A commonly discussed indicator of achievement in long-term care is quality of care, but it needs to be seen as only an ‘intermediate’ measure of benefit. This is because quality of care, while potentially an important determinant of user outcome, is not directly a measure of that outcome itself. It is concerned with staff-client ratios, the suitability of the built environment, staff-client relationships, social environment, safety and so on. Good quality of care by those criteria is potentially important as an achievement, and goes beyond simply measuring the resources expended on or devoted to long-term care, but the association between any quality of care indicator and user outcomes is likely to be heavily context-specific and individual-specific (Davies and Knapp 1981). In using any quality of care indicator (e.g. in an inspection process, or in writing contracts for public sector commissioning), it is therefore fundamentally important to be confident that the indicator is strongly associated with outcomes as experienced in the lives of the people who use that care.

A number of measures of quality of long-term care have been suggested. One of the best known formal measures is the Resident Assessment Instrument (Hawes et al. 1997). Other quality of care measures have now been developed in many European and other countries (summarised and discussed well in OECD 2015, especially chapter 3; and see volume 16 of Eurohealth published in 2010 for some country examples). In England, the current approach to quality assurance in long-term care includes assessment of user experience: the User Experience Surveys ask about aspects of the care process, such as timeliness and flexibility of care, characteristics and behaviour of care workers, and include a question on satisfaction with care (Malley 2010). In this way, the approach tries to overcome a major limitation of quality of care measures of being poorly connected to how people with care needs live their lives and view the support the receive. These processes are linked to performance assessment (see above).

Given the inherent practical (and often conceptual) difficulties in measuring user outcomes from long-term care, quality of care measures might provide an intermediate indicator of achievement, but their limitations need to be recognised.