The bare minimum is not enough

Care providers have been given a benchmark to
judge their services against. But independent consultant Jef Smith
says the emphasis should be on raising standards rather than merely
scraping by.

The laborious task of setting national minimum
standards for a range of care services has at last come to
fruition. The National Care Standards Commission has started work,
armed with a battery of documents outlining the quality to be
expected of providers. The documents provide the benchmarks against
which levels of service can be judged.

So can all of those who have been involved in
defining the standards that will govern social care for the 21st
century now take a welcome break? Certainly not!

The process of writing the standards has been
long and messy. The work covering service areas was not initially
co-ordinated, resulting in considerable late redrafting to achieve
consistency of presentation. Pressures of legal advice within the
Department of Health slowed the later stages. The methods of
consultation were not thought through, so that in some areas
stakeholders had several chances to comment on draft documents and
in others providers complain that they were presented with what was
more or less a fait accompli. Some groups were strident in their
criticisms of items in draft and in several cases successfully
lobbied ministers for them to be watered down. Input from service
users and their representatives was at best patchy, at worst
non-existent.

Whatever one may think of the quality of the
resulting documents, it is important to remember that these are
minimum standards, not optimal or aspirational or even average
standards. Any service provider who fails to meet these standards
should be ashamed of themselves. They could technically be put out
of business by the NCSC, but the body has already been told by the
health minister, Jacqui Smith, to go gently in the early stages.
The government is clearly worried that rising standards will
destabilise the care market, although it is obvious that there are
many other factors, such as property prices, that are a more
significant factor in the closure of residential care homes. Anyone
who cares about the quality of care must hope that the NCSC will
use all its powers sensibly but vigorously.

If a care home for older people fails to
produce, for example, full and properly prepared care plans or a
policy on dying and death – both clear requirements of the national
minimum standards – it may be realistic that it will be spared any
immediate sanction provided that the manager can produce a
plausible action plan aimed at rectifying the situation within an
agreed timescale. No one wants homes to be closed overnight, least
of all the residents, but the NCSC must show that it will not
tolerate excessive foot-dragging. That could undermine the
credibility of nationally enforceable levels of care. Too much
flexibility in enforcement would re-introduce the sort of
inconsistencies that everyone deplored in the old regulatory
arrangements.

A second element of the standards, which is
less often noted, is that they are open to revision. One of the
advantages of secondary legislation of this type is that variations
can be made from time to time without the need for the whole
legislative procedure to be repeated. This means that, when he or
she thinks fit, the secretary of state can revise both the
standards and the regulations that provide the more formal
framework for the practice of care, simply by laying new drafts
before parliament. The minister would not, of course, use this
power capriciously or without consultation, but the Care Standards
Act 2000, which provided the statutory authority for these
documents, is silent on when revision might occur.

It is likely that the NCSC itself will take
the initiative. Although the standards remain the responsibility of
the secretary of state, much of the expertise about where they need
to be changed will in future lie with the commission. Indeed
several of the people involved in drawing up the initial standards
now work for or are members of the commission and will be even
better placed to offer their expertise next time round. The
announcement by NCSC chairperson Anne Parker at the 2001 Social
Services Conference that the commission would be making suggestions
for changes to the standards next year is therefore welcome.

The case for ensuring that the first revision
takes place sooner rather than later is strong. Health and social
care are changing rapidly and we need to set appropriate standards
of performance as each new service is established. It is difficult
to remember, for example, that intermediate care, now an
established feature of the system for promoting independence in
older people, was created – at least in its current form – only in
spring 2000; the relevant standard had to be hastily inserted into
an almost finalised document. Over the coming months and years
there will doubtless be many similar initiatives, which will soon
make the current standards look dated and incomplete.

It is not only policies that change; public
expectations also develop and need to be reflected in better
quality care that can be clearly regulated. Multiple-occupied
rooms, communal clothing and physically restraining chairs were all
common within living memory, but are now – more or less – outlawed.
The shift of attitude that made these practices unacceptable was
reflected in, and to an extent brought about by, the gradual
ratcheting up of standards by local inspection units. Now that we
have a central written set of standards, that sort of informal
improvement in the quality of care could become more difficult.
Minimum standards will now only change when the minister says
so.

The danger is that, having so publicly defined
the lowest acceptable levels of care, we will be stuck with them
and nothing more for the foreseeable future. Issues on which the
standards are silent, such as the right of older people in homes to
an active sex life, may never be considered because managers of
homes believe they are already doing a good enough job. The NCSC
could find itself the custodian of mediocrity, rather than a beacon
of progress.

The process of drafting the minimum standards
began more than three years ago. The standards already recognise
that in some areas, such as room space, there is a need for a
transitional period, so some requirements will come into effect
only in 2007. We need to incorporate that sense of progressively
improving the quality of care into all of the issues covered by the
standards and to start the process of review right away.

Jef Smith is an independent consultant and
trainer. He is a former director of social services and general
manager of a voluntary organisation.