Indicators flash green

John Dixon, Association of Directors of Social
Services’ disabilities committee

“Regulation and performance management are here to stay.
Citizens and government want to know that their services are safe,
of good quality and do what they are supposed to. The problem is
that although services evolve, regulation practice and performance
indicators (PIs) tend to drive activity in the direction of the
ideals of a decade ago, and in some instances directly away from
current national and local policy aspirations. This is because data
collection is a complex and time-consuming activity, more amenable
to measuring inputs than outcomes. Changing PIs or moving away from
the measurement of room sizes is fraught with methodological


Which is why the determined attempt by the Commission for Social
Care Inspection to change the entire culture of regulation, and
focus on outcomes for service users, was so much welcomed across
the whole sector. Now that we have been told that the CSCI will be
integrated with the Healthcare Commission, albeit some years down
the line, we must insist that this promising initial direction is
not compromised. If it means that the performance management of
health and social care are more joined up then that is welcome, but
if it serves to reinforce a bias towards the acute sector, we will
all be the losers.


I chair a regional group working on performance data, and
benchmarking what we do with others across the country. We are
pleased that the Department of Health is going to set up a group to
review the fitness for purpose of all the PIs in the light of the
new policy direction signalled by the green paper. If the new PIs
can at last be made to fit with those which drive performance in
health, then service users will see real


Angela Greatley, chief executive, Sainsbury Centre for
Mental Health

“The green paper recognises the importance of regulation and
performance assessment. Standards have to be set, change has to be
seen to be achieved in social as well as health care and
improvement will be needed in providers who do not meet
requirements. There has been much resistance to target-setting and
to performance management regimes. However, we must accept that
both are needed to inspire confidence among people who use the
services and to measure change. The devil lies in the detail of how
best to set up the measures so they look for the right things
without skewing priorities in the system.


For mental health as for other social care services, we’re
looking for outcomes that are shaped by the preferences of the
people who use them. The green paper states that “the voices
of people receiving social care should be heard at all
times”. This aspiration is to be commended. However, NHS
experience to date has shown that targets are often set for things
that can be counted and measured and that efforts to assess more
subtle issues about choice, responsiveness and quality of life have
always dropped off the agenda. This approach cannot be right for
social care and should not be replicated here.


Mental health requires measures that are geared to people’s
aspirations for a good quality of life in the community as well as
key indicators about availability of services. For the future we
would like to see a closer alignment of standard setting and
performance management for health and social care. But this move
needs to be towards the right measures and not simply towards
measures borrowed from acute health care and ill-adapted to other


Heléna Herklots, head of policy, Age Concern

“It is good that the government’s aim is to move to a
system of performance management that supports outcomes. Whether
the merger of the CSCI with the Healthcare Commission is a helpful
step towards this is more open to question, particularly given the
resource savings that are being made as part of this


The outcomes for care that are proposed in the green paper look
right: improving health and quality of life; enabling people to
make a positive contribution and have choice and control; ensuring
freedom from discrimination or harassment; economic well-being; and
personal dignity. Underpinning several of these outcomes must be an
inspection system that ensures users’ rights are respected.
Inspectors should look at potential risks to users not just in
terms of health and safety, but risk to their status as citizens
and as full members of society. This means that human rights need
to be at the heart of the approach. 


Users should have stronger voices in assessing performance, and
important but apparently defunct initiatives such as lay inspection
need to be revived or reinvented. 


The recent Office of Fair Trading report on the care home market
shows that there is an urgent need to improve the provision of
information to users, ensure transparency about what services cost,
make contracts clearer, and improve access to making complaints.
How the government responds to the OFT recommendations will give an
early indication of what its approach will be in practice, and
whether it will be a driving force for regulation and inspection
supporting personal dignity and choice and


Jo Webber, policy manager, NHS

“We believe it makes sense that the regulation of health and
social care is being streamlined alongside the move towards
strengthened partnerships between the different sectors.


We think that the Healthcare Commission’s new standards of
assessment are a big improvement on the star ratings and we welcome
the concordat for smarter assessment and regulation led by the
commission which should ensure that unnecessary duplication is


Service users need to be fully involved in inspection so their
experiences are at the heart of the process, rather than looking at
the provision of care from the point of view of health and social
care professionals or even an inspector.


Joined-up thinking needs to be a buzz phrase for performance
management and we would welcome the extension of joint area
reviews, currently being set up for children’s services, to
adult services because this is a more accurate way of assessing the
patient or client’s experience. It makes sense to monitor
closely the implementation of joint area reviews in
children’s services so we can learn the lessons for adult


Joint performance indicators for primary care trusts and councils,
based on prevention, also make sense because making a real
difference to people is everyone’s business and not about
artificial divisions between health and social care. For example,
preventing someone’s admission to a nursing home is often the
result of the efforts of staff working across sectors for a joint


Jeni Bremner, programme director, education and social
policy, Local Government Association

“The performance of local government social care is improving
and although we cannot be complacent we have much to be proud of.
For the fifth consecutive year our performance has improved. 


Local government and other service providers need to be able to
demonstrate both to ourselves and to communities and citizens that
local services are meeting needs and that they are continuously
improving. The breadth of the agenda set out in the green paper
supports the proposal that we need to develop a system of
performance management built on outcomes. We must ensure that the
services we provide are of good quality and that they make sense to
those using the service and to local people.

While government can set the national framework we need it to give
much more flexibility to develop local performance indicators that
make sense in the local context.


The challenge for the commissioners and providers of service will
be to develop robust local mechanisms for monitoring and reporting
across services. Delivering the green paper requires action across
public, private and voluntary sectors and a challenge for us is to
support that with an appropriate and proportionate performance
management locally as well as nationally.


It is into this complex picture that the changes to the performance
management regime and the moving of functions from CSCI appear. At
the very least there are real concerns that the shift of adult
social care performance to the Healthcare Commission will result in
the delay of this approach to performance management. CSCI and the
Social Services Inspectorate before it have supported councils to
make real improvements in their performance. We must not lose this
momentum or some of the tried and tested models of inspection and
improvement that have been used to such good effect.


Independent view

Carolyn Denne, strategy manager for the Commission for
Social Care Inspection

“To make informed choices, all citizens need to know about
the quality of services they might want to use.  

Like any other citizen, someone using social care may expect to
contact a range of services – across local government,
education, health, the criminal justice system, voluntary and
community services and others. Promoting well-being for people
requires a broad perspective, with each component of the system
being accountable.


The Commission for Social Care Inspection is committed to
developing a more coherent approach, putting people’s
experiences at the heart of our work. We have already begun to
improve the way we regulate services. The green paper calls for a
strategic shift in what we measure and how. This will take time to
get in place. Irrespective of structural arrangements, we need to
work towards better alignment of performance measures across the
system. Our starting point is to check that outcomes reflect what
people have told us they want, and to involve them in plans to
improve how we measure whether they are being


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In this article, leading professionals from the social care sector
look at the green paper’s implications for the regulation and
performance management of services.


Forthcoming articles

Next week, the final article in our adult care green paper series
will examine strategic commissioning.

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