Evaluating Outcomes in Health and Social Care is the fifth in a series of five books on health and social care partnerships, recently updated to take account of new studies and changing policy developments since first published in 2008. The book is aimed at students, practitioners, managers and policy-makers in health and social work/care. Health and social care partnership is in itself a topic which has presented considerable challenges to policy and practice in different countries for decades. In addition, this book also aims to tackle the complex issues of evaluation and outcomes, which is no mean feat. The authors usefully blend context and history, an overview of evaluation methods, theoretical approaches, practical examples and links to reading and resources in pursuing their quest.
A key point made in this book is that although evidence of outcomes of partnership working for people who use services is still thin on the ground, a patchwork is emerging. The first author has long argued, as have others, that this evidence gap is not necessarily due to the ineffectiveness of partnership, but to the immense challenge involved in its evaluation. The authors explore the reasons why the drive for partnership continues, despite the lack of an evidence base. They identify that the evidence of harm caused to individuals by lack of partnership is easier to establish, referring to a history of serious case reviews to illustrate this. In the preface the authors refer to other human ‘harms’ caused by lack of joined-up services, such as individuals having to repeat their story and not being listened to, and delays resulting in deterioration of people’s health. The authors acknowledge more generally that services need to work together because people do not live their lives according to the categories the care systems have created. Real-life problems are nearly always harder to define and more difficult to resolve than one service can manage, a point revisited below.
Case studies, including evaluation of Health Action Zones and the Sure Start programme in England bring the book to life in exploring the thorny issues involved in evaluating outcomes in real-world situations. These examples demonstrate strengths and particularly limitations of classic method-led approaches to evaluation design. The authors then make the case for theory-led approaches such as Theories of Change (ToC) and realist evaluation to evaluate multifaceted issues, recommending a blend of both. ToC is prospective with the evaluator involved in an iterative and ongoing process with the people being evaluated. While this approach can offer an accurate view of what is happening within partnership it tends to be process-based. Realist evaluation involves exploration of the interactions between context, mechanism and outcomes, seeking to discover what works for whom in what contexts. The authors suggest that in the context of partnership it is more appropriate to ask which service users do partnerships improve outcomes for, when, where and how.
As Dickinson has long argued, the issues of attribution and causality are perhaps the largest challenges which partnership evaluations face, particularly given the breadth of outcomes outlined in recent health and social care policy. The authors argue here that a theory-led approach can help where there is a lack of existing evidence as to causality. However, it can be argued that what is required is a shift away from the attribution conundrum surrounding outcomes to focus on contributions. Considering contributions towards outcomes allows different agencies and indeed the people themselves to contribute towards the same outcomes, thereby offering potential to support both partnership and person-centred practice. Certainly, it is important in evaluating outcomes that any theory of change should avoid rigidity in defining the outcomes expected from a given intervention. The unintended outcomes of interventions can be at least as important as those that are anticipated. Further, factors not originally anticipated in the theory may have a stronger bearing than the intervention of interest.
The authors refer to the type of evidence preferred in health as compared to social care, which has implications for the approach to evaluation, and particularly for conceptualisation of outcomes. These evidential leanings have corresponded with historical tendencies towards more clinically focused acute interventions in health, as compared to the community-based orientation of social care. Thus, there have been significant differences in how outcomes for people are conceived, with a tendency towards more treatment-oriented, standardised outcomes in health, and longer-term quality of life outcomes in social care. However, these distinctions are becoming blurred as more people are living with complex long-term conditions, with a more holistic focus required.
The book provides a sound foundation for consideration of how to untangle the complex web of factors involved in the evaluation of outcomes and partnership working. The authors acknowledge that partnership can be extended horizontally and vertically, to reach beyond statutory health and social care. However, it could also be argued that the long-standing mission to overcome barriers between health and social care has prevented the realisation of a necessarily broader look at how human services in general collectively contribute towards better outcomes for people, despite the complexity involved. In any case, this is a useful second edition which achieves what it aims to do in locating a trio of tricky issues in the context of new evidence and of more recent policy, in England in particular. It is to be hoped that the book will encourage the production of further patches to contribute to the evidential quilt long sought in relation to partnership working.
