Review

When the market isn’t the answer

SOCIAL CARE MARKETS
Wistow G, Knapp M, Hardy B, Forder J, Kendall J Manning R
Open University Press, 1996, £15.99

Markets for care are certainly not perfect markets — if such ever exist. The logic of markets that are very far from perfect is that those in charge must manage or shape the markets to get the desired outcomes.

This was hardly part of government rhetoric when the purchaser-provider split was introduced, but the authors of Social Care Markets make a very convincing case that social care, and by implication health care, markets will not automatically bring benefits.

In fact if they are not going to do harm, they have to be consciously managed on very different lines from the old fashioned simplistic private sector model. To quote: ‘A task for local authorities is to develop strategies which can promote and sustain trust between trading partners, indeed to shape this trust so that it lubricates transactions and generates desired outcomes’; and: ‘effective purchasing depends on recognising that purchasing and providing are interdependent rather than separate activities’.

It follows that for anyone who is interested in market management the last two chapters of the book are essential reading.

The theoretical discussion of how social care markets should or could work uses the model developed by the Personal Social Services Research Unit at Kent. This makes it clear that markets for social care are extremely difficult to operate. Local factors such as the amount of information available on costs and quality vary greatly. So will the assessment of individual service users and the related decisions on how much care they can be offered.

The effects of these market imperfections are extremely unclear. It is quite certain though, that not many senior managers in social services came into the profession to sort out market imperfections.

The most important message, not spelt out but implicit in the book, is that accurate measurement of the quality of service outcomes is too complex for social services departments. It is (probably) theoretically possible with a large research grant from the Department of Health, but otherwise the type of outcome measures that can be written into contracts and, still more difficult, effectively monitored, are very limited. Market managers are therefore expected to shape the market without the information that some would think was most important — the quality of service outcomes.

Add to this the enormous local variations in the types of private and voluntary services available, and the different policies of social services departments, and it is not surprising that social care varies so greatly over the country. Even greater variation is to be expected in the future. As the authors say, it may be that hierarchical (their term for pre-reform social services) forms of organisation work as well as markets.

The rest of the book reports on interviews with directors of social services, chairs of committees and some lead persons in private and voluntary residential services. The interviews date from 1993 and so are more speculative than informative on what the market for care has produced.