The ‘efficiency/ resource savings’ storyline

Stakeholders’ explanations of how technologies could enhance efficiencies in care provision aligned in several ways; for example, in the organisation of care, digital care management systems that could be accessed remotely by providers and care workers were commonly cited as a way to reduce administrative costs. Stakeholders also discussed the emergence of introductory platform care agencies, which connect people in need of support with self-employed care workers, as generating efficiencies and resource savings by “strip[ping] out the middleman [you] actually bring down the price by about 30%” (homecare stakeholder 4). Online training was also commonly seen as saving resources by removing the need for care worker travel time and venue costs.

Stakeholders also cited examples where technologies could create efficiencies in ‘hands-on’ care delivery. For example, some argued EM systems were used to contain costs by facilitating payment for care ‘by the minute’: “‘you were only there for thirteen minutes and thirty-four seconds, so therefore we’ll pay you for that’” (homecare stakeholder 1). Other stakeholders argued short ‘checking’ visits could be replaced with ‘virtual’ care using online video-calling services (including via mainstream IoT devices) or passive sensors to remotely monitor wellbeing. In turn, the data produced by these devices could be analysed in ways to facilitate preventative measures, saving on future costs. Stakeholders in all groups, however, argued that the ability of technology to completely replace care workers in care delivery, even with the use of robotics, was an unlikely and undesirable scenario. One commissioner argued technology should be “augmenting rather than replacing the workforce… we free people up to do the stuff they need to do” and that “if you do something that, with a piece of equipment rather than a human being it’s cheaper, immediately, however what you then have is the impact around social isolation and everything else that kind of bites you later on” (LA stakeholder 6). Where robotics were discussed, this was largely in terms of ‘co-bots’ or exoskeletons to assist with lifting, removing the need for ‘double-handed’ care visits. For example, “a piece of kit that costs £25K saves you having to use two care workers. It’s not going to take that long before you’ve got a return on that investment, before that’s cheaper than having a second person” (homecare stakeholder 1). Stakeholders also emphasised how technologies could collect and relay data between different parts of the health and social care system, promoting integration and efficiency.

The ‘quality’ storyline

The Basic Themes that contributed to the Organising Theme of ‘quality’ included ‘independence, choice and control’ and ‘safety’ for people receiving care, and ‘wellbeing/ outcomes-focused’, ‘responsive’ care delivery. Some examples were cited as enriching quality in more than one way. For example, stakeholders working in platform introductory services felt this model promoted care and job quality as both care workers and care recipients could set their own rates for payment and select who they wished to engage, enhancing their choice and control.

In homecare delivery, digital care records utilised to send information about care visits in ‘real time’ including medication compliance and fluid intake were viewed as improving quality by enhancing safety and enabling more ‘responsive’ care. In addition, there was some overlaying of arguments related to care and job quality. Some stakeholders, for example, argued replacing short care visits with virtual appointments or technology to remotely monitor clients (either specialist ‘telecare’ or mainstream devices) could be a way of providing ‘good’, less intrusive care and improving job quality, as “they are ‘eyeballing’ somebody, closing the curtains, making sure they’re taking the tablets. They’re not exciting [care visits]” (homecare stakeholder 5). Similarly, ‘co-bots’ were presented by several stakeholders as a means of safeguarding care workers’ musculoskeletal health and physical wellbeing as the device bears the weight of the client.

There were examples of where the policy storylines of efficiency and quality were blended in the interviews demonstrating ‘discursive affinity’ (Hajer, Reference Hajer, Fischer and Forester1993), i.e. where discourses not only “sound right” together, but “flow into each other”. For example, narratives related to the use of technologies to remove the need for ‘in-person checking’ and ‘double-handed’ care visits were blended to propose these could be a way to save resources but also provide ‘good’, less invasive care and ameliorate physically hard aspects of care work. A further example is the narrative that EM systems could facilitate the precise payment of time-based costs to the minute, but also safeguard against vulnerable people not receiving timely care. Technologies to facilitate prevention and integration between health and social care were also cited as ways to reduce unnecessary costs, but also to contribute to good quality care. As such, some uses of technology were presented as a ‘win’ for commissioners, providers, care workers and users of homecare.

Pine Care – Franchise Model

Pine Care’s overarching franchise directed the agency’s approach to technology, advising caution that its use should not detrimentally impact care quality or brand reputation. Pine Care used an EM system integrated with payroll and invoicing, and a digital care management system that emailed monthly rotas to care workers. The EM system’s scripts required care workers to dial in and out from the client’s landline phone to record their time of arrival and exit from the property. Late arrivals or departures triggered calls from management to care workers’ personal mobile phones to check for issues. Managers drew on the ‘quality’ storyline to explain how the EM system would alert them to deviations from the allocated time with a client, enabling them to adjust care plans and packages accordingly. EM was also viewed as a means to monitor if deviations from the time schedule were a consequence of care worker behaviour; care managers stressed the need to adhere to the franchise model meant they did not want to employ “mavericks… the kind of people who are always going to do it their own way” (Pine Care Manager [M]1).

The care workers’ storyline, on the other hand, presented EM as a safeguarding tool: “it triggers off a phone call to us to say why are we late, because we’re not providing a duty of care to the client, and it might be that we might in a traffic accident, things like that, or it might be that you’ve forgotten. So that telephone system works for both the client and the caregiver” (Pine Care Care Worker [CW] 2). A care worker told us about another provider where an ex-colleague had claimed to have made 14 care visits in an hour and a quarter, to exemplify how the EM system guards against poor practice: “there is no way that she could have gone in, asked them how they were, prompt medication” (Pine Care CW8). However, in use the EM presented issues for some care workers, as this quote illustrates: “that login system is pretty lacking. Sometimes I get a phone call to say, ‘have you logged out?’, ‘yep’, ‘well, it’s not recorded’” (Pine Care CW7). The integration of the EM system with payroll meant errors could have financial repercussions. Care workers also had to immediately engage with its scripts as opposed to the person receiving support, as one care worker explained: “sometimes you walk into a client’s home, and you’re talking, and you forget to log in” (Pine Care CW1).

For the digital care organisation system, managers used the efficiency storyline, arguing the emailed rotas removed the cost of printing and posting hard copies. Some care workers felt the system’s simplicity was an advantage, as it did not require them to engage with an additional platform or app but acknowledged it could also be a source of stress when incorrect rotas were amended, resulting in multiple emails when not at work. Revised rotas only included shifts from the date of amendment onwards, requiring care workers to keep accurate records: “I’ve got an Excel spreadsheet which is helping me log all the hours that I’ve actually done, because we also have to submit a sheet in with our travelling expenses. If I’m going to do a tax return, I’ve got to be clear, it’s got to be auditable” (Pine Care CW7). Therefore, while the technology contributed to efficiency from an organisational perspective, it simultaneously created additional tasks for care workers.

Oak Care – LA Commissioned Model

Oak Care’s marketing cited ‘technology’ as one of the organisation’s core pillars and they had employed a Business Development Manager to oversee the piloting and implementation of various technologies. In practice, however, the tech-focused approach was frustrated by the relationship with the LA who would not commission technology-enabled care from Oak Care, encouraging instead a time-and-task approach to care in 15-minute blocks. As such, technology was primarily limited to ‘back office’ tasks, such as scheduling, invoicing and payroll with a digital care management app to allow staff to view rotas and limited client information (name and address) in ‘read only’ mode.

Despite the LA’s commissioning approach, Oak Care aspired to introduce digital care records because the care management app in situ caused frustration for senior care workers responding to emergency situations without ready access to information, such as next-of-kin details. In addition, Oak Care had piloted a digital care records system in the hope it would facilitate the communication of ‘softer’ care outcomes and enable the collection of data to make “better management decisions” (Oak Care M2). More specifically, it would reduce care workers’ informal use of ‘WhatsApp’ to share information about client visits with each other. The ability of managers to access information being transferred via this medium was a cause for concern, as a manager explained: “WhatsApp groups are fantastic and you know thankfully it’s all encrypted but it’s difficult to control the messages that go on there and difficult to extract the information out of those platforms… people may walk out the door with that knowledge in their heads and you know that is value to this organisation and value to our clients and our other care staff, we have to be able to protect that” (Oak Care M2). Care workers however told us WhatsApp helped them provide ‘good care’ by quickly relaying information directly to other care workers, rather than the slower method of sending messages via area managers: “It’s good to text like, ‘Mrs X has erm a bruise on her shoulder can, can you just keep an eye on it?’ or like a rash or something like that… it takes loads of pressure off the area manager… Because we would have, I mean, we would be ringing her a hundred times a day to report stuff” (Oak Care CW3). The managers’ storyline that the piloted digital care records would deliver efficiency was frustrated in practice by the commissioning LA’s requirement that care workers maintained hand-written records in addition to using the digital system. Managers spoke of reticence among care workers to undertake this additional task and raised concerns about the staff attrition that may result. When we re-interviewed a manager during the COVID-19 pandemic, we learnt Oak Care had formalised the use of WhatsApp as a communication tool, utilising it to disseminate information on infection-control measures. Thus, the wider context of commissioning arrangements thwarted the Oak Care’s aspirations for technology, and at the practice level, care workers were able to resist the imposition of certain technologies in favour of those they felt enhanced care.

Cherry Care – Outcomes Model

A technological system for scheduling, invoicing and payroll was an integral part of the organisational model at Cherry Care- its ‘paperless’ and ‘premise-less’ approach (hiring a local hall for team meetings) had reduced overhead costs. Care workers were provided with smart phones with two apps: one for care plans, recording incidents and information related to visits (including medications and photos to document ‘softer’ outcomes); and another for communication between care teams. The apps were used in a creative way by the organisation in a “kind of hacked together tool” (Cherry Care M1) to meet the company’s requirements; a manager explained that ‘off-the-shelf’ apps and platforms are: “all designed around having a manager in an office, telling individuals in the field what to do. It doesn’t fit with our self-managing team set up” (Cherry Care M1).

The storylines presented for the use of technology by Cherry Care managers and care workers were in sync: technology provided administrative efficiency for ‘back office’ functions and record keeping and created conditions for quality care by facilitating communication between care workers. The care organisation app was seen by management and care workers to enable more responsive care delivery for clients, with care plans amended in real time. The communication app was also reported to be easy and efficient to use and care workers said the flow of information meant they felt supported by their colleagues, as a care worker explained: “we use the [app] to keep each other upbeat” (Cherry Care CW3). While this app facilitated interaction, care workers told us the ease of communication created a sense of always being ‘tuned in’. Some care workers, for example, reported that they were never ‘unavailable’, which had implications for their personal lives; several said they had looked at the app or responded to messages or calls during family holidays, explaining this was necessary to manage the volume of messages and to avoid information overload on their return to work. While some care workers viewed this to be their problem to solve, others expressed there was an unwritten expectation among team members that they needed to regularly check the communication app: “there’s slightly funny comments that people aren’t checking [the app] and they’re not replying to these messages, and even if they can’t cover a shift, they should at least be saying no, and I’m thinking well, what if I’ve just not seen the message in the first place? And I think the expectation is that people should be looking at it most days. It is the main negative of this job to me, because it’s very hard to switch off when you’re not supposed to be at work” (Cherry Care CW5). The use of technologies in practice therefore was felt by both managers and care workers to deliver on the storylines of quality and efficiency, but with the unintended consequence of blurring boundaries between work and free time.

Maple Care – Introductory Model

Maple Care’s marketing material used words like ‘revolutionary’ to describe its ‘simpler system’ to allow ‘families’ and care workers to connect via an online platform. While it appeared be an automated process to people using the website, the matching of care workers to customers relied on human input to ‘tame’ the technology. The algorithm would produce a longlist of care workers matched to each customer, from which the office staff then created a shortlist. The decision to adopt this hybrid approach was viewed as important to navigate factors such as “personality… that’s really hard to put into an algorithm (Maple Care M2), and had evolved: “when we started we were very keen on it being very automated, a bit like ordering an Uber, but it’s a very personal purchase, you want to be able to speak to someone… you’re talking about really crisis moment in your life, so you don’t just want to be going to a bot” (Maple Care M2). The company automated several ‘back-office’ processes: care workers’ timesheets were pre-populated based on their schedule for them to check and submit via the platform which sent an invoice (including the service’s commission) to the customer for approval, and then the care worker would be paid.

Cost savings produced by automated back-office processes was a key storyline expressed by Maple Care’s management who argued these were passed on to families and resulted in higher wages for care workers, compared to ‘traditional’ providers. Quality through choice was also a storyline used in marketing materials and by managers, with the platform removing the traditional ‘middleman’ care agency, allowing care workers to set their own wages and be selective about their work; customers also chose their own care worker/s. The platform was integral to Maple Care’s operational model and its scripts placed additional responsibilities on care workers (and those receiving care): one of the company’s ‘golden rules’ observed during ‘on-boarding’ training sessions was that care workers “engage with the platform regularly”.

Reflecting on this Basic Theme of ‘choice’ and corresponding storyline of ‘quality’, all care workers interviewed appreciated the control they had over working hours – for example, “essentially, you’re your own boss… I like the flexibility. I like the control; I find that quite empowering” (Maple Care CW1). The promised freedom to set their own wages was limited in practice as managers felt care workers had unrealistic expectations. In response, Maple Care had introduced guidance charging ‘reasonable’ rates. Ultimately however, the technology was viewed to have facilitated customer choice at the expense of care workers’ wage levels and work opportunities as some were lowering their rates to ensure they attracted work. Managers told us this pattern was related to discrimination “we have a problem with racism, as does every single care agency probably, so we were seeing a slight trend in that people were paying more for a white carer, which just isn’t what we want at all” (Maple Care M1). This resulted in Maple Care at the time of the fieldwork introducing a new system of standardised rates based on the level of care required, which a manager explained would make “it fairer, it’s making it more about your experience, your skills and the match, rather than the cheapest person” (Maple Care M1). The choice the technology was supposed to facilitate had become unbalanced towards the customer and therefore Maple Care was becoming more prescriptive for both care workers and those receiving support.