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I was speaking to a commissioner recently about the difficulty she had negotiating with some providers over fees, because nobody at a local level was able to make decisions. Inevitably, some ‘suit’ from head office had to be mustered to enter into any discussion about changes in funding. This person was usually a financial expert and as far removed as it was possible to be from the delivery of care.
Having worked for both large groups of care services and smaller, localised concerns, there are certainly benefits to the service user of the latter. If the management is more connected to the day-to-day operation, the service can be more flexible and responsive, since local decision making can be speedy and relevant. So, if a commissioner wants to talk about the fee structure, the person they are talking to has to have a very close relationship with the budget and resources.
Small enough to care?
Now a report, from The University of Birmingham, examines the way micro enterprises (defined as employing fewer than 5 people) compare with small, medium and large organisations in terms of personalisation, innovation, value and cost effectiveness. It reviewed the sampled organisations over two years and used surveys of staff, carers and service users of the organisations.
In examining personalised support, the survey found that this was particularly good in micro- and smaller providers, where there was greater flexibility, more awareness of individual need and greater continuity of staff. It noted that staff were more autonomous and could respond quickly to service user needs.
On the other hand, it argues that larger providers are able to have greater choice of provision, offer more opportunities and are more able to cope with staff shortages and vacancies as they have a larger pool of staff to call on.
Out of the Box
The study also found that micro-organisations were more innovative; they were able to ‘think outside the box’ when it came to care delivery. They could respond quickly to service user needs and found different ways to tackle challenges. The fact that many of the micro-enterprises weren’t regulated by CQC was a help here, since they could innovate without having to deal with regulatory notification or any of the restrictions that can be a feature of regulated care.
Larger providers who had regulated services were certainly less agile in delivering innovation, but could provide a track record of quality and the assurances that regulation provides safety for the client.
Where micro-enterprises in the sample did score well, was in the cost of care. They were overall the best value option for clients, due to the low overheads they had. Much of their service was directly purchased whereas the larger organisations were commissioned by local authorities that in the main dictated the hourly rate. This disadvantaged the small and medium sized enterprises who had still significant overheads but lacked the economies of scale enjoyed by the large companies.
Better or just different?
Overall, the report concluded that micro-enterprises delivered more personalised support at better value to the service user. It makes very interesting reading, particularly around the way non-regulated services can offer greater flexibility and freedom. Given the number of people with learning disabilities accessing support in the community, micro-enterprises could be the way to go to achieve integrated supported living and independence.
I doubt that micro-enterprises pose a threat to larger providers at this time, nor will they really ever put more traditional service delivery at risk, but this report makes very interesting reading for those who are looking at alternatives to the care home model.