9. Situación actual. La caza en cifras
9.2. Un segmento del turismo internacional en auge:
Quality in long-term care is an important policy issue not only in England but also in other OECD countries (Colombo et al. 2011). The debate about the importance of quality in long-term care service is driven by three main arguments. The first is associated with the concerns regarding the safety of the services due to situations of abuse and/or neglect. The second refers to the need of policy makers to show taxpayers that public money is spent wisely and services are delivered effectively preserving good standards. The third argument consists of the responsiveness of services to meet users’ needs. To this extent, the way quality is measured depends notably on the relationship between carers and cared-for and regulators must design the right incentives to ensure suitable levels of quality. A good understanding on the association between carers and cared-for shapes aspects regarding the equity, efficiency and accessibility of the services.
As Malley et al. (2017) argue, there are two main approaches to measure quality. The first, pioneered by Donabedian (1988) focus on the production process and distin- guishes between structural inputs and the outcome indicators. The structural inputs mainly correspond to environmental characteristics (staff, premises, etc. . . ) and are not focused on the caring process. The second approach concerns quality dimensions that are determined according to their policy relevance. The current quality system of long-term care in England follows the second approach.
Furthermore, there are a number of instruments to enhance the quality of long-term care. These include regulatory instruments, economic instruments and information instruments. Regulatory instruments determine legislative rules to influence the behaviour of the main actors involved in the process of care. Additionally, these regulatory instruments can be implemented by means of directions, methods for surveillance and/or methods of enforcement. In England there are various directions aimed at influencing different parts of the care process. These directions are mainly
Chapter 2 The organisation of long-term care
based on outcomes20. Surveillance mechanisms are intended to detect compliance with the directions. An example of these mechanisms are the inspections carried out on care homes by the CQC in order to monitor their quality. Finally, enforcement methods are applied when non-compliance is detected and there is risk of harm for users as well as a threat to preserve appropriate quality. For instance, the CQC may undertake enforcement powers when a provider repeatedly delivers inadequate care (Care Quality Commission 2015a).
Economic instruments set incentives or disincentives to influence the behaviour of the actors. The main types of interventions are based on incentives aimed at improving the long-term quality and at promoting competition in terms of quality. These incentives are normally financial and may adopt different forms. There may be quality related subsidises, such as the workforce development subsidies, quality payment schemes, such as the pay for performance systems applied for care homes21 and quality related public procurement by which the public purchaser can increase competition in quality and prices.
Finally, information instruments are implemented to influence the behaviour of act- ors by affecting the transfer of knowledge and communication. There are several types of interventions although the most widely used consists of public quality reporting systems22. Most of the empirical literature has focused on the latter issue examining the effects of public reporting on the quality and consumer care choice (see Grabowski and Norton (2012) for a review). The main conclusion is that reporting generally has a positive effect on quality but it is modest and inconsistent (Huang and Hirth 2016). Examples of these inconsistency may be Werner et al. (2012) who find a small positive effect between quality reporting and the choice of nursing homes with higher levels of quality and Grabowski and Town (2011) who show no association between the
20These directions are complemented with information from National Outcomes Framework (NHS OF). This is a set of indicators developed by the Department of Health and Social Care to monitor the health of adults and children.
21See Norton (2018) for a review of these methods in long term care.
22There are, however, other systems such as education and knowledge management or the systems based on quality improvement and management tools
Chapter 2 The organisation of long-term care
reporting of information and the choice of consumers or the quality of care. Other research has studied the interactions between competition, the increase of available information and the increases in quality (Zhao 2016) as well as the effects of quality reporting on prices (Huang and Hirth 2016). All these studies are mainly based on the US market for long-term care. Yet, research consisting of other markets is sparse.
There is a recent strand of the literature that is analysing the impact of new sources of information based on Internet references to quality aspects of long term care. Trigg (2014) introduces the main points associated with the use of online quality reviews in the context of long-term care. Despite some challenges related to the adoption of these sources of information by the current generation of users and providers, the author concludes that online reviews will become more important and suggests the design of review sites that reflect accurately the characteristics of the sector. Along these lines, Konetzka and Perraillon (2016) examine these new sources of information finding that although consumers were receptive, their decision was limited due to other elements such as the specialisation of the services, the location and proximity of the care home to family or the availability of publicly subsidised beds. Hefele et al. (2018) analyse the adoption of Facebook in care homes and the relationship of their reviews with the quality and find no association. Their findings are consistent with previous studies addressing the use of social media in health care (Hawkins et al. 2016; Greaves et al. 2014).
2.5.1 Quality inspection system in England
Since October 2014, care homes are inspected according to a new inspection system monitored by the CQC. The main difference compared to previous systems, is that the new system implemented more systematic inspections driven by five so called key lines of enquiry (KLOEs) that structure the inspections in sets of 5 key questions. These questions are associated with issues to determine to what extent services are safe, effective, caring, responsive to people’s needs and well-led. In addition to the assessment of each of these dimensions, the CQC also releases an overall rating. Both
Chapter 2 The organisation of long-term care
the overall rating and each of the other 5 questions are rated according to four possible categories: outstanding, good, requires improvement and inadequate. The previous system was composed of 28 regulations on 16 outcomes that defined the quality and safety standards but were based on a low and unclear bar (Care Quality Commission 2013). Table2.1presents the main differences between both approaches.
An important component of the system is that the inspections are carried out from a people-focused perspective23without prior announcement by specialised inspectors and teams of experts. Before, these inspections were conducted by generalist inspectors. The information used to derive the ratings comes from different sources that include quantitative measures, the direct observation from the inspectors and the feedback from both patients, relatives and staff working in the care homes (Barron and West 2017). Also, the frequency of inspections is determined by the rating obtained. Thus, worse ratings lead to more frequent inspections. Having an “inadequate” rating also implies the adoption of special measures, close monitoring and a re-inspection in 6 months (Care Quality Commission 2015a). The level of quality seems to be unaltered during the last two years. In 2018, about 80% of the inspected care homes obtained a good rating. Yet a 20% required improvements or were inadequate. Figure
2.7shows the local variation in different levels of quality. This figure is similar to the information provided by the CQC for 2016/17 (Care Quality Commission 2017). Within the new quality framework, rather than the CQC who had an active role in care homes’ improvement, providers and commissioners are responsible for the quality improvement.
23There are other methods, such as the Adult Social Care Outcomes Toolkit (ASCOT), that adopt this people-focused approach. This tool aims to measure the domains of quality of life most affected by social care and is equivalent to the quality-adjusted life year (QALY) in health. Further, it is mostly designed for economic evaluations of long-term care interventions. Netten et al. (2012) provide details of this tool.
Chapter 2 The organisation of long-term care