Destination unknown

Melanie Henwood argues that there has been insufficient focus on outcomes

In many ways the most important line in the white paper lies in its confirmation of the green paper’s vision of “high-quality support meeting people’s aspirations for independence and greater control over their lives, making services flexible and responsive to individual needs”. The green paper had proposed seven outcome dimensions for adult social care services structured around the central concept of well-being. As Bob Hudson argued in the first article in this series, that vision is one with which few people would disagree. But the vision is also one which remains minimally developed or articulated.

For those who anticipated that the white paper would provide detailed elaboration of those outcome dimensions (because this is surely where it should have been, given the lack of detail in the preceding green paper), there is disappointment and frustration. No such development is evident. The white paper endorses the outcomes “towards which social care services should be working with their partners”, offers the vague assurance that “we will build on them to develop outcomes that apply both to the NHS and social care”, and nods in the direction of the Commission for Social Care Inspection’s work on developing indicators. Such indicators will be vital, particularly in moving towards integrated performance management, but measures cannot be produced until there is much greater clarity over the nature and dimensions of outcomes.

There is a missed opportunity here; there was already a good model for how to approach this development in the work that accompanied Every Child Matters. The separation of responsibilities for adults’ and children’s services has done more than create challenges around transitional care; it has also created an unwillingness or inability for shared learning to flow across policy arenas and government departments. Merely restating the seven outcome headings does not provide the level of detail that is needed in order for performance objectives, targets and measures to be elaborated.(1) 

In contrast, the Change for Children document set out a national framework for local change programmes which unpacked the five broad outcome headings (from Every Child Matters) into 25 specific aims, followed by targets and indicators and inspection criteria.2 It is this equivalent layer of aims which is notably absent from the adult social care agenda.

The Change for Children framework has its critics, particularly on the lack of fit between innovative outcome specification on the one hand and old-style targets and indicators on the other which bear scant relationship to the vision for change but attempt to fit old data into a new template. The lessons of this for adult social care are clear: there must be coherence between the components, and that will need a radical approach to new indicators and performance measures bold enough to step away from the straitjacket of star ratings and a preoccupation with structural solutions.

There is a level of confusion in the white paper between ends and means. The primary focus is on some of the “means” for delivering the adult social care agenda in the shape of: improving access to support; developing care closer to home; enabling people to have greater control (such as through individual budgets and direct payments), and promoting integrated care. But these are simply means of delivering the desired outcomes (or ends) of improved well-being. 

The risk in focusing on the means is that these become confused as ends in themselves and indicators and performance management become similarly process-driven. It is only after consensus is achieved around outcomes that there can be any real progress in addressing what needs to be done to deliver the local change agenda. 

The whole systems change model which infused the children’s agenda is absent from the white paper. Indeed, the terminology of “whole systems” frameworks does not appear to feature at all. This is not merely a semantic issue; it is an essential difference of philosophy. The absence of a comparable change model in Our Health, Our Care, Our Say does not simply leave a gaping hole at its centre, but it arguably inverts the process and effectively puts the cart before the horse.

It is vital that the work on outcome definition does follow, and it may be the case that this needs to be taken forward by the Care Services Improvement Partnership and IDeA alongside work that is beginning in this area at CSCI.

This work is especially important if all seven outcome dimensions are to be tackled with equal vigour. Choice, control and independence are the social care buzzwords of the white paper, not least because direct payments and individual budgets offer tangible ways of beginning to address some of the objectives. In fact, it might be argued that the pace of change in this area has allowed an acceleration of the ends and means framework around choice and control without it needing to be spelt out. In effect, innovative practice has been leading policy. This is much less true in respect of the other outcome dimensions.  

It is only by systematically working through the sequence of outcomes -> aims -> support -> targets and indicators -> inspection criteria that a coherent and mutually reinforcing framework can be structured. Most vitally, if the white paper agenda is to have strategic coherence it has to be more than a loose collection of aspirations, and needs to be geared into a delivery system. The vehicle for this potentially resides in the architecture and leadership of local area agreements and the local strategic plan (which also offer the means of connecting to the wider well-being agenda), but this is not immediately evident in the absence of a clear outcomes framework.

The fact that the white paper has not offered such a model does not mean it cannot be grafted retrospectively. But if it doesn’t happen soon, those responsible for implementation on the ground will become bogged down in process demands. The white paper has a broad vision for health and social care which sets out dimensions of “what needs to happen” next in key implementation tasks of structures and processes, but there is potential for much more than this. 

The missing pieces of the jigsaw are those that will connect these elements to the big questions of “what are we trying to achieve” and “how will we know when we’ve done it?” That will be judged not by how rapidly individual budgets and direct payments can be rolled out, nor by the extent of integrated networks or joint teams or how rapidly practice-based commissioning can take off, but by what difference any of this makes to people’s quality of life and general well-being. How that will be judged demands that we rapidly establish a much clearer understanding (and specification) of where we are trying to go, and not merely concentrating on how we are planning on getting there.

Melanie Henwood is an independent health and social care analyst with particular interests in community care, older people and their carers. She is also a lay member of the General Social Care Council.

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The white paper failed to provide the anticipated elaboration of the nature and dimensions of the seven outcomes in adults’ services. It is essential that work on outcome definition follows as a matter of urgency. Without clarity there is a risk that those responsible for implementation will be side-tracked by process demands and become mired in a confusion of ends and means in adult care.

(1) M Henwood, B Hudson, Independence, Well-being and Choice: the ADSS response to the green paper on adult social care, ADSS, 2005
(2) Every Child Matters: Change for Children, DfES, 2004

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