I once had a friend who used to mark their partners cooking out of ten. I’m not quite sure how the rating scale worked – but I hasten to add that their partnership didn’t last long. Which leads me to on to the whole industry of performance targets and measures in social care and health and why I have such an aversion to them. Yes, it’s important to know that public money is being spent well, but is spending so much money on checking up on peoples performance a good use of public money and do performance measures make any difference to outcomes for people with care and support and treatment needs?
I think the challenge comes down to our muddled understanding of the difference between qualitative and quantitive measures.
For me a qualitative measure of a successful outcome for people with care and support, health and treatment needs, draws on the real experience of people who have or are using that social care or health care service and is based on a mutual conversation about what has and hasn’t worked well. This way of working enables people to explore qualitative outcomes in way that the conversation itself can identify ways in which care and support, health and treatment can be improved and how mistakes made can be remedied or explained. These measures are subjective, and success is measured from the perspective of the recipient – the individual, the person and how the support and treatment meets their needs.
A quantitive measure in my mind is a set of numbers that give you an indication of how much ‘stuff’ exists or has been done for a particular number of inputs. This way of working might give you a picture of ‘how many’ things were completed, but it gives you no indication about satisfaction and whether for not any of the ‘stuff’ done was any good. A quantitive measure is likely to be more subjective than a qualitative measure as the person interpreting the ‘stuff’ bases their understanding of the quantitive measures on what they want the measures to tell them. This can be done without any reference to the people who might have received care and support and treatment.
I think you might have guessed by now that I’m more of a qualitative person than a quantitative person when it comes to understanding if care and support, heath care and treatment activity has enabled someone or not to become independent and well.
I have sat in many meetings with senior leaders where they ask for the numbers and then want to know the story. It’s the story on which they then make their decisions – which makes me wonder why they needed the numbers in the first place.
Let’s take the omnipresent example of hospital discharge.
Quantitive success measured as the number of people discharged from hospital gives us absolutely no indication of whether or not each persons discharge was actually successful. For instance, if someone is discharged home on a Wednesday and then readmitted on a Thursday because they weren’t really well enough to be discharged on the Wednesday, in terms of numbers this would count as a new episode of health care and therefore when that person is discharged again a few days later they become another successful discharge from hospital (even if they might be back in hospital a few days later). This quantitative measure of success based on numbers – people discharged from hospital is utterly meaningless and probably quite easy to game (not that I’m suggesting anyone has ever done this).
Qualitative successful hospital discharge isn’t about numbers, it’s about a person and their families experience of discharge from hospital. Did they feel that the people discharging them explained to them why they were ready for discharge? Were the support options to ensure they didn’t end up back in hospital explored and were they helped to prepare and make choices that made sense to them? If they were going home, what arrangements were put in place to make sure they were okay? If they or any of their family support needed to learn new skills to make sure their care and treatment at home was successful – has this learning done with them before they went home? (This not about giving someone a load of leaflets to read). These qualitative measures of success might take a bit longer to go through and may well challenge the expected norms for social care and health workers. However they will give a much more nuanced perspective on what is and isn’t working and over time provide a much more accurate picture of how peoples experience of hospital discharge can be improved.
I wonder, is the reason we focus on quantitive measures is that we just don’t trust our social care and health care workforce to do the best they possibly can to care, support and treat people? If that’s the case then why do we spend so much money training people when we then don’t trust them to do their best?
Jim Thomas
November 2024
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