In response to this situation, we decided to increase our efforts for transformation by bringing together the various parties involved. A key part of collaborating is knowing when to ask for help; at this point that ICA:UK were invited to join the initiative, bringing their experience of participatory processes and facilitation to convene people, to deepen the relationships between the various parties and to identify a common way forward. In December 2017, a meeting was called to bring together system partners, health and care, private and public sector, operations and commissioners that were involved with or impacted by the provision of domiciliary care in Torbay. The purpose of the meeting was to explore how the various players could best collaborate in order to respond to the expected pressure on the service that occurs during the winter months. Although the room was decorated for Christmas, the atmosphere was hardly festive. Apart from the seriousness of the issue, there was a feeling of reluctance, even resistance, which people brought with them, based on years of not being listened to; memories of previously failed efforts to work together more effectively, and a sense that nothing would change. People from all parts of the system held back, often staying in small groups of those they knew, not mixing; the perceptions and feeling held through existing relationships being reinforced.
Nevertheless, progress was made. The ability for participants to have a voice and with this way of working, for those views to be made tangible (a record for reflection, review and action) was a key success factor. One might consider it ‘managed venting’.
Through the evident energy in the room we managed to identify and agree together a number of areas in need of attention, some short-term (in the face of the annual winter pressures) and others more medium term. Reaching such an agreed set of priorities was helpful, but without discernible action, there was still the danger of them joining the long list of previously agreed priorities which, for different reasons, had not become reality.
We responded to this challenge in part by addressing the aspects of transparency and accountability. Meetings were scheduled quarterly, and over the next two years, emphasis was put on involving people in the agenda-setting, in ensuring that people had the opportunity to speak and be heard, but also in encouraging openness and greater accountability both at the level of organisation and named individual.
The response, however, was not just about increasing the number of meetings — it was important to make progress and to demonstrate and share that progress with everyone involved. A “you said, we did” session takes place in every meeting, setting out the actions agreed at the last meeting and the extent they have been implemented in the months since. Significantly, that has evolved more into “we said, was done” scenario, recognising that success depends on “we” not “us and them.”
From the initial meeting, the group agreed the key areas for attention in December 2017 were:
- to streamline the brokerage process (allocation of packages of care to the providers)
- to manage expectations
- to match capacity with demand
- better care of staff
- financing
- to work better together as a team
- to meet specialist needs.
Specific actions were prioritised within those for short-term attention, but those areas have remained the key focus behind the changes subsequently introduced.
In our work we distinguished between changes that were more transactional (designed to increase capacity within the existing system, more concerned with effectiveness and efficiency) and those we saw as transformational (aimed at achieving better outcomes for all by developing a new system, changing relationships between stakeholders). The distinction between the two categories is not always clear cut. We learned, for example, that transactional changes can have transformational outcomes, and how a transaction can become transformational by the way in which it is introduced and implemented. During 2019-20, for example, the decision to move from a primary provider model (contracting with one provider to bring in and oversee others) to a framework agreement with multiple providers working as a together could be seen as transactional. The way the decision was taken, however, and the subsequent process through which the agreement was developed and refined with the providers selected was transformative in itself. Never before had the providers been involved in formulating the agreement, setting the Performance Indicators, nor had the Procurement team embarked on such an inclusive and participatory approach to finalise the new contract. In turn, providers felt heard and listened to, more respected and deeper ownership of the contract which they had helped shape.
At the same time the specification size was reduced by a third (57 pages to 38), was tighter and more meaningful with all agreeing that the outcomes were clearer and better for clients and staff, driving person centred care; result: no surprises in the contract, collective commitment to delivering it and making it work.
We also recognised that, while our ultimate goal is transformational, small improvements within the existing system can play their part too, contributing towards the sense of progress, maintaining momentum and helping to raise morale. Even small developments like obtaining NHS lanyards for care workers and enabling them to access discount schemes with vouchers for goods and services can make a difference. More substantive actions included response to the issue raised in respect of Christmas with short term increased funding, demonstrating a commitment, carrying a message of progress, and improving morale and motivation.
Other actions were designed to be more transformational from the outset. The setting up of the Care Collaborative itself, for example, provided a regular forum for all stakeholders and allies to come together to share successes and tackle collective challenges. The transformation programme also established its own representative governance structures with providers as clear partners being members of the working groups (task forces) and decision making boards, establishing and applying criteria for projects, allocating funding and liaison with the senior leadership of the council and local NHS.
It was through this Board structure that the attitude to risk changed — seeing projects as “experiments” — there to explore new approaches and ideas. If they work, to go on to share and expand; if they don’t, to learn from or refine. It was a step in developing a culture of “no failure where there is learning.”
In 2018, three task forces were set up to carry forward the themes of recruitment and retention of staff, self-managing teams, and the development of an e-platform to enhance communications and knowledge management. In addition to the experiments, they also carried out research and worked to bring in new developments. At the same time, individual providers were also trying out new approaches and ideas, both for their own development but also to share with others and for them to adopt or adapt as appropriate.