1 The Point of Departure: Different Concepts of Assuring Quality in Personal Social Services
Personal Social Services (PSS) have been a major growth industry in all European countries. With the current changes in both quantity and impact, the prevailing views and concepts with respect to quality have changed as well. There have been processes of professionalization; changes in social rights to care; transitions from charity- or state-based systems to mixed markets; changes concerning the readiness of families to use outside help and concerning aspirations when using PSS. If one agrees that caring in the widest sense is the essence of PSS - caring being understood not only as providing material help but also as providing advice and personal and social support - then these changes can be summed up in what I call a âchanging culture of careâ (Evers, 1995). The same moving forces that operate behind the changing images of care are also behind the changing notions of quality.
In light of this, one ought to distinguish two separate yet related items which are (i) quality measurement (especially for standard-setting and control from the outside) and (ii) quality improvement (as a way for doing better within a given broader framework). The following considerations will revolve around Quality Assurance (QA), which is meant as a label to cover both issues. There are four important types and traditions of QA that can be distinguished (also see the typology suggested by Rajavaara in this book).
The first comes from the field of professionals and their organizations - these are the traditions of peer reviews by colleagues, standards and ethics given by and controlled within a professional association. This model is linked with the development of the welfare state, which helped to professionalize the field of help, care and social work. It is about both setting and controlling quality standards and about quality improvements.
The second type is the âinspectorate approachâ, sometimes executed by people from the same professional field. This model has flourished alongside the welfare state as a provider of universalistic services meant to be highly standardized and uniform, e.g. in the area of schools and hospitals. The inspectorate approach is very much about the processes of laying down what is seen as a general standard and about guidance on quality control (for the diversity of the prevailing styles, see Klein and Bland in this book).
The legacy of the third type of defining quality and assuring it, basically stems from the late 1960s and the euphoria of being able to construct bottom-up models for new service relationships based on both individual and collective citizen and consumer control and participation (see Harding/Beresford, 1996; in this book especially Beresford/Croft/Evans/Harding).
The fourth type of quality assurance comes from outside - the business sector - with concepts suggesting reforms in organizational and management structures. These range from top-down models (Kelly, 1991) to comprehensive concepts for constant institutional reform, such as Total Quality Management (TQM) (Deming, 1982). These concepts differ from the first type in many instances but especially to the degree they address the entire body of a firm or organization; some of them try to create, at least for a while, a high level of joint readiness and commitment to question not only inherited structures and routines but also prevailing individual perspectives. Altogether, the business-based models are very much concerned with doing better than the others within a shared culture and environment (see the descriptions and remarks concerning development and purposes in PSS by Mantysaari, Oppen, Pollitt and Rajavaara in this book).
It is well known that in European public services today, the concepts coming from the market sector clearly prevail (see the picture given in the overview by Pollitt/Bouckaert, 1995). To a large part, this is in line with the fact that the global ideological trends have shifted towards an increasing impact from market liberalism: the majority of the shifts in the âwelfare mixesâ in PSS have been towards more market values, arrangements and mechanisms (Wistow/Knapp/Hardy/Allen, 1994). This has had a number of positive effects for the culture of care, as well as for the type of QA which is thereby emphasized. Let me enumerate a few:
The new care culture and business concepts of QA seem to be more prepared to look at the wishes of the people cared for; after a century of client concepts, the idea of serving the consumer has finally given some fresh air to the PSS sector.
Q A business concepts are in line with rearrangements in the service sector towards more freedom of decision at the decentralized level of the single unit, and towards greater possibilities to change routines and to innovate, basically allowing for more diversity. This stands in direct contrast to the hierarchical top-down control model, such as the inspectorate tradition; and it makes a difference in the professional model, one constantly in danger of becoming autistic by using criteria and professional standards which have lost touch with reality in the working environment.
Finally, the business approach can help to bring a teamwork orientation into settings where hierarchical characteristics marched hand in hand with the inspectorate tradition and where professional rivalry was an obstacle to professional QA models (for similar arguments concerning suitability, especially of TQM, see Rajavaara in this book).
2 The Point of Concern: Defining the Challenge Linked with the Introduction of Business-based Concepts
However, as some of the readers may have already suspected, such an appraisal is just an introduction to a more critical discourse about the role and limits of business-based QA concepts. I will concentrate on them because they currently prevail in both discussion and practice. In fact, the main purpose of this paper will be to collect hints, experiences and reflections concerning the problems of introducing a business approach into the domain of PSS. My argument is, that the respective approaches do not and sometimes cannot grasp some of the peculiarities of the area of personal social services.
At first sight, this means argueing - like many of my colleagues (as well as a number of contributors to this book; for example, Mantysaari) - that there are problems with business-based QA concepts coming from the outside, and that it is a challenge to adapt them to the specific realities of the PSS sector. In fact, the central argument of this article will be a different one. In order to give the reader an idea of this difference, one can begin with the simple question of what is special in the PSS sector. Usually, the answers will be twofold:
First of all, there is a structural difference: a personal service is constituted by a personal interaction, in contrast to a material good or product.
Secondly, there are empirical and perhaps also contingent differences, many of them concerning the fact that the services are state-based and thus seen as public goods. Others relate to differences in the economy, such as the prevalence of small-scale providers and a huge diversity of service organizations and styles in many countries.
However, beyond the basic abstract principle that constitutes the structural difference just mentioned between material products and personal services, there are in fact many different ideas about how to shape the interactions between service providers and consumers. Some tend to minimalize the difference to ordinary consumer relations, e.g. with the idea of a quick and ready-made service - a perspective which helps to take over the market vocabulary. On behalf of the empirical and somewhat contingent differences between the service and market sectors, various standpoints can also be found when it comes to describing their impact. If one is in favour of turning PSS more into private provision rather than treating them as public goods, this will have a clear impact when discussing the suitability of business-based QA; the same will hold true with respect to the question of whether it is better to keep the PSS economy as diverse as it is, with large parts being restricted to local boundaries or allowing for large capital to take over and create standardizing effects.
In other words, the position and vision to which one refers with respect to the future design of PSS, will influence oneâs judgement not only about the different concepts of QA but also about the degree of changes which a business-based approach has to undergo to make it work. This holds true not only with respect to different interest-based preferences - e.g. on the part of the state, professionals, users or the tax-paying public - detected in deliberations on quality (Munro, 1995; for quality as a plural concept, see Pijl and Rajavaara in this book). The global visions which can be found and have their basis across different (interest) groups are themselves critical. There will obviously be fewer reservations towards business-based concepts of QA if one already envisions a more business-like organized PSS sector. Therefore, the discourse should not be about changes needed in order to adapt business models to a given reality of PSS, but rather about changes and challenges for QA in relation to a specific concept and vision for change in PSS and its culture of care.
Many present contributions to the debate on the future of PSS seem, however, to lack such a vision or to transport it implicitly. The one orienting the following considerations is different from the business/consumerist vision for future PSS, which in many countries may be already mainstream. In line with former work about the culture of care and the welfare mix in the PSS sector (Evers, 1995), the emphasis will be on the importance of factors which today play a very limited role in usual market places. Here are a few examples:
the positive contributions to be made by the co-producer and co-decision-making role of family- and community-based networks; and
the importance of state guarantees and interventions to create social citizenship rights and to represent collective perspectives and common interests as a counterbalance to what are so often praised as individual âpreferencesâ.
By emphasizing the importance of such dimensions, these reflections will probably contain more reservations concerning the role of business-based QA than others. Peculiarities associated with QA issues will be addressed in three sections:
the fact that personal and care services are forms of personal interaction and community-related relationships, different from the usual producer-consumer relations (section 4);
the fact that these partly belong to a different âlocalâ and âmoralâ economy (section 5); and
the fact that questions of public interest and citizen/user concerns are at least as important as consumer preferences (section 6).
From there follows an idea about quality and its assurance which is in a way multidimensional. It should take account of people as co-producers, citizens and consumers (Evers, 1997), which likewise means that there should be a place for each of the four roads to QA sketched above. Within such a policy mix, maybe the third and fourth of them - user involvement as well as market and consumer approaches - are presently both more important and more difficult than others, simply because they have been traditionally so much neglected compared with such professional or social-policy criteria for quality as equality and security.
However, before turning to these points, some observations will be presented concerning the sociopolitical context and the fact that so much emphasis is presently put on QA issues.
3 A Special Point: Quality Development in a Given Sociopolitical Context
Asking how important quality development is, might be of interest in order not to be trapped by the emphasis given to one item, which always means giving less to others. We should not forget that asking parents about the quality of their kindergartens, or a caring relative about the quality of his/her home-care arrangement, means arguing about a part of a much broader question, which could be, âHow good is your municipality or your country when it comes to helping you in child- raising or elderly care?â Quality in terms of this broader question no longer revolves around a specific service action to be singled out, but rather about a complex arrangement entailing such questions as the level of obligatory fees, the difficulties in finally becoming entitled for a place in an institution, and many other similar questions. The restricted perspective of the predominant contributions to the present quality debate, however, is exactly one of the reasons behind its attractiveness: it promises clear, quantitative statements on limited issues where vague discussions on broad issues generally prevail. Yet the attempt of âmeasuringâ the quality of a single service arrangement should not make us forget about the broader dimension of quality - one which includes the fairness of our welfare institutions, rights and our culture at large (Hoyes et al., 1992).
In view of this, one should keep an eye on the fact that potential investments in quality development are usually suggested at times when we find an unwillingness to invest in closing care gaps or in better training, and when the emphasis is usually not on better quality but on getting by with less money. Therefore, the boundaries between reorganization processes oriented towards improving quality, and a New Public Management (Naschold, 1993) concerned with doing things more quickly and with less staff, should be kept in mind. Usually there is a link between quality-development items and increasing productivity (see Pollitt in this book); and one should ask about how these might be balanced.
Therefore, in an environment where we presently find little or no concern with what could be called âquality at largeâ, it is indeed questionable if we look most closely at the quality of what single service units deliver: often, the low quality of a service is to a great degree determined by outside decisions which result e.g. in understaffing or wasting of time and resources due to bureaucratic rules imposed from the outside. One could argue that, just as happens in the general rhetoric about strengthening individual responsibility, there is the risk of blaming the victim - here, an individual PSS unit, its care workers or managers - for problems set by the economic or social policy environment. So, an impact investigation might pay off which states the balance of inside and outside factors concerning e.g. the five most important quality items found to be deficient in whatever PSS un...
