Outsourced austerity or improved services? A systematic review and thematic synthesis of the experiences of social care providers and commissioners in quasi-markets.

Social care services are commonly delivered by a combination of for-profit, public, and non-profit sector providers. These services are often commissioned in quasi-markets, in which providers from all sectors compete for public service contracts. The outsourcing of social services to private providers has resulted in a predominantly for-profit provision. Despite the rationale that open bidding facilitates better services and improved consumer choice, the outsourcing of social care has been criticized for prioritising cost-efficiency above service quality and effectiveness. However, the experiences and perspectives of those operating within quasi-markets (providers and commissioners) are poorly understood. To address this gap, we systematically identified, appraised, and thematically synthesised existing qualitative research on social care commissioners and providers (for-profit, public, and non-profit) published in the last 20 years (2000-2020). Twenty-six studies examining the perspectives of social care providers and commissioners relating to the quasi-market provision of social care were included. The synthesis demonstrates consistent concern among non-profit and public providers with regard to spending cuts in the care sector, whereas for-profit providers were primarily concerned with creating a profitable market strategy by carefully analysing opportunities in the commissioning system. All provider types described flaws in the commissioning process, especially with regards to the contracting conditions, which were reported to force providers into deteriorating employment conditions, and also to negatively impact quality of care. These findings suggest that in a commissioning environment characterised by austerity and public budget cuts, it is insufficient to assume that increasing the market share of non-profits will alleviate issues grounded in insufficient funding and flawed contracting criteria. In other words, no ownership type can compensate for inadequate funding of social care services.