Thematic national workshop for better care
The Better Care Support Team (BCST), supported by the Social Care Institute for Excellence (SCIE) and PPL, put on two national workshops, exploring the themes of intermediate care and multi-disciplinary team working. The events took place in Birmingham on 28 November 2017, and in London on 6 December 2017. The Birmingham event was for the Better Care Fund Midlands region, with the London one for the South region.
Both sessions were well-attended, and generated a good deal of discussion, insight-sharing and learning for delegates, who were a dynamic mixture of statutory, voluntary and private sector staff, including those working directly on the BCF programme, and others with a general interest in partnership working. Each event was hosted by a senior BCST lead, and by a local social care leader. Then there were two workshops – one on intermediate care and one on multi-disciplinary teams - each run twice so delegates could attend both.
This report gives brief details of the key workshops and speakers, as well as providing links to their materials. There are also links to some other useful resources in this area, and a discussion of some of the main themes and messages that emerged from the events.
Midlands region event
28 November 2017
The Birmingham workshop was hosted by Jane Lord, Regional Relationship Manager for Midlands & East and London, Better Care Support Team, and David Watts, Director of Adult Social Services at City of Wolverhampton Council. Following Jane’s opening remarks, David began by pointing out the relative success of Wolverhampton Wanderers compared to their wealthier neighbours, Birmingham City and Aston Villa; evidence, perhaps, that good performance need not always be tied to money, a theme which ran though both events. He spoke of relatively low-cost, simple schemes, such as the Red Bag programme, in which people entering hospital from care homes take with them a red bag filled with key information, medication and belongings. This facilitates good quality care in hospital, and therefore a swifter return home.
The multi-disciplinary team workshop was run by Dr. Robin Miller, of the Health Services Management Centre at the University of Birmingham. He led and stimulating a challenging session looking at the evidence behind successful multi-disciplinary working, and how to avoid the pitfalls of pseudo-teams, in which organisational restructuring gives the illusion of integration, but fails to create cohesive team work. Delegates shared their own views on what constitutes success in multi-disciplinary working, and examples of how to achieve it.
Simultaneously, Zeph Curwen, Urgent Care/Intermediate Tier Manager for the Pennine Acute Hospitals NHS Trust, and Steven Blezard, Assistant Director of Operations, Rochdale Borough Council shared the work going on in the Rochdale area to develop intermediate care - services aimed at keeping people at home rather than in hospital, or helping them come home from hospital as early as possible. They spoke of Rochdale being the birthplace of the Co-operative Movement in the 19th Century – and how those principles of collaboration and partnership still shape they work they are doing. An example is HEATT – the Heywood, Middleton & Rochdale Emergency Assessment and Treatment Team – a car that goes out instead of an ambulance to many 999 calls, and with a mixture of practical and nursing support manages to prevent many hospital admissions. 85 per cent of the 660 people to whom the HEATT care responded in the pilot phase of the project were kept at home.
David Watts, Director of Adult Social Services, City of Wolverhampton Council – BCF achievements, - Red2Green Reablement process
- Intermediate Care, Zeph Curwen and Stevan Blezard
Zepth Curwen –Urgent Care/Intermediate Tier Manager – and Steven Blezard –Assistant Director of Operations- ‘Welcome to Heywood, Middleton,
Rochdale Care organisation and integrated care system’ and ‘Towards Integration and the Development of a Local Care Organisation’
- Discharge to Assess - Standards for Greater Manchester (August 2017)
- Discharge policies monitoring framework (August 2017)
- Policy for Patient Choice across Greater Manchester (August 2017) in relation to ongoing care upon discharge from hospital
- Standards for a Greater Manchester Trusted Assessment (August 2017)
Multi-disciplinary Teams, Robin Miller
Robin Miller, Health Services Management Centre, University of Birmingham Integrated Care Academy, ‘Multi-Disciplinary Teams: Making them work’
South region event
6 December 2017
The South workshop was held in London, and was chaired by SCIE’s Chief Executive, Tony Hunter, and Rosie Seymour, the Better Care Support Team’s Deputy Programme Director. Rosie stressed that the work being done was about much more than delayed transfers of care, and strove to ban the phrase DTOC from the day’s proceedings. Tony acknowledged the difficult environment in which everyone is operating, but cited a challenge from a user of services, who said “I want you leaders to make good things happen, and stop bad things happening”, and suggested that the shared wisdom in the room ought to be able to make progress towards that simple goal.
Jane Townson, Chief Executive of Somerset Care, then led an intermediate care session, looking in the main at an innovative link-up between her organisation and Yeovil District Hospital, in which intensive reablement in a Somerset Care home after a spell in hospital meant people got home more quickly, with fewer ongoing needs, and at lower costs to the public purse. Emerging practice from the Netherlands about the development of care hotels, and alpacas, also featured in Jane’s workshop.
The MDT session for the South was led by Phil Wrigley, Integrated Care Commissioning Manager for NHS Islington CCG, supported by Henry Leak and George Katsande, both Integrated Care Managers for West London CCG. Phil explored how in Islington they had tested the hypothesis that multi-disciplinary working would lead to better patient outcomes, greater staff satisfaction and more financial efficiency, with promising results. He spoke too about CHINs – Care Closer to Home Integrated Networks - which are showing positive outcomes. Henry and George then spoke about West London’s “My Care, My Way” model, developed by multi-disciplinary teams in GP practices across the region, which has produced a standardised operating model across the CCG. The aim is to embed a one team approach to primary care that emphasises community treatments and avoids hospital admissions wherever possible.
Intermediate Care, Jane Townson
Jane Townson, Chief Executive at Somerset Care Group, ‘Collaboration between Somerset Care Yeovil District Hospital: Oct 2015 - present’ and ‘Care Hotels in The Netherlands’
Multi-disciplinary Teams, Phil Wrigley, Henry Leak and George Katsunde
Phil Wrigley – Integrated Care Commissioning Manager, NHS Islington CCG - ‘Islington Integrated Networks’ and ‘West London CCG and My Care My Way’ by Henry Leak and George Katsunde - Integrated Care Managers, West London CCG.
Across the two events, a number of topics recurred, often overlapping the discussions about intermediate care and multi-disciplinary teams.
These key themes were:
Collaboration and relationships. Partnership working is evidently vital to the success of MDTs, and the importance of “genuine co-operation” as opposed to simply sharing an office and formal functions was a theme in both the MDT workshops. At the Birmingham event, the significance of partnership working being role-modelled at the top of MDTs was stressed. Ideas were shared as to how to develop genuine collaboration: away-days; shared learning and development; and a clear focus on the needs of the individual person being served, rather than the organisations, were all mentioned as helpful.
David Watts of the City of Wolverhampton made the point that good working relationships between front line staff – OTs, physios, ward sisters and social workers – are vital in prompt discharges from hospital, exemplifying how collaboration is at the heart of successful intermediate care. Zeph Curwen spoke of an “us and us” mentality between health and social care in Rochdale, which extended to a willingness to invest financially, even if any savings came to another part of the care system. The devolution of funds to the Greater Manchester region is perhaps a factor here. But Somerset Care’s successful work with Yeovil District Hospital in getting people out of acute care was based on the relationship between the two organisations, which meant they could act for the benefit of patients without waiting for other partners to approve the plans.
An interesting point was made that, by setting up structures by which local areas are measured and compared to their neighbours, the whole system around the Better Care Fund militates against the cooperative sharing of good ideas. But generally a clear theme emerged about the centrality of collaboration, based on strong inter-personal relationships, which could transcend barriers in order to better serve people using care and support systems.
- Trusting relationships with the voluntary sector. Closely linked to any notion of decent relationships is the question of trust, and both days included discussion about how trust in one’s colleagues, at front-line or strategic level, was a vital component in working together across systems. Often, debate focused on trusted assessors, and the extent to which statutory services would trust partners, including those from the voluntary sector, to assess people on their behalf. Unsurprisingly, where that trust existed, fewer barriers to discharge from hospital were reported, and this linked into a wider discussion about the role of the voluntary sector. Where a local area - a colleague from Wandsworth suggested theirs was one - was genuinely able to make use of the full range of community assets, then people’s care plans could be much more flexible and person-centred, and there was greater ability to shift perspectives and tackle challenges in new ways.
- Person-centred care. This theme of person-centred care was another recurrent message. Jane Townson stressed the importance of a patient being fully engaged with their step-down programme in order for it to be effective. There was a good deal of delegate discussion across the events about the need to have clear goals and outcomes, set by the person, as the guiding force behind any interaction with a patient. One delegate called for the criteria for different types of intermediate care to be based on a person’s desired outcomes and not, as currently, on their degree of need. Linked to this, there was a clear message about being clear in our communications: if we talk about step up, step down, Home First, and home vs. bed-based reablement, we risk the people we serve getting completely lost in the jargon, and disempowered as a result. Open and clear conversations from the start about what people can expect, and what they want to happen, are key.
- Senior leadership. If we are to achieve a cultural shift to open and trusting relationships across the system, then the lead for this has to come from senior managers. This is not to underplay the vital role of patients and service users themselves, and of front line staff, in making change happen. But large organisations will typically change more quickly if the change is embraced at the top as well. We mentioned earlier how useful it is to developing multi-disciplinary relationships if good collaborative working is role-modelled at a senior level, but managers also need to give their permission, and backing, to new ways of working. This includes, as we heard in Phil Wrigley’s workshop, actively selling the benefits of change to stakeholders. It also involves, Steven Blezard and Zeph Curwen argued, giving senior support to people to try things, perhaps fail, but learn from the failure without being punitive or shying away from experimentation in the future. They mentioned also the backing of unions in trying new ways of working as a helpful facilitator of change.
Austerity-led change. A common motif across the workshops was that change was made necessary by austerity. In part, the ways of working people were introducing have been brought about because funding existing approaches had ceased to be viable. Tony Hunter cited work he had been doing with the Disability Living Foundation, based on their recognition that a lack of money forces you to do things differently. One aim of multi-disciplinary teams has long been to improve efficiency, as well as the user experience. Intermediate care is also explicitly about a more efficient use of resources, and Jane Townson spoke of the long-term financial value of front-loading expenditure, by providing intensive therapy to people immediately upon them leaving hospital. In one workshop the “sense of desperation” that budgets cuts can bring was mentioned as the thing that did in the end enable changes to be approved.
- Using data. Maximising the benefits of relatively scarce resources relies on good quality data about how money and staff time are spent, and what effect this has. The active use of data – financial and otherwise – was frequently discussed at both events. In a time of limited resources, the need to know that inputs are effective becomes all the more vital, as no organisation can afford to waste effort or resource. Data demonstrating that a particular approach is effective is a powerful tool in driving further change. Robin Millar spoke of evidence that cancer patients receive better support from MDTs as helping to embed the approach, and Phil Wrigley spoke of the decrease in acute admissions for people served by MDTs locally. Jane Townson was able to cite to local authorities evidence of savings of over £1.5m in ongoing homecare costs to help gain their backing for her work, and the HEATT scheme in Rochdale generated £4 in savings for every £1 spent. Data can also help target efforts: Phil Wrigley and Zeph Curwen separately spoke of targeting their interventions on the 2 per cent of their populations who generated the most costs. David Watts talked of calculating the costs of the Red Bag scheme against the savings it could bring. Data can also illustrate where things are not working effectively; Robin Millar cited studies showing that in some MDT meetings, an average of three out of fourteen attendees actually contributed, highlighting a potential waste of people’s time. Either way, a good use of data would appear to be a key requirement in well-targeted and effective interventions.
- Flexible pragmatism. Speakers and delegates also pointed to flexibility and pragmatism as important elements in integrated working and intermediate care. It was evident that every area and organisation approached these challenges slightly differently, and the willingness to flex local arrangements to suit local circumstances was seen as helpful in securing the best outcomes for people. Light-touch discharge assessments by Transfer of Care nurses were given as an example of how pragmatic measures could help speed up the provision of appropriate care. Practical measures - such as Rochdale’s provision of step-down flats, with bread, milk and other necessities in the fridge for when people arrive; or the provision of men’s health clinics at football grounds – can also prove valuable. Another example of flexibility was the creative use of Disabled Facilities Grant money to prevent falls in care homes. Flexibility inherently involves a willingness to change, and to try new things, and both events touched on the need for everyone to take responsibility for this. A delegate at the South event pointed out that “everyone thinks it’s someone else who needs to change”; this sort of thinking has to be challenged.
- It does not have to be innovative to be useful. While there was a lot of focus on change, speakers and delegates alike also stressed that much of what is being done is not new. Much of it is borrowed from other areas – delegates were urged to “pinch with pride”, and to conduct peer reviews to learn from neighbours – and as David Watts stressed in the Midlands, little of what is happening is ground-breaking. This brings us back to the other key themes: effective multi-disciplinary working, and good intermediate care, both depend on good relationships; on being willing to try new things, confident in the backing of one’s managers; and on knowing how to evidence whether the new approach has worked. But most of all it depends on listening and responding to the desired outcomes of people using services – which will often be efficient and compassionate care, as close to home as possible.
- Jane Townson’s video on care hotels
SCIE materials on promoting independence and reablement
NICE guidelines on intermediate care
Health & Care Workforce Strategy: Facing the Facts, Shaping the Future – Health Education England consultation document
Enhancing Health in Care Homes – The King’s Fund
Local Systems Review: Interim Report – CQC
Red 2 Green campaign to improve discharges from hospital – NHS Improvement
- Red Bag Scheme – improving care in Wolverhampton