Measuring the Quality of
Long-Term Care in England
Juliette Malley
Personal Social Services Research Unit
LSE Health and Social Care
London School of Economics
Structure

Key players in England

Main features of quality assurance
programme

Quality measures

Evidence on quality

Limitations of measures
Key players – focus of inquiry


NHS not focus

LTC is social care not health care

LAs responsible for social care
Dual focus on Local Authorities (LAs) + care
providers

Quasi-market – LAs commissioners

Private market – social care is means tested
Key players – Measurement

Policy-makers

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
Regulator

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
Department of Health (DH)
Communities and Local Government department (CLG)
Set policy, QA framework, objectives & what data should be
collected
Care Quality Commission (CQC)
Drive quality improvement
Others – limited role


Academics
LAs for contracting purposes
Approach to quality assurance (QA)

National system supported by legislation

Comprehensive

‘Business approach’

Inspections integrated into performance
assessment

Measures support QA i.e. PIs…

…& emerge from QA process i.e. ratings
Quality measures

What is the object of measurement?

How is quality conceptualised?

How are the measures specified and by
whom?

How are the measures used?
What is the object of measurement?


LAs

Role as commissioners

Role as market-shapers
Care providers

Provision by residential providers

Provision by home care providers
How is quality conceptualised?

‘Outcomes’ for service users



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
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
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Improved health & emotional well-being
Improved quality of life
Making a positive contribution
Increased choice and control
Freedom from discrimination or harassment
Economic well-being
Maintaining personal dignity and respect
NOT clinical outcomes e.g. pressure ulcers
Previous focus on ‘structure’ and ‘process’
How are the measures specified and by
whom? (1)

Performance indicators (PIs)





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For LAs only
Quantitative measures
From surveys and data systems
Various types: activity, costs, process & structural
quality
No outcomes but new PIs under development
E.g. % of items of equipment and adaptations
delivered within 7 working days
How are the measures specified and by
whom? (2)

Composite measures



For LAs and providers
Rating awarded on scale of one to four
Judgement made by CQC inspectors

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
Based on mix of qualitative and quantitative data


Annual for LAs
After key inspection for providers, frequency depends on
judgement
Inspections, management, self-assessment, PIs
Aim to address partial picture presented by PIs
How are the measures used?

PIs

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Support planning process locally
Accountability
Used by CQC in performance assessment
Targets, with financial reward
Composite measures

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
Determine relationship with regulator e.g.
frequency of inspections, degree of intervention
Public accountability
Correct information asymmetries – efficient
markets
What is the quality of LAs?
Quality of LAs measured by composite rating
100
90
80
Frequency of LAs
70
60
Zero
One
Two
Three
50
40
30
20
10
0
2002
2003
2004
2005
2006
2007
2008
And for providers…
Quality of providers measured by composite rating
70%
Percentage of providers with quality rating
60%
50%
40%
Zero
One
Two
Three
30%
20%
10%
0%
2008
2009
Nursing home
2008
2009
Home care agency
2008
2009
Residential home
And from the user survey data…
Quality of LAs measured using data from user experience surveys
Percentage of respondents responding above PI threshold
90.00
85.00
80.00
75.00
70.00
65.00
60.00
55.00
2000/01
2001/02
2002/03
Help quickly PI
Satisfaction PI
2005/06
Suitable times
2008/09
Limitations of measures (1)

Composite measures

Sensitivity questions

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Reliability/accuracy questions
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Averaging across different domains
Consistency of inspector judgements
Sensitive to rules applied for scoring
Policy changes means data & rules used changed over
time
Not updated annually for good/excellent providers – rely
on stability and self-assessment
If measures are not sensitive/reliable
will/should they be used for commissioning?
Limitations of measures (2)
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PIs
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Changes in definitions
Policy changes – new PIs & old dropped
Captures aspects of process to date, not
outcomes
Limitations of measures (3)
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Measures used to change behaviour
Improvements could be result of pressure applied to
improve
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e.g. PIs are targets – distribution condenses
e.g. increased monitoring & intervention for poor
performers – distribution condenses
e.g. provider ratings for good/excellent not updated
annually – tend towards improvement
If measures do not have variability are they useful?
Independent data would be valuable
Conclusions

Great start…

National & comprehensive system for QA

National quality measures

Combine ‘soft’ & ‘hard’ data

But some questions over accuracy & sensitivity…

Some questions over whether these measures are
useful for commissioning, particularly in long-run

Independent assessment of validity & reliability of
national measures would be valuable