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The debate about the findings of the Royal Commission on Long-Term Care has so far focused on cost. But isn't it time we improved the quality of care that is provided - irrespective of cost, asks Linda Green.

It says a lot about the value society puts on elderly people that the issue of cost, rather than quality, has monopolised the debate on long-term care. All the headlines from the recent Royal Commission on Long-Term Care centred on who should foot the bill. The quality of care barely warranted a mention.

Earlier this year, the Centre for Policy on Ageing's advisory committee published its proposed national standards for residential and nursing homes. But even here cost dominated the debate with a row over the business implications of setting minimum room sizes.

Now the growth sector of sheltered housing with extra care has stepped into the debate on quality. John Graham, managing director of the Midlands-based ExtraCare Charitable Trust points to independent research that shows that residents in ExtraCare flats, typically with over 40 square metres of space, not only lived longer than expected but achieved a quality of life far exceeding that of residents in traditional institutionalised care.

Graham, who says he found the room size debate laughable, acknowledges that ExtraCare's charitable status allows it to do things the private sector may not be able to afford. But he also believes you cannot put a price on quality.

"The quality of residential and nursing care is generally pretty poor," he says. "You can't escape the cost equation, you get what you pay for and if you don't pay for quality it's very difficult to see how you are going to get it.

"Registration standards should be based a lot more on outcome than on the process. There's far too much emphasis on the forms being correct rather than the residents' well-being.

"The role of residential and nursing homes as long-stay provision, in their current format, should be history. We got rid of workhouses at the end of the last century, we should get rid of residential and nursing care for long-stay this century."

Anne Bailey, manager of Wolverhampton Metropolitan Borough Council's older people's strategy team, is spearheading the authority's move away from residential care to very sheltered housing schemes. Research carried out by Bailey's team has shown that one in 50 people going into the ExtraCare sheltered housing scheme in Wolverhampton die within the first six months compared to one in four of those entering traditional residential homes in the area. "It's about re-investing the money we spend on services, which institutionalise and make people dependent, into services that maximise their independence and give them back their control," she explains.

"We need to completely change the way we train and motivate care staff so that the job satisfaction is about how much you're able to improve somebody's independence and quality of life - not how dependent they are on you."

Peter Shearer, care initiatives manager at Middlesex-based Hanover Housing Association, says: "Extra care has got a great many advantages but the Royal Commission on Long-Term Care's findings suggest that it's not necessarily cheaper, in overall terms, to the public purse.

"The question is do we always have to go for the cheapest option or is it best to go for quality?"

But Shearer accepts that residential care still has its place. "We must be careful not to over-sell the extra care product. We were very concerned about people with dementia and we looked at whether we could build a housing complex for them but found that, for various reasons, residential care may be more appropriate."

Sheila Scott, chief executive of the National Care Homes Association, controversially resigned from the CPA's advisory committee on national standards in the row over room sizes. She remains adamant that quality cannot be defined by the size of a room and would like to see a more level playing field with very sheltered housing being subject to the same registration and inspection regulations as residential care homes.

"There is now and will continue to be a need for varying models of care. When people say there will be no need for residential care I don't believe they have the full picture. The dramatic shifts in the level of dependency have not been fully appreciated."

As for the research on mortality rates in Wolverhampton, Scott dismisses the findings by suggesting they did not take into account different dependency levels and the degree of illness. "This is about a certain sector promoting themselves and not seeing that there's room for everybody and people have a right to choose."

Jeremy Ambache, chairperson of the Association of Directors of Social Services older people's committee, says: "I hope we see more research like that in Wolverhampton because there's very little outcome research for service users. Some residential care has been absolutely excellent but there has been an image problem. If the focus has been on cheapness and cost it hasn't necessarily been on what is a really good standard of care from the user's point of view."

One thing, which everyone agrees on, should ensure quality becomes the key issue, whether or not the government leaves the Royal Commission's proposals to gather dust. The next generation of older people will be much more discerning about the standards of care they are prepared to accept.