Standards bearers?

Labour
has upheld the principles underlying John Major’s Citizens’ Charter and applied
them to long term care. But their application varies widely across the UK,
reports Bob Hudson .

The
idea of charters as a policy tool for both central and local agencies emerged
during the late 1980s when quality and consumerism became central to the
Conservative government’s thinking about how best to manage public services.
Standards were seen as a device by which the public would know what to expect
and what to complain about if these expectations were not met. The
Conservatives took to charters like ducks to water – within 18 months of the
publication of the Citizen’s Charter in 1991, a further 28 charters had been
produced.

Despite
growing scepticism about the value of charters,¹ the Labour Party
manifesto of 1997 contained a commitment to reviewing the patient’s charter,
updating the principles of the Citizen’s Charter and introducing a charter for
people using health, housing and social services over long periods of time –
another illustration of continuity between Conservative and Labour policies.
The latter, led by social services, were to be local charters based upon a
national template and have become known as Better Care Higher Standards
charters.

The
first round of local charters were produced in June, and the Nuffield Institute
for Health was commissioned by the Department of Health and Department of
Transport, Local Government and the Regions to analyse their contents.²
The findings can help to show whether charters under Labour really differ from
those associated with the Major years.

The
investigation found that charters varied widely in their content, style and
approach. Differences in approach across several key dimensions were
identified.

–
Charter availability. One locality visited published 20,000 copies of the
charter, a second produced 5,000 plus 15,000 publicity leaflets in 12
languages, while a third could manage only 1,000 copies. Just over half of the
charters were available in alternative formats, and while ethnic minority
languages, hearing and visual disabilities were relatively well catered for,
few were accessible to those with a learning difficulty.

–
Involvement in charter development. The national guidance requires the
three charter authorities to involve a wide range of individuals, groups and
agencies in charter development. While some appeared to be making strenuous
efforts to do so, others encountered the sorts of difficulties that generally
affect such exercises – time limitations and "consultation fatigue".

–
Contribution of key agencies. The first line of the national charter states
that "co-ordinated help and support from housing, health and social
services can make it easier for people to continue to live independently, and
for family and friends to support them". The survey suggests that in most
areas the three partners were working together, but often this tended to be
retrospective rather than developmental, with sections separately produced and
subsequently put together. With social services taking the lead, their
involvement was assured, but securing the full co-operation of the NHS and of
housing agencies was sometimes difficult, especially in the case of two-tier
councils.

-Range
of charter information. Two different approaches to the range of
information which should be contained in the charter emerged – comprehensive or
signposted. In the case of the former, the aim of the charter is to act as a
wide-ranging information resource or guide so that the reader does not need to go
to many other documents. But more commonly, charters were kept short and
described themselves as "signposters" to other, more detailed,
documents. It was not uncommon for localities to have started out with a
commitment to a comprehensive document and then retreat into signposting once
the scale of potential input became apparent.

–
Charter areas. The issue of whether to describe the sorts of services
provided or to identify specific service standards that must be attained, lies
at the heart of local charters. A number did not go much beyond a service
directory, and there are in any case few rights in the sense of entitlements in
law to the services covered by the charter. The most common emphasis was
accordingly upon what sort of expectations should be aimed for. There can be
little objection to the notion of ensuring that public sector organisations
articulate acceptable standards, but there are dangers in setting standards
that are inappropriate or cannot be delivered. Most charters were very cautious
in this respect, with some failing to contain any standards whatsoever. Where
they were included, the tendency was to focus upon matters of process, such as
assessment waiting times, rather than standards of service output or outcome.

–
Charter champions. Each of the three local agencies is required to appoint
a lead "champion" who should be named in the charter to take
responsibility for its development. Around a third of charters failed to even
name the champions, which gives a poor message about access and accountability.
Champions do not always find their role straightforward – it may be bolted on
to existing responsibilities and left in the hands of unsupported middle
managers in social services. The better charters tended to arise where
ownership of the role of champion was corporate rather than individual; the
poorer charters fused the champion role with that of complaints procedures.

–
Organisational ownership. A local charter will never be meaningful if the
frontline staff who have to implement it know little about it, but in some
areas it seemed that relevant staff were only dimly aware of its existence.
With some honourable exceptions, joint or even single-agency training was
noticeable mainly for its absence.

Compared
with their predecessors, the community care charters, the Better Care Higher
Standards charters are much more uniformed, but the first round of charters
has not resulted in the sort of consistency that may have been expected.
Whatever the rights and wrongs of central prescription, the latest set of
guidance from DoH and DTLR³ leaves ever less room for wriggling out
of the demands of a national template. Some of the key requirements of the
revised guidance are:

–
Charters should set minimum standards in relation to both process and outcomes
for users and carers.

–
Authorities must develop a jointly agreed strategy for providing information
about long-term care services for inclusion in the 2002-3 charters, including
details of training for frontline staff and the provision of one-stop shops.

–
Named charter champions should in future be second-tier managers to ensure
charter development receives proper consideration and priority at senior level
across the three services.

What
all of this suggests is that the Better Care Higher Standards charters
are not going to be allowed to wither on the vine in the same way as the
Conservative initiatives of the past decade. There is a better understanding
that charters need to be more explicit and that those charged with
responsibility for implementing them need to more clearly accountable. And
there is a better recognition that unless charters are, at least in part,
shaped by the views and concerns of those who implement them and those who may
benefit from them, then their effect will be peripheral.

This
is all to the good, but what will worry local authorities is that they may be
stampeded into setting standards that they cannot find the resources to meet.
One possible approach may be to distinguish between different types of
standard. At least three types can be identified: minimum standards which must
be reached; average standards (or norms) – levels of service that most
providers may be expected to meet most of the time; and best practice – that
which is aspired to but which it may not always be possible to meet.

Charters
seldom specify which type is being referred to, and all three could be in play
simultaneously. There may well still be some legitimate suspicion of the whole
notion of charters, especially where these are being centrally imposed. But is
it not reasonable for a potential or actual recipient of long-term care to
expect to be able to identify at least some unequivocal minimum standard of
care which will normally be made available? cc

¹
IBynoe, Beyond the Citizen’s Charter: New Directions for Social Rights,
Institute for Public Policy and Research, 1996.

²
DoH/DTLR, Better Care Higher Standards: Guidance for 2001/02. LAC 6: HSC
20001/006, 2001.

³
B Hudson, PFletcher, TRandall, and GWistow, Meeting the Standard? Analysis
of the First Round of Local Better Care Higher Standards Charters. Nuffield
Institute for Health, 2000.

The
government guidance Better Care Higher Standards can be viewed at www.doh.gov.uk/longtermcare/index.htm

Bob
Hudson is principal research fellow at the Nuffield Institute for Health,
University of Leeds.