CHAPTER TWO EFFECTIVENESS - DEFINING QUALITY OUTCOMES FOR OLDER PEOPLE
2.1 This chapter reviews several ways in which effective social work with older people may be defined. Our starting point emphasises the importance of older people's views about what helps them to live well in later life.
Older people's views about effective social work
2.2 A key factor in determining quality is the extent to which older people themselves are satisfied with both the assessment of their needs and the services provided. Services which provide high quality care according to economic or clinical criteria are far from ideal if, as a result of that care, the user is unhappy or dissatisfied.
2.3 A review of the literature on older people's satisfaction with services in Britain and North America (Bauld at al 2000) concluded that
" older people's responses to satisfaction questions are affected by a range of complex and interrelated factors. Disentangling the effects of user and carer characteristics from expressed opinions poses considerable challenges for those hoping to use satisfaction surveys to gauge service quality."
2.4 The authors list nine factors or characteristics which they anticipate will influence responses or make interpretation difficult. These include:
- fear of dependency or reprisal
- reluctance to criticise individual workers
- entitlement (Users with limited resources receive services as an entitlement; this naturally may reduce their willingness to criticise or comment on quality, as they are not 'consumers' in the usual sense of the word)
- expectations (Older service users are often characterised as having low expectations of services, which may affect satisfaction ratings. Expectations often centre around interaction issues - the manner in which services are provided - rather than the nature of the services or quality of care)
- lack of knowledge
- physical and mental health (including cognitive impairment)
- life satisfaction.
Bauld et al (2000) comment:
"There is clear evidence that people who use social services attach considerable importance to the relationships they have with staff (Barnes 1992, Qureshi 1999), and that these relationships have a direct impact on their overall sense of well being. Secondly, life satisfaction or perceived well being also has a direct impact on how users judge any services they receive."
2.5 Older people may be unlikely to identify the contribution of a particular professional, such as a social worker, preferring to focus on the quality of the overall service.
Evidence from the users and carers' panel
2.6 As part of the wide consultation process for the 21 st Century Review of Social Work, a panel of users and carers was invited to describe its dreams and aspirations for how services should be provided in the future. They offered the following ideas:
- people should be valued as individuals: it is important to be an integrated part of society
- need to understand where social workers are coming from, and vice versa
- need to be aware that carers need someone to talk to too
- freedom from fear and being able to share and contribute in a valued way
- choice and control through direct payments
- services should be about choice and control as consumers
- engaged listening - social worker's skill of listening important - when practiced, much more effective-life changing
- development of a skill set, centred round issues (the manner in which services are provided) rather than the nature of the services or quality of care.
(Extract from a Minute of a users and carers' panel meeting, part of the 21st Century Review of Social Work, provided by Review staff)
2.7 This panel also made several references to the importance of assessment and review:
- often services delivered by the social work department are not what the user wants
- need for whole person assessments - not simply about ticking boxes
- more of a capacity model of assessment
- the need for regular reviews of support to determine whether the service offered is still working or if it needs to change.
(Further extract as above)
Further evidence - the care development group
2.8 Jones et al (2001), in research undertaken to inform the work of the Care Development Group about the implementation of free personal care, asked service users and carers what kinds of support they valued. A strongly expressed view emerged in focus groups that there should be
" free entitlement to packages of personal care tailored to individual need , properly assessed, and extending to whatever kinds of support were necessary to keep the individual living as independently as possible, with dignity and a good quality of life' (p 48)".
There was a clear consensus amongst groups of both older and younger people that they - and, they thought, older people in general - would wish to stay in their own homes as long as they could.
2.9 Of particular relevance to our review, group members emphasised that caring for an older person:
- must be individual, recognising both service users' unique needs, and the other support available to them
- changes over time, with needs often increasing
- must deal with the whole person - not separate 'nursing', 'social' and 'domestic' tasks
- requires sensitivity and flexibility - and involves a relationship
- should attend to dignity, pride and quality of life, not just maintaining life and hygiene (Jones et al., 2001:61).
2.10 Group participants in this work for the Care Development Group thought that assessment should:
- be prompt when help was needed
- take account of individual needs, circumstances, and preferences
- use information from a range of sources e.g. GP, District Nurse
- be multidisciplinary and undertaken only once, not lots of times by different people
- be reviewed regularly
- listen to the service user's view - but also not always be totally determined by this because the service user's perceptions can be at odds with what is happening
- take account of and value the family carer's contribution, recognising that carer support can prevent greater needs arising (Jones et al, 2001: 66).
2.11 There has been considerable debate about the value of user satisfaction studies, particularly in England and Wales. The Scottish Executive has commissioned research which aims to develop reliable methods of assessing user and carer satisfaction with single shared assessment (MacDonald 2004). One particular study produced results of relevance to this review, particularly in relation to the social work tasks of assessment and care management with older people (Chesterman et al 2001). This suggested that service users whose care manager was a qualified social worker were more satisfied than those whose care manager had been trained as a home help organiser. Furthermore, the greater number of social worker hours invested in setting up services, the greater the reported satisfaction with the experience of social services.
2.12 Research on satisfaction or effectiveness more often focuses on older people's perception and experience of social services. It is hard to find studies which focus specifically on social work. This may reflect the relative indifference of this client group to the qualification of the person who is offering them help, compared with their interest in staff's personal qualities, their approach and values. Studies also show that older people give great importance to services which assist them in every aspect of their lives, not just personal care or relationship needs (MacDonald 1999). Another study has suggested that 'low level' services, like help with housework, gardening, laundry and home maintenance, both enhanced quality of life for older people and helped maintain their independence (Clark et al 1998). Clearly, these are not the kind of services which social workers are, or need to be, centrally involved in arranging.
2.13 Thus our review of effective social work with older people needs to concentrate on the key social work tasks of assessment, review and care management for people with more complex needs, and it needs to maintain the distinction between this process and the provision of social services which assist the majority of older people in need, who do not require the intervention of qualified social workers.
ANOTHER APPROACH TO EFFECTIVENESS -WHAT WORKS?
2.14 Outcomes, and particularly 'what works', have been a key concern of policy makers in this field in Scotland since at least 1998. While the relationship between social worker and client - and the process of social work intervention - may be valued by both, it is the result, or 'outcome', which is considered most important within the 'what works' agenda.
2.15 The Social Policy Research Unit at York University has conducted a 5 year research and development programme, funded by the Department of Health (Qureshi 2001), examining outcomes of social care. The aim of the programme was to develop and test practical ways in which agencies which provide or purchase social care could collect and use information about the outcomes of services for users and carers. The programme focused on older people, carers and adults of working age who have physical and sensory impairments. User and carer involvement was a strong theme at all stages. In commissioning a five year programme, the Department of Health recognised that medium-term work was required to address the methodological, practical and conceptual questions involved. The first stage of the programme consisted of research with a range of stakeholders to clarify outcome concepts suitable for social care practice, and to identify realistic opportunities in the current social care context to use these outcome ideas in practice. The second stage involved research and development work over two years, aiming to introduce a greater outcome focus into care management along with the collection of feedback from service users and carers (Qureshi 2001).
2.16 The project identified three different kinds of outcome which social care agencies were aiming to achieve:
- maintenance of quality of life, for example, maintaining acceptable levels of personal comfort and safety, social contact, meaningful activity, control over daily life and routines
- change, for example, improving confidence or accessibility of the environment, reducing risk or regaining self care skills
- impacts of service process, for example, whether people feel treated as an individual, valued or respected, and whether services fit well with other sources of help and with individual preferences and life choices (Qureshi 2001).
2.17 It is important to state two reservations relevant to this review. First, it should be emphasised that the outcomes considered are the outcomes of social care services, not specifically or exclusively of social work. Indeed there is evidence that the outcomes classified as 'maintenance' may be largely achieved through the provision of services such as home care, day services and transport (Qureshi 2001). Further, while it will be readily agreed that the impact of the process is highly desirable in social work terms ' for example, whether people feel treated as an individual, valued or respected' such values and qualities are not confined to social workers.
2.18 It is also important to note that the SPRU project is not an evaluation of social work practice nor of social care services. The aim was to
"introduce an outcome focus into practice, and [to use] outcome related questions in the collection of evaluative information from service users and carers."( Qureshi 2001).
2.19 To paraphrase, the study provides a strong framework for work with older people, particularly for assessment, which helps practitioners, service users and carers to articulate more clearly what outcomes they need and want and (for practitioners) to articulate what they are intending to achieve through their assessment and intervention.
2.20 Nonetheless, the framework is important for our purposes, given that the programme is grounded in the researched views of users and carers. Indeed, it may be that the second of the three different kinds of outcome described - the 'change' outcome - is the one most likely to feature in effective social work intervention with older people:
" Change outcomes…generally reflect attempts to tackle problems or remove barriers which stand in the way of achieving desired levels of quality of life." (Qureshi 2001).
2.21 In an earlier publication, the same team elaborates on this change outcome as follows:
- changes in symptoms and behaviour: this desired outcome was mentioned by people with functional mental illness. People wanted to feel less anxious and depressed, for example, to relate better to family members and to be more active and interested in life.
- improvement in physical functioning
- improving confidence and skills: these were seen as essential steps on the path back to managing without services.
- improving morale: the argument here is that improved morale is an indirect effect which flows from the achievement of other outcomes. People who used day care, particularly those who used facilities for people with mental illness, described more direct effects, saying for example "it lifts you" or "it keeps you going" (Qureshi 1998).
2.22 The SPRU project also identified a concern among older people for relationships and values, echoing the views of service users and carers in the two other consultations mentioned above.
2.23 Thus far, we have concentrated on definitions of effectiveness emanating from, or influenced by, older people. An alternative approach is to look at performance information: are the goals of services and policy makers being achieved? The Interim Report of the 21 st Century Social Work Review identifies the current difficulties in this approach, and the work of the Performance Improvement Sub-group will provide a range of suggestions for overcoming these limitations in the future.
2.24 The implications for our work again centre round the difficulty of disentangling the contribution of the social worker to such objectives. For example, it has long been a policy objective that older people are enabled to maintain their independence, and a good quality of life, in their own homes for as long as possible. So we could look at the number of people who receive home care services, how often, and how intensively; we could compare this with trends in admission to care. However, it would be impossible to determine how far these outcomes were dependent on the contribution of social workers.
2.25 Another example occurs in the phenomenon of delayed discharges from hospital, the majority of which affect older people. Over the last four years, there has been a gradual decline in the number of delayed discharges at national level. Social workers are the professional group most likely to be involved in the assessment of older people ready for discharge, although this may change as single shared assessment develops. We have not been able to identify any work clarifying the distinctive contribution of social workers to the reduction in delayed discharges. Indeed the 'whole system approach' analyses performance in a rather different way.
2.26 The data available at this stage is quantitative. In a later chapter, we look at effective social work in other settings such as care homes and day care. The quality standards used by the Care Commission to inspect such settings are therefore a potential source of evidence for effectiveness. Again, however, there is a difficulty in distinguishing the contribution of one group of staff from the collective quality of care.
2.27 Social work with older people cannot be considered effective unless older people themselves are satisfied with it. However, this may be difficult to gauge: satisfaction surveys have a number of methodological problems. In addition, older people may be unlikely to pick out the contribution of a particular professional within their care package.
2.28 Similarly, research about effectiveness tends to focus on older people's experiences of social services generally, not social workers in particular. Older people appreciate services which support them in various aspects of their lives, not just with personal care and relationship needs. Many value low level preventative services which enhance quality of life and help maintain independence. However, it is not appropriate for social workers to provide this kind of support.
2.29 This underlines the need for effective social work with older people to focus on the key tasks of assessment, review and care management for those with complex needs.
2.30 Service users want to be listened to and recognised and valued as an individual. They want support which enables them to exercise choice and control. Older people see relationships as an important part of the process. They appreciate social workers who take a holistic approach to assessment and regularly review their care to ensure needs are well met.
2.31 An important outcome goal for effective social work with older people is to bring about positive change, including improved physical functioning, increased confidence, better skills and an enhanced sense of well being.