Why measures of adult social care don’t work

Getting to grips with the Adult Social Care Outcomes Framework (ASCOF) is no simple matter. We’ve just been given access to some of the outcomes data on a new website: http://ascof.hscic.gov.uk/Outcome . The technology behind it is impressive and it’s clear that the effort behind the whole ASCOF exercise is substantial.

We’re told by DH that “The ASCOF measures how well the care and support system achieves the things we would expect for ourselves and for our friends and relatives. People who use care and support, carers and the public can use this information to see how well their local authority is performing, helping people to hold their council to account for the quality of the care they provide, commission or arrange.” This sounds good but it’s a claim we have to look at with some scepticism. This is for three main reasons:

  • There are reasons to question the assumption that this kind of data tells us something useful about the quality of social care.
  • There are reasons to question the methodology behind ASCOF and the reliability of its results.
  • There are reasons to question the analysis that is applied to the data.

This isn’t an insignificant matter. We’re told that ASCOF informs and supports national policy development. It’s used as the basis to prompt and persuade local authorities to address themselves to particular issues. It’s fair to say that it skews how authorities act, how they set their priorities, how they defend their positions and so on. The outcomes are used when the local authority produces its Local Accounts and these are the measures that hold all the weight during peer reviews. If ASCOF is unhelpful, the impact is felt throughout the system. ASCOF is significant as well in terms of the resources it takes up each year. Administering and responding to DH’s data requests that go to make up ASCOF, and analysing the data subsequently, take up many hours of staff time at all levels of Adult Social Care.

Addressing all the questions that ASCOF raises would take up many pages. A couple of examples, however, serve to illustrate the problem.

Let’s take the measure of “the proportion of all adults with learning disabilities who are known to the council, who are recorded as being in paid employment.” This is included because it is argued: “There is a strong link between employment and enhanced quality of life, including evidenced benefits for health and wellbeing and financial benefits.” This sounds fine, so what’s the issue? First, employment is most likely to be secured for people with moderate learning disabilities, and the evidence of the benefits of employment relates largely to this group. A Council that focuses its resources on people with more substantial needs will be marked down because it will be giving less attention to those with moderate needs, perhaps for very good reasons. A Council that supports inclusion by enabling people to take up voluntary work or participation in social enterprises will be marked down because these will not amount to paid employment; but it may be doing so for good reasons and may be bringing benefits to more people than if it had focused on paid employment. A Council that supports people into paid work, but those people don’t get reviewed or assessed because the work is provided by a third sector agency with its own admission criteria, will be marked down. The measure says nothing about the proportion of people with learning disabilities in total who secure paid work, many of whom will never come near the Council for assistance, nor does it say anything about the benefits of its other kinds of support for people with learning disabilities, nor does it say anything about inclusion or economic disadvantage for people with learning disabilities in the area. So, what is it telling us?

Let’s look at something central to current social care policy: the measure of “the number of adults, older people and carers receiving self-directed support in the year to 31st March as a percentage of all clients receiving community based services and carers receiving carer specific services.”  ASCOF guidance says “Research has indicated that personal budgets have a positive effect in terms of impact on well-being, increased choice and control, cost implications and improving outcomes. Studies have shown that direct payments make people happier with the services they receive and are the purest form of personalisation. Therefore, the two-part measure will help capture both overall progress towards personalisation and use of best practice.” Now look at the comparison between the results of two authorities Nottinghamshire and Somerset. The DH criticises the low numbers in Somerset (less that a quarter) receiving personal budgets while Nottinghamshire has over 90 per cent. We would suppose than that Nottinghamshire service users would be more satisfied and feel more in control. In fact there’s very little difference in their ASCOF performance in terms of client satisfaction with care and support, and social care related quality of life. Somerset does better on carer satisfaction and, surprisingly,  with “service users with control over daily life”. There is something wrong here with the pretext for the measure or the methodology or both. Whatever the problem, the ASCOF measure is not giving us useful data.

In fact, the methodology raises more than a few worries. Not least is the fact that local authorities carry out the user survey which forms a central part of ASCOF in the way they choose while keeping the form and content of the survey within DH specifications. We know that many social care customers are frail and uncertain and that many are grateful for any help they receive. In general, they are not going to want to rock any boats by criticising the agency on which they depend. An astute local authority will present the survey in a way that yields the most positive response from the people contacted, as will the care homes who assist their residents to respond. There is no quality control over the management of the survey or key features like telephone interviews of respondents. Then, there are some questions and possible answers that  seem to have only a tenuous link with the performance of the local authority. Consider this multiple choice response to a question about how respondents spend their time: “I’m able to spend my time as I want, doing things I value or enjoy.” This may have something to do with social care, but also with the person’s income, whether they have a car, whether they have family who take an interest in them, whether they have a friendship group of which they are part, whether there is a local church or community group that goes out of their way to take an interest in them and so on. As an indicator of the quality of social care the person receives it has little or no value.

Getting a measure of how well social care is working is undoubtedly difficult, more so when the measure is of the outcomes people experience rather than the services they receive. Good outcomes emerge when staff and organisations base all their support on clear and sound values, when front-line staff have the necessary skills and training, and when the relationships between people who need support and people who provide that support are respectful and are built with close attention to the quality of engagement. ASCOF does not succeed at what it attempts to do. To suppose that we can capture the quality of a person’s lived experience and how much one part of a local service system has contributed to that quality, in such a condensed and sometimes convoluted way, is over-ambitious to say the least. As it stands, even to the most experienced person, attempts to use ASCOF to make any sort of helpful comparison between localities of the quality of support to social care customers will usually end in frustration and confusion.

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