In pursuit of excellence

by Mitchel Fleming

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Pursuing excellence is like searching for the Holy Grail. People frequently hold different views as to what excellence is and, accordingly, they can find themselves searching in different directions. In my view the pursuit of excellence is best thought of as a road to be travelled rather than a final destination. Just when you think you are getting close to attaining excellence, new challenges arise and new roads open up ahead. Over the years I have come to recognise that there are three broad avenues along which services for people with disabilities, enduring mental health problems and older adults travel in the pursuit excellence. Firstly, there are those services that travel along the ‘resource-driven’ path. These service providers believe that excellence can only be achieved if they can obtain sufficient resources to meet the varied and multiple needs of people who use their services.

Often the focus is on creating a perfect haven by constructing a purpose built ‘centre of excellence’ that provides shelter from the hazards of life found on the outside. Emphasis is typically placed on special facilities and amenities, staffing levels and on physical appearance in the belief that service users will have little reason to look outside the centre where they live in order to have their needs and wants met. The management structure in resource-driven services tends to be hierarchical and those in charge often direct their energies outside their service to campaign for more finances and resources. In practice, the search for resources is never-ending as the construction of the ‘perfect world’ away from the community where most people live will require limitless recourses. Because of the tendency by senior management to concentrate on what is happening on the outside, service users, families and frontline staff can feel that they are less important than the acquisition of resources and, therefore, that their concerns are ignored or put on hold. The next route towards the pursuit of excellence is along the ‘treatment-driven’ road. Treatment-driven services have a long history going back over two centuries in the area of disability and mental health. From the 1960s onwards there has been a tendency to equate treatment-driven services with the medical model, though in fairness educationalists were among the strongest early advocates of this approach.

These services hold the belief that excellence can be attained only through quality therapeutic intervention. Typically, treatment-driven services tend to focus on achieving excellence in one area of service delivery, e.g., physical disability, learning disability, mental health, and very often focus on one treatment approach. Examples that come to mind are the PETO Institute for conductive education, psychopharmacology, intensive behavioural intervention and various types of psychotherapy. Emphasis in this model is usually placed on a careful assessment and diagnosis, followed by treatment, which aims to cure or ameliorate the deficits and enhance the service user’s coping capacity. In treatment-driven services there is typically a professional hierarchical structure where those with the greatest expertise are placed in the most influential positions. Emphasis is on ensuring treatment integrity. Services are usually located in a specialist facility, though sometimes attempts are made to provide the service in an inclusive setting. This model is beneficial for those who respond to the treatment, but offers little solace to those who don’t. Treatment-driven services are always keen to highlight and advertise their successes.

Service users who fail to respond to the treatment are usually encouraged to persist with the approach, but this is often in vain. With time, expectations for a cure or improvement diminish and the service users who don’t respond can get overlooked as more service users enter the service. The final category I have encountered is what can be termed ‘rights-driven’ services. Here the emphasis is on providing service users with the necessary supports and environmental adaptations to enable them to participate as citizens in their community. These services focus on ensuring that people’s rights are regarded as paramount. These rights include: freedom (which in practice is often referred to in its negative form, i.e., the right not to be detained against one’s wishes), the right to make choices, to be treated with respect, the right to protection, to be treated as an equal member of society, and the right to receive education and medical care. The vision of the service is to enhance people’s quality of life, citizenship, inclusion and self-determination.

The process focuses on meeting the rights and needs of service users, rather than diagnosis and treatment. The management structure aspires to be flat and decision-making powers are devolved down to the service user or those working closely with the person. The typical concerns expressed about this model are that a person’s deficits and limitations are ignored; that service users are denied access to expert help and specialist supports; and that vulnerable people are exposed to ridicule and possible rejection in their community. In addition, rights-driven services struggle to be fair to all who require services and attempt to ensure the equitable distribution of scarce resources. Many rights-driven services that are committed to supporting people with disabilities or mental health problems can quickly become overwhelmed by demands placed on them. Ideally it would be wonderful if all services had sufficient resources to provide the best treatments, while at the same time ensuring that service users’ rights were protected. In practice, of course, many services do try to embody all three models, by focusing on resources, treatments and rights simultaneously. When they do this they encounter various tensions and struggles. The resource-driven and rights-driven models focus on changing the environment, the first by creating a haven of excellence inside the service, the latter by establishing a supportive community of excellence outside. The treatment-driven model seeks to change the person.

Typically within any service one model tends to dominate, which in turn defines the ethos of the service. Over the years I have had the privilege of visiting many different services for people who are unable to manage without the support of others. These have included services for people with learning disabilities, autism, sensory and physical handicaps, mental health problems and services for older adults. Only a small number of these would, in my view, approach a level of excellence. Service excellence is more than simply treatment approaches, staffing expertise, sharing community facilities, interior design and décor. In my opinion, services that attain excellence are distinguished by the palpable sense of respect shown to service users and the concern expressed for each individual’s welfare. It is usually possible to detect this high level of commitment towards service users within the first hour—if not minutes—of visiting a service. Excellent services behave in ways where you know that decisions are always made in the best interest of those who avail of the service and are truly person-centred.

Those who provide services of excellence tend to be modest in their claims, eager to share and talk about their experiences and open to new ideas as they struggle to find better ways of delivering services. Excellent services are those who are way ahead of other service providers and as such are travelling along an uncharted and uncertain path.

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