Measuring social care outcomes
How the ASCOT toolkit helps services improve people's lives
The Adult Social Care Outcomes Toolkit (ASCOT) is designed to measure the aspects of an individual's quality of life that can be affected by social care. We call this ‘social care related quality of life’ (SCRQoL). The toolkit can be used across a wide range of service user groups and social care support settings, including residential and community care. Put simply it tells us how well individuals are faring in eight areas of quality of life: control over daily life; personal cleanliness and comfort; food and drink; personal safety; social participation and involvement; occupation; accommodation cleanliness and comfort; and dignity – and it does so in a way that reflects what people say about what makes the most difference to their quality of life. This information is useful for understanding which services have the greatest potential to improve people’s lives.
ASCOT is freely available and helps to answer questions that are important for policymakers, service commissioners and providers, service users and their families alike. It can demonstrate how the care and support provide by social care services affects quality of life; which areas of SCRQoL have the highest levels of unmet need; whether levels of need are associated with services not actually helping or not being delivered; and which groups of individuals have high levels of needs in specific areas of SRCQoL.
The toolkit was developed over more than a decade through a number of projects led by PSSRU in collaboration with other experts and organisations. It has its origins in the Older People’s Utility Scale (OPUS) project that we published in 2002. Focussing on older people aged 65+, this was the first ‘preference weighted’ measure of social care outcomes. Preference weighting quantifies the way some outcomes matter more to people than others. By asking a series of questions we are able to elicit how important people thought it was for their needs to be met in various different quality of life ‘domains’. The most recent analysis shows that control over daily lives is most important to both service users and the general public.
As governments became increasingly focused on measuring the effectiveness, productivity and outcomes of public services, a series of projects fed into new iterations of the measure and extended it to more client groups and to wider outcomes domains. These projects included work on estimating productivity of personal social services in national accounts (2005), the young adults user experience survey (2006), the individual budgets evaluation (2008), and the Office of National Statistics (ONS) led Measuring Outcomes for Public Service Users (MOSPU)’ project (2010). The ASCOT website was launched in June 2010 but intensive work continued on testing, developing the refining the tool, funded by the Health Technology Assessment programme. This enabled us to consolidate all the different strands of work from the previous decade and to generate the outcome domains and preference weights that are currently in ASCOT. One of the more challenging contexts in which to measure outcomes is residential care, where many services users cannot themselves answer the questions, so the care home version of the toolkit also required the development of a staff training programme.
One of the most exciting recent developments has been council and provider organisations’ use of the toolkit to improve care practice and care quality. We had one example of someone going into a care home and using ASCOT to report back to management on what they had observed. The staff in the home were shocked by what they heard. They saw that they were so busy in their roles that they never took time actually to talk to residents or consider how bored and lonely they might be feeling. They were good at keeping residents safe, clean and fed but had not realised that residents would sometimes go more than two hours without anyone even speaking to anyone. Six months later the care home had been transformed in response to the findings. A follow-up study has just finished that concluded that staff found feedback based on ASCOT helpful and there is real potential for building ASCOT into a quality improvement approach.
Other recent activity has looked at whether we can produce a version of ASCOT that works at the level of the care come, rather than the individual, the latter being too time demanding for use by local authorities when they go into care homes. One local authority is seeing if ASCOT could be introduced into the care planning process to help the service user and care manager focus on the outcomes that people want to achieve. All these developments have huge potential.
Looking back, when OPUS published in 2002 no one really took much notice. People were just not focused on outcomes at that time – it is a huge mental shift to think in terms of people’s lived experiences rather than ‘the service’. After the ONS study, while we hoped that ASCOT would be taken up more actively by researchers, we thought it unlikely that there would be much active interest in some elements, , particularly the care homes aspect of the toolkit which requires training. Instead we have been surprised by the level of demand, from both the research and practice communities. We are now putting together a ‘train the trainers’ course because we cannot keep up with demand. While ASCOT was originally conceived as a tool for researchers, these days it is widely used by local authorities and providers and even in other countries. The introduction of a more formal licensing system for the toolkit will in future give us a better idea of the balance of users – although it is important to emphasise it will still be free for non-commercial use. The toolkit currently has more than 1000 registered users.
There is still huge potential in terms of translation of ASCOT for use in other countries. The Netherlands, Finland and Denmark have each either successfully translated the tool or done some work on it. I would expect preferences regarding outcomes to differ between countries because of the varying social and cultural contexts but we do not know how. So there is a lot more work still to be done.
Interviewed by Teresa Poole
Professor Ann Netten joined the Kent branch of PSSRU in 1987 and was Director from late 2000 until retirement in March 2013. She is also a founding member of the NIHR School for Social Care Research (SSCR) and a member of the Academy of Social Sciences. Here Professor Netten explains her long involvement with the development of the Adult Social Care Outcomes Toolkit (ASCOT) and its impact on policy, service delivery and research.