by Jim Thomas, Skills for Care
Whilst being invisible is a good thing from a support perspective, I have started to wonder if invisibility gets in the way of the improving the general public’s perspective of social care. If you don’t notice social care workers, why would you see the need to value what they do?
Read in full at the official blog of BMJ Leader: https://blogs.bmj.com/bmjleader/2021/09/19/sometimes-being-invisible-isnt-helpful-by-jim-thomas/
In the first of a series of blogs, Vic Citarella considers the crucial role of the workforce in Fulfilling Lives for people with multiple and complex needs. Vic is keen to start a dialogue with projects on this topic. You can get in touch with him using the details below.
“The CFE and University of Sheffield 2nd annual report into the national evaluation of Fulfilling Lives: Supporting people with multiple needs programme has chapters on ‘interventions and approaches’ and on ‘working the frontline’. The report says it raises as many questions as it answers but without doubt it pinpoints the workforce and what they do as the mission critical factor in the projects. More is promised by way of research and future evaluation. That means, among other things, dialogue with the practitioners, the managers, the stakeholders and the customers of the services.
What better way to exchange views than by identifying some themes in a Blog?
A question of purpose
The evaluation reports that users of the services value the ‘sense of purpose’ that the project workers share with them. Clearly we need to know how that ‘purpose’ is articulated and shared. What is it about the mission statements, vision, values and principles that motivates and convinces the workforce that they are doing the right thing? There is a saying that: if you lose your ‘why’ then you lose your ‘way’. Well, we have to know why.
There are a number of big pointers in the annual report and perhaps foremost among them for the workforce is a purpose which includes:
- Meaningful service user involvement
- The concepts of open-endedness and persistence
- Psychologically Informed Environments (PIEs)
- Systems change
These are themes that need further probing for workforce implications.
A question of detail
Few people remember the second half of the quote: The Devil is in the details. It goes on to say: so is salvation. The problem with specifics is sorting out what is important and what gets in the way. There are some clues in the annual report that will warrant further exploration.
The projects all work through some variation of keyworkers. We know from the report that this means in practice both personal, relationship-based support and service coordination or navigation. Knowing the detail of how these twin roles are demarcated and overlap will help prepare operational job descriptions and person specifications, make for effective values and skills based recruitment and ensure appropriate support and training for the workforce.
Knowing what types of people that you want to perform what roles and tasks is about sorting through the specific details to make clear statements of what is important.
So for example it appears from the annual report that service user involvement and peer support are both important. Quite right, but what are the important details?
A question of pragmatism
Everyone wants to know how to do things – a handy guide, top tips or a readiness checklist. There is no shortage of these on the web to encourage best practices for the workforce and their managers. They may not be exactly useable off-the-shelf but a lot of general policies and procedures can be customised to the multiple and complex needs project scenario. What may be challenging is undertaking the customisations.
The annual report spells out that pragmatism, practicality and perseverance are the order of the day in projects. It flags up a number of workforce issues that will need further evaluation. Among them are:
- People with lived experience on the frontline as volunteers and/or employees
- Caseload management
- Navigation and systems brokerage as emerging job roles
A question of curiosity
The annual report makes it very evident that members of the workforce are at the heart of evaluating progress with the projects. It is they who complete the two measuring tools – Homelessness Outcome Star and the NDT Assessment – with the service beneficiaries. One of the features that workers enjoy about the projects is the move away from target driven approaches. We need to know how, without the target driver, projects capture the imagination and creativity of practitioners in working alongside beneficiaries in getting as full an evaluation picture as possible.
So for example projects could share views and opinions on:
- The skills and training required to make good use of the tools
- The amount of time it takes to collect the data and information
- What helps and what hinders in using the tools
- How the data and information is useful to them in their work
- What makes data collection less challenging
The continuing evaluation must be inquisitive about the interventions and approaches. The more we know about what works and why the better. In this way the best workforce can be recruited, trained, supported and retained. What follows is an effective service. As Einstein said: \”The important thing is not to stop questioning. Curiosity has its own reason for existing.”
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So, I have been doing some Better Care Fund (BCF) work for a local authority and I’d like to share some of my thoughts around this somewhat controversial topic.
Controversial because BCF can either be seen as a cynical move to make it look like local authorities and the NHS have been given a load more money to spend on integrating services or as an opportunity to start to generate responsibility across the health and social care system for certain big ticket outcomes; such as reducing non-elective admissions, timely hospital discharge, reducing admissions to residential homes, helping people to live independently at home… and lo and behold managing the system costs better so we can meet future demands.
Unusually for me, I am choosing to think the second option; yes, after doing this work I am going to choose optimism. I’m beginning to think it could just work. I was engaged to work with the differently-funded elements of the programme to build the business cases and evidence for:
• why their services should continue to be funded at the same levels
• what is their contribution to the BCF objectives and high level outcomes
• what cost-benefits they are generating.
I have also been tasked with developing some sensitive metrics for each scheme which could be reported to the Performance Review Group so that assessment could be made of which services were making the best contribution to the outcomes data – i.e. data which can show a link between a certain number of x-type services and, for example, a reduction in delayed transfers of care.
I have also been looking at funds like Disabled Facilities Grants and community equipment – mandatory to put into the BCF pot – and the services supporting allocation of those funds, such as OTs. I don’t really need them to build a business case for the use of adaptive technology, it’s worth noting, as perfectly good research has established this, including a fabulous PSSRU paper from 2011
Relevance and Responsiveness
What I do need these services to establish is that they do this well. So it comes down to a few criteria, the crucial ones, I think, being relevance and responsiveness. Do they assess the right people? Do they do it quickly enough and provide the service, whatever it is, be it a care package, item of equipment, hospital procedure, whatever in a timely way, to ensure a more costly alternative is diverted somewhere down the pathway?
To answer these questions, I’ve been having a look at a lot of potential metrics that could be of use. I’m very interested in standardised tools for measuring health and quality of life gain at the moment, especially ones which can link to determine quality of life year gain QALYs. (To my mind, these clearly include tools like EQ5D, SF36.) I’m also interested in mental health tools such as WEMWEB, in scoring used in services like intermediate care such as Barthel Index, and the Nottingham hip fracture score. I’m no expert in this area, to be fair, but I have been putting in the hours to build my expertise in this area; and as a result, I am finding it fascinating.
As a result of all this, I suggested that a lot of the services adopted a similar or the same tool and then we could measure and compare the health gains generated by, say, a mental health outreach service or an equipment service.
But a story keeps recurring to me. A number of years back when I was involved in the allocation of grant funding to voluntary organisations, I spoke to a group of young carers who were involved with a young carers’ project which networked them, did crafts and groups and took them on away days etc. I asked them, if I could spend the £200K we spend on this project on whatever they wanted, what it would be.
The outcome of the discussion was almost unanimously – and very surprisingly – that they would spend it on equipment and adaptations for their parents or siblings to make them more independent as that would relieve the caring burden on them – not, as we were doing on group meetings and networking and ‘treats’.
In an ideal world you would have both, of course. Those young people certainly deserved it. The conversation was a real eye-opener for me. There are always alternative ways of getting to the same result, after all – but it only takes asking the people involved to find out what that is. Do we really need a lot more evidence for what works?
As a result, this morning I am coming round to a new stream of thought. The BCF can work really well and it can deliver on its objectives. To do that, the BCF Performance group needs to be sitting round monthly (or even more often), not talking about numbers, as tended to happen in the past, but looking at people in the system, maybe even down to individual names and needs.
It needs to be looking at system sensitive information, such as who is waiting where, what can be done to make things happen quicker for them. Useful questions here might be, could money cross over scheme boundaries to make that quick thing happen without a business case or a lengthy trail through a governance regime? Can we get people managing the services to sit down and look not at what happened but at what is going to happen next?
In other words, we need to start looking at the numbers that predict the future, not those which tell the past – and, see if someone else is already doing this first, by the way.
We still have to decide what information should be brought to the group. But my guess is it won’t be as complex as the information I originally thought we might need. All this might even be described by some people as bean counting… but you know what, if beans have already been proved to be highly nutritious if you eat enough and likely to give you wind if you eat too many – why wouldn’t you make sure you are counting them accurately?
Sue McGuire learns about metrics
How do we know if what we are doing is working? Or judge how effective it is?
One of the differences I noticed in the different cultures of the Health and Social Service worlds I have worked in (if you can consider them separately), is that in Health they seem to be much more rigorous about knowing and establishing the evidence base for what they do. (I know measuring has changed a lot since I worked in a purely Social Services setting so I’m ready to be shot down here.)
I wonder if that’s because, in Health, the range of treatments and interventions is so wide that the need to establish the most effective ones is vital. Or could it be that because the risk of doing harm is great, in addition to the possibility of patient claims against the system, makes its practitioners more rigorous?
Whatever the cause might be, there seems to be a more established research culture supporting clinicians, commissioners and patients themselves to make choices about what they use and where money gets spent.
Massive Open Online Courses
Following my interest in these questions, I started a FutureLearn course recently called ‘Measuring and Valuing Health,’ the third FL course I have done to date: if you’re not familiar with it, FutureLearn is one of the providers involved in opening up FREE learning on line in the MOOC environment (Massive Open On Line Course). The other courses I have done have followed my literary interests, specifically in Shakespeare, delivered by world class lecturers such as Jonathan Bate of the University of Warwick, and Michael Dobson, Director of the Shakespeare Institute at the University of Birmingham. FutureLearn brings together 1000s of participants throughout the world, a process that generates lots of discussion, comment, information sharing and networking. In short, if you’ve not tried this resource yet, you are missing a treat (and the range of subjects on offer is increasing all the time, too).
I am involved with a voluntary organisation which aims to improve the life and health of vulnerable families and we run something called a ‘Families Fit for Life’ course. (The ‘Fit for Life’ course is about improving skills, knowledge and behaviours around many areas of a family’s life – health, diet, activity, parenting, finance, social engagement.) I am learning now about the techniques behind developing measuring tools, literature research, and patient and clinician engagement, focus groups, hoping to do some technology transfer and apply some of these tools to track our group’s impact.
To get back to measuring, I was part way through week one of the course, learning about how to develop a Patient Reported Outcome Measure (PROM), when the old debate about what we call people sprang to mind – Patients, Service Users, People? We couldn’t use a PROM; the people on our courses are not patients. But it struck me we could rename it a BROM – a Beneficiary Reported Outcome Measure. Well produced BROMs could be more widely used across of spectrum of social service interventions, family support, home care, even for comparing the effectiveness of assessment teams.
So I think we can agree there is a lot of ‘science’ going into the Health side of measurement. But like I said, I think we are very far behind in Social Care. For example, for many years I was involved in delivery of the grants to voluntary organisations programme of a large council. Almost every year I did this, the budget was cut, and decisions had to be made about which services we could not support any longer.
I struggled to bring some objectivity to this work, as I disliked comparing apples with pears, and I tried to develop a way of outcome reporting. I don’t think I really achieved that much, despite all my efforts; I think the struggle on that still has to be won and for services delivering more ‘social functioning improvement’ than health improvement, I think it is vital we strive to get the same rigour and academic support into this as health has.
I rather hope someone is going to tell me it’s all happening already! Which is fine – but if you’ve found out nothing else from this blog, I’ve promoted Futurelearn which I can’t speak highly enough about. Go and check it out! https://www.futurelearn.com/
Sue McGuire takes a look at ‘the grass on the other side’
The other side of the fence is a place where you can learn a lot… even if you were the sort of person who didn’t know there even was a fence – or who thought they’d been pretty good at looking over it but who often found on the actual other side of it that it’s not just ‘there,’ it’s a lot bigger and denser than you thought it was!
I know this for a fact in my own case – as after about eighteen months of retirement from 23 years in Health and Social Care services I’ve been involved in supporting relations through three continuing health care assessments, none of which looked or felt anything like I thought they were supposed to look or feel when I worked; and believe me, I should have known what they were like.
What I am saying is that I thought I knew it all… but there is always more to learn, as there always is when you think you know it all. I’m willing to give the benefit of the doubt and believe that most local authorities, CCGs or Health Trusts aren’t deliberately trying to hide much. But I do think they are awful at making information as accessible as it really should be to the public. Try entering any local authority website and just finding out who the main people responsible for Safeguarding are, for instance – and you are likely to find yourself having to wend your way through several pages to get to a place where you can download some minutes of a committee or an annual report to find some actual names.
For contact details it’s even harder; the Wooden Spoon award has to go to Birmingham City Council, which you might almost believe had made a deliberate decision not to reveal any management names below the Chief Executive – unless it’s the courageous people responsible for the library service. Grr Come on people; if you want to be paid to be responsible for something as important as Safeguarding, put your name on it! Gold award would go to Coventry who bravely publishes an easily accessible and fabulous list of all its senior managers with their job titles and salaries, which makes it a snap to spot immediately who has safeguarding in their title.
When I was a busy middle manager, I remember the air turning blue when a Freedom of Information (FOI) request came through and had to be added to my seeming never ending list of ‘Things to Do’. To be fair, many such requests did not feel like they were citizens trying to find out what they needed to know to negotiate a tricky system; many were from businesses really wanting to know what systems and products we used and thus who they should rugby-tackle to try to get a foothold for their own brands (or they were from researchers for MPs or political parties wanting to ask awkward questions to score points).
The thing is, now I have found a use for ‘Freedom of Information’ information and bless their cotton socks, our fellow citizens who have been beavering away at getting information suddenly seem very useful. Specifically, I have been trying to gather a list of safeguarding lead names for the West Midlands but the varying quality of local authority, heath trust and CCG websites means that while some have excellent information almost immediately discoverable by very simple searches, others are like searching for the proverbial needle in the vast haystack. Luckily, great website called \’Whatdotheyknow\’ as come in very handy for my purposes; if I want to know it, you can bet someone else wanted to know it before me. WhatDoTheyKnow is run and maintained by UK Citizens Online Democracy, a group that wants to help enable people to frame their FOI requests in a brief note and then they send the request to the relevant public authorities.
And it’s a job it is doing very well, let me tell you; plus, any response received is automatically published on the website for all to find and read. So I recommend you have a go yourself – go onto the Whatdotheyknow website and type in a search for Safeguarding. You will immediately see how many requests begin with a desire to know who the responsible person for Safeguarding is. The website makes the requests and the answers as accessible as they really ought to be.
A lack of consistency between councils in respect of naming senior managers is not really excusable and likely to be just another thing that feeds anxiety and distrust. This I can see, now I am on ‘the other side of the fence;’ maybe if it was all easily accessible some busy middle manager might not have one more thing to add to their list…?