Innovation in UK independent homecare services: A thematic narrative review

Abstract This paper reports the findings of a thematic narrative review of peer‐reviewed articles exploring innovation in UK independent homecare services published between January 2009–August 2021. Our analysis of 15 papers reveals four broad innovation types: personalised funding, operational models, workforce development and assistive technology. We conclude that research focused on innovation in independent homecare offers important insights into the positive and negative outcomes of different types of innovation for providers, care workers and people receiving care. There are, however, also areas which are neglected and need further elaboration, including more robust evidence of outcomes and clearer articulation of innovation processes.

Given the significance of the independent homecare sector to the provision of care in the UK, it is important to understand the relationship between innovation in these organisations-hailed as a means to create stability and improve outcomes-and service quality. Innovation is a prominent focus of policy, practice and research, as will be explored in the next section, yet the wider literature is characterised by two issues: first, conceptual ambiguity with no widely accepted definition of 'innovation' (Crossan & Apaydin, 2010;Linton, 2009) and second, that the focus of much research is on identifying positive outcomes of innovation, thereby overlooking the specifics of how innovation is generated and developed, and why some innovations fail (Seelos & Mair, 2012. This paper aims to provide insight into innovation in UK independent homecare organisations and services since 2009-10 (when innovation became a particular policy focus), identifying the types of innovation examined in academic research. Drawing on an understanding of the term 'innovation' as referring to the operationalisation of some kind of potential with a commercial or social motive by implementing new adaptive solutions that create value (e.g. Singh & Aggarwal, 2021), we start by briefly describing and critiquing UK policy context vis-à-vis innovation. We next introduce the methodology used to search, filter and review past research on innovation in independent homecare organisations. Following an inductive thematic analysis of the selected papers, four areas of innovation and their corresponding outcomes are identified. Finally, we discuss key areas where further elaboration is required.

| INNOVATI ON , SO CIAL P OLI C Y AND A SC
Although innovation has been a prominent discourse in UK parliamentary debates since the 1960s, it is a concept that lacks a precise definition (Perren & Sapsed, 2013). It tends to be understood as a policy agenda through which governments have sought to strengthen the UK's economic base (Edmiston, 2015;Sirovatka & Greve, 2016) and tackle societal challenges (e.g. UK Industrial Strategy 2017). The 2000 Green Paper, A Quality Strategy for Social Care, set out actions to improve the quality of social care services, promoting innovation as a key mechanism to do so whilst also stabilising the cost of care.
To support the delivery of these aims, the then Government established the Social Care Institute for Excellence (SCIE) (which became an independent charity in 2002) to create a network of innovative providers, commissioners and interested citizens and encourage the spread and scaling up of localised innovations in social care (SCIE , 2019). There has also been funding available to the sector, such as the Social Impact Bond 'trailblazers' to support English local authorities (LAs) to encourage homecare providers to 'rise to the challenge and to develop innovative and high-quality care and support options' (HM Government, 2012: p. 45-46). Specific to innovation in ASC more broadly are two key policy priorities: (1) the 'personalisation' of care and (2) the deployment of technology to improve care quality and contain costs. 'Personalisation', whilst itself not well-defined (Glasby & Littlechild, 2009;Needham, 2011), has been a central part of policy rhetoric, promoting core values of 'choice' and 'control' since the 2000s (Lymbery, 2014) but has been linked with ASC since the 1980s as part of the independent living movement. The Community Care (Direct Payments) Act (1996) gave localities the power to make direct payments ii to people to control their own care, which was made a duty in England and Wales in 2001and Scotland in 2003(Hall et al., 2020Needham, 2011). As such, over time 'quality' care has come to be understood as care that is personalised (amongst other features); in turn, personalised funding is a mechanism to deliver personalisation. In terms of investment, in England, the Partnerships for Older People pilots (2006/7 and 2007/8) were established to encourage innovation and quality through the use of direct payments and individual budgets iii (Department of Health, 2006).
Technology in ASC has also been a key area of policy focus and public investment, often coupled-or at times treated as synonymous with-innovation. Policymakers have frequently pronounced technology's 'transformational' potential, with innovations in both the design of new products and systems or the application of existing devices to caring contexts cited as having the ability to increase care quality and workforce capacity whilst reducing costs (Hamblin, 2022 • There has been national and local investment to support innovation in homecare in the UK.
• Health and social care research has largely focused on the positive effects of innovation, neglecting to define the concept or explore its complexities.

What this paper adds
• We map the scope and focus of extant academic research into innovation in independent homecare organisations in the UK.
• The paper identifies four types of innovation in independent homecare organisations explored in the existing academic literature.
• We highlight gaps in knowledge and propose an agenda for future research.
Local Government Association (LGA) and Department for Health and Social Care (DHSC) and NHS Digital funding. Through these initiatives, emphasis has been placed on the development, adoption and diffusion of digital technologies within ASC and homecare (Wright, 2020).

| CRITIQUE S OF INNOVATI ON
Whilst government policy and initiatives assert innovation is good for the economy and society, some scholars argue that definitional ambiguity allows multiple understandings of the term to flourish in policy, practice and research (Crossan & Apaydin, 2010;Godin & Vinck, 2017). Scholars have also warned that research risks reproducing policy's pro-innovation bias (Fagerberg et al., 2013;Godin & Vinck, 2017) and that it tends to be treated as an outcome, therefore implying 'that innovation occurs when desired outcomes such as positive change can be observed' (Seelos & Mair, 2012: p. 45).
Reviews of research investigating innovative practices and services in ASC in the UK more broadly than our focus on independent homecare organisations have found significant gaps in knowledge and data or weak evidence of positive outcomes. A Local Government Association (LGA) (2017) review of the use of procurement to encourage innovation found a problematic lack of data on innovative activities; other reviews of areas of innovation in ASC related to technologies (but not focused on independent homecare provision) have reported conflicting evidence of positive outcomes for different users (Davies et al., 2013). In reviews where positive outcomes of innovative practice in ASC were found, and innovation transfer to other localities was attempted, there was little acknowledgement of how localised cultural, social and economic contexts and condition-mediated outcomes (Trivedi et al., 2013, focused on inter-professional working) and others have highlighted a lack of evidence on specific factors that result in successful and sustainable innovations (Dawson et al., 2015;Trivedi et al., 2013;related to dementia care).
Whilst the policy discourse presents innovation as a means to ameliorate some of the effects of an under-funded, under-staffed and fragile system (DHSC [Department of Health and Social Care], 2017; SCIE , 2019), it has been argued that evidencing outcomes of innovation can be difficult to achieve when the agenda contains the dual, and often conflicting, objectives of containing costs and improving care quality. For example, personalisation has been highlighted as a mechanism to stimulate change in business processes, resulting in greater efficiencies including tightening access to services, greater auditing and increased use of IT systems (Carr, 2010) but this link to cost savings and efficiencies has been argued to be at odds with the drive to improve care quality (Pearson & Ridley, 2016).
Whilst these reviews illuminate the range of innovations more broadly within ASC and what factors support or hinder their effectiveness, less is known about innovations specific to the independent homecare subsector. In this paper, we report the first review (to our knowledge) of peer-reviewed research on innovation in independent homecare organisations, asking: (1) What modes of innovation does research show to be emerging in the independent UK homecare sector? and (2) What are the reported outcomes of these innovations?

| ME THOD
We conducted a narrative summary review (Dixon-Woods et al., 2005;Greenhalgh et al., 2018) of the literature focused on innovation in, or associated with, independent homecare organisations in the UK. Our aims were to provide further nuance to the conceptualisation of innovation by examining the variation in the type of innovations, their prevalence and outcomes.
As innovation is a contested concept, a narrative review is appropriate as it combines interpretive and discursive methodologies to provide clarification and insight (Greenhalgh et al., 2018) and has the potential to allow theory-building through thematic analysis (Hammersley, 1997). Through thematic analysis within the narrative review method has been critiqued as 'limited in its ability to deal with contradictions, other than by describing them' (Dixon-Woods et al., 2004: 15), we argue that whilst highlighting contradictions may appear 'descriptive', it is crucial for building an understanding of how 'innovation'-as a vehicle for tackling problems of fragility and poor quality care in the ASC that is also conceptually ambiguous -is defined and implemented. This approach brings studies using a range of research methods into the scope and allows us to examine a phenomenon that is ill-defined, with the potential to generate new insights After filtering, 15 papers met our criteria (10 empirical research articles drawing primarily on qualitative research, three commentary papers and one review paper) ( Table 2). We adopted a data-driven approach to thematic analysis, where the themes were generated through the exploration of the literature (Dixon-Woods et al., 2005).
Our analytic approach involved several steps. Two members of the research team independently read each paper several times to identify the type of innovation. Together, the team members then compared their findings and grouped similar innovation types together. This resulted in four groupings, which we labelled to reflect the topics examined. Papers within each category were re-analysed thematically to reflect the focus of the innovation in combination with the objectives driving its implementation. Where discernible, we identified the reported outcomes of the innovation for the people involved in giving and receiving care.

| FINDING S
Our analysis identified four narrative themes in the literature related to innovation and UK-independent homecare organisations: (1) personalised funding and choice; (2) alternative operational models; (3) training regulation catalysing change; (4) assistive technologies for enhanced care. The aims, type and outcomes of innovations within each theme are summarised in Table 2.

| Personalised funding and choice
Papers from this category conceptualised personalised funding as a mechanism through which innovation was operationalised, particularly in driving change to enable people to determine and shape the care they receive and who provides it. These papers focused on if and how the implementation of personal budgets could diversify homecare provision and increase personal choice. Baxter et al. (2013)

TA B L E 2 (Continued)
often returned, resulting in frustration amongst providers at repeated recruitment costs.  argued that commissioning practices adapted for managed budgets were better able to provide flexible responses to meet the needs of individual care recipients. However, barriers to increased flexibility between localities and service providers included: lack of budgetary devolution to frontline staff; limited cash flow; limited availability of providers with an organisational culture that facilitated creative care planning. Brookes et al. (2015) studied personal budgets and other innovative practices (e.g. integrating care with housing and preventative services), finding personalisation to be a significant driver of change (noting that the practices studied were developed pre-austerity).
They found various interventions which facilitated personalisation: resource directories and signposting; programmes to support direct payments use; an online vetting and matching service for personal assistants; assistive technology uses during assessment; funding voluntary organisations.

| Alternative operational models
Papers in this category conceptualised alternative organisational and/or community-based models as innovations offering more flexi- The paper illustrated the complexity of community dynamics and the need to factor in local contexts when establishing new services. Overall, the shift from the in-house provision by the locality to a social enterprise model was a source of concern for those involved, raising questions about who was ultimately responsible for provision.
Westwood's (2016) review paper identified that most independent homecare failed to address the needs of Lesbian Gay Bisexual   analysed three innovative service models: a reablement project that aimed to increase care recipients' independence following hospitalisation; a case-management approach; and the creation of a group lunch project for people in receipt of meals-on-wheels. The authors suggest that innovations are often inspired by a libertarian (democratic participation) critique of the traditional welfare state, but move to more neoliberal ideals (consumerist participation) as their services become established, expand and scale-up.  was the only paper found that examined the innovative potential of training regulation. The authors focused on regulations introduced through the Care Standards Act (2000) on the provision of UK care services and examined how these mechanisms triggered innovation by creating the conditions through which homecare organisations were able to comply with requirements and innovate workforce training. They argued that regulation is sometimes the catalyst to alter organisational behaviour and provide impetus to change which was 'already going in the same direction' (Rainbird et al., 2011. p. 3739). The example offered examined how 'dementia training' developed team-working at homecare to provide more flexible and responsive care and offer an alternative to 'the normal time-limited and task-oriented delivery of domiciliary care services' (Rainbird et al., 2011: p. 3736). They note the importance of 'multiple sources of funding and the activities of enthusiastic local actors' (Rainbird et al., 2011. p. 3739) to foster innovative activities.

| Assistive technology for enhancing care
Whilst the focus of recent policy and funding opportunities has been on technologies more broadly, these papers focused specifically on assistive technologies (AT and highlighted the need to understand the low take-up of AT, but offered weak evidence for its benefits.  considered AT to have the potential to maintain and increase a person's ability to live independently at home, but also highlighted its low take-up. They argued that care assessors tended to lack appropriate knowledge for suggesting how AT can support people to remain living independently at home, and found that a lack of support following the initial installation led to underuse by care recipients.  provided a more nuanced examination of the potential of ICT telehealth technologies to assist older people living in remote and rural areas to manage chronic pain. They found health and care professionals viewed technologies as a means to increase opportunities for care recipients to connect socially and access additional information about their condition and pain management. The authors suggested that ICT technologies can supplement in-home visits and recommend including health and care professionals in decision-making in commissioning ICT for chronic pain management.
However, care workers noted that some of their care recipients did not engage with the ICT technologies, and the authors highlighted that aspects of the ICT device design, ergonomics and infrastructure, such as unreliable broadband coverage and connectivity prevented their optimal use.

| DISCUSS ION
The literature on innovation and ASC more generally, we suggest, is wide-ranging, fragmented and conceptually 'messy'. These characteristics mirror concerns related to definitional ambiguity and underconceptualisation of innovation within and across disciplines and sector-based studies. Although innovation is an important priority for UK ASC policy, research into innovation in independent homecare organisations is relatively underdeveloped.
Our thematic analysis of the papers which met our inclusion criteria produced four main categories of innovation explored in the literature, and whilst we have categorised the papers by type of innovation, there is overlap between them. Many papers addressed the extent to which a personalisation agenda was being met, either directly or indirectly. One group of papers highlighted that personalised funding as a personalisation mechanism generates flexibility , choice (Baxter et al., 2013), change (Brookes et al., 2015) but also implications for the homecare workforce (Baxter et al., 2011), with both positive and negative outcomes.
Positive outcomes included improved engagement between provider and service users, and creating renewed partnerships (Brookes et al., 2015). The findings of these studies underline the importance of micro-level (individual and group) and meso-level (organisational) environments for understanding the context-specific factors that inhibit or support innovations to achieve successful and long-lasting outcomes. One anticipated effect of personalised funding was that the market would create more diverse provision, but as has been noted this increased 'choice' is not always easy to achieve (Baxter et al., 2013) or available . The market's ability to respond to needs may also have been impacted by austerity insofar as 'personalisation' was focused on 'budgets and cost-cutting', rather than 'choice and control' (Brookes et al., 2015: 91). One negative effect of personalised funding was recruitment costs for homecare organisations when care workers were 'poached' to directly work for care recipients (Baxter et al., 2011), and may also have fuelled the recent growth in micro-enterprises . Whilst microproviders have been shown to be more adaptive and flexible to meet individuals' needs and improve care outcomes, they also create more precarious employment opportunities because of their susceptibility to cash-flow problems and business fragility.
The group of papers which characterised innovation as alternative organisational models also reflected a drive for more person- to prevent social isolation , but on the other hand, it can increase social isolation for residents with dementia, as the stigma from other residents without dementia can cause segregation . Social enterprises were claimed to have the potential to empower employees .
The evidence offered by Jones (2009) was weak, but  more robust analysis of the positive and negative effects of implementing social enterprises demonstrated that a bottom-up approach to developing co-produced services could foster a sense of community, empowerment and personal satisfaction. However, this also led to feelings of pressure, strain and frustration and a reluctance to embrace 'transformative' co-production. The result was that the traditional provider-user dynamics were maintained and highlights the difficulties in implementing and maintaining an ideal. Similarly,  discussion of three initiatives founded on values-based service innovation had to adapt to the requirements and expectations of the wider social care system, demonstrating how principles driving the innovation can drift towards a more neoliberal agenda concerned with issues of income and capital.
The impact of top-down influences on innovation and outcomes was demonstrated by , who focused on the implementation of training regulation as a means to promote quality care.
Central to this paper's argument is that the organisations' responses to top-down regulation can create opportunities for innovation and that this is more likely when the intended change is aligned with the regulation's direction of travel. The focus of this paper, whilst highlighting some of the positive outcomes of innovation such as increased staff motivation and a 'learning culture', is about the conditions which foster innovation, with key enthusiastic personnel and funding emphasised as vital for an innovative culture to develop and nurture change.
Given the focus on technology as a policy priority (Wright, 2020), surprisingly only three papers were identified in this group. This is not to say that research around technology and care is not being undertaken, but that technology is little discussed in relation to homecare organisations, and where studies have been conducted, they have focused narrowly on assistive technology (AT). What was clear from these papers, however, is that the use of AT to promote independent living is assumed to be positive and yet the evidence to support such claims was not strong. Therefore, statements related to the positive outcomes of AT were speculative at best (Caleb-Solly, 2016), or based on an implicit assumption that increased take-up of such technologies would improve care outcomes . Roberts et al.'s (2015) paper highlighted problems with poor digital infrastructure and connectivity but suggested that increased engagement with technologies will only complement, not replace, care provided by homecare organisations. A key benefit argued in the policy discourse of AT is cost-effectiveness, but the papers did not detail the financial implications of using AT or their potential/ actual savings. Whilst it was acknowledged that AT cannot replace all the features and benefits of costlier 'hands on', face-to-face care, it is argued to be very difficult to compare technology-produced cost savings when face-to-face care visits provide an unquantifiable source of social support for care recipients and their families . Overall, the negative outcomes of the use of technology tended to be underexplored in these papers and the benefits for those receiving and providing care were often assumed.
Furthermore, AT was treated as the innovation, rather than considering if the way the AT was used in homecare was innovating the services. Positioning technology as the innovation is argued to ignore the context within which AT is located and the importance of the interactions with users in mediating outcomes. As Science and Technology Studies have highlighted, technology both shapes, as it makes some things possible or impossible, and is shaped by context and interactions (people can engage with, and can disable/enable its functions); ATs are 'not neutral, predictable phenomena whose outcomes could easily be captured in isolation' (Hamblin et al., 2017: p. 79).
What is apparent from our analysis is that research examining the process and operationalisation of innovation in independent homecare organisations-from initiation to implementation and dif- Methodologically there may be an element of subjectivity whilst identifying the type of innovation. Whilst interrater agreement offered fairly robust groupings of types of innovation, there may be the scope of subjective interpretation in the process. We did also find that the boundaries between the groupings overlapped as discussed above. The inductive and iterative approach methodologically helped guide us through this process.

| CON CLUS ION
Our aim was to provide a deeper insight and add nuance to how innovation in UK independent homecare organisations can be understood, identifying the form innovation can take and any corresponding outcomes to arise from the change. We identified and discussed four types of innovation: personalised funding, operational models, workforce training and AT. Viewed through the notion of innovation suggested by Singh and Aggarwal (2021), we discussed earlier in the introductory section, these findings help in building an understanding of 'new adaptive solutions' considered and/or implemented at the level of homecare organisations in the UK, 'the motives' for their use', and in some cases, the 'value' these might add. Understanding innovation in homecare organisations therefore might require attention to what the new adaptive solution is (an approach to funding and/or care philosophy, operational model and/or ethos, tools or processes etc.) and why it is being implemented (cost saving, effectiveness, quality improvement in care, care jobs, to the local community).
What was less evident from the review is a focus on the organisational practices and process through which innovation is generated, achieved and sustained is largely missing. Whilst Gripenberg et al. (2012) warn of a 'pro-innovation bias' in research, the findings suggest that investigation into innovation in homecare organisations examines both negative and positive outcomes (with studies of AT being the exception). Specifically, this review highlights how innovations can enrich care work jobs , increase organisational responsiveness and flexibility , promote choice (Baxter et al., 2013), but also generate unintended consequences such as the challenge of recruiting a diverse workforce   Diane Burns prepared the initial draft. All authors contributed to the review and editing.

E N D N OTE S
i 'Locality' is used to encompass the different terms for local government.
ii Direct payments refer to cash payments from localities that allow individuals to arrange and pay directly for their own care.
iii Individual budgets are a personal budget that is means and needs assessed, paid by the locality towards social care and support needs.
iv Other wildcards were trialled, including 'home care' but these generated results which were not relevant to our research questions e.g. nursing homes, care homes and residential care.