Podcast Episode: Fit for the Future in Argyll and Bute
Category: Adult social care
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.
RM - Rhiann McLean
JR - Jim Robb
JC - Jackie Connelly
AA - Ann Austin
RM In 2014, the Fit for the Future project worked with Argyll & Bute Council and local independent sector providers to explore new approaches to the commissioning of care at home. Fit for the Future is a joint Scottish Care and Iriss project which aims to inspire better outcomes for older people by working with independent sector providers. In Argyll & Bute we worked locally with providers, commissioners and key strategic leads from the local authority and NHS to understand the current commissioning and delivery of care at home. We also explored the issues around it, particularly in rural areas. Then we brought all of that local effort and understanding together in an unconference of ideas where the partnership collaborated with the independent sector to form new and innovative approaches to commissioning. This Iriss.FM is a round table reflection on this project.
RM My name is Rhiann McLean and I am an Associate with Iriss and I am the Project Manager for the Fit for the Future project.
JR Jim Robb, Head of Adult Care, Social Work, Argyll & Bute Council.
JC Jackie Connelly, Performance Improvement Officer with the Procurement Commissioning Team, Argyll & Bute Council.
AA Ann Austin, I am one of two Development Officers for Scottish Care, covering Argyll & Bute.
RM And today’s discussion is about the project that we did around commissioning and care at home in Argyll & Bute, and it might be useful for Jim to set the scene.
JR Where we have been over really a number of years in Argyll & Bute, we periodically had specific areas that have been difficult to serve in terms of home care services. This is not really a new scenario - you can go back 10, 15 years when we had specific areas and specific problems in specific area. However, probably the last 3-5 years, the issue in terms of recruitment, retention, capacity generally, have become an increasingly difficult issue for us. That has to be put in the context of a growing older persons' population, both in terms of numbers and the level of disability that is associated with that. What we have effectively now is a growth in home care numbers approaching double figures every year, certainly over the last 2.5 years I think we have seen roughly about a 25% increase in the number of clients that we are trying to serve. Combine that with, as I say, increased complexity in terms of the nature of the job, very much around personal care, high dependency care, dementia care, moving and handling … combine the 2 issues and you have a problem developing. And interestingly, myself and Jackie Connelly had met with the care (… unclear) providers, probably around about Easter time 2014, to have a general discussion about conditions of service, which led to a far more wider debate about recruitment, retention, capacity, more efficient deployment of staff, how we serve difficult areas. And that discussion effectively coincided with a piece of work that we had been doing in partnership with Iriss over the last 3 or 4 months. Just some contextual information in relation to the growth of home care - really looking at the stats from 2011/12 through to 2013/14 - we have seen an increase in the number of clients that we are working with of basically about 29%, and the growth in the number of hours provided coming in about 13.8%. Now obviously the growth in clients is higher than the number of hours, but if you even just look at the number of hours increase over a 2-year period of 13.8%, that is significant - because your general growth in the population for 65+ comes in at about 2.5% per annum projection, whereas this is an equivalent of the best part of 7% growth per annum. And that has been the case for a number of years. We did a piece of work with the Special Projects Team in the Council, going back 3, 4 years ago, in terms of where we started around the commissioning and the externalisation of service. At that time we were talking about a growth of service hours between 5-6%. So we have now had certainly a period of 5, 6, 7 years of a growth between 5-7% per annum, the number of hours going out the door. And when you combine that with the working population, at best standing still in Argyll, if not actually coming down, we are trying to put more hours out the door, with fewer bodies, in what I’d say a crucially an unsocial form of employment - we ask people to do shifts, evenings, weekends - that suits some, it doesn’t suit many. Particularly I think the younger generation of folk, coming out of school, coming through college, look at social care and think “maybe day service Monday to Friday, 9-5, or a care home where the shifts are predictable, but home care is actually quite complex, shift work all over the place, unsociable hours, maybe not the greatest pay in the world. Is that really for me?” So when you combine the different factors of population growth with actual growth in the service, combined with the nature of the job, you can see the kind of task that we have got.
RM So in terms of where we came into the project, we were approached to do a little bit of work with Argyll & Bute Council, and particularly with the providers of care at home in the independent sector. Do you want to explain a little bit about the work we undertook?
JC Yes, just picking up on the changing landscape that Jim described there - when Susan Spicer and myself initially made contact with providers, those were the very issues that providers were raising with us. And we were then approached by yourself, Rhiann, from Iriss, and it seemed like the right time for the partnership to work together with the independent providers, just to look at the issues that were coming up. And Susan and I, along with yourself, set to, to kind of design a series of workshops that would identify the issues, but also look at possible solutions. And we did that - we had a series of workshops across Argyll, culminating in an event where people used the issues that had been identified throughout the workshops, which were primarily recruitment, retention, partnership working - how we might make a difference in those things. And at that event people started to think about action plans and how they would take those issues forward, in a very positive kind of way, I would say.
RM Yes, I mean for me I think a lot of the project was about helping providers come together as a group for the first time and really hash out what the issues were. It felt quite simple to say “well the issue is recruitment and the reason we have issues with recruitment is because of population and wages” - but actually once we started to break those issues down, they were much more complex than that, and I think it gave the providers a bit of space to talk about what was genuinely happening to them and see that some of the other partners were experiencing similar things - it wasn’t just to do with their business model - this was a universal issue. And suddenly problems which were seen as their problems or our problems, you know, we start to recognise that these are things that are happening across the board which I think helped people come together for that final event - because they were suddenly thinking “well if they are all of our problems, let’s come up with a solution that can serve all of us”. Can we talk about who was involved with those particular workshops?
JC There was a range of providers from across Argyll & Bute - not all of the providers took part, but as the workshops progressed, we made a point of contacting people who hadn’t been involved to try and encourage them to become involved. But alongside the providers there was the Commissioning Team from Argyll & Bute, and on occasion we had Area Managers and Clinical Service Managers from Health and Social Work. The providers themselves identified that there wasn’t a great presence from Health and Social Work at some of the workshops - and I think that definitely could have been a difficulty, but I think we worked with that. We tried to encourage, after the first round of workshops we tried to encourage more of the Area Managers and Clinical Service Managers to come on board with that.
RM Can I ask you, given the fact that you kind of held lots of locality meetings where these sorts of things had been brought up - was there any difference between what you had experienced in the past and the kind of things that were happening in our workshops? Did you notice anything?
JC I noticed a real need for true partnership working. Before we set off on this, providers had partnerships with the Commissioning Team or with Adult Services - but what I did notice during this process was that providers started to form partnerships with each other, which was more important, from my perspective that was far more important than the partnership that they had with the Commissioning Team.
RM And we want to talk about now what the challenges were in working in this way - we have maybe touched on one already around the membership of the group - and I certainly felt it in some of the groups that, considering we were using this as an opportunity to really start a change process, the lack of representation from Health & Social Care at a couple of meetings was seen by providers as a statement. But I think the final event managed to kind of pull that back and make people feel like they had all made the same effort to come together - and certainly the ideas that were presented at that last group were group ideas - they had come from this collaboration. And were there any other challenges, that you can think of, in terms of the way we worked?
AA I think initially some of the providers had issues with the timing of the initial workshops, and we changed the time and the proposed days of workshops to fit better with their business - because we were meeting with people at a time where they were facing a lot of challenges in their business - so I think it was important to get the events kicked off, so we used the times where we could all be available. But I think the providers came forward with their issues with that, and I think there were some preconceived ideas among providers that it might just be a talking shop or whatever. So we had to overcome that a bit. But I have to say that the providers helped greatly in overcoming that, because they identified those issues themselves and said “that’s not what we want - we want to move forward - we want to forget what has gone before and for this to be different”.
RM I would say absolutely, there was a real desire for action coming from the groups, which I suppose was a challenge for us from a facilitation perspective, that it wasn’t good enough to work through these issues and talk through these issues - we were on a bit of a tight timeframe to make sure things actually happened, and it did feel like there was a lot of pressure to have action. But in a way, that is quite positive, because it meant we were, you know, really motivated to do something about it. And it meant that when we went back to providers and asked them to do something about it, they had kind of set those terms themselves, so they were much more willing to take that responsibility, because that is what they had expressed that they really, really wanted to do. Can we think of any other challenges we want to discuss?
JC One of the bigger challenges that I faced initially was that we were asking providers to work collaboratively, but they had very different business models. But I must admit that all the providers showed a willingness to resolve the issues as they came up. And I think we have overcome that, to a certain extent - there is still some work that we need to do there.
JR Yes, and I think rather than present that as a problem, I was actually quite pleased that a lot of independent companies were prepared to look at the issue in terms of strategic planning and strategic commitment. Now obviously that is still to be tested, but they have certainly all making the right noises in terms of looking at it as a strategic issue, working in collaboration and working in partnership - not just with us, but with each other, in terms of more efficient deployment of staff, looking at issues around recruitment, retention and training, etc. I have to say I have been pleasantly surprised by the groups' willingness to actually come together on that.
AA I think one other issue that came up was a difficulty sometimes in some areas of statutory services to just give permission to providers to move on from their preconceived ideas of providers who were difficult to work with, who had a business model that was narrow and things like that. And I think that was quite challenging for us, as facilitators, to kind of get underneath that and try and move that forward. And that is possibly still a challenge, maybe more, for the statutory services.
RM I think our approach was really trying to make providers think “well why not? Let’s actually think of this in a positive perspective”. And I actually found it a barrier as well of how scared of regulation and inspection providers were. So when we started talking about innovative ways of working together, of 2 companies maybe collaborating on one area to make sure they were giving the right level of service in really rural areas - they were immediately starting to think about the impact that it might have in terms of Care Inspection and quality and their perception of the inspection process as being unfair or punitive towards ideas like that. So there was a sense of, you know, really wanting to protect yourself - particularly those who were really proud of the quality they were delivering - saying “well we can’t risk that”. And again, one of the challenges was that we didn’t have the Care Inspectorate at the final event as well, so it felt like there is that missing link to where we are starting to give each other permission to do things, but on a national level we quite wanted a bit more permission from the Care Inspectorate to say “these are the sorts of things that we want to work with providers to do, to make sure they are maintained, their standards of quality”. The impact of the sessions, they were really well evaluated by everyone who attended. People felt that it was an opportunity to talk about not just the issues that were affecting them, but also the future, specifically the local areas that we were talking about - you know, what does self-directed support really mean to us? What does integration really mean to us as providers? And it was an opportunity for them to really hash that out with each other and start to think about how that might affect their business in the future. The larger event was also really positively evaluated and was seem to many as a start of a new way of working, and people certainly felt like they had been heard or had an opportunity to really contribute to how commissioning was going to take place in the future.
JC I think there was a real emphasis from the providers on moving forward and working in partnership with each other and with the other services across Argyll. And that was really important to them - they saw that as a key to how things would work well in the future. Some of the big ideas that came out of the day were things like starting to share training, using a training passport, so everyone was trained to the same level, so they would be a bit less nervous about working with each other to cover patches, about working together in patching areas so that people received outcome based care at the time that they needed the care and that the emphasis was on the outcome for the person, not time and task approach. They talked about a different approach to assessment and review - and there was another idea about a multi-agency responder service to out of hours and the tele-care equipment, so we give more people access to tele-care and tele-health equipment. So some really concrete ideas to take forward to the future.
RM I mean I was certainly surprised that the ideas had so much range and that providers were actually interested in getting involved in things like assessment, and actually thinking about strategic planning, rather than just thinking “oh these are the services we are delivering and this is how we might deliver them differently” from that kind of bigger level saying “well maybe we could look at the way these are planned and maybe we could look at the geography of this and how we can make sure that we are delivering this more efficiently as a group”.
JR Yes, I think there is a starting issue here and I don’t think we have quite cracked it - the independent providers actually feel that they are equal partners. And I thought it would be difficult because we do commission them, there is an economic relationship there. But if you look at service delivery across older people in Argyll & Bute, both in care homes and in home care, you are probably talking about anything up to 80-85% of our work is commissioned externally. And I (… unclear) in this so that we are encouraging innovation, we are encouraging empowerment - that we need to continue to work at developing the view that yes, we are talking about partnership. Now it can be difficult because as I say there is an economic relationship, it can also be difficult because certainly in Council, you work in the political context - and some of the members have … well there is varying views around the membership of the Council about external services as against in-house services - and you get myths created about good and bad an indifferent and all the rest of it. Because the more we encourage and understand the partnership working, we can start talking about innovation, we can start talking about joint commissioning properly … not just ticking the box, but actually involving the independent sector as part of that. I think what we have done this year has been quite a shift in trying to achieve that, but I don’t think we should understate that there is still an awful lot of work to be done in creating that culture of trust, partnership, etc, etc. I think some of the things that we did talk about, and there was one independent provider who talked about moving away from commissioning on time to commissioning outcomes - that is a crucial issue for us, because if you can achieve that, you can start deploying your staff quite differently, far more efficiently, into teams, servicing groups of clients over commissioned periods of time of about 3 or 3 ½ hrs, and that is a very different model, and it moves us away from one of the chains that are constantly around our neck about Mrs Jones, getting there at 9 o’clock and getting her 30 minutes. Now free personal care for over 65 is free, so it’s not as if they are actually buying it - if people need ½ hr, they get ½ hr. If on a bad day they need 40 minutes, we should have a system that empowers the home care staff working in that patch with enough authority to make those decisions by themselves, to say “well Mrs Jones needs 40 minutes today, but we can tidy that up over the next 3, 3 ½ hrs by moving stuff around”. So there are cultural issues in terms of how we work together, but there are also cultural issues in terms of how we manage the staff. And that was an interesting discussion that I had - I challenged a number of managers, both internal and externally, about the management culture, Monday to Friday, 9 to 5 - as against a management culture between 5 and 10 o’clock at night on the weekends - and it’s completely different. They empower their staff far more in evenings and weekends to get on with the job. So that needs to be transferred over as well. As I said before, strategic recruitment - I think they need to try to move to a model that we are trying to recruit to home care … or possibly even wider in terms of social care in Argyll & Bute. Home care is the main issue for discussion, but we will have issues in our day services, our care homes, the NHS has recruitment issues as well even for qualified staff. So recruitment and retention is a major issue for us, that again with a partnership we need to look at more strategic ways of thinking rather than competing against each other. And finally, in terms of future commissioning - a lot of present models about 3 preferred model of a split of 60/25/15. In a sense we have already ditched that - we are not working towards that. We will formally ditch that come January 16. We will want to put commissioning of enablement and re-ablement on the table. Now we need to do that now, it’s not about surprising people a year down the road. We need to start having that discussion going into 2015 about what kind of model of care we want to commission from the independent sector in future - and that ties into strategic training, etc, etc. So it’s about continuing to build on the work that we have done, re-emphasise partnership working, re-emphasise strategic thinking, efficient deployment of staff, a more flexible service and where we want to take that in the future.
RM It’s certainly one of the areas that I found really interesting, is that when we were talking about models for the future, the independent sector didn’t bring up re-ablement. And I think that’s because historically they haven’t been part of it or they haven’t felt like they are part of it. So it was a shift to get people thinking on that bigger level, you know, what does a full picture of re-ablement look like? Because if we are only doing in-house re-ablement, but the majority of home care services are outside …
JR I think there is a history with the Health Service … the Health Service believe enablement and re-ablement belongs to them, within specialist teams. I am quite comfortable with specialist teams that work on re-ablement for short periods of time, whereas if home care providers come in “what happens after that 6 weeks?” Because if you do something for 6 weeks, then you stop doing it, people will invariably fall off the cliff, 3, 4, 5, 6 months down the road and you are back in. So it’s about how you sustain re-ablement and enablement, and that’s where home care services … we do the long term piece of work in terms of sustaining that. And I think most people in the Health Service and the independent home care companies, got a few kind of lightbulb moments on that, in terms of rethinking historical positions of them and us - Health Service believing that agenda belonged to them and them only, and then having to start to think wider about the long-term sustainability of it.
AA I think that is one of the real main opportunities to embed partnership working, is through re-ablement, because it’s an opportunity for people to kind of work together and learn about the strengths that each other has. Because in working in re-ablement, you have to get your sleeves up and work together for the outcome for the person that you are supporting. And I think it would be a really positive way forward if the independent sector were included in the re-ablement agenda, because I think they are shifting slightly. But when we started, they didn’t see themselves as part of the re-ablement agenda for Argyll & Bute - “that’s not really our business”, and I think that is shifting and we need to monopolise on that, I think, and use it as positively as we can.
RM Certainly, from my perspective, this piece of work was just the very first step in a long journey, and I think in terms of a lot of the ideas that came up, they are quite longer-term outcomes, ideas, so we might not see that immediate change right now - but what we have learned is that particular way of working, this way of kind of opening doors and sealing partnerships together, has led to a lot more movement in terms of culture and opinions of each other. So I think in terms of my own personal learning, it is that approach. Long term I am excited to see what comes out of it - but I am aware that there are huge issues to be overcome that will take time. So it’s about making sure that the independent sector are continued to be supported through that process, and making sure that that partnership continues to grow from strength to strength.
JR Yes, I mean I think both strategically and politically, as I said, I think we need to build up that relationship in terms of partnership with the independent sector - it’s important that the likes of myself are able to present that to our politicians and sell that to our politicians as the way forward. There is some disquiet within Argyll & Bute because we have some (… unclear), probably for the first time in a number of years, that some simplistic view has been taken that because we externalised the service we have created problems. The level of growth both in terms of the number of clients and the number of hours that we are putting out to date since we externalised doesn’t reinforce that view - and also the fact that where we have retained the service, specifically in the Mid-Argyll and Kintyre area, the biggest problem that area manager has is recruitment and retention of staff. So I need to take this through a kind of political process in terms of giving us a sustainable long-term commitment to working with the independent sector - because the last thing the independent sector need is me saying one thing and the politicians saying another. And it is … some of this is very simplistic in terms of getting political buy-in to commissioning an outcomes rather than commissioning on time - Mrs Jones getting the 9 o’clock for ½ hr is very understandable. Mrs Jones getting what she needs some time between 8 o’clock and 10 o’clock is politically a bit more grey. But that is what we need if we are going to deploy staff efficiently and be outcome focused. So the strategic political work that I need to do - myself and Jackie … well Jackie has already started on a Committee paper that we need to build up on. There will be meetings with senior political members over the next couple of months - my job and Jackie’s job is really to reinforce the work we are doing here and the work we are doing re the reshaping care for older people framework, is achieving best value, good outcomes and quality. In terms of sustaining things, obviously we have got the reshaping framework, we have got the joint commissioning plan - but as I said, I have got a political piece of work to manage as well. But I think, as I said earlier on, I have been quite heartened by the approach of the independent sector on this. We have identified a number of issues that we want to progress on. I suppose the challenge will be making those ideas into reality, because it does challenge some of them in terms of their own independence, as independent companies moving into joint recruitment strategies, joint deployment of staff strategies, joint training strategies. I think the majority are up for that - but there maybe are one or two who want to retain their independence within that. But by and large I think the last 6 months on this has been relatively good news, but we need to use 2015 to actually start putting down some markers and time frames for things to start happening.
AA For me it’s been an absolute privilege to be part of this piece of work. I think the commitment that has come from the providers and the will to come to the table and look at the issues and identify them and work on them. And I think it’s absolutely crucial that that good will is retained and sustained. What has come out for me, when I have been reflecting, is the amount of experience and skill within the sector in terms of how they conduct their business, and that is not always recognised by other partners. And I think they have got a lot to offer the partnership in terms of some of the bits of work that they are particularly good at. I think it will be really important in moving forward, because one of the issues for the providers was that at the point where the current contract came into being and they were bidding for that contract, in no way did they or any of the other partners expect the growth in home care that has happened. So they have taken this opportunity to reflect on the difference of the service that they need to provide - and I think we really have to harness that and move forward with people. I think it’s really important, reflecting on what Jim said, that somehow we have a way of building bridges with the politicians in the independent sector, because sometimes the politicians are speaking from a point of view of a personal opinion, maybe not as well-informed as people who work with the providers every day. So I think it is really important that together we look for a way of getting politicians and the independent providers together to kind of explore some of the issues.
RM Yes, certainly when we were in the sessions, that was what the providers were identifying as one of the main struggles to them, is the public opinion of what they do and a misunderstanding of what it is they are delivering. And the reality is that they are delivering the majority of support out in the community for older people. So supporting them to do a good job shouldn’t become political, because they are out there and they are doing it. And another thing that surprised me was I think there is a lot of assumptions about what the independent sector can and can’t do. We have been calling them ‘businesses’, but in many ways they were focused on the people out there who they were supporting. They were always trying to put that end focus on - and they were really capable of being innovative and forward thinking, and sometimes they were leading that process in the room, as providers. So that was something that was really interesting to me.
JC I was actually amazed about how our partners all agreed and the willingness they showed to work together. One of the unexpected outcomes that I got from the day was from Argyll College - Argyll College have agreed to provide an Access to Social Care course, and it actually fitted in really well with the work that I was currently doing with the providers. That was one of the options that we could implement immediately. So Argyll College came to the next Care At Home forums, and by coincidence, the DWP were also attending those forums to set up some social care academies with the providers. So it was great to see the added benefit of having 2 organisations there that could then work … form a formal partnership together, so we weren’t just forming partnerships with other agencies - there was joint agencies forming partnerships and taking things forward because of the joint working, or the joint work that they were planning to do. It fitted in well with the care academy’s - the DWP’s work fitted in well with the care academy’s. Next step - I think the most important thing that we can do is to ensure that we retain the momentum of the project so far and move forward with all the options - the same enthusiasm and commitment that has been shown up to date.
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