What do private providers of home care want? An analytical framework

ABSTRACT

Private for-profit home care providers are key participants in European long-term care regimes. Yet, their policy preferences toward market making and market development remain under-researched. We present an analytical framework that identifies and explains those preferences. It outlines three key types of policies that shape home care markets: regulatory, financial and labour policies. We illustrate private providers’ views on those policies by reference to Ireland’s home care regime. Irish home care is a compelling case for this study. A major package of regulatory reforms is currently being introduced and private providers have outlined clear preferences about it. Our paper is based on interviews with 14 leading individuals involved in the home care sector. We find and explain how private providers wish to increase regulation over their activities; to split purchaser and provider roles; to reduce private forms of financing; and to expand the pool of labour available to them. We discuss how those preferences shed light on the political economic power dynamics that shape the Irish care regime. Our analytical framework may be applicable to other welfare markets at different stages of development and in other institutional contexts.

KEYWORDS:

• Long-term care
• marketisation
• welfare markets
• private providers
• care regimes

Introduction

European long-term care marketisation and associated policies of outsourcing, contracting out and cash-for-care schemes have been studied extensively (Brennan et al., 2012; Da Roit & Le Bihan, 2010; Ranci & Pavolini, 2013). A key consequence of those reforms has been the growth of private for-profit home care providers that now account for a significant portion of service delivery in many countries (throughout this paper we use the terms ‘private’ and ‘commercial’ interchangeably to refer to private for-profit providers) (European Commission, 2022). Yet, relatively little research has focused on commercial providers themselves, prompting calls for in-depth investigation (Anttonen & Meagher, 2013; Mercille & O’Neill, 2021). Existing work has examined their corporate and marketing strategies (Leiber et al., 2021), their lobby groups (Ledoux, Encinas de Muñagorri, et al., 2021) and their power to influence policy (Mercille & O’Neill, 2022). Nevertheless, we lack analyses of the key forces and interest groups that constitute the ‘welfare industry’ (Pieper, 2018) that has become central to long-term care regimes.

Accordingly, we document private providers’ policy preferences with respect to the marketisation reforms currently underway in Ireland’s home care regime. Care regimes are part of national welfare regimes and refer to the ways in which caring responsibilities are allocated in a country between key actors such as the state, commercial companies, non-profit organisations and the family (Bettio & Plantenga, 2004; Fischer et al., 2022; Giordano, 2022). This paper focuses on private providers and their preferences. Answering this journal’s recent call for political economy perspectives (Speed & McLaren, 2022), we draw from the literature on the sociology of markets, which maintains that markets are both dynamic (Beckert, 2009; Fligstein, 2001) and ‘fundamentally systems of power’ (Fligstein, 2001). Commercial, state, non-profit entities and service users attempt to shape rules and normative understandings about what is exchanged in markets, how competition is regulated and who can buy and sell goods and services (Aspers, 2011). This applies to welfare markets, defined as ‘politically shaped, regulated, and state-supported markets, which provide social goods and services through the competitive activities of non-state actors’ (Ledoux, Shire, et al., 2021).

We discuss how private providers’ policy preferences shed light on the shifting power dynamics among key actors to shape care regimes in line with their interests (Mercille, 2024a). For example, care regimes can be dominated or controlled by the state, private providers or service users (Gingrich, 2011). The sections below discuss those power relations in Irish home care. The case study is pertinent because Ireland is currently in the process of finalising a major reform called the ‘home care statutory scheme’ (Sheehan & O’Sullivan, 2023). This scheme would bolster home-based care significantly by providing entitlements to services, resulting in increased resources allocated to the sector, along with tighter regulations on service provision. Private providers have voiced their interests in relation to the scheme, which thus constitutes a compelling case to study their views on market development in long-term care.

We begin by presenting an analytical framework that identifies private providers’ preferences in market making and market development in home care. After this, we outline the main features of Ireland’s current home care regime. The remaining sections identify and explain private providers’ key policy preferences and discuss their implications for the evolution of the long-term care market, including the shifting balance of power among its constituent actors.

Analytical framework

Several authors have presented frameworks to classify long-term care regimes and welfare markets according to their key characteristics and actors (Fischer et al., 2022). Our framework (Figure 1) modifies the work of Ledoux, Shire, et al. (2021) and focuses on private providers’ preferences with respect to government policies that organise and support long-term care market development. It identifies three key types of policies: (1) financial, (2) regulatory, and (3) labour policies. It then outlines a number of specific issues under each of those categories about which private providers have policy preferences and over which they compete with other actors to attempt to shape home care markets in line with their interests.

Figure 1. Policies shaping home care markets.

Regulatory policies lay out rules about competition and quality in care services. Providers decide whether or not to enter the market depending on their ability to meet those requirements while making an acceptable profit. A range of instruments, actors and institutions can facilitate the purchase and delivery of care services. These include vouchers or cash allowances to clients (Ranci & Pavolini, 2013); brokering agencies matching care workers to families (Leiber et al., 2021); and state agencies allocating clients to providers, as in Ireland. Providers can be licenced by a state or independent body upon meeting specified quality and operations criteria, and a regulator can periodically oversee the quality of services delivered while providers are in operation, through inspections and surveys. The public provider may act as both a provider of care services and a buyer of services, or those functions may be split (Le Grand & Bartlett, 1993). Finally, effective regulations to prevent cream-skimming by providers (e.g. selecting clients that are cheaper to care for to boost profits) affect which organisations choose to enter the market. Regulatory policies influence the balance of power between actors in multiple ways. For example, a purchaser-provider split strengthens commercial companies relative to the public provider, the latter having to operate as one provider among many without the advantages of simultaneously controlling demand (purchasing). In contrast, strong regulations imposing high barriers to entry into the market or preventing cream-skimming weaken private providers; however, they may still be desired by dominant private providers to eliminate some of their competitors unable to fulfil those requirements.

Financial policy instruments apply to service demand and supply. On the demand side, clients may pay out-of-pocket or be entitled to ‘personal budgets’ and cash-for-care programmes (Da Roit & Le Bihan, 2019), or alternatively, the state may provide tax rebates for clients’ expenses (‘fiscalisation’) (Carbonnier & Morel, 2015). On the supply side, providers can be paid directly by the state, which can also subsidise their workers. Financial policies have consequences for the politics of the market, its development, and the power balance between its constituent actors. For example, the state tends to gain leverage over private providers if it funds them directly, especially if public funding comes attached with conditions. Conversely, if the state funds the demand side by giving cash allowances to clients to spend on providers of their choice, the state relinquishes some control over commercial providers.

Labour is central to home care and we divide relevant policies into two categories: those related to the labour supply (number of available workers and their training/skills level) and those that pertain to working conditions. A large available pool of labour and low-skilled workers tends to lower labour costs/wages, which benefits private providers. Indeed, there is a global old-age care industry that sends migrant workers from poorer countries to more wealthy nations (Horn et al., 2021). However, investing in worker training can be profitable if it increases quality of care – although private providers may or may not benefit financially depending on how much training costs and who pays for it (e.g. the state, private providers, etc.). Secondly, it is well documented that care workers face difficult working conditions due to marketisation reforms, New Public Management doctrines and funding cutbacks (Strandell, 2020). Precarious working conditions increase private providers’ power within a care regime by giving them more flexibility to manage their staff according to business needs. On the other hand, poor working conditions can also impede on companies’ ability to recruit workers who possess the required skills.

Irish home care

Ireland’s care regime has traditionally relied significantly on informal care, religious organisations and the family, similarly to the situation in some Southern European countries (Daly, 2018; Ilinca et al., 2015). However, the state also plays an important role and has developed a substantial public supply of long-term care (domiciliary and residential) over the last several decades (Ariaans et al., 2021). There is no social insurance system and home care services remain largely unregulated, fragmented and of uneven quality (Kiersey & Coleman, 2017). In recent years, privatisation and marketisation have grown significantly (Lolich, 2019; Mercille, 2018, 2024b; Mercille & O’Neill, 2021) and it is on this aspect of the Irish care regime that we focus.

Most of the care provided professionally is paid for by public funds spent on delivery by a mixed system of public, private and non-profit providers. The public provider is the Health Service Executive (HSE) and it coordinates the home care sector. It delivers care itself and selects private and non-profit providers to be put on a tender based on a range of criteria. The HSE assesses clients’ needs and allocates them to itself (public provision) or to private or non-profit organisations on the tender. When care is thus outsourced, the HSE pays providers directly for a specified number of hours of care for a client.

In addition, there is a private pay market in which clients pay providers out-of-pocket, often to top up hours paid for by the HSE. The government subsidises out-of-pocket payments as clients can claim up to 40% tax relief on their expenses, a substantial support for private companies (Mercille & O’Neill, 2021). Reliable data are unavailable, but anecdotal evidence suggests that large private providers currently derive about 25% of their income from the out-of-pocket market while the proportion is often higher for small providers (Mercille & O’Neill, 2021).

There is no licencing system to determine which providers can operate and there are few obstacles to setting up a home care company, of which there are over 150 today, most being small and operating in local or regional markets (Department of Health, 2022). Private provision is dominated by a few global franchise chains (e.g. Home Instead Senior Care, Bluebird Care). Private providers are organised and represented through their lobbying group, Home & Community Care Ireland (HCCI), which includes all large companies operating in the country. Its members deliver 90% of home support hours provided by for-profit providers under the state’s home support scheme (Home and Community Care Ireland, 2019). It is estimated that approximately 10,000 home care professionals work for the public provider (HSE), up to 14,000 are employed privately (the bulk of which for HCCI members), and 3,500 work for non-profit organisations (Murphy & O’Sullivan, 2021). Care work is difficult and precarious, particularly with private providers, while the HSE offers relatively more advantageous and stable employment conditions (Mercille et al., 2022; O’Neill et al., 2023).

Irish home care is currently transitioning from a ‘new’ to a ‘stable’ market status (Fligstein, 2001). A new market is ‘fluid and is characterized by multiple conceptions of control proposed by actors from various firms’, whereas a ‘stable market requires the construction of a conception of control to promote noncutthroat ways to compete’ that are accepted by all key actors (Fligstein, 2001). Indeed, over the last two decades, the number of private providers has mushroomed following the government’s establishment of the ‘home care packages’ scheme in 2006, through which a large portion of home care hours has been outsourced to private companies (Mercille & O’Neill, 2021). Private providers now account for 61% of total hours delivered (a small part of this is delivered by non-profit organisations) while the public provider (HSE) accounts for 39% (Health Service Executive, 2023a).

However, more recently, the unregulated nature of home care, the large number of companies and uneven service quality have been criticised, leading to the major reforms currently in preparation (the home care statutory scheme and associated regulations), which would stabilise the market. Indeed, since the early 2000s, a number of measures to regulate the activities of private providers have been proposed and implemented, but with variable effectiveness in ensuring stability and quality of services (National Economic & Social Council, 2012). First, regulations are contained in tenders and service-level agreements (SLAs) between home care providers and the HSE. Second, HCCI has voluntarily drafted and implemented standards that its members have to follow (Home and Community Care Ireland, n.d.). Third, private providers also apply standards developed by private sector companies, including franchise agreements and accreditation regimes (e.g. JCI, Joint Commission International). However, those regulations have been relatively ineffective in bringing the industry to desired standards (Daly, 2018; Health Information and Quality Authority, 2021).

In order to stabilise the market, private providers and other stakeholders now support the upcoming statutory scheme, which would bolster home care by providing a statutory entitlement to it (as of now, home care is a discretionary service in Ireland and there is no automatic entitlement to receive the service). It would introduce stronger regulation of services. At the time of writing (January 2024), the scheme’s precise parameters are being finalised; draft regulations have been published and stakeholders have provided feedback to the government (Houses of the Oireachtas, 2023a; Sheehan & O’Sullivan, 2023). It thus constitutes a pertinent case to study commercial providers’ preferences and interests within the Irish home care regime.

Methodology

To examine private providers’ policy preferences, interviews were conducted with 14 individuals (Figure 2) occupying positions of leadership in the home care sector, in particular, with members of HCCI and the Home Care Providers Alliance (HCPA). The HCPA is an organisation established recently by leading private and non-profit providers to lobby for the introduction of a home care statutory scheme (HCPA, 2022). The HCCI and HCPA overlap considerably in membership and policy preferences and represent all leading companies in the country. This paper focuses on those organisations instead of smaller companies that operate locally and that are more marginal to national strategic debates. Thus, our sample is considered adequate to identify and explain industry preferences regarding market development.

Figure 2. Interviewees’ profile.

Interviewees were identified through a mixture of convenience and snowball sampling. Semi-structured interviews took place via Zoom between January 2022 and January 2024 and each interview lasted between 20–90 minutes. Questions explored private providers’ views and preferences regarding the main regulatory problems facing the home care sector today; the roles that the state and public provider should play in the market; the type of regulation that private providers would like to see enacted; the mode of financing they favour; and the policies that should be implemented regarding the supply of care workers. Ethical clearance for the project was granted by University College Dublin’s Human Research Ethics Committee (HS-E-22-04-Mercille, 13 January 2022). All interviewees provided informed consent to take part in this study. Relevant documentary sources produced by the industry were also consulted to provide context to our analysis and interviews.

Private providers’ policy preferences

Regulation

In interviews, private providers insisted that the home care market now requires stronger regulation and standards. The problem is that anybody can set up a home care company with little supervision in the private pay (out-of-pocket) market and regulations associated with the tender are too weak. In short, ‘since we have a completely unregulated market, it’s akin to the Wild West’ (interviewee 6).

According to private providers, without stronger quality regulation, a substantial unregulated gig economy could emerge in the private pay market, in addition to reducing quality among providers on the tender. As one interviewee explained:

unless you get to regulation quickly, there is a danger we will see the development of the gig economy given the deficits and availability of home care that we currently have … and that would have huge risks for quality and safeguarding. (interviewee 6)

In other words, ‘bad apples’ risk undermining the reputation of the industry. Thus, established private providers ‘welcome regulation’ (interviewee 8) because it ‘perhaps is going to protect providers themselves from unscrupulous providers that are actually out there’ (interviewee 8). As several explained:

And that’s why I would like regulation, I want statutory instruments, because sometimes companies like ours, I feel brought down by companies that don’t do what they’re supposed to and they don’t do within the right way and again that’s a byproduct of that deregulation [i.e. the growth of outsourcing in previous years] that led to lots of these small private regional providers cropping up that, they’re just not at the same level. (interviewee 2)

As a result:

I have to compete today against unmanaged services who have no clinical governance, no corporate governance, we have companies that we have to compete against for cases, who are literally working and registered from their kitchen. (interviewee 2)

Importantly, voluntary codes of regulation adopted by private providers have remained too superficial, lacking enforcement power and the capacity to coordinate with other key parts of the health and social care systems. Thus, regulatory supervision and enforcement should be the responsibility of an authoritative body overseeing the home care sector as a whole. As one private provider explained:

Can voluntary codes be enforced to the same degree as statutory ones? My belief is they cannot … Organisations, whether statutory or non-statutory, including the HSE, don’t always comply with HSE home support service standards, let alone voluntary codes. (interviewee 5)

Second, private providers argue that a licencing system should approve companies to operate in the market if they meet certain service quality benchmarks. Licenced providers would compete based on the quality of their operations and clients’ choice of providers (see below). The licencing system would also transform the existing system by splitting the roles of purchaser, provider and regulator. Currently, the HSE both commissions (i.e, purchases), finances and provides home care. Thus, for private providers, ‘the HSE is wearing too many hats’ (interviewee 7) and it ‘has a monopoly’ (interviewee 5) in home care, so ‘we need the HSE to get out of commissioning’ (interviewee 5). Instead, private providers want to compete against the public provider on an equal footing and they want all providers regulated by an independent regulator. They argue that the existing system gives unfair advantages to the HSE, which has, for example, priority over other providers to deliver home care.

Thirdly, private providers wish to change drastically the nature of competition by basing it on quality instead of price, the latter, in their view, having been over-emphasised in the tendering system (until recently, see below). They believe this is detrimental for two reasons. For example, it leads certain providers to propose unrealistically low prices to get on the tender, forcing other providers to do the same. As many have noted, ‘this race to the bottom on pricing has been a negative experience’ (interviewee 8). As one explained, it has been:

largely driven by the ability of people who had no footprint or no capacity to deliver, being able to enter into a price-based competition, and underbid, but then not deliver, and in the process, force everyone else to bid lower than they should bid … So the view is that price competition has been self-defeating. (interviewee 6)

Moreover, price competition leads to instability when providers ‘poach’ care workers from other private providers by offering more attractive wages, which happens regularly. This happens when providers that tender at a high price are then paid more per job by the HSE, and then have the capacity to pay their workers more compared to providers that got on the tender by offering to do the jobs at a lower price. One private provider summed up the situation as follows:

There shouldn’t be a competitive nature to home care, it’s wrong that you make companies drive down costs … Why don’t you set a market rate for home care, so you say, we will pay €28 per hour for home care. We expect you to have clinical governance, corporate governance, we expect you to have these type of staff … So the HSE can set the boundaries, the framework, to which we all operate … it gives price security, pay security, it means that we’re not competing. (interviewee 2)

In short, in key respects of regulation, private providers wish to reduce marketisation. As will be seen below, their wishes have now been realised in the latest tender of August 2023 that specifies that they are now all paid the same amount for home care jobs (€31), which should reduce price competition considerably (Health Service Executive, 2023b).

Financing

As part of their preferred statutory scheme, private providers favour publicly funded personal budgets given to clients to allow them to exercise consumer choice among the range of licensed providers available (private, non-profit, public). Private providers thus wish to reorientate funding away from a supply-side model in which the state funds companies directly, to a demand-side model under which clients are funded. However, if personal budgets were not implemented, providers are open to considering other financing mechanisms. Their aim is to ensure that sizable and stable funding is allocated to the statutory scheme, which could be accomplished through various funding models, for example, ‘primarily via a general taxation model, supplemented with some modest means-tested co-payments’ (Home and Community Care Ireland, 2019).

Interestingly, other funding models are assessed as inferior. For example, out-of-pocket payments for clients with no public funding are not desirable because they ‘are generally not an effective way of raising large sums of money on the scale needed for a statutory scheme for home care’ (Home and Community Care Ireland, 2019). Nevertheless, private providers argue that existing tax relief should be maintained for clients who may wish to buy home care out-of-pocket (Home and Community Care Ireland, 2019). Importantly, if means-tested co-payments by clients are to be introduced to supplement general taxation, ‘it is vital that clients be charged minimal costs’ and that ‘payments should be progressive’ and waived for low-income clients (Home and Community Care Ireland, 2019). In other words, private providers are calling for a scheme that is funded generously by the state and provides for significant amounts of home care services, a large portion of which they would deliver. As one interviewee stated, the scheme would give private providers more ‘certainty about the volume of hours of home care work they will do’ (interviewee 7).

Labour

Home care currently faces a shortage of care workers as well as waiting lists for publicly funded home support of some 6,000 people (Houses of the Oireachtas, 2023b). Accordingly, private providers wish to increase the labour supply available for home care because one of ‘the most important challenges with the home care market in Ireland is a lack of capacity to meet need, and if you want to meet need, then you have to address the supply side, and fixing the supply side is about a sustainable career structure’ (interviewee 6).

Thus, private providers argue that work permits should be issued to non-EEA (non-European Economic Area) home care workers (Home and Community Care Ireland, 2019). The Irish government had for long declined to do so, but it recently issued 1,000 such permits for non-EEA workers given the acute labour shortages in home care (Department of Enterprise, 2022), a measure welcomed ‘cautiously’ by private providers (Wright, 2022), pending its longer-term implementation. Recruiting from non-EEA countries increases the supply of workers and lowers costs (all else equal).

Second, private providers wish to see changes to the welfare benefits system, which hinders their ability to recruit workers (Home and Community Care Ireland, 2019). At present, individuals receiving the Jobseeker’s Allowance are only permitted to work up to three days a week, receiving the allowance on the days they do not work. This disincentivises them from working part-time each day of the week, a schedule common in home care, which restricts the labour pool available to the industry (Department of Health, 2022). Our interviewees explained that the government is reluctant to change welfare rules because although a more rational system could be implemented for the home care industry, the new rules would likely cause challenges in other economic sectors.

In terms of working conditions, private providers state that they want home care to offer sustainable careers and call on the government to give them more money so that they can provide better terms to their workers. The issue surfaced with the latest tender of August 2023 which compensates all providers on the tender with a common hourly rate of €31, with the condition that they pay their workers a living wage. However, private providers regret the fact that the living wage remains poorly defined and that the payments they receive are not indexed to its variation due to inflation (Home and Community Care Ireland, 2023). Moreover, private providers do not believe that unionisation of the workforce is an appropriate solution to improve working conditions (the private providers’ workforce is largely non-unionised in Ireland, but it is unionised in the public provider, the HSE). They argue that if the right regulations are in place, there is no real need for unions, as one interviewee explained:

So I just don’t see the need in a proper functioning economy and a proper functioning service for unions, if you’re looking after your staff and doing the right things by your staff and adhering to the law, I don’t see why you need collective bargaining and things like that. (interviewee 1)

In general, private providers have called for an expansion of home care services to cover mental and social needs in addition to physical needs; more time for carers with clients; better pay and grade pay as competences rise; and they oppose casual ‘if-and-when’ contracts because they are unpredictable for workers (Home and Community Care Ireland, 2019). In other words, the preference is for better careers, funded by increased public funding.

Discussion

The above section has outlined commercial providers’ preferences with respect to reforms in a time of transition between a ‘new’ and ‘stable’ market (Fligstein, 2001). Here, we discuss those preferences and their implications for the power dynamics in the Irish care regime. It is important to underline the fact that while those interpretations apply to the Irish context, private providers’ policy preferences in other regimes are expected to vary due to differences in historical and institutional contexts.

First, private providers are calling for tighter regulation of their activities, which is an interesting finding because commercial entities are often viewed as advocates for deregulation and ‘free market’ ideologies – whereas as the evidence from this study shows, they wish to constrain the market in several ways. This is an important preference at the current stage of market development (transitioning from ‘new’ to ‘stable’) to stabilise, or dampen, competition (Fligstein, 2001). Indeed, although a market needs competition to foster capitalist growth, companies have an inherent interest in shielding themselves from competition to prevent price wars and reduce uncertainty (Beckert, 2009). An unregulated environment in Irish home care results in chaotic developments and makes it more challenging for business to plan for growth. As mentioned above, private providers fear, for example, that weak regulation could result in the growth of the gig economy in care services. In Ireland, online platform companies where service users can find carers are few and relatively small but there are many local companies. It is difficult to ascertain the extent to which these would grow absent regulation, however, tighter regulations would certainly reduce their number because many would be unable to meet regulatory requirements due to lack of resources.

Another reason why companies support strong regulation is that larger providers, which dominate the private home care sector, enjoy an inherent advantage to meet regulatory requirements. They have the administrative resources to process large amounts of paperwork, run extensive compliance checks, and meet legal and governance requirements. This is not always the case for smaller for-profit and non-profit providers. Indeed, it has been a factor in the displacement of non-profit organisations by private companies in recent years, as the former often did not have the financial resources of large multinational chains that are necessary to operate in an increasingly commercialised sector (Mercille & O’Neill, 2021).

Thus, the essential role of the state or an independent body to regulate the Irish care regime must be emphasised. Voluntary codes of regulation by the business sector are seldom effective as some companies may ‘cheat’ and overall enforcement is difficult to accomplish, as analysts have pointed out long ago (Kolko, 1965). This is also the situation in Irish home care, explaining private providers’ calls for binding regulation enforced by an authoritative body.

As seen above, private providers wish to shield themselves from market forces by eliminating the ‘price wars’ they say have led to instability. In fact, the latest tender (2023) has met their requirements on this front as all providers on the tender will be paid €31 per hour (Health Service Executive, 2023b). This is a key concession to private companies that our interviewees recognised will move competition away from price and towards criteria like quality and governance. This change should thus bolster the power of private providers in home care because they will benefit from a more stable business environment while the reduction in price-based competitive pressures should increase providers’ margins (all else equal). It remains to be seen how this development will unfold in time.

Second, private providers’ insistence on splitting the functions of purchaser, provider and regulator illustrates that they remain committed to certain key elements of marketisation in home care, even though they simultaneously seek to blunt some market forces. A purchaser-provider split would subject the public provider to more competitive forces, which would likely result in private providers growing their relative market share. It would mark a shift in the current balance of power, in which the public provider oversees the market and allocates funds to private providers, giving it directional power over companies.

Third, private providers’ preferences about funding models reveal their wish for increased and predictable amounts of public funding. Indeed, they favour a system funded by general taxation, while being reluctant to endorse funding models that include out-of-pocket or means-tested payments. If the latter arrangements were adopted, they should include as many people as possible, in particular, low-income individuals. Moreover, private providers call on the government to preserve the existing tax benefits for clients who choose to pay out-of-pocket. In other words, commercial companies prefer funding arrangements that cover as many people as possible and that will make home care most accessible. This is in their interest because they are expected to be responsible for a large portion of home care services delivered within the statutory scheme (Walsh & Lyons, 2021).

Fourth, personal budgets also would remove the leverage that the state currently enjoys over private providers by making public funding conditional on meeting certain requirements (Gingrich, 2011). Moreover, private providers could select less costly clients (cream-skimming) and exert more control over users, although this could be attenuated through adequate regulations. In any case, it is unclear that personal budgets would function as efficiently as private providers claim. In 2016, such a scheme was piloted in selected geographical areas, where clients were offered the opportunity to choose their home care provider. An evaluation (Phelan et al., 2018) of the pilot demonstrated that it was the accessibility of care rather than choice that was considered important to care recipients and their families. The study also showed that there were capacity challenges to give recipients a real choice of providers, particularly in rural areas. The scheme was not pursued beyond the pilot.

Fifth, on workforce issues, private providers have argued that the Irish government should allow them to hire more non-EEA workers – on which they have been recently successful – and adjust welfare rules so that more individuals are incentivised to work in home care part-time in combination with some welfare benefits. Those two measures should increase the size of the available labour force. This favours private providers because more clients on the waiting list will presumably be allocated; also, a larger labour supply tends to depress wages as more workers compete for available jobs. On the other hand, raising wages and improving employment terms and conditions for workers is an obvious way to address labour shortages, which would benefit private providers. Indeed, the latter say they wish to improve working conditions through increased public funding allocated to outsourcing, but not through unionisation. It can be inferred that private providers assess that more public funding for them would increase their profits and bolster their position as key actors in home care, while an empowered workforce could cut into their profits and reduce their relative power in the home care market. From a critical perspective, one should be careful about private providers’ statements that they wish to improve working conditions because profit incentives often lead to their deterioration. On the other hand, private providers’ claims can also be taken seriously. They wish for a larger home care sector, including a better resourced workforce, which they would oversee – it is therefore a rational plan from their perspective to call for a larger and more adequately supported workforce, because they would benefit from it.

Overall, private providers’ policy preferences regarding the upcoming regulatory scheme have complex consequences for power dynamics. On one hand, they reinforce the position of dominant companies by stabilising the market and eliminating some of their competitors who cannot meet standards. In fact, one commercial provider maintained that ‘the statutory scheme is going to turbocharge [dominant] private providers’ presence in the market’ (interviewee 12) due to the guaranteed demand for services paid by a guaranteed payer, the state. Significantly, this could lead to a transformation of the home care sector into one that is dominated by private equity and other large investors that are looking for such sizable, guaranteed sources of income. Indeed, ‘that’s manna from heaven for private equity and investors like that, and so when there’s a statutory scheme introduced, we will see a huge amount of money piling into home care … we’ll see a huge increase in the dominance of private providers’ (interviewee 12). If this were to happen, current private providers could be either displaced by more powerful global players or take advantage of this influx of capital to cash out on their current business.

On the other hand, tighter regulations constrain private providers’ freedoms, which can weaken their position in certain respects – especially small providers. Moreover, the regulator becomes a powerful actor in the care regime. If it enforces private providers’ preferred system, the state will lose its dominant status in the care regime and become one actor among several, without control over the commissioning of services and without the priority it enjoys over other providers in service delivery. However, a different balance of power could emerge if the regulator is strongly independent of private providers’ preferences; opposes personal budgets to clients; forces private providers to offer better working conditions; and maintains the public provider’s role in commissioning. In that case, the public provider and state would exert significant leverage over home care and private providers would be more constrained.

Conclusion

The policy preferences of commercial actors toward welfare markets in long-term care remain under-researched, even though private providers now account for a substantial proportion of care delivery in many countries. This paper has presented an analytical framework identifying key policies that make and shape long-term care markets. It has documented commercial companies’ preferences with respect to regulatory, financial and labour policies. Overall, leading private providers call for stronger regulations to tame the excesses of the current deregulated environment. While deregulation two decades ago allowed many private companies to be set up and grow, dominant providers now wish to stabilise the market by organising it around fewer large players that some critical voices could describe as an ‘oligopoly’. This has a number of implications for the balance of power between actors in the Irish care regime. Most importantly, dominant private providers would see their position bolstered due to the increased demand likely to result from the statutory scheme, the elimination of smaller competitors, and the weakening of the public provider if a purchaser-provider split is implemented. Dominant private providers’ power could nevertheless be reduced by a strong regulator that forces them to operate following tight quality rules and by offering better working conditions to care workers. The ways in which the new regulations will be implemented will be determinant in this respect.

The paper’s findings are based on the Irish care regime, however, our analytical framework may be applicable to other long-term care contexts. Thus, we propose a research agenda to map out and explain the diversity of private providers’ policy preferences in long-term care markets and their implications for the power dynamics inherent in care regimes. For example, how do commercial providers’ strategies vary according to the developmental stage of the welfare market they are operating in? How do historical-institutional contexts and national care regimes affect private providers’ views and policy preferences? Business strategies for growth as well as relationships with the state, non-profit organisations, other commercial providers and the regulator, would be expected to differ in welfare markets at various stages of development and in different care regimes.

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Funding

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