The quango NHS England has just published guidance on “Expected ways of working between integrated care partnerships and adult social care providers“. This is the latest direction on how to implement the contentious 2022 Health and Care Act, that received Royal Assent in April 2022. The Health and Care Act 2022 is remarkably permissive; this […]
Government by diktat: adult social care companies must have decision making powers about NHS and social care commissioning
“Some patients stay weeks, even months in hospital beds because of complex issues relating to the interplay of their health and home situation.
I have a man who has been stuck in bed too long because he has eight cats…”
The government and, in particular the NHS are masters at inventing arbitrary names, often allayed with acronyms to describe obscure pathways and processes. It is what they do best. I imagine a conversation between the regional manager for NHS Y (can’t be NHS ‘X’ as that is, unsurprisingly already a thing) and their child:
Freddy: What do you do when you are on the computer in your office?
Mummy: I organise things.
Freddy: Are you a key worker?
Mummy: Yes, I suppose I am.
Freddy: What do you organise?
Mummy: I find ways to move patients and staff around a diminishing system to maximise output, retention and wellbeing of staff and patient care. I also invent acronyms.
Freddy: Can I watch Disney?
OK, what is this about?
Well, I want to focus on patient experience – in layman’s terms, and depending on your age and state of health, that…
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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:
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:
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 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.”
Vic Citarella
Company Director CPEA Ltd. 07947 680 588| vic.citarella@cpea.co.uk
Janet Pearson, CPEA Director attends a consultation meeting: CQC – A new start
CQC has been re-invented, with the aim of being a strong independent regulator on the side of the people who use services. It’s moving away from the previous pass/fail approach to one of helping services to improve, ensuring that they are safe, effective, caring, responsive to people’s needs and well led. Sir Mike Richards is Chief Inspector for hospitals and Andrea Sutcliffe was appointed for social care recently, while a third Chief Inspector for general practice will also be appointed.
CQC has been consulting on how it inspects the NHS and independent acute hospitals and as a result anticipates new legal powers to award ratings for hospitals and re-introduce them for social care. The reformed regulator’s new approach to regulation will therefore be based on:
• Registration – a more rigorous test with named accountable leaders
• Surveillance – continuous monitoring to identify failures and risk of failure using local and national information sources and qualitative information from people(hopefully including Healthwatch)
• Expert inspection teams, with longer inspections for hospitals possibly spending 5 days on site rather than the current 1 day format and more time talking to people
• Simple clear standards based on three levels – the fundamentals of care, expected standards and high quality care
• Ratings to help people choose between services – outstanding, good, requires improvement and inadequate
In terms of the new legislation, the new regulations become law in April 2014 and changes to inspections for adult social care, mental health and learning disability services, including ratings will commence in 2014 – 2015 (and 2015 – 2016 for community health care and ambulance trusts). Inspections of acute hospitals are commencing ahead of the legislation and 10 trusts have already been identified for early inspections.
The model of three levels of care will apply to all services though specific expected standards will be drawn up for different service areas when the Chief Inspectors are in post. At this stage CQC are consulting on the suggested Fundamentals of care – based on the Francis Review of Mid Staffs NHS Trust:
1. I will be cared for in a clean environment
2. I will be protected from abuse and discrimination
3. I will be protected from harm during my care and treatment
4. I will be given pain relief or other prescribed medication when I need it
5. When I am discharged my ongoing care will have been organised properly first
6. I will be helped to use the toilet and to wash when I need it
7. I will be given enough food and drink and helped to eat and drink if I need it
8. If I complain about my care, I will be listened to and not victimised as a result
9. I will not be held against my will, coerced or denied care and treatment without my consent or the proper legal authority.
The fundamentals read as a ‘bill of human rights,’ however missing in many people’s eyes is the key point of person centred approaches, of people being treated with dignity and respect and working in partnership with professionals to co-determine treatment and support plans.
At the consultation strong views were expressed about obvious omissions of user and carer involvement and that the focus of questions was not right. The audience was not confident that CQC is really listening. CQC was however interested in opinions regarding the length and frequency of hospital inspections and whether these should be announced or unannounced.
The new ratings will be based upon standards found at inspections.
The three levels are represented in the diagram below.
More details on the consultation can be found in the CQC report – A new start. www.cqc.org.uk/inspectionchanges
Last week I and a number of CPEA Ltd colleagues went to big Health+Care event at the Excel Centre. Seminars, exhibitors and networking from right across both the health and social care worlds. The emphasis was on integration and commissioning but there was something for everybody – safeguarding, home care, residential, meals, telecare – you name it.
A couple of things struck me along the way:
First the exhibition was a microcosm of the true market place out there for customers – the health services of all types well displayed and social care providers more reticent. People need to see and hear about the choices available. They need to understand how they interact and how one option can prevent the need for another. People need the space to test and taste what is offer before they make decisions. Critically they need to be engaged in the value and emotion of services and not just the cold facts of how they work. This is how we can all make best use of our money both individually and as communities.
Second Health+Care demonstrated complexity and gave some indication of the type of approach that can be used simplify things for customers. Provision across health and social care is characterised by its plurality. The economy is a mixed one and likely to get more so. However fragmentation is not inevitably a bad thing if opportunities are made and taken to collaborate. Some of the networking witnessed and partaken in at the exhibition will serve me well. I noted how thoroughly this aspect of the event was enabled by layout, timing, presentation and a number of navigation formats. Again there is a lesson here in how our real health and social care markets can develop and learn from commerce.
So a welcome addition to our calendar at CPEA Ltd. There are reasons for optimism about the way forward for health and social care commissioners and providers if this type of message can be replicated locally and in the market place.
A couple of weeks back I was in and out of our local hospital on daily basis as my father was poorly. Learning to use the rear exit for easy access to the car park I noticed this sign which I snapped and tweeted, \’Hospital #socialwork – life in the NHS portakabin\’.
Whilst not trending as such it created two separate flurries of activity – considerably more than my normal response rate
Was it because social workers are amusingly ‘way out’ or because their offices are actually frequently located in a portakabin in the car park? Both interpretations brought about knowing chuckles from tweeters across the land.
It did strike me though that if we are to secure the benefits of integrated health and social care (as intended in the Care Bill) then social workers should be:
• located at the heart of hospitals not outside in temporary office accommodation in the car park
• included in the governance of hospitals at practice management level to advocate for patients, argue the corner of the profession and make the case for resources
• have access to the excellent support facilities of a hospital – administration, equipment and training budgets
Over the years I have been involved with hospital social workers in several major hospitals and they were always led by a ‘Principal’ grade located on site. My guess is that is no longer the case. Perhaps it would not be too ‘way out’ to reconsider professional leadership of hospital social work as one feature of the integration agenda that will help realise some of the benefits for the users of hospitals.
Richard Banks, senior associate at CPEA Ltd, considers the remit of the Cavendish review of health and social care settings and offers some personal notes and thoughts.
Jeremy Hunt, the Secretary of State for Health, has asked Camilla Cavendish, Associate Editor and columnist at the Sunday Times, to lead a review looking at both NHS and social settings. The review will consider:
• recruitment
• training and development
• leadership, management and supervision
• engagement and support
• public confidence and assurance
The remit of the review does cover care staff in social care as well as those described as Health Care Assistants – but as is often the way, the Department of Health managed to appear to add social care as bolt-on to an NHS project. There are, of course, some shared issues but some important differences in particular that most social care staff work in private, voluntary or direct employment settings and not in the NHS. There are also differences in how you might go about communicating with the 1.7 million people working in more than 49,700 different adult social care settings in England.
Care and support are about values
Issues about the social care workforce are closely linked to the overall policies toward the provision of support to people who have disabilities or needs related to being older. The Government in England have avoided tackling the fundamental funding and policy issues of the aging population or the growth in the numbers of people with disabilities. Despite occasional protestations to the contrary government clearly see the aging population as a burden not as evidence of a successful welfare system or as an exciting opportunity to reconfigure attitudes toward older people as an active part of society. Attitudes toward adults with disabilities have become distinctly nasty, as they have been caught up in the government’s attempts to smear anybody using benefits. When looking for failures in values in a service a start at the top of a hierarchy is a reasonable place to begin. The government has not taken any action that communicates its value of people who require social care support. The last few years have seen an increase in the confused and overlapping requirements and initiatives from government and government funded agencies for and about adult social care. It is clear that most of these are political activities designed to give the impression that something is being done while avoiding any real commitment. The effect is an increasing state of confusion and risk of individuals and organisations being driven into cynicism.
Really good social care is often almost invisible.
The purpose is to care and support a person to live their life as they choose. So a really skilled social care professional should not ‘stand out in front’ of the work they do. This particular social care attitude and related behaviour will be alien to our self-aggrandising politicians. Rather than bombard the social care workforce with ill-considered attempts to manage them from Whitehall might it not be better invest in them as professionals? Registration of social care staff would go some way to start that change. I hope the Cavendish review will examine the progress being made in other parts of the UK on this and use that experience to inform English policy. Not surprisingly given the poor conditions they work under, individual social care staff often appear to have low self-esteem. When asked about their work the response is generally prefaced with ‘Well I just…’ they then go on to describe a complex mix of psychological insight, knowledge, practical creativity and skill. This low self-esteem may well suit those who continue to underfund and apportion blame but it does nothing to sustain or learn from good creative care. The National Institute for Health and Care Excellence (NICE) and the Collaborating Centre for Social Care has hopefully been set up to do this. The centre needs to find a way to set its own agenda with the social care sector; rather than be pushed by short term Government directives. The big tasks will be to create a coherent set of messages about excellent practice and find ways to get that information to the sector. The test of effectiveness will be use by carers, social care staff and their organisation.
Does Cavendish remit avoid strategic questions about resources?
It would be unfair to view the Cavendish Review yet another attempt to divert attention away from the woeful failure of government to provide leadership and get some integrated policy across departments. However the remit does avoid strategic questions about workforce policy and resources. The questions asked by Cavendish are important but have been answered before (in the Sector Skills Agreement and related work from Skills for Care) what is required is concerted action to provide coherent government policy with intelligently managed resources to match. Hopefully that is where the recommendations of the review will focus.
Richard Banks April 2013
Contact: CPEA Ltd 07947 680 588
The NHS is currently in the process of implementing a major programme of reform following the passage of the Health and Social Care Act 2012. This is designed to support the creation of a health service that is clinically led, patient centred, dedicated to the delivery of world-class outcomes and focussed on improving the health of the population.
It is essential that there is clarity about responsibilities in relation to safeguarding within these new arrangements – and about how the new system can help drive continued improvement in practice and outcomes.
In the final report (May 2011) of her review of child protection, Professor Eileen Munro expressed concern about the possible impact of the health reforms on effective partnership arrangements and the ability to provide effective help for children suffering, or likely to suffer, significant harm. In response, the Government committed to establishing a co-produced work programme “to ensure continued improvement and the development of effective arrangements to safeguard and promote children’s welfare as central considerations of the health reforms”.
The Government is also committed to working to prevent and reduce the risk of abuse and neglect of adults.
Thus reads the background and context of the new Interim advice from the NHS Commissioning Board on children’s and adults safeguarding – with adults as an ALSO. It goes to recognise itself as primarily geared to children when it says: Although this advice focuses on the statutory requirements to safeguard children, the same key principles will apply in relation to arrangements to safeguard adults. There are, of course, one or two fundamental differences of principle but never mind.
For those who have been wrestling with the health and social care interface in adult safeguarding for many years there is the welcome prospect of the incoming NHS CB and CCGs having statutory responsibilities. Particularly important for patients in commissioned services such as those that were at facilities such as Winterbourne View Hospital – the interim advice is unequivocal about where statutory responsibility will lie in the future.
The description of the designated professionals’ roles in adult safeguarding is interesting in that it expects expertise in the Mental Capacity Act as well as a broad understanding of policy and training across local authorities, police and the third sector. It anticipates this expertise stretching across older people, people with dementia, people with learning disabilities and people with mental health conditions. It does not see them as being hosted within the commissioning support services. Thus their host is likely to be an NHS provider. It is to be hoped that the proposed service level agreements will recognise the potential for conflicts of interest in such arrangements – conflicts that come to the fore in serious case reviews scenarios.
As the advice develops the ‘also ran’ status of adult safeguarding becomes more apparent. Funding is acknowledged only to the Safeguarding Children’s Board. The Director of Adults Social Services may be able to offer advice. Priority is given to numbers of children in need. A muddled message emerges on inspection between CQC and OFSTED. Reminders appear about designated professionals engaged with Looked after Children, around the DfE production of the revised Working Together and about the Royal College of Paediatrics and Child Health. A Safeguarding Children Transition Board is established.
Missing is recognition of the issues around continuing health care, the messages around the care programme approach from Winterbourne View and any acknowledgement of the fact that safeguarding in health and social care involves a massive diversity of provider settings. The third sector is recognised but not the private sector – yet residential nursing care is largely a private enterprise in the small business sector. Private providers are a vital aspect of support at home services – where they are well placed to initiate much needed joined up health and social care in the community. These developments will be enabled by a policy and practice climate that draws on advice that is cognisant that personalised services are safe services and vice versa. That is a climate where providers are partners in the truest sense of the word.
All in all the interim advice smacks of a cobbled together document to allow the timetables for the NHS CB and CCG infrastructure to be met. It has clearly suffered from delays in the production of the revised Working Together and uncertainty about what the eventual Care and Support Act will actually make statutory requirements and when. As a consequence it has the effect of relegating adult safeguarding to an ‘also ran’ shadow to the priority of children.
However the advice ends with the statement: We anticipate that it will be replaced by a more comprehensive document in the autumn, alongside the revised Working Together statutory guidance. It being September we also look forward to adult safeguarding soon emerging from the shadows before the winter sets in.
Note
Available on: education.gov.ukEven Google finds it first on the DfE website but also available after several search clicks on: commissioningboard.nhs.uk
Cpeanose 