Alex Baylis and Susie Perks-Baker: Embedding enhanced health care in care homes

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Speaking our conference on  Enhanced health in care homes on 5 December 2017,  Alex Baylis, Assistant Director, Policy, and Susie Perks-Baker, Senior Consultant, Leadership and Organisational Development, share findings from The King’s Fund’s report, Enhanced health in care homes.

Transcript

So we wanted to talk to you today about our new report that is now on our website.  This is a report on enhanced health in care homes which we did really because we’ve been developing our work in this area for some time through conferences and we set up a learning network to try and share good practice and practical support to areas developing enhanced health in care homes, and we were really struck by lots of research that said, oh, you have to allow time, it’s all about relationships and building trust, and we thought what does that actually mean?  What does that look like in practice?  How can you get into the detail of what that actually involves and how do you actually go about contextualising your approach to your local area?  What does that really involve?  

So we wanted to take learning from the learning network and from other areas and try to illustrate what people are doing in practice to do this building relationships, to do the tailoring to local context and to make stuff happen that works for their area, because unfortunately there is no single how to do it for enhanced health in care homes.  Every area has to work out their own approach of making it work and our aim was to try and help them in that process of working out how to do it.  

Our first finding was that every area should be thinking about enhanced health in care homes and I don’t know how to say this with the right degree of diplomacy, but the areas we spoke to there were a couple of vanguards but usually you talk to areas about good practice and you find it’s the usual suspects that have been doing this for 20 years or have had extra money from central government. These were all quite ordinary areas actually that didn’t have special funding, that didn’t have very longstanding relationships, some of them were at very early stages of developing the relationships, but we found they were making progress and even though there’s a lot of research evidence about how long it takes to embed cultural change we found that the results … you don’t have to wait all that time for the results to start being visible, that even within a few months you can start to see results. You still have to go through a process of embedding, but these areas were seeing results quickly.  

So we concluded that essentially this is a feasible idea for every area to be thinking about and that they shouldn't be too cautious because you can get results quite quickly. You should be aiming quite high was our thinking.

Throughout this we were really conscious of the role of leaders and the way in which leaders develop those relationship and processes and make it all work and so that was a really strong theme through our findings. So I’m going to ask Susie, with her leadership development hat, to say a little bit about how we thought about leadership in these services. 

Thank you. Thank you, Alex. Alright, I’m Susie and my bit is this, is I’ve got my name on report but Alex wrote it, so that’s excellent, but what I did do with my colleagues Annie and Julian was facilitate the first learning network here, run within the leadership development department here, bringing together people from care homes, health, housing and social care.  

So it was a pilot learning network and we invited people to apply in teams from whatever locale across the country and six different teams came together and joined our learning network and we ran a facilitated workshop four times across about nine months, something like that, for them, and there were participants from CCGs, from social care, from local authorities, the NHS, GPs. I think we’ve got a couple of participants in the room, they can correct me if I’m wrong, I don’t think we got anyone from the acute provider sector which was tricky but is a bit of a sign of the times. Did have people from emergency services, certainly care home managers from the independent sector, and the whole idea is that they took time out and were able to learn and work together. Of course, there were all sorts of guest speakers but there was also just practical, hands on work in the room around this business of enhanced health for care home residents.  So they got time to work together as teams and learnt across the teams.  

What they don’t know, because it’s only just occurred to us, what we observed and admired was much but what we really saw quite a lot of was some system leadership developing.  So the King’s Fund and has been banging on for ages about the no more hero leadership approach, that you don’t need great superheroes to run organisations, we’re more and more advocating a much more distributed, collective, shared model of leadership and with the advent of STPs of course the whole nature of leadership is changing again.

So you’re going cross boundary, cross organisation, crossing all sorts of very well entrenched fracture lines between public and provider and health and social care and all of that sort of thing, and we’re saying this is going to require a different type of behaviour, and then we were on the learning network with these teams coming from different parts of the sector, some of whom knew each other and were working on stuff already, but a lot of whom hadn’t actually met each other before even though they came from the same area; and there in the spot, with no show, no grandeur really, people just got on with working together to think how they could advance the enhanced health in care homes agenda.  

For another bit of work I do I was looking at all the characteristics of system leadership and realised that what was going on in the room was exactly what the characteristics of system leadership are all about.  So it wasn’t a top of the tree super leader approach, it wasn’t hierarchical or I’m in charge of the whole patch type of approach.  The word leadership, and you can tell me guys who worked with us if I’m wrong, but I don’t really hear it come up very much or discussed much at all actually, people just work collaboratively and collegiately together using complementary skills, using the time and space afforded by the learning network to get on with doing the job.  

We’d heard in the network reports that care managers, and I’ve heard it today as well actually, that the care home sector, and I’ve certainly seen it in the literature, sometimes experience feeling slightly on the margins sometimes in relation to discussions across the health care landscape.  This wasn’t the case in the learning network at all, people very much worked together.  So those what you might call status issues were neatly ironed out really.  So what we had in the room, and we think we’re rather marvellous for doing this without even knowing and actually it was the participants who were marvellous, was system leadership in action.  So all the talk about needing to drive system leadership across health and social care and their care homes were right in the centre of it doing it.  So well done to you and I just wanted you to know that we noticed that and it’s in our report so absolute pleasure working with you all.  

So what we’ve tried to do is to capture what people told us about their real experience of what it actually feels like and involves to developing enhanced health in care homes and we got quite a practical flavour in the report.  We describe some discrete types of activity, so some themes that come up is the way in which training often by health service staff for care home staff is approached in different areas and how they develop that program.  

It was a really interesting observation of doing the study that a lot of the research that you can find in literature reviews and in peer review journals and so on is very much from a health service perspective and a lot of the research that is out there on social care specifically sometimes has a more practical focus and isn’t so accessible for traditional literature review approaches. We were interested that in every area they’d thought about training care home staff but none of the areas had actually anticipated that NHS staff might need training as well on how to work with care homes and yet, over time, they all found that they were learning in both directions, but they didn’t start off with that assumption and possibly that’s related to the fact that a lot of the research and good practice guidance is through an NHS lens or a health service lens.  

We found that it didn’t necessarily matter how services started off, they all started off in different ways, sometimes it was some very passionate and committed individuals who made something work on quite a small scale, sometimes it was across an area usually with leadership from a CCG or a local authority, or sometimes it was a more targeted approach either at care homes with the highest level of hospital admissions or in a very small locality to act as a pilot and actually it didn't matter how they started off but over time they would need to get a balance between responding to some quite organic issues that come up from the care homes themselves and balancing that with the system wide objectives across CCG areas or local authority areas and they approached that in different ways but they all started striking that balance, and it was one of the things that actually they couldn’t quite predict how that was going to work out at the beginning.  As Susie was saying, this is actually a really key leadership skill of negotiating that balance, but they just did it is how it worked out. 

We found a lot of examples of ways in which there was regular, usually comprehensive geriatric assessment and gold standard care planning and anticipatory planning which often involved ward rounds of GPs or advanced nurse practitioners coming into care homes regularly.  We found a lovely example where there was one provider who had six care homes and in five of them they were working with the GPs doing ward rounds and in the sixth one the GPs were, “Oh no, we’re too busy, we can’t do that,” but actually when they looked at the number of visits that they were having, the number of ambulance calls the one that didn’t have the regular visits from the GPs was massively using NHS services more than the ones that were planning ahead rather than just reacting to crises.  

We also found some really good examples and some quite different ways of doing this of the way in which health services and care home staff were just getting to know each other by spending time and regular catch up meetings, having regular reviews of their performance information or looking at incidence, for example, of when people get admitted to hospital, doing a root cause analysis and not just focusing on training but focusing on reflected practice and learning in quite a broad sense together and that seemed quite a sophisticated way of building the relationships.  Even though they might have started with training and skills it got into learning much more broadly.  

There were some very clear messages about if you see this in terms of leadership that you need good leadership at service level but you also need leadership at system level over time and you need both facing in the same direction. So we got some examples of how that worked and what it looks like.  

When I first got into this I thought, goodness, this is going to be such a tall proposition because first of all getting all your care homes across an area together is like herding cats because they’re all different, then you’ve got all your GPs, that’s like herding cats as well.  This is not an easy thing to do, but actually we found some really good examples of where people were getting provider forums to work together and the really key thing in that was having a practical focus to give people ownership of coming up with solutions and not just having talking shops. We found there was some quite seminal moments that areas had where they had workshops where they organised people to work out, well, what are we going to do, who’s going to take responsibility for sorting this out and then how are the system leaders going to remove the blockages to make those solutions rolled out?

A lot of discussion from areas about evaluation and the thing that was really interesting here was people were worried about having overly conclusive evaluation about this is solved or it worked in that area so we’re just going to import it here, and the emphasis that all the areas placed on formative evaluation, so to inform more learning not to say job done.  We noticed that one of the key characteristics of people in leadership roles was a certain amount of assistance actually, that they really just kept at it and a number of them described themselves as dogs with bones, because this is a long-term thing that people do need to really be quite passionate about for quite a long time. 

We found a number of challenges were quite common as approaches were maturing and rolling out across an area. One of the things that was really striking was that even though people don’t necessarily use this jargon about leadership and modelling partnership working and so on, actually it’s essential from the absolute beginning to be really open and transparent with the different providers, especially care homes, and above all to treat them as equal partners from the outset. Almost every area said that they or their colleagues had been through a journey so that instead of doing things to care homes they were doing them with care homes.  That came up as a really strong theme and actually getting that tone from the start was really important. 

We found a number of areas where actually it was pretty hard work to get care homes on board at the beginning, it really took quite a lot of engagement and building up trust, but once they’d done that care homes tended to be fairly well networked for the word to spread around an area and it became easier.  It wasn’t the case for GPs, there was a real issue about engaging GPs early and using the right language particularly around audit and evaluation data as part of the discussion and getting the CCG involved so that you don’t have conflicting contractual incentives and that needs thinking about early rather than late. No area had really cracked hospitals, in fact even when they had good relationships with hospitals the minute the hospital was under pressure everyone got drawn back into the hospital.  No one had really got that working as well as they wanted to.  

It was really striking that even in some areas … we spoke to one area where they’d been working on enhanced health in care homes for seven years and even in that area they found that actually old ways of working still kept on resurfacing, that every so often even when you thought everyone had got it, there were still cases where people would just make decisions on behalf of care homes and tell them what they were doing or would approach this in terms of finding ways to make the care homes essentially fit in to improving access for the health service’s convenience rather than really thinking about what the people want here.  These kept on recurring, so it was a constant challenge for leaders to keep on reinforcing culture change because you can never assume that actually it’s fully … certainly in that seven-year period it wasn’t enough to assume that it was fully embedded.  It still takes time to work at it. 

We also observed that it’s very understandable but the focus in most of these areas was really around developing relationships, getting to know each other and looking at care processes for coordination.  The underpinning behind the scene stuff around, well, how do you get the money flows working, how do you get the governance, all these slightly boring things actually they’re essential for embedding new ways of working in the long term and most areas hadn’t got their heads round yet around the implication for commissioning strategies, for looking at work force planning in a broader sense than just the individual care home for example and joining up with broader strategies for the areas. So that’s not necessarily a criticism it’s just to say that in time that does need to be considered too.  

We were also quite struck that each area was basically having to work it out for itself about, well, how do you measure impact, how do you decide how much funding, how do you know if it’s the right level of funding, how do you know if you’re getting a return on the investment, and these felt like issues that actually there was a lot of potential for duplicated effort there and it would be quite useful to have some national guidance around what those things look like.  

We were particularly struck that almost all the staff we spoke to said the reason they were doing this was to improve quality of life for older people, to improve their health and yet actually when you looked at how they’re measuring their impact it was much more about reducing hospitals admissions, about reducing pressure ulcers, things not happening or not needing to be done, which isn’t the same thing as measuring quality of life.  It may be a bit of a tall order to expect individual areas or individual providers to work out how to measure quality of life, this may be another area where we need some national guidance around practical approaches on that because at the moment the focus wasn’t always in line with what people were actually trying to achieve, they were measuring things that were quite indirect indicators of them. 

So we also drew out a number of wider reflections, one of them, as I say, is that we do need to have a bit of national discussion about what actually is the expectation for health services being provided to people living in care homes.  There’s been a traditional pattern of not having the same level of access to services as people living elsewhere and we still see some examples of that.  We saw a number of different views around things like some areas saying really proudly that they provide training to staff in care homes on exactly the same basis as NHS staff, others saying, “Well we’re doing it but we’re not sure if we can sustain it,” others saying, “These are businesses they should fund their own training.”  Again, a bit of a national discussion about, well, what’s the expectation there about public sector bodies investing in the independent sector, because this is actually about older people in your local area?  That’s the primary consideration. 

Alongside this was the recurring issue that actually one of the things we’re talking about here is whether it’s an equal partnership between providers who are organising their various efforts around promoting the health and wellbeing of older people, because a lot of those discussions ultimately take you back to that. 

We’ve said quite a lot in the report that again this is not necessarily the way that people in services describe it, but when you observe what is happening it’s a key leadership role that people are actively managing and rebalancing power dynamics, they’re changing culture between the ways in which health services make assumptions about care homes and equally care home staff set up relationships so that they’re treated in a certain way by health services  providers and that kept on coming up as one of the themes throughout our interviews.  

As the King’s Fund we’ve started increasing the amount of work we’re doing with social care services. Traditionally we’ve really focused on funding but we’re getting much more into quality of care and ways of working across the health and care divide, if you like, and we feel it’s quite important to say that this isn’t just about quality improvement initiatives within care homes, this is part of the overall move towards joining up services across an area.  So one of the consequences of that is that we think that care home providers need to be involved in those discussions.  What we observed was that commissioners were quite often involved almost as proxies for the providers which is not really the right way to do that.  

We also made the observation in the report that there is no Five Year Forward View for social care.  We’ve got this for the NHS, we’ve got it for primary care within the NHS, for mental health within the NHS, but there is no overall framework of how to develop the social care role within integrated place based approaches and there is a question, which we’ve raised in the report, about how does the national leadership of this agenda develop?  NHS England have clearly had a really important role with the vanguards and supporting learning from the vanguards across other systems as well.  The vanguard program ends at the end of March it would be good know that there isn’t going to be a vacuum there because it’s an important part of the picture.

I mentioned that it would be good to get better at measuring the impact in terms of quality of life and quality of care. There is still a risk that joining services up simply involves improving access to the same health services without actually changing the way that the services are organised around people.  We observed that even though all of the providers we spoke to place a really strong emphasis on personalised care and involving people in decisions about their own care, none of the areas we spoke to had really got all that far in involving service users, residents and their families in thinking about, well, what does good coordination look like.  They weren’t really involved in that discussion even though some areas were definitely thinking about it but it hadn't quite developed yet.  

Then, just to reinforce our final quote, a lot of this is about leadership and it’s actually very demanding of leaders, it requires skill and it’s quite an ongoing long-term process.  We felt that in the learning network that we did with My Home Life that that sort of thing was a really important way of providing support, recognising what was going on in providers and sharing learning between them.  So we were quite keen that we might have a role in doing more of that but others might as well, whether that’s at national bodies, the statutory sector or in the trade and professional bodies.

I think that’s what we wanted to say as an introduction to our report, hope you’ll find it useful and stimulating.