evolving towards an
increasingly complex mix of public, not-for-profit and for-profit provision and financing. The
most policy-relevant aspect of this new constellation is the lack of a regulatory framework
that would enable the State to monitor the multiple and diverse providers with the view to
ensuring the quality of home care services.
3
Introduction
There is a paucity of research on the supply side of Irish domiciliary care; studies available
have tended to focus on the not-for-profit sector and are now out-of-date. The most recent
comprehensive overview of domiciliary care services for older people in Ireland was
published in 1994 (Lundstrom & McKeown, 1994). While reference was made in this study to
the emerging provision of public services via the newly-established role of health care
assistant, the report focused almost exclusively on the not-for-profit sector, and at no point
referred to the for-profit sector (unsurprisingly, since there were no more than one or two
private providers operating in the country in the early 1990s).
Our research, conducted in 2005–06, is the first study of the structures and operating
principles of the formal domiciliary care services sector in contemporary Ireland (Timonen,
Doyle & Prendergast, 2006). The intention was to gain a better understanding of the ‘division
of labour’ between the public, private and not-for-profit sectors in the delivery and financing
of home-care services for older persons, and of the parameters within which each sector
operates. While informal (family) care and, increasingly, care delivered by (migrant) care
workers operating in the grey market are of undoubted significance within the Irish context,
they were outside the remit of this research which focused on the formal care sector only.
The focus of this article lies in the key policy-relevant developments in the Irish domiciliary
care services for older people, which are established via analysis of recent policies, on the one
hand, and by teasing out the main organisational and operational characteristics of the three
provider groups (public, private and not-for-profit), on the other. We also identify the main
policy challenges that remain to be tackled in the Irish context if the complexity of the current
4
system is to be managed in a way that leads to the emergence of a more controlled and
integrated system.
Research methods
More often than not, domiciliary care systems operate at the local or regional level rather than
at the national level (Curtice and Fraser, 2000). Cognisant of both the national and regional
diversity of domiciliary care services in Ireland, a mapping exercise of only the greater Dublin
region was undertaken. This was justified, not only by the fact that this area contains almost
one quarter of Ireland’s population, but also because the pluralism of service provision is
most evident in this area. As was stated above, this was the first study of domiciliary care
provision in Ireland since 1994; as such, we started from a very low level of knowledge about
the sector which was compounded by the lack of a centralised system for collecting data about
the provision of domiciliary services in the country, and the absence of suitable ‘ready-to-go’
sampling frames.
As a first step in the research project, archival and desk-based research was carried out with
the view to uncovering the evolution of the current system of domiciliary care services.
Following this, 55 semi-structured interviews with 125 informants working in the area of
home-care provision for older people in Dublin were conducted. These informants were
drawn from the three ‘pillars’ of the public, private and not-for-profit sectors, and from the
three ‘layers’ of care workers, their managers and individuals charged with planning and
financial control of domiciliary care services (see Figure 1).
The Dublin area is divided into eight local health offices (LHO) that have their own
organisational and management structures. Senior public servants within these LHOs have
5
responsibility for the planning, (partial) funding and strategic provision of services in their
respective areas. Across the eight LHO areas, 28 senior public servants working in the area of
services for older people were interviewed. These interviews enabled us to map the services
available within each area and to explore the interaction of key LHO personnel with both the
not-for-profit and for-profit sectors that are part-funded by the state.
In the case of the newest provider sector, the private home care sector the lack of a centralised
registry on the sector meant that we had to start by establishing the number of operators in the
Dublin area. The compilation of a contacts database of private providers, postal mail-out to
these contacts and subsequent follow-up telephone conversations and snowballing enabled us
to establish that 14 private home care organisations with a significant focus on older people
operated in the Dublin area. A one-page postal questionnaire was dispatched to these
providers, and completed by all but two of the organisations1. Interviews were conducted
with directors from ten of these organisations representing approximately 70 per cent of
providers in the Dublin area, and as such the data gathered at the level of company directors
can be regarded as representative for that point in time.
The not-for-profit sector is considerably older and larger than the private sector and, given the
time constraints and qualitative nature of the interviews, we were not in a position to cover all
the not-for-profit providers. However, we did interview 17 directors of the not-for-profit
agencies (from a total of 28 not-for providers functioning in the Dublin area) which represents
60 per cent of the not-for-profit organisations in the Dublin area. While it could be argued that
the data pertaining to this group are not ‘representative’ in the strictest sense of the word, we
1
These two providers delivered less that 25 per cent of their services to older people and were consequently
omitted from the research.
6
observed a saturation of themes and a high degree of consistency regarding the key issues
raised at both the management and operational levels.
Using a semi-structured interview schedule the interviews with the for-profit and not-for
profit home care directors explored the background, remit, structure and focus of the
organisations along with their relationship with the Health Service Executive (HSE), the
central government agency that channels funding via the LHOs.
At the workforce level, 63 interviews were conducted with the not-for-profit (n=20), for-profit
(n=23) and public sector care workers (n=20). The interview schedule used with this cohort
covered the topics of training and qualifications, social security entitlements, work conditions,
relationships with clients and employers and the perceived challenges and problems of their
job.
Data analysis was done both manually and with the aid of the QSR N6 qualitative data
analysis software programme. Dominant themes were identified within each of the prespecified interview schedule categories and cross-checked by the researchers. The article at
hand draws for the most part on the interviews conducted at the higher management levels
(the top layer in the figure below)2.
Insert Figure 1 here
Research findings
An analysis of the evolution of the domiciliary care sector frequently illustrates how
institutional forces, cultural factors and church-state relations have had an important impact
2
Timonen and Doyle (2007a) offer a detailed analysis of the differences between the three sectors and draw on
interviews across the three sectors and layers.
7
on the development of service provision (Bahle, 2003). In Ireland formal care services
evolved from a reliance on charitable provision (Table 2, Stage 1) to public provision of
institutional care (Table 2, Stage 2), to a greater home care focus based on religious and notfor-profit (voluntary) provision (Table 2, Stage 3), to a complex mix of limited public
provision and state-funded not-for-profit (now largely secular) and for-profit sector provision
(Table 2, Stage 4). A constant feature throughout this development was the dominant role of
family care3 and, in the post-independence era, the increasing emphasis on subsidiarity4 (see
Timonen & Doyle, 2007b, for detailed discussion of this historical evolution).
Insert Figure 2 here
We will now turn to discussing the three recent key developments in the Irish domiciliary care
sector that were identified on the basis of the documentary and interview analysis, namely (1)
the first steps, in the Irish context, towards a quasi-market, (2) the introduction of cash-for
care and the subsequent notable segmentation of care tasks between the three sectors, largely
resulting from the differing ways the state channels funding to the three sectors, and (3) the
rapidly increasing reliance on private sector providers.
3
While Ireland shares many of the trends that are evident in other countries, it has not to date expanded the
incentives for informal care as strongly as for instance Germany has done. This is somewhat surprising in the
context of a strongly familialist system.
4
The subsidiarity principle in the context of social care dictates that care should be provided, whenever possible,
by the social unit closest to the person in need of care. In the first instance, this means the family and other
informal carers, and following them (religious) voluntary organisations. Only when these organisations have
reached their limits should the state intervene. To this end, not-for-profit organisations received special treatment
by the Irish State (via so-called Section 65 grants) and to this day are the dominant suppliers of domiciliary care
services for older people in Ireland (Donoghue, 2001).
8
Transition towards a quasi-market, Irish style
Quasi-markets have become an increasingly prominent feature of the social care systems of
several European countries5. In a pure market transaction, ‘consumers come to the market
with their own resources which they use to purchase the goods and services they require’
(Propper & Le Grand, 1997: 5). In a quasi-market, on the other hand, ‘purchasers funded by
general taxation buy services from providers. The purchases may be the service users
themselves, but more commonly, they are agents appointed by the state to purchase on behalf
of the end-user’ (Propper & Le Grand, 1997: 7).
Proponents of the introduction of quasi-markets purport that they ensure more efficient
delivery of services, encourage competition, improve consumer choice, autonomy, quality of
domiciliary care services and enable the public authorities to co-ordinate and regulate service
provision more objectively. Practical issues such as resource constraints, recruitment
difficulties and inadequate specialisation of services have also been advanced as reasons
behind the new trend of out-sourcing and privatisation (Bahle, 2003). Regulations and quality
standards for the providers are usually specified at either a national or regional (local
authority) level. Typically, service providers document the suitability of their companies in
terms of staffing and monitoring arrangements and generally will be accepted only if they
5
Examples of the introduction of such quasi-markets include the passing of the Community Care Act in England
and Wales in 1993, which originally mandated local authorities to sub-contract 85 per cent of their services to
the not-for-profit and private sectors (Curtice & Fraser, 2000; Wiener & Evans Cuellar,1999); the passing in
2003 of new legislation in Denmark that enabled private domiciliary care providers to compete with public
sector providers (Rostgaard, 2004);; and Germany’s Long-Term Care Insurance programme introduced in 1994
which actively encourages service provision by the for-profit and not-for-profit sectors over public providers
(Bönker & Wollmann, 2005). Common among all these countries is the change in the emphasis in the role of the
public authorities, from the provider of services to the purchaser of services.
9
offer their services within a specified price range.6 Under such arrangements, it is assumed
that service providers will be forced to offer better quality and more competitive services or
exit the market.7
While the introduction of quasi-markets is not as explicit in the Irish context as in many other
countries, new methods of contracting-out care and engaging in competitive tendering
processes are increasingly observable. Direct tendering-out of care contracts, in addition to
the channelling of finances via the home-care grants packages to private providers, is being
piloted in one LHO area. The introduction of the cash-for programme (as discussed below)
has also introduced a new market system, whereby the LHO draws up a list of ‘approved
providers’ from which individuals who are given a home-care package (i.e. a sum of money to
be spent on care) choose.
At present the Irish home-care market is largely disorganised and unregulated. However, the
entry of private providers to the publicly funded home care market has led to increased
attention on the issue of accountability and documentation. Private providers that liaised
closely with the HSE were more likely to raise concerns about the lack of regulation of both
the private home care industry and the not-for profit sector. These providers frequently
6
Frade and Darmon (2005) argue that such measures create a ‘bureaucratic burden’ for the small local
providers, and favour the larger national providers and in some areas have threatened the viability of the
traditional domiciliary care services rooted in the local community. Economists, however, would argue that
competition between providers ultimately benefits the consumers [care recipients], because the system allows the
consumer to choose and shift to providers that offer the best service (Hirschman, 1970).
7
Research on this is not conclusive. For example Ranci and Pavolini (2006), who conducted a comparative
analysis of the long-term care systems in France, Germany, Italy, UK and The Netherlands, concluded that while
the introduction of social markets did improve consumer power, much of the power still resided in the public
sector, with possible negative consequences for some of the providers or indeed the degree of competition
possible between them.
10
reiterated the importance of ‘accountability’, transparency’ and ‘quality assurance’, and called
for regulation in the form of monitoring, training and the payment of care workers’ social
security and insurance coverage:
There are a lot of agencies out there that I would call matching agencies… We are
trying to get the government to regulate what’s going on, cause in that scenario
there’s no training, there’s no supervision, there’s no background checks… We think
there’s a Leas Cross scenario [this is the name of a nursing home that attracted
considerable media and political attention following a documentary showing abuse of
residents] out there in home care. [Director, for-profit home care company]
Grievances about the unequal playing field in which the private home care sector and the notfor-profit sector compete was voiced by a number of private home care directors who argued
that their higher service fees result from better trained and supervised staff. Many believed
that they have higher overhead costs than the not-for-profit organisations and that the
government should cover some of these costs, including the cost of carer training. These
directors called for a more market-driven home care sector, which would end what they
regarded as the comparative advantage levelled to the not-for profit sector through the
allocation of funding via section 65 grants8.
The introduction of quasi-markets within the Irish care sector has not been an explicit
ambition of senior mangers within the HSE, however resource demands and capacity
constraints have meant that by default the evolution of a more pluralistic provider landscape
is becoming more evident. Senior LHO managers interviewed acknowledged the long
8
As stipulated in the Health Act 1953.
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tradition of co-operation between the not-for-profit sector and HSE, but had ambivalent views
on whether or not this privileged relationship would continue. The majority of these managers
indicated that while in principle they would prefer to contract all of their care requirements to
the not-for-profit organisations, since they were ‘linked more closely’ to the HSE structures,
many organisations did not have the required capabilities or resources. Concern was voiced
that some not-for-profit providers are not interested in expanding their services or delivering
their service in the most efficient manner, and the belief that private providers would have to
fill this void in the care market was common.
When the interviews probed into the reasons for using private sector providers (rather than
not-for-profit providers), the interviewees at the LHO level justified this by referring to the
‘critical mass of resources’, the more ‘professional’ management of the private sector
companies, their greater ‘flexibility’, the ‘clear contracts’ with care workers and the ‘quicker’
processing of background checks. Although some LHO managers interviewed noted concerns
about particular private sector companies that continue to act as intermediaries to care
workers who are in principle ‘self-employed’ but remain outside the tax and social security
net, several also cited reliability, training, insurance status, flexibility and ability to offer a 24hour service 7 days a week as distinct advantages of the private sector. However, adequate
supply of quality private care services was not available within certain LHOs, with some
LHOs personnel intimating that they are having difficulty finding adequately trained and
insured private home-care providers.
In light of the recent transformations within the care sector and new business relations
particularly with private providers, there was a recognition at LHO management level that
more formalized improved accountability mechanisms were required for both the private
12
sector and not-for- profit sector. A prevalent sentiment was that the current disorganised care
market would ultimately have to be better organized and moderated, which would likely
introduce a more clearly defined quasi-care-market as visible in other European countries.
Introduction and impact of cash-for-care
A key development in the provision of domiciliary care services in Ireland came about in
2001, when the Department of Health acknowledged that the existing arrangements were not
sufficient to successfully support home care, and encouraged the Health Boards to pilot homecare grant schemes (Timonen, 2004). The provision of additional funding has largely been a
consequence of the lack of adequate community care, which is currently leading to large
numbers of older people using acute hospital facilities after their discharge date i.e. as longterm care (HSE, 2002).
Home-care grants (or home-care packages) were envisaged to complement, not replace, the
existing provision of services via the public sector and not-for-profit organisations. However,
the rate at which home care packages have been introduced and expanded since 2001 suggests
that in some areas they are replacing rather than complementing the work of the not-for-profit
sector (Timonen, Convery & Cahill, 2006). Different funding mechanisms exist for this cashfor-care programme; in some areas prospective payments are made directly to recipients
(allowing them to choose their own providers of care), in others care recipients choose a
provider from a list of ‘approved’ private providers, while in other areas services are delivered
by pre-contracted private or not-for-profit providers. By the first quarter of 2006, 952 homecare grants were being funded by the Health Service Executive in the Dublin area, compared
with 192 in 2003.
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The private sector has been the main beneficiary of the move towards cash-for-care, and
growth of this sector is largely driven by this public funding mechanism, rather than by direct
private spending on care. In contrast, the extent to which the not-for-profit organisations have
embraced the home-care package funding stream varies. Some organisations interviewed
restructured their business to accommodate these packages, while others took on only a
handful of home-care package clients or considered the delivery of home-care packages (often
requiring care provision ‘out-of-hours’ or at weekends) to be outside their capacity. A number
of the not-for-profit managers were critical of their current unstable relationship with the HSE
which has been exacerbated by the introduction of home care packages. Many not-for profit
directors suspect that the HSE is attempting to introduce new business arrangements between
the state and the not-for-profit sector which could potentially jeopardise their viability and
serve to advantage private home care companies. Furthermore, a number of the not-for-profit
sector representatives interviewed stated that a lack of HSE investment to cover
administrative, management and support staff costs makes it more difficult to compete with
the private sector and provide more flexible round-the-clock care as required through the
home care package scheme.
Increasing reliance on private sector providers
The private home-care sector first emerged in Ireland in the late 1980s/early 1990s. This
sector had not been explored prior to our research, but anecdotal reports suggest that the
sector was in a constant state of flux until the introduction of publicly financed home-care
packages that resulted in an expansion of demand for private sector care services. At the
moment the private providers do not have to engage in open competitive tendering. Instead,
contracts are allocated either on an ad hoc basis directly from the health services
administration (the HSE via the LHOs) to the private sector companies who meet basic
14
minimum criteria, or indirectly via the ‘consumer’ who, once entitled to funding through a
care package, can choose the provider that best meets his/her needs.
For all but two private providers interviewed, the HSE home-care packages are the main
source of their clientele, which in turn means that they are strongly, if only indirectly (via
their clients), reliant on public funding. Presently the ‘market share’ of the private sector
when compared with the not-for-profit organisations is small. However, a majority of the
directors in this sector expressed confidence that thanks to government plans to expand the
cash-for-care programme their client base has the potential to expand strongly:
We would expect to be caring for about 5000 individuals in about 5 or 6 years…my
expectations have gone higher now than the day we started in terms of how quick we
can expand and how much the service is needed. Effectively I would expect to have 20
offices throughout Ireland… [Director, for-profit home care franchise]
This increase in the role of the private sector should be put into the context of developments
in the public and not-for-profit sectors. Direct delivery of public domiciliary care service is
very limited in Ireland and takes place via the Health Care Assistants (HCAs), who deliver
non-paramedical personal care to older people in their home. The main rationales for the
introduction of HCAs in 1994 were the increasing demands on Public Health Nursing teams
in the community and the realisation that a different kind of care worker (non-medical) was
needed to provide personal care. In the Dublin area, there are approximately 85 healthcare
assistants. This number is far from adequate, but recruitment difficulties and ceilings on staff
numbers in the public sector mean that the LHOs have not been able to increase their numbers
15
over the last half decade, and consequently demand for this service outstrips supply. As one
director of public health nursing put it,
We ran a twilight service for years but because we did not have enough staff, the [care
staff] were exhausted so the scheme was phased out. Subsequently the decision was
made that unless the person is terminally ill such a service would not be offered. For
such a scheme to be viable, you need a dedicated team.
The not-for profit sector is currently (and has been since the mid 1950s) the predominate and
largest provider of publicly funded domiciliary care. The not-for-profit home-care sector in
Ireland is frequently referred to as the ‘voluntary home-care/help sector’. However the
introduction of the minimum wage in 2000 and subsequent professionalisation of the
workforce means that the title ‘voluntary’ home-care service is a misnomer and should be
replaced with the term ‘not-for-profit’ home-care service. . The Health Service Executive
provides the bulk of the funding for these organisations as outlined under section 65 of the
Health Act 1953. Approximately 1.25 million home-care hours are provided by the 28 notfor-profit home care organisations in the Dublin area annually (administrative figures
obtained from the Department of Health and Children). The distribution and allocation
however, of these home-care hours varies considerably across the different LHO areas,
largely reflecting the unsystematic and uncoordinated funding relationship between the HSE
and these providers. Traditionally, and still in some areas, the not-for-profit providers deliver
only domestic care, although recent organisational changes within this sector has seen an
increasing number of care staff (particularly in the larger organisations) working in a dual
capacity, delivering both personal and domestic care .
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Policy implications
Our research illustrates that the Irish domiciliary care mix has changed substantially in the
past five years. While not-for-profit providers are still the predominant suppliers of statefunded domiciliary care, the private sector has managed to fill an important niche in the
home-care market, which neither the not-for-profit nor public sector have been able, or
allowed, to supply. The new cash-for-care policy (home-care packages) is the main driver
behind this change, and illustrates the powerful role that public financing plays in altering the
profiles of providers and their respective positions of power or weakness. Specialisations of
the three sectors are to a large extent the result of the differing ways in which the state has
channelled funding to the three sectors. Whereas funding for the not-for-profit sector is
retrospective, i.e. largely based on past delivery of a certain number of home help hours,
private sector agencies and companies ‘bid’ for a set of care packages, or for inclusion in a list
from which care recipients choose their service providers. The manner in which funding is
channelled to the two sectors, therefore, creates a strong incentive for the private sector to be
as flexible as possible, whereas not-for-profit organisations are constrained and ‘disincentivised’ by the retrospective nature of the funding arrangement.
Because both the not-for-profit and for-profit provider organisations are able to operate in a
complete or partial ‘vacuum’ in terms of policy guidelines and regulations, they have
diversified and established their own procedures and protocols for areas such as staff
qualifications and quality controls, tax compliance, hiring and contractual practices, and
insurance. The extent to which individuals and organisations are left to ‘make up rules as they
go along’ is illustrated by the following quote from an interview with a LHO representative:
17
We are chasing some of the larger private care agencies and trying to use those who
have insurance and some form of training for their employees, but again no-one is
checking up on them as such. The way it is going and we use one or two agencies, it
will cost a lot and we’ll have to go to tender and we’ll have to draw up standards
about how an agency inducts and trains it staff … the push has just been to discharge
people from hospital … these things will have to come into play.
If the current funding arrangements are maintained, it is likely that the not-for-profit sector
and the private sector will continue to evolve along different paths. In a more regulated and
service user-driven alternative (such as those in operation in Denmark and Germany), any
provider that meets quality, training and monitoring requirements would be free to offer their
services to individuals who are given entitlement to services (see Doyle and Timonen, 2007).
The pivotal issue in this regard is the regulation of services and the creation of a level playing
field that draws out the strengths of different providers and ensures a greater degree of
consumer direction and quality control.
Undoubtedly, additional oversight and monitoring of public monies invested in both the
private and not-for-profit home care sectors will have to be enforced. However, policy makers
have a difficult task in formulating these monitoring procedures. It seems probable that
increased regulation of the not-for-profit and for-profit sector will have substantial financial
ramifications. Increased regulation in the form of mandatory training and supervision will
mean higher overheads for the state, particularly in the current environment where the forprofit providers intimate that they are not prepared to cover the costs of training themselves.
Furthermore, it will have to be established whether training and monitoring requirements shall
be universal among private, public and not-for-profit employees alike, what realistic and
18
desirable minimum training standards are for care workers, and also whether these standards
are applicable to all carers even if they only deliver domestic care.
Whether or not the state will continue to support the position of the not-for-profit
organisations is unknown. Currently their generic budgets are separate from the home-care
package budget, but it is difficult to surmise whether these funding streams will continue to
remain separate or merge in the coming years. The stated intention by the government to
extend and roll out more home care packages may have negative ramifications for the not-forprofit organisations if they continue to be awarded in the present uncoordinated fashion. One
plausible alternative that would protect the not-for-profit organisations is that the state will
continue to fund their generic budget enabling them to continue to deliver domestic care and
low-level personal care and contract-out more intensive personal care to the for-profit sector.
However, even if this is the case, it is probable that more formal standardised service level
agreements will be negotiated with the not-for-profit providers.
The ‘care mix’ of public, profit and not-for-profit providers is likely to evolve, given the
complexity of the problems of older people living at home and the projected rise of older
people in the population. It is estimate that the demand for domiciliary care in Ireland will
increase by 100 to 215 per cent by the year 2051 (Hughes, Williams and Blackwell, 2005).
Such a rises in the demand for domiciliary care services, coupled with fiscal pressure at a
national level, could result in a rationing or targeting of services to those deemed most in
need. If publicly funded care is delivered only to older people with extensive care needs, it
would seem that the requirement for dual capacity carers, as currently available in the private
sector and available only to a limited extent in the not-for-profit sector, will be required. Were
this to happen, the majority of the not-for-profit organisations would have to radically re-
19
structure or cease to operate. In such a scenario, persons with less extensive care needs would
be left without any public assistance and therefore have to rely on informal family care, the
private sector or care obtained via the grey market.
In the light of experience in other countries that have embraced quasi-markets in the care
sector, it appears that the central issue of quality is not straightforwardly related to a pluralism
of providers. From both the perspective of the recipient and the care worker, quality has been
found to correspond more closely to the amount of time the carer is allowed to spend with the
client, the ability of the recipient to direct the work of the carer (Stack & Provis, 2000; Staehr,
2005) and the age and employment conditions of the care worker (Netten, Sandhu & Francis,
2006). Independent budgets are currently being piloted in 13 local authorities in the UK
(Glendinning, 2006). In the UK context, this signifies a departure from quasi-markets to a
more open market system where the care recipient instead of a ‘third party proxy’ chooses
both the care tasks (including transport and help with leisure and recreational activities) and
the service provider (including informal carers, pet minders, taxi drivers or other service
provider of choice). The strengths and weakness of this new care arrangement are currently
under review across five universities in the UK (www.ibsen.org). Preliminary analysis from
this project elucidates the complexity of these new care systems particularly for frail or
cognitively disabled persons, but also reflects the growing awareness that care recipients want
to actively control their own care arrangements (Glendinning, 2006). In Ireland it is highly
probable that the debate on both the dis/advantages of opening up the care market and
offering greater consumer choice to home-care recipients will continue into the foreseeable
future. Whatever the outcomes of this debate, it is imperative that the state does not
relinquish its responsibility to monitor, the delivery of home care services that it finances both
20
directly and indirectly, the level of competition between the various providers, and the ability
of providers to compete as a consequence of quality and cost stipulations..
Conclusion
This article has illustrated how the current form of the domiciliary care sector in Ireland is
more the result of gradual evolution than systematic planning. The rise of the private homecare sector over the last decade is a highly significant development that has its origins both in
the limited funding made available to the public and not-for-profit sectors and in the increased
emphasis on cash-for-care (Timonen, Convery & Cahill, 2006). The channelling of public
funds to private companies is therefore the newest and still evolving manifestation of the
state’s role in the delivery of domiciliary care services and arguably one that has new and
different implications from the point of view of monitoring and quality controls. As Bahle
(2003) argues, forces such as privatisation and decentralisation are not necessarily the
antidotes of integration and control of social care systems. In the case of Ireland, too, it is
possible that more integrated and better controlled systems of home care will emerge from the
current highly complex and unregulated system.
Lastly, the complexity of home care also poses a challenge for regime theorists. A good
regime classification is able to serve as a useful simplification of reality. The question must be
asked: Is it possible to construct social care regime classifications on the basis of the kind of
complexity that is evident in the case of Ireland and many other countries where the state both
provides and finances care, increasingly through a multitude of private and not-for-profit
organisations that exist alongside informal and grey market provision of care? While much
valuable work has been done by those attempting to construct such classifications (e.g.
Anttonen & Sipila, 1996), the area of social care has rapidly become more complex, and the
21
classifications developed in the not too distant past are arguably already out of date. The task
of developing social care regime classifications that serve as useful simplifications of the
complex reality poses a great, and perhaps insurmountable, challenge to social scientists.
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23
Figure 1. Interview matrix and breakdown of interviews in each sector.
Matrix of Persons Interviewed
Public
Sector
Private
Sector
Non-Profit
Sector
Planning and Financing
(LHO Managers of Services for Older People
and Directors of Public Health Nursing)
Operational Management
(LHO personnel above, Home Help Organisers
and Private Agency Directors)
Care Workers
(Health Care Assistants, Home Helps and Private Care Workers)
Public
Private
Not-for-
Total
Profit
28
n/a
n/a
28
2 (+9)
11
21
34
Delivery
20
23
20
63
Total
50
34
41
125
Planning /Financial
Management
24
Figure 2. Historical evolution of formal elder care services in Ireland.