Care analysis: How do you shape the care market?

‘How do you Shape a Market? Explaining Local State Practices in Adult Social Care’

Needham and colleagues proposed key principles that shape the residential care market. The model is a valuable tool for the sector to analyse the market and business model in greater depth and fully appreciate the change drivers in play. 

The authors commented on the state of the care market, highlighting “that local authorities’ hybrid approaches risk antagonising providers and further unsettling an unstable market.”. The authors also reflect, “The Care Act 2014 gave English local authorities a duty to 'shape' social care markets and encouraged them to work co-productively with stakeholders." 

It’s in this context, that HWL is pioneering innovative co-designed approaches to inform positive change.

Figure 1. 'A typology of care market shaping'. Source: Needham et al. 2023. Cambridge University Press

The four part typology can ‘show how cultural patterns are both “internalised” in individuals and “institutionalised” in policy contexts’ (Simmons, R. 2018, p. 235). As Swedlow explains, ‘the social relations of the four ways of life specified by cultural theory are simultaneously specifications of four ways of making decisions, constituting authority, and exercising power’ (2014, p. 469).

For example, hierarchy means ‘the proper authority decides’, individualism means ‘I decide’, fatalism means ‘others decide’ and egalitarianism means ‘we decide’ (2014, pp. 469-70).

We use the four types to understand rule-relationship configurations in English care markets. We focus on engagement between local authorities and care providers since a market shaping strategy is primarily revealed in the way local authorities engage with the provider market (although we recognise that this is a simplifying assumption and there may also be a role for families, communities and other stakeholders).

On the grid dimension (which we call rules), local authorities can use contracting and monitoring processes to set down rules in a prescriptive way, leaving providers to follow them. Alternatively they can be more flexible, engaging providers as co-producers (e.g. through commissioning for outcomes, (Bovaird, 2014). Entwistle et al. describe a high grid approach as being about ‘the use of hard regulatory instruments and the maintenance of hierarchy’, and a low-grid approach as ‘government having to rely on the soft instruments of diplomacy, partnership and trust’ (2016, p. 899).

For the group element (which we call relationships), local authorities can work closely with an ‘in-group’ of preferred providers or can stimulate a dispersed market with weak coordinating factors. Some local authorities, for example, may set up block or framework contracts with a small number of large providers, whereas others may encourage multiple providers to operate and compete on their patch, with more ‘spot purchasing’.

Combining the two variables produces four types of market shaping as shown in Figure 1:

• Procurement (strong rules, weak relationships)
• Managed market (strong rules, strong relationships)
• Open market (weak rules, weak relationships)
• Partnership (weak rules, strong relationships)

Of the four, we see the two low rules types as most compatible with the vision of social care set out in the Care Act, given the Act’s promotion of user choice and control (most easily facilitated by the open market approach), and co-production (the partnership approach) (Department of Health, 2017).

Cultural theorists anticipate that any collectivity will have all four types present within it, but that one of the four types is likely to be dominant and institutionalised (Thompson et al., 1990; Simmons, 2018). There is a competitive element to their co-existence: ‘each culture defines itself by contrast with the others’ (Douglas, 2007, p. 8).

Beyond offering a descriptive model, cultural theory also explains how one institutional or cultural type deepens or changes into another through feedback dynamics (6 and Swedlow, p. 869). This dynamic analysis of grid-group patterns avoids ‘bird spotting’ studies, which merely identify examples of the four types (Mamadouh, 1999, p. 405). It also provides space for agency and fluidity, avoiding the determinism that can be attributed to grid-group categorisation (Logue et al., 2016, p. 1591).

Through studying the interaction of the four types in local markets it is possible to identify dominant cultures, how they interact with the other types, and how domination changes over time.

References

• Bovaird, T. (2014), ‘Attributing outcomes to social policy interventions – “gold standard” or “fool’s gold” in public policy and management?’, Social Policy & Administration, 48, 1, 1–23
• Department of Health (2017), Care and Support Statutory Guidance. London: The Stationery Office
• Douglas, M. (2007), A history of grid and group cultural theory, Toronto, Canada: University of Toronto
• Entwistle, T., Guarneros-Meza, V., Martin, S. and Downe, J. (2016), ʼReframing Governance: Competition, Fatalism and Autonomy in Central-Local Relationsʼ, Public Administration, 94, 4, 897–914.
• Logue, D. M., Clegg, S. and Gray, J. (2016), ‘Social organization, classificatory analogies and institutional logics: Institutional theory revisits Mary Douglas’, Human Relations, 69, 7, 1587–1609
• Mamadouh, V. (1999), Grid-group cultural theory, GeoJournal 47, 395–409
• Swedlow, B. (2014), ‘Advancing policy theory with cultural theory’, Policy Studies Journal, 42, 4, 465–83 CrossRef.
• Simmons, R. (2018), ‘Using cultural theory to navigate the policy process’, Policy & Politics, 46, 2, 235–253.
• Thompson, M., Ellis, R. and Wildavsky, A. (1990), Cultural Theory. Boulder, CO: Westview Press.
• 6, P. and Swedlow, B. (2016), ‘Introduction to the Symposium. Public Administration, 4, 94, 867–880.