Review of care service definitions: challenges and recommendations

7. Conclusion

This research uncovered a range of challenges posed by the current care services definitions and the ways in which they impact on social care workers, providers and those accessing support. It has drawn out tensions, implications and risks and made a number of recommendations to consider. These range from the specific to the transformational. Overall, stakeholders agree that the status quo is not going to achieve the desired future of social care and that more work must be done to better understand gaps, gather missing perspectives and unpack experiences. The section touches on evidence and approaches that can support sector recommendations for transformation and for next steps to be taken collaboratively.

Thinking in systems

Approaching the care services definitions as part of a system which interacts with other systems (e.g. inspection, registration, qualifications, self-directed support) may be a helpful lens through which to view changes, tensions and risks. System and process mapping can help to identify pain points and places to intervene.

Places to intervene in a system:^[4]

(in increasing order of effectiveness)

9. Constants, parameters, numbers (subsidies, taxes, standards).

8. Regulating negative feedback loops.

7. Driving positive feedback loops.

6. Material flows and nodes of material intersection.

5. Information flows.

4. The rules of the system (incentives, punishments, constraints).

3. The distribution of power over the rules of the system.

2. The goals of the system.

1. The mind-set or paradigm out of which the system – its goals, power structure, rules, its culture – arises.

Based on the above list, changing the legislation could be seen as 'Point 4: changing the rules of the system'. The data from this research suggests mind-sets (Point 1) have already shifted away from restrictive ideas of care and now need the support of new system rules to fully realise personalised support and achieve the future of social care presented in the Feeley Review.

Systems redesign and transformation

Naylor & Wellings' (2019)^[5] report details the elements of a system redesign. It argues that radical changes involve the emergence of an entirely new form/ structure, often prompted by a shift in what is considered possible or necessary, which results in a profoundly different structure, culture or level of performance. The King's Fund has carried out research which suggests that successful transformational change in health and care is more likely to happen when a number of enabling conditions are in place, as listed below (Dougall et al 2018)^[6].

• Transformation is often emergent 'from within' and led by frontline staff and service users, rather than being imposed by external pressures such as national targets.
• Transformation requires collaborative styles of leadership in which power and responsibility are distributed across the system, and with relationships that cut across boundaries.
• Transformational change in health and care systems is often organic, with strategic goals emerging over time rather than in advance, albeit transformations are often guided by a core purpose that is constant.
• Learning and adapting are a critical part of the process of transformation and organisations need to have the right data and skills to be able to change direction when necessary.
• Significant time is often required to allow new relationships to be built and for trust to be established before transformation can take place.

Ham, Dixon & Brooke (2012)^[7] also advise that transforming delivery means:

• Enhancing the role of users in the care team
• Changing professional roles
• Rethinking the location of care
• Using new information and communication technologies
• Harnessing the potential of new medical technologies
• Making intelligent use of data and information

They also indicate that locally embedded health and social care systems are essential to effective service delivery that is meaningful to the community and the individual.

Reviewing the conditions needed for transformation as outlined here can be a useful starting place for planning a large-scale change, helping assess what enablers or levers are already in place and identifying potential barriers.

Redesigning with people

This project was an initial piece of research with a limited number of organisations involved. Stakeholders were aware of missing voices from frontline practice and those accessing support in particular. Changing the definitions and the systems they are part of needs the involvement of people affected by those systems. Taking an inclusive approach to involving people through co-design, co-production and service design methodologies can ensure meaningful engagement with the change process and new systems. The Scottish Approach to Service Design (SAtSD) for example is recognised as having a critical role to play in transforming services around people's needs and creating new cultures (Digital Health and Care Strategy, 2018)^[8].

Final reflections

What we have heard from stakeholders in this research is a desire to bring in those who access support into the decision-making. We have also heard from those who want to see a fundamental change of professional roles to be based around the needs of a person and their care, as opposed to being restricted by a service definition or geographical boundary. We have also been told about the challenge of providing digital support to people to help them stay connected to family and friends, and to help them stay in control of their own care. If a route is chosen for transformational change around defining care, then these elements will need to be addressed. The core purpose and constant (that care and support is person-centred, flexible and in the right place at the right time for people) was at the centre of many of our discussions with stakeholders. This seems to indicate an environment, alongside recent developments around The Promise and the Feeley Review, that sees transformational change as being both possible and necessary.