My blogs in the past month have focused on my desire for delivering radical change in adult social care support. In these pages – and through LinkedIn Pulse and Twitter – I’ve succeeded in creating a dialogue with like-minded professionals who are eager for something similar.
This time I’ve asked Tandra Forster, Head of Adult Social Care, West Berkshire, to help me build the story behind the changes now taking place at West Berkshire.
Drivers for change
The council was looking for a new away of delivering the requirements of the Care Act – that would engage and inspire their staff – and build on an existing directorate commitment of ‘doing with’ rather than ‘doing to’.
We were also motivated by the ‘graph of doom’, which shows that unless something changes councils shortly will be doing nothing else except trying to meet the needs of vulnerable people in their communities. As a relatively small council, we were being particularly hit by budget pressures. We believe West Berkshire has one of the worst budget settlements following the recent comprehensive spending review.
What we did
We worked on a ‘story’ with the staff, the council and the partners about a different approach to adult social care. It got rid of the old-fashioned contact conversation that followed a script and aimed to signpost away as many people as possible – followed by an ‘assessment for services’ experience – and replaced this with a set of three precise conversations:
- Conversation 1: How can I connect you to things that will help you to get on with your life – based on your assets, strengths and that 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 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 the community to support you? How can I pull them together in an ‘emergency plan’ and stick with you (like glue) to make sure it works?
- Conversation 3: 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?
These conversations have rules; for example, you must have exhausted all possibilities of positive change through conversations 1 and 2 before using 3, certain words and actions are banned – including ‘triage’, ‘signposting’, ‘assessment’, ‘services’, ‘respite’, ‘hand-offs’, ‘referrals’ and ‘waiting lists’. A way of working with these 3 conversations needs to be co-produced from the bottom up by the staff using them. In conversation 2, you ‘stick like glue’ to someone for a short period of time.
Learning by doing.
We established two innovation sites (we call them bubbles, and the innovators are ‘bubblers’) based on the interest we received when we invited people to put themselves forward. These sites also have rules – that replace the current ones. These new rules include: you must collect data every day about what you are doing, you must agree to reflect on your practice with your peers, you must get to know the communities and neighbourhoods of the people you are conversing with, people and families are experts not us, you can spend small amounts of money as part of making a conversation 2 plan really effective. The two innovation sites we started with were a proportion of the First Contact team, and a team working with people who had existing care arrangements.
What we learnt
You can have a significant impact on ‘demand’ and where it ends up. Being able to compare existing contact activity with the innovation site alongside it was powerful. The ‘conversion rate’ of new contacts that become ongoing packages of support went from 1:10 in the ‘business as usual’ environment to 1:19 in the innovation site. This ratio has been maintained now for more than a year. That has had a significant impact on our spend.
Rachael Wardell, Corporate Director, Communities said: “It has been important for the council to reduce its costs, but not at the expense of meeting the needs of vulnerable people.
“We wanted to show that we could work with people, building on their strengths and capabilities and focusing on their lives, rather than on the way we deliver our services. We have been able to stop being a council that says “no” to save money and instead to find ways of saying “yes” differently.
“Staff love the new way of working and do not want to go back, though say that it is challenging, can cause people to feel de-skilled for a while and ‘brings the pain’ into people’s working experience. But the feeling of being empowered, liberated to use skills and common sense and see things through to a conclusion more than outweighs this.”
This is the perspective of one frontline ‘bubbler’: “In discussions and supervision sessions team members seem to know more about people, their families and background. The team are establishing good rapport quickly and people seem to be more open with them. The team are dealing with a full range of cases and are highly supportive of one another. Stress is less apparent and dissipated by having time to talk and ‘off load’.
“The work culture is more positive and I feel more motivated in my job. We are supporting West Berkshire Council residents in a friendly ‘can do’ way rather than being more controlling. It is good to be pro-active rather than reactive and firefighting all the time. Please don’t make us go back to the old way of working.
People and families (and partners) expressed amazement at the speed of the response. Instead of telling your story multiple times, being placed on a waiting list with no understanding of when or if you would get to the top, people were now experiencing an immediate and real conversation aimed at helping them get on with their lives. One person who had contacted the council some months ago for some help and had experienced the old, clunky experience based on lots of questions, waiting and poor information, described the new experience as like ‘being struck by lightning’.
Numbers of on-going care packages across the directorate have gone down despite demographic pressure and despite the Care Act that significantly shifted eligibility for West Berkshire – one of only three councils operating at ‘critical’ prior to the Act. Why is this? We believe it is because we are seeing people earlier where they are less likely to be in crisis and less frustrated with our response. We are using their assets and strengths and those of their communities first. When people are in crisis we are being much more effective in resolving that crisis and enabling people to regain control of their lives.
We have learnt that this way of working takes a little longer – but that is because people are doing a lot more work, and seeing things through to a conclusion rather than passing work (people and families) on via waiting lists, to other teams. That is, we are learning how to be much more productive. Even though 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 really listen to what people have to say. Each site is collecting data everyday about their experience of these conversations, and the impact they are having.
12 months on from starting work we are now ready to organise our skills and resources around this model rather than ‘force’ it into our current structures. We have had a second phase of innovation which has grown our confidence that the way of working is scalable. We are now embarking on a process that will ‘design in’ the three conversations into our work – creating community based teams who will be expert in their local neighbourhoods and ready to respond quickly and creatively using the three conversations. We are also looking forward to learning through the same innovation process how to integrate responses with the NHS particularly through working with people on GP held.
By Tandra Forster, Head of Adult Social Care, West Berkshire and Sam Newman, Director, Partners for Change