Building capacity and capability for improvement in adult social care
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Overview
It is a time of great change in the adult social care sector, with plans to introduce a new Care Quality Commission assurance framework and integration with health services under way. This moment of change is an opportunity to rethink the approach to improvement in adult social care and the support that is offered.
Local authorities spend £23 billion a year commissioning adult social care services and put huge effort into trying to improve the quality of adult social care both locally and nationally. This improvement activity aims to enhance the quality of life of those who draw on social care and can also focus on improving the experience of the workforce or putting the finances on a more sustainable footing.
To explore how local authorities make improvements and measure success, and what type of support they use to make improvements, we conducted 27 interviews with those involved in improving adult social care in local authorities. We explored the adult social care improvement ‘stories’ in five local authorities and compared what we heard with established approaches and principles of quality improvement used in many sectors.
We found examples of excellent work on improvement and local authorities drawing on the support offer that is provided through ‘sector-led improvement’. Adult social care staff shared best practice through this programme as part of a strong regional community for improvement.
We also saw huge variety in approach and a lack of a shared language or codified set of methods for improvement. At times, the absence of a shared quality improvement approach appeared to lead to improvement activity that was reactive, focused on short-term fixes and one in which the data and measurement were lacking.
In this discussion paper, we don’t make recommendations. Instead, we ask some questions, intended for the adult social care sector, about what the future should look like.
Exploring improvement in adult social care with a quality improvement lens
In this discussion paper, we look at how local authorities in England improve the quality of adult social care. This discussion is timely because the government intends to increase funding for improvement activities to support the reforms of adult social care. There are also plans to introduce a new Care Quality Commission (CQC) assurance framework to assess local authority performance in delivering all their adult social care functions.
We used a quality improvement lens in this research. Quality improvement relates to a systematic approach to making things better, rooted in the discipline of improvement science, and is used widely in public and private sectors. We used this lens in two ways:
in our interviews, as a way of navigating the varied approaches adult social care teams in local authorities take to improvement
in our analysis and interpretation, as a way of provoking discussion about the future of improvement in adult social care.
In doing so, we do not intend to prescribe or transplant a quality improvement approach from another sector to adult social care. Instead, we use this lens to identify which principles of quality improvement might already be in action and pose a series of questions about how such an approach could be further developed and what it might mean for the way adult social care teams are supported to improve through sector-led improvement.
Successes and challenges in improvement approaches to adult social care
We found examples of local authorities doing excellent work in very difficult circumstances. In particular, we found that there were good examples of local authorities creating a supportive environment for effective improvement through:
building capacity, for example, by borrowing staff with specific expertise from neighbouring areas
building capability, for example, by inviting staff to regular senior management discussions to expose them to quality issues
demonstrating leadership, for example, setting a clear strategic vision for quality improvement
creating a culture for improvement to thrive, for example, by creating a safe environment where staff feel comfortable raising concerns.
However, overall, much of the activity described to us did not share a common language or methods. While there is good work going on across the five local authorities we selected, many of the markers of a quality improvement approach were missing – for example, being able to define and agree what quality includes, a clear theory of change, measurement of impact or continual efforts to continue and sustain improvement.
There are good reasons why those working on improvement in adult social care in local authorities may struggle to adopt and put into practice some quality improvement principles. In particular, in addition to severe pressures on resource and capacity to do this work, local authorities also lack a national framework to guide their efforts or in many cases control the levers to effect the change on the ground – with a lot of care being delivered by independent care providers.
We used the traditional stages of a quality improvement approach to illicit and map the improvement journeys described by local authorities. These include prioritising areas for improvement, exploring and understanding areas for improvement, implementing change and demonstrating impact.
Stage one: prioritising areas for improvement
This first stage of the improvement journey was the clearest and easiest to identify. Local authorities were putting huge effort into collecting data to help inform decisions about where to focus improvement activities. Directors of adult social services were also using peer reviews, benchmarking across regions and participation in regional networks – all part of the sector-led improvement support offer – to decide key areas to address.
However, there was a lack of consistency in the approaches and language used, suggesting a lack of an agreed method. In addition, much of the activity was part of more ‘business-as-usual’ performance monitoring processes, which, in many cases, meant improvement activity was largely reactive.
Stage two: exploring and understanding areas for improvement
Interviewees often referred to this step as a ‘deep dive’. We found it hard to discern distinct methods or approaches and a significant amount of exploration and understanding seemed to occur at regional level. Local authority staff are actively involved in the regional networks supported through the sector-led improvement programme, but they rarely mentioned this during our conversations.
There is a great deal of activity around exploring and understanding what the problems are, but few consistent methods or underlying principles of what good looks like. Support from the sector-led improvement programme is not always visible, applied consistently or recognised.
Stage three: implementing change
For this stage, local authorities described methods and approaches for developing solutions, many of which used the sector-led improvement support – in particular using the regional networks to share best practice.
However, we heard comparatively little about work to either test or embed solutions, not because this work is not being done, but more likely because there is a lack of a common language or set of methods. Our findings point to a potential for quality improvement principles to be further embedded into this stage and into the sector-led improvement support offer.
Stage four: demonstrating impact
Measurement is at the heart of continuous quality improvement; showing whether projects are on track and delivering high-quality care consistently or whether additional changes are needed. However, local authority leaders face significant challenges in measuring the outcomes of improvement activities, including pressure to move on to the next improvement project and a lack of data, in terms of both quality and content.
Interviewees saw this stage as the one where there is the greatest room for sector-led improvement to develop its support offer.
Questions for the future of improvement in adult social care
What if sector-led improvement crafted a new narrative around continuous quality improvement?
What if sector-led improvement has done enough to instil confidence in the value of a sector-led approach to allow it to focus more on ‘improvement’?’
What if co-production sat at the heart of this new narrative on continuous quality improvement?
What if sector-led improvement rooted itself more in the wider quality improvement community?
What if the Department for Health and Social Care recognised its contribution to a sector-wide culture of quality improvement?
Planned reforms to adult social care, further integration with health services, and a new CQC assurance framework are creating significant demands on existing capacity for improvement activity in local authorities.
These challenges dominated our interviews, with participants feeling there was a real risk that most of the capacity they have for quality improvement will be diverted to tackle these challenges. Many participants anticipated that the Department of Health and Social Care-funded sector-led improvement programme (currently known as the Care and Health Improvement Programme (CHIP)) would be almost wholly repurposed to address the new assurance regime.
We think this type of repurposing would be a mistake. There is a need to support local authorities through this moment of change, and there should be a solid support offer in place for this. However, this moment also provides an opportunity for local authorities and the adult social care sector as a whole to ask itself some questions about how it can develop its improvement activity to enhance the lives of people who access support to live full and independent lives.
Below are some questions about how improvement in adult social care could move forward, and what the role of the sector-led improvement support offer should play in this.
What if sector-led improvement crafted a new narrative around continuous quality improvement?
There is an opportunity for sector-led improvement to define a strong identity for itself outside the CQC assurance framework – one focused on continuous quality improvement. But, for this to happen, does SLI need to craft a new narrative that provides people with a shared language of improvement and codified methods that feel relevant and appropriate for adult social care?
What if sector-led improvement has done enough to instil confidence in the value of a sector-led approach to allow it to focus more on ‘improvement’?’
While the rallying cry of ‘for the sector, by the sector’ comes across powerfully, the ‘improvement’ aspect of the sector-led improvement programme has been lost. The government’s recent decision to invest more in the sector-led improvement offer
is an endorsement of the value of having improvement led by the sector. Does the sector need to consider how it evolves and what kinds of relationship it can build now for further improvement?
What if co-production sat at the heart of this new narrative on continuous quality improvement?
User engagement through all stages of the improvement cycle is seen as a pre-requisite to successful improvement. However, we found mixed evidence to suggest that users of adult social care are routinely and systematically involved in improvement activities. Could this be an opportunity for sector-led improvement to provide greater clarity and leadership about how and when people who access adult social care can be involved in improvement?
What if sector-led improvement rooted itself more in the wider quality improvement community?
Improving adult social care offers a rich source of learning for anyone interested in continuous quality improvement. But the lack of a shared improvement language within the sector seems to prevent the dissemination of ideas and learning. Could situating sector-led improvement more firmly within the broader quality improvement community offer insight into possible new ways of approaching entrenched problems?
What if the Department of Health and Social Care recognised its contribution to a sector-wide culture of quality improvement?
There needs to be leadership for quality improvement at every stage of the quality improvement journey and at every level of the system. Our research highlighted the lack of an overarching strategic vision for adult social care, which was problematic for many working to improve outcomes. The Department of Health and Social Care has a critical leadership role to play in setting strategic direction and with others, can help address the confusion that exists over the purpose of adult social care, and the role improvement support plays. In shaping that strategic direction, the Department may also need to mitigate the risk that national leaders will increasingly look to inspection and regulation as the lever of change at a time where CQC’s oversight is growing.
Where next?
This paper is intended to prompt fresh thinking about how to support people to improve adult social care – a highly skilled and challenging task. Quality improvement is not a magic bullet, it needs resources, expertise, and a willingness to work differently. During our research, we found people willing to work differently, who are – without exception – interested in learning by doing, committed to driving improvements, and championing the distinctive contribution that adult social care can make to people’s lives. What if now is the time for adult social care to embrace continuous quality improvement?
This report was funded by the NIHR Policy Research Programme (grant number NIHR200702) as part of the Partnership for Responsive Policy Analysis and Research (PREPARE), a collaboration between the University of York and The King’s Fund for fast-response analysis and review to inform the Department of Health and Social Care’s policy development. Views expressed and any errors are those of the authors only and not those of the NIHR or the Department of Health and Social Care.