"If you people can't be clear about what it
is you do that is special, I suspect there isn't anything!"
This challenge was issued by Derek Thomas, the Director of the
National Development Team for people with learning disabilities,
at the end of the first workshop of UK autism service providers
in the process established to define and develop a system of accreditation
for specialised services for adults with Autism.
The need for such a process had been identified by
the NAS who were concerned to both promote quality, demonstrate
specialised expertise and ensure viability and durability of provision.
As local autism societies are in the main affiliated to the NAS
as the national body it was also important to monitor the quality
of services delivered in the name of the NAS and, in an increasingly
demanding purchasing climate, provide tangible evidence of value
for money to purchasing agencies. With a substantial grant from
the Government Department of Health, the NAS set out to develop
such a system which would have wider application than autism services
and promote quality specialised provision. This was against the
general trend of the time as very few UK organisations had any
form of effective accreditation (Scrivens, 1995) but in keeping
with a more general ethos of partnership and the driving up of
standards.
Staff within the various services were initially
concerned that an additional inspection would impose unwanted,
and unwarranted pressures and merely serve to duplicate the already
existing statutory inspection process. The initial workshop therefore
confronted these concerns with participants invited to identify
their fears. These largely focused on loss of control or autonomy
or an erosion of flexibility and innovation. Despite such fears,
a working party was established from the membership of the workshop
to explore further the criteria for identifying and developing
specialised services autism. This working party was also charged
with the development of a mechanism for providing independent
oversight and adjudication of the process. Other quality assurance
processes were considered, including ISO 2000 and BS5750 and while
acknowledging that these were helpful as internal instruments,
it was not felt they would achieve the broader dissemination of
professional expertise, good practice and ideas which would arise
from an accreditation system specifically geared to autism.
It was felt that the process should be participative
rather than inspectorial and was decided that a model of service
review undertaken by an experienced team of professionals and
others from the field of autism be developed and the adoption
of mechanical standards avoided. In this it was important to
develop a shared vision of what an effective service might look
like. Early discussions were enlightening in that, although there
were usually (but not always) clear and identifiable features
of services which were specialised, there were differences in
ethos and the way such delivery occurred.
There was broad agreement on the functional nature
of Autism based on the triad of impairments (Wing, 1992) and the
need to organise services so that help was targeted specifically
toward those needs but which were not merely deficit orientated.
Service and programme designs were considered along with other
fundamentally important aspects including financial viability
and plans for future development. The agreed emphasis of review
however, was to focus on outcomes for the service user.
Quality of Life measures identified by O'Brien and Blunden (1988),
viz:
were adopted with specialised approaches identified
which would assist the service user to achieve as full
a quality of life as possible by tackling the disabling effects
of autism.
It was agreed that a review approach involving professional
staff, parents, relatives, service users and other professionals
was the method most likely to succeed in achieving informed outcomes,
dissemination of good practice, ideas and the opportunity for
services to reflect and improve. 'Ownership' of this process
was crucial to its success.
Having agreed a framework for service review and
assembled a structure which was independent of the NAS and chaired
independently, the time came to pilot the process. A National
Autistic Society adult autism facility was randomly chosen to
serve as the pilot project. As the overall Manager of NAS services
I was acutely aware of the need for staff to view the process
positively and to be supported. Managers have a key responsibility
to encourage and stimulate new ideas even if uncomfortable to
facilitate 'learning organisations' (O'Brien, 1987). Inspection
by a statutory agency is one thing, a review involving one's peers
is quite another. The sensitivity which must be incorporated into
the selection of review teams and their briefing soon became obvious.
The appointment of a Manager for the process who would be 'arms
length' from the NAS was crucial. This individual, who had credibility
within the UK autism network, was tasked with the administration
of the process and with recruiting and selecting teams relevant
to each service.
The anxiety and energy which preceded the pilot was
predictable but initial concerns of staff were alleviated by the
quality of the team recruited. These were experienced professionals
with a background in autism, a service user and a parent of a
young man with autism.
As the process has developed there have been remarkably
few problems between team members and service professionals relating
either to the process or the potentially difficult area of interpersonal
relationships. There have however been difficulties in representation.
It had been hoped to include as a matter of routine,
service users as team members but despite some limited success,
it is a disappointment that this has not yet been achieved and
more work must be done to facilitate such participation.
There is a growing expertise on how to manage the
process more effectively including briefing and debriefing of
team, the co-ordination of reviews to avoid disruption, preparation
of service users, parents and staff and the modification and refinement
of standards.
The majority of the National Autistic Society schools
and units have now been reviewed. In addition to tangible improvements
in the service, the network of service providers has also been
strengthened with regular meetings to focus on issues of practice
and policy as it relates to autism. My own experience of chairing
a review of an independent service caused me to look hard at how
my own services compared and how good ideas could be shared and
I believe this is a common experience among team leaders. The
existence of the independent review committee has also had significant
impact on the way the process is perceived, comprising as it
does, representatives of services, parents, local authorities
and other professionals with an independent and impartial chair.
It is this Accreditation committee and not the NAS
who have the responsibility for ensuring that only those services
who demonstrate a body of knowledge which is specific to Autism
and which is applied in practice are awarded accredited status.
The committee is also concerned that once accreditation is achieved
it is maintained. They seek regular reports on the progress of
each service towards achieving specific recommendations. A further
Government grant from the Department of Health has been awarded
to underpin the accreditation process by ensuring that examples
of good-practice are disseminated throughout the network and beyond.
The committee does have the power to disaffiliate a service if
it shows unwillingness or inability to comply with the agreed
standards but the intention is to encourage and stimulate good
practice, thus strengthening the network of specialist providers,
not weaken it by, casting out those who at present do not comply
with the standards.
The effect overall has not been to introduce blandness,
as was feared, but rather to stimulate good practice by more effective
sharing of ideas, support and approaches among a growing network
of providers. The week long review visits are physically exhausting
but valued by the team and services as representing a range of
experiences. The process continues to be refined and improved,
particularly in feed back and dissemination. As a service provider
and 'paying customer', I would regard accreditation by review
as having already had significant impact on the quality and viability
of our services. It has assisted in the clarification of the
specialist nature of our work and has provided invaluable staff
training and development opportunities. It is further my view
that any organisation providing a network of services could benefit
from a similar process.
References
Blunden R, O'Brien J (1988) in Brown R I (De)
Quality of Life for handicapped people
Croom Helm - London
Wing L. (1992) Autistic Continuum Disorders: An Aid to Diagnosis
National Autistic Society - London
O'Brien J (1987)
Embracing Ignorance Fear and Fallibility (In Community Integration for People with Severe Disabilities)
Steven J Taylor (Ed), Teachers College Press
Scrivens E (1995)
Accreditation Protecting the Professional or the Consumer
Open University Press, Buckingham, Philadelphia