Performance Indicators in Social Care for Older People

David Challis, Paul Clarkson

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351912198
• Edition: 1
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

The growing focus on performance review and monitoring means that awareness and use of performance indicators has increased throughout a number of public services. Set within a national context, this book reviews the historical development and measurement issues of performance indicators within social care and the public sector for older people. It then provides an approach to effective local performance measurement in services for older people and an organizing framework within which organizations can arrange their performance appraisal for older people's services. The development of performance review in social care of older people is examined, as is the process of developing local performance measures and engaging staff in enquiry and quality management. The book also reviews the process of developing performance indicators and their utilization at an agency level. Performance Indicators in Social Care for Older People will be of particular interest in the UK for local service providers who are developing approaches for local performance review. It will also be of interest internationally, especially in countries where services for older people are currently developing in a similar direction.

Chapter 1

The Emergence of Performance Review

The Government are very keen on amassing statistics – they collect them, add them, raise them to the nth power, take the cube root and prepare wonderful diagrams. But what you must never forget is that every one of those figures comes in the first instance from the village watchman, who just puts down what he damn pleases.

(Stamp, 1929, pp. 258–259)

Measuring the performance of whole health and long term care systems is set to become a defining issue in the 21st century (Mulligan et al., 2000; United Nations, 2002; World Health Organisation, 2000). In the UK, a number of documents testify to the greater measurement and regulation of both health and social care activity at a national level. Recent initiatives for the organisation and management of community and long-term care are being shaped by the use of performance information in a way inconceivable even ten years ago. Community care services, particularly those for frail older people, which represent the bulk of social care expenditure, lend themselves to the use of such monitoring systems. Problems remain, however, in translating the need for such data into adequate systems for monitoring the quality of services, particularly at the local level. This book brings together a framework for integrated local performance evaluation with a series of exemplar indicators which may be employed as part of this framework grounded in the lessons of early development in one locality. It is designed to contribute to more comprehensive and effective performance measurement processes in social care.

To date performance measurement has assumed importance at the central government level whereby extensive data are being used increasingly to ensure the regular and effective monitoring of health and social services performance. The White Paper Modernising Social Services (Cm 4169, 1998) made such measurements of performance a mandatory requirement. This and other guidance (Department of Health, 1999a,b), provided a framework and measures by which the performance of social services authorities could be judged nationally. This has been accompanied by some tough-sounding announcements concerning the consequences if departments do not show improved performance, including powers to take responsibilities away from failing authorities and hand them over to neighbouring councils (Huber, 1999). Despite these warnings, authorities confront real problems in collecting the relevant information and in analysing performance information. Some of these problems are at the conceptual level, concerning which aspects of performance need to be monitored; some are concerned with measurement issues, such as how to devise relevant data and analyse it effectively; and others are at a technical level, such as how to disseminate information effectively within authorities. However, while solutions to these problems are sought, problems remain with the accuracy of such data, as the quotation from Josiah Stamp so effectively illustrates.

The problems of eliciting reliable and useful information from which to monitor care services are not of recent origin. Routine evaluation of the activities of community care has been plagued with difficulties throughout its development. In the original PSSRU case management experiments prior to the UK reforms of the 1990s, some of the barriers to pursuing effective and efficient management practices in support of long-term care for older people have already been described (Challis and Davies, 1986). These included the structure of social work itself which has, until only recently, relied on routine monitoring on a case-by-case basis as a way of establishing its effectiveness. Management practice has also failed to base its operations on more precise generalisations about the deployment of services. From the original Kent study, an early initiative was developed that enabled information to be used by front line staff in improving the performance of their work with frail elderly people (Challis and Chesterman, 1985; 1986). Information from individual client records was fed into a system that made data concerning needs, care processes and resources available to staff. This, at a more aggregated level, could provide management with the information they needed for longer-term planning. The use of information systems in this way is valuable in improving our ability to predict the likely consequences of certain actions in service delivery. However, in contrast to such action research evaluations, the facility to routinely use information has only recently become available, both nationally and, to a lesser extent, within departments themselves. Comparable information is now available to make possible a wider appraisal of performance: to pursue aspects such as efficiency and effectiveness; to invite comparison between teams or districts; and to compare work with other authorities nationally. The fact that a more sophisticated approach to monitoring has now developed across the government’s current modernisation programme serves to underline how influential such developments have been and how far we have come. One task of this book is to help managers and senior practitioners in social services departments confront the further challenges ahead in managing the performance of their services.

The work contained in this book considers a scheme for measuring the performance of social care for older people that relies on the introduction and use of a set of performance indicators (PIs). Its intentions are to review the current state of knowledge concerning the use of indicators in this context. Being a relatively new development for social care services, the use of PIs for local and national concerns inevitably covers a number of themes. Quite apart from the current regulatory concerns, there are the pressures (which have always existed in local government planning) for the continued development of financial and monitoring systems. There are themes drawn from academic research in business, public sector management and policy analysis, which have contributed to a conceptual debate concerning the use of indicators. There were also a number of central government initiatives in the 1980s, which forged a climate of opinion around the idea of efficiency in managing public resources, giving impetus to the use of performance indicators in the public sector. Lastly, there have been specific directives, from the Department of the Environment, the Department of Health, and the Audit Commission, which have had particular relevance for the development of these measures within a social care context.

Many of these initiatives have been attempts from the centre to monitor and regulate public services at a national level. The challenge for social care, however, is to devise measurement systems for use in a local context, so that the performance of key aspects of a department’s work can be evaluated, monitored and appraised. Indicators can then be used by managers to assess the work of a department against policy priorities, local circumstances and national guidance. They can be used to motivate staff and explore the extent to which services conform to their expected uses. They can also assist in bringing to light concerns about quality and user choice in service provision, both of which are common currencies in the operation of a modern social services department. It is hoped that this book will provide valuable information to help in accomplishing these aims.

Performance indicators in social care for older people are set in context through work undertaken in Cheshire Social Services Department, described later. The was an authority with a particular commitment to the use of computerised information systems in pursuing its objectives more effectively. The work was designed initially to assist in devising a set of performance indicators that could be used within an existing client-based information system. The technical and conceptual work emerging from this collaboration has led to some major refinements to the knowledge base for measuring performance at the local level. The information presented could usefully be extended to other client groups in receipt of long-term care. It could also, we believe, assist departments in setting out a general approach to measurement. This would aid them in complying with some of the recent initiatives. In the remaining sections of this chapter, the scene is set by reviewing some of the arguments concerning performance indicators; why they were originally devised, what they are, and the procedures necessary to implement them.

Social care performance: why and how

The recent trend towards performance measurement within social care has its precedents in an earlier period of social services history. The difficulties in coordination, service delivery and flexibility that characterised social care in the past have gradually given rise to an increased emphasis on monitoring performance. At the time of the Seebohm reorganisation (Cmnd 3703, 1968), the focus was on the problems of co-ordination, inadequacies in the amount and range of provision and the quality of such provision throughout the country. Proposals for a unified service were seen as a way of ensuring a more efficient and comprehensive response to meet need (Cmnd 3703, 1968, paras 152, 153). Throughout the early 1980s, debate centred on a more or less constant reappraisal of these changes. So, there occurred an assessment of the problems encountered in a universal, generic service (Challis and Ferlie, 1986; 1987; 1988), such as the relative neglect of work with elderly people, the lack of specificity in service response, and the difficulties in co-ordination brought about by fragmentation of the system (Challis and Davies, 1986). These more general debates about the performance of social care were increasingly replaced by more specific concerns. The major legislative changes of the late 1980s, of which the White Paper on community care, Caring for People (Cm 849, 1989) was central, raised a number of issues about the care for older people. These included concerns about poor assessment and targeting of services, the inappropriate placement of many elderly people in residential care and the rising costs of institutional care (Audit Commission, 1986a; Parker, 1990). During the early part of the 1990s the focus was largely on monitoring the impact of the community care changes. Important early work (Wistow et al., 1994) sought to measure the workings of the new system for social services departments. From central government, there was an increased concern with monitoring social services performance from the viewpoint of the consumer (Black, 1994) and the quality dimension emerged as important (Coote, 1994). The emphasis changed in the later part of the 1990s with the incoming Labour government’s stress on a consistent national approach to defining social care performance throughout the country (Department of Health, 1999a).

As opposed to previous periods, in which care provision was observed and recorded mostly within the context of individual cases, the recent reforms bear witness to a sea-change in the way overall care is monitored and appraised. In care for older people, many social services departments are now attempting to monitor the work they do in a way that assists managers and practitioners to think on a more global level. Much of this has been bound up with the emergence of a more market-oriented philosophy in social care, stemming from the community care reforms of the early 1990s (Cm 849, 1989). The reforms required the establishment of quality assurance mechanisms within social services departments (Coote, 1994). This engendered a more competitive environment, with many different players operating in the long-term care field. It is therefore now essential for staff to have some grasp of how their activities fit into the overall provision of care. Related to this, there has been a shorter-term history of budgetary constraints, with the needs of older people often outstripping the supply of well-organised and efficient care. Knowing how services perform and whether they are achieving their objectives has thus become one way of responding to these competing pressures.

At the macro level, central government has responded to these demands by setting standards for the way individual local authorities manage the care they provide. However, this has not been a simple linear development. There have been changes in approach, consequent on the overall economic environment. Often standards have been set down in the style of requirements, where financial and other control mechanisms are imposed if departments do not come up to the mark. At other times, performance standards have been more implicit. Central government, through the Department of Health and Social Services Inspectorate, monitored local authorities by inspection and guidance rather than by imposing mandatory standards. Performance has been measured at the local level with departments devising their own monitoring mechanisms. Recent developments, which may be grouped under the banner of the government’s modernisation agenda, now seem to be bringing us full circle. The Social Services White Paper (Cm 4169, 1998) and other initiatives stemming from it (Department of Health, 2000), put considerable stress on a central government role of regulator for care standards at a national level. The consistency of services across the country is one theme that has emerged as important and relevant. The local nature of social services has still often been emphasised, as authorities must respond to local need as they determine it. However, a reliance solely on local standards of service has led to inconsistencies in response throughout different areas of the country. A framework of national standards by which to view performance is seen as one way to tackle this. There is a tension, therefore, between central and local government requirements in the development of performance indicators, which is an underlying theme for social care. In other words, a tension emerges between the need for workable systems of local performance against those that are relevant to national policy concerns.

The influence of all these factors calls for coherent methods of measuring performance in a way that reflects the actual operation of social care. This necessitates a full description of the care system in order that measures are designed with reference to the environment in which they are to operate. At the design stage and in subsequent analysis, measures must, on the one hand, be simple and understandable to use while, on the other hand, be generalisable to the wider context. Performance measures must act to support enquiries into the way services operate and help raise questions concerning different aspects of the service system. Indicators often do this indirectly by drawing to attention aspects that deviate from what is expected or by reference to important policy concerns. Once analysed and interpreted, these measures have a range of uses, from commenting on efficiency and effectiveness to judging services according to user-defined criteria of choice and acceptability. Throughout this book several of these issues around the use of PIs are discussed and translated into a context for social care.

Performance review and measurement

Performance indicators are part of a structure of activities required to monitor the different aspects of performance in any organisation. Much of this structure was drawn originally from the private business sector. The technical arguments concerned with such a structure have been summarised for some time. Performance measurement, and the use of associated indicators, draws largely on the theory and techniques of management accounting, which uses information summarising the sum total of an organisation’s actions in quantitative terms (Emmanuel et al., 1990). From this point, it is argued that control can be brought to bear by the use of techniques which enable output to be measured against the objectives of the organisation. Corrective action can then be taken if there is deviation from these objectives, with possible causes of error being sought by the use of predictive models based on routinely generated data. Correcting errors in the system produces further information which can be used to inform subsequent actions. Such techniques are now well developed in the private business world. For example, Helfert (1965) in his Techniques of Financial Analysis outlined a number of measures that could examine the performance of any business unit. These tools were developed to appraise the performance of business organisations according to the relevant concerns of financial prudence, efficiency and profitability. They were designed to ask specific questions of the running of a business unit, such as its productivity and the meeting of objectives. Performance indicators are expressed in the form of ratio measures, which relate units of information to each other. The resulting measures are intended to express important aspects of a company’s overall performance. So for example, indices such as the current ratio (current assets/current liabilities) and profitability ratio (net profit/total assets) are used to assess different aspects of a business’s operation (see, for example, Helfert, 1965, pp. 54–68). A fuller picture of performance can only be gained by examining the relationships between these ratios. These relationships, if interpreted in a meaningful way, can comment on the overall workings of an organisation; they can confirm hypothesis and lead to tentative conclusions concerning important aspects of performance.

It is clear from the work contained in this book that ratios are not available in such a ready form for use within social care. Unlike private business, there is no indicator of profit or share price, the famous ‘bottom line’, which can act as a summary measure of performance. Nor is it possible, as some business analysts have done, to relate indicators together in a precise arithmetical way (see, for example, Kline and Hessler, 1960, p. 799). In social and health care, performance itself becomes more difficult to measure. What is to be measured is often contested and there are no broad, overall measures that can serve as indicators of performance as a whole. Measures must, instead, focus on the particular workings of specific services. In social services, and other public services, there are several outputs reflecting multiple objectives and a variety of measures are needed (Anthony and Herzlinger, 1980; Jackson, 1988). These must help to define and comment on the objectives of services, their efficient operation and their conformity with specific policy targets. Therefore, a challenge has to be faced in devising appropriate indicators that can serve to emphasise major aspects of current service operations. For social care, these measures can help to answer significant questions concerning the purposes and success, or otherwise, of the care provided to vulnerable people.

Various components of performance review have been identified within the wider public sector (Butt and Palmer, 1985). These include, first, setting clear strategies and objectives for the service. Without these, it is difficult to determine whether policy aims have been achieved. Budgetary processes follow on from this as a means of ensuring the accurate consideration of competing priorities. An effective monitoring mechanism needs then to be in place so that performance of key tasks can be reviewed against targets or standards. PIs are measures designed to reflect aspects of the system to enable this to take place. Indicators have commonly been expressed as ratios between the input and output of a service (Beeton, 1988). For social care, these might include measures such as the cost per home help hour or the number of home help cases per organiser. In order to identify wider-ranging dimensions of performance, these may need to be extended to investigate more subtle processes, such as the adequacy of complementary and substitute services in a particular area (for example, district nurse contact rate/elderly population 65 plus). These can be later combined with other indicators to judge the operation of servic...