Six Steps to managing demand for Social Care

Six months on since Professor John Bolton and Philip Provenzano published the report Six Steps to Managing Demand in Adult Social Care - a performance management approach.  We have been encouraged by the work organisations have initiated to implement the models of good practice and performance indicators suggested.  On Monday 2nd October 2017 we hosted a a web-chat to begin an on-going community to further build on this approach and work together towards a 6 Steps version 2.0.  John and Philip were joined by IPC Principal Consultant Juliet Bligh, an edited transcription of the event is below.

Developing the ‘Six Steps’ approach to managing demand – webchat (integrated conversions)

Participant comments against bullets

Hello everyone. I thought it would be interesting to start by hearing your thoughts on the challenges people are facing in this area - John and Philip?

  • James Lampert - Hi everyone, James here, Commissioning Manager at Kent County Council… We've taken much the same approach as was in the paper. We started off with driving lots of people through enablement. Now doing some work to re-look at how we direct people out and back into the vol sector before they get in at front door. Also about to tender for an “older persons core offer” which includes things like care navigators and other traditionally grant funded vol sector community support…challenges incl management of people with LTC (helping to achieve outcomes) and how to recruit, train up and retain staff that can do all this

Juliet – thanks for getting things going – do councils have the ability to measure their outcomes? And do they understand the practice required to improve outcomes?

  • James Lampert - Talking outcomes – we've been doing some work on LD and older people looking at practice and how goals / outcomes can be set and then developed measures to determine what has happened. Pilots, not systematised yet note though!

James – there is a lot of evidence to help us know how to best help people who have a LTC. we need to understand what this evidence is telling us and to adapt our practices accordingly. eg there is much to tell us about how we might help people after a diagnosis of dementia, much information on this is on the Alzheimer society website. James – re LD outcomes, love to see these – can you please post here or bring along to our conference later in the week. We say in our paper that you should start by focusing on the outcomes that deliver greater independence (depending on level of disability of course)

  • James Lampert - One of the challenges is how to achieve cultural change (and direct change) at the frontline with commissioned services (not within council managed social care) – and how eg home care workers can be skilled up to directly work on someone's goals, review and re-set them?
  • Julie Vollor - Hi, Julie Vollor here from Derbyshire – our challenges including struggling to recruit and retain care staff, and fragile care market.

James – thanks for bringing this up – we have been working with a number of organisations, particularly in Wales on looking to develop the right type of behaviours and culture through the performance management discipline of coproducing practice framework and standards for social work staff.
My (John B) experience is that domiciliary care is rarely commissioned mostly procured. If we were commissioning we would recognise that dom care is a range of different services expecting different outcomes for the range of services that need to be provided.

  • James Lampert - think you're right John – I'm leading our transformation project here looking at exactly that – how to move away from buying time and task home care at fixed fees to an outcome based, personalised care and support model that incentivises providers to do the right thing. And that doesn't cost the earth. And is long term sustainable. And meets the evolving integration requirements.
  • Lucie Eden - Hi. I'm Lucie Eden, I work across Gloucestershire County Council and Gloucestershire Clinical Commissioning Group in the Integrated Hub (Health and Social Care).  I've got to be honest and say I am stepping into the web chat for a colleague and whilst I know we have been looking carefully at this area, and have employed 2 rising soon to 4 Care Navigators I don't know so much so was hoping to find out about other areas. It looks as though we are all in the fairly early stages, is that representative nationally? Our Care Navigators are based in the hospital, with the aim of reducing demand on packages of care, they work closely with Reablement and other commissioned services, e.g. Telecare
  • James Lampert -  We've (Kent CC) recently released a consultation doc about our OP core offer – detail in here about Care Navs and how we see them.  We've had Care navs on one form or another for about 10 years now, usually employed by vol sector providers (but commissioned by us)
  • Lucie Eden - Thank you James, this will be really interesting to look at
  • Ian Haines - Hello. I am from Notts CC.  As most council's we have done all the stuff on provider prices, workforce analysis to see where reductions can be made etc and have saved £93m. We have known for a while this is not enough and have done a lot to resolve queries at the front end robustly and reviewing packages to find savings. We know there is a long way to go to transform our services so that more is done to resolve queries at the front end (resolve and not just signpost), to expand preventative services and improve a culture
  • Julie Vollor - We are working with our local vol. sector to see if we can find ways of providing dom care in the most rural areas – i.e. the non-personal care: we are about to procure for them to explore setting up circles of support.
  • Anna Grainger  - hi am I online also Anna grainger from city of London, we are here to listen to what others have done as we are early doors in our work on demand management.  What grade of staff do you have at the front door ian to resolve the problems? is the front door managed by another part of the council or outsourced?
  • Stephen Vickers - Stephen Vickers from Herefordshire – we've been on a 2 year programme looking at whole system change. Culture across our internal workforce has been a huge challenge. The 6 steps research was timely for us and a useful tool to map progress, modelling and performance.

Thanks to everyone for their examples – we would love to hear about the performance management part of this – how are you measuring the outcomes and impact of this work?

  • Ian Haines - we have started to report to service directors on the most pertinent performance measures eg % of LD who a programme of independence. Our intention is to benchmark our current performance and set our own internal performance targets – these need to be stretch targets that improve over time. we are way off some of the performance measures in the 6 Steps report but they do give a direction forward.

That sounds good but you are right we need to exceed current expectations – this requires both individual and collective performance review
Are there any health colleagues out there? We would love to hear from you?

  • James Lampert - Talking LD as an example, we're working on a basis that we want 100% of people to have goals / outcomes set as part of support planning. You could argue that this should already be happening as part of good practice person centred support (but is it in reality??)… and then taking this on a step, asking providers to report progress against outcomes at set intervals, using an outcome measurement scale (based on the Care Act Outcomes). Doing in a pilot area with one CLDT at moment and ab
  • Anna Grainger  - thanks for the link to the consultation on kent's approach to funding a new way to manage grants etc. james – useful.  We might be looking at the outcomes star as a measure of success and self defined outcomes – has anyone else used this?
  • Ian Haines - James – that sounds interesting. We are working on good support planning as you say it is patchy in reality. How are you asking providers to report progress and at what set intervals. What does you outcome measurement scale look like? how is your pilot going?
  • James Lampert – That’s OK Anna – effectively what is means is that grants are ending and money being moved into contracts – gives us greater control and helps us meet our strategic objectives
  • Stephen Vickers - Herefordshire have mapped and redesigned the end to end process taking account of the performance measures set out in the report. Our work is modelled against our AWB blueprint, our prevention approach and a new customer journey for those coming in to contact with ASC. Quite literally, this is a system wide approach so performance is mapped against all areas. Front door – % of contacts offered advice, % in to planned short term care, % in to reablement, # of hospital avoidance etc. Reablement services have been redesigned to take account of associated targets (i.e. % older people supported, % discharged with no further care etc). Long term
  • James Lampert - I'm keen on outcomes star too. Our Carers Support orgs use it – some to a greater degree than others. We still need to work out strategically if we go with that or not on a wider level but to me makes a lot of sense – and of course links with nationally available datasets / benchmarking too

James and Ian – great to see that you are looking at this, but the challenge from John and I is that what James described is a process outcome – i.e. everyone has an outcome – but what about understanding the impact of those outcomes?

  • Anna Grainger - I didn't finish typing before it whizzed off – is there a network in adass or somewhere to share the work on this?

Anna – not sure that there is a network out there – should we create one?

  • Ian Haines -  i defo think a network is a good idea as we are all essentially struggling with the same issues and all probably have good things we can share to prevent inventing the wheel constantly

John B says that we really like the Herefordshire approach – can you say any more about the outcomes achieved?

  • James Lampert - Exactly… it's the “So what?” question. What I hope this will lead to is a better understanding of what works well (and for whom?), what doesn't work? Where do we have gaps (geographical, meet some outcomes better than others), so what do we need to do about it (from a commissioning, contract management, market development (training, sustainability, etc) perspective?

James – Philip here – you are right, but interestingly you have mentioned I don't think what needs to be done about care management staff – our experience is that it starts here

  • James Lampert - We do similarly to Herefordshire in terms of measures, so got good idea of where we're at now. What we are trying to change though is that customer journey to manage demand, get (?better) outcomes within an ever decreasing budget

Can someone say more about the change in different outomes being achieved – towards independence?

  • James Lampert - You're right Philip re: care management staff. So a couple of things here – have we got the current model and staffing right? So do we need care managers doing what they do now or something else? What does the council NEED to do vs. what functions could sit with provider org staff? Assessment, review, outcome setting? On cultural change, there's a realisation here that you could actually pretty much leave the current LD support market alone – but change the culture within teams linked to Prac PS – I second some kind of network, good idea
  • Ian Haines - We have done a lot of work with staff around what good support planning looks like and the importance of promoting independence work for social care but we need to go much further I think and start working with individual teams looking at their commissioning behaviour on an individual worker level to improve practice around support planning and promoting independence. To this end we are starting to have meetings with groups of local teams to design objectives and performance measure around prom

Ian – sounds really good and very similar to the work we are doing in Wales, maybe we should compare products?

  • Stephen Vickers - Phillip – we have invested in full community service mapping for 1 year to establish what is out there and consider how we build the community element in to support and care offer, factoring in well being as well as meeting support needs. Staff retrained to all front line staff retrained in strengths based assessment etc over summer period. model will be fully implemented by mid November

Stephen – Your description of the mapping is really interesting and a good start here – what are your next steps once you have this mapped? Do you intend to then engage with these resources differently, and what impact are you looking for, particularly to assist care management staff?

  • Stephen Vickers - We have introduced new community broker function across the county to support social care staff to tap in to community support more effectively. early signs very positive.. first 8 cases resulted in 6 supported entirely by community – no formal care. Community broker function includes supporting social care front line but also identifying and filling gaps in community provision. In addition, talk community function modelled on work in Shropshire..
  • Anna Grainger - Stephen – is the community broker similar to a village agent/community navigator role and I assume it is commissioned from the vol sector?
  • Stephen Vickers - community broker employed by ASC at this time. one of the primary functions is to support front line staff with their care and support planning. felt at this point better in house but future may in vol sector.

John B says that is all very positive – I am really interested if you can describe the difference all this has made? 25% less demand??

  • Ian Haines - Philip – happy to talk! I think that good data analysis is key but we are feeling our way on this. Individual teams and social workers in Notts do not know currently how they fare eg how good are they at promoting independence compared to the social worker at the next desk or team? We have dipped our toes into this and have data on how teams compare eg why is the cost of direct payment in one team on average 20% higher than a similar team in another area? We hope to use this data to ask teams to set objectives to improve. It might sound like i know what i am on about but i am not sure i do – it's all new really!

Ian – let's do that…

  • Anna Grainger - Are you looking at the high impact change model for acute services – we have looked at improving support for people at weekends with a provider who can take people home and supply 24/7 support for up to 72 hours at weekends if people need to return home. we can then assess from home which is hopefully a more realistic environment.

Anna, John B says that in his work with councils and health partners we have been looking for a high impact model. This is covered in the paper om Six steps to manage demand – Glasgow, Somerset, Carmarthenshire, and others have all developed this with some good successes.

  • James Lampert - Sorry, had an interruption… on earlier question. outcome would be that person getting support has more agile, flexible support that better meets their goals, done with people who already know them well – rather than a one off conversation once a year with someone from the council tasked with “doing a review”

Thanks James – we like that, again we would like to test out with you here, who is offering the challenge to the client and provider as to how far they can go?

  • Julie Vollor - Have you seen the Hampshire CC TEC model – of identifying outcomes from the TEC provision – and tracking impact over time???

We would like your views on where we go next with this subject – the idea of a network has been mentioned, we could do this virtually and then come together, to continue discussing, learning and sharing ideas and work?

  • Julie Vollor - Yes, that would be helpful for me…
  • Anna Grainger - not aware of the Hampshire tec model
  • James Lampert - tell us more Julie?
  • Julie Vollor - I'm off to our senior management team meeting – it's been interesting and I hope we can find a way to continue to share ideas etc. Ta-rah.
  • Ian Haines - In Notts we have established 4.5 posts for community broker role. A problem is the small number of posts but the bigger problem is that this does not change the culture of commissioning for social workers who do not want to stop using formal care routes.

As I mentioned earlier, IPC are currently working with a number of organisations to explore how to get the right behaviours and overall demand management culture right for practitioners and the performance management discipline and so we would be happy to have specific discussions with individual organisations about this. Again we could then feed the learning from this into a “network” – comments?

  • Stephen Vickers - yes more please
  • Ian Haines - i think a network is a good idea and this should be achievable without meeting in person? A lync conference call would do the same trick? People more likely to ‘attend’ if they can come remotely?
  • Stephen Vickers - and yes helpful to get together

No sorry, I'm not sure what the TEC model is, however I have been interested in the work Hants are doing around the front door and have asked them to present at our conference this week…

  • Anna Grainger - It would be good to have a network and also to look at changing practice culture – I think principal social workers are key in this
  • James Lampert - We've just recruited a Principal SW post. Also have a similar post for OTs for professional leadership.
  • Stephen Vickers - thanks for organising this get together. some useful links and ideas to take forward. I am happy to share any learning if people are interested. I will be at the national conference in Bournemouth presenting at one of the breakout sessions if of any help

Anna – agreed re PSW, this is who we are targeting in the work we are doing to coproduce practice frameworks and quality standards… happy to talk more

  • James Lampert - Ian – you're right. It's a challenge to change culture and practice in teams. Need to do something so disruptive that it prevents from from arranging standard care services (or change those purchasing arrangements or services so they just can't buy what they want or the wrong thing)

Stephen – you're welcome – John and I will be in Bournemouth too – tell us when your session is and we can come along, or let us have your contact details and we can catch up

  • James Lampert - Thanks all, have to go. Interesting conversation.
  • Anna Grainger - thanks to all – interested to see what develops

Thanks to everyone you took part, we hope you found it useful – we certainly have. We will send out a copy of the transcript and keep in touch about next steps.
Good bye from John and me in Oxford and Juliet in Bath

  • Lucie Eden - Thank you, it has been helpful, would second a network