Burden of bureaucracy is compromising care, says new Joseph Rowntree report
Caring Times, April 2014
Some care home managers say they spend 20% of their time on paperwork rather than on leadership activities that could improve the quality of care for residents.
Research by the Joseph Rowntree Foundation published in February, identifies more than 100 separate items of paperwork that must be completed regularly in care homes, responding to a range of regulatory and commissioning requirements.
The JRF report – Is excessive paperwork in care homes undermining care for older people? – says paperwork has limited the ability to quantify and measure the quality of interactions between care staff and residents. “Paperwork has become an industry in its own right, fuelled by fear and insecurity,” is a key finding of the research. Others include:
- Poor co-operation and co-ordination between agencies responsible for regulation, monitoring and purchasing care results in information being duplicated, often several times with a slightly different emphasis each time. This effect is referred to in the study as a ‘composite burden’.
- Staff see some of these information demands as bearing little relation to an assessment of the quality of care a home provides for its residents.
- In the care homes visited, about half of the paperwork produced was used infrequently. Some staff felt that paperwork was inefficiently designed or implemented. Providers’ interpretations of the value of regulatory paperwork also varied widely.
- Some staff felt they were judged more on an ability to produce quality paperwork than an ability to deliver quality care.
The research was conducted in two care homes in Birmingham and one in York. Focus groups and interviews were conducted with residents, relatives, volunteers, frontline staff, managers, commissioners, providers and regulators.
“Paperwork has limited our ability to quantify and measure the quality of interactions between care staff and residents,” the report says in its summary.
“Paper offers false assurances in this regard and yet it is these interactions that are of ultimate value to residents and their relatives. Care should be provided in a way that is ‘human’ – focusing on the creation and maintenance of meaningful relationships between care staff and residents.”
Care homes have a list of core ‘must-dos’ based on key legislation and embodied in 28 standards of quality and care. Yet different agencies also make requests of care homes and these requests have different emphases across the country.
“In addition to this moveable feast of ‘must-dos’, views about how guidance should be interpreted to meet funding or regulatory requirements also vary,” the report continues.
“Additionally, some requests made by inspectors and regulators are seen by care homes as bearing little relation to the quality of care provided.
“There is little co-operation or co-ordination between different regulators and commissioners and duplication arises when they ask for much the same information, but tailored to their individual needs. From their point of view, what is requested is reasonable but the impact of several commissioners asking for similar but slightly different information places an extraordinary burden on the home. This composite impact is often what homes are describing when they complain about a ‘paperwork burden’.”
The researchers said many care home managers interviewed as part of the study felt that the issue reflected deeper system-wide uncertainty about what should be valued in care and what high-quality care should look like.
Perhaps the strongest criticism comes in the report’s conclusions and recommendations which begins by saying “The balance between prevention of poor care and promotion of good care is out of kilter. Care homes spend an inordinate amount of time attempting to cover themselves against potential blame or litigation for poor care. Instead of being an addition to care quality, paperwork can lead to ‘subtractions’ – literally taking away from the delivery or management of care. Five of the most significant subtractions are:
- Leadership: Many interviewees felt that time spent by leaders on paperwork could be better spent on leadership activities, being a visible presence in the home and demonstrating how to build good relationships with residents and staff.
- Value of care: Interviewees suggested that the value placed on paperwork was too high compared to the value placed on providing high-quality care.
- Vocation: Staff are judged more on their ability to complete paperwork than on their ability to deliver good care. This can distance staff from their job and reduce their sense of vocation.
- Co-operation: Paperwork does not drive providers, commissioners, contractors and regulators to higher levels of co-ordination, nor does it help them establish a shared value system for care.
- Professional autonomy: Regulation can lead to regularisation; reinforcing the mechanistic nature of some care practice, for example regular bed-rail assessments. Staff in care homes need to take action because they recognise that it is the right thing to do at the time. Routine should not undermine staff autonomy or be a substitute for professional judgement.
The report suggests a number of “limited steps” to improve regulatory paperwork in the short term:
- Adoption of a single incident reporting form.
- Alignment of national inspection criteria across agencies such as the Care Quality Commission, NHS and local commissioners.
- Sharing and use of information across inspectors of care.
- Geographical alignment (improving consistency of approaches to inspection taken by commissioners and regulators in specific local areas).
- Organisation of paperwork for different audiences (organising a set of paperwork that can be owned and used by the resident and organising paperwork that is used more by staff on a day-today basis).
The researchers say longer-term systemic improvements will require more ambitious change. They say:
- Providers and residents should play a greater role in defining the criteria for high-quality care. At a care home level, consultation should be used to identify the ‘moments that matter’ to residents, relatives and staff. This bottom-up vision of care quality should form the basis of how that care home is judged by inspectors and commissioners.
- Care home inspection should involve observed assessment of care, giving real weight to choice, participation, dignity and respect. These are observable in the day-to-day interactions between residents and staff and should be at the heart of any inspection and regulatory regime.
- The primary role of risk management should be to enable residents to live their lives in a way that they value as opposed to defending the home from potential litigation or reputational loss. This requires additional training and a better understanding of risk and enablement among regulators and commissioners. Care homes, commissioners and regulators should generate more collective approaches to accountability to reduce defensiveness and improve shared learning and calculated risk-taking across the care home sector.
– The full report is available as a free download at www.jrf.org.uk