Could self-management work in care homes?

This blog is co-authored by Helen Sanderson, founder of Wellbeing Teams and Alex Fox, CEO of Shared Lives Plus.

Social care’s inspectors, CQC, consistently find that smaller care homes are, on average, better than big care homes. John Kennedy’s JRF research into older people living in care homes found, unsurprisingly, that relationships are key: people want where they live to feel like a real home.

The number of small care homes is reducing, however, because the economics of running a small care home are increasingly difficult. Care home businesses are consolidating as the pressure increases. This shouldn’t inevitably mean that each individual service gets larger, but care homes for older people with 100 beds are commonplace. This may create economies of scale for those businesses, but it may equally create dis-economies of scale, as the markers of great value in care can become harder to achieve in services which reach institutional scale: feeling connected and human both inside the service and with the wider community. Where those businesses are hierarchical, it can also be harder to foster the trust in workers, personal sense of responsibility and autonomy that create transformational support relationships in social care. Some of the largest businesses have financing and ownership models which feel a long way from the idea of ‘community’ or ‘social’ care, and appear to have been used partly as vehicles for risky property speculation. We have seen some huge care provider bankruptcies affecting thousands of older people and there may be more on the way.

So, given that half a million people live in care homes is there a way to create the high value and quality of small care homes, with the economies of scale on things like training and registration which larger businesses can enjoy, but without the added costs of large management infrastructures and profit-hungry big business models?

One approach is the household model, where a care home is divided into small, self-contained households with a focus on creating a family like atmosphere. Dementia Care Matters supports care homes to use this approach and become Butterfly Care Homes. One Butterfly Care Home in Nottinghamshire reports a 43% reduced incidence of falls and 1.7% reduction in staff sickness.

Belong villages have a similar household model. Each Belong household is grouped into an ‘extended family’ sized community for around 12 people, with bedrooms that lead into an open-plan shared communal space, and a kitchen.

In both Butterfly Care Homes and Belong Villages team members often have greater autonomy than traditional care homes. Could self-management take this further?

One of the most promising and widely-talked about ways of organising care and support teams is the Buurtzorg community care model from the Netherlands: recruiting people who are able to work as part of small self-managing teams, supported by coaches rather than a traditional line management structure, with use of tech and data to track activity, payments and outcomes. This model can create better-paid, more fulfilling and autonomous roles, in which people have the time to build consistent relationships, and get better outcomes, at lower overall cost where people can move to independence, because of the better outcomes and vastly reduced need for management infrastructure.

A new briefing paper from the RSA boldly suggests that self-management could save social care. The paper describes five case studies from the UK. One of these case studies is Cornerstone in Scotland, who have drawn inspiration from it to completely reimagine what a large support business looks like around a self-managing rather than hierarchical management structure. The Wellbeing Teams model, which provides integrated, holistic community care on Buurtzorg-like principles, has already been awarded ‘outstanding’ by inspectors, CQC, as has a Buurtzorg UK team. Building-based care services have been slower to experiment with the self-managing model, perhaps because people who are attracted to a devolved, relationship-based way of working have tended to have more affinity for community-based care, but the model’s benefits are arguably most needed in the part of our sector which is most at risk of institutionalisation.

A fully scalable self-managing approach to care homes would perhaps look something like this:

• Small, ‘home-sized’ care homes or using a household model, with teams recruited who had the skills and aptitude to self-manage, sharing responsibility rather than leaning on a traditional management structure.
• Those small, largely autonomous businesses networked within a franchise-like structure, with a centrally-developed IT and finance system to track activity, outcomes and payments.
• Coaches supporting each team and communities of practice for teams to share their challenges, innovations and learning.

Self-management wouldn’t be a panacea for the care home industry: self-managing teams in care homes would also need to adopt the most personalised and empowering cultures and approaches. The best care homes have strong links with their local communities. Few people want to volunteer for a large, faceless company, but where a care home feels genuinely like part of the community, there is huge scope for added value through volunteering, forming Community Circles and the invaluable benefits to health and wellbeing of feeling part of a community, not removed from it. This would fit particularly well with a mutual model of ownership, in which residents, families and perhaps even the wider community had a stake, as well as workers.

Often when we talk about reforming and personalising social care, we focus on models which are the most community-embedded, or, like Shared Lives, seen as the most innovative. But we need to gains of personalisation to reach the whole of social care: they can’t be reserved for the lucky few. There may be models of self-management in the care homes industry which we haven’t included here, so we would be grateful to hear of any examples we have missed. And if you are in the industry and just hearing about or starting to consider this radical transformation, we would love to hear from you. We will be happy to add links to this blog, but most of all we would love to start a new conversation.

Teal people in an Amber world

In the summer I was privileged to spend some time with one of our members, Cornerstone, which runs Shared Lives services and a large number of supported living services across Scotland. Cornerstone has been attracting a lot of interest, having taken the incredibly bold decision to restructure its work around self-managing teams, as part of a wider cultural change. It has learned from Buurtzorg amongst other proponents of the self-management model, which involves creating cultures and systems within which front line workers can use structured collective decision-making to take all the decisions which are usually taken by managers on their behalf, from buying new equipment, through changing their priorities or even their whole roles.

Cornerstone’s CEO Edel Harris now sees her role and her colleagues’ in the central office, not as holding the decision-making power, but as supporting small, self-managing teams across the country to take decisions, and responsibility. This has seen local teams decide to change services, start new activities and even acquire new buildings. Edel says, “self-management isn’t the end result but rather a vehicle to ensure more personalised services are provided and is just one (important) part of the Local Cornerstone model” (See picture.) I met the team of people who use Shared Lives support, and their colleagues who cooked us a wonderful lunch at the New Beginnings café in Irvine, which they have developed together. There was a striking fit between their Shared Lives support, which combines independence and connection, and the social enterprise ethos, as the team run, develop and embed their business within their community.

Local cornerstone model

For a while, I’ve instinctively felt that we need to see the emergence of local Shared Lives schemes in which ownership is shared between Shared Lives carers, local coordinators and disabled people and their families. We’ve been talking with a couple of local groups and potential partners about trialling this, but found considerable barriers. Although the Cornerstone model currently focuses on self-management amongst its staff team, rather than amongst the wider Shared Lives carer community, the organisation sees self-management as one part of a much broader cultural change, in which increasing local ownership is a key part. And it was interesting to hear Cornerstone’s Shared Lives team saying that for them, the new self-management ethos had not felt like a huge change: they were used to working as an autonomous but mutually supportive small team.

The cultural theorist Frederick Laloux would see Cornerstone as becoming ‘Teal’, in the colour-coded theoretical framework which suggests that organisations and human culture have evolved through a number of stages, from hierarchies based on raw power (Red), through the development of bureaucracies which have fixed hierarchies and are good at stability but poor at innovation and change (Amber), then meritocratic, profit-driven, innovative, but often voracious organisations (Orange), like many profit-making corporations. Some organisations strive for more social value, shared decision-making and shared ownership through co-op models (Green). Now, just emerging ‘evolutionary’ Teal organisations are removing traditional head offices, management hierarchies and centralised functions, and instead creating cultures and systems within which front line workers can (and must) use structured collective decision-making to take all the decisions which are usually taken by managers on their behalf, from buying new equipment, through changing their priorities or their whole roles, to hiring and even firing their peers. For these self-managing organisations to work, people need to be able to behave and communicate with each other in much less hierarchical and competitive, and with much more emotional intelligence.

In my book, I used the framework of asset-based thinking to contrast Shared Lives and emerging asset-based support models, which create meaningful and reciprocal relationships between individuals who are both valued, with traditional support approaches, where systems and hierarchies too often force people to focus on risks, deficits and attempts to ‘fix’ people which are doomed to failure. But thinking of Shared Lives carers as essentially ‘Teal’ people operating within hierarchical / Amber organisations, helps to illuminate both the success of the model and the need for us as sector to rethink the management and governance structures we continue to impose upon Shared Lives carers. Regulatory regimes tend to be ‘Amber’, but the Shared Lives regulatory and practice framework has created space for people to embody many ‘Teal’ characteristics: Shared Lives carers bring their whole selves to work, by bringing their support role, family role, home and workplace together. They are largely autonomous within the national practice framework, and this allows them to take decisions, and risks, which people working in conventional support organisations feel unable to. But that space can shrink very rapidly when there is a problem or crisis such as a professional practice or safeguarding concern. At these points the system attempts to impose hierarchical thinking, which can destroy longstanding households very quickly, sometimes entirely unnecessarily.

I don’t think that self-management or the ‘Teal’ concept holds the whole solution. Laloux applies his ideas only to the workforce of his exemplary organisations, many of which are for-profit organisations which have customers rather than people whose lives they intimately impact upon and control. Shared Lives carers perhaps hint at a further stage of evolution, occupying a space between workforce and community. Laloux is sceptical of the family as the organising principle for an organisation, pointing out that families can be dysfunctional, preferring the image of the organisation as a living organism or ecosystem, depending for its health on the interaction of its living parts. This puts the organisation’s health and success as the primary objective, but that idea has the potential to be sinister when applied to support organisations (and echoes attempts in the US to give corporations greater rights than people, by designing them as ‘persons’). To put the organisation’s wider stakeholders at the centre, would not be compatible with LaLoux’s sector-neutral model but for me that would be the next stage of evolution.

When a charity or public service organisation sees itself as more important than the people and lives it touches, it loses the compassion which is fundamental to its success. Models like Shared Lives, Buurtzorg and Cornerstone all address this in different ways through creating frameworks in which large numbers of people can consistently build much more equal and human relationships. But if we can combine asset-based thinking, which insists on the greater value of individuals than the organisations which seek to help them, and self-management ideas, I wonder if we could imagine a stage of organisational evolution which goes beyond even ‘Teal’? Where current distinctions between professionals and their clients or customers break down, and we can give and receive support from each other more freely and equally? Such organisations would need to be places where both people who seek and people who offer support can safely and productively bring their whole selves: their capacity, potential, challenges and their trauma. Ironically, this new way of living would also be a return to ideas of community which pre-date the professionalisation of public support.

As I’ve noted here before, Shared Lives is an incredibly radical idea…. from the 14^th Century.

Really NICE home care

NICE, which has for some time been the body setting out what good looks like in healthcare, has in recent years been in partnership with SCIE to issue good practice guidelines for social care too. NICE guidelines aren’t compulsory, and their purpose may be changing in an increasingly personalised system in which social care is purchased by individuals and not commissioners, but they are important because they will be used a reference point by councils when they purchase home care. They may give social care providers a new way to push back against the bottom of the barrel prices which social care commissioners have for some time demanded from them, particularly in the care of older people.

One of the recent publications is NICE’s homecare guidelines. The expertise and ethos of SCIE is very obvious in the focus on person-centred, consistent care (interest declaration: I’m a SCIE trustee). This describes homecare as it should be and as the vast majority of homecare providers those guidelines would like it to be. But it is striking that they will be difficult to implement in most state-funded home care as it presently purchased, where councils will not always even pay enough to allow providers to pay the legally enforceable minimum wage and there is a widespread belief that the costs of the new National Living Wage will bankrupt many of those providers which remain in the state funded market.

It is equally striking but how closely aligned the guidelines are with Shared Lives day support. For instance, NICE says that home care should focus “on what people can or would like to do to maintain their independence, not only on what they cannot do… people have preferences, aspirations and potential throughout their lives”. Home care is generally made available to people based on them being able to demonstrate a high enough level of need and contracts tend to specify help to do the most basic tasks to enable someone to live at home with a modicum of safety, not to follow their dreams. Shared Lives day support however, for typically similar costs, enables people to spend much more time together and with much more freedom to do what they enjoy. This is partly because Shared Lives is not paid by the hour and partly because people are matched around a shared belief that they will enjoy each other’s company.

Matching is a key process in Shared Lives and remains rare outside of it, so it is very welcome to read in these guidelines that homecare provision should ‘prioritise continuity of care by ensuring the person is supported by the same home care worker(s) so they can become familiar with them.” Providers should “ensure there is a transparent process for ‘matching’ care workers to people, taking into account the person’s care and support needs, and the care workers’ skills, and if possible and appropriate, both parties’ interests and preferences.” Again most state-funded homecare would struggle to do any of this on current rates of payment, but we would expect every Shared Lives arrangement to do all of this and more. The reality of continuity and matching can be seen in the guidelines about what to do when continuity is not possible, including “informing people in advance if staff will be changed and explaining why, and working with people to negotiate any changes to their care….recognising that major changes (for example moving from home care to use of personal assistants) can make people feel unsafe.”

Shared Lives is one of the few ways in which these aspirations can be met consistently and affordably. Another would be to re-design homecare away from the assumption that it is based around the managed but inevitable decline of an older person’s wellbeing and life, and instead thinking about how home-based care and support from a number of different kinds of organisation could help many people to achieve more independence, resilience and connectivity to their communities, which will cost more in the short term but as models like Buurtzorg in the Netherlands have shown, result in lower rates of dependence and lower system costs in the long term. We hope to see Shared Lives continue to grow as a homecare innovation but we also need more ‘traditional’ models of homecare to be valued, developed and resourced. Without significant social care funding increases, it is hard to see how this will happen.