A workforce fit for integrated settings: working and learning in integrated teams across the UK.

1. A workforce fit for integrated settings: working and learning in integrated teams across the UK. THE SOCIAL CARE WORKFORCE: EVIDENCE FOR CHANGE Project findings showcase, 17 November 2009, Dr. Guro Huby, Dr. Pam Warner, Dr. John Harries and Dr. Eddie Donaghy. University of Edinburgh Professor Peter Huxley, Dr. Sherrill Evans, Dr. Chris Baker, Ms Jo White, Ms Sally Philpin, University of Swansea Wales

2. ‘Modernization’ of UK NHS and Social Care: new demands on health and social care staff ‘Our Health Our Care Our Say’ (England) ‘Delivering for Health’ (Scotland) ‘Fulfilled Lives – Supportive Communities’ (Wales) Health care • Bringing more care into the community • Reducing pressure on acute medical services • Managing long term health needs between health and social care • Preventive, pro-active care • Delivering personalization Social care Vol. orgs Housing Self care Carers The ‘Kaiser’ Pyramid: new relationships between and within occupational groups delivering care.

3. Responses to challenge: ‘top down’ and ‘bottom up’ • Service change and transformation • ‘Integration’ between health and social care • Wholesale structural change / incremental change by local collaborations? • Governance • Quality, safety, equal standards, performance management against targets • Impact on the ground? • Workforce development • Registration, mapping of skills to roles, accreditation, provision of educational facilities • Roles shaped in negotiation among professional and occupational groups

4. Different ‘integrated’ settings • Three UK health and social care economies • England: market driven competition. Joint commissioning key mechanism of integration. • Scotland: local co-operation centrally supported and performance managed. Local Community Health Partnerships key mechanism for integration • Wales: the best of both worlds? Local partnerships embedded in Health Boards with LA representation. Joint commissioning through Health Boards key mechanism of integration. • Care for older people and people with mental health problems • Both care groups key social work responsibility • ‘Integration’ of health and social care in sectors between acute and primary health services • Different policy drivers and guidance -similar (health driven) organizational pressures • Needs of client groups constructed differently • What models of integrated care emerge in different settings, and what are the implications for social care roles?

5. ‘Social care’? • the wide range of services designed to support people to maintain their independence, enable them to play a fuller part in society, protect them in vulnerable situations and manage complex relationships. (Department of Health 2006). • Policy ideal – implementation?

6. Workforce implications: the evidence • Existing evidence refers mainly to single staff groups within health care • Evidence is lacking about changing relationships between several professions and occupational groupsin specific contexts. • What is happening in social care? • What new roles are emerging? • How are boundaries shifting • Within social care? • Between social care and other professions? • What are the implications for training and support for social care staff?

7. The study • To capture key patterns in (social care) work-roles in integrated health and social care services in English, Welsh and Scottish settings, • To investigate local contingent factors which shape these patterns and compare their constellations in different settings, • To identify practical implications in terms of the management, support and training of social care workers in integrated settings, focussing on English settings.

8. Three stage mixed methods design • Aim 1: Survey of integrated older people and mental health teams in England, Scotland and Wales • Team composition and size • Work patterns and satisfaction in teams. • Aim 2: Eight in-depth case studies. • England and Scotland: 2 MH and 2 OP team • Team members and managers interviewed • How different team members and managers talk about • How roles are defined, how staff understand their own and colleagues’ work, what skills are seen as needed, and their development, perceptions of support and place within organisation. • Aim 3: Structured feedback questionnaire and workshop.

9. Some findings (mainly) from case studies • Patterns of teamwork and 4 different role types • 2 ‘Positive types’: coming together • 2 negative ‘anti-types’: pulled apart • Learning new skills: • individual and professionally ‘owned’ skills • governance implications • Management • supporting the provision of care • supporting the management of provision of care? • Implications: balancing ‘top down’ and ‘bottom up’

10. Case study sites England Scotland MH OP MH OP Fishing Town Suburb Town Small city SeasideCity Northern city Big City Industrial City Rural Town

11. Analysis • What respondents said: ‘ideal types’ • Themes identified • All interviews coded • Themes explored across setting and professions • Analytical constructs from themes • Checking hunches:exploring theories across settings, survey data, feed-back exercise, workshop

12. Dimensions of roles Care management X X X X X Grey area Social Care Health Care X X X X X Care delivery

13. Movements • Towards ‘grey area’: • From division between health and social care • Away from ‘grey area’ • Towards division between ‘care management’ and ‘care delivery’

14. 4 ‘Ideal types’ • Model 1: Role blurring and interchanging of tasks: • ‘key worker’ organising and delivering care, drawing in team members’ expertise as needed • ‘Health’ vs. ‘social care’ • Mental health teams • Model 2: Collaborating from distinct roles. • ‘key worker’ organises a ‘care package’ which is delivered by other workers. • ‘Care management’ vs. ‘care delivery’ • Older people’s teams • ‘Anti’ models: • Anti model to 1: Individual worker isolation – ‘hanging on to a case’ • ‘Anti’ model to 2: Occupational ‘Siloes’

15. Learning: the gap between skills and role • Moving away from professionally defined roles and skill sets to learning in ‘grey area’ on the whole seen as up-skilling • Moving from ‘grey area’ to care management seen as de-skilling • Differences among professions • Holding on: minority professions • OTs, Psychologists • New roles; interface health and social care.

16. Informal learning in ‘grey area’ • Informal learning • “not typically classroom based or highly structured and control of learning rests in the hands of the learner” (Marsick and Watkins 1990: 12) • Incidental learning • the by-product of some other activity, such as task accomplishment, interpersonal interaction, sensing the organisational culture, trail-and-error experimentation, or even formal learning.” (Marsick and Watkins 1990: 12)

17. Talking about learning Just listening, just seeing what was going on, working with people and you know going into appointments with them when they’re in with the doctor and listening to you know, what they’ve said. And knowing, through experience, that if they do for a short period of time, take a bit of extra medication, it will help with whatever’s you know, the voices, their delusions, whatever, you know the anxiety, whatever it might be, going on at that moment in time. So just experience I would think, and reading. But I think just being part of the team and seeing what goes on and observing. Scotland Big City Social Work Team Leader.

18. ROLES and NON-FORMAL LEARNING How “talk” about non-formal learning relates to peoples’ understanding of their role in the team and service. • In services where work was distributed amongst roles that were clear, bounded and distinct from one another non-formal learning was not emphasised. • In services were roles were flexible, relatively unbounded and “blurry” non-formal learning was emphasised. • ‘Formal’ professional/occupational training a pre-requisite for informal learning

19. Understanding skills • Model 1: Role blurring and interchanging of tasks (MH teams) • Skills ‘belong to’ individuals • Training an individual project • Moving from roles where skills are defined by profession or occupation seen as up-skilling • Innovation, energy and creativity – but governance? • Model 2: Collaborating from distinct roles (OP teams) • Skills ‘belong to’ profession or occupational group • Training a professional or organisational project • Care management/care delivery distinction seen as deskilling • Control, regulation and oversight – but innovation and energy?

20. Management and support • Factors working against ‘’integration’ • Protection of professional territory • Concerns among ‘minority professions: OTs and psychologists • Nurses and social workers : varied with context • Organisational pressures: targets, budgets, performance management • Delayed discharges in older people’s services.

21. The impact of governance requirements • Paperwork: the impact of governance requirements • ‘Paperwork’: • needed for communication and co-ordination • ‘bloody paperwork’ • Separates the doing of care from the accounting for the doing’ • ‘Management’ and alienation: • Care in interaction between workers/users alienated from ‘system’ • ‘Management’ opaque and unhelpful • Relationships to individual managers important for satisfaction

22. Service change and workforce development • Training: • Service change and learning – what comes first? • Who directs change? • Governance: • ‘Management’ embedded in governance systems – Relationships? what is the role of ‘the manager?’ • Balance between • Innovation/regulation • Autonomy/oversight