Amidst the row over the lack of progress on funding reform, one could be forgiven for thinking that the Government’s social care reforms have been greeted with hostility by those in the sector perhaps even to a greater extent than the NHS reforms.
However, despite the extreme disappointment voiced by the sector on the absence of detail on funding, the Government has won support from most quarters for its broader approach to social care reform, one which seeks to address variations in provision, improve the quality of commissioning, increases access to information for users, their carers and families and improves outcomes.
Ultimately, the success or failure of the social care reforms will be judged on whether they deliver better outcomes for users of services and their carers. MHP Health Mandate’s Atlas of variations in social care demonstrated the extent of the current variations in outcomes for social care users and the challenge facing the Government in embarking on a drive to improve outcomes in social care. However, determining what is a good outcome for a user of social care services and their carer is far from simple – in fact it makes measuring outcomes in the NHS look relatively straightforward. This inevitably presents challenges for a Government which will need to communicate the potential successes of its reforms in the future.
The difficulty of measuring social care outcomes
The challenge of measuring social care outcomes is demonstrated in a short analysis of the main framework to measure them. The Adult Social Care Outcomes Framework is the least ambitious and developed of the three outcomes frameworks that will be used to assess the outcomes of those using public health, NHS and social care services. Whilst the NHS Outcomes Framework has 60 indicators across its five domains and the Public Health Outcomes Framework has 68 indicators, the Adult Social Care Outcomes Framework has just 16 across four domains. In addition, the current 2012/13 framework has six placeholder indicators for indicators that are not fully developed.
It can certainly be hard to determine what is a good outcome for a user of social care services, and outcomes are arguably even more tailored to the needs and wants of the individual than in the NHS making the creation of universal measures even harder. For example, the admission of an individual to a residential care home may be as a result of poor preventative care and against their primary wishes, but could on the other hand be perfectly natural and the desired wish of the individual and their family.
No command and control to deliver
The Government has been at pains to position its social care reforms as empowering local communities and users of local services rather than as a centralising initiative to drive through quality improvements from the centre. Thus, whilst the NHS Commissioning Board will oversee the NHS Outcomes Framework and Public Health England will oversee the Public Health Outcomes Framework, there will be no comparative body overseeing implementation of the Adult Social Care Outcomes Framework:
“The ASCOF is not a national performance management tool. Government will not seek to set targets or manage the performance of councils in relation to any of the measures in the framework. It will be for councils to set their own local priorities, driven by both the framework and by their local Joint Strategic Needs Assessments and joint health and wellbeing strategies.”
The Adult Social Care Outcomes Framework, will help inform the development of local accounts: “which councils will use to set out their priorities and progress to citizens, supporting local accountability.” To date how these accounts will work and the information they will contain has not been made clear. Based on previous MHP Health Mandate research on NHS provider quality accounts,in order for these accounts to be effective they will need to be standardised to allow comparisons to be made between different areas. Such standardisation of reporting and transparency should drive up standards as commissioners can be benchmarked on the outcomes they deliver against one another. This transparency will be important as a common criticism has been the poor quality of local authority commissioning, which many argue has compromised the development of a sustainable sector by focusing solely on cost at the expense of quality.
All about the data
One of the challenges with determining good outcomes for social care is existing data collection methods and processes. Councils currently collect a vast array of data on social care spend and usage, however information on outcomes for users is largely confined to general data collected on user experience and admission and re-admission rates.
In addition, the returns from councils are often not standardised leading different councils to collect data differently. This is the case for example on telecare usage where some councils include community alarms in their telecare returns, whilst others do not leading to vast disparities in supposed telecare uptake, rendering the data meaningless.
In order to address such disparities and streamline the social care data collection process the NHS has been undertaking a zero based review of social care data returns from councils. An update on proposals for future returns is expected by September and will need to perform a delicate balancing act between proportionality and usefulness.
Whilst councils will be keen for the Department of Health to adopt a similar approach to that taken by the Department for Communities and Local Government on particular local authority grants, the Department of Health will be aware that when local health commissioners are given freedom to spend grants as they choose, the money sometimes has a tendency to be used to plug other funding gaps. Given that NHS funding is already being used to support social care services, the occupants of Richmond House will be eager to know what services they are getting for their investment.
NICE is also set to have a role in this area, with plans to develop quality standards in social care set to take off in force from April 2013. Currently NICE is developing two pilot standards for people with dementia and the health and wellbeing of looked after children which will shape its development of a broader suite of standards. Given that such standards are designed to, where possible, have outcome measures in them to allow commissioners to assess their effectiveness, the development of such standards could also play an important role in developing new social care outcome measures.
In addition to delivering improved outcomes in social care the success and or failure of the reforms will be judged on whether they can also lead to improvements in outcomes across the other frameworks. The integration imperative means that a more joined-up approach to assessing the outcomes from services is also now needed. Currently seven (44%) of the indicators in the Adult Social Care Outcomes Framework cross other frameworks, relating to:
· Proportion of adults in contact with secondary mental health services in paid employment
· Proportion of adults in contact with secondary mental health services living independently, with or without support
· Proportion of adults with learning disabilities who live in their own home or with their family
· Carer reported quality of life
· Proportion of adults with learning disabilities in paid employment
· Proportion of people who use services who feel safe
· Delayed transfers of care from hospital, attributable to adult social care services
The White Paper includes plans to expand the number of joint indicators with welcome new proposals to address the problem of social isolation. Further measures, including indicators on re-ablement, would help embed integration across the three moving parts of the new system and provide useful points for cross-organisational joint working at local level, potentially through new health and wellbeing boards.
As it consults on its social care reform plans, and beneath the noise caused by the disagreements on funding, the Government will be heartened that there is broad support for its overall approach to social care reform. However, this broad acceptance will only be sustained if principles are translated into better services and outcomes. The challenge of demonstrating this is just beginning. Whether it will be possible without progress on funding remains to be seen.
In the coming weeks MHP’s social care team will be producing an assessment of the current performance of social care services against each of the domains of the Adult Social Care Outcomes Framework, similar to those produced by colleague Mike Birtwistle when analysing the NHS Outcomes Framework.