In our recent conversations with other experienced and esteemed practitioners in the field of health and social care, a regular topic keeps coming up. Why aren’t we seeing real progress in Adult Social Care transformation?
Why now is it still seen as ‘progress’ when a student Social Worker talks about a person they are supporting on the basis of their skills and strengths? This is not new, and it is not innovative. In fact, if a social worker is describing this type of practice, they are merely demonstrating their compliance with the Care Act and Care & Support statutory guidance. We are not seeing change, because those who are the gatekeepers of the change are still seeing ‘new innovation’ as practice which is aligned with what the innovators were discussing and doing 30 plus years ago.
Innovative work is often observed from an external position, where the work of the innovators is recognised, admired, heralded and celebrated but still seen as separate to ‘what we can do’; therefore those that are in a position to make a difference do not recognise the role they have to play in making it happen. They don’t recognise how they can be part of making the difference themselves – always seen as something the the people on the other side of the statutory fence do. It is common practice to attend conferences and online events which are presented as ‘an audience with the innovators’. The problem with this is that innovation continues to be seen external to the audience and the very gatekeepers of change.
So what would it take for people not only to see and admire the ‘innovative’ work but to embed it into their practice, for them to model this approach and build it into what they do, rather than celebrating it as ‘best practice’ and ‘something to aspire to’?
Is this about providing support and guidance; and to be alongside people, building it into their practice as they stretch their comfort zones until it becomes part of their comfort but preventing them from going into the place of panic? Is it about bringing in what is covered in the Be Humankind practitioner experience around recognising your circles of influence, concern and curiosity; functioning from a position of influence and courage whilst being in high states of self care?
Organisations need to focus on building an organisational culture that has psychological safety as a foundation, so that those with the passions, skills and understanding can dare to do things differently and to feel safe and supported in the pursuit of this. We need a health and social care system that is not defined by users and providers but by people being alongside each other in the pursuit of a better life experience.
Wherever the answer lies, it is this dynamic shift in culture and practice we need to see before we can expect to observe any dynamic shift in the way care and support is organised, sourced and experienced.
Independent Support Brokerage creates the shift by working with one person at a time. It does not start with standardisation of processes, forms and templates (which often squeezes out creativity and innovation). Instead it focuses on some key principles:
Listen: to what is happening for the person. Use discovery conversations to understand what the person wants to change or achieve. Start with the strong stuff. Relationships, skills, interests, passions, connections, hobbies. Learn from listening about what a good life looks like for the person. From this foundational information, exploration and planning can happen.
Explore: From the basis of what has been learned from the person, support the exploration of possibilities, opportunities and resources which are available to support the person in what they want to change and achieve. From this stage of the listening, learning and thinking, the person can begin to form some clear ideas of how they want their life to look, and how they would like to be supported with it.
Connect: From the exploration which has taken place, create some ‘maps’ of assets, relationships and opportunities which the person wants to include in their planning. Make connections. Facilitate conversations. Access resources (which could include statutory funding such as a Direct Payment of Personal Health Budget) and secure assets which will support the implementation of the person’s ‘good life’ plan.
Action: Support the bringing together of the final plan. This may need to be signed off by statutory decision-makers, so it is important that the plan meets eligibility and requirements for sign-off. The plan should include costings for any paid-for elements of support, but could also include non-paid elements which still contribute towards the person’s overarching wellbeing outcomes. Once the plan is agreed, an action plan to support the implementation of supports and resources is helpful to ensure that support is put in place for the person. Ongoing support around review and update of the plan may also be helpful.
Imagineer supported a lady who had been identified as eligible for social care support. She was supported by the direct payments team from her Local Authority, but the social worker refused her a direct payment on the basis they did not believe she could manage the arrangement. This resulted in a commissioned provision being identified. The provider of the commissioned support focused on meeting contractual requirements and was not prepared to meet the woman’s needs in a personalised way. The provision broke down on two occasions. A new social worker began working with the lady and arranged for a new provider to meet her, without having a conversation with her about who she wanted to be supported by.
When the lady raised the fact that she wanted to explore other options available to her, the social worker ceased the direct payment, and she was left without support. Imagineer supported the lady to make a complaint via the Local Government Social Care Ombudsman, which was upheld and resulted in the social worker offering to carry out a new assessment. The lady refused because the whole process had been so traumatic. She decided to self-fund her own support in a way which makes sense for her, so she has self-funded a cleaner to help her with domestic tasks, and somebody to take her shopping. Imagineer provided Support Brokerage through each stage of the process until she reached the solution which made most sense for her.
If you’re interested in the range of ways in which Support Brokerage can assist Self-funders in arranging their own care & support, please contact us at: info@imagineer.org.uk
The majority of commissioning for Adult Health and Social Care is still focused on fixed and outdated service models which are determined and designed by profit-making service providers; squeezing individual and often complex needs into a broken system which is no longer fit for purpose. The result is that people experiencing a complex range of challenges in their lives often fall into a cycle of crisis, knee-jerk commissioning responses, placement breakdown, trauma and further crisis. Is the person being supported in the system complex? Or does the current system propagate complexities?
These linear commissioning processes are still the norm. Yet we all know the world of Health and Social Care changes quickly. Let’s say goodbye to traditional commissioning processes and embrace a more flexible and individualised approach. It’s called Self Directed Support.
Traditional commissioning for Adult Social Care and Health started at a time when the world of Health and Social Care was more stable and financially predictable than today. It made sense to those holding the budgets to have a model which used universal needs analysis of geographic areas (‘misery maps’) as a starting point, and then went to the Provider market place to seek solutions for meeting those needs. Provider organisations jumped to attention. Commissioning budgets quickly got tied up in framework and block contract arrangements agreed via European tendering processes and costly procurement systems which were designated by service label, and need. Lots of ‘specialist’ provider services sprung up- ranging from small Learning Disability homes to private Mental Health ‘Assessment and Treatment’ facilities and blocks of flats for people with Dementia. Lots of little ‘Care Ghettos’ were created around the UK.
There was profit to be made. It attracted the Venture Capitalists. Their cost and volume discounts stifled the small locally-based, community provider organisations, charities and social good organisations (who existed to help people to live well, learn to self-advocate and uphold their rights, enjoy citizenship in their local communities and experience a good life). The Health and Social Care market became a place for the giant corporates. The individual receiving support was forgotten- buried under the swathes of corporate governance, regulation and cost efficiency measures.
Because of this system the very need for Self-Advocacy exists, and we see an ongoing advance of legal challenges such as Judicial Reviews for people within the system who are fighting for their rights.
But this model of commissioning and market-shaping is outdated and provides a perfect breeding ground for the deprivation and abuse of human rights of the very people it should be there to protect and serve. Ultimately, it is costly, damaging and just plain wrong.
Instead of a narrow linear path to services, support by hours and tasks; we argue for flexible budgets—based on genuine person-centred and strengths-based assessment. Rooted in the intrinsic motivation and aspirations of the person and reflecting the need for flexibility which comes with the very natural and human process of changing & evolving interests, changing needs and ageing; and we argue to support the development of community connections and cohesion. Effectively the same level of connection, choice, control and flexibility which other citizens are able to access and enjoy when they are not reliant on statutory funding and provision to lead a normal life.
We argue for a recognition that Support Plans which are designed primarily around the person’s strengths, passions and motivations; rather than need, deficits and risks are more likely to achieve outcomes long-term, keep the person safe and ultimately reduce their dependency on the public purse or the repeated cycles of crisis which result in the need for high-cost emergency interventions.
We argue for more flexibility and less standardisation. For more variety and opportunity to use budgets more flexibly in order to build good personalised support which is tailored to the individual, and fewer blue-printed service models from large provider organisations. (Who wants to live in a care ghetto??) We argue for people to hold and control their own budgets, with good support to manage them if needed. We argue for ordinary homes in ordinary neighbourhoods. Good support. More courage, kindness and respect for human rights. More value for people as citizens and fellow humans. More focus on the strength and opportunity of connected communities, neighbourhoods and localities as the starting place for finding solutions. We argue for local democracy and decision-making power for communities to develop and build what makes sense for them on a local level, rather than what is determined by decision-makers who live far away, hold the purse strings and don’t have any understanding or experience of what it is like to live in those communities.
We’re thinking of the brave ones out there who challenge the current system and embrace new ways of working and stewarding the public purse. We’re thinking about a world where everyone matters and everyone has a voice.
(Based on an image concept by @waitbutwhy)
It’s called Self Directed Support. It’s actually been around for years. It’s embedded within current Health and Social Care legislation. It’s a right in law (Care Act 2014) for people to have it. Self Directed Support is where the person entitled to receive support is given clear information about their options, and a choice to use the financial resource allocated for their support (by their Local Authority and/or CCG) in a flexible way which makes most sense for them. Effectively, the person can design their own support plan. So why is it not the obvious first option?
It’s because we are still stuck with the old traditional systems for commissioning and contracting for support. We have very expensive Local Authority & Health departments and systems which are inefficient and not fit for purpose. We spend a lot of time and money on trouble-shooting poor commissioning and support arrangements which have not met people’s needs and have triggered the cycle of crisis. We have a pool of social workers entrenched in a focus on crisis intervention and budget cuts. There is no room for proactive or preventative approaches. Everybody is fire-fighting.
Let’s stop trying to re-invent a buckled wheel, calling it by a different name and expecting it to change things. Let’s be radically different.
Where are the some of the good solutions happening already?
Self Directed Support makes absolute sense- it connects naturally to all of these Strengths-based approaches. Let’s learn how to make life work well for everyone.
For more information about Self Directed Support, visit our website: www.imagineer.org.uk
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Here, Sarah shares some of her story about caring for her young adult daughter who is diagnosed with Autism Spectrum Disorder.
I care for my daughter who is now 20 , she needs help with daily social/ living skills. She has Autism Spectrum Disorder (late diagnosis 3 years ago), and has had a huge mental health crisis during the Covid-19 pandemic which resulted in her having to be hospitalised. She has had the most horrendous year and has been traumatised because of it (as have we her family) .
As a result, she now needs help on a daily basis. Her daily needs include: Daily living & independence skills, needing to be heard in a trusted relationship, feeling safe enough to show her need and managing new and different situations (which is very hard for her). She is building trust in her PAs and has other key supports in her church, family and a small number of trusted professionals.
She is an amazing, funny, intelligent person who is working very hard to understand herself and manage life. I am very proud of her journey.
Currently, we are provided 25 hrs of care per week (2-1) and apart from times when she is in appointments, I am her sole carer and am available 24/7 the rest of the time. Sometimes she needs me in the night as she still gets recurring dreams of her time this past year when she stayed in a mental health hospital avoidance unit. Now at home, we can only have care at the times when the agency are able to provide staffing- not always at times when we need it.
Currently, even though we have scheduled care in the family home, I often still need to be available for crisis support.
When it’s a good day, I love to meet friends, go out for meals, do craft etc.
I would love to see family and friends that live at a distance. I love to go to church and volunteer to do activities.
When things open up more theatre is great to visit.
As a carer I have had to tackle a wide variety of issues by personal research and enquiry. It has felt that on each occasion I have had to gain skills in unfamiliar areas when there should be information available.
For example : education (EHC) tribunal, legal action, safeguarding, mental health, social care, etc.
It would be helpful if there was a source for all these challenges in one place so you don’t feel like you’re alone and reinventing the wheel each time. Peer to peer advice would also be helpful.
Professional help seems there for the client but the carer may be traumatised, in need of support eg counselling etc , and are expected to continue until breakdown. Carer hubs seem to deal with a limited range of basic support. Independent support for carers in the form of a budget for counselling/ advice, etc would help prevent breakdown of care in the home.
At Imagineer, we work alongside unpaid family carers in many different ways; but one of the key ways that we can assist is by providing Support Brokerage.
If you are interested in receiving assistance from one of our Support Brokers, please contact us: info@imagineer.org.uk to request a call-back for an informal discussion, or a referral form.
For more information about Carers Week 2021, visit: Carersweek.org
In the practice of Independent Support Brokerage we often have conversations with people who are accessing social care support for the first time and discover that they don’t have any awareness of their rights under the Care Act.
This can make the whole process of navigating a social care assessment very tricky. How do you know what to say if you don’t know what your rights are?
The emphasis of the Care Act is on well-being and the ‘well-being principles’. It is supposed to be a ‘whole life’ or ‘holistic’ process, but often the social care practitioner carrying out the Care Act assessment focuses solely on the narrow view of individual ‘outcomes’ rather than the overarching well-being principles; meaning that they may not focus on the correct areas of life where the person needs most support.
It can often mean that the focus is taken completely away from the factors of a person’s life which determine their well-being, and therefore resources or services provided by Adult Social Care to meet that perceived need are just not a good fit for the individual.
It’s a little bit like talking to a mechanic about the problem with your car, then at the end of the conversation finding out that the mechanic knows all about motorbikes but not much about cars at all.
So let’s look at the well-being principles first:
These are the principles (enshrined within law) which are recognised as the determinants of well-being, in relation to Social Care eligibility.
When a person requests (or is offered) a Care Act assessment, their eligibility for support is determined by the following criteria:
The ‘outcomes’ specified under the Care Act are:
Anybody can ask for a Care Act assessment, and they should not be told that they are not eligible for support under the Care Act unless an assessment has taken place. In some areas of the UK we have seen ‘screening’ assessments being used by some Local Authorities as a way of filtering people out for assessment, but this is not within the guidance (or the spirit) of the Care Act. We have also heard from people we have worked alongside, where they have had a telephone conversation with a social care practitioner (such as a social worker) without any awareness that an assessment was being carried out, and have later discovered that their assessment took place over the phone. Most people would be unaware that they can challenge this.
There is little information shared within the public domain, and in accessible language- which explains people’s rights simply and helps them to navigate the assessment and support planning process. For example- most people would be unaware of their right to lead on conducting their own assessment (should they wish to) and to gather and share the information which goes into the assessment themselves. Could this be due to suspicion from Local Authority officers that people may abuse the system or manipulate information in order to secure support? Or is it due to Social Care departments being so stretched that they are being forced to adjust their practices around assessment and support planning to ensure minimal admin burden and lower uptake of resources?
Again- many people are not aware that they have a right to request a copy of their completed Care Act assessment and to request amendments to any of the information that is inaccurate (or missing) from it. There is often a delayed response when such a request is made; or when the assessment is shared with the person it is clear that there has been poor evidence capture and complete lack of detail- often by a practitioner who has not spent any meaningful time with the person they are assessing in order to understand their individual circumstances thoroughly. Could this be due to overstretched caseload and lack of capacity with social workers? Is this impacted by the person being uncomfortable disclosing personal information and details about their individual circumstances to a complete stranger? Could this be due to poor assessment skills, or a deliberate way of managing a very stretched resource?
Finally- at the conclusion of the assessment process, if the person has met the eligibility criteria there should be a clear discussion about the ways the person is entitled to receive support via a Personal Budget. Often, the person is only made aware of the option of a commissioned provider service (such as domiciliary or residential care) or a Direct Payment. Often people are talked out of the Direct Payment option by being told it will be stressful and burdensome to manage. Practitioners carrying out the assessment may not have the full complement of knowledge, insight & skill to help the person navigate their entitlement to support in the way which makes most sense for them individually.
In our next few blog posts, we will be expanding on this area of thinking further. If reading this blog post has made you question your own level of knowledge and understanding in relation to the Care Act and people’s rights, you may be interested in joining our Quick Bite for Lunch webinar series on ‘Rights’ which is starting on Weds 20th January 2021 at 12.30pm.
We’ll be exploring the whole area of ‘rights’ in relation to Social Care and Health assessment- sharing our professional experience of supporting many people through the Care Act assessment and Support Planning process in different Local Authority areas across England over the past 10 years.
There will be an opportunity for participants to share their personal experiences and ask questions too.
Visit our ‘webinars’ page for more information or email us: info@imagineer.org.uk to request a booking form.
Liz Leach Murphy is the Founder of Imagineer Development UK CIC, Chair of the National Brokerage Network and a Freelance Consultant working on personalisation within the Health and Social Care sector/community space.
Sarah Holmes is a Freelance Consultant working on personalisation within the Health and Social Care sector/community space; and a Director of Imagineer Development UK CIC
Both Liz and Sarah are practitioners, trainers and coaches in Independent Support Brokerage and consultancy for Strengths-Based Approaches with collectively over 40 years of experience in the Health and Social care and community sectors.
Imagineer Development UK CIC is a social enterprise based in the North of England with a national reach; originally set up as a test bed for Independent Support Brokerage in the UK. Imagineer is the hosting organisation for the National Brokerage Network, which is a community of practice for Independent Support Brokers. Imagineer provides a range of training & consultancy services in Support Brokerage, Person-Centred and Strengths-Based Approaches.
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It’s quite common to hear about ‘person-centred approaches, ‘choice and control’, and ‘self-directed support’ in Adult Learning Disability and Autism services; but we don’t often hear about innovations and personalised approaches in the delivery of older people’s care and support arrangements.
Imagineer has been delivering training in person-centred approaches including support brokerage for many years; and recently we were approached by a forward-thinking provider organisation in Devon- Love2care
This organisation provides home care support services mainly to older people across the Torbay area of Devon. They are rated as ‘outstanding’ by CQC and have a really unique, creative and personalised approach to the way they deliver their services.
Traditionally there are 3 main types of service model adopted for the care and support of older people:
The founder of Love2care Devon- Maddy Bird was keen to train her staff team in the principles of self-directed support and to develop their skills as Support Brokers so that they could really open up the way they supported their clients both at home beyond the traditional models of support, and also when there were any transitions into a hospital environment or a change in their care and support needs. Love2care commissioned Imagineer to deliver the full accredited Support Broker training to an initial group of staff at the organisation. Due to Covid-19 restrictions, the training was moved to online delivery, via the Zoom platform.
Maddy talks below about their experiences of doing the training and the impact it is making on their work as an organisation:
Love2care has people at the very heart of the service, and when we talk about ‘people’ we don’t just mean the person we are caring for. We mean them – absolutely, but their loved ones also – the carers who provide paid and unpaid support. We also value our team and employees, as people. We focus on getting to know what matters most on an individual basis – not just feeling like we are completing a set of tasks for someone; but that we are facilitators and part of a support system, as advocates, listening ears, and objective eyes.
I often say to people that Love2care is a person-centred organisation, because although we may be juggling a lot of changes or difficult situations; we are disciplined in our practice, ensuring that others don’t feel that strain. We are careful to ensure that people feel listened to, heard and valued. We then support each person to look at ways to address what it is that they want to achieve.
Our service is very much focused on building & maintaining positive relationships, and having clear boundaries. We work hard to avoid getting caught up in bureaucracy. We truly try to work with the people we support, so that they can live the life they want to. For me, the word ‘facilitators’ is very apparent within the organisation.
My work background prior to Love2care was in a corporate organisation, and my role was ‘brokerage manager’ – working under a ‘prime provider’ framework with my local authority. I loved being able to help secure care and support for people, but what I quickly realised was just how ‘un person-centred’ the processes were. I felt that (for me) care has been a vocation, and a journey, and yet throughout my career I was starting to come further and further away from the person. I was brokering care and support for people whose names I didn’t know, as it was done via an excel spreadsheet. For me, this just wasn’t ok.
I felt that I needed to do more.
I then established Love2care, and through my work, I have just always had a passion for changing that experience. I have been able to do that via Love2care in some areas, but I then had a vision that my team around me would have the competence and the desire to support people more, enhance their lives, and also have meaningful conversations.
I think within our service we regularly felt like we had more to give, but less autonomy through local authority contracts. We equally wanted to support our local community – so there were definitely feelings of restriction and limitations in our role. I developed an idea using support brokerage, and using our CQC registration, which explored a new model of care offering the potential to free up social care time and resources; and work in a much more personalised way with people to self-direct their own support.
We really enjoyed our training. There were a couple of things for me, firstly being able to invest in my team to develop them personally and professionally; giving them a skill set and knowledge base that not all front-line social care staff have the opportunity to normally receive. The training is giving them the confidence and competence to be able to have more in-depth conversations, and autonomy to look beyond a task list for people.
Secondly, what I also took away really positively was that our care and supporting planning was really person-centred already. Recognising that as a home care provider, we had the resources and we were utilising them; but through completing the training we were able to go deeper. I now have more resilience and flexibility within the service, to offer people we may not necessarily need to provide with direct support, but to offer them a brokerage service that means they are feeling heard, and that they can self-direct their own support.
My staff team have the autonomy and confidence to go beyond the norm. They understand how to look at different resources, so people remain independent for longer. Even just our conversations as a team have changed – I feel that we have given people more choice and control – allowing them to make the decisions they want for their lives.
Our local commissioners are really enthusiastic about us thinking differently. We are looking at developing Individual Service Funds (ISFs) within our local teams; however, due to the restrictions of Covid (and now heading into winter pressures), I think there is some delay – even though in one sense and in an odd way, I also feel that because of Covid – we are years ahead.
We will keep doing our thing, and hope that people see that a new model of care could really make a difference.
Surely we have to try?
Are you interested in finding out more?
Imagineer offers accredited support broker training, mentoring and other training/resources relating to self-directed support and strengths-based approaches regularly throughout the year.
Visit our explore our website for further information which can be found under the drop-down menu heading ‘What we do’’ for further details, and subscribe to our mailing list to be kept up to date with future training dates.
To find out more about the work of Love2care- Devon, visit their website: https://love2care.uk/about-us/
About us:
Liz Leach Murphy is the Founder of Imagineer Development UK CIC, Chair of the National Brokerage Network and a Freelance Consultant working on personalisation within the Health and Social Care sector/community space.
Sarah Holmes is a Freelance Consultant working on personalisation within the Health and Social Care sector/community space; and a Director of Imagineer Development UK CIC.
Maddy Bird has worked within Adult Social Care for 10 years, in various roles from Community Carer, Care Coordinator, Brokerage Manager in a prime provider commissioning model, and is now founder and leader of an Outstanding Rated organisation, Love2Care Devon – established in 2017.
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