Transcript: Changing how homecare is commissioned and delivered

Experiences from the Gwynedd social care team in Wales

Podcast Episode: Changing how homecare is commissioned and delivered

Category: Innovation and change 


What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

Meylis: Hi, I’m Meylis from North Wales. I live here in Gwynedd and I’ve worked in Gwynedd for quite a few years. And currently I’m in a role across health and social care, leading a programme of change called the Community Transformation Programme. And one of the key things I’m working on and have been working on for a long time, is trying to change the way that we commission and deliver home care in Gwynedd. And I say commission and deliver because Gwynedd Council provides around 50% of the home care in Gwynedd which is quite unique in Wales and beyond, I think. So, this is just our story; where we’ve come from, where we’re trying to get to; we’re still on that long and windy road. We haven’t tackled everything; we haven’t got everything perfect but hopefully I’ll make some new connections today and we can share ideas and thoughts.

So, going back a few years, we were in the same position as many of the local authority areas and health boards, just facing what’s commonly called a ‘social care crisis’. Not being able to find enough workers, always in a crisis mode and really struggling. And we decided that we needed to look at the whole system through a different lens because, I’m sure this is really familiar; we’ve got Covid pressures, more recently Brexit pressures, many shortages, etc. So, we decided to be really courageous and thought, right, let’s be honest with ourselves; let’s see whether what we’re doing is the best thing. And at the time, when this project started, I was in a role as a senior business manager and part of that role was to do with commissioning and procurement. So, I had to be honest with myself and acknowledge the fact that I really didn’t understand fully what we were commissioning, where the money was going, and whether we were actually meeting outcomes for people.

So, we set about to use the Vanguard method which is a method which takes you through step by step to understand your whole system from the citizen’s perspective and that’s really important. But also helping leaders and staff and organisations and people within the community to really see how that system affects citizens. And I could talk at length, and I’ve been on many courses around the Vanguard method but that’s just a snapshot of what the method is. And it’s got three main parts to the methodology; check, plan and do. So, rather than maybe sitting in an event like todays and hearing about what someone else has done and then jumping into a project plan to try and implement what we’ve heard about; we start by doing check which is learning and understanding from the citizen’s perspective and understanding the true nature of demand, where our money’s going, whether there’s a waste in that system or it’s bureaucracy, etc.

Before moving on into the planning stages which is experimenting and trying to develop a new model that meets our demand locally and does the right thing for people. Before then, the stage we’re at now which is making it the norm which is going out to tender and redesigning our inhouse provider to meet the model that we’ve developed. When the check process, I’ve mentioned, we learned about conditions within the system and just really, really understand each step of the process; not just in terms of a business process perspective but also in terms of the person’s experience of that system which is slightly different emphasis and we did this with a partner called Cartrefi Cymru, this is a third sector as it happens, organisation who are also really engaged with the Vanguard method. And we mapped end to end from the minute somebody decided that somebody needed to be assessed for care all the way through to paying for that service and charging the individual and everything in between.

And for that to happen, we needed to involve a provider as well and that’s what we did. No surprises, typical time and task model, people were just given a list of tasks at a specific time of day, specific number of minutes. And more often than not; 99% of the time, that care plan looked exactly the same every single day of the week regardless of changes in the circumstances or need for that individual to deal with whatever they were dealing with. So, this is, I think, a good illustration of the system that was built up; not just in Wales, in many places. And it’s very uncommon, I think, to see a system that is different to the system where you’ve got a list of staff, list of clients and you squeeze people into boxes on a spreadsheet in a glorified system and then you hope for the best. And despite everybody’s best efforts and the best possible staff, you’re just working to the spreadsheet rather than allowing staff to build up relationships with people and be very flexible in how they offer them support.

So, we moved into the next stage which was the planning or experimentation. We did the initial experiment with Cartrefi Cymrum but then we worked with Gofal Bro an external company with our inhouse provider and also with Gofal Seibiant, and Alison from Gofal Seibiant is with me today. She’s going to talk a little bit about her experience and that’s why I’m whizzing through this presentation because I really wanted to hear from Alison and her experience. But we just started with a clear purpose; so, we wanted to help people live their lives as they wanted to live it. That’s our mantra; that’s what we’re trying to achieve. And I must be honest, I stood in front of all our providers a few years ago and I said; I know exactly where I want to get to, I want people to be able to continue to live their lives as they want to live it, as they will always live their lives. Have really strong sense of purpose and be happy and have really good wellbeing but I haven’t got a clue how I’m going to get there. And that’s where I engaged the help of all our providers to do all of this experimentation, but we literally started with a couple of people who needed support and a couple of care staff. And we sent out those care staff and we said, your job is to get to know people and come back to us as a group of leaders and managers and people from different care and health professionals and just talk to us about what could make a difference and how this service can be built up. And as we got more and more people into that experiment, we started to learn about what we were doing that worked for people, but also what we were doing that didn’t work and where the blockages were in our wider health and social care system.

We very quickly learned that this wasn’t just a tender exercise that everybody would have to change. Everybody would have to reflect and look at their expectations, their understanding of the system and be willing to change and this is right down to the citizens themselves and community. We’ve built an expectation about each additional model that we need to now work on. Changing those expectations and allowing people to expect something different and not be bound by measuring quality in terms of whether somebody stayed for the full 30 minutes for instance. And we’ve got lots of work to do to change our social work practice, to work with commissioning and contracts teams and finance colleagues.

And I’m really happy to say that after working on this and helping people to see why we want to do things differently; I’ve got total support now from colleagues in those support services. But it hasn’t been easy, and I’ve had loads of ups and downs and challenging conversations with people. And I wouldn’t over emphasise the importance of those relationships with everybody involved in this massive system. So, over time this new model emerged from the system we were in which was very disjointed; one person assessing, passing on to broker, broker looking for a provider. Very often looking for the cheapest provider, and then in the most recent years just looking for any provider who could pick up the package because it was such a scarce resource. And then the provider would start all over, essentially, and do their own service plan with the individual and then start the care. And we could easily see six weeks pass between the beginning and the end of that process.

So this new model that we’ve developed, which is person-centred – where we’ve decided that we really, really need the provider whether they’re commissioned or whether they’re part of the inhouse provision; the provider needs to be part of the team. And it sounds so obvious to me now but that’s not how we used to work. We need the provider alongside social workers, therapists, district nurses and depending on your world, your service, that group of professionals would be different. But we needed the provider to be at core, part of the team. And we now encourage not having a one-off assessment, but it’s an on-going process of building up relationships, understanding what matters to somebody and trusting the staff to do the right thing. And not having to go back through many, many hoops for a change, a very small change in the care plan, to be authorised by somebody within their own organisation and then within other organisations.

So, this in a nutshell, is the model that we’re now working towards and we have started to implement this in many areas in Gwynedd. To try and describe what we’re aiming for, we very quickly reached the conclusion that if you want to support somebody well, you need to be collaborating with other professionals and people supporting that individual. For that to happen, you need to be in local areas and we used to have a spot purchase and if you look at this map of Gwynedd and imagine that maybe a provider would be dotted across most of the areas in Gwynedd and they never had an opportunity to really build up those local relationships with nurses and social workers, etc.

We reached the conclusion that if you want to meet what really, really matters to somebody, you’ve got to tailor that support to that individual and to those sets of circumstances; you can’t just have a blanket approach, you can’t have a standardised care package which is essentially what we used to have. You need an awful lot of flexibility because people with health conditions, for example, or with just normal day-to-day life, they don’t do exactly the same every day. They don’t need exactly the same thing every single day, so the staff need to be allowed to be flexible.

But in that model I showed you, where people are pushed into boxes; they can’t be flexible because once that call is over, that 30 minute call is over then very often staff members would go home, maybe for a couple of hours and they weren’t there on the ground. So, we decided that we needed to create an environment where people were there in the community on the ground and we needed to move away from being obsessed by calculating every single minute of what we call contact time. So, this led to the decision that we probably needed shift patterns and this is what we’ve started to implement with the inhouse provider. And lots of our providers are now moving to that pattern of working for their staff.

You can’t, as a provider, commit to shift if you’re only paid on a spot purchase basis for the hours that you’re doing contact time. You can’t expect your providers to give those hours, to give the staff contracts, etc. So, we’re now moving to pay our providers on a block purchase basis. So, we started doing this with a few providers who’ve been experimenting with this and as part of the new contract that we’ll be signing hopefully mid-summer. Then all providers will have a block payment arrangement with us. We now strongly believe that if you want to achieve value for people, you need more than just the contact time; which again is common sense. Why on earth did we never realise this previously?

And I think the Vanguard method has definitely helped us to understand this. If we think about any family member, the time I spend with my children is really, really valuable, obviously or hopefully, I’m sure they’d say that they value that time with me. But it’s not just that time that’s important. I spend a lot of time doing some online shopping, ringing … for instance, this morning I rang the dentist because I needed to take them to the dentist and these sort of examples where you need to be able to do those things outside of the time that you have with the person. And we are, in the new model, expecting providers to be tapping into community opportunities to support people and they can’t do that within the short period of time they have with the people. They need that time to be engaging with the sector, the community groups who maybe need this.

So, it’s a very community-based model that we want; we don’t see care in the formal commission sense as being an island; we see it as being within the context of the community. This model, the Ashby model, I’m sure you could Google; read lots about but basically, it’s illustrating the point that in our old world we only had a very limited number of responses. We had a very standardised approach and what that led to was that if you had an issue, a problem, a need that wasn’t met by one of those standardised responses then really, we were shoehorning people into a service that wasn’t appropriate for their needs. Whereas now we’re looking at it in terms of understanding the true needs of that individual and working with care providers to upskill, to change, to pull in support etc. So, it’s a much more tailored approach.

This is just a really quick story, a couple of stories I have to illustrate the point, I suppose. So, I had a gentleman with MS, the provider was delivering three or four calls a day for this gentleman and you know he was being kept safe and he was relatively healthy under the circumstances but his passion was football and he really, really wanted to go and watch a football match with his brother. So, under this new way of working where we’ve supported managers and staff to think differently; they worked with the local therapist to get hold of a wheelchair and took him to the match with his brother. Not with Super Mario as the picture suggests, with his brother. Spent a lovely time at the football match and he asked the carer on the way home, is there any chance we can stop in the garage so that I can buy my wife some flowers because I haven’t been out without her for so long? She’d had some time to herself, he went home, she was so pleased because he’d had some time doing something he really enjoyed; going back to the way he used to live, a bit. And it just demonstrated the power of putting that care team in contact with other professionals, thinking outside the box. And also allowing them to work flexibly so the staff members in this story volunteered to work at a different time of day for that week so that they could accommodate this gentleman’s needs. So, really simple, common-sense stuff but the system we had previously just wasn’t allowing that way of working.

This is a story about Gofal Seibiant and Alison was key to the success of this piece of work where we had a team of staff working shifts in one particular area of Gwynedd called Nefyn. And when the Covid pandemic struck and there were issues around people visiting GP surgeries and GPs being under pressure, we upskilled Allison and her team. Upskilled the team of carers to be able to use basic equipment to go out and do some observations on behalf of GPs. So, because they were working flexibly, working shifts, they were there in the community, they could pop in and see somebody and do blood pressure checks, oxygen checks, pulse, etc. Just basic things that we would never have dreamt in the past of asking care member of staff to be doing. And then they would ring the doctor, give them the readings and the doctor would then decide the next course of action. So, really pulling some of the pressure off the GPs and really being part of that GP team.

Another really quick story of how the model has changed the way we do things, had another provider in Caernarfon and they realised that they were sending seven carers to see seven different people on the same housing estate to help them with lunch. And they thought what if we brought these seven people together? And they worked with the local housing association, got cheap rent in a building and here they are; they’ve got a lunch club. And by now, I think there’s about 32 people who go. The director of the company has pulled in some colleagues who are volunteers with the local football club committee and they’ve got this young lad singing and playing his guitar.

So, it just shows the same amount of money being spent on that provider but supporting many, many more people and those people who go just enjoying themselves which is what it’s all about. There are those really local things, the individual stories which are fantastic but we’re also trying to tackle some huge issues which I’m really pleased to say by now that the Welsh government are looking at, in a very structured way, but three or four years ago we were trying to struggle through some of these issues. And this book is a really great read by Linday Hayes about how, over the years, we’ve used employment law. And we haven’t exactly broken it but we’ve interpreted the law in a way that means that we’ve been able to get away with not treating care staff in the best possible way.

So, we’ve worked really hard on recognising no one’s going to get more money but trying to use that money differently by moving out of the orange which is the management cost, the bureaucracy cost and reinvesting that money in staff terms and conditions. And I could talk a lot more about how we’ve managed to do that, some of the savings that we’ve done within the inhouse provider and restructuring that we’re planning, etc. So, please at any point in this presentation, if you feel that I’m running through things, please make note and please come back to me. And we are working towards less managing the staff and more self-management. And I’ve been in contact with a provider called Bellevue who’s been working on this and there’s a lot of similarities between the Buurtzorg model and what they do and what we’re trying to achieve. So, we’re still learning about how we can help staff manage themselves with some coaching and mentoring but less micromanaging.

This is the Vanguard method for developing measures and the key thing in this is that we need leading measures. We need to be asking ourselves time and time again, do people have a better life? Are we helping them with what matters to them? And a lot of what we’ve been measuring historically, are either planning measures to help us manage demand or they’re lagging measures. And if we focus on really trying to help people get a better life, what we found is that the lagging measures; so how much we’re spending, how many hours people need, how the staff feel, how families feel, those measures are improving because we focused on doing the right thing. So, we do have a suite of measures that I could share with anybody who’s interested.

So, we are going out to tender at the end of March, we’re opening up the process and it will be a block purchase for a given geographic area. We are joint commissioning with health. Up to now it’s been separate commissioners which isn’t useful in terms of competing against one another. And really allowing providers to do what matters for people – building up trust, having a relational based contract and not counting every single hour and every single penny. Responding and amending the level of the contract. If we find the demand dramatically goes up or down but not being obsessed by counting the money and counting the minutes.

What we needed to get this far is a question I’m often asked. We needed really strong leadership, really strong purpose; we keep on going back to that vision, that purpose, being relentless about not giving up and also having enough capacity. There’s myself, a couple of team members who work with me and we have had the project team for quite a few years and I think without that it would have been really challenging. We need time, relationships aren’t built in a day; we need time to build those relationships. It’s going to take a long time for providers to trust us. We need to be able to change mindset and have the skills, the intervention skills to be able to change mindset. I’ve got a fantastic communications and PR manager who works with me and I think that’s invaluable because there’s an awful lot of stakeholders that we need to bring along with us and we need to be really resilient.

This has been a rollercoaster ride, if ever there was one. And I’m sure I sound quite upbeat today but there have been the down days as well. So, we’ve had to be determined and just believe in what we believe in. Tendering, but also looking at our social work practice development, how we’re developing our communities, helping providers embed the new method, etc. So, this is just the beginning of a really, really exciting period for us. We’ve got the tendering exercise, business processes to be reviewed, we need to embed the new model. Alongside this we want to develop micro-enterprises and we want to communicate all throughout this massive programme. So, just illustrating the point really that I might be rushing through this and it might sound simple but it’s a lot to think about and it’s very exciting. So, thank you very much. I’ve gone through that really, really quickly. So, now I’m going to hand over to Alison.

Alison: Thank you Meylis. We started a patch which was in Nefyn. I don’t know if you saw it on the map, it’s quite a remote place really, isn’t it Meylis? And we started that about four years ago. So, setting up a new team in that local area; that had its own challenges. But it was much easier knowing that we had a block contract when we were going out to recruit because we were able to offer shifts which we’d been doing previously in another area. But being able to offer shifts was important to us and to the staff but it also allowed us to have a look at how we were going to pay the staff; what wages we were going to pay them. So, we were looking at a tiered system. So, you had like an entry level and then you had a more advanced level, then more of a sort of mid … somewhere between advanced and management level then. So, with the idea of career progression.

So, people could come into it who had maybe never done care before, see how they liked it and then were able to do courses. Were able to have the experience and then were able to see that they could progress up and use this as an opportunity to look at home care as a career rather than maybe as a stepping stone into something else. Which, I must admit we’ve had that team, we haven’t had a huge turnover within that team, obviously when Covid hit, everything then did seem to go a little bit different, I won’t say bad but it went different. We had people who were in other professions who thought, you know because they were on furlough, that they would give care a go and we’ve managed to keep some of them; they’ve not gone back to whatever job they did before and they’ve stayed and enjoyed it. By being able to offer them things like (YOBS … unclear) training, that gave them additional purpose and they felt that gave their job more value as well; so, they’ve really enjoyed that bit.

One thing that’s very important to us, and this block purchase enabled this to do, and moving away from time and task was palliative care. We view our palliative care people as VIPs so they get what they need. So, when we do have, you know our other citizens; we do tell them, when we come, okay, we’ll be there usually between, for example, eight and half nine in the morning; roughly that time. But if we do have a palliative citizen then they get what they want or stay with them as long as they need. And the person that might be waiting for their care that morning are not worried that we’re half an hour later than usual or an hour later than usual. We will give them a courtesy ring if we need to, to let them know but they’re all aware there’s that flexibility in time. Also, if there’s an unfortunate incident; if you arrive at somebody’s house and you find them collapsed and you need to call a paramedic and things. It leaves the carer being able to stay with them without the panic then that they’ve got to be on the next call and then they need somebody to come and cover. It’s trying to keep everybody cool and calm and do what they need to do.

There’s been a lot of opportunities by doing more flexible working, when we recruit, to also be flexible with the staff that we can recruit. So, we’ve gone for school friendly hours because we’re able to move some calls to start after quarter past 9 or if they’re using breakfast club, they can start a bit earlier. So, it’s just that little bit more flexibility within it. Definitely the block purchase also lets us then look at the way that we provide additional support to the staff like our HR, our training. We’ve even got a … I call it a co wheels car, it’s like a base car that the staff can have. So, we’ve looked at other ways, so it’s not just the hourly rate, it’s the terms and conditions as well. But because we’ve got the block purchase we can then look and go; we need additional training manager time or training assistant time. So, we know that we can go out and we can afford it and this is what we need for this period of time rather than, oh, if our calls drop then our income’s dropped and we’re not going to be able to afford to keep so and so. So, it gives us far more flexibility but also that better grounding when we try and plan out the whole system really.

We do work with another local authority nearby which they’ll do spot purchase. Out of fairness to staff, we give them … because we believe we’re giving the staff in Gwynedd shift pay, we’ve also given the staff in the other local authority shift pay. We actually were there first before we came to Gwynedd. And it’s really difficult then if you’re in a very rural area and you’ve got a contract for that patch not to try and plan your time. So, you might have staff going 10/15 miles between calls and if you’re not, as a company, you’re not getting paid that; it becomes really quite difficult to sort of manage that bit. The one big thing I would say about going into the spot purchase and the Vanguard was a whole system change was getting, not only so it had to be us, it had to be the staff coming on board especially if they’d been somewhere else had done it time and task to unlearn that and to do it differently. But it also meant that social workers and everybody else had to understand that it was, not to say they’ll be there at 8 in the mornings, they’ll be there for 25 minutes and you phone me if they don’t. So, there was that opportunity. The citizens, they’re encouraged to bring forward what it is that they want from their care. So, they tell us what matters.

One quick thing I could tell you is, I remember one lady who, she wanted to get up in the morning and have her breakfast but after a couple of days of going there, what she really wanted was having a cup of tea in bed in her China cup and saucer while she woke up. And then she liked to get up maybe 20 minutes/half an hour later. So, the staff were able to do that; make her a cup of tea, then go down the road, start somebody else, you know; go see them, and then come back to her. So, that’s what was really important to us, it wasn’t all just bunched up into, she wants a cup of tea and she wants to get up, she wants a wash, she wants to get dressed. It’s how she wanted it; down to the china tea cup, that’s how she wanted it.

There was another lady who really wanted to go to chapel, Sunday late morning, but would not go in a pair of trousers. And she felt she had to have her trousers because she had compression bandages on, the district couldn’t get there to put the bandages on differently. Because there’s a different way of doing them, any earlier. So, the team worked together so that the staff could go in after the district nurse had been with these compression stockings on so that she could wear her skirts to go to chapel, then come back and then the district nurse would come back and put compression bandages on. But it was really important that this lady was able to go to chapel but in her skirts. It would have been absolutely beyond the pale if she was expected to go in trousers; it just wasn’t going to happen. So, things like that but it wasn’t that the staff then came back and said, well I was an extra half hour with her. They’re paid a shift so; it didn’t matter how they worked that shift; it was flexible for them. So, I think that’s possibly it in a nutshell…

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