How would we know?

If an area becomes ‘asset-based’ in everything it does, how would you know? You would expect to see everyone – public services and charities; citizens and people with power – thinking, speaking and behaving differently. This is the second of three blogs written with the Chair of Think Local, Act Personal, Clenton Farquharson MBE, and available in full here. Last time, we revisited the Asset-Based Area (ABA) model which tried to distil down how an area can become asset-based in everything it does from strategy down to the grassroots, into ten actions, starting with mapping your local assets, and including sharing power with people who are usually excluded, and building a diverse range of community approaches which are now gathered in an online catalogue. Three years after the original thinking, we are developing the ABA model in more detail through the Social Care Innovation network.

In this blog, we want to think about how we would know that an area had become asset-based. What would we measure and how?

Greater Manchester has adopted use of system activity measures collected every quarter, combined with a range of personal outcome measures collected locally across the city region. These include measures already well-established across public services, such as health outcomes, measures of demand and cost, and wellbeing outcomes: recognising that wellbeing – living a good life in a good home and a welcoming community – is intertwined with more clinical outcomes.

Key Human Indicators

Many areas and organisations have Key Performance Indicators (KPIs). Perhaps every area needs Key Human Indicators. Are people achieving wellbeing? That usually means that people who need support are able to experience the right balance of independence and connection for them, which will change at different times in their lives. For workers and systems, KHIs will include warmth, kindness (as set out in Julia Unwin’s brilliant report) and dignity. Networks can be more important than bureaucratic service structures. In Shared Lives, friendships are seen as key indicators of wellbeing, so Shared Lives Plus’ national outcomes measuring tool asks participants how many friends they have and whether Shared Lives support is helping them make and sustain those connections, or getting in the way.

Read the rest of this blog on the Social Care Institute for Excellence website, in the Social Care Innovation Network’s minisite.

Rainbow

I’m so excited to see the ‘rainbow’ of community approaches launched on the Think Local Act Personal website. Social care is often talked about as being at the heart of the perfect storm, so I love the fact that our colleagues at Nesta came up with a rainbow to give this snapshot of some of the many inspiring asset-based approaches which are transforming people’s ideas about care, support, inclusion and community development. It shows that these community models stretch across the public service system from prevention and whole-community work, so work at the acute or crisis end. The online directory which sits behind it aims to include scores more models to help commissioners and others find their way through this new world.

Here’s my blog marking its launch:

How do you make big changes to how people are supported, when the kinds of support which work best are nearly always those which feel small and personal? TLAP’s new resource – examples of innovative models of community-centred support – aims to show how to do things differently.

James lived in an epilepsy centre for twenty years, where his medical and support needs were labelled ‘complex’. But his goals were simple: friends and a job. He was able to pursue them in the small, homely setting of Andy’s household, when Andy became James’ Shared Lives carer. James moved in and lived as part of a busy household, before moving around the corner into his own place, with close ties to the household when he needs them.

St Joseph’s hospice noticed that there was a gap in the support for families, which was not easily filled by traditional volunteering. When someone approaches the end of life, it can be an isolating experience for a family. Some friends and neighbours withdraw, or worry about ‘intruding’. Agnes said, “I have friends but no-one turns up to see me, why? I needed to go back to the hospital because … if I was in hospital then people would come to visit me.” Agnes was matched with Lucia through the Compassionate Neighbours programme, which enables people to take on a more personal, open-ended role. Lucia says now she and Agnes are “more like family”.

The changes which Shared Lives carers, or Compassionate Neighbours, achieve in people’s lives are huge for the individual, impacting on their whole life. The challenge for ‘asset-based’ models like these is reaching more people, attracting investment and referrals in public service systems that are designed to make much more specific interventions across very large populations. Large parts of the NHS, for instance, are organised around treating a particular medical condition across populations of hundreds of thousands of people. The senior leaders who control vast council and NHS budgets are expected to be strategic, avoiding getting ‘bogged down’ in detail and taking a ‘helicopter view’. From a helicopter, people’s lives can look very small and insignificant.

Read on here

How can we bring proven models to more people?

Ewan King, Chief Operating Officer at the Social Care Institute for Excellence wrote this blog for the Richmond Group of charities here. Here is an extract:

In January along with our partners Think Local Act Personal we launched the DHSC-funded Care Innovation Network.  Our goal is to answer this question: “How do we take proven person-centred models of care and support and bring them to more people?”

Locality leaders report that bringing the best to scale has perhaps been hindered for many reasons, in particular a short-term approach to funding, parochialism, lack of long-term planning – and regulatory barriers. But good initiatives have also failed to spread because statutory bodies have not always sufficiently engaged with others, especially the voluntary, community and social enterprise sector (VCSE) and citizens and communities.  More engagement would support both the establishment of more innovative forms of care, and also their growth and expansion.

Alex Fox, CEO of Shared Lives Plus, in his review of VCSE’s involvement in delivering care, bemoaned the sector’s often peripheral role.  He wrote: “Through drawing on people power as well as money, VCSE organisations are often uniquely able to offer support which looks at the whole person and whole family, thinking preventatively and whole-lifetime”. Moreover, VCSE organisations are increasingly creative in accessing resources such as social finance, and then applying different business models – such as franchising – to grow services.

The Care Innovation Network seeks an alternative route to growth of what works. In our network, we have many VCSE providers – like Shared Lives, Local Area Coordination and Stay up Late, so that they are part of the way forward from the outset. Working alongside us, applying co-production principles, are people with the experience of using services and their carers, so that solutions are well thought through, tested, and more likely to achieve the intended benefits of better experiences and outcomes.

Read more here. 

The real reasons we still don’t co-produce

It’s rare to hear senior public service and voluntary sector leaders talk openly against the idea of co-production. Some still confuse it with consultation. As I heard a senior leader say recently, “We will come up with ideas and then co-produce our plans with local people.” (If you’ve already come up with the plans, it’s not co-production.) Many still describe it as difficult, either in terms of the process (despite so many co-production toolkits out there from Think Local, Act Personal; the Coalition for Collaborative Care, SCIE and others), or in terms of it being risky and time consuming. It is risky: it involves placing trust in groups you do not normally work with, and being willing to take the first step forward, knowing that the other side may just take a step back. It also takes time, but how much time do we waste rushing headlong in the wrong direction, coming up with plans that never work, because the most important people were not part of the planning conversation? That’s why in my book, I argue for a slow policy movement.

But I always think that when something is talked about so positively, but done so rarely, there must be something else going on. Here are some reasons we don’t co-produce which we don’t talk about.

  1. Heroic leadership. The news pages of a number of trade magazines/ websites remain dominated by stories of who is moving in and out of the big jobs. We remain hooked on the idea that the right leader will make or break a service. We see this happening: an inspirational leader comes in to a troubled organisation and galvanises the team around a new vision with great results. But for every example of a leader achieving this, there are dozens of it not happening, as well as some of leaders being key factors in toxic cultures. The culture of looking to powerful individuals is part of the problem: it creates the conditions for disempowerment, hopelessness and at times, bullying. But most people with any power in public service organisations are somewhere on a career path predicated on the value of the brilliant individual leader. It can be easier to be a leader than an ally. Co-production is the opposite of heroic leadership: believing in it is difficult if you aspire to be the hero.
  2. When co-production is real, the group of people involved in decision-making doesn’t just grow, it diversifies. This means that co-production is at odds with monocultures. The gender imbalances and “snowy white peaks” of those at the top of the NHS and other public service organisations has been well documented, but there is also a less-frequently talked about class divide: those running public services and charities come from predominantly middle-class backgrounds; whilst health inequalities and the impact of the social determinants of health mean that those making most use of those services and charities are significantly more likely to be working class. Co-production is part of the effort to diversify decision makers, and those efforts are resisted by any number of conscious and unconscious biases.
  3. Co-production an only work where there are people with lived experience in a position to co-produce. That usually means not only having their own lived experience, but also having the support, training and networks that anyone else needs to be an effective decision maker. No-one can be ‘representative’ of a large and diverse group of people who use services, unless they have been chosen by a number of those people, and ideally are in regular communication with them. This can only be achieved by investing in training and development for individuals, and more broadly investing in user-led and grassroots organisations. Our public services are reluctant to that at the best of the times and these are not the best of times. User-led organisations are falling by the wayside in alarming numbers: our social capital and our co-production capacity is reducing just when the argument is being won for the value of co-production. This needs to be reversed.

The common theme running through these three problems is power: its unequal distribution and the discomfort those with it feel talking about it, let alone sharing it. I’d be interested to hear other barriers to co-production which you are seeing but which aren’t talked about. Naming these barriers is only a first step to changing them, but it is a start.

Government funds our innovation network

We’re excited to be part of a partnership led by the Social Care Institute for Excellence and the Think Local, Act Personal network, to help local areas scale innovative community-based approaches to social care. This builds on the partners work which has developed models and guides on how to take a whole-area, whole-system approach to innovation, getting away from endless small-scale, short-term pilots which lack ambition. In the current climate where budgets have been slashed and pressures are rising, the most inspiring areas are taking an all-or-nothing approach which recognises that, while initiatives may start small, there must always be a plan to move core resources into the models which work and away from those which don’t. (See Total Transformation, the Asset-Based Area and the family of community-based approaches launched at Social Care Future).

We’ve already had a large number of applications from local areas and from innovative support models and we’ll be building on the 2,000-strong TLAP Building Community Capacity network, which brings together activists, entrepreneurs and organisations working in this space.

Government backing for this initiative is a promising sign that, despite the delays in publishing the Green Paper, the Dept Health and Social Care recognises the need for radical thinking and inspiration for our sector, which is under unprecedented pressure.

Evidence matters

The Think Local, Act Personal partnership supports a national network of activists, practitioners and leaders who are engaged in building communities, which I chair. We have done lots of thinking about how we demonstrate that the many incredible initiatives in the network do what they claim to do. At today’s seminar in Manchester, for instance, we heard from Debs who talked about Creative Minds helped her swap pills for paints, after a lifetime inside a mental health system where people with power had reinforced her view of herself as someone who would always be ill, never in work and always in need of significant support and medication. She is now an accomplished speaker, professional artist and change maker. Her daughters, who had been her carers, have both now won places at University. She has now had several years without medication or NHS support and no longer needs to claim benefits.

Some impacts of Debs’ interaction with Creative Minds can be counted: the cost of her medication alone, let alone hospital stays, welfare benefits and unsuccessful support packages far outweighed the cost of her Creative Minds support. But could you measure her impact upon the audiences she talks to, the training sessions she delivers, and the benefits to her daughters and the community? Are stories, however powerful, even considered to be evidence? The difference between medicine A and medicine B may be possible to isolate and measure, but what about the difference a single support intervention makes to someone’s life, given how messy and complex all our lives are?

We have been developing ideas in response to these questions, such as those in our report in response to the government’s assessment of the evidence for personal budgets. With a Green Paper on the way, we wanted to develop some more actions for Think Local, Act Personal, its members and the wider system. Here are some we came up with today:

  1. Think Local, Act Personal (in liaison with SCIE’s Prevention Library) is using the Six Innovations format to gather one page examples of community-orientated interventions, which we will put into a catalogue to help commissioners and others understand some of the many approaches out there and how to makes choices between them. If you want to submit your initiative or organisation’s work, please contact Think Local, Act Personal.
  2. Measuring the impact of complex service systems is almost impossible using traditional methods. But in Engaging and Empowering Communities, we and all the main health and care bodies agreed that, whilst there is endless variety in our sector, all of us are aiming for a small set of shared outcomes for people, which include (in Prof Jane South’s formulation), people being in control and more connected to each other, and greater equity. We will explore the possibility of making measures for those universal outcomes available to any organisation, so that data on them could potentially be collected about large numbers of people.
  3. TLAP Chair, Clenton Farquharson made a powerful point: if we accept something as a basic tenet of a decent society, we stop demanding evidence for it. Few people in health and care would ask if there is evidence for the idea of providing support with dignity for instance. So if it were accepted across the system that connectedness, being in control and equity are the universal values they appear to be, would the question of evidence feel less of an excuse not to pursue them?
  4. There are one or two places which are doing lots of community-orientated or asset-based approaches, such as Wigan, Thurrock and Leeds. Does this offer the opportunity to observe and evaluate something approaching whole-system change? Some of us are already working with Thurrock and Birmingham University to consider its programme of work. Today we heard more about the whole-system approach being taken by the Greater Manchester city region. Do you know of other areas out there which are taking a whole system approach?

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Feeling important

“Feeling important is awesome. I want everyone to feel important.” Nick, one of our Ambassadors opened our annual conference alongside the incoming President of ADASS, Margaret Willcox as co-chairs and instantly had the whole room of Shared Lives and Homeshare colleagues and participants engaged. He was talking about the experience of working with Shared Lives Plus as an Ambassador, doing work which makes a difference, as well as about the feeling of belonging and mattering that is at the heart of all good Shared Lives.

At the annual social services conference the week before, I’d enjoyed, as I do each year, catching up with a huge number of colleagues, making new links and learning about some of the most interesting initiatives around the country (not to mention being rubbish in the annual quiz). But a question from a parent of a disabled daughter stuck with me: “I’ve been looking at all these sessions and discussions and wondering where I will find my daughter in them?” The conference did include a small number of sessions led by people with lived experience including the launch of a new model of ‘coproduction’ from the group of people with lived experience at the heart of the Think Local, Act Personal partnership and an inspiring fringe event with DanceSyndrome and Community Catalysts. But in too many of the main sessions there was a yawning gap between the discussion’s topic and participants and the people whose lives were being discussed. When you put a lot of ‘important’ people together, it can be easy to lose sight of what and who is really important. As Nick told us at our event, it’s great feeling important but that feeling should be for everyone.

Our conference now attracts Shared Lives carers and people using Shared Lives, as well as one or two family members and there are sessions which are designed particularly with them in mind, but I suspect that they will at times have felt that gap in some of the discussions at our event too. Involving people who use Shared Lives and Shared Lives carers as speakers, co-chairs and part of the support team has made a huge difference and hopefully prevents us from straying too far from what we are all supposed to be about, but we know we have further to go. Now that our conference has a Homeshare strand for the first time, we are also starting to think about how people who live in Homeshare households can be a part of future events.

Coproduction, as experts like Clenton Farquharson will tell you, is a journey. If you think you’ve arrived, you’ve probably just stopped. At our event, I was immensely proud of the work that we do, of our team and the membership network of which we are a part. It’s rare I think to be at an event for 200+ which feels both nationally important and ‘like family’ as one participant put it, not to mention smoothly run by our amazing office team. But it’s important I think to keep asking ourselves: where are the people who we are talking about in these discussions? If they are in the room, leading those discussions, having helped to design them, the answer to that question is much more likely to be clear to everyone.

Future social work

The Think Local, Act Personal partnership has published a paper which I helped to author: Developing a Wellbeing and Strengths-based Approach to Social Work . Here is my foreword to the paper which looks at how social work could change to deliver the Care Act’s vision for wellbeing, drawing on Asset Based Community Development thinking and similar ideas:

Talk to social workers of a certain vintage about community development and many will begin to recall fondly the days of ‘community social work’, when social workers were expected to think whole-community in their approach to supporting people and perhaps even had the time and freedom to do so. Since that period, pressures upon social workers have increased with rising demand and falling budgets. The professionalisation of social work took the sector away from community social work, which was sometimes seen as hazily defined and weak on evidence of outcomes. It would be foolish to believe there was a ‘golden age’ and this paper is not a call to return to the past. Despite increasing pressures, social care can claim to have reformed itself more radically than any other public service sector. The concept of ‘personalisation’ is still contested and imperfectly implemented, but it is unarguable that thousands of disabled and older people have a level of choice and control which was unheard of until recently. Half a million people have personal budgets and a fifth of those have taken their personal budget as a cash Direct Payment, enabling them to create and manage an entirely new workforce of Personal Assistants. There are hundreds of innovative small and microscale enterprises, helping people to live well through interventions which look nothing like traditional services. Community-based interventions like Shared Lives are growing rapidly despite the pressures of austerity. So there is much innovation in services and support, alongside much-raised standards of skill and accountability amongst social workers, but we are also starting to understand the limitations of services acting on their own and the huge potential for support which fits around and enables people’s informal support relationships with their families and communities. That change does not make social work any less important, but it will require a new (or rediscovered) set of social work skills and attitudes: a social care workforce with the humility to use its power and access to resources not to take charge, but to enable people and families to take charge. It will need to be a workforce confident in its expertise but also more confident in the expertise and potential of individuals, families and communities. Models like Local Area Coordination and community navigators create the space in which professionals can get to know individuals and families well enough to understand what their goals and capabilities are, as well as their needs. Making those deeper relationships the norm will be a huge challenge in a financially stressed social care system, but meeting that challenge is the only way to a sustainable system, good lives for people with long term conditions and a workforce which is the best it can be.

Full paper here: bit.ly/1TTo3P3

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

 

 

 

 

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.