During the past few weeks I’ve written several pieces about the radical changes needed to deliver adult social care support.
I was hoping to provoke a discussion and – happily – I’ve succeeded. Overall, I’ve had very positive feedback from people who want to see change happen and I’ve also been asked to pull out examples of the work we’ve been doing. People want to see evidence in practice – and so they should.
So with the help of Karen Wright, Director, Adults Operations and Care Act Implementation Lead, Essex County Council, here is the story of one council learning to do things very differently.
We recognised that the traditional approach, involving a large call centre diverting people away or passing them through to social care teams, was simply ‘sucking people in’. It had to change.
Moreover, most of the community teams had become part of the ‘assessment for services’ factory. This to some extent presumed the solution for people was some reablement-focused activity, mainly supporting people coming out of hospital and/or formal paid care services.
Although this system worked efficiently and well, it was never going to meet the requirements of the Care Act – with its emphasis on wellbeing, prevention and independence. Likewise, with the financial pressures on all local authorities we could no longer afford to continue as before.
As a result, by reclaiming social work, Essex is adopting a simple and different approach. Having created a number of innovation sites, and coached staff in the art of having three different conversations, evidence is emerging to show that this is the way forward.
The conversations are:
- ‘How can I connect you to things that will help you get on with your life – based on assets, strengths and those of your family and neighbourhood? What do you want to do? What can I connect you to?’
- When people are at risk – ‘What needs to change to make you safe? How do I help to make that happen? What offers do I have at my disposal, including small amounts of money and using my knowledge of community, to support you? How can I pull them together in an emergency plan and stay with you to make sure it works?’
- ‘What is a fair personal budget and where do the sources of funding come from? What does a good life look like? How can I help you use your resources to support your chosen life? Who do you want to be involved in good support planning?’
Although all three conversations are proportionate ‘assessment conversations’ under the Care Act, staff are encouraged to leave behind their old ‘assessment’ culture and practice and learn how to have proper conversations that listen to what people have to say.
This is not an invitation to a fluffy and non-specific chat; there are some clear and simple rules, which include:
- always start with the assets and strengths of people, their families and their communities and think about services last
- you have to prove to your peers that you have exhausted conversations one and two before embarking on conversation three
- you can’t have conversation one effectively without knowing the communities and neighbourhoods of those people you are listening to
- if someone is in crisis and having a conversation two never plan long term. You must ‘stick to them like glue’ for a short time to ensure the plan has a maximum chance of success
- you must really know what you are doing and the impact you are having through the daily collection of data, and reflect on it and your practice all the time to keep learning.
There are a series of ‘banned words’ and activities that innovators are trying not to use, these include ‘assessment’, ‘referral’, ‘allocation’, ‘waiting list’, ‘handoff’, ‘triage’, ‘services’ and others.
Changing the approach of providing information and guidance to one that is more interested in ‘connecting people to people’ rather than to services, and referring to ‘my colleague’ when needing to gain specific input of others rather than handing off or referring, has also started the cultural change journey towards integration.
The usual local government approach to change management programmes is to do a lot of thinking before testing the approach. This time we rapidly communicated our intention to work very differently according to these rules and then asked for volunteers, who were prepared to change how they were working, adopt this new approach and commit to gathering data as evidence of the impact every day and learn together.
Within 2 months eight ‘innovation sites’ had emerged and not all led by the council. In fact, the first to step forward was health. All had to describe very precisely what they were going to do, and how they were going to use the core approach. Sites include a number of specialist advisors within the contact centre; a team of people including a GP, Care Advisor and Voluntary Sector having conversations with people identified from a GP frailty list, a site within an acute hospital ward, another working with known adults and carers with long-term conditions and a cohort of people living in a supported living unit.
So what have we found – 9 months in?
- The nature of the conversations is fundamentally different. People listening in to the contact centre can immediately detect a difference between the old conversation (a formulaic list of questions) and the new one. This is where the person is really being listened to and is leading the conversation. In the supported living unit families heard that the review was taking place and expected the usual tick box activity. They were surprised to experience people being interested in the lives of their sons and daughters – and how they could get better (hence the name of our programme – ‘Good Lives’).
- Having a system that is not built around the assumption that formal care services are solutions means that fewer people end up with them. Early evidence suggests that the rate at which people end up with care teams significantly reduces and the rate in which they become recipients of ongoing support has halved. What has been demonstrated is that with a truly local approach and one which is committed to paying attention to what people really want, rather than what service we can give them, peoples’ issues get resolved quicker and without recourse to paid care. In fact, evidence so far is suggesting that no one supported in a crisis has been resolved with a residential solution.
- Staff love this way of working. They quickly say they don’t want to go back to the old way; person-centred practice is valued and while some social workers thought they already worked in this way, they quickly recognised that having the time to build relationships with people and the framework of the conversations moved them away from the traditional role of care management. One nurse thought her practice was holistic, but realised the pressures within the hospital had stopped her thinking about the wellbeing of the patient. Having a different conversation has regained the identity of the patient. Everyone fed back that they liked working closer with colleagues – the sites stopped talking about referrals.
- Gathering data every day and publicly scrutinising it was crucial – we were able to evidence the financial business case for ‘Good Lives’ with innovation sites reporting that if it rolled out across all teams, upwards of between £3m-£12m of benefits across the health and social care system would be realised. In addition, we were able to look at key performance data differently shifting from measuring by activity (where productivity equals numbers of assessments ‘done’) to one that looks at outcomes. This will enable us to change our recording systems so that we can gather information systematically. We can now shape commissioning decisions about investment for preventative services on evidence we now hold for the first time about connections that have worked. Who would think that a ward would prescribe pet therapy as part of a discharge/’conversation’ 2 plan alongside reablement services, time banking and other community resources?
- While system leaders are looking at how integration will be developed and delivered strategically, innovation sites are showing how people can work together, hence the term ‘colleague’ and the potential for different roles to work closer together; for example, GP Care Advisors and Community Agents alongside Third Sector Partners and Social Workers possibly through a community hub?
- It’s not all plain sailing – we still have the usual issues of sharing information and systems that can talk to one another, but there is a willingness to resolve these and we are now at the stage of thinking about how we scale up to ensure a sustainable change. The next four innovation sites have already emerged, including a Transition from Children’s services keen to learn from the others and take the journey for themselves.
Despite all the pressures and challenges, it’s an exciting time!’
By James Bullion, Director for Adult Operations, Essex County Council, Karen Wright, Care Act Implementation Lead, Essex County Council, Sam Newman, Director, Partners for Change