Choices! Choices! Techniques for analysing the dilemmas of balancing the interests of stakeholders in community care.

<p>The paper analyses the consequences of alternative prioritisation of outcomes, and so of stakeholders for whom the outcomes in question are particularly important. It does so with the help of a new approach to deriving and handling evidence put forward in the authors’ new book Equity and Efficiency Policy in Community Care: Needs, Service Productivities, Efficiencies and their Implications. It argues that in the absence of ways of handling evidence of this kind, it has been too easy to argue either as if an improvement in the benefits most valued by some stakeholders had no costs in the loss of benefits valued highly by others, or that the improvement of one benefit would be wholly resourced by losses in the form of other benefits, ignoring the potential reduction of one inconsistency, inefficiency, for achieving gains of some kinds without losses of other kinds.

<p><p><p>This paper is based on Equity and Efficiency Policy. It uses the results of research designed to estimate the effects of levels and mixes of service inputs on outcomes of direct evaluative importance (hereinafter called ‘outputs’), taking into account user and carer ‘need-related circumstances’ (including ‘risk factors’). It illustrates the use of these estimates in conjunction with other information to discuss some of the dilemmas of choice now relevant to the steering of community care policy and practice.

<p><p><p>Having listed the basic elements of the approach, the paper shows some implications of maximising each of three outputs:<p><p>extending stays at home, increasing user satisfaction with services, and reducing felt burden of care-giving. The paper illustrates how differences in priorities work through differences in the input mixes that efficiency would require, and so gives a quantitative feel for the dilemmas of choice. It demonstrates the importance of managing the markets in which commissioning and decommissioning take place, and the way in which incrementalist budgeting reduces the range over which there can be win-win solutions. It illustrates how analysis of alternative policies based on the approach illustrated here but based on the wide range of outputs and scenarios for which estimates are provided in Equity and Efficiency Policy can usefully complement what can be argued from other forms of research, and add new meanings to existing knowledge.

<p><p><p>Paper presented at the British Society of Gerontology's Annual Conference, September 2000.