Changing social care: an inclusive approach
Case study: Willowbank
Willowbank is a rights-based, service user led community resource centre based in the Armagh and Dungannon trust area, Northern Ireland. It is a grass-roots community voluntary organisation formed in 1962 to address the absence of statutory service provision for adults with physical disabilities and/or sensory impairments. People who use services are an integral part of the management of Willowbank and 60 per cent of the board are persons with physical disabilities or sensory impairments. The focus of Willowbank is on empowering and enabling users through accredited training opportunities, vocational training, information, advice, advocacy and personal care.
Willowbank is open 48 weeks a year, employs 10 people and sees 30 people a day. The core funding of £87,000 per year is from Armagh and Dungannon Health and Social Services Trust, alongside a cocktail of project funding.
Willowbank was originally set up based on a ‘benevolence model’ of social care, which sees social care services as necessary to meet needs caused by medical conditions and thus views service users as people in need of care. In the 1980s, following the appointment of a new director, the organisation shifted from the benevolence model to an offshoot of the social model of disability. In this new framework, the barriers put up by society’s response or lack of response to people’s impairments were viewed as the causes of disability.
The adoption of a social model of disability moved Willowbank away from the charitable, goodwill approach to social care to a rights-based equality agenda. Willowbank is now an organisation that is controlled by people with disabilities that works with and for people with disabilities.
The following sections review the information gleaned from our director interviews and the staff and service user focus groups with Willowbank, focusing on our three key themes: (1) leadership and purpose; (2) employee involvement; and (3) stakeholder involvement. Each theme comprises a series of sub-themes and we provide relevant examples from Willowbank as illustrations. Refer to the knowledge review, practice review and analytical report, 'Improving social and health care services', for a full review of the themes.
1 Leadership and purpose
A key theme that emerged from our knowledge review was that effective leadership – namely an inspiring and resourceful executive director – was central to successful implementation of change. This leader must be able to harness the support of employees by empowering them and spreading the passion of their vision. A clear sense of direction for the organisation was critical.
Leaders need to establish a clear sense of purpose and ideology to enable change and improvement
Having a clear sense of organisational purpose and ideology to guide actions was crucial to all of our case study organisations. Willowbank hired a new director in the 1980s and this new recruit inspired a shift from the organisation working under the belief that disabled people need to be ‘cared for’ to one based on empowerment. Willowbank is now an organisation controlled by people with disabilities that works with and for people with disabilities. Willowbank sees a person with a disability as a person with a ‘solution’ if they are encouraged, enabled and empowered to articulate what they want and need to help overcome the barriers they face. Willowbank is a small organisation, but argues that a larger organisation could also adopt its model. As a board member commented:
If the ethos doesn’t work in a big organisation, then the ethos doesn’t work in society. And if it doesn’t work in society, then we need to own up to the fact that equality can’t work in society. This isn’t true so we need to find away to make it work in bigger organisations.
The director of Willowbank instigated change subsequent to her arrival. She was chosen due to her previous experiences leading organisations and her viewpoints on key issues (e.g. service user involvement, employee engagement, ideology). Having clarified the underlying purpose, the next step was to identify what specific components of the organisation needed to change to ensure that its ensuing activities supported its purpose. She consulted staff to tap their expertise as well to identify their needs in the change process. Decisions were then made about how to specifically implement those changes. The agreed sense of underlying purpose came first and mechanisms that enabled necessary changes such as funding were subsequent.
Leaders create the conditions to enable change and improvement
All staff interviewed acknowledged that the arrival of the new director had been the turning point for change and that she had enabled the change. That is, beyond driving the new purpose or ideology for the organisation, the director also created conditions that allowed it to shift in the desired direction. Staff members were very clear about the incredible impact that the director had in enabling the changes to happen.
In Willowbank, the director’s underlying ideology was that of empowerment. According to a staff member, ‘She began to shape things in terms of more independence and voice of the receivers of the benevolence. She moved to suggesting that some of the service users might actually contribute to management.’ Increasingly over time, service users began to sit on the board of directors. While the first frontiers were ‘persons with acquired disabilities, who had previous experience of the business sector’ (Willowbank service user), over time the user directors were service users who had ‘come up through the ranks and are probably more reflective of our user group’ (Willowbank service user).
Another way the director of Willowbank helped the organisation align with its purpose was to open up leadership and management and make it more transparent. For example, access for disabled persons is not purely about physical access to a building (though the staff were able to quote examples of where councils had set up meetings where they knew that people with disabilities would attend and had booked a meeting room with no wheelchair access), it is also about ensuring that all participants have equal understanding of the history, events and key people involved in the organisation. One way access was subtly thwarted in Willowbank was when people in positions of power (e.g. at stakeholder meetings) used ‘insider’ language, abbreviations and other jargon in mixed company. This made the information being communicated interpretable only to a select few and was a barrier to new attendees. A board member at Willowbank believed in breaking down or ‘demystifying’ the information so that it was intelligible to all:
People are afraid of boards as they don’t like jargon and are afraid they won’t understand anything and that board rooms are full of people saying things that don’t mean anything. People are afraid to ask and question it, [our director] breaks things down to what things really mean. For example, finances are full of jargon and baffle people. People present lots of tiny figures and people can’t see them or make heads or tails of them. They don’t want to say my eyes are sore or I don’t get what this actually means, so you need to say exactly what it means.
For some people, this process of opening up leadership and management was uncomfortable and challenging. Staff at Willowbank acknowledged that empowering some people disempowers others. One staff member claimed:
Some people at the top whose sense of authority and control is based on them being more knowledgeable than service users and being benevolent will be disempowered [by transparency]. ‘What you’re doing is not a favour for me, I have a right and you have a duty. Don’t tell me that it would be great to have a course in a college but insurance won’t cover this group – get the insurance that would cover it.’ Some people, for example, think they’re doing you a favour by letting you into a shop or providing you with somewhere outside your house to spend your day in. It’s those people who get disempowered.
Staff at Willowbank recognised that resources can be limited, but they did not use this as a reason for not doing something. If they could not get resources one way, then they found another way. Although this may sound simplistic, it reflects Willowbank’s basic ideology rather than the ease with which tasks could be accomplished. The enthusiasm and passion of the director drove this attitude throughout the organisation.
Respond to issues, but do not compromise on direction
Willowbank’s position of not comprising on the basic ideology of service user empowerment meant sometimes having to challenge things imposed upon them from outside bodies. For example, one individual with a physical disability was referred to Willowbank, but the referral authority was treating the person as if they was not capable of making their own decisions. Willowbank therefore challenged the authority, asking them to certify that the person was no longer able to make decisions for themselves. If they were not able to certify this, then the authority had to accept that the person was able to make their own decisions about the care and support they wanted.
Communicate underlying purpose and ensure actions are consistent with this purpose
Willowbank is quite a small organisation, which may have favourably affected its ability to be so forward-thinking. However, part of Willowbank’s ability to overcome problems is its approach – that of breaking things down into smaller units and seeing where it can intervene at this more micro-level. A Willowbank board member argued that larger organisations may ‘need to see if their organisation can be broken down into small network units [to help make the model work]’. In Willowbank, the passion the director has for the way the organisation should work is highly infectious. The staff commented on how the director’s ideas and enthusiasm have been essential. Willowbank is a small organisation, but communication of the direction of travel was no less crucial to the success of the change than it would have been in a larger establishment. The change in Willowbank involved empowering the people who use services and staff, not only to see people with disabilities as an essential part in the design and creation of the service, but also embracing a ‘can-do’ attitude and eradicating the word ‘can’t’. Throughout Willowbank there is an atmosphere of achievement. If something needs to be done, there is a way to achieve it. For example, when service users with visual impairments said that they wanted to do a computer course, they overcame the lack of funding barrier by applying for and obtaining funding to purchase the software with the encouragement and help of staff. A second barrier arose: to make the particular IT course viable they needed more people to enrol. In addition, the speaking packages used by people with visual impairments were often a distraction to other people who use services. The group searched for possible solutions and decided that if they invited their hearing-impaired colleagues, the noise deterrent of the software would be a non-issue. In both cases, a solutions-focused perspective was applied.
There is an acknowledgement among directors and staff that education may be necessary to show people a new way of looking at things. Willowbank is quite used to spreading its vision and ideology to those with a basic underlying understanding or sensitivity to user empowerment. However, Willowbank believes that it was not possible for everyone to come on board with a vision. As such, teaching a fundamental way of thinking is not always possible. As one Willowbank board member stated, ‘If you have the music we can teach you the words,’ indicating that people must come equipped with the basics and the organisation can fill in the blanks. If, however, a person does not subscribe to or is inherently against the basic purpose or ethos, it is unlikely that educational efforts will be effective.
Stakeholders need to be on board with the underlying purpose
The director of Willowbank worked with the enthusiasm of the staff that already existed to build a central nucleus of supporters. She worked directly with the staff, people who use services and other wider stakeholders.
Willowbank also had a clear policy of not accepting behaviour that was inappropriate and incongruent with the underlying purpose of the organisation. This strategy was particularly evident from the examples cited by both staff and board members. A main component of this ideology was mutual respect for others. Where people who use services were not respectful of each other or of staff, staff challenged the individuals’ behaviours. One woman who was both a staff and board member stated:
Just because you’re in a wheelchair or have a speech problem, if you do something that is wrong, you should be told about it. You can’t get away with it just because you have a disability. Having a disability or acquiring a disability does not bring with it goodness. Therefore people who behave badly are challenged on their badness. [A disability] does not stop you from being a bigot, racist etc. For example, we have said to a particular person: ‘We appreciate that you are wheelchair-bound, but...your behaviour is intolerable and you need to do something about it. You are the only one who can do something about it. People don’t just treat you badly. They treat you badly because you treat them badly. You get away with it because of your wheelchair, but that is not allowed here.
Willowbank was clear that sometimes it may be necessary to remove people who do not feel able or are not willing to get on board with the underlying purpose.
Willowbank acknowledged a limit to the director’s abilities to ensure that the values were spread throughout the organisation. Even where staff, people who use services and other stakeholders had been specifically encouraged to shape the underlying purpose, there was recognition that not everyone would be comfortable working in that environment. The director had to be flexible and in some cases devote more attention to one or two individuals.
2 Employee involvement
After establishing the new purpose and ideology for the organisation, the director had to set up a method of practice change that was aligned with the purpose and ideology and engaged its staff members. The director recognised that employees were the key deliverers of Willowbank’s services, and thus real improvements could not happen without them. The director also recognised that good practice in involving employees in change and improvement programmes builds on staff expertise and how they do their job. Effective involvement meant ensuring that employees had ownership of the changes and improvements. The employees were encouraged to view continual change and improvement as part and parcel of their work and were readily engaged in the process of clarifying how the purpose be best carried out.
Engage employees – give them responsibility
In Willowbank, giving employees responsibility was seen as way of empowering staff and people who use services. For example, one staff member was given the opportunity to train up as finance director and take control of her development. Other staff members were encouraged to seek the training they required, decide how to manage their workloads and manage their days. Moreover, people who use services were empowered to take control and responsibility for their own development. In this situation (as with most situations in Willowbank), the applicable rules and actual roles for people who use services and staff overlapped considerably. At the start of the improvement initiative, individuals needed a lot of personal encouragement to recognise that they were capable of doing things and thus take responsibility for their own development. A board member commented, ‘A lot of people wouldn’t have been given the opportunity, wouldn’t know how to switch on a computer. Willowbank challenges that, asking “why can’t you?” [The director] would have been their voice while empowering them.’
Establish a structure that allows engagement
The organisational structure of Willowbank was described by staff as ‘circular’ and the feeling of empowerment, embodied by Willowbank staff and people who use services, stemmed in part from the structure and overlapping job roles.
Directors, people who use services and support workers all make an equal contribution to the purpose, management and direction of Willowbank. In terms of job roles and boundaries, no one individual has exclusive ownership of a task. The overlap of individuals as people who use services, workers and board members also contributes to this structure. In Willowbank there is one team, and the fluidity of the roles of staff ensures that they are all engaged in the workplace. According to a Willowbank staff member, ‘We all mix around and help each other out.’ For example, anyone can answer the phone, anyone can contribute to budget planning and anyone can make the dinner. There are, of course, individuals who have particular skills (e.g. financial), but these skill sets do not mean exclusive ownership of financial tasks or permission for other staff to ignore financial issues in their everyday work. Teamwork ensures that skills are shared and all those in the centre work together.
The structure is open and encourages two-way communication, creating an atmosphere where people can contribute and feel as if their contributions are heard. In Willowbank, openness was achieved partly by using straightforward language rather than ‘management jargon’.
The structure of Willowbank is not superior to others, rather, organisations need to establish roles and boundaries in a way that will maximise employees’ sense of empowerment and ‘being heard’, yet provide enough support and structure to enable them to get their jobs done. Interdepartmental working and teamwork were effective methods to get different employees working together for a common cause.
Get communication channels right
For Willowbank the most appropriate communication method depended on the type of information being communicated: letters, e-mails, talking to people and notice boards were all used. Due to the size of the organisation, in-person communication was often the most effective and efficient method to use. The director ensured first that all staff and people who use services had the ability to use and access the chosen communication methods.
Work with resistance
The term ‘resistance’ is often viewed as destructive and unhelpful to improvements. However, as with all our case study organisations, the following points emerged through our content analysis of Willowbank to ensure resistance is used to the benefit of the improvement process:
- give people who dissent a platform to air their views
- give people time and support to come on board
- provide training for people to get the skills they need
- lead by example
- discourage inappropriate behaviour (examples include people who dissent but make no attempt to become involved in the changes, offer alternate solutions or provide reasons for their dissent).
Give staff support to adjust and adapt to improvements
In Willowbank, the fluid job boundaries ensured that all team members supported each other’s development. Comments from staff members include:
We all pull together to make time so that we can do the training or whatever. And every time we get a new service user that’s a change, that’s how we work, you adapt to them. It would be hard if you had an organisation pushing against you asking you to do this, but here I think it’s because everyone is trying and wants to do this. You do feel part of the organisation here.
I have always been able to say I would like to learn a bit more about this or I would like to do this sort of training. You are given the opportunity, whether it is help from someone internally or going on a course.
Beyond supporting the training and development needs of staff during times of change, staff members reiterated the need for support on behalf of their leaders. In Willowbank, the staff were clear on several ways they felt their director showed clear support for them:
- she listens to concerns
- she doesn’t miss staff meetings
- she’s approachable – ‘her door is literally always open’
- she compromises when appropriate
- she explains the reasoning behind decisions.
3 Stakeholder involvement
In this context we refer to stakeholders as governing boards and people who use services or member organisations. In Willowbank, as with all of our case study organisations, people who use services and high-quality service delivery were at the heart of the improvements. This section will review some of our findings on effective stakeholder involvement from Willowbank.
People who use services should be at the heart of change and improvements
Willowbank was perhaps the most progressive of the organisations in this area: the involvement of people who use services had become so embedded in the functioning of the organisation that it did not naturally come up during our discussions as a separate topic and it was almost difficult for interviewees, when asked, to think of specific examples of service user involvement. Encouraging and enabling involvement was ongoing at Willowbank. Some examples included encouraging:
- continued learning to enable staff and/or people who use services to become board members
- users to outline the class rules at the start of each teaching course
- users to run and manage their annual service reviews
- users to undertake large-scale involvement in lobbying and activist groups
- users to be members of different consortia and commissions
- users to participate in Northern Ireland and EU politics.
One service user remarked:
It [the centre] has changed from just keeping the service user warm and fed to giving the service user the chance to expand both mentally and physically. Five years ago I was happy to walk round the garden and plant a lot of bulbs. Now, I’m an equality commissioner for Northern Ireland and involved in other things that the centre has given me the chance and the skills to do.
In Willowbank, the involvement of people who use services was dependent on the individual. The support workers explained that because they had good personal relationships with individual service users they were able to work closely with them to establish how they wanted to be involved and what they needed to enable this. When asked how they found time to have such personal relationships with each service user, they said ‘we just do’ – they made the time. When pressed for more detail, one staff member commented on how they ensured they were not ‘bogged down by admin and lots of other things…We are here to support the users. We take time with them to have a laugh. You find out more about what the person needs through sitting and interacting with them.’
The Willowbank model of user involvement would suggest that routine daily involvement, where this involvement is at the core of all activities, is part of the answer. For example, if staff wanted to ask service users’ opinion about aspects of the service, they often found the best way was to ask them in general conversation. Staff would then write up any points made about the relevant issue to enable them to go forward for consideration (always with the consent of the service user). Thus, it may be that organisations need to go back to basics when involving users and move away from a more ‘formal’ approach. Willowbank illustrates how formal user involvement can be complemented by less formal approaches. The key to Willowbank’s approach is that front-line staff establish relationships with their users that then enables simple back and forth communication to occur.
However, Willowbank recognised that just as staff members will not necessarily be able to come on board with improvements, so also there is a limit to some service users’ desired involvement. Even in Willowbank, there was a point where the support workers had to respect users’ decisions not to be more proactive and involved at the centre. As a staff member pointed out:
We sit and talk to the service users and talk about what they want to do. You can’t force someone to do something they don’t want to do. We try and make it happen, but you have to learn to accept that some just don’t want to move on. It takes a while to know the person and then help. We can help them but say it is a personal decision. Telling them about what’s out there is really our job. [It’s also about knowing when enough is enough], it takes a while to get used to as well. Making an effort and it not being accepted is difficult.
Organisations need to work in and with the communities they serve
Another example of successful stakeholder or community engagement from Willowbank highlighted the importance of continual adaptation to enable the organisation to meet the needs of the local community. Situated in Northern Ireland, Willowbank had continuously had to adapt its services to keep in line with the religious and cultural changes experienced more broadly. More recently, Willowbank’s community has witnessed increased migration of Polish nationals, thus creating a language barrier between support workers and new service users. As part of its duty, Willowbank has to ensure it can find ways to communicate with them and understand how Willowbank’s services may need to be adapted to suit their needs. Currently, Willowbank is working on translating some of its materials and potentially offering language support classes. Further work goes beyond language barriers to understand potential cultural barriers. One service user stated, ‘Internally we have people researching the cultures of the regions people are migrating from so we have some understanding of the culture of the country of origin.’ Willowbank found that this willingness to continually adapt has allowed it to benefit from diversity within the community.
The improvements at Willowbank are ongoing and therefore the evaluations are not simply one-off in nature. In Willowbank, evaluation engages board members, staff and people who use services, and ranges in scope from individual user programmes to detailed financial budgets. In terms of the overall aims and achievements of Willowbank, the directors’ team set a five-year plan outlining goals they wish to achieve, activities they plan to do and clear financial targets. After the board establishes the range of services on offer at Willowbank, subsequent evaluation looks at whether an adequate range has been offered, whether Willowbank has delivered what it set out to deliver, and staff turnover. People who use services and staff at Willowbank each have a personal programme. Evaluation and review of these programmes enables everyone to establish whether they are getting what they want from Willowbank and the level of user satisfaction.
As previously discussed, employee alignment with underlying purpose and ideology was a crucial element to the success of the improvements. Willowbank’s awareness of this issue continued into the evaluation process. Conscious of the cost and difficulty of recruitment, Willowbank pays close attention to staff development to ensure it retains the right people and benefits from the skills and potential abilities that already exist within Willowbank. To this end, Willowbank has completed a skills map to evaluate the current skill level of its staff. The intention is to use this map to identify where to develop staff to ensure that Willowbank will remain successful in the years to come – even if the director decides to retire. Again, as previously mentioned, the case study organisations commented on the ability to teach people skills but not ethos. One of the board members stated:
What we need to be looking for in new people coming in is the base triangle of rights, equality and empowerment. If a person did not fundamentally believe in [this] core triangulation, they would be in the wrong job.
Willowbank is now investigating ways to measure whether someone has the base triangle of fundamental beliefs in rights, equality and empowerment it is searching for. Although interviewing techniques cover some of this ground, Willowbank is seeking ways to assess potential staff members more rigorously. The organisation realises that the careful development of existing staff and hiring the right people is advantageous both in terms of cost and service delivery.
People who use services at Willowbank also conduct their own annual reviews focusing on whatever aspects of their lives they feel to be important. Further, it is up to the discretion of individual users if they wish to share these reviews externally with their social workers.