“Outcomes” refer to the impacts or end results of services on a person’s life. Outcomes-focused services are therefore those that aim to achieve the goals, aspirations or priorities of people who use care services. They can be contrasted with services that are standardised, rather than being designed with the needs of individual users in mind, and services that are organised according to needs determined mainly by those who commission or deliver them.
An older person’s well-being may depend on the quality of the care package that he or she receives from the local authority. Ideally, the package will be outcome-focused, thereby ensuring that the older person’s needs are fully met and their aspirations taken into account. However, the research shows that there are a number of barriers that prevent care managers from providing outcomes-focused packages and the result is that older people receive inadequate care that badly affects their quality of life.
The 1980s community care demonstrations projects gave care managers small caseloads and devolved budgets to purchase flexible, individually tailored services. However, since 1993 care managers have had less face-to-face contact with clients. They have adopted increasingly routinised approaches and have been restricted by financial constraints. There are significant variations between social services departments in their care management arrangements, particularly regarding whether the services commissioned extend beyond basic physical maintenance to wider, quality of life outcomes.
There are also variations in the autonomy devolved by commissioners and care managers to front-line service providers, with some provider managers frustrated by inflexible and uncompromising commissioning arrangements. For example, if no allowance is made for time spent travelling between appointments, home care staff may be tempted (or encouraged by their manager) to curtail visits once essential tasks are completed. Changes that users wish to make to the content or timing of a service may have to be notified to care managers and new assessments conducted. Such restrictions may be particularly true of services commissioned from independent (voluntary and for-profit), rather than in-house, providers.
Barriers to outcome-focused home care services arise when social services purchasers place restrictions on the range of tasks they are willing to pay for. Older people have expressed particular concern about the lack of help with housework and other domestic tasks, despite the fact that having a clean and orderly home environment is an important maintenance outcome (see below).
A further barrier is the failure by care managers to recognise the importance of relationships between older people and care workers the quality of these is central to process outcomes. Thus older people may benefit from any spare time left in “time-centred” visits if care staff can use this simply to talk. However, some care managers discourage the development of such relationships as “unprofessional”.
The way care packages are contracted by local authorities at an organisational level also has an impact on outcomes for individual users of services who have home care. Some authorities operate “cheapest first” policies when setting contracts for home care services driving down costs can drive down quality. The contracts for home care services offered by many authorities have been criticised for being short term and including conditions that may be unattractive to providers.
Many contracts contain little flexibility to vary prices. This helps purchasers plan their expenditure (and may also help safeguard provider stability), but makes providers vulnerable to risk arising from changes in costs that occur during a contract and reduces their ability to tailor services to the requests and circumstances of individuals. Flexible, spot-purchasing or contingency-sensitive pricing would shift some of the risk back to purchasers and provide greater incentives to providers to respond to changes in users’ circumstances. It is very important for purchasers to develop trusting relationships with providers to enable them to take on decision making and make changes to services without the constant need to check back.