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Issues in Social Work and Mental Health Quality Issues

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An Analysis of a Range of Issues in Quality Frameworks, Processes and Methods of Measurement in Mental Health Work and Social Work Practice

Introduction

In equating the various range of issues with respect to quality frameworks, processes as well as methods of measurement in mental health work and social work practice it is important to understand the meaning of these terms as well as their respective applications in the United Kingdom, which represents the subject focus for the aforementioned. Mental health is defined as (Houghton Mifflin, 2006):

“ A state of emotional and psychological well-being …” whereby individuals are able to utilize their respective “… cognitive and emotional capabilities …” to function as members of society as well as to “… meet the ordinary demands …” which are a process of daily living”

In the context of mental health services it relates to “A branch of medicine that deals with … achievement and maintenance …” (Houghton Mifflin, 2006) of the psychological well-being of individuals. The International Federation of Social Workers (Bouldertherapist.com, 2006) defines social work as a profession that “… promotes social change, problem solving in human relationships …” as well as giving individuals the empowerment and liberation “… to enhance their well-being”. The profession, as maintained by the International Federation of Social Workers utilizes “… theories of human behavior and social systems …” in a context whereby the profession intervenes and interacts with individuals at the areas where they “… interact with their environments” and whereby the principles of both human rights as well as social justice are underpinnings in the field of social work (Bouldertherapist.com, 2006). These two fields have a denominator in common, which is that they exist to serve people and help them to improve, as well as cope with their aliments and to ultimately return to a healthful state.

The process of serving individuals in this capacity represents some of the most challenging professions in that the analysis of effectiveness, quality, processes and the methodologies utilized in measuring the aforementioned with respect to the varied issues arising from the active practice can be subjective in most instances. This examination shall look at the mental health and social work professions from the context of a range of issues representing quality frameworks, processes and methods of measurement to determine the progress made in providing better service and quality to patients and carers.

Total Quality Management

Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) are all proponents of ‘Total Quality Management’ which is a strategy dedicated to building into an organization the awareness of thinking in terms of embedding quality in all phases of an organization’s processes. The International Organization for Standardization (2006) defines ‘Total Quality Management’ as being “… a management approach … centered on quality … which is … based upon the participation of all its members … that aims at long-term success …” (Wikipedia, 2006) achieving the foregoing through customer and or client satisfaction that generates “… benefits to all members …” (Wikipedia, 2006). The preceding includes the organization itself as well as society. In equating quality, the usual context in which one thinks of this word is in products, rather than services such a those products which are made with a minimum of problems, of good materials and which work properly and achieve this through consistent operation. However, quality as an end result is an organizational mind set, and as referred to in the International Organization for Standardization (2006) definition as a process “… that aims at long-term success …” achieving the foregoing through customer and or client satisfaction that generates “… benefits to all members …” (Wikipedia, 2006).

Deming (Aquayo, 1991, pp. 6-10) is an American consultant who exposes the importance of implementing a quality oriented organization that permeates every facet of an organization’s structure and culture, regardless of department or function. Deming (Aquayo, 1991, pp. 8) states that organizations must produce “… products and services that help people to live better” and that the preceding “… is the raison d’etre …” (Aquayo, 1991, pp. 8) of the organization. His philosophy is that through the adoption of quality products and services, which is a function of management inculcating its staff in quality and innovation measures, the end product and or service improves as does its relationship with its customers and or clients. Crosby (1980, p. 1-5) indicates that mistakes or poor organizational habits and or policies are costly in terms of corrections and the damage to reputation and morale and that all members of an organization have the responsibility to perform their jobs which enhances the performance of other functions thus becoming a synergistic effect. Crosby (1980, p. 4-8), as does Deming (Aquayo, 1991, pp. 6-10) and Juran (1992, pp. 171) all emphasize the importance of quality in increasing an organization’s ability to provide services that meet and exceed client expectations through the effect that quality orientation has on internal interpersonal relationships and openness to ideas.

The heart of the work level philosophies held by Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) is the contribution of ‘quality’ to the equation of improved services and innovation in heightening organizational standards. The term ‘quality’ can thus mean in this context (Wikipedia, 2006):

  1. the excellence and or achievement of an object or service, meaning that it is not inferior or sub-standard,
  2. a meaning of excellence in its own right

‘Quality’ is a term in this context that is synonymous with good, which represents the criteria utilized as the standard being applied. Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) equate this word in the following manner:

  1. Deming (Deming, 1988) states that improved quality helps to reduce operating costs through less error and correction measures. He indicates that to attain the preceding a consistency of purpose needs to be inculcated throughout the organization with an overall plan that is maintained. Deming (Deming, 1988) stresses the need for improved consistency on an ongoing basis and to remove the barriers between various departments to increase and improve communication, feedback and intra-company working processes. Deming’s (Deming, 1988) thirteen point program stresses that it is management that leads and sets the example as well as supports ongoing quality through active participation that involves everyone within the organization as well as suggestions and contributions from working partners and clients.
  2. Juran (1992, pp. 154-198) states that quality application in organizations is defined by crafting them to be utilized in context with the organizations purpose to improve performance.
  3. Crosby (1980, pp. 189-216) also trumpets the application of quality throughout the organization as a management down function that must be maintained, taught as well as communicated to bring the staff not only on board, but committed to the adoption of quality and improvements as an organizational way of thinking.

Moullin (2002, pp. 2-7) advises us that quality in health and social care fits within these fields as it is important to:

  • patients as well as service users,
  • staff, and
  • the application of quality can aid in the reduction of costs as well as provide better service in the context of budgetary and cost constraints.

It is interesting to note that Moullin’s (2002, pp. 2-7) points are the same as those emphasized by Deming (Aquayo, 1991, pp. 138, 248), Crosby (1980, pp. 212-223) and Juran (1992, pp. 171) in the general context of total quality management, and that the application in the health and social care fields is the same as for manufacturing, banking, or any other industrial sector. Moullin (2002, pp. 2-7) points out that quality in the health and social care fields is important in that not only do patients as well as service users benefit in that their differing requirements are met in a better, more comprehensive and complete fashion, the benefit of quality also affects both these groups each time they come into contact with the organization(s) and thus their individual confidence levels rise with the expectation that they will receive good service and be well treated. Moullin (2002, pp. 5) advises that patients in need of health and social services are usually stressed, worried, vulnerable as well as frightened with respect to the outcome of their need(s) and that long waits on the telephone, in lines, for responses, little or insufficient information, poor facilities and insensitivity exacerbate the preceding. He (Moullin, 2002, pp. 6-8) indicates that quality in these fields, health and social care, is important in that:

  1. The staff benefits as the vast majority elected for a career in these fields out of a desire to help others, rather than for monetary gains and that poorly organized staffing functions contribute to frustrations for employees reducing their morale as well as effectiveness.
  2. Moullin (2002, p. 6) adds that quality is important in the reduction of costs as he advises that the correlation between resources and quality represents a strong relationship. And while the amount and number of staffing is important, quality can be improved irrespective through the application of new innovative techniques, technology, work flow planning, scheduling and other means. Moullin (2002, p 6) indicates that reduction in costs sometimes means increasing services and or staffing in one area whereby the work load flow will thus lessen the impacts on another thus either balancing out or reducing costs through flow adjustment.

While it is difficult to place an exact date or year on when quality became an active force in the health and social care sectors, the concern over spiraling health care costs, inefficiencies and deteriorating services began to surface in the late 1970’s and early 1980’s in the United States, as well as a result of the increasing costs burdening the governments in Europe’s socialized medicine schemes (Bennett et al, 1999). The era of unlimited access and treatment as the foundation of quality oriented services in the health and social care fields began to give way to the spiraling costs of advancements in diagnostic techniques and therapeutic modalities, with the rising costs of health and social care exceeding the rise in the costs of living in the United States as well as Europe and the expenditures for socialized medicine threatened the economies of many nations in Europe (Lighter, 1999, p. 265). In addition to the foregoing, the aging of the world’s population as better medical care has increased life spans, and this combined with the fertility transition has increased the proportion of older adults and has contributed to the concern for quality in health and social care (Demeny et al, 2003). Health care spending in most OECD (Organisation for Economic Co-operation and Development) countries, such as (OECD, 2006):

  • Australia
  • Austria
  • Belgium
  • Canada
  • Czech republic
  • Denmark
  • Finland
  • France
  • Germany
  • Greece
  • Hungary
  • Iceland
  • Ireland
  • Italy
  • Japan
  • Korea
  • Luxembourg
  • Mexico
  • Netherlands
  • New Zealand
  • Norway
  • Poland
  • Portugal
  • Slovak Republic
  • Spain
  • Sweden
  • Switzerland
  • Turkey
  • United Kingdom
  • United States,

amounts to in excess of eight percent (8%) of their Gross Domestic Product (GDP), with health related spending in the United States projected at fourteen percent (14%) (World Trade Organization, 1998). The public’s concerns over increased costs for health and social care services prompted the privatization wave on the mid 1980’s in the expectation that the measure would increase efficiency as well as reduce costs, but those expectations from this initiative have been elusive (Bach, 1989). The preceding created a climate whereby governments in Europe under socialized medicine, as well as the private health care structure and governmental social care system in the United States began to look for measures to control and reduce costs while increasing quality.

In 1998 the Department of Health in the United Kingdom issued a ‘White Paper’ titled “Modernising Social Services” (Department of Health, 1998) which represented the United Kingdom governmental response to public opinion as well as mounting social care costs to introduce quality frameworks into the system. The White Paper set forth a framework at the national level that called for (Department of Health, 1998):

  • the establishment of “… clear objectives for social services…”that created a “… clear expectation of outcomes …” which social services would be “… required to deliver.” (Department of Health, 1998),
  • the publication of a “… National Priorities Guidance…” (Department of Health, 1998) that set up key targets that social services would achieve in the intermediate term, and
  • putting into place “… effective systems …” (Department of Health, 1998) via which to monitor as well as to manage performance.

The Department of Health’s White Paper in 1998 clearly set forth that the government of the United Kingdom was putting into place “… new resources to support …” (Department of Health, 1998) the programme, and in return for these added resources, pegged at £1.3 billion over 1999/2000 – 2001/2002, and the United Kingdom government made it clear that it expected “… to see improvements in quality and efficiency …” (Department of Health, 1998). The Best Value framework represented another name for Total Quality Management in the context of health and social services care in the United Kingdom. Under the “Best Value” framework indicated under this White Paper, the government set forth that (Department of Health, 1998):

  1. Local authorities were mandated to establish “… authority wide objectives for performance measures” (Department of Health, 1998) in consort with the national objectives as well as government set standards and or targets.
  2. Local authorities were also provided with the responsibility to conduct and “… carry out fundamental performance reviews …” (Department of Health, 1998) concerning all their services in a five year framework utilizing these reviews for assessment and the establishment of “… local performance plans…” (Department of Health, 1998).
  3. That the local planning process will be underpinned and supported via data obtained “… from a new statistical performance assessment framework” (Department of Health, 1998).
  4. “… Local Performance Plans …” will be utilized to identify the targets for improvement compared against performance indicators on a local level and “…. The National Best Value Performance Indicators …” (Department of Health, 1998).
  5. Annual reviews of the aforementioned local performance plans will be conducted by the Department of Health utilizing Social care Regional Offices to assess progress and identify problem areas (Department of Health, 1998).
  6. The White Paper put into place an independent inspection system utilizing data from the performance assessment framework (Department of Health, 1998).
  7. And lastly, the ‘Modernisation’ programme set forth a system of Joint Reviews reducing the time table to five years from seven (Department of Health, 1998).

The new programme set forth a performance assessment framework that specified performance areas defined by (Department of Health, 1998):

  1. cost and efficiency,
  2. effectiveness of service delivery and outcomes,
  3. quality of services for users and carers, and
  4. fair access.

Analytical Methods of Quality Measurement and Standards

Balanced scorecards represent a top-down hierarchical set of management tools that link long-term financial goals with performance targets (Kaplan et al, 1996, pp. 75-84). The United Kingdom’s National Health Service utilizes what is termed a ‘Star Rating’ system which is an example of the balanced scorecard (British Library, 2002). Kaplan et al (2001) advise that this methodology, specifically designed for the public as well as voluntary sectors has a link between performance measures and strategy, and thus the method should represent one of benefit in these regards. The caveat is that there are varied difficulties arising from its use by organizations as the financial perspective measurement is not the defining factors of organizational purpose in the public sector (Dickson et al, 2001, pp. 1057-1066). Kaplan et al (2001, pp. 135) agree with the foregoing and add that in utilizing the balanced scorecard governmental agencies should consider the utilization of an overarching objective at the head of their respective scorecards which is reflective of the long-term objectives (Kaplan et al, 2001, pp. 135). The difference in the utilization of the balanced scorecard in a not for profit and governmental agency mode as opposed to business is the way stakeholders are considered. In a business atmosphere stakeholders are involved as it represents the best means to conduct business, however in a not for profit and governmental agency sense, these organizations usually exist for the benefit of the users of the service as well as other stakeholders thus changing the emphasis whereby stakeholder contribution is more fundamental (Moullin, 2002, p. 167). Moullin (2002) adds that user involvement takes place at two levels, one represents helping to develop the service to meet their needs and the second entails the involvement of users and carers in the decisions concerning their health as well as the care given and received.

Benchmarking, as a term, has numerous definitions, however at its core it represents a process of “…sharing information, learning and adopting best practices …” (PSBS, 2006). The European Benchmarking Code of Conduct states that it is a process of making comparisons against other organizations and thus learning from the lessons these comparisons reveal (The European Benchmarking Code of Conduct, 1998). In the context of social care, benchmarking entails the understanding or and utilization of knowledge gained across a range of services and compilations to utilize in formulating standards of measurement as a guide to rating and understanding the performance of services in individual local authorities. The weakness of benchmarking is that it can not stand as a total measurement without revision and modification as newer and more effective techniques and methods prove themselves. Thus as a standard in a state of flux, benchmarking represents a system that is based upon existing methodologies, that are changing, being modified and or amended. Thus benchmarking represents a useful, yet temporary methodology whereby the practitioners must be mindful that existing standards are subject to change, which in conjunction with other measurement methodologies has contributed to improving quality and performance in the health and social care sectors.

Quality Approach

The utilization of balanced scorecards, and benchmarking fall under the concept of Total Quality Management which is termed Best Value under the Department of Health’s Modernization Programme and is illustrated by an example provided by Gillian Crosby (2004, pp. 7-8), the Director of the Centre for Policy on Ageing. She indicates that the problem in the social services arena, is wrongly based in concentrating on the solving of their problems as well as users of services rather than as their being active contributors to society. Crosby (2004, pp. 7-8) indicates that the NHS views social care as well as society’s older individuals as a “problem” which in what Crosby (2004, pp. 7-8) terms a “… very narrow approach …” thus creating a focus on delivering intensive services which thus “… excludes … older people and their careers”. She further states that in the aspect of quality as it relates to social services the systems of initiatives, pilots, and projects that have been created and put into place to audit, evaluate, monitor and investigate service development and provisions have been in place for years. Crosby (2004, pp. 7-8) maintains that the problem is the “… sustaining and maintaining …” these areas and “… building them into effective …” provisions through utilizing these collective findings and synthesizing that information. Crosby (2004, pp. 7-8) indicates that this void causes good ideas to stagnate rather than permitting them to be explored and utilized where warranted and she cites that quality thus suffers as a result of duplication and what she terms as “… pilot fatigue …”, indicating that the system needs to implement as well as create and find more innovative ways in which to service elder citizens in a manner whereby these initiatives are “… developed and maintained.” Crosby (2004, pp. 7-8) that there are numerous examples of individual cases whereby instances of good practice have been demonstrated through partnerships that have improved service provisions for elder citizens, citing the “London Older People’s Service Development Programme” as an example. The preceding utilized a collaborative model that promoted optimized care and independence and grew into a tool implemented by the National Service Framework for Older People in London with the hallmark being its “… single assessment process” (Crosby, 2004, p. 8).

The foregoing example is an instance whereby the practice of Best Value and allied tools need improvement to respond to the specialized needs of a segment of social care services, but this example does not indicate that system wide the measurement has not produced results. The system has shown “mixed progress” as reported by the BBC (2005) as the quality of care has improved since the adoption of the Modernization Programme, but as the BBC (2005) reports, “… there are still worrying gaps …” with regard to service as reported by inspectors. The BBC (2005) report indicated that three quarters of the council departments received ratings “… in the top two categories …” as opposed to slightly “… over two thirds in 2004”. Thus progress has been made as a result, yet there is still sufficient room for further improvement.

The NHS Mental Health sectors foundation for improvement in its quality of services was set forth under the National Service Framework in 1999 which established a blueprint for care throughout the United Kingdom …” (Department of Health, 1998). The initiatives established for a modern NHS resound with the word ‘quality’ as its foundation (Appleby, 2000, pp. 177-291). The process filters down into every job description utilizing the word “quality agenda” (Appleby, 2000, pp. 177-291) which is composed of six elements:

  1. treating patients as well as service users with the dignity they deserve,
  2. the creation of the proper environments via which patients can recover and utilizing their views to accomplish how services should be developed,
  3. recognition of the skills of families in the roles of carers,
  4. linking service activities to needs so acutely ill individuals receive urgent care access through a comprehensive range of services,
  5. making the best as well as most effective treatments available, and
  6. emphasize patient safety

The success of the system is contained in the regional rating system which measures the number of ‘Local Implementation Plans’ in red, amber and green (Appleby, 2000, pp. 177-291). The National Service Frameworks set measurable goals as follows (Department of Health, 2006):

  • the setting of national standards and the identification of key interventions with respect to defined service and or care groups,
  • placement of strategies that support implementation,
  • establishment of means via which to ensure progress in defined time frames,
  • introduction of the new NHS and A First Class service that re-emphasized the position of NSF’s as the key drivers in the deliverance of the modernized agenda.

The success of the NSF is assessed by what are termed interface indicators which are a part of the performance assessment frameworks which has seen demonstrated improvement throughout the system as a result of the Department of Health Modernization Programme and as contained in the Mental health NSF Performance Report of July 2005 rated all ongoing programs as meeting the prescribed targets of achievement (Mental health NSF, 2005). In 2005 26 councils received the three star top rating, which represented an increase of six councils over the prior year (BBC, 2005). The total results indicated (BBC, 2005):

  • 83 councils received two starts as opposed to 78 in the year 2004,
  • 31 received one star, which represented a decrease from 36 the year before,
  • 3 received zero stars, which decreased from eight in 2004.

The foregoing indicates that the Modernization Programme has demonstrated progress and as a result of the varied programmes and measurement systems there is in place a means to equate progress.

Clinical Governance is a term and process which grew from the commercial arena under standards for financial management for companies in the private sector (Palmer, 2002, pp. 470-476). In the framework of the NHS it represents a methodology and framework whereby organizations are accountable for the continuous improvement in the quality of their services as well as high standards of care through the creation of a climate and environment whereby excellence with regard to clinical care grows (Department of Health, 1998, p. 33). Since the implementation of the Department of Health’s modernization programme NHS community and acute trusts have been charged with the creation of established structures as well as processes for clinical governance which is monitored by the CHI. It represents a comprehensive approach comprised of four areas (Palmer, 2002, pp. 470-476):

  1. definitive and clear lines of responsibility for overall clinical care quality,
  2. programme of quality improvement regarding activities that includes a clinical audit,
  3. development and utilization of clear policies that manage risks,
  4. procedural methodologies for all groups to identify as well as correct poor performance areas

The heart of the system is the clinical audit which places accountability on the managers and utilizes performance management as the process of delivering the objectives throughout organizations to filter down to each individual and job description thus providing management with clear roles and set priorities. The programme has been rated as successful in terms of it providing a clear set of measurement data to gauge and compare progress through point in time comparisons under its clinical audit segment which represents a new system that did not exist (Palmer, 2002, pp. 470-476). As such it has aided in the achievement of measurable improvements in the field of patient care, making such an established routine.

The Commission for Social Care Inspection utilizes a framework of fifty performance indicators that when assessed as a whole provide an overview of the manner in which local councils are serving the needs of their residents concerning social care service delivery (East Sussex County Council, 2006). Inspections are carried out a minimum of once in a three year period and can be conducted at any time and is comprised of three types of inspections (Commission for Social Care Inspection, 2006):

  1. Key Inspections:

These are comprehensive and through inspections that are unannounced and are conducted at least once for all adult social care services during a year period. It represents on sire as well as documentation reviews and inspections of all areas of service categories without any prior notice.

  1. Random Inspections

This type represents targeted specific issue inspections conducted in addition to key inspections in the follow up of complaints and or progress from an earlier inspection calling for specific areas of concern.

  1. Thematic Inspections

These inspections represent follow up to regional and or national issues concerning medication, nutrition or similar areas and are also in addition to key and random inspections which can be conducted at any time.

The preceding inspections provide the formulation for ratings and represent a gauge on progress, standards and adherence to established policies. The performance indicators represent fifty differ areas ranging from (National Statistics, 2005):

  1. Children’s Pls
  • placement stability
  • employment, education and care leavers education
  • unit cost of residential care
  • unit cost of foster care
  • children reviews
  • core assessments
  • long term stability
  • children in need
  1. Adult Pls
  • emergency admissions
  • drug treatment program participation
  • unit costs of residential and nursing care
  • adults at home
  • services for carers
  • client reviews
  • carer assessments
  • waiting times

The methodology has been successful in terms of providing a measuring device via which the CSCI can assess progress and improvements as well as backward movements in services. The audit commission’s role promotes the utilization of performance data to fuel improvements in services provided to the public (Audit Commission, 2006). The Audit Commission works with varied governmental departments, agencies and local authorities to define a broad array of performance indicators applicable to their circumstances. As a department the Audit Commission’s success is represented by the performance indicators it assists in the development of for the aforementioned and is a success as these varied programs have improved the ability of these agencies, departments and local councils in assessment of the services under their charge.

Conclusion

The NHS Modernization framework has been devised to oversee and create improvement in the world’s largest government public sector health and social care programme which stands in excess of £9 billion and is responsible for delivering a huge variety of services to every corner of the United Kingdom (Department of Health, 2006). Serving individuals in these sectors represents a demanding subjective function whereby the standards of quality and service delivery are defined by consistently improving services and new methodologies which change the standards as innovation introduces newer and improved techniques. Total Quality Management represents a technique that under the NHS Best value programme and Modernization plan of 1999 offers a means via which the system can monitor itself as well as agencies and local authorities with the foregoing fluctuating basis and improve its quality of service delivery in keeping with changes and improvements in care.

The preceding is important as a result of the lessons learned in spiraling health and social care costs that surfaced in the late 1970’s through early 1990’s. The SSI/Audit Commission through its process of Joint Reviews provides invaluable data on the quality of services that are being delivered in terms of effectiveness as well as value (Department of Health, 2006). And while the system as well as service delivery is not perfect it has found many instances of good practice as well as examples of poor service delivery and inefficiencies. The Best Value framework has put into place a means to make the foregoing analysis and identify performance on a national, regional and local authority level which enables corrective actions to be taken as well as to learn from those examples where superior service is being administered. This system provides the foundation to increase and improve quality across the board and has been demonstrated by the system results as indicated in the BBC (2005) report revealing:

  • 26 councils receiving the three star top rating, representing an increase of six councils over the prior year,
  • 83 councils received two starts as opposed to 78 in the year 2004,
  • 31 received one star, which represented a decrease from 36 the year before,
  • 3 received zero stars, which decreased from eight in 2004.

The system not only identifies stellar performance, it also represents a comprehensive methodology to work with under performers and determine with them the causes of their operational problems utilizing comparative data from those organizations generating good to superior results.

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