IMPACT Change Model

IMPACT has been supporting change within social care across the four nations through the use of research evidence, lived experience and practice knowledge.

We have learnt that whilst each situation and opportunity is different, there are common challenges and obstacles which prevent improvements being made and sustained in the long term.

We have used the learning from our projects to develop a set of core principles for evidence-based change in social care.

These are explained below, with examples from IMPACT projects as to how the principles can be used within a social care change project.

We also provide an overview of the change tools we have used within our projects to help stakeholders understand a change and discuss how best to take forward their collaboration.

Agreeing on the issues

There is often a pressure to move quickly into making practical changes, but to avoid changing the wrong things, it’s important everyone understands the current situation, opportunities and challenges. Learning about what has been done before, including things that didn’t go well, can help you to predict and plan for any barriers.

Often, change can begin with a focus on outcomes but we lose sight of this in the busyness and messiness of the process. Be clear on what you’re trying to achieve together and what success would look like for different people involved – this can help inform where to put resources and then evaluate on whether the change has gone well.

It’s important to create a ‘safe’ environment for people with lived experience and practitioners to openly share their hopes, frustrations and concerns. This will encourage positive and respectful change. Being open and honest about what can and can’t be changed allows for focused discussions and avoids people spending time discussing options that will not be considered.

Examples within IMPACT

The Facilitator project in Ebbw Vale initially focused on introducing a decision-aid to support carers of people with dementia who are approaching end of life. However, there was a potential clash between the culture of the organisation and staff values, which were focused on promoting the voice of the person with dementia, and the decision-aid tool, which was designed to support carer voice. This potential lack of fit between the local context and the chosen tool prompted a range of conversations with wider stakeholders including carers of people with dementia. The ability of the Facilitator to recognise this and adapt their approach in line with the real needs of the hospice was integral to the success of the project. Staff did not feel that it was part of their role to engage with research evidence, but then introducing lived experience evidence was successful in encouraging their engagement. Practitioners recognised the value of the decision-aid only after hearing about the benefits it had for carers, underpinning the importance of published research being translated so that its practical application and benefits are made explicit. By encouraging open discussion to understand carer and staff needs, the project was able to instigate culture change, with the hospice becoming more evidence-informed in its practice and having a renewed focus on the needs of carers (alongside the needs of the person with dementia).

IMPACTAgewell is an asset-based community development project located in a rural locality of Northern Ireland. Link workers meet older people in their own homes to learn what matters to them and discuss options to improve their social situation and health conditions. Where appropriate and with their agreement, the older person is connected with relevant community groups and statutory bodies. The Demonstrator project’s aim was to widen access to IMPACTAgewell within local communities and share learning outside Mid and East Antrim. The project was led by two steering groups – a Community Group involving older people and voluntary sector organisations, and a Practice Group involving professionals, health and social care organisations, funders and broader networks. The steering groups set out key implementation questions to be explored initially through research, practice and lived experience evidence. Insights from evidence were discussed at a World Café event involving professionals, older people, and community groups. A ‘theory of change’ was developed following the event which identified these areas for development: engagement from professionals, including GPs, social workers and pharmacists; accessibility to older people from minority communities; strengthening collaboration with and across the community sector; and widening learning and impact. At the end of the project, a second World Café enabled stakeholders to reflect on the progress and learning and to identify recommendations for future practice and policy.

Networks follow a collaborative process in which members help to shape the questions and content for discussion and provide insights from their own practice and lived experience. At the initial briefing meetings, an online post-it wall is used to ask co-ordinators to feed in suggestions of what the first evidence review-based discussion material should include. They are then invited to feed back on the first draft of its scope and content, and to share examples from practice or lived experience that the evidence review process hasn’t picked up. For example, in the Remodelling the Front Door Network, members identified a gap in understanding about population needs and the importance of this in shaping approaches to managing the ‘front door’ when people first try to access social care support. In response, action plans were established to gather data to understand local population needs and strengthen involvement of lived experience evidence to understand if needs have been met.

Mobilising the evidence

With growing pressures and often insufficient funding for social care, it is even more important that scarce time and resources are focused on things that might make a real difference – change can’t afford not to be evidence-informed.

Evidence in adult social care should include:

different types of research
the lived experience of people who draw on care and support or who are carers
the practice knowledge of people working in adult social care
diverse perspectives and experiences

Evidence should be gathered sensitively, considering the risks of power imbalances, unheard voices and discriminatory bias.

Different groups may value different types of evidence, for example, those based on stories or economic impacts. Taking a broad approach can give a more thorough perspective.

Evidence does not always provide a clear ‘answer’ – but often it gives you a sense of what might be fruitful, a starting point for dialogue and further questions to help you make progress together. Evidence helps to achieve outcomes which matter to people who access and work in social care – so should inform day-to-day activities and decisions.

Examples within IMPACT

The PA Wellbeing Demonstrator started from the position that enhancing PA well-being will be beneficial for both PAs and their employers. To improve understanding among PA stakeholders of what ‘well-being for PAs’ means and how it could be improved, the project undertook a review of international literature and established two expert groups to ground the evidence in lived experience and practice knowledge. Combining published evidence with lived experience and practice knowledge enabled the evidence to be grounded in real-life issues. Co-producing the recommendations helped to provide credibility with key stakeholders by aligning with the values-based of the independent living movement. The evidence was provided in an accessible, easy-to-read format in advance of group meetings to enable people to understand the evidence. The facilitation skills of the IMPACT Coaches were valued by partners, including their ability to engage ‘thoughtfully and inclusively’, whilst having a budget to pay people for their participation was also a critical enabler in the project.

The Facilitator project in Moray was focused on tackling loneliness among older people living in a rural area. To build on insights from research, and to understand local resources and experiences, the project sought to map the approaches currently available in Moray. This started with an evidence review, web searches, visiting communities (exploring notice boards and in conversation with local people) and speaking with people involved in delivering services and approaches (local authority, NHS, church and community). The Facilitator then met with older people, their families and those who provide support to seek their views on factors which lead to loneliness; what helps people feel connected; and what would reduce loneliness in Moray. The project focused, initially, on Speyside and Buckie and their surrounding areas – allowing for comparison between a rural farming and a coastal fishing community. This was then widened to include Elgin due to the concentration of services and activities for specific groups of people in the town. The experiences and views of other groups of people, for example, people with learning disabilities or sensory impairment, individuals living with dementia and their carers and other minority groups such as the LGBTQ+ community were also actively sought.

All four UK nations are characterised by alarmingly high levels of people with learning disabilities and autistic people admitted to long-stay hospitals, with an average stay of 3 years (and more). Often discharge plans are delayed due to lack of adequate community services. At the first meeting, the members of the local Network groups discussed the evidence review and their experiences of long-stay hospitals and late discharge for people with learning disabilities/autistic people. Between the second and the third meetings, Networks used the initial review and their subsequent discussions to start identifying the key areas where they wanted to see changes. Changes between meetings included building connections with other organisations, benchmarking their practices against the ‘10 top tips’ for helping people to leave hospital (from the original evidence review), organising demonstrations (i.e. more ‘direct action’) and holding a conference at the Scottish Parliament. It became clear from the Network meetings that the issues and challenges are collectively felt across the four nations, and a collaborative approach could be effective in raising awareness and encouraging local and national action. This has included the production of a film highlighting the issues, developing case studies of effective examples, and setting up a community of practice. ‘Turning up the volume’ on lived experience and practice knowledge alongside research evidence has led to clear and impactful actions and practical ways forward.

Engaging with people

Too often there is pressure to move to taking actions, and to carry out the process without enough time and resource built in to engage meaningfully. The way we engage people in change can build respect and trust beyond the initial focus and activities.

A clear plan is necessary for the process of listening, involving and responding to people. This will ensure people’s passion is not restricted, and the process can reach a point where there is agreement on what’s needed and possible. Asking people to engage is an ‘opportunity cost’ for them – if they are working on a change, then they have less time for something else in their work or personal lives, so they must believe it will make a difference (and this needs to be genuine).

People who draw on care and support, carers and practitioners have often been promised positive changes in the past, but then felt let down when this didn’t materialise – so trust must be built through open and respectful communication.

‘Backroom’ and more technical functions like procurement, HR, finance and IT can sometimes get left out till later in the proposed change – involving them from the start can avoid later obstacles.

Examples within IMPACT

The Network considering Choice and Control involved people with lived experience from Swansea. They had previously set up a user-led co-operative called ‘Friends United Together’ to pool their budgets after their support service was retendered. They joined the Network as they were keen to attract new members and share their learning more broadly. The Network connected Friends United Together with local authority staff, the support provider and the Cwmpas development agency. The group created a video to share learning about their co-operative and highlight the increased choice, control and independence they had experienced. IMPACT supported the group to tell their story in a way that they chose, providing training on videography so they could make their own film. This helped to amplify the voices of people with lived experience, which led to the development of positive outputs and outcomes. The film is a powerful tool that can be used to promote the work of the group and share learning and good practice with other social care stakeholders.

The Waiting Well Demonstrator was hosted by the East Midlands Association of Directors of Adult Social Services (ADASS) to respond to concerns about people waiting to access adult social care services. The project brought together people who draw on care and support, unpaid carers and staff from the region to hear about their experiences of waiting. The project undertook several activities to collect and collate evidence as the basis for decision making including a literature review, co-production workshops, survey and interviews. A Co-production Steering Group was established with members including people who draw on care and/or support, unpaid carers, front-line local authority and care provider staff, Healthwatch UK and voluntary services organisations alongside East Midlands ADASS. The Steering Group met monthly and provided strategic co-production oversight, support and challenge to the project. In addition, monthly meetings of the Project Management Group, consisting of a senior representative from each local authority in the East Midlands, colleagues from East Midlands ADASS and Partners in Care and Health, supported the effective and successful delivery of project outcomes. The successful co-production with people with lived experience has provided a blueprint for future regional co-production including a process for paying people for their contributions.

Taking informed action

There can be pressure to move quickly to the action stage, but considering a range of potential options helps to avoid investing time and resources on activities which may not then have an impact.

Good project management is crucial to turn inspiring plans into practical actions. Other stages of the change model can also help identify actions and why people think these would work – sharing these assumptions helps those involved to understand others’ viewpoints and discuss which should be chosen.

There are often tensions between what is ideally hoped for in a change and what is feasible within the time and resources available – being realistic from the start helps to prevent people becoming disillusioned later. There are many reasons why people may be unwilling to engage with a change, including previous experiences and anxiety about what it means for their lives or work.

Regularly reviewing actions and the assumptions behind these enables plans to be adapted to new insights and changes in the situation.

Examples within IMPACT

Gwynedd introduced a radical new model to organise home care support in 2022 but there was a disconnect between different teams and parts of the system, with unclear boundaries and a lack of resource to embed change. The Demonstrator project aimed to accelerate practice changes from the new arrangements, enhance workforce experience through supporting practitioners and leaders, and encourage joint working between commissioners and providers. The IMPACT Coach introduced a range of change-related activities. These included a strategic event designed to accelerate change; multiple workshops focused on the principles of the new home care model and its value for different groups of staff; service improvement workshops focused on managing workloads, person-centred care and process improvement; training sessions and one-to-one coaching with senior leaders; and acting as a critical friend, for example, supporting an internal audit of project spend and assisting with a review of training. Peer learning was also embedded through the initiation of Communities of Practice for home care supervisors and the Care Leaders’ Forum, both designed to foster mutual learning and collaboration, and to identify solutions to address barriers to change.

The Social Care in Rural Areas Network focused on the many barriers related to geographic distance, staff recruitment and limited choice. An evidence review formed the basis of discussion materials which then supported the Network meetings. The Networks met regularly over six months to discuss common challenges, experiences and learning. A range of different mechanisms and activities were then undertaken by the Networks to best achieve their aims within their local contexts. For example, Self-Directed Futures used video libraries, a roundtable for commissioners and a briefing paper for evidence provision. Mencap Northern Ireland used a survey and focus group to identify needs and issues, in addition to liaising with community transport and developing a programme of learning disability awareness training for transport providers. Carers Northern Ireland also used a briefing paper, stakeholder roundtable, experiential film and piloted an information and support hub for carers in rural areas. Hywel Dda UHB Wales mapped local needs, through collating existing reports and documents through the Network, a survey and individual and group conversations. They also utilised a roundtable to communicate the importance of transport to adult social care colleagues.

Embedding co-production

For IMPACT, co-production means that people with lived experience have been co-leaders of the change throughout and that the following four principles are embedded – equality, diversity, accessibility and reciprocity. Below are some of the ways we have made this work:

Be honest about what level of engagement you are working at. True co-production is the goal, but if you are only able to ‘consult’ or ‘engage’, be transparent and don’t call it co-production
Make an effort to connect with people from different backgrounds, cultures, and experiences – especially those who may have been excluded before
Recognise that all types of involvement require time, planning and resources such as travel, digital access and carer support
Being involved should not only help the process of change but also be beneficial for the person with lived experience through, for example, growing their networks and skills
People’s expenses should be met and there should be financial recognition of their time
Sometimes co-production is messy. People might disagree, trust might break down, or things may not work out as expected. Be open to learning, reflect together and be willing to make changes
There are often unequal power imbalances in which people who receive support are expected to comply with what is asked. Co-production requires equal relationships with shared decision-making
People who have previously participated in co-production can help to mentor and support those getting involved for the first time, which can help people to develop confidence and skills
Co-production works best where there is a long-term collaboration as this enables people, practitioners and organisations to develop a more open, honest and trusting relationship. Building in time to get to know each other throughout the process enables relationship building
Following a project, it is important to inform people with lived experience how their views influenced the change, what was not possible and the reasons for this.

Examples within IMPACT

Prior to the Neighbour Demonstrator in Leeds, the city council had decided to pilot a new approach to homecare contracting in which a single organisation would be responsible for supporting people in a locality. This was initially developed in discussion with a citizens’ panel of people who access home care support and family carers through the facilitation of Healthwatch. However, funding for their support had ended and due to the busyness of the project team, the co-production arrangements had stalled. To maintain the voice and influence of people with lived experience in the next stage of the process, the citizens’ panel was reactivated. This was reoriented to a service improvement way of approaching issues, to generate ideas and emphasise specific areas of practice that needed change. Citizen panel members said that they felt listened to and valued and had been collaborators in co-producing the practical changes within the delivery of the new home care approach.

The Positive Futures NI project is seeking to change practice from minimal involvement, towards planned, regular (monthly) co-produced/developed involvement in the monitoring of internal quality of support. To achieve this change, an expert by experience monitoring group, ‘The Incredibles’ (adults with learning disability), has been established to meet monthly during the lifespan of the project. In addition, the IMPACT Facilitator has been working closely with the Positive Futures advisory board (a group of experts by experience with a lived experience of living with a disability to help inform and shape the project). Pre-testing of the experts by experience monitoring group has been undertaken at the beginning of the project and again at the end to identify understanding of monitoring and regulatory processes with this group.

The peer-led approach to this project has developed a sense of ownership and connection for those involved. They have been able to provide several ideas to help the outputs of this project (for example, recommending a video/animation/artwork to share their key messages). Given the diversity of the group, it has been important to use participative methods of engagement and to adapt to each member’s individual needs. To mitigate some of these challenges, we have been working on the strengths of the group and establishing a ‘contract’ from the outset to identify how we will work together. Using plain language and easy-read communication aids have been key. Further key learning has been the use of inclusive practices for people with learning disabilities who do not communicate verbally or unable to attend groups.

Trying out in practice

Local context is shaped by internal and external factors. Differences in local contexts can mean that change approaches used elsewhere may need to be adapted to work in your area.

It is important to be clear about which aspects of the process and/or impact are being explored when trying out in practice, and how these will be measured and understood. Having a clear process helps those involved to follow a cycle of trying out, reflecting on what did and didn’t work, and learning from this.

Different types of data can be helpful, including views of people with lived experience and practitioners, activity and outcome measures, and comparing against previous data. Data is rarely perfect but it’s often about having enough to provide the necessary insights to decide if the change should carry on, stop altogether, or be used in a different way.

People involved in change can often be worried about being seen to have ‘failed’ if an approach does not achieve what is expected – but this is important learning. It’s important to encourage openness, celebrate innovation and learn from successful and less successful changes.

Examples within IMPACT

Through considering wider evidence and engaging with people with lived experience and practitioners, the Demonstrator project in Mid and East Antrim identified opportunities to strengthen the asset-based approach. These included better engagement of social workers as a key profession that supports older people and their families. To see how this collaboration could work differently, the project piloted the involvement of IMPACTAgewell staff within the discharge of older people from hospital alongside the social workers who were coordinating the process. This enabled the project and its partners to understand the potential contribution of the asset-based approach to people returning home from hospital and highlighted practical challenges to realising this in practice.

Networks have brought people together to support resident well-being and build more two-way relationships with local communities. In the Care homes and communities Network, a care home consortium was established in Stoke-on-Trent where care homes are collaborating, rather than competing – working together to organise joint activities to promote well-being. Greater community integration was also promoted in this Network to reduce isolation, encouraging family and community members to volunteer. In one example, a care home in Scotland supported a resident to become a volunteer for a community walking group.

Sustaining for the long-term

There is always a risk that practices and processes will go back to their previous ways even after a successful initial period of change – this is why planning for sustainable change from the beginning is vital.

Being able to connect with a wider set of developments within your organisation can help to ensure engagement and investment in the longer term – you may need to communicate links clearly.

The more diverse those involved in the change are, the more likely it is to continue as there will be greater energy and capacity to do so.

Other parts of the change cycle will help us to understand what has and hasn’t worked locally. Evaluation insights can also help build the credibility of the change. Recognition from those who control funding and capacity will not only encourage people involved but will also demonstrate that the change is making a positive difference.

As local contexts change, the change approach may need to be adapted too – continuing to focus on the outcomes which matter will help to steer this.

Examples within IMPACT

The Facilitator project in Leicester aimed to understand if services at all stages in the Direct Payment process were culturally appropriate and, if no,t how/where/when changes in the service could be implemented. It was completed at the same time as wider developments on strengthening co-production within the improvement of adult social care. The learning generated through the project was used to develop staff training to enhance local skills and capacity, and direct payment guidance was updated and translated into different languages. Twelve months following the project, the co-production group is now representative of the wider population, Leicester has changed the language they use to communicate with people who draw on care and support, and have adapted commissioning processes so direct payments are more accessible.

The Facilitator project in Glasgow supported the implementation of the ‘Care Technologist’ role, a new way of working initially developed by Scottish Care. The initial plan was to introduce a rolling programme of staff training, but this was impeded by staffing capacity issues and instead a paper-based resource was identified as being more suitable. This change was informed by feedback collected via a staff survey on training needs. Three case studies were developed on implementing technology in care at home services that could be presented to local authorities to demonstrate what mechanisms support and hinder the use of technology. An independent evaluation found that the role fostered a more holistic approach by integrating technology with physical, emotional and social support. The Care Technologist role also delivered significant social value; from an investment of c.£77k they provided a total social value of c. £250k, providing a Social Return On Investment (SROI) ratio of over 3:1.