Fragmented time and domiciliary care quality
| DOI | https://doi.org/10.1108/ER-05-2018-0142 |
| Published date | 06 January 2020 |
| Pages | 35-51 |
| Date | 06 January 2020 |
| Author | Carol Atkinson,Sarah Crozier |
| Subject Matter | HR & organizational behaviour,Industrial/labour relations,Employment law |
Fragmented time and domiciliary
care quality
Carol Atkinson and Sarah Crozier
Business School, Manchester Metropolitan University, Manchester, UK
Abstract
Purpose –The purpose of this paper is to examine the marketization of domiciliary care, its consequences
for employment practice, specifically fragmented time, and the implications for care quality.
Design/methodology/approach –Focus groups and face-to-face or telephone interviews were conducted
with carecommissioners, serviceproviders and care workersacross Wales. There were113 participants in total.
Findings –These demonstrate fragmented time’s negative consequences for service providers, care workers
and, ultimately, care quality.
Research limitations/implications –No care recipients were interviewed and care quality was explored
through the perceptions of other stakeholders.
Social implications –For policy makers, tensio ns are evidenced between aspi rations for high-qualit y
care and commissioning practice that mitiga tes against it. Curre nt care commissioning practices need
urgent review.
Originality/value –The research extends the definition of fragmented time and integrates with a model of
care quality to demonstrate its negative consequences. Links between employment practice and care quality
have only previously been hinted at.
Keywords Marketization, Care quality, Domiciliary care, Fragmented time
Paper type Research paper
Introduction
As western populations age, so the demand for adult social care increases. Domiciliary care,
one form of social care, affords personal care, protection or social support for vulnerable
adults in their own homes (Gray and Birrell, 2013) and should improve quality of life for
(mainly) older people (Francis and Netten, 2004). Yet high profile UK scandals have raised
concerns over care quality (Kingsmill, 2014; Flynn, 2015) and, while the context here is
Wales, these concerns are reflected internationally (Cunningham et al., 2014; Broadbent,
2014). Inadequacies in care provision have substantial ramifications. Directly, some of
society’s most vulnerable adults suffer poor care and thus poor life quality. Indirectly,
effective operation of health care systems is compromised by, for example, “bed-blocking”,
whereby hospital discharge is delayed due to a lack of available social care provision
(e.g. Marsh, 2016), to an extent that threatens to de-stabilise health care provision. Delivery
of high-quality social care is thus an urgent imperative.
Addressing this imperative requires an adequate and skilled workforce (Rainbird et al., 2011),
which depends upon effective employment relationships. Yet recently in this journal, Rubery
(2015) outlined a series of trends that adversely affect employment practice and are particularly
pertinent to domiciliary care. First, fragmentation, where marketisation promoting outsourcing
and use of external providers has created a move away from standard forms of employment,
with social care being a particular example of resulting insecurity and zero-hour contracts
(Rubery and Urwin, 2011). Second, flexibilisation of employment being demand- rather than
supply-led, again with resultant workforce insecurity. Finally, feminisation of employment,
Employee Relations: The
International Journal
Vol. 42 No. 1, 2020
pp. 35-51
Emerald Publishing Limited
0142-5455
DOI 10.1108/ER-05-2018-0142
Received 22 May 2018
Revised 21 January 2019
25 February 2019
Accepted 26 February 2019
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0142-5455.htm
© Carol Atkinson and Sarah Crozier. Published by Emerald Publishing Limited. This article is
published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce,
distribute, translate and create derivative works of this article ( for both commercial and non-com-
mercial purposes), subject to full attribution to the original publication and authors. The full terms of
this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode
35
Fragmented
time and
domiciliary
care quality
which is highly relevant given the gender segregation that prevails in social care, and which
facilitates insecurity (Moore and Tailby, 2015). These trends have, in combination, degraded
working practices and created what Rubery et al. (2015, p. 753) have recently described as
“fragmented time”in which insecure and highly flexible working patterns dominate. Given that
the link between employment practice and service quality in other contexts is well-established
(Whyman et al., 2015), the paper addresses the research question:
RQ1. What are the consequences of fragmented time for care quality?
The paper makes a valuable empirical contribution to the social care employment research
base (Cooke and Bartram, 2015), importantly adding careworkers’views (Cunningham, 2010)
not just on theiremployment situation,but also on care quality.Theoretically, it both confirms
Rubery et al.’s (2015)definition of fragmentedtime, evidencing anemployment offer predicated
upon zero-hourcontracts and episodicworking, and extendsit in adding visit length(Bee et al.,
2008). Further, it integrates fragmented time with Francis and Netten’s (2004) dimensions of
good care to demonstrate the detriment to quality that fragmented time brings in reducing
continuity, reliability and flexibility of care. This moves beyond the thus far tentative links
proposed in existing domiciliary care research (Broadben t, 2014; Cunningham, 2016) to
evidence that poor employment practice compromises care quality. For policy makers, the
paper demonstrates substantialtensions betweenpolicy’s aspirationsfor high-quality care and
funding/commissioning practice that mitigates against good employment practice.
The paper proceedsby outlining the marketizationof domiciliary care and the implications
for social care employment relationships. It then theoretically frames fragmented time and
care quality, before presenting research methods and findings/discussion. It concludes with
research contributions and implications.
Marketisation and domiciliary care employment relationships
In many neoliberal economies, there has been marked reduction in the state provision of
domiciliary care over recent decades (Cunningham, 2008). A shift to marketised
relationships has occurred in which the state, via local authorities, commissions most
domiciliary care from independent (private and voluntary) sector service providers
(Cunningham et al., 2014). Understanding of commissioning is essential to the examination
of both wider employment practice (Rubery et al., 2013) and, specifically, fragmented time
(Rubery et al., 2015). Marketisation draws on supposedly efficient business principles and
aims to improve care quality. In practice, the external commissioning of care has long been
associated with quality concerns, related in large part to the cost pressures that have
dominated local authority commissioner agendas (Cunningham, 2010). Indeed,
Cavendish’s (2013) review of UK care failures argued that the local authority
monopsony of commissioning suppresses rates and UK Home Care Association, the
employers association for domiciliary care providers (UKHCA, 2015a), reports that care is
often commissioned at less than its cost price[1]. Inadequate funding is compounded by
insecure commissioning arrangements, with a move away from block contracts, where an
agreed number of hours are purchased whether used or not, to spot contracts, where
payment is only made if care is taken up (see Knapp et al., 2001 for detailed explanation).
Time is the unit of account adopted (Rubery et al., 2015) and domiciliary care provision is
typicallymeasuredinminuteswith,inadrive for efficiency, the increased use of short
visits of 15 and 30 min or less (Bessa et al., 2013). Using spot contracts, commissioners
operate framework agreements that accredit service providers as operating at an
appropriate quality level (Bessa et al., 2013) and providers submit tenders for care
packages on a price-by-case arrangement. In combination, these practices have created
inadequate and insecure funding streams for independent service providers. This has
substantial implications for social care employment relationships (Broadbent, 2014)
36
ER
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