Boulders on the Train Tracks

By Alison Barker – Director of Adult Social Care, Hull

Hull Volunteers

We do need a new social care future, where things are different from how they have been. It needs to do more to help people and communities earlier and differently and make much better use of all the resources in a place – often to help people avoid services or need them less. When people do need longer term support they need to be much more able to design and direct it with help from skilled professionals. In Hull it is my job to work with others on what that really means in practice and to take action to make it happen. As a working director, therefore, I want to offer a blog that perhaps goes into some of the techy and systems detail about what one locality is trying to do, what obstacles and challenges we are facing and some of the help people like me need to give to colleagues working hard to make things better

As I was thinking about these issues for this blog, a strange thing happened …I was in an Adult Social Care (ASC) meeting of senior leaders discussing our local transformation programme, and I heard someone say:

We need help…there are boulders on our train tracks!’

Now a number of things struck me about this. First of all, I thought, colleagues in the Transport department would seriously question this! – but apart from that rather trivial thought, I wondered what we meant by ‘train tracks’ in adult social care, what we saw as ‘boulders’, what help we (senior Adult Social Care managers and leaders) felt we needed, and where that help might be coming from. Suffice to say the discussion was very interesting, and something I would like to share as a contribution to the wider discussion about the direction of the emerging health and social care system and the big issues to tackle.

Train tracks

The discussion about train tracks began with an explanation of Hull’s new “operating model” – the way we are going to be doing things, It was a discussion that is probably familiar to Directors of Adult Social Services (DASS) and senior managers up and down the country. Apologies to those who might be unfamiliar with some of the language used – but I’ll try to make it as clear as possible:

  1. Demand management and prevention – a track for people via our ‘front doors’, getting our early conversation with people who might need some kind of help right, using solution focussed conversations, in the way we present information and advice, support independence, self-care and self-assessment.   Our tracks here take us from the Corporate Customer Service (CCS) centre, to Hull’s jointly commissioned Social Prescribing Service, to our adult social care “See and Solve” teams in the community and at the Hospital, and of course fully uses Connect to Support Hull, a web-based information and advice resource which enables early access to Independent Care Act Advocacy, and Hull’s form of local area coordination. People don’t want more involvement with social services than they need and we are trying here to play a part in helping people find solutions that don’t draw them in to more involvement than they want and need
  2. Goal-based early intervention – this is a track for people who need more than help to help themselves, but can ‘get back on their feet’ with some specific and targeted professional early intervention. These tracks lead from See and Solve to Active Recovery – a team of Occupational Therapists and Assistants, Social Workers, and Social Work Support Officers. This team provide integrated professional support operating for a few weeks to help people achieve their short-term goals. This also leads to a Supporting Independence Team that, when tasked with helping people achieve specific short-term goals will ‘re-able’ people to achieve them – whatever those goals may be.
  3. A strengths-based integrated social work and occupational therapy element works with people who have ongoing needs, focussing on more complex situations which might even sometimes involve dealing with disputes, work with clinical partners or the Court of Protection.
  4. An internal brokerage service which undertakes the support planning function of social work, this includes meeting eligible and non-eligible needs and prioritises connecting people to their local communities – freeing social work time up to spend more time using their particular skills – professional social work rather than service provision.
  5. Commissioning of formal services which we can be increasingly confident are really being ‘person-centred’ and ‘whole person focussed’ and integrated (the significance of which I will come to shortly)

So the purpose of the new ‘train tracks’ was understood in our team– it’s about changing from the existing to new and better ways of working – Over the last few decades adult social care understandably has focused on the things (tracks) set out in policy: Statutory assessment of eligibility and care and support planning, resulting in the establishment of packages of care that are intended to address independence and wellbeing

Hull’s new operating model changes the train tracks, now they follow a different route: Assessment on this new track is more proportionate, we are more focussed on supporting prevention and early intervention and assess appropriately for that. We do carry out our statutory assessment, but that ‘professional assessment’ is strengths and not deficit based, and is an intervention in its own right. Care and support will be explored first in terms of what goals the individual can achieve for themselves, then how families and communities can support, and finally, what professional support can achieve working with the person, only then sourcing services.

The modern ASC train tracks are longer, more complex, but they place wellbeing and independence in the engine room right up front and centre before formal services are set up.

Loneliness, isolation and mental health problems are poorly addressed by formal services. They require meaningful relationships between people, connected to community groups and organisations, mobility around that community and a focus on key social work issues such as bereavement, family breakdown, housing, discrimination, and equality.   Addressing these things first means most services are provided later, and focussed on those people who need longer term assistance

The Boulders

There are three boulders that have fallen onto these nicely laid down train tracks for Hull’s New Operating Model. The first of which is Hospital discharge, the second the provider market, and the third workforce challenges.

Hospital discharge

Winter pressures, Delayed Transfers of Care (DTOC), use of the Better Care Funding, can create a real distraction from focusing our concerted efforts on avoiding hospital admissions. The impact of shifting the attention, even on occasion obsessing about, the DTOC agenda has consequences, and these are felt in the community. The time and resources expended to support hospital discharges is not being spent on delivering prevention and early intervention. But worse than that, the first two elements of our new operating model are delivered to people in their homes or in communities for people not attending A&E.  With the focus on hospitals, people in this community setting can be left for too long resulting in escalation of need resulting in a statutory intervention that could possibly have been avoided

Provider market

Time and task based contracts for providers that are unable to flex service provision around the needs of the individual and instead expect people to fit into their service ‘offer’, are not on our new train tracks – they are not going in the right direction. To be fair, the cash to support the providers (of all varieties) to get on the train tracks and go in the right direction is being stretched too thinly. Delivering market change in this financial context is a long-term and difficult ‘boulder’ to remove.

Workforce challenges

We have been recruiting for over a year in Hull, and the posts that we have found most challenging to fill have been the experienced social work and occupational therapy posts. We have a burgeoning and subsequently resource demanding ‘Assessed and Supported Year in Employment’ (ASYE) programme, induction and training programme, but we still lack the experienced workers who can manage the more intensive situations and the demands of the Court of Protection. We can win, or at least be competitive in, the battle with Aldi and Tesco and the retail sector, the restaurants and the hotels sector in our search for new staff, we have key things they do not: we can offer a personally rewarding career. That is if we articulate it carefully and market it appropriately; and develop the right links to universities and schools. But how we retain staff and develop them to become our senior practitioners is a major and long-term challenge.

So what is the answer…how do we lift the boulders off our train tracks and deliver a modern fit for purpose adult social care system in this context? Which brings me onto the final issues in this blog: What help do we expect, what help is available and what do we do about the boulders?

There are no answers, only solutions!

I heard the cry for help, I considered the suggestion – that we have boulders on our train tracks, and I concluded that this is indeed at least a part explanation of our current issues, and that in the wider context there is no help for us to call on – there are no answers, but as a system we do have some solutions.

The idea that we have clear ‘train tracks’ – systems and processes for what we want adult social care to be and how we want it to operate is fine, and it is also fair to say that system pressures, provider capabilities and workforce issues are preventing our carefully designed train lines taking us where we want to go. These do indeed represent some serious issues we are grappling with in Adult Social Care in Hull with the implementation of our New Operating Model. Indeed, these issues are so significant, that I am going to extend the metaphor somewhat now! We have created sidings, shunting yards, and various supplementary train track diversions around the boulders. I sympathise with middle managers and senior leaders, we do indeed have boulders on out train tracks – it is a nice analogy, but whilst it helps us understand our adult social care predicament, the metaphor is totally inadequate to capture the bigger picture.

What we have is a whole array of differing modes of transport, and we need to understand each of them, and then link them together at key interchanges. It’s not just about train tracks, it’s about the motorway system, ferrys going to and from Hull to Rotterdam, cycle routes, and flight paths, all of which are working alongside the train tracks. Even the Hull yacht club has a role to play! Ok I have very seriously over extended this metaphor; but the point is twofold:

  1. In addressing our adult social care problems, we can’t just look at them in isolation to the rest of the system. The boulders aren’t our boulders; they are system demands and need to be addressed as much by our ASC systems and processes as by our partners to make the system work. No one can build the new infrastructure for ASC and health in isolation, these are shared issues and shared agendas, that the citizen needs us to resolve
  2. The future lies in working in integrated ways – collaborative ways, across the whole sector. That means people who use services and carers, providers working in all our markets, the voluntary and community sector, primary care, acute care and NHS Trusts, and across a whole range of issues including, but not restricted to: commissioning, workforce development, coproduction, and funding.

In response to the heartfelt ‘there are boulders on our train tracks’ cry for help, what about the help element? Well to put it simply – there isn’t any. Well no one or no thing that can do the work for us. Despite all our capacity issues, the acute austerity councils have experienced over the last 8 years or so, the increasing demand issues, the additional unfunded initiatives from NHSE, the increasing technological context, and quite reasonable increasing expectations of people who use services and their carers, the only people who can sort this out are us – the people in different parts of ‘the system’. We have to keep picking up the phone, sitting down and talking about and acting upon collective ways round the boulders. There are no easy answers, few win-win situations anymore, but greater collaboration across all our partners has got to be (is) the (only) solution.

As the driver of the train it was a tough message to adult social care staff, about our newly designed adult social care operating model. It brings me to my final point for this blog. As system leaders, we need to remember that the social care and health future – however collaboratively we construct the new systems and processes, making changes to citizen experiences – boils down to the workforce making changes to their practices. We have to support our workforce to change – as senior managers and leaders that’s the help we have to deliver.