Stories of stabilisation: creating, implementing and resisting the National Care Homes Contract in Scotland

Abstract

In Scotland, as in many other welfare states, the organisation of care homes for older people takes place in a highly contested space where debates about demographics, limited financing and changing expectations of the state compete with questions about choice, rights, equality and models of care. These services intersect the formal boundaries of the public and private sectors as well as the lines between public and private life. The production of care home services crosses several policy spheres, including local governments, the devolved Scottish administration and the UK government and includes numerous organisational bodies, such as care home providers, the care regulator and the voluntary sector. At the centre of this intersection lies the work of contracting and the production of a national framework agreement for care home services in Scotland called the National Care Homes Contract (NCHC). This contract is both the bridge between the public and private sector and a formalised link between the individual and the institution. In this thesis, I depict the NCHC document as an artefact which links these spheres and the work of contracting as the practice of maintaining that relationship. I take up the concept of boundary objects and suggest that the NCHC functions as a bridge between multiple fields of practice and is a useful tool for understanding the competing perspectives of people who plan and deliver care home services in Scotland. In this thesis, I reveal the different, and at times competing, perspectives which surround care home services for older people and the stabilising work that is undertaken to manage these differences. This research utilises an interpretive approach to examine the creation and ongoing implementation of the NCHC. Fieldwork for this research was conducted over 12 months and includes interviews with local authority planners and contract managers as well as care home owners and managers from the independent and third sector, each of whom do particular kinds of work to create, implement and use the text. A textual analysis of the framework agreement is also used to support this research. I examine the work of making, re-­‐making and using the NCHC at three levels: national policy actors, local government contract managers, and managers of local care homes. Each group undertakes a kind of policy work: first to create the NCHC, then to implement it in local jurisdictions and finally to use it within local service delivery. Stabilising work takes three primary forms: text work designed to stabilise meaning, relational work designed to translate meaning across boundaries of practice, and ethical work, a value-­‐ based emotional work that underpins the first two kinds of everyday labour. I suggest that this work is first and foremost driven by a need to stabilise the care home sector and that it is deliberative in nature and conflict ridden such that the use of the contract in practice is often resisted. In working to stabilise this system, the values of this work come into conflict – triggering both caring and resistance responses within the sector. In giving an account of stabilisation, I provide a micro-­‐sociology of the meaning making, relationship-­‐building and conflict which underpins policy work. I draw conclusions from this about the discretion of policy actors at all levels of the system, the rational-­‐technical and emotional nature of their work, and the unexpectedly deliberative policy space of contracting in Scotland.