Jose-Luis Fernandez reflects on his first large project after joining CPEC (formerly PSSRU) almost 20 years ago was to investigate how community services affect the well-being of older people and their carers.
We started this project in 1995, two years after the community care reforms had come into effect. The aim was to understand, in the context of those reforms, how the provision of community care services affects the well-being of individuals and their carers, and how this varies for different types of clients. For the first time we were able to model these relationships quantitatively and link investment in services with social care outcomes for different groups of older people.
The 1993 reforms had brought major changes to community care in England and the Department of Health commissioned this research to help understand their impact. One of the main reform objectives was to prevent older people from moving into residential care. To this end, care management was introduced so that responsibility for planning an individual’s care package was concentrated on a care manager, who would act both as an agent of the state and as a representative of the care user and their family. The intention was that care packages would fit the individual needs of users, thereby improving outcomes. Separately, the responsibility of purchasing and providing social care services was split, opening up a market for outsourced services.
On the ground the reforms meant that the system shifted from spreading services across a large number of older people, to concentrating more intense provision on those with highest needs. The number of households receiving home care thus fell dramatically even though the total care provided increased. The expectation was that this would reduce the risk of someone moving into residential care and would achieve substantial increases in quality of life, but evidence was needed to establish if this was in fact the case.
Our research, led by Professor Bleddyn Davies (and with input from Bülent Nomer), carried out the analysis in terms of the ‘production of welfare’. If one thinks of the care system as a factory that produces well-being, its output covers a range of welfare outcomes such as reducing carer stress, improving mental well-being, increasing levels of activity, and extending time living in one’s own home. Using the production of welfare approach, the analysis was able to measure the extent to which investment in community care services was translated into improved outcomes. At the time of our study, this contrasted with previous approaches which had focused on looking at user satisfaction.
Our research used successfully for the first time a quantitative approach to assessing care “productivities” for community care. In all we used 17 indicators of care outcomes and established the contribution that services were making to improving these outcomes for people with different characteristics – for example, for those with different level of dependency, cognitive function, psychological wellbeing, and availability of informal care. We looked at just under 500 services users, and a unique feature of the study was that we also collected information from their informal carers and care workers.
The findings, published in 2000, demonstrated that while the biggest determinant of quality of life is the level of an individual’s needs, community services did make a significant contribution to the well-being of service users and there was a predictable relationship between the care received and outcomes. We established that the nature of this relationship varied significantly between different types of individuals, because how much a service will help someone depends on their characteristics (for example, the extent to which day care helps to keep someone out of residential care will depend, say, on their level of cognitive impairment). Overall, the policy change of concentrating services on individuals with the highest needs was shown to have worked in terms of producing more welfare gains overall, even though services had been withdrawn from individuals with lower levels of need.
While the project could have been more proactive in disseminating its findings more widely, the methodology used in the research had an enduring impact on social care research by establishing new types of models for understanding the impact of services on outcomes. CPEC has used the approach in a number of important subsequent studies, such as the evaluation of individual budgets. It helped to put social care research on a firmer quantitative footing – a trend that has still further to go.