Summary of the impact

This research improved policy-makers' and practitioners' understanding of well-being among residents of social care facilities by identifying the factors contributing to residents' quality of life. This research resulted in the development of the Adult Social Care Outcomes Toolkit (ASCOT), whose use is rapidly increasing both in the UK and internationally. Evidence from beneficiaries including policy-makers, experts and service practitioners, as well as interviews with service users, indicates that ASCOT captures aspects of well-being that are highly valued by service users and policy-makers alike.

Underpinning research

This research was led by Netten (who joined Kent in 1987 and became a Professor in 2003) and involved other Personal Social Services Research Unit (PSSRU) researchers at Kent and LSE who have contributed to the development, testing and analysis of datasets generated by multiple studies and surveys relating to the outcomes of social care.

The research underpinning this case study developed a measure of social care outcomes for older people [see reference 3.1], followed by Department of Health commissioned work on social care which fed into the 2005-06 Atkinson Review of the measurement of public sector productivity in National Accounts [ref 3.5]. Collectively, the research demonstrated:

• That existing measures were inadequate for establishing the outcomes of existing social care services.
• That a robust measure was needed that captured social care related aspects of quality of life (i.e. dignity, autonomy, comfort, safety, personal cleanliness, social participation, occupation, food and drink).
• That any measure needs to take account of individual preference weightings to allow for comparison across cases.
• That measures need to be anchored to an equivalent health state (`being dead') to facilitate a wide range of applications.

The measure developed as a result of this initial research was used in the major collaborative Individual Budgets Evaluation Network which evaluated Individual Budget pilot projects (2006-08), allowing the applicability of the measure to be compared across service user groups [ref 3.6]. Following the Atkinson Review, further developmental work was supported by the Measuring Outcomes for Public Service Users (MOPSU) project, funded by the Treasury and led by the Office for National Statistics. This project, led by Forder (who joined Kent in 2007 as a Professor and became Director of PSSRU in 2013), included an approach to measuring outcomes for residents of care homes [ref 3.7] and for measuring outcomes of low-level services (such as day care) [ref 3.2]. A National Institute of Health Research (NIHR) funded methodological study, undertaken in parallel to the MOPSU study [ref 3.4], tested different preference elicitation methodologies by surveying 500 members of the general population and 450 service users [ref 3.3].

Based on this research the Adult Social Care Outcome Toolkit (ASCOT) was launched in June 2010, and made available online. Subsequent research has been commissioned to support the use of ASCOT in the national Adult Social Care Survey (ASCS) and Outcomes Framework. Feedback about use of ASCOT in practice, and demand for a care home version, have also resulted in the commissioning of further projects, funded through NIHR School for Social Care Research, testing and developing these approaches.

References to the research

Research Funding

This research was funded through a variety of awards totalling over £2,500,000 following the initial award from the Department of Health to develop a measure of outcomes of social care for elderly people in 1997. The most significant awards include the following:

• Financial valuation of PSS outputs, Department of Health, £126,109 (2005-2006).

• Provision of research services in support of the Invest to Save Bid project titled "Quality measurement framework" (Ann Netten and Julien Forder), Office for National Statistics, £950,950 (2007-2010).

• Outcomes of social care for adults: developing a preference weighted measure (Ann Netten and Julien Forder), HTA, £436,884 (2008-2011).

• ASCOT Feedback Intervention Study (AFIS): exploring the feasibility of an outcomes- focused intervention on care home practice (Ann-Marie Towers, Nick Smith and Ann Netten), NIHR School for Social Care Research, £322,849 (2012-2014).

• Developing a care home quality indicator based on residents' social care related quality of life (Ann-Marie Towers, Jacquetta Holder, Nick Smith and Ann Netten), NIHR School for Social Care Research, £32,223 (2013-2014).

• Development of a care home quality indicator based on residents' social care related quality of life: formats and interpretation of reported results, (Jacquetta Holder, Ann-Marie Towers, Lizzie Welch and Ann Netten), NIHR School for Social Care Research, £30,000 (2013-2014).

• Policy research unit in quality and outcomes of person centred care: estimated funding for stream of work to support ASCOT, (Ann Netten and Julien Forder), Department of Health, £400,000 (2011-2016).

Details of the impact

David Brindle, writing in The Guardian in 2010, suggested that ASCOT would `shake up adult social care' by enabling social care providers to measure the worth and value of the work they perform [see corroboration 5.1]. The beneficiaries of ASCOT are hence multiple, and include local authorities, independent providers and other stakeholders looking to improve the effectiveness of workplace practice, with the key impacts being as follows:

Development of a robust measure of quality of life integrated into service evaluation:

At a policy level the Department of Health has used ASCOT `in the development of policy proposals for the Caring for Our Future White Paper to understand the variation in outcomes at a local level' [corrob 5.2]. In 2011 the Department of Health commissioned a national Policy Research Unit in Quality and Outcomes of Person Centred Care, which has an agreed stream of activity designed to explore the use and application of ASCOT and related measures. This workstream has resulted in website development and support, responses to individual requests, annual workshops in the UK, and training. Partly as a result of the inclusion of ASCOT in the Adult Social Care Statutory Survey and its key role in the Department of Health's Adult Social Care Outcomes Framework [corrob 5.3], councils including Bolton, Cumbria, Slough, Redbridge and Hertfordshire are making increased use of the toolkit and its developments for the purposes of enhancing professional practice and improving the effectiveness of workplace practices. For example, in Cumbria ASCOT has been introduced with the aim of `supporting cultural change in focusing on outcomes and person-centred care planning and review', generating data that has supported their planning and management of services. Cumbria's Head of Social Care attests that `ASCOT is proving an invaluable tool in helping us move to more outcome focused practice' [corrob 5.4]. The Senior Monitoring Officer, Quality Monitoring Team East Sussex County Council states `ASCOT has transformed the way we audit care homes. In the past it used to be a paper- based exercise, with very little focus on the client. Now we spend much more time observing and we feel that the evidence we use is much more robust' [corrob 5.5].

Influence on professional practice and standards:

Feedback from workshops and training has indicated that reporting qualitative and quantitative information based on the ASCOT measure changes the focus of care work, resulting in improved quality of care and outcomes for residents. For example, Saga now conduct regular surveys of their service users and are collecting ASCOT data both for the purpose of demonstrating outcomes to commissioners and for monitoring and improving practice. In this light, PSSRU are currently conducting a feasibility study, funded through the NIHR School for Social Care Research, to examine how feeding back scores derived through ASCOT results in improved quality of care. In total there are 806 registered users (an increase of over 160% between 2012 and 2013), including many users from local councils and service providers. At least 25 organisations have used ASCOT. Training and workshops have proved popular: between 2011 and 2013 training was provided to over 160 people from 45 different organisations. In addition, 177 people have attended workshops about ongoing developments and use of ASCOT.

Influence on planning and managing services:

ASCOT has provided a means for benchmarking cost effectiveness across the social care sector, with the structure and basis of the measure (for example, domains of quality of life used) having fed into quality assurance procedures by both local authorities and independent providers of services. For example, the Social Care Institute for Excellence (SCIE) use ASCOT as a basis for defining excellence in social care to support improving practice, and recommends its use in evaluating the cost effectiveness of social care interventions [corrob 5.6]. Hence, while ASCOT is still relatively new in terms of developing an evidence base, it is designed to be used in economic evaluation and thus to provide evidence of cost-effectiveness of services. When used in the economic evaluation of personal health and social care budgets ASCOT provides evidence which supports better resource management resulting in improved service delivery.

A network has been set up to facilitate international communication and collaboration in the use of ASCOT. Given this, international interest has been widespread with attendees at workshops from Israel and Japan, with considerable interest from Scandinavia (there is a Finnish section on the ASCOT website) and Europe. Similar policy and practice impacts to those in England are therefore starting be felt internationally. A recent OECD report [corrob 5.7] identified that `other OECD countries, such as Denmark, Austria, Finland and the Netherlands, are starting to use ASCOT'. For example, a Finnish evaluation of outcome measures reports ASCOT as `exceptional as it can be used as a research tool and also as a practical tool in improving service production and social care practices' [corrob 5.8]. In Denmark, two large scale ASCOT studies of home care and care homes for older people have been conducted on behalf of the government, with a leader of the principal NGO for older people calling for the measure to be included in regular national surveys [corrob 5.9]. ASCOT has also been translated into Dutch and here and elsewhere proposals are being developed to undertake preference studies to reflect national preferences in scoring for different countries and cultures. A version has also been developed for the Austrian Home Visits and Counselling Programme [corrob. 5.10]. Individual providers are taking an active interest, among them NGOs in Australia (Domiciliary Care Adelaide) and Finland (Solutos Oy mental health and substance abuse service), while in Israel ASCOT is `serving to better think through policy and program objectives' [corrob 5.11]. These examples demonstrate the wide international influence of ASCOT on the planning of social care.

Sources to corroborate the impact

5.1 - As cited in Brindle, D. (2010) `A new measure that will shake up adult social care' The Guardian 9 June 2010.

5.2 - Statement provided by ID 1 (Statistician, Department of Health), corroborating the uptake of ASCOT as a measure which provides accountability for outcomes in adult social care for Ministers and parliament at a national level.

5.3 - ASCOT is the preferred measure of quality of life for people with support and care needs in the Department of Health's Adult Social Care Outcomes Framework 2013-14.

5.4 - Statement provided by ID 2 (Research and Information Officer, Adult and Local Services Directorate, Cumbria County Council). See also Cumbria's `Using Quality of Life Questions at Assessment and Review'. This corroborates the use of ASCOT in local authority assessment and review processes in the UK.

5.5 - Statement provided by ID 3 (Senior Monitoring Officer, Quality Monitoring Team, East Sussex County Council) corroborating use of ASCOT in the evaluation of social care services.

5.6 - The recommended use of ASCOT in SCIE's (October 2010) is shown in Finding Excellence in Adult Social Care excellence definition materials.

5.7 - Good Life in Old Age? Monitoring and Improving Quality in Long-term Care OECD report corroborating the increasing uptake of ASCOT in an international context and notes that ASCOT is a `standardised instrument widely accepted in health care'.

5.8 - Statement provided by ID 4 (Research Professor, National Institute for Health and Welfare, Finland) corroborating international influence on planning and management of social care services.

5.9 - See Rostgaard, T., Nøhr, R., Og, B., and Fridberg T. (2012) Omsorg Og Livskvalitet I Plejeboligen, Sfi Rapport. København: SFI, which used ASCOT to show that meeting `higher order' patient needs requires higher levels of investment.

5.10 - The Austrian report on quality in home visits and care homes - Qualitätssicherung in der häuslichen Pflege (Bmask, 2013) - demonstrates how ASCOT can be adapted to different national and cultural contexts.

5.11 - Statement provided by ID 5 (Director of Myers-JDC-Brookdale Institute, Habib), corroborating international influence on planning and management of social care services.