Select Committee on Health Memoranda

Table 4.12.2

England £m
1990-911994-95 1994-951995-961996-97 1997-981998-991999-2000 2000-01
(with unallocated(with unallocated (with allocated(with allocated (with allocated(with allocated (with allocated(with allocated (with allocated
central admin)central admin) central admin)central admin) central admin)central admin) central admin)central admin) central admin)
Service strategy 106.3135.4137.9 135.9137.9155.5 164.9126.3
Children and families
Assessment and care management450.1615.4642.0 640.8660.4697.7 771.9788.8
Residential care599.5 636.5723.9721.9 728.4742.1758.3 809.7779.7
Non-residential care652.6 805.5932.7961.9 1,005.51,023.81,124.8 1,287.41,296.1
Total1,252.11,892.2 2,272.02,325.92,374.8 2,426.32,580.82,868.9 2,864.6
Older people (aged 65 or over)
Assessment and care management308.9418.1436.8 469.2460.9452.2 481.5497.6
Residential care1,280.7 2,042.82,234.92,610.9 2,977.53,164.23,328.7 3,529.73,591.7
Non-residential care1,022.6 1,365.71,543.61,608.1 1,625.81,657.91,679.9 1,757.31,810.1
Total2,303.33,717.4 4,196.74,655.85,072.5 5,283.05,460.75,768.6 5,899.4
Adults aged under 65 with a physical disability or sensory impairment
Assessment and care management83.3111.7125.3 125.9130.8136.1 138.9152.8
Residential care81.6140.4 155.1175.0200.5 214.8228.2247.8 257.9
Non-residential care153.5 281.3326.4381.7 395.7411.0420.7 464.4448.0
Total235.1505.0 593.1681.9722.2 756.6785.0851.1 858.7
Adults aged under 65 with learning disabilities
Assessment and care management64.791.8104.7 103.4108.0106.5 108.0104.8
Residential care269.2 516.2575.9641.4 736.8792.8877.3 942.51,015.3
Non-residential care304.4 400.5460.9492.0 499.6523.4581.1 618.8631.8
Total573.6981.4 1,128.61,238.11,339.8 1,424.21,565.01,669.2 1,751.9
Adults aged under 65 with mental health needs
Assessment and care management98.5124.2134.8 143.9148.1161.6 181.7192.0
Residential care54.6122.0 136.7168.4205.2 223.5234.1246.9 259.6
Non-residential care39.9 117.8138.1161.5 169.6181.8194.8 218.2225.5
Total94.5338.2 399.0464.8518.7 553.4590.5646.8 677.2
Asylum seekers and other adults111.5 96.4103.4100.1 106.7157.8218.2 345.2669.5
Field Social Work728.9
Area Officers/Senior Managers140.5
Unallocated central admin987.9 1,050.8
Total6,286.68,828.2 8,828.29,601.510,270.6 10,739.311,355.712,314.8 12,847.6
Included in the above:
Training74.999.3 99.392.386.2 90.179.885.6
Occupational Therapy29.6 47.647.643.7 50.651.069.7 80.1

Source: RO3 and PSS EX1 returns.


  4.13  Could the Department provide details of any forthcoming changes to statistical information the Department collects on personal social services? [5.10]


PSS user satisfaction survey

  1.  In 2002-03 all local authorities will be required to undertake a new user satisfaction survey. This will cover elderly home care users rather than those that were recently assessed and then went on to receive services. As in the past information from this survey will be collected by DH and will produce two of the Best Value indicators and will also be included in the Performance Assessment Framework indicator set. Local authorities will include additional questions in their surveys for their own use. This survey will be repeated in three years time, in the meantime surveys of the satisfaction of users from other client groups will take place.

Workload and performance of registration and inspection units

  2.  The results of the Registration and Inspection survey for 2000-01 was published in August and are given at and Responsibility for these data has now transferred to the National Care Standards Commission.

Ethnic origin data

  3.  As the committee was advised last year, ethnic data in DH central collections is collected on a basis consistent with the 2001 census categories; with a transition period for datasets where ethnic data are already being collected in whatever form (generally based on 1991 census categories, or variants of them). The first dataset to report ethnic data on the new basis was the Children in Need census 2000.

Internet Data Collection (IDC) Facility for PSS Returns

  4.  This facility is not strictly a data collection but is a key development as part of DH's contribution to the e-government initiative.

  5.  This year DH has made most social services returns available in electronic format over the Internet—either as downloadable Excel spreadsheets or as part of the IDC system. This is consistent with the e-government initiative for handling returns electronically. These returns will have the advantage of including validations that will enable data providers to check on the accuracy of the data provided, at source. The following returns are currently included in the IDC facility:

    —  Children on Child Protection Registers (CPR3)

    —  Number of homes and places in residential care homes (RA Form A, Parts 1,2 3)

    —  Independent sector nursing care homes registered under Section 23 of the Registered Homes Act 1984 (RH(N) Summary, Parts A/1 to A/3)

    —  Local authority supported residents (SR1)

    —  Register of Deaf or hard of hearing (SSDA910)

    —  Personal Social Services Expenditure (PSS EX1)

    Newly added:

    —  Key statistics (KS1)

    —  Home help/home care services (HH1)

    —  Outcome Indicators for looked after children (OC2)

    —  Annual PSS Staffing return (SSDS001)

    —  Referrals, Assessments and Packages of care (RAP) census 2001-02

  Note: examples of the returns and the publications referred to above can be viewed on the DH Internet site:


Care leavers on their 19th birthday

  6.  Local authorities have been asked to provide data about the occupation and accommodation of their care leavers after they have left care. Starting in April 1999 this scheme required councils to keep in touch with young people leaving care aged 16 and provide data on a proportion of them when they reach 19 years old. Data collection began in 2001-02 with results due in November 2002.


  4.14  Could the Department provide details of any research work not reported last year that is currently being sponsored by the Department on the outcomes and effectiveness of social care? [5.11]


(This includes both new research and new developments of work reported on last year).

  1.   New Research Initiative on "Valuing People: Inclusion, Partnership and Services for People with Learning Disabilities" [new work].

  This new research Initiative is designed to underpin the implementation, and assess the impact, of Valuing People. 10 projects have been funded to date, reflecting between them the central themes of: Inclusion, choice and control, quality services and making change happen. All will indirectly inform assessment of effectiveness of services, but three focus explicitly on this dimension (more detailed information can be found at the end of this summary section):

    —  An Evaluation of the Impact of Person Centred Planning;

    —  The Effectiveness of Cognitive Behavioural Treatment for Men with Learning Disabilities at Risk of Sexual Offending;

    —  Developing Measures of Core Competency to Inform Performance Assessment of Residential Support Staff.

  2.   New Programmes of Work in the Personal Social Services Research Unit (PSSRU). [new work]

  Building on earlier work on related themes, strands of the new research programme (2002-05) focus on the factors affecting performance, effectiveness and service outcomes. Three projects are of particular relevance (more detailed information can be found at the end of this summary section):

    —  An Exploration of the Links between Commissioning Arrangements and Performance;

    —  The Costs and Consequences of Different Commissioning Arrangements;

    —  Relationship between Costs, Efficiency and Service Outcome.

  3.   Research and Development Work at the Social Policy Research Unit (SPRU) on Outcomes Focussed Practice. [new development]

  A long-standing programme of work has been undertaken by the SPRU on the identification of service user-defined outcomes and the implementation of an outcome-focus in routine practice. This work continues with three new areas of research and development activity (more detailed information can be found at the end of this summary section):

    —  Developing Outcome-focused Care Management and User Surveys;

    —  Outcomes for Disabled Service Users;

    —  Outcomes for Disabled Children and their Families.

  4.   Findings from the "Outcomes of Social Care for Adults" Research Initiative. [new development]

  Covering the full range of adult service user groups, but with particular emphasis on Older People, this large-scale research programme had three central themes:

    —  Developing Outcome Measures;

    —  Implementing an Outcome-focused Approach;

    —  Evaluating the Outcomes of Specific Services.

  The report for 2001 noted that the individual research projects had completed their work. An overview report has now been produced which pulls together the findings from the individual projects and identifies the central policy and practice messages (more detailed information can be found at the end of this summary section).

  5.   New Research Initiative on Quality Protects [new work]

  This new research initiative contributes to the evaluation of the impact of Quality Protects on services for children who are looked after by local authorities, children in the child protection system and other children in need. The initiative includes the assessment of the effectiveness of services and outcomes for children and their families in relation to their welfare and quality of life. Eight projects are being commissioned and are concerned with placement stability; children's protection from significant harm; the life chances of children looked after, young people leaving care and children in need; and services to disabled children and their families. All studies within the initiative will indirectly consider the outcomes and effectiveness of services, but five have a particular focus on these dimensions: (more detailed information can be found at the end of this summary section). They are studies of:

    —  the reunification of looked after children with their parents: patterns, interventions and outcomes;

    —  children placed with relatives and friends: placement patterns and outcomes;

    —  outcomes for children placed with family and friends as a result of care proceedings;

    —  participation of disabled children and young people under Quality Protects;

—  services to enhance placement stability.

  6.   New Programme of Work at Thomas Coram Research Unit (TCRU) [new work]

  Elements of TCRU's new DH-sponsored programme (2001 to 2005) consider the effectiveness and outcomes of services for children's social care. (more detailed information can be found at the end of this summary section.) Three studies are especially relevant. They are studies of:

    —  repeated use of accident and emergency departments by young people.

    —  teenage conception among young people looked after by local authorities.

    —  advocacy for looked after children and children in need.

  7.   Research and Development Work at the Centre for the Child and Family Research (CCfR) [new work]

  CCfR is continuing its long-standing DH-funded programme of work on outcomes for children in need and vulnerable children. The Looking After Children research and development programme on assessing outcomes in child care is now incorporated into the work of the Centre. New phases of longitudinal studies have begun examining:

    —  outcomes for looked after children: transforming data into management information.

    —  outcomes for children in need: an in-depth study of babies who entered care and accommodation before their first birthday.

  Other outcomes-related development work includes projects to:

    —  help local authorities make better use of information on children in need.

    —  link the Looking After Children materials with those related to the new Framework for Assessment of Children in Need and their Families to develop the Integrated Children's System.


1.   Research Initiative: Valuing People: Inclusion, Partnership And Services


  Valuing People set out the government's plans for better services for people with learning disabilities. In the autumn of 2000, the Department of Health announced a £2 million funding initiative for research to inform and assess the implementation of Valuing People. A total of 144 initial research applications were received, with ten being initially selected for funding. These reflect between them the central themes of: Inclusion, choice and control, quality services and making change happen.


  The following three studies have a central focus on the assessment of the impact and effectiveness of services:

    —  An Evaluation of the Impact of Person Centred Planning Provider: Institute for Health Research, University of Lancaster. The study will examine the impact of person-centred planning (PCP) on the quality of life of people with learning disabilities, in respect of their independence, social inclusion and health status. Analysis will be made of the organisational factors that facilitate or impede the impact of PCP. Start: 1 November 2001. Duration: 36 months.

    —  Effectiveness of Cognitive-Behavioural Treatment for Men with Learning Disabilities at Risk of Sexual Offending. Provider: Tizard Centre, University of Kent at Canterbury. This study will examine the extent to which cognitive behavioural group treatments that have been proven to be effective with the male population generally are effective with males who have learning disabilities. Start: 1 November 2001. Duration: 12 months.

    —  Developing Measures of Core Competencies and Job Performance in Residential Support Staff Working with People with Learning Disabilities. Provider: Institute for Health Research, Lancaster University. This project seeks to develop a set of core competencies for residential support workers in consultation with service users/relatives, residential support workers and managers. Based on these competencies, parallel job performance measures will be devised to develop an evidence base for the assessment of job performance. Start: 1 October 2001. Duration: 15 months.

Service User Involvement:

  From the outset, the research initiative has reflected the participatory approach of Valuing People by involving individuals with learning disabilities and their carers/supporters in all stages of the process. In addition to their involvement in the commissioning process, people with learning disabilities are members of the reference group overseeing the progress of the initiative, with full support and funding being provided as necessary. A group of learning disabled researchers has been commissioned to work with those people with learning disabilities who are being involved in each of the individual research teams and describe the nature and quality of their involvement in the research. Their summary of this experience, and recommendations about good practice in respect of the involvement of learning disabled people in research, will form part of the final overview report on the work.

  A central objective is to ensure the direct flow of information from the research to those who can influence policy and practice. As this may not need to await the completion of the projects, an infrastructure is being established from the outset to communicate the early findings of ongoing work to relevant audiences. These emergent findings, moreover, may not be the product of researchers' perspectives alone, but may be generated in partnership with people with learning disabilities.


Exploration of the Links between Commissioning Arrangements and Performance and the Costs and Consequences of Different Commissioning Arrangements

  Research Provider: PSSRU at the University of Manchester

  Abstract: Commissioning behaviour is at the heart of the mixed economy of care, being the means by which local Councils turn local and central government plans into action. Surprisingly, relatively little is known however about current commissioning arrangements. The PSSRU team is undertaking regular comprehensive surveys of social care commissioning arrangements in English local authorities. Based on these data, and routine collections undertaken by the DH and other bodies, the team will undertake two related research investigations:

    —  an examination of the relationship between commissioning arrangements (at local authority and provider levels) and performance (market or locality-wide and provider-specific) and the changes in this relationship over time, focusing on residential services in the first instance. Analysis will be largely statistical, including regression and cluster analysis. There will be a need to check the robustness of categorical proxy variables.

    —  a comparative assessment of the costs and consequences of a range of different commissioning arrangements, based on calculations of authority-level total transaction costs (by client group) and the labour and capital inputs of local commissioning activity. Multiple regression analysis will then be used to map the relationship between the magnitude/type of inputs and the costs of commissioning.

The Relationship between Costs, Efficiency and Service Outcome

  Research Provider: PSSRU at the University of Kent

  Abstract: This work represents a new strand of the long-term funded programme on the Costs and Outcomes of Social Care. If the new national Performance Assessment Framework is to provide incentives for local Councils to improve efficiency and the quality of outcomes, it should contain indicators of cost and outcomes that provide clear messages about relative efficiency. Currently the indicators used are generally "proxy" indicators, focused largely on process rather than outcome, raising concerns about the interpretation of any observed variations in unit costs. The drive to improve efficiency may result in unmeasured drops in quality, while missing genuine efficiency gains. The current project aims to improve understanding of how to improve efficiency whilst maintaining or improving key aspects of quality and outcome. In the first instance, the research will look at efficiency in home care services, but will subsequently extend across a range of services, guided by policy and practice requirements. The work will employ a mixed method approach, combining literature reviews, secondary data analysis and discrete choice conjoint analysis with a range of statistical and econometric modelling techniques.

  Outputs and dissemination: The work should be completed by December, 2003. It will contribute to the derivation, interpretation and development of performance indicators and more generally improve the measurement and wider understanding of the relationship between cost, quality and outcome. A series of reports to the DH will describe the results of key stages in the research.

3.   Research and Development Work on User-Focused Social Care Outcomes

  Research provider: Social Policy Research Unit at the University of Kent. The SPRU has undertaken a long-standing programme of research and development on ways to incorporate the views and experiences of service users into outcome measures and to implement these measures in routine practice. Three new research studies have developed from this work:

Development of Outcome-based Care Management and User Surveys

  This involves the production of a resource pack, containing evidence-based guidance and practical resources, to encourage the development of an "outcomes focus" in social care practice and information systems. It addresses two key areas of activity:

  Care management: seeking to integrate models of best practice, including a person-centred approach, with the routine collection of evidence on the impact of services;

  Feedback from users and carers: developing ways of surveying users/carers in ways that focus meaningfully on outcomes (rather than satisfaction). Developed in conjunction with two local authorities, the aim is to contribute directly to the modernisation agenda by assisting those responsible to:

    —  refocus individual practice and service provision on outcomes that are of greatest significance to users and carers;

    —   develop their performance management systems to incorporate the collection, interpretation and use of outcomes information.

Outcomes for Disabled Service Users

  This project is about improving the quality of services for people of working age with physical or sensory impairments by the development and testing of tools for incorporating a greater focus on outcomes in assessment and review. The proposal builds on three previous pieces of work undertaken by the SPRU:

    —  research examining the views of disabled people, staff and managers on outcomes;

    —   working with older people to identify and record intended outcomes at assessment and produce tools to support care managers;

    —  surveying the outcomes of equipment and adaptations.

  Tools suitable for practice with disabled people of working age will be developed collaboratively with the involvement of all local stakeholders, subject to trial implementation and feedback from all involved. Once developed, the effectiveness of the tools will be compared with more conventional approaches.

Outcomes for Disabled Children and their Families

  There is little research on the outcomes that disabled children and their families seek from support services. Whilst the Looked After Children (LAC) system provides an initial framework within which to investigate such outcomes, there are problems with its applicability to disabled children, whose development may be compromised in one or more areas by their impairment. Building on the LAC framework and earlier SPRU research with adults, the study has four central aims:

    —  to identify desired outcomes of social care from the perspectives of disabled children and their parents;

    —  to explore managers' and practitioners' perspectives on outcomes;

    —  working with local authority staff, children and parents, to develop ways of collecting outcome information that can be used in practice;

    —  to pilot and evaluate the use of outcomes assessment in practice.

4.   Dissemination of the Messages from the "Outcomes Of Social Care For Adults" [OSCA] Research Initiative

  Background: Commissioned in 1997-98, the OSCA Initiative comprised thirteen research studies focusing on outcome measures in social care adult services. It was complemented by related work undertaken by the Social Policy Research Unit [SPRU] as part of its DH funded programme. The studies approached the subject of outcomes in various ways: some dealt with the conceptual problems involved in the definition of outcome measures in social care, some set out to develop new, or evaluate existing, measures, others focused on the assessment of outcomes in specific adult services. One examined the role played by systematic reviews in developing evidence-based policy and practice more generally.


    —  Developing a measure of outcomes of social care for elderly people: PSSRU, University of Kent

    —  Subjective and objective quality of life assessment, Applied Research Unit, University of Wales;

    —  Carers' and users' expectations of mental health services [CUES], Royal College of Psychiatrists;

    —  Dementia Action Research and Education [DARE], University of Wales;

    —  The management and effectiveness of home care assistants, SWRADU, University of York;

    —  Goal attainment in community learning disability services, Mancunian Community Health Trust;

    —  Outcomes in social care practice, SPRU, University of York;

    —  12 years On: the Outcomes and Costs of Community Care, Tizard Centre, University of Kent;

    —  Carers' needs and the impact of the Carers' Act, SPRU, University of York;

    —  The routine use of a standardised assessment for measuring outcomes, Centre for Health Service Studies, Kent;

    —  The role of systematic reviews in developing evidence, University of Salford;

    —  Costs and outcomes of alcohol detoxification services, N. Regional Alcohol and Drug Service;

    —  Integrating social and health care for older people and their carers, National Institute of Social Work;

    —  Caring relationships over time: predicting outcomes, SPRU, University of York.


  The main findings of the studies are described below under three headings: "developing outcome measures"; "implementing outcome measurement" and "evaluating service outcomes".

Defining Social Care Outcomes

    —  outcomes in social care are inherently contestable; it is important therefore to involve the full range of stakeholders (especially service users/carers) in their definition and assessment, even though this is methodologically challenging;

    —  outcomes in social care are multi-dimensional and, insofar as they involve inputs from more than one professional group/agency, it may be difficult to isolate the particular aspect of any intervention that leads to change or improvement;

    —  it is important to differentiate maintenance outcomes (where there is no end point to the intervention and the objective is to maintain existing levels of health/social functioning) from change outcomes (where there is an identifiable end point and the opportunity to assess achieved change against desired outcomes);

    —  process outcomes (focused on service delivery) are as important to many service users as change outcomes and may provide the concepts of need etc against which a service can be judged;

    —  outcomes can be differentiated by whether they operate at the individual (eg improved personal social care) or aggregate (eg more accessible and consistent services) level;

    —  it is possible also to identify both "subjective" (meanings) and "objective" (observations) measures; focusing only on subjective measures may be difficult with some service user groups due to low expectations or issues of comprehension, memory and/or expression.

Implementing Outcome Measurement

    —  there is a range of ways in which outcome measures can be used in practice, including assessment/review, the aggregation of individual data for strategic planning and the comparison of different service models;

    —  measures could also contribute to cost-utility analysis, in both research and service settings, in conjunction with appropriate costing information;

    —  it is possible to maximise the involvement of service users with learning disabilities via individualised approaches involving collaboration with speech and language therapists, within a total communication strategy;

    —  it also proved feasible to apply a self-rated measure of the expectations and experiences of users in mental health services, although this was not tested as an measure of outcome impact over time;

    —  the use of the minimum data set-home care (MDS-HC) proved practicable, albeit with social work reservations about the medical model on which it was seen to be based;

    —  the use of Goal Attainment Scaling in community learning disability services was not successful, proving slow and difficult to use and of little obvious benefit to staff and service users; it did however appear to encourage a greater "outcome discourse" at all service levels;

    —  changing a service culture from a process/activity focus to an outcomes focus takes time; introducing such a focus into care management took two years from initiation to implementation, and longer to enter routine practice;

    —  to facilitate implementation, measures should: demonstrate clarity of purpose and the benefits of their use; minimise the demands on social care staff and maximise their sense of ownership of the measures used; be clearly written and easily understood; reflect issues important to service users/carers; be tailored to local needs and circumstances purpose rather than general "blueprints";

    —  barriers to implementation include: the limited capacity of local authorities to analyse and interpret data; the lack of incentive structures and management ownership/support or, conversely, the perception that the measures are a "management tool", imposed from above; involve tools that are too highly structured with too medical a focus.

Evaluating Service Outcomes

    —  characteristics of residential services associated with better outcomes included: "homeliness"; community integration, an individual orientation and high levels of staff attention;

    —  after controlling for resident characteristics, private sector provision appeared less likely to deliver positive outcomes than statutory provision but there appeared to be no association between quality of outcomes and size of the residential setting or staff-resident ratios;

    —  early primary care interventions for people with dementia and their carers did not appear to be associated with improved outcomes; effective targeting of interventions was difficult to achieve as was establishing the effects of early intervention;

    —  in particular, there is no support for the idea that screening for dementia will identify a population receptive to psychosocial intervention;

    —  the role of dementia care specialist appeared to be of value however; intervention with those with acknowledged difficulties is likely to be more productive and any intervention that successfully delays residential placement, without adding to carer strain, is seen to be worth pursuing;

    —  the influence of home care organisers and individual home care staff on the quality of home care services was greater than that of higher level management; this may make it difficult for an organisation to influence the quality of outcomes;

    —  the levels of user satisfaction with home care services were generally high, despite major variations in the organisational characteristics of providers; concerns related to the lack of reliability, the amount of help provided and the speed with which it was given, the lack of predictability of, or control over, which workers arrived;

    —  assuming the role of carer is associated with adverse effects on the individual's mental health, with increased levels of psychiatric distress that disproportionately affect women and rise progressively with the number of hours spent caring;

    —  few carers knew of their right to an assessment, most lacked awareness that an assessment had taken place, were inadequately consulted about the assessment arrangements, experienced difficulties in completing self-assessment forms and/or felt that little consideration had been made of their willingness to continue caring;

    —  carers wanted the assessment process to be more explicit, to be given sufficient information and time to prepare for it, to have an informed choice in respect of separate assessments and for forms not to be used as a substitute for discussion.

    —  the long-term provision of community care services for adults with learning disabilities or mental health problems appears overall to have been cost-effective and good value for money;

    —  the most frequently reported positive aspects of these service users' quality of life were the living environment, the social milieu and independence; the most frequently reported negative aspects were bullying, the social regime and physical condition of the social milieu and feelings of loneliness and boredom;

    —   many receiving care in the community could not answer a question about their future; those that could wished for greater independence, more outings and the need for sexual and personal relationships;

    —  the most important service development issue in both learning disability and mental health concerned the changing demands associated with ageing;

    —  systematic reviews of social care outcomes require an integrated approach that combines both the causally oriented research characteristic of much health research with studies that examine the context, meaning and perceptions of participants.


  A final overview report has been produced, that brings together the findings from the individual studies and identifies the key policy messages. This, and stand-alone executive summaries, will be disseminated widely to policy and practice audiences. A series of regional workshops will also be held.

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