In the UK access to continuing care services is often a gamble and, as consumers of health care, older people have had little choice in where and how these services are provided as the continuing care of many older persons has shifted from the health service to the independent sector. This shift has raised concerns about the quality of care in private nursing homes and has placed the need to determine such quality high on the government's policy agenda. The traditional quality assurance mechanism has relied on a registration and inspection system whereby local government authorities monitor and review service delivery. However, the processes are often bureaucratic and ineffective. More recently, the Care Standards Act (2000) and the Regulation of Care (Scotland) Act 2001 have set out the new regulatory framework for all care homes in the UK. This will provide national standards of registration and inspection, with increased authority for health and social care agencies to take action when poor quality is suspected or detected.

A registration and inspection system can only ever provide one component of a quality system for the continuing care of older people. Research by Wagner et al¹ reported in this issue of Quality in Health Care highlights the difficulties in determining the most appropriate mechanism for monitoring quality in care homes, particularly when the emphasis is on “care outcomes”. The authors point out that it is difficult to determine the impact of quality systems on the quality of care of residents and conclude that there needs to be a greater emphasis on the qualitative aspects of care and, in particular, improvement in the measurement of quality of life.

Outcome can be defined as the end result of care, but outcomes do not directly assess quality of performance; they only permit inferences to be made about the quality of the processes of care. The focus on outcomes is not always appropriate in the context of continuing care. In much of healthcare provision a focus on “health gain”—that is, that the intervention results in a gain in health status for the patient—is seen as the most important outcome measure. In this issue of Quality in Health Care Meiland et al² discuss the complexity of measuring outcome in residents of care homes. By assessing the burden on caregivers, the problems of delayed admission to care homes were identified as well as the continuing effect of these problems on the caregiver following admission of the patient. This suggests that measuring outcome with the patient alone only provides one part of the total picture. Outcomes in continuing care for older people should focus on increasing quality of life rather than longevity. Because quality of life is difficult to define and even more difficult to measure, particularly with physically and mentally frail people, outcomes from care inputs cannot always be clearly articulated as highlighted by Meiland et al. Furthermore, the care of older people in continuing care settings is predominantly based on the maintenance of a normal pattern of lifestyle. However, as pointed out by Wagner et al, such individualised patterns of lifestyle are difficult to measure using standardised instruments. This is not to argue that quality measurement in care homes should not focus on hard outcome data, but that it also needs to include subjective interpretation of quality of life and individual desire and ability. The emphasis should be on the individual's potential to achieve his or her desired realistic health choices.

However, the most interesting finding of the research by Wagner et al is that, despite the dominant rhetoric of user involvement, “the opinion of residents was seldom used to evaluate the effectiveness of quality systems”. Who better to decide on the effectiveness of the end result of care inputs than the patients and others significant to them? In an era where individuals are encouraged to be experts in their own health and care needs, surely we should focus our energies on finding ways to enable older people and their supporters to identify changes in their health status and to establish self-report mechanisms for them to report satisfaction with the care and its outcomes. Reed et al³ reported on one such system (“Qual A Sess”) whereby care homes engaged in a self-assessment of quality and included care home residents as self-assessors. If approaches such as this are to become the norm, then substantial investment is needed to enable older people to have such a voice. If we are going to be committed to enabling older people to plan their own destiny, we need to see investment in local models of peer review and quality improvement in addition to central government models of quality control.

However, there remains a paucity of high quality research with older people in care homes⁴ and, as such, there is little understanding of the most effective ways to deliver such services and measure their impact. If the new national framework of regulation is to be effective, a concerted effort must be made to understand the dynamics of care homes and the desired care outcomes of residents, as well as high levels of investment in staff development and continuing professional development. National standards can only ever be a blunt instrument to measure quality and, if the services for older people in care homes are to be consistently of a high standard, then the empowerment of care home staff and residents to determine their own quality destiny has to be part of the process.