William Roberts: New Care Models - learning from the care homes vanguards

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  • Posted:Tuesday 06 December 2016

William Roberts, National Care Homes Lead of the New Care Models Programme at NHS England, shares learning from the care homes vanguards.

This presentation was recorded at our conference, Enhanced health in care homes, on 6 December 2016.


Thank you and good morning. So I love standing up at things like this, two reasons.  One because I don’t actually do anything, my job is the best job in the world.  I present other people’s work, claim credit for it, and then walk out the room to a massive amount of applause, so thanks for the applause when it comes.  The second thing of why I like doing this is I am really not an expert, so you are going to hear from some top experts, the top experts are the people in the audience today, there are some amazing people in the audience.  If you haven’t met somebody next to you, please take the opportunity to do so.  I can guarantee you that you will learn from them.  I am going to talk a little bit about what I have been doing for the last 18 months of my life, and I am not joking when I say I am not an expert.  My background is in a whole range of things, none of which is care homes.  On top of that, if you were to ask my older son Felix who is now twelve, he was asked at school when he was seven ‘What does your dad do?’  He told them ‘He is a second rate middle manager in the NHS’.  Spot on Felix.

So I am going to talk to you a bit about this work that I have been doing. The enhanced health in care homes Vanguards.  Six places around the country doing amazing stuff to try and deliver better care for people in care homes.  And they are doing that by trying to look at how you provide joined up primary community and secondary care services, working with social care, to support people in those areas, to live better lives and enhance their health.  But...and this is the fascinating thing, and why you don’t need an expert to do my job, because none of this is new.  In fact the first thing I did when I got into my job was absolutely nothing.  I sat down, and I looked at all the stuff that already exists.  So I don’t know if anybody has read Quest Quality, a pretty amazing document, if you haven’t read it, go get it, it does a load of good stuff.  Sky and NICE did some amazing work which gives you incredible guidelines around end of life care, dementia and all sorts of things.  More work if you want to know about oral health for adults in care homes, why not just go to the existing guidance, don’t come to me, I know nothing.

Brilliant work as well if you want to go to Skills for Care. If you have never been to Skills for Care’s website, go there, they are doing amazing work, there is loads of resources on there.  Think local, act personal, so the TLAP and the I statements, again, amazing work done and what do we need to do to improve people’s quality of life, and what are the kind of things that people who live in care homes actually want?  Some amazing work done by My Home Life who I think we might hear from later today, again looking at how you bring together care homes, and the managers particularly, to learn and develop together.  And then you have also got work around the care certificate.  Skills for Care, Health Education England, these people have all been doing all this work.

So one of the things that is really fascinating is, if there is all this stuff, why haven’t people just got on and done it? Because firstly there is a whole range of excellent resources already available, and the last thing we need is somebody like me who has next to no expertise coming in and making a complete hash of it, and deciding here is a new set of guidance that you need to do.  The other thing I have been doing in my job, which is why I love my job, is that I have been going around the country and visiting anybody who invites me pretty much.  So if you say to me come along and see what we are doing, I will come along and see what you are doing.  And the reason I am doing that is because there is amazing work going on out there, you don’t have to be a Vanguard to be doing something amazing.  I was in the North East of England yesterday, I heard from a whole range of people, Sunderland, North Tyneside, people who are doing amazing work in care homes, who were here before me, and will be here after they sack me, okay?

So, if you don’t believe me, because I am not an expert, I went to my friends at the Social Care Institute for Excellence, and I said, “Well can you tell me what really makes a difference? What is the evidence base for this?”  Because everybody tells you there is no real evidence for any of this stuff, except for that is rubbish, there is loads of evidence.  So the first thing to say is, there is a huge amount of evidence that tells you, if you do this, this makes a difference.  So I can tell you that if you actually tailor the services to the residents and you join things up, it will make a difference.  There is randomised control trials that show that, there is Cochrane reviews that show that.  There is a consensus of what the characteristics of high quality care are.  The Quest for Quality tells you what to do, you don’t need a new clinical guide.  You have got amazing things already in there.  And we know that you have got to look at that person as a whole, rather than just looking at them as a body.  This isn’t about doing things to people, this is about looking after them, and delivering better care for them, and a better life.  But we also note all the evidence tells us this is about relationships, this is about behaviour, and how people work together.

And we know that there is loads of evidence that tells us, for this area if you have good leadership, co‑production with providers, residents, staff, families and carers, it is vital, and it makes a difference. We also know that if you put investment into targeted training for staff in both care homes and the NHS, to bring them together, to train together, you get a much better product, and the quality of care goes up.  And then finally, the comprehensive geriatric assessment is an amazing tool that allows you to know exactly what to do for that individual.  So we know all of that.  How do you do it, and why now?  And it is a really interesting question.  And whilst Vic talked about all the challenges we face, and how awful things feel at the moment, actually this work offers you an incredible opportunity.  And actually in this challenge, the conditions are absolutely right for us to do this and to improve.  And in fact I don’t think we could have done this at any other stage.  I think if we had had an opportunity with money, we wouldn’t have been innovative.  If we had had the opportunity to have the profile, we wouldn’t have done it in the way we have done it.

So I am just going to go back to the start of why now? Well firstly if you have read the five year forward view, and I assume most people will have done by now, it is a good read I am told.  Three challenges in that.  There is a significant issue, that we are stopping people from living lives where they are poorly, we are keeping them alive, but we are not stopping them getting sick in the first place.  So there is a huge prevention gap.  Secondly there is a real care and quality gap, that we have less money, and we have got to do more, and the challenge is how do we deliver high quality care at a low unit cost?  And then thirdly there isn’t enough money.  There simply isn’t any more money to pay for health or social care, we have been told that in the autumn statement.  And so therefore we can’t just buy our way out of trouble, or put in more services.  So we wanted to come up with a national programme that did something differently, because if you go back to historic national programmes, they make a difference in some areas, but then they don’t spread, they don’t go further.

So we said in the new care models we want to do something different. We want to go to the frontline staff and engage them in the change, we want to build it from the bottom up with local ownership.  It has to involve patients, residents and people in a real way, that is different to how we have done it in the past.  And then finally people like me have to get the barriers out of the way instead of getting in the way.  So my job isn’t about doing anything, it is about clearing barriers.  We selected 50 Vanguards, six of which were the enhanced health in care home Vanguards, and we will hear about those later today from various people working in them.  But we also face real challenges.  There is three times as many beds in care homes as there are in the NHS, but we are also facing real challenges about the viability of the sector.  If you listen to Mary Hopper from Sutton, she talks about the fact they have a thousand care home beds in Sutton.  And she says if they had a thousand beds in a hospital it is pretty much all they would talk about in the CCG, yet a thousand beds in their care homes gets very little air play, and why is that?

So we have got three times as many people living in long term care as we have hospital beds in the UK, and a significant challenge to that sector in their viability. There is significant financial challenges in the sector as well.  And the difficulty we have got is it is not just that there is significant challenges in the financial sector, but actually the self funder market is relatively buoyant.  So the incentives for providers not to provide State funded care, is growing with every year.  So we have a real challenge about people wanting to support, because it is not in the interests of them financially.  But actually if you go to many of our providers, they are doing amazing care and delivering great services whether you are self funding, or you are NHS or social care funded.  But we also know that people who are in care homes are increasingly complex in their needs and their care.

When I worked as a nurse 20 years ago in Dulwich Hospital, the people I managed on our care of the elderly wards are the people we now see in residential care, not the people we see in nursing homes. The people we see in nursing homes were the people that I managed at St George’s on a post-acute take ward.  This is a completely different type of care we are providing, and we haven’t moved with the times.  So whilst the people have changed, our services have largely stayed the same since 1948.  And then finally, the worst place to go if you are frail and elderly pretty much everybody is a hospital.  So if you have got a relative, if you have got a friend, if you have got a service user, a patient or resident, don’t take them to hospital, it is pretty much the worst place to go if you are old.  Because hospitals are brilliant places for helping you when you have acute needs, but frailty is not an acute need, it is a condition that needs to have long term care and support.  And the other thing is we are all going to live longer.  I will probably still be working at 85 because I won’t be able to draw my pension, which is a terrifying thought, that is another 45 years of second rate middle management in the NHS.

And one in seven people now who are over 85 are living in long term care. So what the Vanguards are doing differently though, because I have talked about all the things that we are doing at the moment, the thing they are trying to do differently, the thing that is unique to them, is trying to do this in a joined up way across a system all at once, because everybody is doing something, but not anybody is doing something in a co-ordinated and joined up manner across health and social care.  But we have also intentionally decided to build on what exists already.  This is not about a new way of working, or starting afresh, this is about taking what exists, and building on solid foundations.  And if you talk to the people in the Vanguards, they will talk about the fact that they were building it on existing good foundations.  And when I was listening to people yesterday talking in the North East of England, or when I was down last week in Wakefield, people were talking about building on the foundations that exist already.  So don’t think you are starting from nowhere, I can guarantee in your area you will be doing something amazing somewhere.

So what is the model really about? Well it is about people, it is about making person centred change really important, it is about thinking about how do we deliver to that individual’s need, rather than the organisation’s needs?  It is about working together, it is about bringing people together to work as a system, and to work as a team, and thinking about how you take that whole system’s approach to working together.  All of the sites talk about how they started with quality.  For most of them their challenges started with some sort of quality challenge, understanding that either the care they saw wasn’t the care that they wanted to be giving, or that they faced a particular challenge around the closure of a home, or the challenges of understanding whether or not the care was good across their system.  And it’s about leadership.  The thing I see when I go out there is great leaders.  But again in the 60,000 miles I covered in the last twelve months, I have seen brilliant and great leaders everywhere.  Great leaders are out there already and it’s how we enthuse, build and support those people to work better and stronger.  I think this is really exciting.

So imagine if my map didn’t look like six, it looked like that, and it was the whole country, so what are we doing to help you do that? Well the first thing we are going to do (s.l. this 00:10:54) is we think you could spread this model, we think it is entirely replicable elsewhere.  We have looked and worked with people to identify the things that we think you can do.  And to do that it isn’t about you decommissioning what you have done already, it’s about taking what you have got and building on it, and bringing people together locally to have the conversation about how are you going to start to deliver better care?  We delivered you a framework which was published in September, and it basically says what are the different bits of the care model, how does it work?  It gives you examples of how we have worked, and it gives you advice about how to spread and how to commission these services.  It has seven core elements and 18 sub elements, and our intention is to spread this across the whole of the country next year.

Hopefully you will have read this document by now, it is a relatively easy read. I have written some of the worst papers you are never going to read in your careers, but this one isn’t one of them, this is a really good document, and I would urge you to go and look at it.  It is practical, it is easy, and it is actually not hard to read, and it’s written by real people.  So like I said other people did all my work for me.  The people who did this were people in the Vanguards, but also doctors, nurses and therapists.  So it has these seven elements to it, and we think these are the things you need to do.  So if you go through this piece of work, how can we help you understand what you need to do?  Well at the moment we are in the process of finalising a self assessment tool, it will be a relatively simple thing for you to do.  But the idea is not for you to fill in a document, or tick a box, the idea is for you to come together, and sit down with people in your area, and bring your partners together to co‑produce the solution, to get people to sit down together and start talking about what you are doing at the moment, and what you need to do.

But I can guarantee you if you do that you will discover things you didn’t know were out there. There is a whole range of amazing stuff in your area that you could access tomorrow that costs nothing to do and is all about you working together.  But we are also looking to offer support to you to develop your work.  We want to be able to give you products and tools that will help you deliver this so you don’t need to write the contract specifications, you don’t need to have the how to guides.  But also to link you in with people that have done this elsewhere, and to bring you together with other people who will work with you, and we are going to look to launch this in the New Year.

So what have we learned? I have been doing this for 16 months like I say.  What have I learnt in that time?  Firstly it is absolutely essential you focus on the individual, and the population’s health, this is not about organisations.  Whether or not you like the organisation you work for, whether or not you think it is really critical that your organisation has viability, the most important thing is the people we serve, and getting our services to wrap around them.  You need to have people coming together.  One of the things that is most exciting about this is if you talk to people in local areas about it, they are excited about it, it is realistic hope, people believe you can do this.  This is change you can actually make happen.  The care homes are critical to this.  Don’t try to do this to them, work with them.  They are doing way more innovative stuff than you are going to be doing, and the things that they will bring to you, you cannot imagine, it is way above and beyond anything you could hope to get.  They are huge resources to us, and they are amazing partners potentially.

You can see the benefits quickly though. We are starting to see some real green shoots that this is working.  Significant reductions in non elective activity, ambulance call outs, but also improvements in residents and their carers, and they are telling us that this is making a difference to them.  And when you talk to people in the area, and you go and you visit one of these sites, you can feel the difference, you can see it, you can touch it, you can feel it, you can sense it, it’s real.  But also there isn’t one change that makes a difference.  Everybody is looking for the silver bullet, but the silver bullet isn’t out there guys.  There isn’t a paradigm shift, there isn’t a silver bullet, and there isn’t a stepped change, there is a lot of very simple, small things you can do, that if you do them altogether in a co-ordinated way, you can make a massive difference.  And the opportunity for this is wider than just care homes.  A lot of the work we have done could be applied to different settings, home care, extra care living, but also some of the things around urgent care out of hours as well.  So have a think about how this could be more than just something to do with care homes.

If you want more information it is all available. Thank you very much for your time, my name is William Roberts, and I really love my job.


Clive Weir

Chairman of ECA and Registered Manager of a Crae Home,
Essex Care Association
Comment date
31 May 2017
I listened to your talk to CAA in January of this year and ECA has attempted to make inroads to the CCG's/STP in our area, but we are having very little success. I should be grateful for your advice.

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