Do we need to look again at standardisation in social care?

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The appeal of standardisation

In human services there are often good reasons to standardise activities. For example, sticking to a standard checklist for operating theatre staff, including checking the identity of the person on the operating table and the procedure that person needs, has been shown to improve the success of operations. There is no reason to quibble with the standardisation of that activity.

In recent years politicians and administrators have been enticed by the idea that almost everything can be standardised allowing them to assess the value and quality of a service in terms of the service’s compliance with set standards. The key tasks by this view are to define the appropriate technical standards then find ways to measure them. Social care has become subject to this approach in a big way.

Local authorities have numerous technical manuals to wade through to prepare their returns to DH. DH is constantly seeking to refine the technical information they require to assess local performance. So, without going into detailed explanation, RAP, ASC-CAR, PSS-EX1, DOLS, AVA are being deleted on March 31st next year, and SALT, SAR and ASC-FR are being introduced. LA’s complain that the Adult Social Care Outcomes Framework is constantly expanding, expecting them to improve performance and capture more data in a world where resources across the board are ever dwindling.

CQC’s mission when inspecting services is to ask the following five questions – are they safe, effective, caring, well led and responsive to people’s needs? To find answers to these questions they have to standardise both what each term means and the method for discovering whether the service has accomplished what is required (eg discovering if a service is safe).

This what we might call a rational/deductive approach: it all makes sense logically and we always come out with a clear cut answer that informs the action we should take. The action, invariably, is to force or persuade the service to adopt, without ambivalence, the prescribed technical standards.

Problems?

Here are four reasons given to question the current approach.

First, the reasoning behind the required performance standard may be badly flawed. For example, local authorities are in a race to get as many people as they can on personal budgets. The ones who fall behind are regarded by DH as performing less well and denying their customers the quality of care they should expect. It doesn’t take too much thinking about to see that this is hopelessly simplistic. The number on personal budgets says little about the quality of support people are receiving, or the amount of that support or the respect with which that support is offered and so on. But this simplistic ‘standard’ has a big effect on the behaviour of local authorities, what they set as their priorities, and what they choose not do to because they are frantically pursuing it.

Second, standards in social care are very difficult to get right. The quality of care I give to someone will have something to do with my values (beliefs about how people should be treated), my skills (abilities to recognise and respond to a person’s needs), and the way in which I engage and form a relationship with that person. These three interrelated and essential aspects of ‘caring’ which help to create what Macintyre Trust call ‘great interactions’ are central to the job of social care workers. But they’re difficult to observe and more so to measure. If we turn to CQC’s Essential standards of quality and safety, in particular to the section on respecting and involving people who use services, it is possible to go through every ‘prompt for providers’ without getting any sense of what it takes to facilitate ‘great interactions’.

Third, standardisation seems to have a strong association with ‘black and white’ decision-making. Service assessments and inspections become exercises in exception reporting with little room for mitigation or negotiation. In food hygiene terms, inspectors are searching for ‘the dead rat behind the freezer’. Of course, the search is legitimate but the consequences for services that are found to have failed, once the ‘dead rat’ has been found, can be catastrophic for staff morale and motivation, and for service quality overall. Personalised support for users of social care, in contrast, is asset-based (building on of the person’s strengths) rather than focusing on their deficits. Services are treated in a different way: deficits provide the focus and one deficit can cancel out any number of assets. It is proper that services should know the penalties for not meeting expectations, but it is also appropriate that people who make assessments recognise the potentially destructive effect of their ‘black and white’ decisions.

Fourth, the interest in standardisation and the evening-out of performance across the country has led to much greater centralisation of regulation and policy making. The CQC has grown in scale since it came into place in 2009 taking over from CSCI. In turn, CSCI 2004 took over from local Independent Inspection Units and from the Social Services Inspectorate. Social care policy and practice has been increasingly subject to micro-management by DH over the last 15 years which has included increasing demands from DH for standardised performance data. Centralisation carries risks because mistakes made at the centre will have far reaching consequences. Nassim Taleb (of Black Swan fame) in his book Antifragile: Things That Gain from Disorder sets out the case for de-centralisation: ‘Decentralised’ might appear messy and might multiply mistakes but those mistakes are far less harmful overall. Right now, the opportunity cost of centralised standard setting, regulation and policy making in social care is just not up for discussion.

Can we imagine something different?

In an interview for the BBC Daniel Kahneman said ‘We understand things by imagining them to be true in our own minds – then if it doesn’t work we conclude they’re not true’. We can perfectly understand why people imagined that standardisation in social care would be a good thing. Maybe now is the time to look at all the evidence, to consider if it has worked as well as we thought it would and, perhaps, to start imagining social care in a non-standardised world. Can we imagine non-standard systems of personalised care? Can we imagine local regulation linked to safeguarding, commissioning, local market incentives and local, customer-led systems of quality assurance? It’s worth thinking about.

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