Published: October 2022
Foreword from Social Care Wales
“Our ambition for care and support in Wales is to ensure that people are at the heart of care and we support their choice, independence and control. We want to promote wellbeing and prevent individuals needing more intensive support, but this is not always possible, and care, support and treatment may be needed in hospital. Individuals, families and professionals are concerned about the length of time individuals stay in hospital as we cannot maximise individuals choice, control and independence in a hospital ward. Evidence shows us, when they are well enough to do so, people recover better in their own home.
One of the factors that can increase the amount of time a person is in hospital is professional risk aversion, and a lack of collaboration across services. The focus has for too long been on process- rather than person-centred planning. Knowing ‘what matters’ to the individual and understanding what strengths and capabilities they have (including the resources of their family and community) builds a more holistic discharge plan and helps prioritise areas of support, to enable a timely ‘good enough’ discharge.
Social Care Wales developed and tested a programme called ‘Balancing Rights and Responsibilities: Supporting a Cultural Shift Integrated Health and Social Care programme’ (referred to as BRR). This programme aimed to develop new skills and capability to rebalance the reliance on risk- and problem-based approaches, with a view to developing and delivering person-centred care.
The joint programme (BRR) was a hybrid of the ‘Collaborative Communications Skills’ (social care) and the Care Aims (health) training and skills development. Both well-established existing programmes that shared common principles and brought together the ‘what we need to know’ with ‘how do we do it ’and ‘what this means’ for effective and aligned decision making. Building on these existing programmes enabled us to develop a programme with the added benefit of multi professionals coming together for learning, reflection, and skills development. The programme included frontline training as well as planning sessions for management buy-in and support for the frontline.
In partnership with NHS Delivery Unit, Aneurin Bevan Health board (ABUHB) and the local authorities of the Greater Gwent region we tested the programme with multi professionals involved in hospital discharge in the region.”
This report was commissioned by Social Care Wales and presents key findings from an independent evaluation undertaken by SCIE.
What could embedding BRR achieve?
Mentors who were engaged in the programme for at least six months thought it could achieve the following:
- shorter hospital stays
- more integrated care for individuals as multidisciplinary teams (MDTs) take decisions together
- some repeat patients would not so readily return to hospital/services
- identifying individuals’ strengths/resources including family and community to support discharge and longer term wellbeing
- having essential conversations with patients and families earlier
- more effective and efficient referrals that ensure that conversations have been had with the person without the constant need to repeat the exercise. This can be further progressed with the role out of trusted assessor models.
Following the training and support programme:
- Nearly all participants reported an increase in skills in “listening to understand”, “listening reflectively”, “helping people understand their strengths” and “summarising outcomes and actions”, as well as an increased understanding of duty of care.
- Undertaking and supporting/encouraging other colleagues to undertake collaborative discussions was achieved.
To enable the embedding of BRR, the culture of an organisation, and required processes and paperwork needs to align and support the approach and focus on questions which support appropriate person-centred and accelerated discharge.
- Barriers and challenges include:
- Responding when colleagues do not wish to engage in a person-centred BRR ethos and approach.
- A blame culture (between teams, individuals, or social services vs hospitals).
- Lack of time for effective communication with patients and professionals; competing pressures do not always allow the right person to have the right conversation at the right time.
- Organisational auditing and record keeping is not aligned to what matters to people/families.
- Decisions coming from a place of risk and problems, rather than strengths and a ‘good enough’ outcome for patients, focused on what really matters to them.
- Families tending to look to medics as the lead viewpoint in the team which is hard to challenge.
Social Care Wales – next steps
For a number of years health and social care policy in Wales has focused on strengthening community care services. This is central to the delivery of the ‘A Healthier Wales – Long term plan for Health and Social Care’ and the National programmes; the Strategic Programme for Primary Care, the Urgent and Emergency Care Programme, the Regional Integrated Fund and the ‘Further Faster’ mission which focus on achieving this. However, delivery has struggled due to the rising population and associated demand.
The principles and findings from the Balancing Rights and Responsibilities programme can help to shape the behaviours, relationships, skills, and leadership, required for integrated multi professional teams to work more effectively together. In terms of the current and ongoing issue of delayed discharges, the evidence and experience of staff, shows that refocussing conversations with patients and colleagues encourage more effective discharge arrangements. A much clearer understanding of what individuals need as a priority, and what they, their families and community can contribute to supporting their health and wellbeing benefits all concerned and relieves pressures in the system.
The achievement of embedded person-centred care and support across social care and health requires actions at team, organisation, interagency and national level. To use the learning of this report and look to improve our practice in balancing rights and responsibilities Social Care Wales will:
- Share the findings from this report across the health and social care sector including: ADSS Cymru Heads of Adult Services, Strategic Programme for Primary Care; initiatives to support Community Capacity building.
- Consider with HEIW how the findings from this work can be embedded into the 10-year workforce strategy.
- Use learning to inform developments on Virtual Wards, Multi Professional Framework and Trusted Assessor workstreams.
- Continue to deliver outcomes and strengths-based support and training across the Social Care Sector, including maintaining a network of champions to embed in practice.
- Work with Care Inspectorate Wales (CIW) and partners on how to support the embedding of positive cultures.
For more information about the Balancing Rights and Responsibilities programme, please contact Jessica Matthews.