The London Borough of Redbridge began The Three Conversations^® journey in autumn 2017. I was invited to a project board meeting with our Director and other senior managers, where I met Sam Newman from Partners4Change, and believe it or not, my first thought was – wow! This man is passionate about The Three Conversations^® but at the same time I felt quite sceptical about how it would work in practice. Sam began by telling us about the approach with an overview of how it fitted in with personalisation, the Care Act and Making Safeguarding Personal, as well as the financial benefits of using such an approach. 

It did all make sense – the only thing was, we were all thinking, well, what’s new? We have been doing this for years! Sam really made me question my own practice. Having worked in Adult Social Care for over 30 years, was The Three Conversations^® really going to teach me anything different, and could I continue to make a difference to people’s lives both on an individual, team and organisational level?

It was important for the team to own the work that we were embarking on, and it was therefore equally important for the whole team to feel involved throughout the implementation phase. So, with this in mind, we began thinking about a name for our Redbridge model and came up with ‘People Matter’, since we believe that ultimately, that is what matters most to us: the person, and whether they are receiving the level of support that they need, regardless of budgets and other constraints.

We did some preparatory briefing work with one of our teams in preparation for the pilot and were brave enough to test out the model with our front door service (First Contact Team). Within the First Contact Team, we decided that it would be best to split the team in to two and to have the ‘old world’ (the status quo) run alongside the ‘new world’ (The Three Conversations^®) so that we could continue to keep the show on the road. As you may already be aware, this type of team is very busy and comes up against all kinds of challenges such as safeguarding, crisis intervention, carer breakdown situations, police reports etc. So, we decided to have 3 innovators working in the ‘new’ way and the other 3 wellbeing officers working in the ‘old’ way.  

We ran the innovation site for 13 weeks – beginning in December and ending in March 2018, and we can honestly say that we were not prepared for this roller-coaster ride of differing emotions that we all went through. In no particular order: from feeling, inspired, motivated, autonomous, satisfied, creative, fed up to overloaded. However, the regular briefing sessions gave us the space we needed to talk things through and be there for one another – it brought the team closer.

It wasn’t all work, work, work. We decided to have some fun along the way too…so we came up with the idea of doing a music video to showcase our journey! At the beginning of the innovation site the team did not even want a photograph taken, but by the time we had finished we had everyone dancing, coming up with ideas on what to include and even had the Occupational Therapist singing the song – we really did ‘Do it our way’! 

We have learnt a great deal working in this new way and some of the initial evaluation data has demonstrated staggering results where we were able to make a significant difference to the number of people requiring “transfer for long term support”. Not only that, but we also had some amazing stories from people, and have been able to transform the way that we work with individuals. It has been so exciting to see the confidence and creativity of staff emerging and coming through, enabling them to engage with people and being able to build relationships that form the basis of empowering people to help themselves.

Sometimes as practitioners, we feel that we must take on full responsibility for everyone including all their risks, and feeling that we must protect everyone, but also that we have to give people something and do things for them. However, The Three Conversations^® has shown us that the best thing that we can do for people is to encourage, motivate and empower them, so that they can become more self-sufficient and resilient and problem solve to self-manage. It has also highlighted that the learning that we have achieved from this model fits in nicely with the philosophy of Occupational Therapy. This is why we have really noticed that with efficient, timely Occupational Therapy input, people’s independence has been maximised and cost savings have been achieved by avoiding long-term support.

We have received some amazing feedback from people who have been taken through the People Matter model rather than the ‘old world’ model. Their comments included:

“You are a life saver!”

“What would I have done without you?!“

 “It was really quick and easy to access help.”  

“I only had to deal with one person, who actually supported me”

So, in conclusion, do we believe that people matter? Yes, we do, and we believe that The Three Conversations^® supports this to happen.

Occupational Therapists (OT) are interested in how a person interacts with their environment, and the impact that this has on their daily life. The Royal College of Occupational Therapy (RCOT) defines occupation as “the practical and purposeful activities that allow people to live independently and have a sense of identity”.

This could be anything from essential day to day activities such as self-care, all the way through to work commitments or leisure activities.

OTs consider how these occupations are:

• Motivated: what are the person’s values, interests and motivations?

• Patterned: how behaviour is organised, such as daily tasks and the development of regular routines.

• Performed: how the person performs the components and overall function of the activity.

The ‘outcomes’ from an OT perspective, focus on how a person functions at an optimal level despite any barriers that they may face. We analyse, and then adapt and modify activities whilst considering all the physical, psychological, social and environmental needs of the person.

So, how does an OT work within The Three Conversations^®? How do we support people to have a renewed sense of purpose, widen their horizons, and improve how they feel about the future?

The Three Conversations^® approach and the OT’s role.

Conversation 1: Broadly, this involves listening and connecting people with a strong focus on sustaining their independence. An OT’s skills in optimising independence ensures that, through the conversation at this level, the outcome for people is that they can get on and live their lives. For example, equipment and/or adaptations may remove environmental barriers thus enabling a person to live independently. Or perhaps supporting someone in their ability to use a computer will enable them to keep in contact with family or play interactive games online which will help to facilitate their sense of independence.

Conversation 2: These conversations aim to support people intensively through a crisis. It is here that we would consider what needs to change urgently to regain stability, and longer-term resilience. Again, OTs can respond and support through their interventions to restore or provide adaptive solutions to enable the person to return to a position of stability. For example, OTs may be involved in both delivering or commissioning short term reablement support to restore a person to optimum independence or could use activity analysis to establish a graded programme of intervention to support a recovery model in Mental Health. Equally, it is at this point where the provision of specialist equipment or adaptations to ensure that the person can complete the task or function with greater, or complete, independence would be added into the mix.

Conversation 3: This conversation considers how a person can build a good life and what longer term support is available from the person’s own resources and networks, or through a fair personal budget. OTs can contribute to planning and organising support ensuring optimum independence within the support arrangements. For example, OTs can contribute to planning how a person’s long-term care and support needs can be met whilst ensuring their independence is maintained as far as is possible. This could include advice on manual handling techniques to ensure that the support arrangements are sustainable or exploring housing arrangements or adaptations which will ensure that the person can remain living at home with reduced barriers caused by their environment.

Having personally had the opportunity to work with people using The Three Conversations^® in Adult Social Care, I feel it provides a much more collaborative approach, where we are able to work with the individual, their families and other professionals involved, so that we can support them rather than implement a formulaic list of questions which must be responded to. This has proved to be personally and professionally liberating, as a way of working. By enabling a truly person centred and proportionate approach through Occupational Therapy, we are able to do the jobs we trained to do. It no longer feels that “assessment” is a one size fits all process, but instead a set of meaningful conversations leading to meaningful outcomes. It has been a real privilege to work with like-minded OTs, who, through this approach are developing real innovations and are able to respond to the high demand for OT services through liberating OTs to respond at a level which is tailored to each individual’s needs.

Many thanks to Medway and West Sussex OT’s who through their innovative work have contributed to this blog.

Partners4Change have been asked several times how The Three Conversations^® works within a provider setting.

Susan Ripton from ECL Sensory Service stepped forward to share the organisation’s experience of taking The Three Conversations^® forward as part of Essex County Council Good Lives programme as a Trusted Assessor.

The Good Lives model creates a new relationship between professionals and the people they are working with. So, when ECC asked for volunteers to become an innovation site, ECL Sensory Service stepped forward. The innovation site focussed on a cohort of people who were newly certified with sight impairments by a hospital consultant and whom we contacted to offer information and support. This role was previously carried out in a very structured and scripted process undertaken by a generic ‘front door’ where the emphasis was on providing information, advice and referring on to specialist workers for any other work. This involved waiting lists and people having to tell their story more than once. ECL Sensory Service had already identified that this approach did not work for people who had been newly certified with sight impairments, so this was the first thing to go and to instead be replaced with The Three Conversations^®.

So, how did this look, practically?

Conversation 1: initial contact

“How can I connect you to things that will help you get on with your life – based on your assets, strengths and those of your family and neighbourhood?  What do you want to do?  What can I connect you to?”

Conversation 2: when people are at risk

“What needs to change to make you safe and regain control?  How can I help make that happen? What do I have at my disposal – including small amounts of money – and using my knowledge of the community, to support you?  How can I pull them together in an emergency plan and stay with you to make sure it works?”

Conversation 3: when long-term support is needed

“What does a good life look like?  What is a fair personal budget and what are the sources of funding?  How can I help you use your resources to support your chosen life?  Who do you want to be involved in support planning?”

Each of these conversations alone supports a proportionate assessment. The ability to have a ‘conversation’ without a ‘script’ opens the dialogue between the person and the professional, enabling us to gain an all-encompassing and detailed understanding of the difficulties people are experiencing.

By working in this way, we very quickly discovered that the outcomes we achieved are rarely possible through a scripted conversation. Sometimes after a short conversation we realise that we need to move to conversation 2, but we never move to 3 without a conversation 1. It is important to understand this is not a linear process and people can move between each of the conversations as circumstances change.

From day one, the dialogues have been open, friendly and aimed at resolving issues. To start with we look at what support they already have and build up a picture of their daily life. Together we look at the aspects of their life in which they feel they are lacking, be it social networking, getting out to talk to friends, visiting the church or getting to hospital appointments, and we then use our local knowledge and resources to help them manage this themselves, or guide them to people who can help them. There are no time-scales for conversations and no targets for how long we may spend talking to people: the only criteria we are working towards is that no one has to wait to have a conversation. We are led by the person and work to their pace, even if this needs to be a conversation over several calls.

As part of working in this new way, we stopped sending out a standard pack of information leaflets to every person contacted and now send information tailored to the individual, after which point we guide the person to where they can find the information for themselves. It was identified by people on receiving the packs, that they did not want reams of paper – often unrelated to the issues they are facing, and in inaccessible formats. We discovered that not only was this way of communicating a waste of resource and time for all, but was in some cases distressing since people had to wait until they had a visitor who could read the contents to them only to find it wasn’t personalised and much of it not useful. This new way of working gives people the opportunity to read through the information and make an informed decision to contact specific agencies for themselves, instead of being passed around via a referral or triage service through other professionals which is in no way empowering to the person. We are of course on hand to help make these connections if need be.

Another process that we stopped from day one, was blanket referring to all sensory organisations. Whilst the idea behind this was initially a supportive one, it ended up becoming more of a hindrance to people who were bombarded with a variety of agencies calling and visiting them regarding the same issue causing confusion and duplication. The individual’s journey involved answering the same questions over and over again to organisations who didn’t communicate to each other.

We now have a flow of information constantly moving in line with the person’s changing needs. This is what really gives people a “good life”.

Data

We gathered detailed daily data so we could accurately look at the outcomes of the different approach. It was evident from week 1 that changing the culture of speaking to people would greatly and very positively impact them, and the way the staff were working. It was difficult though to identify where the financial benefit fell because it spanned across the health and social care system and there was no whole system data to bench mark. For example, I had a conversation with one gentleman about his newly certified as sight impaired. Initially he stated things were fine, but through having a good conversation 1 it transpired that he had stopped going to the shops to get his newspaper every morning and felt unsafe out on his own. This conversation resulted in him having a connection made to a rehab worker for white cane training which supports him with his mobility and orientation and confidence in being able to get out independently. If this conversation was ended at the point he stated he was ok, it could have resulted him having a trip or fall outside and having a hospital admission, or a decline in his mental health from being socially isolated from his community. The benefit in the long term through this connection was that the gentleman stated he felt “more confident being out and about now, he was able to access his local community”

Outcomes

• Reduction in social isolation.
• Reduction in trips and falls.
• 100% satisfaction with the service – with comments such “involvement with ECL Sensory Service has been life changing”.
• Staff reported feeling valued and enjoy coming to work each day.
• Increased number of Adults volunteering as sensory champions, contributing to speaking at conferences and sensory awareness training.
• Improved working relationship with ECC colleagues as we work together to build on people’s strengths and involvement within their communities.
• Improved communication between professionals within specialist sensory services, reducing the need for people to tell their story twice (or more!).
• Reduced formal packages of care whilst still evidencing we are supporting people’s needs.
• Sharing of access to ECC IT system, which reflect the Good Lives model.
• Development of Trusted Assessor role within a specialist service.

So, I hear you asking, is it more work to start with? Yes, it probably is, but the long-term benefits to all involved far outweighs the fact you need a slightly longer conversation to start with. It makes the job far more enjoyable and you know that you are really making a difference to people’s lives.

What people are saying…

“I considered the lady who visited me extremely helpful.  Her advice and suggestions were first rate and the fact that she too has a hearing disability, like myself – she was mindful of my problems” – Mrs W, Rochford

“It was wonderful to have been able to be supported by the same lady as last time.  Thank you SC – you are a treasure” – anon

“L who visited me at home was very good on explaining to me the help I could get if I needed. She has made me a little more confident and part of the community by attending classes that are available for me. As I live on my own, I do not communicate easily. Looking forward to a brighter future” – Mrs SM, Basildon

It is an exciting time in Essex. They have just completed the full implementation of Good Lives – their programme name for implementation of The Three Conversations^® across Adult Social Care, including implementing within Transitions, Hospital and Prison Settings.

So how was it achieved?

Approach: It was agreed – with support from the Executive Team and the Adult Leadership Team – that Essex wanted to achieve a sustainable approach to change. The usual approach of another organisational change in staff and ‘Big Bang’ approach was disregarded in favour of an incremental approach. All staff were invited to join in the Good Lives conversation, using the same three-month methodology that was applied to the innovation sites. This involved kick off meetings, clarifying what was going to be different, defining success measures and finally an evaluation at the end of the three months. Whilst it was possible to have some common success measures across all teams, there was also the recognition, that within each team, there may be differences.

Most teams took six months to fully implement within their team, because they invited half of the staff to work in the new way first, and then brought in the other half at the three-month evaluation point. All staff had access to a mentor from a previous innovation site.

At the time, this was seen to be the right approach in order to minimise the impact on productivity whilst staff were learning to have different conversations. On reflection, this could have probably been achieved by taking a whole team approach. Staff not included within the first invite were keen to be working in the new way and were hearing different conversations as they sat next to their colleagues.

Workforce: It was important to know the workforce requirements and productivity levels, in order to ensure that teams had the right resources to enable the change in practice. As a result, there was minimal need to move front line staff, but there was a recruitment drive to fill vacancies across the workforce. Whilst no one likes to discuss waiting lists, there is a need for transparency and for difficult decisions to be made about priorities – something that Essex achieved by understanding the gap between workforce requirements and productivity.

Whilst there was no formal classroom training for staff to attend, action learning was fully embedded across all teams and supported by mentors from within the early adopters.

Systems: The case management recording system was radically changed to capture the conversations which were influenced by those staff within the early innovation sites. The benefit of this approach has resulted in practice driving the system rather than the system driving the practice. The down side was the impact on collecting data: the system must capture all data reporting requirements (relying on spreadsheets and complex hand offs) in order to support the analysis and validate the success of Essex’s version of The Three Conversations^® being implemented.

Financial evidence: Gathering the data and agreeing the evidence was the single most difficult part of implementation. Essex already had a number of saving plans in place, and so as a result, it was important to avoid double counting the financial benefits. However, implementing The Three Conversations^® enabled Essex to say how the benefits will be achieved across other saving plans. Having the right conversations at the right time, building on the assets and strengths of people, their families and their communities, and thinking about formal services as the last offer, has to be the right thing to do. We need sustainable outcomes for people and their families, as well as across the social care and health system.

This is not the end of Essex’s journey, but rather the beginning of a new chapter. Essex are now working with providers to fully develop a trusted assessor role as part of their next developmental step.

On 6 October, I received an unexpected call from a colleague.  They had an opportunity for me, “did I want to work for a company that really listens to what people need?” Of course I did!

During October to December, I spent time getting to know a little more about The Three Conversations^®, helped to design and create some tools to support the work, and met the team for a karaoke session and a few Christmas drinks in London.

On the 4 January, I started my first change partnership with Medway Council in Chatham. What a welcoming team! Sam Newman (Partners4Change Director) and I held some initial planning sessions called “Kick off sessions” to explain The Three Conversations^® and its basic, fundamental rules.

The Three Conversations^® ground rules often present a challenge due to the fact that we have spent so much time in the ‘assessment factory’, ticking boxes and making assumptions about the services required.

The Medway team are really passionate about having better conversations which focus on the whole family and community environment as a whole. They have not made assumptions and are really listening to what people need and want. As a result, they are offering solutions which help to prevent and delay the need for longer term care and support.

We kicked off the Medway innovation site on the 13 March taking people from the ‘front door’ who all came from one post code – ME4. The first few weeks, like any new change project, didn’t go without some challenges. It’s like starting a new job, it’s a significant move from the old to the new! It’s not easy and it’s a journey.

In weeks one and two, it is fair to say that the flow of calls was not as high as expected, so within the framework of the model we agreed that we would ‘turn on the tap’, and ‘turn off the tap’ as much as needed to ensure the right level of work.  We did exactly that, adding another postcode area – ME5.

We are now in week five and the team reported some clear and powerful stories of difference along with data collections which showed signs of improvement with some early examples of cost avoidance. We talked about the barriers and challenges so far, and we are co-designing solutions to make things easier for the team.

And finally, to finish off – one story. One of the Medway innovators took a call from a sister who was ‘petrified’ about the wellbeing of her own sister – who she felt had become reclusive, not allowing people in to her house, withdrawing from support and in clear distress. It was clear from the history that these two people had been bounced around the health and social care system for a while – with no-one taking responsibility or actually listening or doing anything. There is no easy solution, but at least in an environment where we are no longer allowed to refer people away, or hand them off to other members of staff or teams, the sister is now being listened to properly, we are sticking to her ‘like glue’ and a plan is being put into place that supports the first sister, and will enable her sibling to get the health response she needs.

We will provide another blog update with more data and people’s stories in the near future.

Well done Team Medway.  More biscuits and cakes on their way!