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.