The Goldilocks Question: What Size is Just Right for Health and Social Care Organisations?

Catherine Needham

The Care Quality Commission yesterday published its annual State of Health Care and Adult Social Care in England. The headline finding was that, despite lots of great practice, the variation in the quality and safety of care in England is too wide and unacceptable.  CQC Chair David Behan warned, ‘CQC is calling time on the unacceptable lottery of poor care’.

One of the interesting sub-findings related to the size of organisations. The CQC reported that larger GP practices do better than small ones, whereas in social care provision smaller providers performed better than larger ones.

The report doesn’t explain what it is about size which makes it a relevant variable in explaining performance, nor does it account for why big is sometimes good (GP practices) and sometime not so good (care homes). It is the explanatory power of size that is the focus of research that we are currently undertaking at HSMC. We are testing whether micro care organisations employing five people or fewer outperform larger care providers in delivering services to users that are valued; innovative; personalised and cost-effective. The project is located in three case study sites and draws on interviews with 108 people who use services and carers, and with 20 people who run care organisations, spanning micro, small, medium and large scales.

In trying to use size as a key measure we have come up against a number of difficulties:

  • Size is a dynamic variable: organisations can grow and shrink fairly rapidly. Many of the organisations that were micro at the start of the research have grown whereas others have disappeared.
  • Organisations which are local franchises of national care chains are hard to categorise, having elements of both large and small organisation.
  • And, crucially, it is size per se that makes a difference or might it be something else about small organisations that leads to better care outcomes?  For example, micro-enterprises are more likely than larger companies to be run by people who are self-employed, which has been found to lead to people being particularly motivated and committed to their work (RSA, 2014). These people may also be likely to be older and more experienced, having moved into setting up their own business after personal or professional experience of care services, something which is known to have a link to quality of care (Lewis and West, 2014). 
These are all issues which we are engaging with as we work through the project data. Findings from the project will be available on the website in the spring.