Abstract

This paper is not about a single reform, or series of reforms. It documents some major changes that have taken place in the organization and delivery of long term care in England over the past two decades – in particular the introduction and elaboration of quasi-markets, and what might be considered to reflect New Public Management ideas aimed at improving efficiency both within long term care and at the interfaces between long term care and acute health care.

However, it also documents the failure over the same period to achieve reform in the critically important area of funding. It is widely agreed that the current budgets for long term care services are woefully inadequate and unsustainable in the longer-term; and that the ways in which these resources are allocated are neither fair nor transparent.

It is difficult to interpret these contrasting developments as characterizing any one of the modes of transformative change proposed by Streeck and Thelen. Indeed, it is striking that one series of policy preoccupations – quasi-markets and choice – has been pursued so consistently and assertively over two decades by Conservative, Labour and Conservative-Liberal Democrat coalition governments alike, when all have found more fundamental funding reforms much harder to achieve.

The paper will focus primarily on developments (and the lack of developments) within social care. These developments are characterized by the simultaneous co-existence of, and tensions between, institutional inertia and incremental innovation (particularly the extensive marketization that has been introduced into English long term care over the past two decades.

Thus, long term care services have been transformed by two distinct waves of quasi-market development, and by the search for greater efficiency in service organization and delivery. At the same time, there have been repeated – and continuing failures to reform a system that is widely regarded as inadequate, inequitable and unsustainable; indeed, it is arguable that the twin pressures of liberalization and efficiency have actually increased the difficulties of introducing more radical, transformative change.

The paper describes these contradictory developments and their consequences: the introduction and elaboration of quasi-markets within adult social care; the drive for improved efficiency; and the unresolved problems of funding and fairness.

Slides