Adapting for Change: evaluation

Chapter 6: Streamlined local partnership working

AWG recommendation: Streamlined local partnership working and governance

The AWG highlighted the importance of adaptations services being integrated within the wider health and social care agenda, with a common, agreed approach supported by clear governance arrangements. Issues connected with developing a robust, partnership-based approach to delivering change are covered in Chapter 3. This chapter focuses on specific work the test sites have been taking forward around working together to improve systems.

Key research evidence

The case for developing pathways

Considering the pathways which people take through adaptations services has been a clear focus of activity across the test sites. The on-going priority being given to this work very much reflected a strong and clearly articulated view that improvements to the adaptations process could not be achieved by any partner in isolation.

Although there was consensus about the importance of developing an agreed pathway or set of pathways, this is not to suggest it has been an easy task; the feedback suggests it has been a resource intensive but very worthwhile process. This process varied between test sites but usually drew on existing processes for one of the key agencies involved. For example, in one of the test sites, one of the key stakeholder agencies had already mapped their own adaptation-related processes. This was then used as the starting point for mapping how other agencies were involved, including how and when a service user might be referred between agencies.

Points relating to the pathways mapping and redesign process raised by Project Board members from all sectors included:

• Surprise, and occasionally dismay, at how complicated and unwieldy parts of the existing process can be, particularly where a number of agencies are involved, or impact on one another. There was a frequent view that taking a step back and looking at the range of ways someone could experience the system has been a very useful but sobering exercise.
• Specifically, the mapping of existing pathways has helped highlight areas of delay or duplication. Although experience varied between test sites, a significant number of key stakeholders across all sectors reported difficulties caused by the absence of a single, integrated approach. There were particulars concerns about the possible pathways a more complex case might take through the system. These concerns often focused on the sheer number of stages to go through and the potential for delays to occur at many of these stages.
• For example, there were concerns about the potential for multiple assessments to be taking place and, in particular, for both a hospital-based and then a community-based assessment to be considering the same issues. These concerns were raised by a broad range of key stakeholders and by a small number of service users.
• The number of 'hand overs' between one organisation and another was identified as having the potential to build-in multiple and potentially avoidable delays. For example, one test site has identified significant delays associated with carrying out the financial assessment for private sector adaptations, with work otherwise unable to progress while that assessment is outstanding.

The feedback from those involved in the mapping process within the test sites, suggests that it can be useful to involve a wider range of staff, including frontline staff, in mapping the current approach and the redesign process. Involving staff in this way has the potential to break down barriers within and between organisations as people come to better understand each other's roles and responsibilities. Involving a range of staff in the redesign process can help in supporting people through change.

Pathways redesign

One of the test site areas has simplified pathways by encouraging direct referral to the Care and Repair Service from a wide range of sources, including housing associations, GPs and hospital-based OTs, along with referrals from social work OTs. The assessment for adaptations is carried out by a specialist OT within the Care and Repair team. This single pathway approach is now well-established and seen as simplifying the process from both a service delivery and a client perspective.

In the other test sites, redesigning of the pathways is generally well underway or has been completed. The redesign process has of course varied according to the overall model and structures within each test site but has always focussed on creating a clear, coherent pathway through services. This has generally included:

• Looking at the range of ways people can access the system, including how this may be influenced by the tenure of the property in which they live or other circumstances, such as whether they have a disability. In one of the test sites in particular this has highlighted the significant range of possible 'entry points' into the system and has allowed the key partners, including third sector agencies, to clarify the arrangements for referring people on to another service if appropriate.
• Both at 'entry point' but then as an on-going part of the process, looking at referral processes beyond those associated with the possible requirement for an adaptation. For example, ensuring that the process encourages referrals for other information and advice, including housing options-related advice.
• Also, ensuring that the adaptation-related pathways speak very clearly and where appropriate are firmly embedded within other key pathways, including those supporting timely and well-managed hospital discharge or telecare services.
• Specifically, considering how community and hospital-based OT services can work together and with other key agencies to support early action and remove any unnecessary overlaps between or duplication of assessments.
• Minimising the number of 'hand-overs' between different agencies and critically any unnecessary waiting times being built into the system as a result. This may have included looking at which processes could run concurrently; an example might include the processes associated with putting funding in place and the work planning stages.
• Reviewing the timescales associated with key stages of the process and whether any of these can be reduced. This has sometimes been associated with looking at ways of reducing pressure around current 'pinch points', such as the assessment process. The approaches being considered include 'triaging' smaller, straightforward work so that a full OT assessment is not required. Other examples include looking at ways to either avoid or at least streamline financial assessments for those happy to cover the cost of the work required and of smaller works in particular.
• In the latter stages of the process, looking at ways the relevant services can work together to ensure the timely, efficient and cost-effective delivery of any adaptation work. One of the test sites will be going on to look at procurement processes and opportunities for joint-working in the future.

A number of other developments were also reported as flowing from the pathways mapping and redesign processes. Examples given included:

• A clearer focus on early information and advice through collaboration with other agencies such as Housing Options Scotland, the provision of digital information accessible to dementia sufferers and early advice and information to individuals currently not in receipt of care or support.
• In one of the test sites, the establishment of a complex care panel to support shared decision making around the package of services required, including adaptations services.

Key stakeholders highlighted a number of factors to be borne in mind during the redesign process. They included:

• It is important not to 'design out' flexibility and personal choice; the focus needs to be on how the system supports and responds to the choices people make, rather than the existing structures or pressures of the organisations delivering the service.
• There should be a clear focus on eliminating delays and this may involve setting delivery timescales for many stages of the process. However, while it will be important for services to be able to deliver according to these timescales, they should not otherwise dictate the pace at which someone moves through the system. If, for whatever reason, these timescales are too rapid for the client, the system should accommodate their preferences. For example, it was suggested that some people may need or want time to decide between possible ways forward, particularly if the changes being suggested involve major work to their home.
• The pathways work provides a mechanism for ensuring that the specialist assessment skills within OT services are put to best use. In particular, it can help ensure that the most complex assessments are carried out by those with particular knowledge and expertise in adaptations.

Key stakeholders frequently identified the development of pathways as the most significant, tangible achievement of their AfC partnership, and as being a piece of work that has the potential to drive very significant change in the future. As noted earlier, the process is at varying stages across the test sites. One of the test sites has now effectively completed the redesign stage and their Project Board is in the process of developing an implementation plan. Other test sites still have work to do around the redesigning process but there is a clear commitment to continuing with this through to implementation. In the meantime, incremental changes are often being made and there is a clear consensus that the process to date is already supporting an improved joint-working culture.

However, for a small number of key stakeholders the pathways work has raised a question as to whether a full redesign could have had even greater impact. Whilst recognising that revising and improving the current approach may have been the pragmatic way forward, it had led them to consider what might have been achieved if designing a system from first principles had been an option.

Information and measuring outcomes

The work of the test sites, including the redesign of pathways, has highlighted some very significant challenges around the availability of data and information to support performance and outcome measuring, particularly but not exclusively noted within local authorities. This has been an on-going challenge for the tests sites, starting with difficulties in pulling together a set of baseline data around system-function and performance at the start of the AfC initiative period.

This is another area in which a number of the tests sites, often working very closely with the ihub team, have invested a considerable amount of time and effort. The work has included individual members of staff spending time extracting data from existing recording systems on a case-by-case basis. However, it has usually only been possible to develop a snapshot of certain functions or for a specific timeframe.

However, in one test site, the single pathway approach has enabled the establishment of a recording system which measures time taken from referral to completion of the adaptation work. This system is also able to record cases where the assessment results in a recommendation not to carry out an adaptation, including because equipment, a re-ablement programme and/or a package of support is considered a better option. The system also records if the property is unsuitable for adaptation. This test site has carried out an outcome analysis, based on a small number of case studies, to demonstrate that installing adaptations could save substantial sums of money to other parts of the Health and Social Care Partnership.

The recording-related challenges have been many and varied, but key issues to emerge from across the test sites are:

• Key data may be held by a number of agencies and services. Within any of those agencies, all relevant data may not be held within any single recording system.
• Systems tend to be focused on case management but have often not been designed to allow data to be drawn from individual case records and made available for performance or outcome monitoring and reporting. This is not to suggest there are any problems relating to the recording of case information for service delivery. However, there have proved to be considerable challenges in making that data available to the service redesign process.
• The definitions and formats used to record data may not be consistent within or between services. This creates difficulties when trying to pull together meaningful information for a process that generally involves a number of delivery partners.
• There have been occasional instances of the AfC Project Boards, struggling to access the data which may have been available, including because of possible data protection issues.

As noted above, there has already been a considerable focus on this issue within the tests sites. That focus has shifted to looking forward and considering how the partners can work together to put in place an approach which gives them robust, outcome-focused information which they can use to assess current performance and which can inform the future change process. Issues which the test sites are taking into account include:

• Any approach needs to be workable for frontline staff; it should not be about introducing time consuming additional burdens but should focus on ensuring that the information already being gathered can be translated into meaningful performance data.
• The approach needs to recognise that many people will start their journey through the system as someone whose wider needs are being assessed. This assessment may, or may not, identify the need for an adaptation and this adaptation may be only a part of a package of on-going support. Any approach needs to be set within this wider assessment and service delivery framework, not least to support any future work looking at the role adaptations play in enabling independent living.
• Making changes to ICT-systems, even in terms of introducing a reporting function for data already held, can be difficult and costly. To ensure that any resources available are put to best use, it will be important to take a coordinated approach. Particular care will be needed to ensure that data held by a range of organisations can fit together to look at whole journeys through the system.

Taking this work forward will undoubtedly be challenging and, to be successful, will require key partners to work together to bring about change. In this respect, it reflects many other aspects of the AfC initiative in that it will be driven by, and if achieved will be testament to, the importance of constructive and thoughtful partnership working between a range of key partners.

Whilst the collection and use of outcome-focused performance information is seen as critically important by the test sites themselves, it is also of relevance beyond each local area. As noted earlier, national policy has a clear prevention focus and adaptations are understood to be a key part of the package of services which can support independent living. This means that the Scottish Government will continue to be interested in outcome-focused information which allows them to develop a clear picture of the contribution housing adaptations may be making to delivering a key national policy.

Summary conclusions

The mapping and redesigning of pathways has been a key process and, in most of the test sites is already a key output from the AfC initiative. It has required the investment of significant time but for those involved this time is generally considered to have been very well spent. The process has helped identify ways that systems could be improved and streamlined, and positive changes are already being seen. As the work continues, and the pathways are embedded into practice, further positive change is expected.

Evidencing the extent and nature of this positive change may be challenging as there is generally an absence of baseline data against which change can be measured. However, the test sites are quite rightly focusing on moving forward and on looking at proportionate ways of gathering outcome-focused data which allows them to assess current performance and identify further improvements which could be made.