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.

Own it

I enjoyed meeting colleagues from Hertfordshire at the council’s annual Festival of Practice: a week of seminars, learning and reflection which the council invests in its social care team and their colleagues in the council, NHS and the voluntary and community sector.

During my session on Escaping the Invisible Asylum we talked about the difficulty of introducing asset-based or strengths-based practice into stressed, medicalised systems, if we want those new approaches to take root and grow. However small the beginnings, the goal must be complete transformation of the local system, so that every intervention in people’s lives is asset-based. Key tests for this are that all services and interventions:

1. Look for what people can or could do, not just what they can’t
2. Connect people and minimise the extent to which they disconnect people – our close relationships are key assets
3. Build resilience for the future, rather than just addressing ‘presenting need’.

Only services and systems which are co-designed with the people who use them and work at the front line will achieve these changes, so these are shifts in who has power and responsibility. For instance, if your service is genuinely asset-based, its systems will treat the risks that people take as theirs to own, but will share ownership of the risks the organisation carries or creates: the individual remains in control wherever they can exercise that control, even when things get risky for them or the organisation working with them. The older person who falls regularly but wants to live at home has that right. Great hospital discharge teams support that person to understand and mitigate that risk, rather than pushing them into a living situation which feels ‘safer’ to the professionals.

We discussed the behaviour changes that would be needed if a system was to become genuinely asset-based, and the systems needed to make those behaviours possible, such as offering help to people to plan for a good life, rather than always starting with a needs assessment. The table below suggests some behaviour changes at the front line, and the leadership behaviours needed to make those changes possible and safe:

Workers and volunteers	Commissioners and leaders
Seeing capacity & potential as well as need	Building in more time: offer planning before assessment?
Humility and courage	Healthy workplaces.
Confidence: focused on what matters most to people	Seeing risk more clearly Measure good (& bad) outcomes
Valuing relationships, networks	Thinking ‘whole-household’
Sharing responsibility: ask more, offer more	Sharing resources, knowledge, power

The most important question, then, is what changes would these new approaches ask of people who use services and their families? And what would they be offered?

Too often, a move towards community-based approaches is framed as asking for more volunteers, or asking more of families who already have unsustainable caring burdens. It is much rarer for those currently in charge of resources and systems to offer to share that power and the responsibility which goes with it. At the heart of that reluctance is a lack of trust, and asset-based thinking starts with trust: faith in people’s ability to take responsibility, in their creativity and that they won’t act purely in their own interests. This is why coproduction is so important: any asset-based system has to be co-designed with the people who will use it, deliver it, share responsibility for it and ultimately own it.

The smaller picture

I suspect I’m not the only person in a senior leadership job who regularly feels like a fraud: am I doing enough to justify my position? What vital opportunity or threat have I missed? Am I being strategic enough?

Ask most people who profess to know about how to do senior leadership and what makes a good leader, and they will often talk about ‘being strategic’. Taking a step back, getting a ‘helicopter view’, seeing the bigger picture.

There is truth in this: often as a senior leader you are in a unique position to have an awareness of what every part of an organisation is doing, which means you should be able to tell whether the parts are fitting together well or not and where the whole thing is heading. If you get bogged down in the detail of a single part, you risk losing that perspective and using up your time and energy on one part of an organisation whilst the others drift.

There are some problems with being strategic though. Firstly, we live in an increasingly unpredictable and chaotic world. However many steps back you take, there are huge changes, like Brexit, which the vast majority of the most powerful leaders did not see coming, and which even now it is happening, feels entirely unpredictable. We live in an age of social movements which bring great shifts in power for good or ill, but which the establishment cannot ignore and cannot always ‘manage’.

So the strategic skill of analysing and building complex systems is becoming less useful. You are as likely to make the right moves by being able to hear and move with fast-moving cultural changes. Savvy senior leaders talk about creating movements, but in reality, those movements are more likely to be started by a personal story and a hashtag, than a research and piloting budget. Working with the world in this way starts with building a shared values base for an organisation and requires closer and more communicative relationships with a much broader range of people.

The trade-off between strategic overview and a relationship with reality has always been under-estimated. For some years now, public service leaders have been talking the language of personalisation, person-centred care, communities and empowerment. Many of them have meant it. Few though, have been willing and able to translate those arresting visions for a more human model of public service into the collective activities of large organisations which continue to be run by middle managers who are performance-managed on balancing their existing budgets and ensuring their teams carry out a narrow and familiar range of tasks. The vision stays unengaged with the real-world pressures.

I see that disconnect when local leaders become passionate about developing their Shared Lives provision, but that passion dissipates as it meets the cynicism and stasis of their just-about-surviving teams. A mentor some time ago suggested to me that complex strategic plans, particularly if supplied by outside consultants, were always works of fiction. Instead, he recommended having a clear view of who you are as an organisation, which in turn would enable you to spot the opportunities to take, and the challenges to respond to.

I’m increasingly convinced of this.

You cannot of course, know who you are as an organisation, if all you have is an overview of it. You have to be prepared to get close to it too. Senior leaders who want their visions to become reality, have to be willing to get out of the helicopter and to work alongside colleagues on ground-level system change. And leaders who want to be sure that what their organisation writes about their values are real, must not only live those values in person but also spend time with people on both sides of its front line.

Step back from a large organisation or system, and instead of achieving a clear, strategic vision, you may fail to see the faulty processes which make the vision impossible to achieve, or fail to hear what people really experience. Bankrupt values will sink an organisation as quickly as bust budgets. The bullying culture

Collaborative Healthcare – new report

Last month in his Comprehensive Spending Review, Chancellor of the Exchequer George Osborne announced a £10bn funding package for the NHS.  We and the like-minded organisations we often work with believe that the NHS now needs to invest in innovations which have often been developed by social and community care organisations, but which also have huge potential as new approaches to healthcare. Often these models involve health professionals letting families and communities take the lead, with the professionals providing their expert input and back up when it’s needed. Here, my colleague Sue Eley (who leads on developing Shared Lives for older people, as breaks for family carers and as intermediate care), guest blogs about the report:

Today sees the launch of new publication from Inclusive Change, a partnership between In Control, Community Catalysts, Inclusive Neighbourhoods, Inclusion North and Shared Lives Plus, with support from user-led organisation CHANGE; NHS England; Think Local, Act Personal; and the Coalition for Collaborative Care.  The report, Collaborative Healthcare looks at ways in which asset and strength based community services can have a positive effect on the well-being of the people involved, bringing significant health benefits to individuals and neighbourhoods.

Through a number of case studies, the report describes initiatives which have helped people to live ‘good lives in good places’ – the overall aim of Inclusive Change.  By working at a local level, involving citizens and leaders, improvements have been achieved in many aspects of people’s lives, one of the most striking being people taking more control over their own health needs.

Some of the case studies have shown how, by feeling more connected and involved in their communities, people have lost weight, given up smoking and reduced both medication and their reliance on health services generally.  This in turn has led to significant financial savings for local health services, particularly for Clinical Commissioning Groups (CCGs).

Many of the case studies highlight what can be achieved with a little investment and the startling results some of these interventions have had on neighbourhoods that have previously been considered to be ‘problem areas’.  By focussing on community led solutions and involving people at every level, this report shows how much can be achieved.

Here are five key messages from the report:

• Personal Budgets alone do not create new choices. There must be an equal focus on building new kinds of intervention, workforces, services and enterprises.
• Many of the people who could gain most from tailored support need the most support to make choices. Support to make real choices needs building into every interaction with services. Advocacy and brokerage are vital.
• People struggle to co-design creative solutions in a system which focuses primarily on need and money. Individuals, families, communities and professionals need to learn together how to recognise and build upon their collective assets, capabilities and potential.
• Choice and control at an individual level needs to be matched by shared responsibility for decision-making at the community and whole-area level. This is not achieved through traditional approaches to consultation or including a patient on a committee, but only through co-production: collaborative conversations right from the start.
• Services are vital, but they are often only one part of a much wider eco-system of support which includes the contributions of family carers and communities. Almost every intervention can be delivered in a way which results in individuals and their families being better informed, more connected to those around them and more resilient.

The report can be found at http://sharedlivesplus.org.uk/information-and-publications/item/251-inclusive-change-release-collaborative-healthcare-supporting-ccgs-and-hwbs-to-support-integrated-personal-care

 

 

 

 

Micro-enterprise: care and support on a scale that’s “just right”?

This is a guest blog from researcher Catherine Needham of the University of Birmingham, who is launching the first research to look at whether size of provider organisation makes a difference to outcomes and cost-effectiveness. The summary is very readable and should be of interest to all care commissioners. Dr Needham writes:

It has long been evident that large-scale care provision on a time-and-task model has not been delivering care and support which is personalised and leads to valued outcomes. This week, a team from the University of Birmingham, of which I was a part, launched findings which solidify the evidence base about the benefits of micro-enterprise over larger providers.

Twenty-seven care organisations in England were included in the study, covering a range of sizes and functions, including day activities and support in the home. Interviews were done by academic researchers working alongside people with experience of local care services on a co-research model. Among the 143 people interviewed were owners, managers, members of staff, carers, and those receiving care services, including older and disabled people.

Findings show that micro-enterprises offer more personalised support than larger care services, and contribute to better outcomes (measured using ASCOT, the Adult Social Care Outcomes Toolkit). These benefits stem from micro-enterprises having greater continuity of staff, greater staff autonomy and greater accessibility of managers compared to larger organisations. The research also found that micro-enterprises offer good value for money: their hourly rates were on average lower than the larger comparator organisations, helped by low overheads.

The micro-enterprises in our sample talked about what had helped them to get started, and what barriers they faced in staying in business. Many had benefitted from local micro coordinators, part-funded by Community Catalysts, which helped them understand care sector regulation and funding.

To keep going the micro-enterprises had to market their services to potential users as they didn’t have a formal contract with the local authority in the way a large care companies did. Most people supported by micro-providers had a direct payment or were self-funding, and had found out about the provider through word-of-mouth or local advertising. The relatively low take-up of direct payments by older people highlights the need to provide alternative routes into micro-enterprise. Social workers, GPs and other care professionals need to be informed about micro-enterprises operating close-by so that they can match up people with support in their local communities.

Like most academic studies, the research answered many questions but generated others. In particular I was struck

Just part of the family – Guardian feature

Shared Lives Surrey features in a great Guardian piece on Shared Lives.

Since moving in with Alex and Greg, Clare has become rooted in the community, and made a strong network of friends – including reconnecting with people she went to school with. She has a big family, with “lots of sisters”, and sees them once or twice a week. “Since I moved, my life has changed. It has got better,” says Clare. “On Tuesday mornings, I volunteer at the Sure Start centre, with babies, and we do baby massage.” She goes to a community centre a couple of mornings a week, and is also doing an adult education course. And she has a boyfriend, who she met at a community group. “It was love at first sight.”

Full  article here.

 

An ownership revolution for public services?

Prof Peter Beresford of Brunel University chairs the user led network, Shaping our Lives. We sometimes find ourselves debating the practicalities of personal budgets and resource allocation systems, but also share lots of common ground when it comes to the values of personalisation. We co-authored an article published in the Local Government Chronicle website on May 14th and on the TLAP blog which argues for an ownership revolution in public services.

Personal budgets: summit or nowt?

At the Personalisation Summit yesterday, chaired by the Minister, Norman Lamb MP, and hosted by Think Local Act Personal and the Dept Health, we had a useful recap on the findings from the second POET survey of people in 20 odd local authorities about their experience of personal budgets. As in previous surveys, the average result of a personal budget is improvement in outcomes and experience, which is encouraging. What was helpful about this survey was that the report also sets out the range of responses, which, even amongst the local authorities committed enough to take part in POET, was wide.

Another striking feature was that the positive outcomes of personal budgets, for both people using budgets and for family carers, tended to be around the quality and experience of support to live independently, with the findings on some less service-related areas of life, including friendships, volunteering and getting a job, showing smaller improvements. In the worst performing areas surveyed, the increase in people gaining employment was almost zero, for instance.

So, on average, having a personal budget is better than not having one. And having that budget as a Direct Payment continues to be associated with better outcomes still. But it is still possible of course to have a personal budget or a Direct Payment (or be deemed to have one) and to experience no improvements, particularly in areas of life where services are less relevant, however purchased or managed.

Personal budgets and Direct Payments are clearly just one – vital – part of achieving change. Helping people who use services to take on or sustain roles and responsibilities within their families, communities and as members of the workforce, needs a deeper change, which only a few areas are achieving. We all need to learn from them if we are going to genuinely Make it Real.

We chose each other

This guest blog was kindly written by Jenny Smith for Shared Lives organisation, ategi. ategi runs schemes in Wales and Buckinghamshire. For films of ategi’s work, click here.

Angela is an ategi Shared Lives Carer. She and her partner Tina share their home with Debbie and Linda, two ladies with learning difficulties who, until they moved in with Angela two years ago lived almost all of their lives in care homes.

Although Angela’s background was in care work, she was working as a cleaner at Aylesbury’s Young Offender’s Institute when she saw the ‘ategi Shared Lives’ advert. She remembers that it said: ‘Can you give a loving, caring home to someone?’”

It seemed to make perfect sense. With Angela’s three children having left home, she and Tina were living in a four bedroom house. Angela wondered if this was perhaps an opportunity to go back to doing what she had always enjoyed most. Caring for people.

Encouraged by Tina, and by her friend Jen, Angela made contact with ategi. There were various important processes to go through before Angela could be accepted as a potential Shared Lives carer – to make sure that everybody’s wellbeing was taken into consideration and that their home was suitable.

Angela remembered a heartbreaking incident she witnessed in residential care, when two elderly ladies who were good friends were split up. One was sent to a different residential home and died only a few weeks later. Remembering this, Angela told Ategi that she would be happy to accept two people who might be unhappy to be separated.

Before coming to live with Angela and Tina, Linda and Debbie lived in residential care for almost all of their lives. Neither had ever completely settled anywhere. When they first came to live with Angela and Tina, they did not talk much, and often found it difficult to make eye contact.

Angela felt for Linda and Debbie, as she herself was painfully shy as a child.

“I understood how they were feeling. But they’ve changed so much since they came to live with us. They dress differently, they act differently, it’s a joy to see.”

Angela, Tina, Debbie and Linda now live together just like any other family. Cooking is a joint effort. They watch TV together in the evenings. They’ll have meals out and day trips. Debbie loves drama, she often sings and does very good impersonations. Linda enjoys arts and crafts.

Like any family, they have different timetables. Angela looks after her baby granddaughter Ellie on Tuesdays and Thursdays, Linda and Debbie go to day centres a couple of days a week and Tina works full time.

There are plenty of visitors, including Angela’s children and grandchildren. Angela’s daughter Becky brings Ellie to visit regularly, and Debbie and Linda love having a baby in the house. Relatives and friends often join them for Sunday tea or a Sunday roast. It’s a busy, happy household.

Angela and Tina make use of ‘respite care’ several times a year. While they have a break, Linda and Debbie will stay with a short-term ategi carer, who they know and trust.

Debbie and Linda’s lives have been transformed since they came to live with Angela and Tina.

“I am much happier living here,” Debbie says, “in the other homes I did not feel loved, and people were mean to me. Now I have a family who love me, and I love them.”

The household also share their home with two cats, Leo and Slinky. Leo came from a family around the corner, but he decided that he was happier with Angela, Tina, Linda and Debbie. It turned out that this suited everybody concerned, so he was allowed to stay.

“He chose us,” said Angela, smiling, “just like we chose each other.”

Why we need the government to act on the Choice Review

With some of our partner organisations, we wrote an open letter last week to Care Minister Norman Lamb MP, urging him to act on the recent Cabinet Office review of choice in public services, which recommended that people should be free to spend personal budgets as they see fit so long as they meet broad outcomes, with the removal of ‘preferred provider lists’ and other traditional commissioning approaches which hamper start-ups, micro-enterprises and other innovators from competing with bigger, more established providers. There’s no point in having control of the money if there’s nothing new or different to buy with it. As reported in Community Care, we warned that without these ‘supply side’ reforms, the risk of personalisation failing in its own terms is high.

A great illustration of the problem is in this Guardian article about how council procurement processes left one social entrepreneur literally starving (at least around lunchtime!) due to their inabiility to renew a contract in a timely fashion. When the basics are so wrong, having an impressive virtual online marketplace for providers and a marketing programme to encourage people to take personal budgets will fall flat.

Our report on Ten ways to stop bashing -and start boosting – micro-enterprise shows how councils can learn from the best work of their peers and get this right, so that we can ‘Make Personalisation Real’, not just another box-ticking exercise.