As mentioned above, the relational aspects of care could impact on choices and satisfaction of users via the identity of the carer and the definition of care tasks. Focusing on older users of PBs in England who have taken the benefit as cash, i.e. as a DP, and building on the different possibilities users have to deploy DPs, the main research question of this thesis is:
How and why are users’ experiences of care affected by choosing to hire a personal carer rather than to acquire services from a formal provider?
Drawing on the theoretical insights reviewed in Chapter 2, it is hypothesised that hiring a PA or paying informal carers could entail higher user satisfaction than contracting a formal service provider, in two possible ways:
• By allowing the user to choose from whom to receive care, which matters to the user given the relational nature of long-term care – hypothesis 1, as described in detail below.
• By increasing the leeway that users have in defining what, when and how care is provided – hypothesis 2, as described in detail below.
Hypothesis 1. The possibility to choose and employ one’s own carer would entail higher user satisfaction because users value the relational aspects of care and the possibility to choose from whom to receive care.
Regulated cash benefits such as DPs give users the ability to choose from a more diverse range of care providers, as DPs may remove barriers to entry faced by providers. One example is associated with the expertise or organisational capacity needed to successfully bid for contracts tendered by public authorities. This allows for the specialisation of smaller providers in niche markets of care (Baxter et al. 2011) or for individual PAs to enter the market. This in itself could entail increased user satisfaction, by enhancing competition and providing a better match between users’ preferences and the care provided as users with DPs are able to act as empowered purchasers.
The case made here, however, is that what is particularly valued by users is the ability to choose the identity of their carer and establish, maintain or develop a rapport with the carer (the latter case if the carer is already known to the user). This stems from the relational nature inherent to caring highlighted in Chapter 2. According to this hypothesis, the relational nature of caring is valued by those in need of care. The different modes of deployment of PBs
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provide users with potentially different degrees of command over the identity of their carer, for example, by hiring as a PA someone they may or not have previously met. The relational nature of care could thus also impact the choice of deployment. Hiring someone the user knows, or who is already caring for the user, may be a way to deal with some of the uncertainty associated with both the experience good nature of care and the unwillingness or inability of users to change provider frequently. This is particularly relevant in the context of imperfect information (see Chapter 2). In this case, the user is already knowledgeable about at least part of the relational component of care26. Even if the user is not already acquainted with the carer, having the possibility to choose the latter’s identity could still allow the user to develop and invest in the relational aspects of care, as well as gather further information beforehand through the recruitment and hiring process (e.g. by conducting an interview). As relationships may change over time, and may indeed require time to develop, it is also salient for hypothesis 1 to analyse how the relationship nature of care evolves over time.
Hypothesis 2. The possibility of hiring a PA or paying an informal carer increases user satisfaction by allowing users to better shape the care they get to their needs and preferences.
The experience good nature of care is not confined to its relational component, but applies also to the tasks performed by the carer. A greater command over the identity of the carer may allow users to better shape the tasks or the timing of care they receive or both, i.e. the when, how and what (Le Grand 2007). This means that users may be more able to shape the care they receive to their preferences and needs, while even accommodating for changes in these same needs and thus derive greater satisfaction from this arrangement. This could take place because users have greater bargaining power with a PA whom they directly employ and manage themselves, or because the latter may be faced with less stringent company regulations regarding the delivery of care. Users may also derive more satisfaction from the simple fact of being able to choose, or having command over choice – i.e. the intrinsic value of choice. It is not, however, satisfaction attached to the mere possibility of choosing that this study aims to analyse here. It is rather the satisfaction derived from receiving care that best suits the users’ needs and preferences.
26 Furthermore, the user could also be knowledgeable about the ability of the carer to provide care according to the user’s needs and preferences, although this would not pertain directly to the relational nature of care.
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Building on the gaps identified in Chapters 2 and 3, this Chapter formulated the research question and hypotheses that will be empirically analysed in this thesis. The next chapter will detail and justify the methods employed to investigate this research question.
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