Abstract

Performance assessment is playing an increasing role in the governance of home care services in Europe. Ideally, the assessment of service quality should capture outcomes for everyone involved either directly or indirectly in the care intervention (e.g. the user, care workers, care managers etc.). Outcome indicators are direct indicators of the final impact of the service, such as the well-being of users and care workers. It is the conversion of inputs to outcomes, and not outputs (such as volume of home personal care hours, number of users, etc), that is central to performance assessment.

However, the most significant problem associated with the outcome-based approach to performance measurement is the notorious difficulty in measuring outcomes, because so many other factors may intervene. Moving beyond these difficult technical questions, we demonstrate how cross-national variations in performance assessment can be understood as responses to the political contexts and features of individual every system. Where provision is organised within a tutelary model (as in Belgium’s home care sector), there are close and longstanding relationships between public administration and providers. There is no system of benchmarking, and performance assessment focuses on intermediate outputs.

Providers have “an obligation to means” rather than “an obligation to results” i.e. to be accredited they must comply with input-related standards. Marketisation creates a clear rationale for particular forms of performance assessment. Where there are quasi-markets, relationships are likely to be of a shorter duration, more business-like and based less on trust. In this situation, purchasers lack mechanisms of direct control. Thus some form of oversight is necessary to gather data about providers’ operations for the purposes of quality assurance and accountability for public expenditure. In the countries where the logic of markets exists, and in the context of the growing role of independent home care providers, the collection and use of service performance related evidence could be critical in order to guarantee the efficient functioning of the care market by helping to address problems of incomplete and asymmetric information.

Important questions remain, however. First, to what extent performance assessment frameworks, in particular those based on highly standardised measurement processes, can fully capture the complex array of factors contributing to good quality and good service performance in the home care sector. Second, how the different approaches to performance assessment support informed choice and improve the efficiency of the market. Due to these difficulties and to the different degrees of marketisation of the care system between countries, we see that performance is not always measured by looking at outcomes. Process and structural quality indicators are still commonly used in the studied countries, even if they provide a limited picture of the performance of the whole system.

Slides