Care is a relationship between two people: one who needs care and another who provides it. Behind this, however, lies a complex set of relationships between financers, planners, regulators, case-managers, providers and service users. Building on ESN’s recently published report on Contracting for Quality, this session provoked a debate about the different perspective on care and quality of various stakeholders and about how the relationships between them can strengthen quality of care for older people in Europe. Panellists below engaged in a role play debate responding to the questions of the chair of the session. The perspective of providers and service users on quality:
Kai: What does quality mean to you as a provider?
Elizabeth: It has a lot to do with choice, about what kind of food people eat, with whom they live, what activities they do. I hope this individual approach to the person will grow in the Czech Republic as we develop more care at home.
Kai: Can we guarantee quality and do for-profit providers need extra regulation?
Anders: You can’t guarantee quality in every case. Regulation is important, but you can’t regulate everything. Quality doesn’t depend on whether a provider is for-profit, non-profit or public sector – there are some for-profit providers who sacrifice quality for profit but in the long-term, profit depends on quality. If the services are poor, users will go elsewhere. The value base within the provider is extremely important: that comes as close to being a guarantee of quality as you can get.
Kai: What do you expect from a provider in terms of quality?
Elizabeth: It’s difficult to pinpoint quality: it’s a lot about the culture of the organisation, not just the attitude of care staff, but of the tea-lady and the cleaner. A good care worker seems able to recognise the person inside the fragile body. Quality isn’t just about one provider either, whatever sector they’re from, it depends on the continuity of care across agencies, e.g. across health and social care. For the older person receiving care, it doesn’t matter, they just want a bath.
The perspective of case-manager, financer and planner on their relationship with service users and vice-versa:
Kai: Is there a real relationship in the German model between the service user and the insurance system?
Jürgen: Long-term care insurance is the youngest child of the German social security system – it responds to a specific new risk by sharing responsibility between the State and the individual. As for a relationship with users, the insurance companies are required to offer independent advice services to older people but this does produce tensions.
Kai: And what about in the UK model – what is the relationship between the older person and the local council?
Andrew: Users have a direct impact on our services and a real relationship – both individually and collectively. Working together, users have helped us to develop new policies, delayed and modified increases in fees and have campaigned against interruption in care services for routine procurement. There is definitely a relationship there that goes beyond paying for those who can’t pay for themselves.
Kai: How do older people see their relationship with the care system beyond the provider?
Elizabeth: Let’s not forget that 80% of care is estimated to be unpaid family care. And even when professional care comes in, carers are part of the relationship too. For users and carers alike, it’s difficult to describe quality, but they know it when they see it, or rather they feel it.
Figure: Care is a relationship between two people but behind this lies a complex set of relationships in the long-term care system.
How to promote quality in the ‘contracts’ between providers and financers/regulators:
Kai: As provider, do you feel under pressure from the financer or regulator to improve quality?
Zuzana: There is a disconnect between quality and money in the Czech Republic – as a provider I have many different financers, but regulation (through accreditation) is entirely separate, so there are not really any contracts that link money and quality.
Anders: It’s important to use financial incentives to boost quality too. The level of reimbursement might for example depend on certain indicators such as prevalence of malnutrition or acute hospital admissions.
Kai: Andrew, what are you doing to promote quality in your council’s relationship with providers as well as users?
Andrew: We are also trying to deliver the sort of care people want: we’re on a journey from large to small institutions to shared housing to care in a person’s own home. We’re also working with providers to promote rehabilitation. Self-assessment by older people is growing: for ‘low-level’ needs service users can be quite capable of saying what they need. The spirit of co-production with the user encourages us and providers to work together in all these areas.
Kai: Elizabeth, what do you think is a good indicator of quality in a care system?
Elizabeth: I think you have to look out for the poorest older people without family support. What happens to them is a good indicator of quality in the whole system.