How micro-enterprise performs

This chapter considers a range of explanations as to why micro-enterprises perform well on aspects of all of the four measures that were used (valued, cost-effective, personalised and innovative). It focuses on the organisational structure of micro-enterprises, suggesting that their size allows these organisations to foster staff autonomy and high levels of adaptability to what is wanted by the people they support. It also examines issues of organisational ethos and identity, suggesting that many of these organisations set themselves up explicitly to distinguish themselves from large providers, and that this is the driver for much of the personalised support and innovative practice that we saw. However there are also vulnerabilities here for these organisations which can lack financial security, raising question marks about their long-term sustainability.

Enacting personalisation on a micro scale

An outcomes orientation can be described as taking a ‘black box’ approach which does not explain how outcomes are achieved. In this chapter the focus is on the process of care in order to explain how far services are personalised, drawing on data from the 143 people interviewed. It discusses the enactment of personalisation, highlighting the ways in which very small organisations seem to be able to adapt more flexibly to people’s desire for sustained and trusting relationships in a care context. The more personalised care provided by the smaller organisations seemed to stem from their greater continuity of frontline staff compared to large care providers, the greater autonomy of frontline staff to vary the service being offered, and the high level of familiarity of managers with individual clients and staff.

Enterprise and care

This chapter focuses on enterprise and care considering the contribution that new delivery models such as social enterprises make within public services more broadly and care in particular. The chapter also considers the ambiguity of the social enterprise label and its capacity to be claimed by a range of governance types, including the for-profit as well as the not-for-profit. The chapter then draws together the evidence on micro-enterprises into four research hypotheses that are tested in later chapters of the book, through qualitative and quantitative research. These are derived from the policy claims that are made by proponents of micro forms of service delivery: that micro-enterprises are more personalised, innovative, cost-effective and outcomes-oriented than larger organisations.

Micro innovation: what, how and who?

Chapter eight draws on the interviews undertaken with people running care organisations, to bring out three types of innovation - what innovation, how innovation and who innovation. This chapter identifies the different types of innovation that are displayed within the specific context of care; referred to here as what, how and who innovations. In terms of what innovations, some micro-enterprises are delivering services that deviate from the traditional residential, domiciliary and day models of care through the provision of flexible ‘one-to-one support’. Whilst micro-enterprises were offering more flexible services, larger organisations were also offering a broad range of services, and in day provision especially, larger services were found to offer more choice to service users. Whilst it tends to be the what and who innovations within micro-enterprises that are most widely reported, it may be the how innovations that are most important when it comes to the context of social care for older people. For people receiving personal care in the home, the scope for micro providers to take a more flexible approach gives them an advantage over large care providers.

What it means to be micro

This chapter is a discussion of what it means to be a micro-enterprise, outlining the approach taken to sampling the 27 organisations in the study, and the meanings that interviewees attached to different types and sizes of organisation. It highlights the practical dilemmas attendant in identifying and working with organisations whose size was not fixed and stable over the life of the research. The chapter also considers how different governance structures can be captured as a set of organisational identities as well as legal forms. These included sole traders and partnerships, as well as charities, limited companies and statutory providers. It draws on interview data to look at the motivations people had for setting up particular types of organisation, helping to illuminate the implications of having different organisational types within local care markets. It also uses the data to highlight how size and organisational type was part of the identity of these providers, with the identity of micro for example being embraced as a form of distinction from both larger providers in their locality and from social care’s institutionalised past.

Methods for co-productive research

Chapter four focuses on how to involve people using and working in care services as co-researchers, framing each stage of the research process as one which required departure from our planned approach and thinking about doing research differently. This is located in the context of existing research on the increasingly significant issue of co-production of research with people who may be considered ‘beneficiaries’ of the research, i.e. people with an experience of using services and family carers. Co-produced research is often presented as an unalloyed good, given its commitment to sharing power with potentially marginalised groups whose expertise can improve the research and give it more legitimacy within affected communities. However more critical accounts of coproduced research are also emerging – for example Flinders et al (2015) description of its potential to be a ‘pollution’ of academic research – which at the very least require a more considered defence of its importance.

Introduction: what size is ‘just right’ for a care provider?

This chapter sets out the context for the research, highlighting the growing salience of debates about the size of care organisations, but a lack of consensus about whether small is beautiful or large is efficient. It also locates the research within high profile policy debates in the UK about personalisation, personal budgets, care outcomes and austerity. The chapter also sets out how micro-enterprises are defined and gives examples of some of the micro-enterprise case studies that are included in the research. The chapter goes on to give more details of the approach to the research design, which examined how 17 micro-enterprises performed compared to 10 small, medium and large organisations in three case study sites in England, speaking to 143 people who work in or use these services. The chapter also discusses the involvement of co-researchers with lived experience of care services. The chapter finishes by summarising what follows in the rest of the book.

Conclusion: scaling down?

The concluding chapter considers the implications of the findings for the future of English social care services and for the broader health and welfare system. It suggests that local care economies are complex adaptive systems in which niche organisations like micro-enterprises can thrive but in which local authorities have weak coordinating tools to support micro-enterprise development. The employment of designated micro-enterprise coordinators within local authorities can enhance support for micro-enterprises, but even in localities with coordinators the micro-enterprises remain fragile. The chapter also considers whether the benefits of ‘smallness’ can be achieved through other means than micro-enterprises, discussing what can be learned from examples of large organisations which have found ways to nest smaller units within them. These discussions suggest opportunities for further research, particularly longitudinal and comparative research which stretch the impact of our findings beyond the timescale and geographical reach of our current study.

Sustainability: are micro-enterprises built to last?

Chapter ten considers these issues, exploring micro-enterprise funding models, which rely heavily on individualised purchasing by people rather than local government contracts. This chapter focuses on four interlinked aspects of micro-enterprises which shape their effectiveness and their likely contribution to future care services. These are: visibility; financial viability; relationship with the local authority; and quality and regulation. These are a combination of factors which are internal and external to the micro-enterprises. They encompass some attributes or structures that the organisations have the power to change and others that lie outside of their control. The chapter concludes that micro-enterprises retain a reliance on formal institutions within the care system – local authorities, the Care Quality Commission – which can limit their scope to ‘break the mould’ when it comes to care and support.

Micro-enterprises: better outcomes at a lower cost

Chapter six examines issues relating to the outcomes of care, bringing in the formal outcomes data from the Adult Social Care Outcomes Toolkit (ASCOT). The chapter sets out the increased privileging of outcomes data, over process and output measures. It also discusses the extent to which outcomes are more elusive than other measures: they are compromised by attribution problems and the absence of counter-factuals. Drawing on pricing data from the organisations in our study and outcomes data from people using those organisations the chapter draws conclusions about value for money. Comparing the hourly rates of care providers in the sample of 27 organisations of different sizes, micro-enterprises were found to be the cheapest. These findings are contextualised within broader debates about how care is financed, and the fit between micro-enterprises and individualised purchasing by personal budget-holders and people who fund their own care (called self-funders).