What works in social care, and how do we know? Such fundamental
questions are of increasing importance since the growing policy
emphasis on developing “evidence-based” practice and the
establishment of the Social Care Institute for Excellence
An invaluable addition to the knowledge base comes from the
completion of a programme of research commissioned by the
Department of Health in 1997, Outcomes of Social Care for Adults
(Osca). This was the first sustained programme of work on social
care outcomes for adults to be undertaken in England.
Thirteen projects were commissioned, alongside a parallel programme
of work under the leadership of Hazel Qureshi at the social policy
research unit (SPRU) at the University of York.
Several of the projects were concerned with developing tools for
measuring outcomes or with attempting to apply existing tools to
evaluate particular processes. Considered overall, the programme
addressed all the adult social care client groups.
All of the projects have produced their own reports and related
publications. In addition, the Nuffield Institute was commissioned
to co-ordinate the programme, and to write a report drawing
together findings and conclusions from across the entire
programme.1 One of the
objectives of the report has been to maximise the relevance of the
research findings to policy and practice – both centrally and
A frequent criticism of academic research is that it is irrelevant,
or too remote and “ivory tower” to engage with the realities of
practice. It is hoped that Osca can be seen to buck that trend.
Already several of these projects have fed into the development of
national service frameworks and other key policy agendas, such as
the work on standardised assessment (project 3) and the development
of the carers’ and users’ expectations of services (Cues)
methodology (project 4).
Busy managers and practitioners have little time to sift through
vast, and often complex, research reports to identify the key
messages they need to extract. However, Osca attempts to provide
some of this distillation. Of course, reducing complex findings to
simple messages is fraught with difficulty. But having offered this
“health warning”, we can usefully highlight some of the key
It is important to remember that the language of “outcomes” is
still developing. Essentially, a focus on outcomes involves asking:
“What is achieved by social care services for users and their
carers, and how do we measure this?” This process moves
considerably beyond looking only at the levels and types of service
provision, which are often termed service “outputs”, to explore
just what difference these make to the lives of people who use
them. Developing an outcome focus has important implications for
the monitoring and evaluation of services and, increasingly, there
is a need to move beyond output measures – which are, at best, a
proxy for outcomes – and to tackle the big questions. These would
include the following:
How can outcomes be addressed within assessment processes?
What are people’s experiences of assessment, and how can these be
What do we know about the relative importance of different outcomes
to different groups of service users?
What are some of the practical and methodological difficulties in
measuring outcomes and, in particular, what are the problems with
judging satisfaction and quality of life?
How can service users and carers best be involved in processes for
What factors are most likely to be associated with successfully
supporting frail, elderly service users at home?
What do we know about the changing population of carers, and the
predictors of likely outcomes?
What has happened to those people resettled in the community from
former long-stay institutional care under the “care in the
community” demonstration projects?
What are the realities of introducing an outcome focus in routine
social care practice?
Space does not allow for an exploration of all these issues here,
but a few of the messages can be unpacked.
There is a growing emphasis on involving service users and carers
in a range of aspects of service development, and consultation
exercises are widespread in social services departments. Within the
Osca and related SPRU programmes, some innovative approaches were
developed. Project 11, for example, identified the need for new
methods to validate the findings and improve the engagement with
Project 2 found that two-thirds of its sample of people with
learning difficulties were unable to respond to conventional
satisfaction scales, because of the level of language and
communication skills required. However, the Twelve Years On project
sought to develop a range of other methods, using symbols, signs
and photographs, to facilitate communication with people with
Despite the challenges sometimes encountered in engaging directly
with service users, without such an engagement, there are dangers
that definitions of outcomes overlook that which is of importance
to service users, or make inappropriate assumptions about the
outcomes that matter most to people.
One of the central questions for practice concerns the relationship
between ways in which services are organised and resources used,
and the results for service users. This was one of the issues
examined by project 10 in looking at the effects of different
models of health and social care integration. In particular, the
likelihood of people aged over 75 remaining in their own homes was
found to be contingent on two main factors: the level of dementia
and depression, and the intensity of home care support.
There are major challenges in the practical use of outcome
methodologies and their application in social care. The following
conditions (or questions) appear to be especially important.
Is the purpose clear and easily understood?
Does it create minimum additional demands on staff time?
Is there any benefit or pay-off in using the approach?
Is there ownership of the methodology and its outcomes?
There is a growing understanding of the factors that support the
process of embedding outcomes knowledge into practice. A positive
environment for an outcomes orientation has major implications for
social services in terms of training, management support and other
mechanisms to bring about the cultural change required in social
care commissioning and provision. Such changes are essential if the
benefit and value of evidence on outcomes are to be fully
translated into deliverable improvements in service quality and
experience for all service users and carers.
Melanie Henwood is an independent health and social care
analyst and an associate of the Nuffield Institute for
1 Melanie Henwood
and Eileen Waddington,
Messages and Findings from the Outcomes of Social Care for
Adults (OSCA) Programme, Nuffield Institute for Health, University
OSCA programme projects:
DEVELOPING NEW METHODOLOGIES
1 Older People’s Utility Scale for Social Care, Ann
Netten, University of Kent
2 Subjective and Objective Quality of Life Assessment, David
Felce, University of Wales
3 Routine Use of a Standardised Assessment Instrument for
Measuring the Outcomes of Social Care, Iain Carpenter, University
4 Carers’ and Users’ Expectations of Services, Paul
Lelliott, Royal College of Psychiatrists
5 Dementia Action Research and Education, Clare Wenger,
University of Wales
6 The Management and Effectiveness of Home Care Assistants, Ian
Sinclair, University of York
7 Evaluation of Goal Attainment Scaling in Community Learning
Disability Services, Mark Burton, Manchester Learning Disability
8 Caring Relationships Over Time: Predicting Outcomes for
Carers, Michael Hirst, University of York
9 Carers’ Needs and the Carers Act: Evaluation of Process
and Outcomes of Assessment, Hilary Arksey, University of York
COMPARING COST AND QUALITY
10 Integrating Social and Health Care: a Comparative Study of
Outcomes for Older People and Their Carers, Enid Levin, National
Institute for Social Work and Steve Illiffe, Royal Free and
University College Medical School
11 Twelve Years On: Outcomes and Costs of Community Care For
People With Learning Disabilities and Mental Health Problems, Paul
Cambridge, University of Kent
12 Analysis of the Costs and Outcomes of Two Alcohol
Detoxification Services, Nick Heather, Centre for Alcohol and Drug
EVALUATING THE EVIDENCE
13 Systematic Reviews: Developing Evidence Based Social Care
Policy and Practice, Andrew Long, University of Salford