In these hope-sapping days of austerity in social care and health there are some who say that the system is starved of money and just needs some more to be ok, lots more, and that the system contains the ‘experts’ who are needed to use a variety of assessment and expert led techniques to decide who gets what from the dwindling pots of health and social care resources and services.
What I am interested in is whether we can live up to a much more optimistic viewpoint and prove that if we engage people much more fully in their own health and well being then their outcomes (horrible jargon for ‘lives’) improve, and their consumption of health and social care resources goes down – a social movement?.
There are a few of us (not as many as there should be and certainly not a majority) in the world of social care – linked to health – who are trying to set out to prove the above aspiration – with hard edged data harvested from innovation sites working very differently where we try and break all the rules of the current system to show that it is obsolete. But we need a lot more participation if we are not to be crushed in the current rush towards an integration of health and social care bureaucracies. What is so good, I wonder, about rolling together one remote bureaucracy next to another similar one – both built on the premise of ‘queues and delays’. Will we not just create a worse less person-centred monolith? Many of us have been ‘talking’ integration for over a decade – is this the way to truly make it happen?
How are we going about this revolution based and assets and strengths? Firstly by telling a story of criticality, then one of hope, and finally one that describes the stepping stones to the birth of a social movement where people really are much more in charge of their health and wellbeing – and their consumption of health and social care goes down as their lives improve.
Telling a story of criticality (cf. Marshall Ganz. Leading Change: Leadership, Organization and Social Movements, Chapter 19 in the Handbook of Leadership Theory and Practice: Harvard Business School Press, 2010) and pointing out the deficits of the current system is both a release and a burden. It is a release because the deficits come as no surprise to anyone – particularly those in the frontline – so owning up to them collectively is liberating. It is a burden because rather than worrying about how we will sleep in our beds if we change things, we should be worrying about how we are sleeping now. My background is more social care than health so I am better equipped to point out its deficits – but I am worryingly confident that you can tell a parallel story in the NHS. Do you know how many elderly people in inspected and registered residential homes are clinically dehydrated, and what the chances are that they will be administered the wrong drugs?. Do you know how many times the government (of all persuasions) has announced the closure of NHS campuses for people with learning disabilities (and they are still there). Do you know what the research says about what happens to people with dementia when they are cared for in ‘respite’ facilities that have no time to really get to know them and how they need to be supported. This is not a pub quiz, it is a catalogue of failure that has happened on my watch that I have participated in. Do you know that in most social work systems people spend 70% of their time on bureaucracy 30% time with people. And oftentimes the 30% is spent filling in ridiculous assessment forms whose questions can be 50% irrelevant and 20% downright rude. And the system can’t cope with ‘demand’ and is running out of (or has run out of in many places) money.
So it seems self-evident to me that the last thing we should be doing is trying to prop up that system – or integrate it with an equally fragile NHS. We should be seeking evidence of how to do things better so that we can make it obsolete. And in doing so we should redesign a new system from the bottom up with our NHS colleagues, with people and families, and with other community based networks.
So my second story – of hope – is how easy it has been to co-design a new set of practices, behaviours and cultures built around the three conversations that are immediately attractive to frontline practitioners in both health and social care. The deficits of the systems that I have pointed to above should never be laid at the door of the minimum wage paid care staff in care homes or the social work/nursing/OT and others team members running faster and faster round the hamster wheel of bureaucracy. It is the environment that we place those people in – of ‘front doors’, of triage, and pathways, and allocations, and waiting lists, and mandatory fields in documents – that has beaten the life out of them. I have seen time after time that when we liberate front line staff from those systems and co-design a brand new way of working built on some communally agreed rules that ensure key principles and values, that workers grab the opportunity with huge enthusiasm – and we now have the data to prove it. Their productivity shoots up, they threaten anyone who even suggests that they may have to return to the old way of working, and their passion is contagious. Simple rules such as – the conversation about long term dependency on services is the last conversation you have, not the first. If someone is in crisis never ever ever plan long term with them. Stick to them like glue for a short period of time and commit to finding the solution (whatever it is – but not just ‘services’) that will work for them. Put peers in charge of practice quality in this new way of working. Never allow anyone to hand off anybody to anyone else. You are accountable! What you do matters!
And the third story is about how you make this happen – how you turn it from a set of platitudes to hard edged reality. I believe the current system is so flawed, so pernicious and so powerful that you have to build protected environments where all its rules must be broken – and replaced by a new set of rules that describe a new way of working. Let the rest of the crazy world carry on – and it will look increasingly crazy. Within your protected environments (‘innovation sites’, ‘bubbles’, ‘test phases’) co-design with the whole community-based system of support (health, social care, housing, voluntary sector etc.) a new precise set of rules. I am convinced that the more precise those rules are, the more liberated people become.
The data we have collected when we have coached and mentored frontline systems to work like this is compelling. We have participated in innovation sites in hospital wards, in social care ‘front doors’, in long term supported housing projects, in specialist teams, in GP surgeries working on their lists of people at risk of admission. Everywhere we have done this we have experienced:
- The consumption of health and social care resources going down – significantly (i.e. it at least halves)
- Demand is not an objective reality – we create the demand we get in the way that we interact with people. In social care terms if we construct an ‘assessment for services’ factory we will create un-sustainable demand for services.
- People and families’ quality of their experience of the interaction with health and social care systems goes up – ‘its responsive, I felt really listened to, I have regained my self-respect’
- Workers satisfaction, fulfilment and productivity shoots up: ‘don’t make me go back, I love my job, what I do really matters, this is what I was trained to do’.
My hope is that we can gather enough evidence in time to inspire a critical mass of both health and social care colleagues to join the growing band of individuals and organisations committed to asset based approaches and together we can demonstrate that integration isn’t about where people turn up to work, or about generic job descriptions, or about who manages you, or about ‘single assessment forms’. It is the integration of fundamental principles and values, and the integration of the experience of people with assets and strengths, living in neighbourhoods and communities, who will sometimes need health and social care support to get on with their lives.