Does Smaller mean Better? Evaluating Micro-Enterprises in Adult Social Care

Lead Research Organisation: University of Birmingham
Department Name: Health Service Management Centre

Abstract

Are care services best delivered through very small, locally-based services that are 'close to the user' or do large organisations offer more efficient and effective care? As care for older and disabled people in England is becoming more personalised and deregulated, it is important to move beyond the anecdotal claims about small, innovative micro-enterprises and establish an evidence base.

The government's Big Society and personalisation agendas are encouraging more very small organisations to get involved in supporting older people and people with disabilities. Within social care, personalisation has led to more people being given control over their own care budget, with the freedom to purchase support from lots of different types of service provider. Micro-enterprises are one of the types of organisation that people can purchase support from. Buying support might mean purchasing domiciliary care (someone to come to the house to provide help with dressing and washing) or paying to attend a day centre. However, it might mean purchasing something very different. One micro-enterprise provides dance classes, for example. It might also involve purchasing something which is better suited to your care choices as a person from an ethnic minority, or as someone who is lesbian, gay, bisexual or transgender.

There is often an assumption that 'smaller is better', because small organisations may be more flexible and innovative. However it is also possible to argue that larger organisations will perform better because they can use economies of scale and deploy a wider range of resources. Existing studies of size and performance do not usually include very small organisations like micro-enterprises, making it hard to draw conclusions about the link between size and performance. Using interviews and surveys with 108 service users and carers in 27 case study organisations, across three local authorities, this research will compare outcomes and value for money across micro, small, medium and large care providers (defined by the number of staff working in them). It will:

- Use interviews to talk to service users and carers about their experience of using the service
- Use a survey to get comparable data between service users across the case study organisations, and compare that to findings in the national Adult Social Care Survey conducted each year by the Association of Directors of Adult Social Services (ADASS) on behalf of the Department of Health.
- Involve some 'non-traditional' service users - black and ethnic minority people; lesbian, gay, bisexual and transgender people - to assess how far micro-enterprises are better than larger organisations at providing tailored support.
- Compare the prices charged for services in the case study organisations with the outcomes reported by users to see how far organisations are delivering value for money.

Talking to users is likely to be particularly effective when other service users do the interviews. This is because interviewees may be more comfortable speaking to other service users and the user-interviewers can design interview questions that get to key issues from their own experiences. The project will recruit and train service users and carers as co-researchers, involved in research design, interviewing, data analysis and dissemination of findings.

The project aims to produce findings that are of direct relevance to local authorities, service users and other organisations as they commission care services, and to social entrepreneurs as they develop provision. It also aims to deepen social scientific knowledge of the relationship between organisational size and performance in welfare services, of relevance to academics working in fields such as social policy and public management.

Planned Impact

In addition to the academic beneficiaries set out in the earlier section, this research will benefit a wide range of groups:

- Service users as they develop support plans and commission care services.
- Frontline social care staff as they support service users in developing support plans and commission care services.
- Local authority care teams as they commission services.
- Social entrepreneurs as they develop provision.
- Think tanks undertaking research on the changes to provider markets in the context of personalisation and personal budgets.
- Charities redesigning their services in the context of personalisation, including setting up social enterprises.
- National government policy makers, such as those within the Department of Health and within arms-length bodies such as Think Local, Act Personal, who may particularly be interested in research into cost-effectiveness in care provision.
- National professional bodies such as the Association of Directors of Adult Social Services and the British College of Social Work.
- Local policy makers, seeking to better understand their local care markets and how they are changing.
- Regulators such as the Care Quality Commission seeking to better understand the relationship between organisational size and performance, and the relationship between qualitative and quantititave outcome data.

The research will contribute to the nation's health through enhancing understanding about what makes for effective practice and organisational design in care markets. This finding has enormous potential impact given that over 1.5 million people use social care services, but that services in the recent past have been characterised by large scale provision often dependent on 15 minute care visits by large care providers or the 'warehousing' of disabled and elderly people in large day centres (Glasby and Littlechild, 2009). As people move towards purchasing more of their own care through personal budgets, it is vital that service users themselves and those that support them (informal carers and social care professionals) better understand how organisational size and performance interact. This research will help care users, professionals and policy makers to understand when and how micro-enterprises can contribute to improved service outcomes and how far micro-enterprises can deliver value for money in a very tight financial context. It will also help people working in or setting up micro-enterprises to understand the advantages and disadvantages of their size and to work to ensure maximum effectiveness.

Key to achieving impact is working with charities, professional bodies and the trade press to disseminate findings through their professional networks, as discussed in the Pathways to Impact statement. The topline findings from the project can start being shared through those channels as soon as the writing-up stage is complete, and should be able to make an immediate impact on those people who are currently designing their support plans. In the context of personalisation it is expected that no one will be tied into a long-term contract with a provider and therefore that they should be able to rework their support plan within a short time scale. However, in practice people are unlikely to want to make constant changes to their support plan, so it is recognised that maximum benefit is likely to come as service users are designing their support plans or those plans are being reviewed; and for service providers at the time that they start trading or undertake a service review.

Staff working on the project will develop or consolidate skills at working with co-researchers, undertaking research with a range of organisational types; and comparing different types of data.

Publications

10 25 50
 
Description Micro-enterprises (MEs) in the care sector perform better than larger care provided on the four research questions addressed in the project (outcomes for individuals; person-centredness; innovation; value for money)

1. Outcomes data for individuals (derived from the Adult Social Care Outcomes Toolkit) showed that MEs scored more highly than the national average on the two domains that were tested: could people do what they wanted with their time; and could they have more choice and control. In the case study sites, MEs also outperformed larger care organisations on the first domain question, but differences on the second domain question were not statistically significant. Qualitative data from the interviews indicated that, in relation to day activities, some interviewees enjoyed the wider variety of activities offered by larger providers.

2. MEs offer more person-centred care than larger care organisations. The more personalised care provided by the MEs, especially for care and support delivered in the home stemmed from the:

a. Autonomy of front-line staff to vary the service being offered
b. Continuity of front-line staff
c. Accessibility of managers to frontline staff and people using services

3. MEs were found to be more innovative than larger providers in delivering more flexible and person-centred care, and in involving people who use services and their families in setting up and running MEs.

4. Price data indicated that the hourly rate for micro-enterprises was slightly below that of larger providers. This was not at the expense of quality, (as indicated by the interviews and ASCOT questions). With the larger providers the cheapest prices were offered by those that conformed to the 15 minute care visit model. The more expensive larger providers were able to match the micro-enterprise offer more closely, providing longer care visits and better staff continuity.

• Enabling factors for the sustainable success of MEs include: dedicated support for start-up and development; strong personal networks within a locality; and maintaining an independent status. Barriers for MEs include few local authority referrals leading to a reliance on self-funders; the difficulty of maintaining a staffing base with only a small number of clients; and the financial fragility of the organisations, some of which were failing to cover their costs.

• We used a measure of size based on staff numbers and took a snapshot of performance at a given time. However we saw change in some organisations' size during the life of the research project, highlighting the importance of studying size in a longitudinal way in future research. We also found that size was an identity as much as a metric: some organisations which exceeded our size thresholds still identified as micro-enterprises, and articulated an ethos which had more in common with other MEs than with larger organisations.

• The research was undertaken with co-researchers who had experience of using services (older people, people with learning disabilities and carers). This strengthened service user and carer perspectives throughout the study, assured greater validity of the research findings and brought new perspectives and skills to the academic researchers.
Exploitation Route • Our findings are directly relevant to the implementation of the Care Act 2014 which creates a potentially fertile environment for micro-enterprises, given its focus on stimulating a diverse local market of community-based providers (and closer links to the health sector). We envisage that our findings around enablers/barriers for MEs will be relevant to national and local care commissioners as they develop market-shaping capabilities, and to providers as they learn the benefits of small-scale provision.

• Local launch events have raised the profile of the research with service users and carers, and the organisations that represent them.

• Project partners and co-researchers are starting to make use of the research findings. For example SCIE and Community Catalysts are citing the work in their own publications. Co-researchers in one locality have been asked to work with the local authority on improving local disability services.

• Academics will be able to draw on the findings from the research to develop knowledge on: the link between organisational size and performance (Public Management); the links between process, quality and price in care services (Social Policy); and the implications of working with co-researchers (Methodology).
Sectors Communities and Social Services/Policy,Healthcare,Government, Democracy and Justice

URL http://www.birmingham.ac.uk/research/activity/micro-enterprises/index.aspx
 
Description In the pathways to impact statement which accompanied the bid, we proposed that the research would have short, medium and long-term impacts. The short-term impacts were to be on influencing the immediate research environment, particularly in building the research capacity of the 18 co-researchers (people who had experience of using care services or of caring for someone who used them). A year after the research has finished, we can see that this capacity-building has been achieved. Researchers with learning disabilities in one site have been approached by the local authority to discuss ways to use the research findings to reshape service provision in that locality. They are also working with a local provider to develop quality measures from a service user perspective. Researchers in another locality have contributed to experts-by-experience focus groups for a National Institute of Health Research-funded project on decommissioning health services. Most significantly, in terms of building long-term research skills, one of the co-researchers will be a co-investigator on a Department of Health Policy Research Programme grant into care market-shaping starting in October 2016. This involves working alongside the same team of academic researchers who undertook the Micro-Enterprise project, with a specific role in leading the co-researcher recruitment and training. The other 17 co-researchers from the Micro-Enterprise project will also be invited back to undertake interviews on this new project, providing an opportunity to use and further deepen the skills acquired through the earlier research. The medium-term impacts we set out in the Pathways to Impact statement were as follows. • In the year following the end of the award, the findings will be disseminated through a range of local and national events, academic and press articles and a website, involving case study sites and people, but also the broader social care practitioner, user and policy communities. In the engagement and publications section of ResearchFish we have detailed the activities we have undertaken to disseminate the findings, through reports and videos on our project website, as well as blogs and articles in outlets such as the Department of Health Social Care blog, the Social Care Institute for Excellence website and Community Care magazine. We also held an ESRC Festival of Social Science event for local commissioners and providers of care services, which was attended by over 40 people. Two county councils invited us to training events to present findings to commissioners from adult and childrens' social care teams. Within Kent, the event we ran (which was in association with Care Coops UK) encouraged Care UnLtd - a local social enterprise in Kent - to set up a funding programme specifically for micro enterprise, and our research will inform the design of that programme. Tracing a direct impact on social care practice is difficult to do, and we see our impact on improving the quality of social care as being a scaffolding process, where widespread interest in our micro-enterprise findings has led to us being commissioned to undertake further research. The quality and relevance of our research on micro-enterprises has enabled us to bid successfully for a large (£550,000) Department of Health Policy Research Programme grant on implementation of the Care Act. This project focuses specifically on market-shaping, and in the research proposal we drew directly on the micro-enterprise project findings to highlight both the problems exhibited in local care systems, and our own expertise in understanding the dynamics of care markets, and what constitutes 'good care'. Beginning this new project in October 2016 gives us enhanced access to Department of Health policy-makers, and opportunities to connect the micro-enterprise findings into broader initiatives to improve care systems. The long-term impacts we set out in the Pathways to Impact statement were to embed the findings in our university teaching. We have done this during the academic year 2015-16, delivering sessions for MSc students taking Healthcare Policy and Management, Public Management; for trainee social workers on the Step Up programme; and for a cohort of international MSc students from the University of Melbourne. Since these courses involve people who are working part-time in practice (or on placements in the case of social workers) we used the sessions to encourage students to consider how to utilize the findings in their own practice. For example, social workers have an opportunity to consider what our respondents meant by 'person-centred care'. Commissioners, taking the Public Management programme, are urged to examine how far their commissioning practices support or inhibit very small providers of care. These modules are delivered annually and provide an opportunity to embed the findings from the research among practitioners over the long-term.
First Year Of Impact 2015
Sector Communities and Social Services/Policy
Impact Types Policy & public services

 
Description 'Commissioning better outcomes for all: the hidden wealth at the margins', a blog by Sarah Carr for Think Local, Act Personal 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Sarah Carr, who is a partner for the project, wrote a blog for the Department of Health-supported national personalisation coalition, Think Local Act Personal. In the blog she drew on research she had conducted as part of our project to make the case for commissioners to include micro-enterprises in their commissioning practices.

The output helped to raise awareness of the research amongst the readers of the Think Local, Act Personal blog
Year(s) Of Engagement Activity 2014
URL http://www.thinklocalactpersonal.org.uk/Blog/article/?cid=10203
 
Description 'Social care for marginalised communities: understanding self-organisation for micro-provision' 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Blog on the Health Services Management Centre website, http://www.birmingham.ac.uk/schools/social-policy/departments/health-services-management-centre/news/viewpoint/2014/social-care-for-marginalised-communities.aspx

This blog was part of a broader strategy of raising awareness about the research amongst policy-makers and practitioners, here focused particularly on the health policy community.
Year(s) Of Engagement Activity 2014
URL http://www.birmingham.ac.uk/schools/social-policy/departments/health-services-management-centre/news...
 
Description Article about co-research in the INVOLVE newsletter 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Patients, carers and/or patient groups
Results and Impact Aimed to share the learning from working with co-researchers on the micro enterprise research. The article was co-written with two of the co-researchers from the project
Year(s) Of Engagement Activity 2015
URL http://www.invo.org.uk/wp-content/uploads/2015/11/INVOLVEAutumn2015newsletter.pdf
 
Description Blog for Dept of Health 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Blog for the Department of Health's Social Care website, which sparked inquiries from care users about how to access micro-enterprises in their area
Year(s) Of Engagement Activity 2015
URL https://socialcare.blog.gov.uk/2015/06/30/do-micro-enterprises-offer-care-and-support-on-a-scale-tha...
 
Description Blog for the RSA 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Blog for the RSA to tie-in with the publication of their report about micro-businesses.
Year(s) Of Engagement Activity 2015
URL https://www.thersa.org/discover/publications-and-articles/rsa-blogs/2015/06/why-the-future-of-social...
 
Description Blog on the Community Catalysts website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Blog about the research findings on the Community Catalysts website
Year(s) Of Engagement Activity 2015
URL http://www.communitycatalysts.co.uk/research-into-micro-enterprise-and-some-unexpected-outcomes/
 
Description Care Coops UK/Kent County Council - presentation of research findings 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact The event was run by Care Coops UK and attended by around 15-20 Kent County Council staff - mostly social care commissioners. The event encouraged Care UnLtd - a local social enterprise in Kent - to set up a funding programme specifically for micro enterprise, and our research will inform the design of that programme.
Year(s) Of Engagement Activity 2015
 
Description ESRC Festival of Social Science event on entrepreneurship in the care sector 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Industry/Business
Results and Impact At this ESRC Festival of Social Science event we worked with Birmingham Business School to share the research with a group of care entrepreneurs and care sector professionals. We learned a lot from hearing the perspective of the entrepreneurs, and widening our understanding of the debates/issues which the Business School is looking at in this area.
Year(s) Of Engagement Activity 2015
 
Description Innovation in social care: it's the 'how' as much as the 'what' - a blog by Catherine Needham for the Institute of Local Government Studies 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Blog for the Institute of Local Government Studies, University of Birmingham

http://inlogov.wordpress.com/2013/10/22/innovation-in-social-care-its-the-how-as-much-as-the-what/

The blog was one of a series of outputs aimed at raising awareness of the research among the policy and practitioner communities. Here the focus was particularly on local government.
Year(s) Of Engagement Activity 2013
URL http://inlogov.wordpress.com/2013/10/22/innovation-in-social-care-its-the-how-as-much-as-the-what/
 
Description Launch of the micro-enterprise findings, North West 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact This was one of three regional events at which we shared the findings from the micro-enterprise research project with stakeholders and research participants in the areas where we had conducted the research.
Year(s) Of Engagement Activity 2015
 
Description Micro-enterprise article in Community Care 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact This was an article in the online magazine Community Care, the leading trade journal in the sector, sharing results from our research
Year(s) Of Engagement Activity 2015
URL http://www.communitycare.co.uk/2015/06/23/micro-providers-offer-good-value-money-struggle-get-referr...
 
Description Micro-enterprise launch event in the West Midlands 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact This was one of three regional events at which we shared the findings from the micro-enterprise research project with stakeholders and research participants in the areas where we had conducted the research. At the event we had a lively discussion about the pros and cons of micro-enterprise and some people reported that they had changed their minds as a result of attending the event.
Year(s) Of Engagement Activity 2015
 
Description Micro-enterprise launch event, East Midlands 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact This was one of three regional events at which we shared the findings from the micro-enterprise research project with stakeholders and research participants in the areas where we had conducted the research. Audiences welcomed the opportunity to network and learn from each other
Year(s) Of Engagement Activity 2015
 
Description National launch of micro-enterprise research at SCIE 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact This national round-table event was hosted by the Social Care Institute for Excellence. One of the project co-researchers presented the findings of the research. It led to debate, and to us being requested to be involved in further dialogue about micro-enterprises with the DH
Year(s) Of Engagement Activity 2015
 
Description Warwickshire County Council - presentation of micro-enterprise research findings 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact We presented the findings from the micro-enterprise project to an audience of 25 commissioners of adult and children's social care services, and discussed with them the dilemmas they face in encouraging micro-enterprise development in their area.
Year(s) Of Engagement Activity 2015