Adalbert Evers, Riitta Haverinen, Kai Leichsenring, Gerald Wistow (Eds.) Developing Quality in Personal Social Services Concepts, Cases and Comments European Centre Vienna Ashgate Chapter 1 Quality Development - Part of a Changing Culture of Care in Personal Social Services Adalbert Evers 1 The Point of Departure: Different Concepts of Assuring Quality in Personal Social Services Personal Social Services (PSS) have been a major growth industry in all European countries. With the current changes in both quantity and impact, the prevailing views and concepts with respect to quality have changed as well. There have been processes of professionalization; changes in social rights to care; transitions from charity- or state-based systems to mixed markets; changes concerning the readiness of families to use outside help and concerning aspirations when using PSS. If one agrees that caring m the widest sense is the essence of PSS - caring being understood not only as providing material help but also as providing advice and personal and social support - then these changes can be summed up in what I call a "changing culture of care" (Evers, 1995). The same moving forces that operate behind the changing images of care are also behind the changing notions of quality. In light of this, one ought to distinguish two separate yet related items which are (i) quality measurement (especially for standard-setting and control from the outside) and (u) quality improvement (as a way for doing better within a given broader framework). The following considerations will revolve around Quality Assurance (QA), which is meant as a label to cover both issues. There are four important types and traditions of QA that can be distinguished (also see the typology suggested by Rajavaara in this book) u » , \ 10 Quality Development - Part of a Changing Culture of Cam This * The first comes from the field of professionals and their organizations - these qual 316 the traditions of peer reviews by colleagues, standards and ethics given bv Eure and controlled within a professional association. This model is linked with the soci; development of the welfare state, which helped to professionalize the field oi- ling helP, care and social work. It is about both setting and controlling quality stand- of p ards and about quality improvements. intrc * The second type is the "inspectorate approach", sometimes executed by people esse from the same professional field. This model has flourished alongside the welfare pers state as a provider of universalistic services meant to be highly standardized anc uniform, e.g. in the area of schools and hospitals. The inspectorate approach is very much about the processes of laying down what is seen as a general standard and about guidance on quality control (for the diversity of the prevailing styles, see Klein and Bland in this book). Giv * The legacy of the third type of defining quality and assuring it, basically stems plac from the late 1960s and the euphoria of being able to construct bottom-up models Eur for new service relationships based on both individual and collective citizen and consumer control and participation (see Harding/Beresford, 1996; in this book pro Thi i.e. of c Bel especially Beresford/CrofVEvans/Harding). the The fourth type of quality assurance comes from outside - the business sector oft " Wlth concepts suggesting reforms in organizational and management struc- cal tures- These range from top-down models (Kelly, 1991) to comprehensive con- rea cepts for constant institutional reform, such as Total Quality Management bo< (TQM) (Deming, 1982). These concepts differ from the first type in many pei instances but especially to the degree they address the entire body of a firm or organization; some of them try to create, at least for a while, a high level Ad of joint readiness and commitment to question not only inherited structures Eli and routines but also prevailing individual perspectives. Altogether, the busi- tiv ness-based models are very much concerned with doing better than the others Di Wlthin a shared culture and environment (see the descriptions and remarks con- is cerning development and purposes in PSS by Mantysaari, Oppen, Pollitt and He Rajavaara in this book). Ee Pr 11 is weI1 Jo10*" that in European public services today, the concepts coming from the market sector clearly prevail (see the picture given in the overview by Pollitt/ Bouckaert, 1995). To a large part, this is in line with the fact that the global ideological trends have shifted towards an increasing impact from market liberalism-the majority of the shifts in the "welfare mixes" in PSS have been towards more market values, arrangements and mechanisms (Wistow/Knapp/Hardy/Allen, 1994) This has had a number of positive effects for the culture of care, as well as'for the type of QA which is thereby emphasized. Let me enumerate a few: Adalbert Evers 11 • The new care culture and business concepts of QA seem to be more prepared to look at the wishes of the people cared for; after a century of client concepts, the idea of serving the consumer has finally given some fresh air to the PSS sector. • QA business concepts are in line with rearrangements in the service sector towards more freedom of decision at the decentralized level of the single unit, and towards greater possibilities to change routines and to innovate, basically allowing for more diversity. This stands in direct contrast to the hierarchical top-down control model, such as the inspectorate tradition; and it makes a difference in the professional model, one constantly in danger of becoming autistic by using criteria and professional standards which have lost touch with reality in the working environment. • Finally, the business approach can help to bring a teamwork orientation into settings where hierarchical characteristics marched hand in hand with the inspectorate tradition and where professional rivalry was an obstacle to professional QA models (for similar arguments concerning suitability, especially of TQM, see Rajavaara in this book). 2 The Point of Concern: Defining the Challenge Linked with the Introduction of Business-based Concepts However, as some of the readers may have already suspected, such an appraisal ls just an introduction to a more critical discourse about the role and limits of business-based QA concepts. I will concentrate on them because they currently rrevail in both discussion and practice. In fact, the main purpose of this paper will P to collect hints, experiences and reflections concerning the problems of introducing a business approach into the domain of PSS. My argument is, that the respective approaches do not and sometimes cannot grasp some of the peculiarities of the area of personal social services. At first sight, this means argueing - like many of my colleagues (as well as a number of contributors to this book; for example, Mantysaari) - that there are problems with business-based QA concepts coming from the outside, and that it is a challenge to adapt them to the specific realities of the PSS sector. In fact, the central argument of this article will be a different one. In order to give the reader in idea of this difference, one can begin with the simple question of what is special in the PSS sector. Usually, the answers will be twofold: • First of all, there is a structural difference: a personal service is constituted by a personal interaction, in contrast to a material good or product. • Secondly, there are empirical and perhaps also contingent differences, many of them concerning the fact that the services are state-based and thus seen as public goods. Others relate to differences in the economy, such as the prevalence of 12 Quality Development - Part of a Changing Culture of Care Thi: qua Eur soci ir.:r ess per pro Thi i.e. Gii pla Eu e: Be the of cal res th Di is H, EP: th small-scale providers and a huge diversity of service organizations and styles in many countries. However, beyond the basic abstract principle that constitutes the structural difference just mentioned between material products and personal services, there are in fact many different ideas about how to shape the interactions between service providers and consumers. Some tend to minimalize the difference to ordinary consumer relations, e.g. with the idea of a quick and ready-made service - a perspective which helps to take over the market vocabulary. On behalf of the empirical and somewhat contingent differences between the service and market sectors, various standpoints can also be found when it comes to describing their impact. If one is in favour of turning PSS more into private provision rather than treating them as public goods, this will have a clear impact when discussing the suitability of business-based QA; the same will hold true with respect to the question of whether it is better to keep the PSS economy as diverse as it is, with large parts being restricted to local boundaries or allowing for large capital to take over and create standardizing effects. In other words, the position and vision to which one refers with respect to the future design of PSS, will influence one's judgement not only about the different concepts of QA but also about the degree of changes which a business-based approach has to undergo to make it work. This holds true not only with respect to different interest-based preferences - e.g. on the part of the state, professionals, users or the tax-paying public - detected in deliberations on quality (Munro, 1995: for quality as a plural concept, see Pijl and Rajavaara in this book). The global visions which can be found and have their basis across different (interest) groups are themselves critical. There will obviously be fewer reservations towards business-based concepts of QA if one already envisions a more business-like organized PSS sector. Therefore, the discourse should not be about changes needed in order to adapt business models to a given reality of PSS, but rather about changes and challenges for QA in relation to a specific concept and vision for change in PSS and its culture of care. Many present contributions to the debate on the future of PSS seem, however, to lack such a vision or to transport it implicitly. The one orienting the following considerations is different from the business/consumerist vision for future PSS. which in many countries may be already mainstream, in line with former work about the culture of care and the welfare mix in the PSS sector (Evers, 1995), the emphasis will be on the importance of factors which today play a very limited role in usual market places. Here are a few examples: • the positive contributions to be made by the co-producer and co-decision-making role of family- and community-based networks; and 13 Adalbert Evers__.__-- • the importance of state guarantees and interventions to create social citizenship rights and to represent collective perspectives and common interests as a counterbalance to what are so often praised as individual "preferences". By emphasizing the importance of such dimensions, these reflections will probably contain more reservations concerning the role of business-based QA than others. Peculiarities associated with QA issues will be addressed in three sections: • the fact that personal and care services are forms of personal interaction and community-related relationships, different from the usual producer-consumer relations (section 4); • the fact that these partly belong to a different "local" and "moral economy (section 5); and • the fact that questions of public interest and citizen/user concerns are at least as important as consumer preferences (section 6). From there follows an idea about quality and its assurance which is in a way multidimensional. It should take account of people as co-producers, citizens and consumers (Evers, 1997), which likewise means that there should be a place for each of the four roads to QA sketched above. Within such a policy mix, maybe the third and fourth of them - user involvement as well as market and consumer approaches - are presently both more important and more difficult than others, simply because they have been traditionally so much neglected compared with such professional or social-policy criteria for quality as equality and security. However, before turning to these points, some observations will be presented concerning the sociopolitical context and the fact that so much emphasis is presently put on QA issues. 3 A Special Point: Quality Development in a Given Sociopolitical Context Asking how important quality development is, might be of interest in order not to be trapped by the emphasis given to one item, which always means giving less to others We should not forget that asking parents about the quality of their kindergartens or a caring relative about the quality of his/her home-care arrangement, means arguing about a part of a much broader question, which could be, "How good is your municipality or your country when it comes to helping you m child-raising or elderly care?" Quality in terms of this broader question no longer revolves around a specific service action to be singled out, but rather about a complex arrangement entailing such questions as the level of obligatory fees, the difficulties in finally becoming entitled for a place in an institution, and many other If__Quality Development - Part of a Changing Culture of Care similar questions. The restricted perspective of the predominant contributions to the present quality debate, however, is exactly one of the reasons behind its attractiveness: it promises clear, quantitative statements on limited issues where vague discussions on broad issues generally prevail. Yet the attempt of "measuring" the quality of a single service arrangement should not make us forget about the broader dimension of quality - one which includes the fairness of our welfare institutions, rights and our culture at large (Hoyes et al., 1992). In view of this, one should keep an eye on the fact that potential investments in quality development are usually suggested at times when we Find an unwillingness to invest in closing care gaps or in better training, and when the emphasis is usually not on better quality but on getting by with less money. Therefore, the boundaries between reorganization processes oriented towards improving quality, and a New Public Management (Naschold, 1993) concerned with doing things more quickly and with less staff, should be kept in mind. Usually there is a link between P ' quality-development items and increasing productivity (see Pollitt in this book); and one should ask about how these might be balanced. ° Therefore, in an environment where we presently find little or no concern with wnat could be called "quality at large", it is indeed questionable if we look most closely at the quality of what single service units deliver: often, the low quality of a service is to a great degree determined by outside decisions which result e.g. in understaffing or wasting of time and resources due to bureaucratic rules imposed from the outside. One could argue that, just as happens in the general rhetoric about strengthening individual responsibility, there is the risk of blaming the victim -here, an individual PSS unit, its care workers or managers - for problems set by the economic or social policy environment. So, an impact investigation might pay 1 off which states the balance of inside and outside factors concerning e.g. the five i most important quality items found to be deficient in whatever PSS unit happens tr to be chosen. Th. qui Eu srx lin of int ess Tli i.e Gi D 15 4 The Peculiarities of Service Relationships It is commonplace that, due to the specificity of a service, its quality is dependent on an interactive process which blurs the demarcation lines between producers and consumers: hence, the speech about "pro-sumers" and "co-producers". But from my point of view, this fact is merely a point of departure for further considerations. Very much depends on the concept of care and service by which the interaction is shaped. This can be done in a way which reduces its differences with the market and product approach, by giving a "full service" and "quick fix" to the consumer in command. For a long time, another contrasting concept had prevailed - a kind of public sector/ professional approach where the client gets something largely predetermined according to professional assessments and detailed social legislation. Adalbert Evers j <. Given the fact that in many cases the former clients and ought-to-be consumers must in fact cooperate actively in negotiating and arranging a service relationship, we arrive at a complicated interaction process where the division of labour as well as the outcome and definition of goals and quality can change considerably over time. This creates, on the one hand, problems for professional and inspectorate types of QA to the degree that they are concerned with setting or reinforcing standards and norms: preparing a meal is hard to write down as a routine item on bills and reimbursement systems if the relatives sometimes help in it. On the other hand, it makes any care-service organization especially dependent on their counterparts when they want to produce quality. Difficult contradictions may arise between process quality, which can be high in terms of sensibility to the need for cooperation, and outcome quality, which may be harmed by the leeway for risky decisions by the "prosumers". A second problem often cited when importing QA is the fact that the quality of a service can only be measured in terms of looking at a chain of acts by different organizations cooperating or transferring responsibility from one to another - e.g. from a hospital to a nursing home. Every institution might be doing well and may be ready to cooperate; but the preconditions and means might be missing. There-tore, creating cooperation for quality between different units and organizations often serving the same clients, is most important. While this is a top quality problem in PSS, nearly all QA concepts have little to offer here. Interorganizational cooperation - something which is more about a system than a unit - has little or no counterpart in the purchaser-provider relations of the business sector. Less obvious are two other challenges in care. These are situated around the question of what makes personal service relations really "personal". First of all, this means simply conceiving caretakers as persons who are more than just the impersonal incarnation of professional roles and skills, something which makes them as service-givers to a degree unique and not easily substituted. In all RSS, we see users clinging to the person with whom they are interrelated, as well as the importance they attach to continuity and trust as essential components of a ■rationality of caring" (Waerness, 1984). The decision on whether to hire outside help and which service to choose, is very much about trust and empathy. This gives at least some hints concerning the degree to which benchmarks for quality in personal social services should be sought not only in the marketplace - which aims basically at making relationships interchangeable - but also by looking at informal, mostly non-professional helping and caring relationships as a reference model. Secondly, the speech about autonomy, choice, empowerment and consumer-led services clouds another important characteristic in many areas of care and PSS -they often deal with especially weak and vulnerable groups, such as frail elderly people, children, marginalized and desocialized persons. This creates specific limits for direct consumer control, as well as for simple one-to-one translations of user 16 Quality Development — Part of a Changing Culture of Care Th wishes into professional tasks. Professionals must learn to cope with an undeni- qu able power over their clients. For quality control and development, some original Eu concepts have therefore been created in the PSS sector - models of regular super- so< vision for professionals or advocacy models for vulnerable user groups, e.g. out- lin side persons on the board of a nursing home. Summing up, it could be said that of any reflections on the balance between enabling and protecting, between consumer- im led and professional-led elements in the social service sector, may quickly bring es to the surface the competing visions and perspectives that influence the attitude pe towards QA concepts. pr Finally, there is a third, perhaps most basic problem related to a demanding Tt definition of a "personal" social service: the impact of shared concerns, core values i-6 and commitments which help to give a caring quality to a service. With a view to that, the more developed business-based concepts of QA, such as TQM, have G: developed a special sensitivity (most QA concepts have not; see the instructive pi contribution of Slagsvold in this book). They concentrate very much on the devel- Et opment of a shared vision, a strengthened corporate identity and commitment on °i the part of the employees. In the care and personal social service sector, two things B seem remarkable in this context. th First of all, the level of explicit reflection of such coherent visions and basic ol values in the public-service sector is usually very low. This is not only due to such c< single factors as training; the generally low level of explicit values about the goals re and quality of a care service has also to do with convictions deeply rooted in our b< liberal culture, insisting on values as very much a private, individual affair (this Pl can fall well in line with the "silent presence" of concepts within a service or organization which are never explicitly thematized). One could take the example of an old people's or nursing home (for the following, see Moody, 1993). What E most often prevails today is the "autonomy" model, which is part of the unfinished liberal agenda on behalf of the vulnerable. Here, quality will be very much about E everyone doing his or her part, while respecting mutual distance, safeguarding is individual rights laid down in contracts, etc. There are, however, very different models of a perhaps more "communitarian" character. Here, fostering an atmosphere of lively exchange and cooperation, as P well as strengthening the ethic of caring and human relationships, are most impor- tt tant. Instead of centring on the defence of and respect for individual rights, the emphasis will be much more on creating a supportive context. But this also calls for more responsibility of all parties concerned than in the liberal model; and this is one reason why such concepts are often regarded with mistrust. Anyone who is tempted to ridicule the value-based communitarian approach, should now be reminded that advanced business-based models for re-engineering organizations, such as TQM, are exactly such an attempt to create a corporate spirit of community amongst the workers and members of an organization. Hence, one could perhaps I 17 Adalbert avers_______ business sector concerned ^^"^L^so^ positive aspects of the one will notice their limitations and perhaps redete»n P, cofflfflitment PSS tradition. The presupposition to create a climate ofju _sp _ and to keep it alive, works perhaps somewhat better inmaU s 6 tions, as compared to big hierarchical org—^ ^S'^ilesthe marketplace"rthel^welftobun^^^^W ^ leeway for creating or confirming strong values^and a mo P F ^ really interesting point concerns the ■^^J^^to* L not only culture aimed at upgrading tts own values and mpac —J M Lraction in e.g. a nursing home beyond th^ ^vel of one unit To what degree can this be 2«J^a^SÍÍta« commit- can perhaps stimulate that; but they cannot substitute it. 5 The Mixed Economy of Care and Personal Social Services Usually.thetermofme^ to the fact that there are different spheres ^^^^voluntary organi-to PSS: market providers, public^^Z'Z^^^^ conceptsforaNewPubhcManagement,^ intertwining of different rationales ™*^^™^iir splits and competition, such as by creating ^^^^^M-Sector compulsory ^^íS^^V"'^ service organizations as hybrids ^ertwinuag sensitivity for economy, such as a voluntary organization with profit.cent ^ Th qu Eu SOI Lin 18 Quality Development - Part of a Changing Culture of Care church- and parish-based provisions, but it can as well be a hallmark of new community-based initiatives in care and PSS, partly contracted into the local service network (see Taylor, 1994). The argument is that the sheer existence of these dimensions of a mixed economy JJd and the strategic position one takes towards it, are important when discussing the jj suitability of QA concepts. Three examples may illustrate this: es The first is about the problems which have arisen with the shift from a closed public system of PSS financing and provision towards different systems of contrading out and compulsory competitive tendering which blur the demarcation lines with the market sector. While these concepts do decentralize decision-making power j J and responsibility, they nevertheless create new problems of quality control. First of all, such systems often give systematic incentives for the single contracted-it: q- service provider to reach for competitive advantages by making savings through pI reducing this or that aspect of quality. This again makes quality control a more El important and difficult issue. At first hand, one could say that a detailed and clear of contract bet ween purchaser and provider might be helpful. However, there are hints B, from experiences in the UK and The Netherlands that making contracts detailed tn enough to allow for effective quality control, e.g. by a renewed inspectorate ap- 0j proach, will lead to a bureaucratic impasse which destroys the flexibility achieved CE by the introduction of the systems themselves. A Dutch study (van der Pennen s: re al., 1995) about the effects of introducing new steering systems in local PSS, draw? J 311 interesting conclusion: enumerating quality benchmarks in a contract will neither p£ give a coherent mission to the organization to be contracted in, nor will it work as the only point of departure for quality control. In order to safeguard that pro-4 viden act according to the wishes of a public body, it needs a more basic presup- £ position which helps to safeguard a kind of general mutual understanding and some basic trust - something the authors of the Netherlands study have called a sharec D "policy vision". Here, a problem already raised before concerning the "corporate spirit of community" comes back to us on the level of a whole policy sector: the H significance of a usually very limited pool of goods, values and tasks to be shared. £ To wllat degree can it be recompensated on the system level by contract and control p approaches? Perhaps this problem is less pressing in the business sector and for [J the QA concepts developed there: they have only one dominating link, the pro- ducer-consumer relationship, in contrast to the more complicated network within the mixed economy of PSS where state institutions, the municipality and a diversity of other organizations related to the field - as well as the customers themselves - can together be "clients" of a service-providing unit. The second illustrative example is about the fact that, in many countries, PSS units or parts of them are intertwined with local communities, subcultures anc networks; they are finely tuned with demands arising from there, as well as b\ their respective values and aspirations. It is not by accident that at least in m\ v. is Adalbert Evers 19 country care services are usually recommended and chosen by word of mouth; the issues of trust and reliability ever come back which are so important for services which invade the private sphere. Furthermore, it should be noted that many small-scale service providers are not led by managers, but rather by professionals; their style of working can be compared with craftsmanship, or with the special commitment of local shop owners. In the French debate, one has called these services "les services a proximite". The hints just given should remind us of the fact that there is a considerable difference between a global and a local economy (OECD, 1996). Preserving a dimension of localism in PSS can be a very controversial issue. Taking a position which does not want to abolish it but prefers to develop it further as part of a rich and diversified landscape of care and PSS providers, will have consequences when assessing QA concepts. Because for this specific local and moral economy, the takeover of models of standard-setting and control coming from the big hierarchical systems - be it something like the public school system or something like big business - will be problematic. The challenge would be to develop methods for quality improvement which respect the peculiarities of this local economy. An interesting example has been presented in a study about reforms in local PSS systems (Evers/ Leichsenring, 1996). The municipality of the city of Delft, for example, runs its own consultancy and developers' unit. Since it is linked to the local field of services for the elderly, it can do consultancy for quality improvement in a different style than external consultancy firms. The third and last example given here refers to the presence of the moral economy recreated in the most important institution when it comes to personal help and care - the family. A lot of research has been produced about what is called in the German discourse the "specific female working attitude and sensibility" - part of the gender difference (Ostner/Beck-Gernsheim, 1978), It is well known that PSS very much depend on one of its aspects - the readiness to work beyond what is formally agreed in the working contract, due to one's commitment to the people for whom one is caring. Many services are based on this readiness and often even exploit it as a hidden resource used in practice while denied on conceptual grounds. Therefore, trade unionism and many concepts of professionalism have for decades tried to block this potential source of what they see as "self-exploitation". However, this specific female working and caring attitude is basic for a special type of intrinsic motivation; and if one adds other types of cooperation, such as volunteering, one is faced with kinds of employees who are very different from the employees in ordinary enterprises. Here, once again, much depends from the attitude one takes vis-a-vis this fact of female predispositions and voluntary commitment. One should examine not only the concepts of structural and outcome criteria but also the ways of proceeding in QA and the modernization of services: whether they are prepared to deal in ~ 20 Quality Development - Part of a Changing Culture of Care constructive ways with such types of care work and the working attitudes related 91 to it, interwoven with special ideas about the quality of a caring relationship. The contributions of Naess/Wasrness and Christensen in this book both illustrate cases of modernization processes implemented in the name of quality not aware of the enormous impact of the "rationality of caring" (Wserness) and its roots in community and household settings for quality defined from the users' perspective. G es 6 Care and Social Services as Public Goods P* P1 The last point of concern to be debated here refers to the fact that the majority of PSS have traditionally been created as "public goods". This can mean that basi-H cally every citizen has a right to the service; and in order to safeguard this, one needs specification procedures and legal norms which concretize, on the one hand, such social-policy related criteria as equality and, on the other, which authorize F- some professional criteria. For the inspectorate approach, both items can play an important role; control is oriented towards norms which define quality not only in terms of professional standards, but also by the degree of successful implementation of legal rights concerning procedures for entitlement and access. In most European countries, the domain where PSS enjoy the clear-cut status of a public good is shrinking. Nevertheless, there are still many PSS within the public responsibility. This, then, has a number of consequences for the meaning of quality and the ways to define it (see as well Stewart/Clarke, 1987): tr o: c; n b r A E :: I ii = (a) Providers have to design their services according to specific social-policy criteria of distributional justice, which are non-existent or far less relevant than in private business. (b) The public addressed cannot be defined only in terms of consumers and customers but has also to be understood as a public of citizens with specified social rights. (c) Public services involve a kind of professionalism which has usually to be in line with standards not only agreed with direct recipients of the service, but with a broader public as represented by administrators and legislators. (d) Public institutions steered by political proceedings can easily become the object of claims for participation and collective forms of user involvement usually unknown in private companies. Once again, the attitude towards these dimensions is important. One extreme position might be a purely consumerist perspective, wherein - e.g. by offering cash instead of services - any responsibility beyond setting criteria for entitlement is removed both from the state and from the citizens. The items on which the money is spent, the quality of the services chosen, etc., become a private affair. Whatever Adalbert Evers 21 the position might be towards such trends, there are areas like, e.g. social work where, due to the high level of legal decisions about freedom and resources, public status and the four dimensions of quality noted above will remain important. Let us see, what that means for quality assurance. (ad a) Public institutions, when designing their "products" - as managerial jargon phrases it - are confronted with social-policy-related questions like fairness and justice which generally do not exist in the private sector, such as whether a local care centre should distribute its limited help resources to many people or give more intense help to a limited number of very frail clients. The problem of defining what is the best quality for a specific group is inextricably linked with the wider challenge of coming to a fair arrangement wherein both the type of service and the size and character of the group are variables. While this example is concerned with providing more space for decisions and evaluating the impact of such additional criteria as social justice when defining a "good product" in PSS, another example is about restrictions. In business, the diversification of a product - e.g. an offer ranging from simple to professional PC equipment - is part of a strategy of constructing a range of "good products" in terms of quality-price relationships. In contrast to that, public services can usually not do this; they have to promise the same rights for different patients even while it takes very different costs and measures to make them effective. To sum up, the narrow question of the quality of what is given when somebody receives something, may marginalize a more important question; how to safeguard that, within the legal framework, there be a democratic process which guarantees a fair decision about who and how many get how much. (ad b) Correlated with social-policy concerns is the dimension of citizen concerns and rights. This brings in criteria of quality and rationales usually not present in an individual consumer perspective. This is important because the goods brought about by many PSS can be as manifold as the potential negative side-effects: e.g. building a school in a deprived area means not only offering some education to a number of single pupils as direct consumers but can also mean bringing about better conditions for the parents concerned or for local associations that can use the rooms, etc. The full potential quality preserved by the school as a product will not become visible when only taking the perspective of the customers but it will if one also considers that of the other local citizens involved. And therefore, besides the school board, a city district meeting may be welcomed as an additional tool. There, quality-related aspects may be raised which would otherwise be missing. So, instead of playing off public and private solutions against each other, one might conceive mixed "round-table" systems which make it possible to articulate different angles and dimensions of service quality and to come to an agreement about Uuatity Development - Part ofaCha^ing Culture of Care a concept entailing priorities and compromises. Switching simply from state-nnposed systems of PSS towards a likewise umdimensional concept of consumer orientation based on marketing studies or individual preferences, I the ut" a democracy without policy" (Montin/Elander, 1995). Why not conceive "exit" and voice principles as complementary and overlapping, instead of fixing them ferent sides involved -producers, public authorities and thepeople to be addressed - as citizens, members of a community, users and consumers? (ad c) The way that issues of equality and citizenship rights have been just dis- n normal business when compared to public PSS, Obviously, concepts of quality improvement which are "customer-led" represent, on the one hand, clear advan S ; of! y IT 3 ttadlti0n °f d£dared PUMC ™ accompanied a reality of poor and meffic.ent services. On the other hand, it is the task of a professional and part of one's professional ethos as a member of public service to make clear why the needs which have been stated by professionals are possibly Afferent rom the mural wishes and preferences of the users. It depends on the le ve and legitimacy of broader agreements between politics and the public on he practices ir.the respective service sector to what degree service workerscan manage to intermediate mdmdual wishes with their professional offers and suggeS £ D1on1ekwhW°rd ^ f b£ neg°tiation-** this d=^ts «e emphasis towards solved In th T m k but wh° ** 3111,6 same time ^ ZnlL T S"baS6d C°nCeptS f°rQA' h0WeV6r'the con™ dimen- sion ,s the only one taken up with all kinds of market research, etc., to be imple- P~ a, roff8 to gard th;user perspec,ive on ^ potential role of forms of d.rect and indirect participation, such as with representatives of user groups on the board of service organizations or special possibilities fortekmgpartinanegotiation process about desi^ganindivMnala^gemen fare* home care. Furthermore, it should be taken into account that thefpecial ™n;fTSr r,°°ted m the local and neighbourhood context (services ties for people at the community level to be involved, 7 Summary and Conclusions Reflecting on possibilities for QA, especially business-based concepts, three points have been h.ghhghted which are critical for the special nature of care and PSS -theinteractive nature of services, the mixed economy in the PSS sector, and their status as public goods. Depending on how these peculiarities are conceptually taken 23 Adalbert Evers____._.__ into regard, the judgement of concepts for quality control and quality development will vary accordingly. • The first critical point identified was the degree to which one can find the presence of strong and explicit shared values and commitments in service interactions which are important for preserving and bettering the personal, caring character of service relationships. Elaborate business concepts like the TQM approach might help in cases where all parties concerned are really willing to engage in a difficult process - defining strong and explicit values as a basis for organizing care in ways that give institutional support to personal commitment. • The second critical point identified was the presence of a local and moral economy including non-professional contributions in care and PSS, usually balanced in a mix with state-public and ordinary market elements. This special dimension of the mixed economy of PSS calls for ways to define and assure quality beyond the logic of big business and bureaucracies, encouraging diversity and its contributions to it, where a "rationality of caring" can counterbalance the rationality of managerialism and consumerism. • The third critical point which has been identified was the impact of questions like social justice, social rights and the professional ethos linked with them, counterbalancing the dimension of individual preferences and consumer satisfaction as the central or even sole criterion of business-based approaches. With respect to the kinds of concepts of QA to be used, or the policy mix to be implemented, it will be important whether these points are taken seriously or are marginalized. Unfortunately, they are seen by many today as impediments and only by a few as points of departure for quality and its improvement. 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