IS IT FEASIBLE TO HAVE A GOOD AND EFFECTIVE REGULATION OF STANDARDS FOR QUALITY OF COMMUNITY-BASED SOCIAL SERVICES? (2008)

In the conditions of the strongly centralized state of the last sixty years have been created attitudes which are difficult to influence and transform in the short run. Despite the current legal provisions for putting into effect the two basic principles of social reform – decentralization and deinstitutionalization – we still cannot speak of real delivery of quality social services in Bulgaria. 

Decentralization (including the financial one) is advancing with difficulties and problems arise not so much because of the legal framework (in that sphere it is adequate), as because of the so called “attitude problem”. Social contracting is still sporadically used by some municipalities (in less than 20% of all municipalities in the country), despite the efforts and the responsibilities taken under different donor programmes. 

The second main priority of the reform – the deinstitutionalization – hasn’t got much further either. Many of the social institutions that do not comply with modern professional social care requirements continue to function in the manner, or almost so, of the last twenty or thirty years. At some places where the reform has started and people have been removed from social institutions their integration was not successful.

Ultimately the main problem arising as a result of the partial reform is the quality of the social services – their assortment is INedequate, they are NOT user oriented, Not easily accessible, INeffective, and are NOT mobile in the sense that if given social care activity proves to be ineffective it cannot be substituted with a new one.

The present paper claims to go into the key principles whose proper and adequate regulation would serve as a precondition to the delivery of quality social services in Bulgaria. The list of key principles is by no means comprehensive but includes, in the authors’ view, the  most important ones which are also assessed in regard to the current legislation and the effect of the its application. In the second part of the paper are proposed specific measures for making amendments to current regulation and its application in order to ensure a better environment for delivery of quality social services in Bulgaria.

Minimal preconditions for delivery of quality social services

1. Resourceful social services able to satisfy various and changing needs
Pursuant to the amendments of social legislation (The Social Assistance Act and Regulations for its application   social services should be delivered according to the personal choice of the user, and to satisfaction of their needs. This is to say they have to be flexible and diverse so as to be able to comply with the widest range of requirements. Legislation has made provisions to allow the use of the so called alternative services (coming beyond the menu of “traditional” services listed in the RFASAA) in case a new service has to be offered to answer a specific need.

In reality alternative services are almost never offered, or if that happens they receive fu nding by independent donors which is at the expense of their long-term sustainability. (The actual reason to disregard the opportunity for offering new services (despite the explicit provision in art. 35, par. 5 of the RFASAA), is the fact that there is no financial standard set up for delivery of these services, or at least a mechanism for its establishment.) Current practice strikes also with the fact that community-based social services which are delivered as an alternative care to social institutions do not actually serve the target groups who need them most; because they are not based on a real needs assessment. Municipalities work out their strategies most often for the sake of appearance, and with no concern for the real needs. Paradoxically this does not bring to reform or termination of existing but ineffective social services while new ones which do not have any users are introduced. This trend is valid for the institutionalized services as well.

2. User oriented social services – social services have to be provided with respect to the desire and personal choice of the user; if users need assistance to identify the service that would most fully satisfy their needs they should receive it; social services should support the user to live an independent and self-sustained life. 

Unfortunately, in the regulation of social services, despite the general emphasis on the interests of the user, the principle of active involvement of the user in service delivery and assessment of their real needs is not fully developed.  Bulgarian social legislation makes provisions for the preparation of individual plans for delivery of social services by social institutions, and for long-term delivery of community-based social services, but this regulation does not stimulate the active participation of users. In reality the provider takes the active role in the preparation of the individual plan and the control of its implementation. Art. 40g, par. 5 of the RFASAA sets a potential conflict of interests by stipulating that social service providers make self-assessment of the implementation of the individual plan every six months and update it if necessary. The role of the user as a recipient of the service is neglected once again.

Users, as well as service providers express the understanding that the essence of social services, including community-based ones, is precisely the care for users which actually does not need their participation. Treating the users as recipients of services instead of active participants makes their integration in the community after removing them from the social institution difficult.  

3. Giving community-based services a priority – meaning a marked accessibility of services – they are delivered at home, or where the users live, close to their family and friends; establishment of a national system for delivery of community-based services as an alternative to the institutionalized social care.
The amendments of social legislations made in 2003 set the principle that social services will be provided by social institutions as a final possibility, and only after all available community-based social services have been ensured. In the process of active decentralization (supported also by many donor programmes) municipal administrations demonstrate their preference all new community-based social services to be provided as “a state delegated activity” because of the secured state funding going with them. It is not realistic to expect that all community-based services will be funded by the state budget. This type of funding is contrary to the principle of decentralization of funding and management of social services.

A serious obstacle to the creation of a good social service system is the separation of stakeholders – providers, contractors and funding bodies. In reality NPOs (which are providers of social services) offer and suspend social services within various projects but their local partners (municipal administrations), and the ASA do not have a realistic picture of these services and respectively have no idea whether they could be used more purposefully and to a better effect (including the possibility to receive a long-term support), creating in this way local social service networks. Thus the erratic and at some places chaotic offering of community-based social services impairs the success of the deinstitutionalization.

Along with this comes up a new tendency which is common to all types of social services – more emphasis is given to the role of social services for protection of their users rather than to development of models for avoiding the institutionalization of social services. 

Also local authorities prefer to offer community-based social services mostly to users in a comparatively good health condition. This leads to opening in large numbers of Day care centres and Centres for social rehabilitation and integration while Protected housing for people with intellectual disabilities, Crisis centres for children who are victims to trafficking or abuse, and other alternative services are not enough.

4. Adequate and strict regulation of quality standards – meaning to have clearly defined and detailed standards for quality of various social services, including community-based services, and those provided by specialized institutions, as well as established measurable quality indicators (criteria).

The analysis of current regulation draws to the conclusion that in Bulgaria, like in other countries from Central and Eastern Europe, standardized indicators for quality assurance have been defined primarily for social services to children. In current legislation for social service provided to children is made a distinction between a quality standard and indicator for measuring the quality. Criteria and standards for social care for elderly people are defined generally for services provided by social institutions and community-based social services. They are defined by different aspects: requirements for localization and necessary equipment, for providing food, health care, educational and information services, for management of the free time of users and ensuring that they keep their personal contacts, and requirements for the assisting personnel. The RFASAA does not make any distinction between standards and criteria for quality assurance of social services. Measurable and identifiable criteria for quality assurance of social services for elderly people have not been established. Indicators, if any, are related mainly to measuring material needs (equipment, food, guiding facilities, etc.) The abovementioned standards do not consider by any means the need of active psychological and social work.  Besides, the regulation of standards for social services, including those for children, does not envisage an assessment of the resources spent to gain certain quality of the service. Here resources include not only financial means but also the qualification of personnel and the cost of their employment. Control of the quality of social services is based primarily on formal criteria for material needs, defined in the RFASAA, and is focused on the accounting aspects of the spending, and the compliance with the rules for budget spending. Current Bulgarian legislation does not make provision that the control of the quality of social services should use the following indicators: efficiency of the invested resources (i.e., do the financial spending, material and human resources, and equipment invested in the service delivery ensure an adequate amount and quality of service; and respectively how can you get better quality services for the same amount of invested resources); the impact of social service delivery on the quality of life of the user. Thus, when the bodies controlling service quality found out (as a result of an inspection) a low quality service, (even when standards for equipment are met), it becomes impossible for them to give prescripts, or to impose sanction, i.e. the control is inefficient.

Following the current regulations, and in addition to the RFASAA and the Ordinance on criteria and standards, the Agency for Social Assistance (ASA) has developed specific methodologies for the provision of several social services. Despite the relatively well defined and detailed regulation we have to note that methodologies do not have a normative effect; in current legislation they are not in a legal relation, and respectively are not binding in effect, especially for providers which do not belong to the ASA. In this context exercising control over the providers and imposing sanctions for an established breach of rules, is not possible. Also, almost all methodologies are developed in the context of the state delegated activities, and there are no elaborated methodologies for even a single local activity – home social patronage, clubs for handicapped persons, etc. This means that the eventual criteria for realization of these activities are supposed to be set up on a local level.

5. Effective, persistent and comprehensive control mechanisms
The ASA is the main authority exercising control over the observance of the established criteria and standards for delivery of social services, and with which social service providers are registered. The ASA prepares general annual reports and analyses of social assistance activities in the country, which are submitted to the Minister for Labour and Social policy. The Inspectorate is responsible for the specialized control over the observance of criteria and standards for social service delivery. 

In reality most of the controlling activities are previously planned and private providers are not subject of substantial control – in most cases they are inspected because inspectors have been alerted to, or because providers work on projects funded under the Social Assistance Fund. The compulsory prescripts are the measures that are taken most often, and much rarely are imposed sanctions for administrative violations.

The Inspectorate to the ASA and the staff of the SACP are the two bodies controlling the quality of social services for children. The rights and responsibilities of these controlling bodies have a relatively clear regulation except for the mechanism of their interaction and the instances when it is demanded. Therefore the control could be uncoordinated, ambiguous and inconsistent.

It can be concluded that both controlling bodies – ASA and SACP are obligated with serious and even too ambitious controlling powers. Pursuant to the law they are expected to exercise control of the quality of social care provided by all types of providers. This is not ensured with either serious human resources (indeed the ASA has an Inspectorate, but the number of its personnel in inadequate to the potential objects of control) or an appropriate financial resources.

6. Equal access of providers to public funding and in regards to the control exercised over their activities

Pursuant to the current legislation in Bulgaria providers of social services in the country are: the state; municipalities; and the so called private providers. Social legislation makes provisions for registration and licensing which apply only to the group of private social service providers. State and municipal structures are not obligated to register or get license in order to deliver social services. In this way no public information is given about the quality of social services delivered directly by the municipalities, and in reality double standards are being applied in the process of control. Compulsory administrative measures that can be imposed by inspectors in cases of established breach of social legislation are defined in art. 34 of the SAA. Withdrawal of registration can be imposed as measure only to private providers of social services and is a measure with serious legal implications which in reality deprives the provider of the possibility to continue lawfully to offer services before eliminating the irregularities and registering again in due form. While in cases when municipalities and state structures provide services as local activity (funded under the municipal budget) the only other two compulsory measures can be applied: 1) giving compulsory prescripts for elimination of established irregularities, and 2) suspending the implementation of unauthorized decisions. But basically these measures do not bring to suspension of direct delivery of social services, even when they do not conform to the standardized quality. Current legislation presupposes another inequality in regards to foreign providers. In practice, according to the current law, only those foreign providers that are registered as traders are allowed to deliver social services in Bulgaria. Under this ordinance (OSPCPP) non-profit organizations, registered abroad are completely excluded of this market (unless they register a Bulgarian non-profit legal entity), which is contrary to the European practice (in all European countries the predominant number of providers are non-profit organizations).

The a priori inequality among providers with respect to their legal status and authority means also that municipalities have privileged access to public funding. Municipalities can be provider and contractor at the same time. This leads to mixing of roles and presupposes inequality of providers. Local authorities desire to achieve decentralization of rights and responsibilities from central authorities, but once they are empowered to take decisions for further decentralization they are prone to keep the financial and human resource management within their responsibilities, as well as to keep the status quo of the existing social services. The mayor has no incentive (and is not obligated) to strive for a better and more efficient management of services and to contract private providers, who in a competitive conditions could offer better performance.

Local authorities are a privileged provider of social services and as such they have an a priory access to financial resources (under state budget or local budgets), they enjoy exceptional powers, and are not obligated to register or apply for licensing along with the other providers.

7. Public information about the existing social service 

Quite often potential users of social services do not have at their disposal accurate information about the existing social services and about which of the menu of available social services would be the most appropriate for them. The present system of social services in Bulgaria actually relies on the “self-assessment” of the user, who in accordance with the current legislation initiates the procedure of provision of social services by filing a petition with the respective authority or provider without having an independent consultation or support of any kind. Social services are delivered according the desires and personal choice of the user which is actually a big step forward compared to the compulsory-administrative approach to social service delivery characteristic for the totalitarian state, but the users are very much left by their selves when choosing a specific social service.

In practice the usual passive approach of users leads to an effective restriction of the access of disadvantaged people to social services because often it is exactly the people with particularly grave problems and serious needs who do not have capacity and information to decide whether they need social services and to choose the most appropriate one, and respectively to file a petition for requesting it. 

8. Public control
Legislation makes provisions for various national and local bodies which consult the respective state agencies on the implementation of their social policy, and also exercise public control of its realization.
All consultative bodies (the Social assistance council, the National Child protection council, Public councils, Users’ councils, Child protection committees) are open to admit to membership representatives of civic organizations active in the social sphere. 

The regulation of national consultative bodies is too general and in reality their activity is not well developed and relatively ineffective. They often include organizations which are not acknowledged by the “third sector” as representing its interests. Consultative bodies acting locally have stricter and more detailed regulation but in reality their activity is very rarely effective (supporting local authorities with their knowledge and capacity, or serving as independent public regulator of local social services). Often they do not represent fully the civic society in the given municipality (usually these consultative bodies include formally organizations that are not recognized by the local NGO environment and providers as representatives of the local community)

Based on the above made analysis of the existing legislation and its application, the present paper proposes the main measures which have to be taken in the sphere of the social service regulation, (concerning providers, funding and controlling mechanisms), in order  to be ensured the necessary preconditions for a quality social service delivery in Bulgaria.

PROPOSED MEASURES

Social services delivery to be based on a realistic needs assessment

The consistent needs assessment is a process with several aspects:
• Needs assessment made on a national level, and identification of target groups. This aspect of the assessment is extremely important as it allows identification of the main target groups, and development of a national social service system, both of which aim to provide the necessary social services as early as possible and with the least intervention which will prevent delivery of further more intensive care. This approach and the assessment allow the provision of preventive services to target groups who do not need an intensive social care at the moment but the lack of preventive service would possibly aggravate their needs in the future.   
• Local needs assessment. Local authorities take the leading role in the process of needs assessment. They should make regular assessment of the needs for social services on the territory of the municipality, and to measure the existing social services against the identified needs. Local needs assessment will enjoy better accuracy if based on sociological examinations of target groups. This applies in particular for big cities. The assessment would benefit if is made also on a regional level which will allow the use of human resources, infrastructures and supporting network of healthcare, educational and other services in small municipalities – all of which are important factors for securing quality services.
• Another very important aspect of the process of needs assessment is the involvement of users and the personnel engaged in the service delivery. In order to make possible an individual needs assessment is necessary the active participation of users in identification of their needs and choosing the right service. Also, the planning of social services delivery should underline that they are user-oriented, and should not be regarded primarily as providing a support in general.

The results of the needs assessment should be made known to the public so that social service providers would be able to plan their activities and invest the appropriate resources. Also, all public funding of social services has to be made depending on needs that have been accurately assessed. In this way will be avoided the funding of social services for which there is no demand whatsoever.
• It is important to regulate the process of needs assessment on a national level. The regulation on a local level is not appropriate because it will bring to considerable differences among municipalities and will give raise to various practices.

European experience and that from the United Kingdom shows that the preventive role of social services has to be stressed upon. Delivery of social services should aim to satisfy not only the needs of people who already have become socially disadvantaged but also of those who have lesser needs and at the moment of delivery are not in the group of people “in grave need”; that will prevent them getting into that group in the future.”

Establishment of an advisory service system to help users choose the right service

The creation of an advisory service system to assist users in making their choice of social service is closely connected to the process of needs assessment.
• It is essential to create a system that will inform about the available social services and providers on the territory of a given municipality. Local authorities or Regional Social Assistance directorates could take care of its maintenance and updating. Users will benefit if they can have an independent expert to work closely with them and make sure they choose the right service.
• In order social service users to be active participant in the process of planning, delivery and evaluation of the quality of services, is necessary the RFASAA to make explicit provisions for the creation of mechanism which will allow that participation.

Case study from the United Kingdom
Devon County Council, UK has the duty to assess the needs of social service users. The process of individual needs assessment (Individual Assessment Plan) is regulated and includes persons from various target groups. It is done under the National service framework for older people, which is an initiative of the Department of Health. 

The process of individual assessment of the needs of users includes getting information about those needs and how they change the quality of life. The assessment looks closely not only into the needs of the person but also at their personality traits. The assessment is made by health care practitioners, social workers and organizations. They make sure that the user will receive the right service in the right time. On the web page of Devon County can be find information about the process of assessment, the people who participate in it and expected results.

The experience in the UK shows that feedback received from users is an essential part of the quality assessment of services. Providers of services to people with intellectual disabilities in the UK have suggested (and introduced into practice) that the effect of the service upon the quality of life of the user can be assessed by using the so called „experts by expertise“. The experts are people who receive social services. Persons who receive services (and especially those with intellectual disabilities) feel embarrassed to speak up their views about the quality of services before controlling bodies. To ease the process and collect information from users in a more roundabout way is requested the presence of an „expert by expertise“, who together with controlling staff help the user to express their opinion in the best way.

Adequate and flexible regulation of the standards for quality of community-based social services
In order to assure a good standard for quality of services is necessary to be defined satisfactory and adaptable standards for the specific services, and indicators that can measure the impact of services upon the quality of life of users.  

To achieve standardization of social services in Bulgaria is necessary to make distinction between a standard for quality and criteria for quality. It is advisable also to define indicators which can very clearly measure the impact of various social services on the quality of life of users; whether users can effectively exercise their rights while they receive a given service; and to what extent the service helps the people receiving it to manage their lives alone and to remain part of the community.
• The Social Assistance Act should explicitly provide that the standardization of various types of social services for adults will be regulated in one or several ordinances for the different types of social services. Additionally could be developed methodologies, which will rather make the indicators more specific. These methodologies have to be elaborated for each service irrespective of the source of funding – state budget or municipal budget.
• It is important when these measurable indicators are being defined to assess the exact amount of resources invested in the service (both financial and human), and the quality received for this investment, which is measured as the effect of the service on the quality of life of the user and their ability to manage alone. To implement this measure are necessary to be made amendments to the existing social legislation.

Case study from the United Kingdom
All social services in the UK comply with the National minimum standards for quality which are specific for all social services. They are defined by the Department of Health. The Commission for Social Care inspection checks how well the services are meeting the national minimum standards. The standards for quality are obligatory for all providers – counties and private providers which have to be registered with the Commission. The minimum standards for quality allow the inspecting body to judge on the following:
• Whether the service satisfies the previously determined needs of the user and achieves its aims;
• To what extent the service helps the user manage their life alone and remain part of the community despite their physical or mental deficiencies;
• To what extent the provider strives to improve the quality of care thus raising the quality of life of the user;
• Whether the social care personnel has the necessary skills and qualification, and if they follow the rules based on good practices;

To include in regulation efficient mechanisms for the quality of social services, and to ensure the effectiveness of the controlling body
Binding public funding of social services to the quality of received care
It is necessary to make provisions in the existing legislation that allow the imposing of effective sanctions when services fail to meet standards for quality. They should apply to all types of social services, and all providers – municipalities, non-profit organizations and business representatives.
• In this sense it would be appropriate municipalities (when they act as providers of services) to be obligated to register (with the ASA, or to apply for license with the SACP, for children’s services). This will guarantee wider public information about their activities and will allow effective sanctions, when necessary. If social services provided as local activity do not meet standards for quality, explicit provisions should be made to allow their suspension;
• It is advisable the allocation of a given amount of public funding to be tied down to a certain quality of social care, that can be measured with indicators;
• Controlling bodies should have a sufficient number and well qualified inspectors who prepare detailed reports after their inspection visits;
• It is obligatory to be allocated financial resources to guarantee a comprehensive and sustained control well provided with qualified and committed staff;
• The regulation of controlling bodies should extend their authority to allow them to impose more effective sanctions (including the termination of social services which are local activity, or to ask about their termination if the service is donor-funded);
• To determine clearly the spheres of action in the control of services of the ASA and the SACP and their structures;
• It is advisable to improve the legislation regulating the system of public control. Criteria for appointment of local community representatives on the Social assistance councils should be changed. This will transform them from formally existing bodies into active ones;
• To include in regulation flexible mechanisms that would allow users to take part in the inspection and control of services;
• If a municipality acts as a direct provider of services and those fail to meet criteria and standards, it is appropriate the imposed administrative sanction to apply not only to the actual provider but to the mayor of the municipality, who runs those services.

Delegating of activities and involvement of partners
Local authorities have a vital strategic and leading role in the planning of social services and the assessment of needs. They have to know well the various target groups among local population and bear the responsibility to ensure that these target groups receive the right services. Local authorities can’t achieve this without delegating activities and drawing partners in them. The involvement in this process of all stakeholders (state administration, non-profit organizations, providers of social services, business, as well as non-profit organizations of social service users and citizens) helps to keep the balance among various types of social care – preventive services, less invasive community-based social services, and substantial social care for people with critical and complex needs.
In this context the mechanisms for encouraging partnership and cooperation among various stakeholders are crucial for the smooth running of the system of quality social services.
• Local authorities in Bulgaria need incentives (including those provided by different funding programmes) to start working in partnership with the non-profit sector and the other actors in the social sphere;
• It would be beneficial to include in legal regulation the possibility for forming public-private partnership in the process of planning, establishment and management of social services;
• For the effective spending of state funding are recommended to be made amendments to the Subsidiary regulations to the State budget Act to regulate the possibility a roll-over of service funding in the next year to be used only for social care purposes. Currently municipalities are allowed to spend this roll-over for other activities, such as improving infrastructure, etc.

IN CONCLUSION
The proposed in this paper measures are aiming to achieve desirable changes in the legal framework of social service delivery in Bulgaria, but also to bring for sustained change of attitudes of users, providers, contractors and controlling bodies. They do not constitute a detailed regulation of standards for quality of services but they certainly present “pre” conditions for the introduction of a feasible and effective regulation of the quality of social services and the control over them.