John Burton, in a recent Guardian article, points out that regulation does not improve the quality of care services. He gives examples of care improving and being supplied to a high quality chiefly through the caring attitudes and motivation of staff and managers. Regulation, particularly by the CQC, he claims, is not improving care, but is simply eliminating poor care as it comes to light through closure of poor services.
This thinking resonates with my experience: like him, I both managed and inspected care services (not at the same time I hasten to add!). Attitudes, of care staff and managers, towards providing quality support and care were always crucial. Outside inspection was often seen as an obstacle to be dealt with, rather than as an aid to develop the quality of the service. To be fair, the current regulator in Scotland operates under a remit where the Public Services Reform (Scotland) Act 2010 requires ‘diversity in the provision of social services [is] to be promoted with a view to those persons being afforded choice; and good practice in the provision of social services [is] to be identified, promulgated and promoted.’
The holds promise for more than home closures by the regulator in Scotland (indeed, there often seems to be a presumption against closure).The Care Inspectorate has a page on its website where innovation and best practice is published, to help services work towards the specified criteria of excellence. And the policy of publishing grades after inspections has produced and evidenced overall improvement in services nationally.
Inspection may not produce motivation
But these developments rely on managers and staff taking up the opportunities in their care operations. Inspection cannot produce that motivation. This idea was first put forward many years ago by the American quality guru W. Edward Deming. His book Out of the Crisis is topical for us today in the care sector. On p29 he says that ‘Inspection does not improve the quality, nor guarantee quality. Inspection is too late. The quality, good or bad, is already in the product. As Harold F. Dodge said, “You cannot inspect quality into a product.”’
Elsewhere, he states that inspection simply increases the cost of production, and gives fourteen points to ensure quality in all forms of production. These include:
- Continuous motivation for improvement
- Strong leadership
- The elimination of fear
- Remove barriers
- Quality is everyone’s business
His reputation is high in quality and systems research: he inspired and guided the spectacular rise of Japanese industry after World War II.
So, can we also spectacularly improve care and support in these times where faith in the regulator is not high, and where austerity means that financial resources are not the answer? Indeed finance will be subject to further restriction, if the post-election plans of the various political parties are implemented: all of them promise more or less austerity to reduce a mysterious ‘deficit’. Cuts in public spending are promised to various extents, and historically the care industry has taken its share of public cutbacks.
The three Ps
Apart from the sound and relevant recommendations of Deming above, I believe the new Care Act has the seeds of showing the way forward. The Act refers to what I call the ‘three Ps’:
- Participation
- Prevention
- Partnership
Participation means involving the person who needs care, and their families and carers, in how that care is to be planned and provided. Co-production is the new buzz-word which encompasses this. The Care Inspectorate in Scotland sees participation and involvement as one of the criteria of excellence for a service: how well does it take account of the views of service users in developing the quality of its service? The website quotes: ‘this means that during your inspection you must show us evidence that people have had opportunities to have their say about their quality of care. You should show us that you involve people, not only in their own care arrangements, but also in assessing and improving all aspects of the service.’
Prevention is the earliest intervention
Prevention is, of course, the earliest possible intervention to ensure that problems are dealt with earlier and more easily, rather than coming to a crisis point where care is difficult and the wellbeing of the service users is endangered. This is most easily carried out where small scale local services are in good and close personal touch with their clients, and with the community they serve. This means quick and effective responses to arising issues.
Partnership is where services and professionals work closely together. This can be more effective in dealing with problems. It covers inter-professional liaison and communication, and closer working between public, private and voluntary sectors. These issues are perhaps the hardest to address. Professionals, and businesses, can adopt a silo approach, to protect what they see as their own interests over and above the interests of others: most seriously, sometimes over and above the best interests of their clients and communities.
How do we plan in social and health care to achieve and to evidence good outcomes through these three Ps?
Five Years Forward
I think the recent Five Years Forward view planning document for NHS England expresses good intentions and methods to achieve better health care through innovative partnerships, involving people, and reducing the level of crisis working which seems endemic in, for example, pressures on A&E departments nationwide.
A specific report (“Inside out and upside down”) has been released by Birmingham University which looks at these issues across six local authorities in the Midlands. The report draws up lessons to be learned in how innovation is to be taken forward, as well as steps which are less than useful and to be avoided.
Positive services which have been developed in these areas include: falls prevention toolkit, social health and exercise-based opportunities, “good neighbour” promotion, befriending, dementia cafes, volunteer-led pop around service to provide brief support to family carers, and many others.
Preventing escalation into crisis
Each scheme has also considered how outcomes can be planned for and measured, and they take account of the person, putting each individual at the centre of assessment and support. Outcomes are based on how well the service prevents escalation into crisis, how favourable is people’s feedback in questionnaires on their participation, and on the level of involving a range of services working in partnership.
These, and other developments, I think point to the ways that all services can refocus in these times of austerity, and take the opportunities which are there to develop quality and avoid crisis and underfunded service provision.
