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Putting People First:
Measuring quality of service delivery in adult social care
Recent demographic indicators reveal that over the next decade the effect of ageing on the UK adult population will result in a 20%increase in those of 65 and a 60% increase in “the over 85 year-olds” by 2027 (DoH 2007a, p.1). This trend, together with the increase in the numbers of the population suffering from medical and health issues, including dementia and disability, presents a challenge to the provision of adult social care, in terms of both funding and the need to deliver appropriate services designed to provide this segment of the population with “equality of citizenship” (ibid).
As a response to the changing demography, in 2006, the Department of Health (hereinafter DoH) produced a white paper outlining a new direction for the provision of adult social care services within the community, which indicated the need for a fundamental change from previously existing policies and procedures (DoH 2006). Subsequent DoH (2007a, 2007b and 2009) publications have served to provide guidance on how it was anticipated these change would transition into the practical environment. The central theme of this new direction was based upon a personalised agenda, with users and their carers being given more control and choice over the care services they required and the format in which they wished these services to be provided. In other words, the objective was for adult social care services to be provided based upon a person-centred approach rather than the internal social care services decision-driven model (Department of Health 2007b).
As with all new fundamental and structural changes of this nature, a key element of the ‘personalisation agenda’ is to ensure that the quality of service delivery matches the health and social needs of the local community. It is this aspect of the new adult social care than forms the basis for this paper. Following a brief overview of the objectives and requirements of the ‘personalisation agenda,’ the paper will outline the measurement hat are required to be put in place to ensure the delivery of the requisite quality service to the end user and their carer (Mullins 2006).
2 The ‘Personalisation agenda’
The basic premise of the ‘personalisation agenda’ programme and its aim of moving control of adult social care services to a user/carer-centred model. In other words, instead of professionals within the social services making the decision in relation to the support services required, and how this would be provided, under the new systems, these issues will be determined by the individual user. Therefore, with the aid of the social services team as and when required, the purpose of ‘personalisation’ was to deliver four main objectives, which are outlined as follows:
The user/carer will have the opportunity to design and create their own budget to cover their health and care needs. Based upon this budget, an allocation of funds will be provided over which the user/carer will retain control
Choice of support requirement spending
Within the context of the budget and resources that has been designed by the user/carer, they will retain the choice of what support services they require and how the budget will be allocated across these services
Choice of service providers
Rather than social services deciding the service provider, that choice will now be in the control of the user/carer. In this respect, the user/carer can decide whether the support services they require should be delivered at their home, at an external location, such as a care home or respite centre and, ultimately, whether the provider of these services should be the local social care service or an external private organisation.
Appropriate and timely access to support
Instead of having the delivery of their health and social care services determined by the professionals within the health case sector, the personalised approach gives the user/carer the right to choose the time of these services, for example, at night or during the day.
To ensure that these objectives could be met, with a target data for their full implementation being set at April 2011 (ADASS 2009), were tasked with introducing a system based upon the following changes:
- Integrated working with the NHS
- Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention and early intervention
- Universal information and advice services for all citizens
- Proportionate social care assessments processes
- Person centred planning and self-directed support to become mainstream activities with personal budgets which maximise choice and control
- Mechanisms to involve family members and other carers
- A framework which ensures people can exercise choice and control with advocacy and brokerage linked to the building of user-led organisations
- Appropriate safeguarding arrangements
- Effective quality assurance and benchmarking arrangements
To deliver these changes successfully within the target time scales set, this process has required local social services departments to take steps to redesign the manner in which their organisation were operating as outlined within the following section of this report.
3 Re-designing the provision of adult social care
For the adult social care departments of local authorities, main areas of change required to develop a user/carer-centred approach to service provision, the most important factors that needed to be addressed were concentrated upon three main areas. These can be defined as follows:
- Ensuring the resources are available to assisting the user with the creation of their own care assessment needs and budget
- Ensuring the facilitators of that choice were available and making sure that the required quality of service is delivered, and
- Providing and communicating information in a manner that enables the user to make an informed choice
Consequently, there was a need to focus upon introducing improvements to three key operational elements:
3.1 Human resource capabilities
It will be apparent that some user/carers may require assistance with the process of conducting a personal assessment of their ongoing health and social care needs and designing the budget required to ensure that these needs are capable of being met. For this purpose therefore, it has been important for the local authority to provide users’ with access to employees with the required level of skills and capabilities to assist the user/carer with this process. In many cases, the requisite skills and competences required to achieve this transformation of services might not have existed within the roles of existing frontline service team members. Therefore, it has been important to introduce training programmes designed to assist the workforce to adapt to the new roles.
3.2 Physical internal and external resources
As user/carers now have the choice of how, where and who they wish to provide their service needs, it has been important to realign existing internal existing and external physical and, in some cases human, resources to provide the appropriate range of choice. In basic terms, this choice can be divided into two main categories, these being whether the user/carer requires the service to be delivered in the home or at an external location and having the choice as to whether the service is delivered by the public or private sector.
Home or external delivery of service
Within this context of choice, the main area of change has occurred where user/carers have wished their service requirements to be delivered in their own home. To facilitate this choice, adult care services have needed to ensure two requirements are met. Firstly, there has been a need to ensure that there is a sufficiency of employees experienced in the delivery of home based care services to users/carers, which in some cases has again meant retraining existing members of the workforce to ensure their ability to transition from working in a controlled environment to one where self-control is the main requirement. Secondly, it has meant that the adult social care service has an adequacy of physical and portable equipment required to facilitate home based service provision.
Public or private service provider
Concerning the choice of provider, it was incumbent upon the adult social care services to achieve two objectives. Firstly, there was a need to develop relationships with a sufficient number of external private care providers to enable sufficiency of choice for the user/carer. Secondly, as part of their remit to providing the appropriate type and quality of care, the department also needed to be assured that the quality of service available from the external private provider complied with the standards and quality of care as set down within the government and DoH requirements. Private health and social care providers in this context can refer to agencies and individuals who are trained in the provision of individual care services as well as the external organisations that are operate nursing, care home and other health care facilities.
3.3 Communication process
The final change required, and perhaps in many ways equally important as those discussed previously, has been the need to introduce a robust process of bi-direction communication between all the stakeholders, which includes the adult social care management teams, employees, external service providers, both public and private and, of course, the service user/carer. In order to make an informed choice it is critical that the user/carer has access to data and information related to all the available options open to them. For example, in the case of private care homes, this would include details of the accommodation amenities, the type of care services available from the provider, and overview of their quality standards and the price of the service being provided. In other words, there is a need to create a knowledge based organisation (Nonaka and Takeuchi 1995). In practice therefore, the communication process within the adult care service environment in accordance with the following diagram (figure 1).
4 Measuring quality service delivery
4.1 The rationale for measuring quality service
Major Service delivery transformation of the nature being discussed within this report requires change and, as Turner (2009, p.1) rightly confirms, “Change: and the need to manage change through projects, touches all our lives, in working and social environments.” This has certainly been the case in designing a process that requires the adoption of a user/carer-centred approach to adult social care. Similarly, as with all changes of this nature, not all aspects of the process can be completed at the same time, in other words it needs to be introduced in stages (Allan 2004, Cameron and Green 2004, Blake and Bush 2009 and Turner 2009). For example, providing carers with information related to private provider service choice cannot occur unless or until these providers have been contacted and a relationship built with them to facilitate their willingness and appropriateness to be included in the process. Lewin (Wirth 2004) in developing what he terms as the ‘freeze model’ suggests that stages required to complete this change are three in number:
- Motivation of need for change (Frozen)
- Design and implementing the change (Unfrozen and moving to a new state)
- Making the change permanent (Refreezing)
Source: Wirth (2004)
Of equally critical importance having identified that structure that needs to be put in place to effect the change/transformation to the ‘personalised agenda’ requirements for the organisation, is to ensure that each aspect of this process is managed in an efficient and effective manner in order to delivery the quality of service that meets the user./carer needs. It is equally important to continue to measure the quality of service delivered on an ongoing basis. The ADASS (2009) have suggested that the transformation to the new service structure should be based upon the extent to which the local adult social service department has achieved the following five key priorities:
- That the transformation of adult social care has been developed in partnership with existing service users (both public and private), their carers and other citizens who are interested in these services.
- That a process is in place to ensure that all those eligible for council funded adult social care support will receive a personal budget via a suitable assessment process.
- That partners are investing in cost effective preventative interventions, which reduce the demand for social care and health services.
- That citizens have access to information and advice regarding how to identify and access options available in their communities to meet their care and support needs.
- That service users are experiencing a broadening of choice and improvement in quality of care and support service supply, built upon involvement of key stakeholders (Councils, Primary Care Trusts, service users, providers, 3rd sector organisations etc), that can meet the aspirations of all local people (whether council or self-funded) wanting to procure social care services.
Source: ADASS (2009)
Consequently, it is clear that as an integral part of delivering these priorities, the local adult social services department to have implemented a number of performance assessment and measurement models are discussed in the following section of this report.
4.2 Measurement models for quality service delivery
For measuring the effectiveness of quality service delivery within the context of any organisation, there are a number of management and measurement models that can be used. The objective of some of these, as Turner (2009, p.357) comments is to analyse and assess the performance of the changes that are taking place, such as the transformation of adult social care being discussed in this report. However, in addition to these measurement models, there are others that are designed to measure service quality for specific elements and stakeholders within the change process and post change performance.
Taking the above issues into account, the focus of this discussion is aimed at measurements to be used during the course of the adult social service transformation, the effectiveness of individual employees and external provider’s provision of quality services and the measurements used to assess the satisfaction levels of the user/carer. This triangular approach is designed to achieve the following objectives for the adult social services department:
- Monitoring quality service delivery against timelines and milestones set
- Enabling department to comply within regulatory agendas
- Ensuring required skills and competences of work force and external provider’s
- Monitoring development of appropriate team based relationships
- Measuring extent to which services provided meet with user/carer needs
In all of these areas, the measurement models being used are designed to be part of a continuing process of ensuring the service delivery remains at the highest level of quality (Mullins 2010).
4.2.2 Project and post-project performance
In the view of the author of this report, in order to evaluate the change and improvement to the quality of service during both its implementation and execution stages, it is considered that the measurement model based upon the KPI and Balanced Scorecard approach which was developed by Kaplan et al (2006) is the most appropriate for use. This is especially true within the implementation stages of the change process. The reason for this is that it provides regular opportunities for reassessment and the rapid introduction of measures to address issues that might have arisen (Johnson and Clark 2008). Moreover, within the context of the ‘personalised agenda’ approach, it has the added benefit of being able to combine the financial as well as the non-financial outcomes. In this respect therefore, when used in the adult social services this model not only enables an assessment of the service quality being delivered but will also help to ascertain whether the user/carer is being provided with value for money.
The design and benefits of this measurement model can best be explained from the following diagram, which clearly shows the objective of the Balance Scorecard is to assess and evaluate the performance of quality service delivery from four main perspectives. There are to provide a process for learning and growth, to provide guidance for the management of the organisation, ensuring satisfaction of user/carer needs and, as a result to achieve the financial objectives (Kaplan et al 2006).
In terms of improvement to the service quality, are clearing identified within the appraisal of the KPI’s (figure 3), in that it provides learning for the organisation, which leads to better decision making and continues the process of improved service quality delivery.
Source: API (2010) http://www.ap-institute.com/kpi_fig3.htm
4.2.3 Employee performance appraisal
Skills and competences of employees, whether part of the internal social services workforce or engaged by an external provider, are another key an essential area of service quality delivery that needs to be constantly kept under review (Leat 2001 and Armstrong 2006). The extent to which an employee is able to perform their duties in a manner that satisfies the user/carer, will have a significant impact upon the latter’s level of satisfaction. Consequently, it is important for managers to work with the employees to ensure that they are both acquiring the skills needed to perform their roles and motivated to undertake these duties in a manner that seeks to achieve excellence.
The most appropriate model in this instance is the use an individual employee ‘performance appraisal’ system. This model is based upon interactive communication and discussion process that takes place between the employer/manager and the employee (Leat 2001). The first stage is for both parties to complete a previously designed ‘performance appraisal’ form, which can be similar to the example that is provided in appendix 1 and attached to this report. The purpose of both parties completing this document is so that the level and standard of the employee’s performance is provided from both perspectives. This provides the opportunity for the employer to gain an insight into where the employee feels they are excelling and/or consider that further assistance from the organisation, perhaps in the form of additional training, may be considered helpful.
Following completion of the appraisal form, the employee will then deliver a copy of this to his/her employer for consideration. It is preferable at this stage to ensure that a meeting has been arranged at which both employee and employer will be able to discuss freely the results of the appraisal (Armstrong 2006). It should be deliberately designed for this appraisal process to take the form of a two-way conversation or discussion. From an employer’s viewpoint, this will provide them with the opportunity to provide the additional assistance that the employee perceives to be missing from their development, and discuss those areas where the employer considers improvements are required. For the employee, this process is likely to lead to them feeling more involvement with the organisation and therefore more motivated to produce the best service performance they can (Leat 2001).
Further, to enhance the levels of employee involvement and motivation, which as Armstrong (2006) argues, is key to gaining the best quality of service from the workforce, it is important that the adult social services department introduces a system of employee discussion groups. During these sessions, all employees should be encouraged to participate and share their views and opinions on the effectiveness of the processes that is intended to improve service quality for the user/carer. Often, these discussion sessions will lead to the innovative ideas being suggested which, although not previously considered, could produced benefit for the process, as well as improving employee’s level of involvement with the organisation.
4.2.4 User and carer service quality satisfaction
Academics and researchers, especially those who are intimately involved with the social and health care sectors, have sought to provide a number of tools aimed at improving the quality of service delivered to the user/carer. Two of these models, which have recently been assessed, are the SPRU and ASCOT models (SCIE 2010), the objective of both being to find ‘excellence in adult care services.”
The SPRU (Social Policy Research Unit) model (SCIE 2010, p.4)
The focus of the SPRU is based upon the conducting post-service delivery assessments and evaluation which, in other words means that this models, through some format, measures the extent to which the service quality has provide the required service and needs priority for the user/carer. It is a model that is often relied upon for inspection and compliance purposes, such as when the Quality Care Commission conducts an inspection of a private care home (Francis 2009).
The ASCOT (Adult Social Care Outcomes Toolkit) model
The ASCOT model of performance measurement is very similar to the SPRU model, with the difference being that in this case there are a more defined number of specific issues that the research in question is endeavouring to use for their assessment of the quality of the service being delivered to or experienced by the user/carer, as outlined below:
- Accommodation, cleanliness and comfort – The person using the service feels their home environment, including all the rooms, is clean and comfortable.
- Control over daily life – The person using the service can choose what to do and when to do it, having control over their daily life and activities.
- Dignity – The negative and positive psychological impact of support and care on the personal sense of significance of the person using the service.
- Food and nutrition – The person using the service feels they have a nutritious, varied and culturally appropriate diet with enough food and drink they enjoy at regular and timely intervals.
- Occupation – The person using the service is sufficiently occupied in a range of meaningful activities whether it be formal employment, unpaid work, caring for others or leisure activities.
- Personal cleanliness and comfort – The person using the service feels they are personally clean and comfortable and look presentable or, at best, are dressed and groomed in a way that reflects their personal preferences.
- Safety – The person using the service feels safe and secure. This means being free from fear of abuse, falling or other physical harm and fear of being attacked or robbed.
- Social participation and involvement – The person using the service is content with their social situation, where social situation is taken to mean the sustenance of meaningful relationships with friends, family and feeling involved or part of a community should this be important to them
Source: SCIE (2010, p.5)
What both of these models have in common is that they are based upon the recognised processes of quantitative primary research, which is commonly used by academics for a wide range of investigations (Johnson and Durberley 2000, Easterby-Smith et al 2004 and Gill and Johnson 2010). With the overall objective of ‘personalised agenda’ being to deliver a quality of service that meets the user/care’s needs and requirement, it follows that the only way that this quality can truly be measured is by gathering information from the source that is intimately connected with, and experiencing, the service being provided, this being the end users. Consequently, it is important for the adult social care department to introduce a continuing process of measures designed to accumulate feedback from the user/carer, which should include:
- Regular conduct of a survey questionnaire aimed at gaining user/carer feedback and comments on all aspects of the services delivery process that they have decided to be included within their care management plan
- Regular individual one-to-one meetings with user/carers to allow for more comprehensive bi-directional discussion related to their experience of the service quality provided
Of course, the most important part of this process is for the organisation to ensure that where issues or concerns are raised by the user/carer, These are referred to the relevant stakeholder group or person within the organisation so that they can be appropriately be addressed. Additionally, regular contact should be maintained with the user/carer, to advise them of the outcome of any measures taken to improve the quality of the service delivered.
There is no doubt that the transformation of adult social care has not only signalled one of the most comprehensive reforms of quality service delivery to the user/carer in many decades, but also one of the most complex in terms of its introduction and successful implementation (DoH 2009). Consequently, ensuring that the quality of the services being delivered are maintained during and post this implementation has required the introduction of a number of measures designed specifically to ensure that that this remains the case. As indicated within this report, those measures, the central part of which is to evaluate and examine the user/carers perception of service quality is being met, need to be applied to all stakeholder groups, including those internal to adult social services and the external services providers whose services are also utilised. It is considered that the measurement and managed tools discussed within this report provide the best models for this purpose.
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