I was part of another discussion about the development of NICE quality standards for social care services the other day. I’m heartened that NICE are talking to the social care sector and seem keen to fit their work around the needs of people using social care, rather than just trying to fit social care into their existing health-focused model of quality standards and guidance.
It’s dry, but important, stuff: where NICE recommends, commissioners (ie public money) follows. NICE is all about ‘evidence-based’ practice, which is very sensible, but also worrying for a sector with no real culture of measuring the outcomes of its work. We need to address this, but if we rush into it, we may end up measuring the wrong things in the wrong ways, with all the perverse incentives that can entail, and which are evident in some NHS health commissioning.
As I’ve been thinking through these issues, I’ve come up with some tricky questions which are all linked, and to which I’m not sure I know, or have yet heard, convincing answers:
- Social care outcomes are not exclusively delivered by interventions which we would normally label as ‘social care services’. For instance, many of our members’ most creative micro-enterprises look nothing like a social care service and people have bought all sorts of things (season tickets to a football club etc) with Direct Payments. So to which services do social care Quality Standards apply?
- How will Quality Standards avoid creating one system (high quality, expensive) which applies to people whose personal budgets remain managed by councils, with another system (unregulated, cheaper) for those who have the freedom to spend a cash Direct Payment more or less as they please?
- NICE quality standards for NHS services are used in a traditional commissioning environment, in which local planners of one kind or another purchase services as part of large contracts, mainly from large organisations. Social care is increasingly purchased by individuals using Direct Payments or their own money (self-funders) and sometimes from very small providers, so how will quality standards be useful for individuals making their own spending decisions?
- Social care is in transition, moving (uncertainly, patchily) towards a more community-based, empowering and personalised system, so how will Quality Standards encourage commissioning to move towards approaches which support the personalisation vision (and which, being new, often lack research), rather than consolidating commissioning of traditional approaches where there is more evidence?
- Much more care and support is delivered by family carers (1 in 10 Britons, contributing around £140bn of care, compared to around £18bn of state social care). So how will Quality Standards encourage providers to work with and support families as partners?
- How will achievement against Quality Standards be assessed – will this be by CQC? If it’s optional and costs money, will it detract from efforts to level the playing field between large providers with extensive infrastructure and small providers with limited resources?
- How will NICE tell which kinds of services deliver the best outcomes, when there is so little outcome measuring in social care?
I’d be interested in your answers to any of these questions. I also think the government needs to convene the leaders of the organisations involved (NICE, their delivery partner SCIE, Think Local Act Personal, ADASS, Care Provider Alliance, the regulators CQC) to make sure that there is an answer to these questions, so that we are sure that NICE and the other agencies working in this crowded space are all supporting each other to reach the same goals.
Here’s a linked blog entry about quality ratings in social care, from a few weeks ago.
A really interesting post on a topic I am quite passionate about at this particular moment. My primary point would be to shift terminology from quality standards to quality assurance (here enter the chicken and egg).
Quality assurance, when used correctly encourages continuous improvement through efficient reporting from all stakeholders and those with a touchpoint on the process. Something gets feedback and the skill of the organisation is to understand the severity of the issue and build appropriate corrective or preventative actions around the issue to eliminate it. Then feedback and sharing of the information is essential in order to encourage the organisation that feedback works and people see the fruits of their actions.
A culture of investing one’s time for benefits is essential – I implemented such a system in a medium sized engineering firm, basically empowering guys on the shopfloor who initially threw my forms back at me until they saw what completing them could bring them.
In many industries we practice ostrich management on the errors we make and the “operational losses” we accept; quality assurance makes a start in addressing this in a mature open and most importantly “blamefree” manner.
A long term vision has to be trusted that improvements will come but primarily form those at the coal face who are constrained by failing procedures.
I would love to get involved in building this system in such behemoths as care, health etc. I am sure others are working hard on it, but they need to be change leaders as it is at the heart of culture where the work needs to be done.
Then we can start about the future and “Careadvisor” being the next app to get feedback alla Tripadvisor.
Thanks for the post.
Thanks for the comment Bob. You might be interested in Care Opinion, which is being developed by Patient Opinion. https://www.patientopinion.org.uk/
Thanks Alex for an interesting post that’s provided us with much food for thought here at NICE. These are some of the key questions that we have been giving a lot of thought to. We don’t have all of the answers (yet!) but we’ve been listening and talking to those who are working in and using social care services. A few thoughts:
– A lot of social care services are delivered (and regulated) within a statutory framework – NICE quality standards aren’t about replacing or competing with these – we hope that they’ll build on the current framework and be a practical tool for people to use (the ‘how’ as much as the ‘what’). We’ve been talking to Govt departments and bodies like Ofsted to make sure that our standards help, not hinder things – there will be something on our website about this soon.
– We see a real opportunity for people using social care services (not just those commissioning or delivering them) to use quality standards (or the info in them) in their own decision-making – because that’s where it’s increasingly taking place. The challenge on us therefore is to make them accessible and relevant, and to work with the organisations people trust to provide information to help them make decisions about their care.
– As to what topics will be covered – we’re literally open to suggestions – have a look at http://www.nice.org.uk/newsroom/news/HaveYourSayOnNICEsSocialCareWork.jsp
– Finally – the research / outcome measurement issue is a really important one, that we’ve been aware of from the outset. It’s going to be very different in social care, especially compared with the vast output in medical research. That’s why we’re pleased that we’re working with SCIE and their partners as part of the new NICE collaborating centre (see http://www.nice.org.uk/socialcare) to help us develop this area…
We’re already talking to many of the organisations you’ve mentioned, but we’re keen to further this conversation to provide a bit more detail to you (and everyone else who’s asked us very similar questions!) – we’ll keep you posted.
Programme director for health and social care quality, NICE
Really kind of you to respond Nicola. I’ve been very impressed by NICE’s desire to co-design throughout my contact with you and your colleagues. Helpful links too!