I N T E R NAT I O NA L J O U R NA L O F SOCIAL WELFARE DOI: 10.1111/j.1468-2397.2008.00598.x Int J Soc Welfare 2008: 17: 324– 332 ISSN 1369-6866 Breaking the mould: new trajectories in the domiciliary care of older people in Ireland Doyle Original XXX Breaking Articles Timonen the mould of Blackwell Oxford, International IJSW © 1468-2397 1369-6866 2008&The UK Publishing Author(s), Journal Ltd Journal Social Welfare compilation © Blackwell Publishing Ltd and the International Journal of Social Welfare Doyle M, Timonen V Breaking the mould: new trajectories in the domiciliary care of older people in Ireland Int J Soc Welfare 2008: 17: 324–332 © 2008 The Author(s), Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare This article reviews the development of domiciliary care services for older people in Ireland over the last decade It reveals three central developments, namely (i) the first steps, in the Irish context, towards a quasi-market; (ii) the introduction of cash-for-care and the subsequent notable segmentation of care tasks among three provider groups; and (iii) a rapidly increasing reliance on for-profit private home care providers The authors conclude that while the Irish social care regime is still anchored in important ways in the primacy of informal (family) care and the subsidiarity principle, it has broken path-dependency by evolving towards an increasingly complex mix of public, not-for-profit and for-profit provision and financing The most policy-relevant aspect of this new constellation is the lack of a regulatory framework that would enable the State to monitor the multiple and diverse providers with the view to ensuring the quality of home care services Introduction There is a paucity of research on the supply side of Irish domiciliary care Studies have tended to focus on the not-for-profit sector and are now out-of-date The most recent comprehensive overview of domiciliary care services for older people in Ireland was published in 1994 (Lundstrom & McKeown, 1994) While reference was made in that study to the emerging provision of public services via the newly established role of health care assistant, it focused almost exclusively on the not-forprofit sector, and at no point referred to the for-profit sector (which is not surprising since there were no more than one or two private providers operating in the country in the early 1990s) Our research, conducted in 2005–2006, is the first study of the structures and operating principles of the formal domiciliary care services sector in contemporary Ireland (Timonen, Doyle & Prendergast, 2006) The intention was to gain a better understanding of the ‘division of labour’ between the public, private and notfor-profit sectors in the delivery and financing of home care services for older persons, and of the parameters within which each sector operates While informal (family) care and, increasingly, care delivered by (migrant) care workers operating in the grey market are of undoubted significance within the Irish context, they 324 Martha Doyle, Virpi Timonen School of Social Work and Social Policy, Trinity College, Dublin, Ireland Key words: welfare mix, welfare pluralism, care regimes, quasi-markets, cash-for-care Dr Virpi Timonen, Social Policy and Ageing Research Centre, School of Social Work and Social Policy, Trinity College Dublin, Ireland E-mail: timonenv@tcd.ie Accepted for publication May 2, 2007 were outside the remit of this research which focused on the formal care sector only The focus of this article lies in the key policyrelevant developments in the Irish domiciliary care services for older people, which are established via analysis of recent policies, on the one hand, and by teasing out the main organisational and operational characteristics of the three provider groups (public, private and not-for-profit), on the other We also identify the main policy challenges that remain to be tackled in the Irish context if the complexity of the current system is to be managed in a way that leads to the emergence of a more controlled and integrated system Research methods More often than not, domiciliary care systems operate at the local or regional level rather than at the national level (Curtice & Fraser, 2000) Cognisant of both the national and regional diversity of domiciliary care services in Ireland, we undertook to map only the greater Dublin region This was justified, not only by the fact that this area contains almost one quarter of Ireland’s population, but also because the pluralism of service provision is most evident in this area As was stated above, this was the first study of domiciliary care provision in Ireland since 1994; as such, we started © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA Breaking the mould Figure Interview matrix and breakdown of interviews in each sector from a very low level of knowledge about the sector, which was compounded by the lack of a centralised system for collecting data about the provision of domiciliary services in the country and the absence of suitable ‘ready-to-go’ sampling frames As a first step in the research project, archival and desk-based research was carried out with the view to uncovering the evolution of the current system of domiciliary care services Following this, 55 semi-structured interviews with 125 informants working in the area of home care provision for older people in Dublin were conducted These informants were drawn from the three ‘pillars’ of the public, private and not-for-profit sectors, and from the three ‘layers’ of care workers, their managers and individuals in charge of planning and financial control of domiciliary care services (see Figure 1) The Dublin area is divided into eight local health offices (LHO), each with its own organisational and management structure Senior public servants within these LHOs have responsibility for the planning, (partial) funding and strategic provision of services in their respective areas Across the eight LHO areas, 28 senior public servants working in the area of services for older people were interviewed These interviews enabled us to map the services available within each area and to explore the interaction of key LHO personnel with both the not-for-profit and for-profit sectors that are part-funded by the state In the case of the newest provider sector, the private home care sector, the lack of a centralised registry on the sector meant that we had to start by establishing the number of operators in the Dublin area The compilation of a contacts database of private providers, postal mail-out to these contacts and subsequent followup telephone conversations and snowballing enabled us to establish that 14 private home care organisations with a significant focus on older people operated in the Dublin area A one-page postal questionnaire was dispatched to these providers, and was completed by all but two of the organisations.1 Interviews were conducted with directors from ten of these organisations, representing approximately 70 per cent of providers in the Dublin area, and, as such, the data gathered at the level of company directors can be regarded as representative for that point in time The not-for-profit sector is considerably older and larger than the private sector and, given the time constraints and qualitative nature of the interviews, we were not in a position to cover all the not-for-profit providers However, we did interview 17 directors of not-for-profit agencies (from a total of 28 not-for providers functioning in the Dublin area), which represents 60 per cent of the not-for-profit organisations in the Dublin area While it could be argued that the data pertaining to this group are not ‘representative’ in the strictest sense of the word, we observed a saturation of themes and a high degree of consistency regarding the key issues raised at both the managerial and operational levels We used a semi-structured interview schedule with the for-profit and not-for-profit home care directors to explore the background, remit, structure and focus of their organisations and their relationship with the Health Service Executive (HSE) which is the central government agency that channels funding via the LHOs At the workforce level, we conducted 63 interviews with the not-for-profit (n = 20), for-profit (n = 23) and public sector care workers (n = 20) The interview schedule used with this cohort covered the topics of training and qualifications, social security entitlements, work conditions, relationships with clients and employers, and the perceived challenges and problems of their job Data analysis was done both manually and with the aid of the QSR N6 qualitative data analysis software programme Dominant themes were identified within each of the pre-specified interview schedule categories and cross-checked by the researchers The article at hand draws, for the most part, on the interviews conducted at the higher management levels (the top layer in Figure 1).2 Research findings An analysis of the evolution of the domiciliary care sector frequently illustrates how institutional forces, These two providers delivered less that 25 per cent of their services to older people and were consequently omitted from the research Timonen and Doyle (2007a) offer a detailed analysis of the differences between the three sectors and draw on interviews across the three sectors and layers © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare 325 Doyle & Timonen Figure Historical evolution of formal elder care services in Ireland cultural factors and church–state relations have had an important impact on the development of service provision (Bahle, 2003) In Ireland, formal care services evolved from a reliance on charitable provision (Timonen & Doyle, 2007b: table 2, stage 1) to public provision of institutional care (ibid: table 2, stage 2), to a greater home care focus based on religious and notfor-profit (voluntary) provision (ibid: table 2, stage 3), to a complex mix of limited public provision and state-funded not-for-profit (now largely secular) and for-profit sector provision (ibid: table 2, stage 4) A constant feature throughout this development was the dominant role of family care3 and, in the post3 While Ireland shares many of the trends that are evident in other countries, it has not, to date, expanded the incentives for informal care as strongly as, for instance, Germany has done This is somewhat surprising in the context of a strongly familialist system 326 independence era, the increasing emphasis on subsidiarity4 (see Timonen & Doyle, 2007b, for a detailed discussion of this historical evolution; also see Figure 2) We will now turn to discussing the three recent key developments in the Irish domiciliary care sector that were identified on the basis of the documentary and interview analysis, namely (i) the first steps, in the Irish context, towards a quasi-market; (ii) the introduction of cash-for-care and the subsequent notable segmentation The subsidiarity principle in the context of social care dictates that care should be provided, whenever possible, by the social unit closest to the person in need of care In the first instance, this means the family and other informal carers, and following them voluntary (religious) organisations Only when these organisations have reached their limits should the State intervene To this end, not-for-profit organisations received special treatment by the Irish state (via so-called section 65 grants) and to this day are the dominant suppliers of domiciliary care services for older people in Ireland (Donoghue, 2001) © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare Breaking the mould of care tasks among the three sectors, largely resulting from the differing ways the state channels funding to the three sectors; and (iii) the rapidly increasing reliance on private sector providers Transition towards a quasi-market, Irish style Quasi-markets have become an increasingly prominent feature of the social care systems of several European countries.5 In a pure market transaction, ‘consumers come to the market with their own resources which they use to purchase the goods and services they require’ (Propper & Le Grand, 1997: 5) In a quasi-market, on the other hand, ‘purchasers funded by general taxation buy services from providers The purchasers may be the service users themselves, but more commonly they are agents appointed by the state to purchase on behalf of the end-user’ (Propper & Le Grand, 1997: 7) Proponents of the introduction of quasi-markets purport that they ensure more efficient delivery of services, encourage competition, improve consumer choice, autonomy and quality of domiciliary care services, and enable the public authorities to coordinate and regulate service provision more objectively Practical issues such as resource constraints, recruitment difficulties and inadequate specialisation of services have also been advanced as reasons behind the new trend of outsourcing and privatisation (Bahle, 2003) Regulations and quality standards for the providers are usually specified at either a national or regional (local authority) level Typically, service providers document the suitability of their companies in terms of staffing and monitoring arrangements and generally will be accepted only if they offer their services within a specified price range.6 Under such arrangements, it is assumed that service Examples of the introduction of such quasi-markets include the passing of the Community Care Act in England and Wales in 1993, which originally mandated local authorities to sub-contract 85 per cent of their services to the not-forprofit and private sectors (Curtice & Fraser, 2000; Wiener & Evans Cuellar, 1999); the passing of new legislation in Denmark in 2003 that enabled private domiciliary care providers to compete with public sector providers (Rostgaard, 2004); and Germany’s Long-Term Care Insurance programme, introduced in 1994, which actively encourages service provision by the for-profit and not-for-profit sectors over public providers (Bönker & Wollmann, 2005) Common among all these countries is the change in emphasis in the role of the public authorities, from provider of services to purchaser of services Frade and Darmon (2005) argue that such measures create a ‘bureaucratic burden’ for the small local providers and favour the larger national providers, and in some areas have threatened the viability of the traditional domiciliar y care services rooted in the local community Economists, however, would argue that competition between providers ultimately benefits the consumers [care recipients], because the system allows the consumer to choose and shift to providers that offer the best service (Hirschman, 1970) providers will be forced to offer better quality and more competitive services or exit the market.7 While the introduction of quasi-markets is not as explicit in the Irish context as in many other countries, new methods of contracting-out care and engaging in competitive tendering processes are increasingly observable Direct tendering-out of care contracts, in addition to the channelling of finances via the home care grants packages to private providers, is being piloted in one LHO area The introduction of the cash-for-care programme (as discussed below) has also introduced a new market system, whereby the LHO draws up a list of ‘approved providers’ from which individuals who are given a home care package (i.e a sum of money to be spent on care) choose At present, the Irish home care market is largely disorganised and unregulated However, the entry of private providers to the publicly funded home care market has led to increased attention on the issue of accountability and documentation Private providers that liaised closely with the HSE were more likely to raise concerns about the lack of regulation of both the private home care industry and the not-for-profit sector These providers frequently reiterated the importance of ‘accountability’, ‘transparency’ and ‘quality assurance’, and called for regulation in the form of monitoring, training and the payment of care workers’ social security and insurance coverage: There are a lot of agencies out there that I would call matching agencies We are trying to get the government to regulate what’s going on, ’cause in that scenario there’s no training, there’s no supervision, there’s no background checks We think there’s a Leas Cross scenario [this is the name of a nursing home that attracted considerable media and political attention following a documentary showing abuse of residents] out there in home care [Director, for-profit home care company] Grievances about the unequal playing field in which the private home care sector and the not-for-profit sector compete were voiced by a number of private home care directors who argued that their higher service fees result from better trained and supervised staff Many believed that they have higher overhead costs than the not-for-profit organisations and that the government should cover some of these costs, including the cost of carer training These directors called for a more market7 Research on this is not conclusive For example, Ranci and Pavolini (2006), who conducted a comparative analysis of the long-term care systems in France, Germany, Italy, UK and The Netherlands, concluded that while the introduction of social markets did improve consumer power, much of the power still resided in the public sector, with possible negative consequences for some of the providers or indeed the degree of competition possible between them © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare 327 Doyle & Timonen driven home care sector, which would end what they regarded as the comparative advantage levelled to the not-for-profit sector through the allocation of funding via section 65 grants8 The introduction of quasi-markets within the Irish care sector has not been an explicit ambition of senior mangers within the HSE; however, resource demands and capacity constraints have meant that, by default, the evolution of a more pluralistic provider landscape is becoming more evident Senior LHO managers acknowledged the long tradition of cooperation between the not-for-profit sector and HSE, but had ambivalent views on whether or not this privileged relationship would continue The majority of these managers indicated that while in principle they would prefer to contract all of their care requirements to the not-for-profit organisations, since they were ‘linked more closely’ to the HSE structures, many organisations did not have the required capabilities or resources Concern was voiced that some not-for-profit providers are not interested in expanding their services or delivering their services in the most efficient manner, and the belief that private providers would have to fill this void in the care market was common When the interviews probed into the reasons for using private sector providers (rather than not-for-profit providers), the interviewees at the LHO level justified this by referring to the ‘critical mass of resources’, the more ‘professional’ management of the private sector companies, their greater ‘flexibility’, the ‘clear contracts’ with care workers and the ‘quicker’ processing of background checks Although some LHO managers noted concerns about particular private sector companies that continue to act as intermediaries to care workers who are in principle ‘self-employed’ but remain outside the tax and social security net, several also cited reliability, training, insurance status, flexibility and ability to offer a 24-hour service days a week as distinct advantages of the private sector However, adequate supply of quality private care services was not available within certain LHOs, with some LHO personnel intimating that they are having difficulty finding adequately trained and insured private home care providers In light of the recent transformations within the care sector and new business relations, particularly with private providers, there was recognition at LHO management level that more formalised improved accountability mechanisms were required for both the private sector and not-for-profit sector A prevalent sentiment was that the current disorganised care market would ultimately have to be better organised and moderated, which would likely introduce a more clearly defined quasi-market for care as seen in other European countries As stipulated in the Health Act 1953 328 Introduction and impact of cash-for-care A key development in the provision of domiciliary care services in Ireland came about in 2001 when the Department of Health acknowledged that the existing arrangements were not sufficient to successfully support home care, and encouraged the Health Boards to pilot home care grant schemes (Timonen, 2004) The provision of additional funding has largely been a consequence of the lack of adequate community care, which is currently leading to large numbers of older people using acute hospital facilities after their discharge date, i.e as long-term care (Health Service Executive, 2002) Home care grants (or home care packages) were envisaged to complement, not replace, the existing provision of services via the public sector and not-forprofit organisations However, the rate at which home care packages have been introduced and expanded since 2001 suggests that in some areas they are replacing rather than complementing the work of the not-for-profit sector (Timonen, Convery & Cahill, 2006) Different funding mechanisms exist for this cash-for-care programme; in some areas prospective payments are made directly to recipients (allowing them to choose their own providers of care), in others care recipients choose a provider from a list of ‘approved’ private providers, while in other areas services are delivered by pre-contracted private or not-for-profit providers By the first quarter of 2006, 952 home care grants were being funded by the HSE in the Dublin area, compared with 192 in 2003 The private sector has been the main beneficiary of the move towards cash-for-care, and growth of this sector is largely driven by this public funding mechanism rather than by direct private spending on care In contrast, the extent to which the not-for-profit organisations have embraced the home care package funding stream varies Some organisations interviewed restructured their business to accommodate these packages, while others took on only a handful of home care package clients or considered the delivery of home care packages (often requiring care provision ‘out-of-hours’ or at weekends) to be outside their capacity A number of the not-forprofit managers were critical of their current unstable relationship with the HSE, which has been exacerbated by the introduction of home care packages Many notfor-profit directors suspect that the HSE is attempting to introduce new business arrangements between the state and the not-for-profit sector, which could potentially jeopardise their viability and serve to advantage private home care companies Furthermore, a number of the not-for-profit sector representatives stated that a lack of HSE investment to cover administrative, management and support staff costs makes it more difficult to compete with the private sector and provide more flexible round-the-clock care, as required through the home care package scheme © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare Breaking the mould Increasing reliance on private sector providers The private home care sector first emerged in Ireland in the late 1980s/early 1990s This sector had not been explored prior to our research, but anecdotal reports suggest that the sector was in a constant state of flux until the introduction of publicly financed home care packages that resulted in an expansion of demand for private sector care services At the moment, the private providers not have to engage in open competitive tendering Instead, contracts are allocated either on an ad hoc basis directly from the health services administration (the HSE via the LHOs) to the private sector companies who meet basic minimum criteria, or indirectly via the ‘consumer’ who, once entitled to funding through a care package, can choose the provider that best meets his or her needs For all but two private providers interviewed, the HSE home care packages are the main source of their clientele, which in turn means that they are strongly, if only indirectly (via their clients), reliant on public funding Presently the ‘market share’ of the private sector, when compared with the not-for-profit organisations, is small However, a majority of the directors in this sector expressed confidence that thanks to government plans to expand the cash-for-care programme their client base has the potential to expand strongly: We would expect to be caring for about 5,000 individuals in about or years my expectations have gone higher now than the day we started in terms of how quick we can expand and how much the service is needed Effectively I would expect to have 20 offices throughout Ireland [Director, for-profit home care franchise] This increase in the role of the private sector should be put into the context of developments in the public and not-for-profit sectors Direct delivery of public domiciliary care service is very limited in Ireland and takes place via the Health Care Assistants (HCAs), who deliver non-paramedical personal care to older people in their home The main rationales for the introduction of HCAs in 1994 were the increasing demands on Public Health Nursing teams in the community and the realisation that a different kind of care worker (non-medical) was needed to provide personal care In the Dublin area, there are approximately 85 HCAs This number is far from adequate, but recruitment difficulties and ceilings on staff numbers in the public sector mean that the LHOs have not been able to increase their numbers over the last half decade and, consequently, demand for this service outstrips supply As one director of public health nursing put it: We ran a twilight service for years but because we did not have enough staff, the [care staff] were exhausted so the scheme was phased out Subsequently the decision was made that unless the person is terminally ill such a service would not be offered For such a scheme to be viable, you need a dedicated team The not-for-profit sector is currently (and has been since the mid 1950s) the predominate and largest provider of publicly funded domiciliary care The not-for-profit home care sector in Ireland is frequently referred to as the ‘voluntary home care/help sector’ However, the introduction of the minimum wage in 2000 and subsequent professionalisation of the workforce means that the title ‘voluntary’ home care service is a misnomer and should be replaced with the term ‘not-for-profit’ home care service The HSE provides the bulk of the funding for these organisations, as outlined under section 65 of the Health Act 1953 Approximately 1.25 million home care hours are provided by the 28 not-forprofit home care organisations in the Dublin area annually (administrative figures obtained from the Department of Health and Children) The distribution and allocation, however, of these home care hours vary considerably across the different LHO areas, largely reflecting the unsystematic and uncoordinated funding relationship between the HSE and these providers Traditionally, and still in some areas, the not-for-profit providers deliver only domestic care, although recent organisational changes within this sector have resulted in an increasing number of care staff (particularly in the larger organisations) working in a dual capacity, delivering both personal and domestic care Policy implications Our research illustrates that the Irish domiciliary care mix has changed substantially in the past years While not-for-profit providers are still the predominant suppliers of state-funded domiciliary care, the private sector has managed to fill an important niche in the home care market, which neither the not-for-profit nor public sector have been able, or allowed, to supply The new cash-for-care policy (home care packages) is the main driver behind this change, and illustrates the powerful role that public financing plays in altering the profiles of providers and their respective positions of power or weakness Specialisations of the three sectors are to a large extent the result of the differing ways in which the state has channelled funding to the three sectors Whereas funding for the not-for-profit sector is retrospective, i.e largely based on past delivery of a certain number of home help hours, private sector agencies and companies ‘bid’ for a set of care packages, or for inclusion in a list from which care recipients choose their service providers The manner in which funding is channelled to the two sectors creates, therefore, a strong incentive for the private sector to be as flexible © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare 329 Doyle & Timonen as possible, whereas not-for-profit organisations are constrained and ‘dis-incentivised’ by the retrospective nature of the funding arrangement Because both the not-for-profit and for-profit provider organisations are able to operate in a complete or partial ‘vacuum’ in terms of policy guidelines and regulations, they have diversified and established their own procedures and protocols for areas such as staff qualifications and quality controls, tax compliance, hiring and contractual practices, and insurance The extent to which individuals and organisations are left to ‘make up rules as they go along’ is illustrated by the following quote from an interview with a LHO representative: We are chasing some of the larger private care agencies and trying to use those who have insurance and some form of training for their employees, but again no-one is checking up on them as such The way it is going and we use one or two agencies, it will cost a lot and we’ll have to go to tender and we’ll have to draw up standards about how an agency inducts and trains it staff the push has just been to discharge people from hospital these things will have to come into play If the current funding arrangements are maintained, it is likely that the not-for-profit sector and the private sector will continue to evolve along different paths In a more regulated and service user-driven alternative (such as those in operation in Denmark and Germany), any provider that meets quality, training and monitoring requirements would be free to offer its services to individuals who have entitlement to services (see Doyle & Timonen, 2007) The pivotal issue in this regard is the regulation of services and the creation of a level playing field that draws out the strengths of different providers and ensures a greater degree of consumer direction and quality control Undoubtedly, additional oversight and monitoring of public monies invested in both the private and not-for-profit home care sectors will have to be enforced However, policy makers have a difficult task in formulating these monitoring procedures It seems probable that increased regulation of the not-for-profit and for-profit sectors will have substantial financial ramifications Increased regulation in the form of mandatory training and supervision will mean higher overheads for the state, particularly in the current environment where the for-profit providers intimate that they are not prepared to cover the costs of training themselves Furthermore, it will have to be established whether training and monitoring requirements shall be universal among private, public and not-for-profit employees alike, what realistic and desirable minimum training standards are for care workers, and also whether these standards are applicable to all carers even if they only deliver domestic care 330 Whether or not the state will continue to support the position of the not-for-profit organisations is unknown Currently their generic budgets are separate from the home care package budget, but it is difficult to surmise whether these funding streams will continue to remain separate or merge in the coming years The stated intention by the government to extend and roll out more home care packages may have negative ramifications for the not-for-profit organisations if they continue to be awarded in the present uncoordinated fashion A plausible alternative that would protect the not-forprofit organisations is that the state will continue to fund their generic budget enabling them to continue to deliver domestic care and low-level personal care and contract out more intensive personal care to the for-profit sector However, even if this is the case, it is probable that more formal standardised service level agreements will be negotiated with the not-for-profit providers The ‘care mix’ of public, for-profit and not-for-profit providers is likely to evolve, given the complexity of the problems of older people living at home and the projected rise of older people in the population It is estimated that the demand for domiciliary care in Ireland will increase by 100 to 215 per cent by the year 2051 (Hughes, Williams & Blackwell, 2005) Such a rise in the demand for domiciliary care services, coupled with fiscal pressure at a national level, could result in a rationing or targeting of services to those deemed most in need If publicly funded care is delivered only to older people with extensive care needs, it would seem that the requirement for dual capacity carers, as currently available in the private sector and available only to a limited extent in the notfor-profit sector, will be required Were this to happen, the majority of the not-for-profit organisations would have to either radically restructure or cease to operate In such a scenario, persons with less extensive care needs would be left without any public assistance and therefore have to rely on informal family care, the private sector or care obtained via the grey market In the light of experience in other countries that have embraced quasi-markets in the care sector, it appears that the central issue of quality is not straightforwardly related to a pluralism of providers From both the perspective of the recipient and the care worker, quality has been found to correspond more closely to the amount of time the carer is allowed to spend with the client, the ability of the recipient to direct the work of the carer (Stack & Provis, 2000; Staehr, 2005), and the age and employment conditions of the care worker (Netten, Sandhu & Francis, 2006) Independent budgets are currently being piloted in 13 local authorities in the UK (Glendinning, 2006) In the UK context, this signifies a departure from quasi-markets to a more open market system where the care recipient, instead of a ‘third party proxy’, chooses both the care tasks © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare Breaking the mould (including transport and help with leisure and recreational activities) and the service provider (including informal carers, pet minders, taxi drivers or other service provider of choice) Preliminary analysis from this project elucidates the complexity of these new care systems, particularly for frail or cognitively disabled persons, but also reflects the growing awareness that care recipients want to actively control their own care arrangements (Glendinning, 2006) In Ireland it is highly probable that the debate on the advantages and disadvantages of opening up the care market and offering greater consumer choice to home care recipients will continue into the foreseeable future Whatever the outcome of this debate, it is imperative that the state does not relinquish its responsibility to monitor the delivery of home care services that it finances both directly and indirectly, the level of competition between the various providers, and the ability of providers to compete as a consequence of quality and cost stipulations Conclusion This article has illustrated how the current form of the domiciliary care sector in Ireland is more the result of gradual evolution than systematic planning The rise of the private home care sector over the last decade is a highly significant development that has its origins both in the limited funding made available to the public and not-for-profit sectors and in the increased emphasis on cash-for-care (Timonen et al., 2006) The channelling of public funds to private companies is, therefore, the newest and still evolving manifestation of the state’s role in the delivery of domiciliary care services and arguably one that has new and different implications from the point of view of monitoring and quality controls As Bahle (2003) argues, forces such as privatisation and decentralisation are not necessarily the antidotes of integration and control of social care systems In the case of Ireland, too, it is possible that more integrated and better controlled systems of home care will emerge from the current highly complex and unregulated system Lastly, the complexity of home care also poses a challenge for regime theorists A good regime classification is able to serve as a useful simplification of reality The question must be asked: Is it possible to construct social care regime classifications on the basis of the kind of complexity that is evident in the case of Ireland and many other countries where the state both provides and finances care, increasingly through a multitude of private and not-for-profit organisations that exist alongside informal and grey market provision of care? While much valuable work has been done by those attempting to construct such classifications (e.g Anttonen & Sipila, 1996), the area of social care has rapidly become more complex, and the classifications developed in the not too distant past are arguably already out of date The task of developing social care regime classifications that serve as useful simplifications of the complex reality poses a considerable challenge to social scientists References Anttonen A, Sipilä J (1996) European Social Care Services: Is it possible to identify models? Journal of European Social Policy 6: 87–100 Bahle T (2003) The changing institutionalisation of social services in England and Wales, France and Germany: is the welfare state on the retreat? Journal of European Social Policy 13: 5–20 Bönker F, Wollmann H (2005) Public Sector Reforms and Local Government in Germany: The Case of Local Social Policy In: Hoffmann-Martinot V, Wollmann H, eds Comparing Public Sector Reforms in France and Germany VS, Wiesbaden Curtice L, Fraser F (2000) The domiciliary care market in Scotland: quasi-markets revisited Health & Social Care in the Community 8: 260–268 Donoghue F (2001) Volunteering in the Republic of Ireland: History, Socio-Economic Context and Meaning Paper presented at Tipping the Balance Conference UN International Year of Volunteering Doyle M, Timonen V (2007) Home Care for Ageing Populations A comparative analysis of domiciliary care in Denmark, Germany and the United States Cheltenham, Edward Elgar Frade C, Darmon I (2005) New modes of business organization and precarious employment: Towards the recommodification of labour? Journal of European Social Policy 15: 107–121 Glendinning C (2006) Improving choice and control in support for older and disabled people: what are the implications of new developments in England? Paper Presented at the XVI ISA World Congress of Sociology 24 June–29 July, Durban, South Africa Health Service Executive (2002) Acute Hospital Bed Capacity : A National Review Dublin, Stationery Office Hirschman AO (1970) Exit, voice and loyalty Cambridge, MA, Harvard University Press Hughes G, Williams J, Blackwell S (2005) Demand and cost of long-term care services, Country report: Ireland Dublin, GALCA project publication, Economic and Social Research Institute Lundstrom F, McKeown K (1994) Home Help Service for Elderly People in Ireland Dublin, National Council for the Elderly Netten A, Sandhu J, Francis J (2006) Home care workers and quality of care Paper presented at the XVI ISA World Congress of Sociology 24 June–29 July, Durban, South Africa Propper C, Le Grand J (1997) Central Government and QuasiMarkets: The Case of Health Care Discussion Paper No The London School of Economics and Political Science Ranci C, Pavolini E (2006) New trends of elderly care policy in Western Europe: towards a social market of care services? Paper presented at the XVI ISA World Congress of Sociology 24 June–29 July, Durban, South Africa Rostgaard T (2004) The construction of consumerism – Free choice of care for the elderly in Denmark Paper presented at the Symposium ‘Consumerism of care for the elderly’ The Danish National Institute of Social Research (SFI), Copenhagen, 30 August Stack S, Provis C (2000) Tensions in flexible employment agreements for caring labour In: Burges J, Strachen G, eds Proceedings of 14th AIRAANZ Conference, February 2–4; Newcastle, NSW, University of Newcastle; vol 2, pp 162– 171 © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare 331 Doyle & Timonen Staehr K (2005) Integration inden for social- og sundhedsområdet [Integration in the areas of health and social welfare] Forbundet af Offentigt Ansatte, Denmark Timonen V (2004) Evaluation of Home Care Packages Eastern Regional Health Authority, Dublin Timonen V, Convery J, Cahill S (2006) Care revolutions in the making? A comparison of cash-for-care programmes in four European countries Ageing and Society 26: 455– 474 Timonen V, Doyle M (2007) Worlds Apart? Public, Private and Non-Profit Sector Providers of Domiciliary Care Services for Older People in Ireland Journal of Aging Studies 21(3): 255– 265 332 Timonen V, Doyle M (2008) From the Workhouse to the Home: Evolution of Care Policy for Older People in Ireland International Journal of Sociology and Social Policy 28(3/4): 76– 89 Timonen V, Doyle M, Prendergast D (2006) No Place Like Home: Study of Domiciliary Care Services for Older People in Ireland Dublin, Liffey Press Wiener JM, Evans Cuellar A (1999) Public and Private Responsibilities of Home- and Community-Based Ser vices in the United Kingdom and Germany Journal of Aging and Health 11: 417– 444 © 2008 The Author(s) Journal compilation © 2008 Blackwell Publishing Ltd and the International Journal of Social Welfare