Gwynedd Embedding Home Care Redesign

Gwynedd Council’s Supporting Health and Wellbeing Service includes a team of project/change managers. This team is led by a senior leader with vision who had developed the change narrative from a set of pilots through to mobilisation of the new model. This team aimed to provide governance, accountability, and strategic change leadership, however, did not have full oversight once mobilisation went ahead. So, there was strong leadership clarity within the transformation team but there was a challenge in translating this across to operational delivery. Our project helped bring together leaders across different levels within the system, initially strategically with senior leadership and then operationally with various teams and tiers of leaderships across domiciliary care delivery. This allowed us to support them in identifying the barriers to change and capitalising on and sharing good practice where it was happening. By the end of the IMPACT project Gwynedd Social Services (Adults, Health and Wellbeing Department) had reframed and redesigned their Project Board in order to have better leadership oversight and more direct impact on operational delivery aspects of the change process.

In 2017, Gwynedd Council began the process of envisioning and testing a new model of home care using the Vanguard Method, with the intent of meeting the Welsh Government’s strategy – A Healthier Wales: long term plan for health and social care. The essence of this was to bring a sharper focus on the individual’s required/desired outcomes through giving the front-line teams more flexibility and more opportunity to deliver according to individual needs, and to integrate a more asset-based approach into how communities and health and social care professionals can support people at home. Between 2017 and 2020, four pilot areas were tested to assess the benefits of defined patch-based working, shift work and block payments, Community Resource Team (CRT) membership for care providers and departure from the traditional time-and-task model of delivery.

The initial pilots had clearly engaged both staff and people drawing on care and support at home. Case Studies expressing their experiences were cited in the evaluation report and used during early information gathering for the Demonstrator project. There was little to no engagement post-tender with either front-line staff or people with lived experience, and this extended to Demonstrator access.

Community staff were aware of changes and had been contracted to deliver the new model, but largely, teams were under significant pressure and struggling to shift to new ways of working. Operational Managers had implemented changes to payments, as well as shift-based employment contracts, so the proposed benefits to front-line staff had materialised. However, systems and processes hadn’t changed in line with plans, the intended asset-based engagement with community resources and assets had not materialised in most patches, and outcomes-focused aspects of person-centred delivery were still in the main stuck on time-and-task. The commissioners, a joint enterprise between Gwynedd Council and Betsi Cadwaladr University Local Health Board were convened by the Supporting Health and Wellbeing Service’s transformation team within the council’s Adults, Health and Wellbeing Department (formerly Social Services). While this team were fully engaged with the Demonstrator throughout the early months of the project, there was less consistent access to other senior leaders in stakeholder organisations due to the pressures of the ‘day to day’. To boost engagement, the Demonstrator coach facilitated a Strategic Review event at a point in time 12 months after the start of the new set of homecare provision contracts. Attendance and engagement were high, and the event showcased achievements to date, facilitated honest conversation about the operational situation, and helped identify how the Demonstrator could best support professional stakeholders in the following seven months.

Once the Demonstrator was deployed it quickly became apparent that there had been no clear guidance for preparation on the ground for the Demonstrator. The lag between the initial IMPACT expression of interest (EoI) and the start of the Demonstrator (just under a year), meant that the live situation was not aligning with expectations. The IMPACT Demonstrator coach recognised that due to delays in system and process upgrading, along with the diffused accountability, the change process was not at an adoption into embedding phase (as originally expected when the EoI was submitted) but was still at a review & adaptation phase. This enabled a pivot to support staff to better engage with the change process and to foster collaborative working. Which, in turn, prompted a number of intervention initiatives, including operational change workshops, work-mindset shift programmes and the development of Gwynedd-wide Communities of Practice for Care Supervisors, and a self-led Care Leaders’ Forum for leaders, owners and directors of commissioned homecare providers.

The Demonstrator project was focused on supporting workforce development and mindset shifts to underpin the success of the new model. Drivers for the new model included shift-based salaries for care workers (rather than the previous zero-hours contracts or payment only for direct care hours worked), a move to person-centred thought and action from care workers (rather than a time and task based operation), an enhanced Community Resource Team (CRT) structure and process, and a move to empower care workers to have more flexibility to use their time in a smaller geographical patch, focused on wellbeing, reablement and promoting independence by engaging with 360 degrees of the life of the person receiving care – including working with families, neighbours, community assets and any other resources available. Over the year, key areas of focus for the Demonstrator became evident such as the support gap for staff at care supervisor level, training needs around reablement, competency development for the Information, Advice and Assistance (IAA) workforce, support for CRT improvement and leadership development for social care and social services management tiers. These areas of focus aimed to optimise care staff and regulated professionals’ expertise, allowed for the release of operational leadership resource and enabled enhanced service delivery and skills development for the social care workforce, both of which will improve outcomes for those in receipt of homecare.

This change initiative instigated by a Partnership between Gwynedd Council and Betsi Cadwaladr University Local Health Board envisioned a community-based homecare provision that removed competition from the process by designating one care provider per smaller geographical patch, and thus, aiming to engender a more collaborative, cooperative, asset-based way of working. The Demonstrator brought additional capability and capacity to the system, which was under significant pressure, and financial resource to support the work. The additional resource allowed space and capacity to bring social care professionals together in ways they ordinarily would not collaborate; and opened the door to new ways of sharing knowledge, combining resources and generating operational ideas. For example, gathering the leaders/directors of multiple care providers (statutory, private and voluntary) together created the opportunity for one commissioned provider to offer their under-utilised staff travel budget to a different commissioned provider who was finding their travel budget stretched. This kind of resource sharing and cooperative thinking could only emerge in a system without competition, and with space created to build trust, develop a sense of team, and allow honest dialogue.

The IMPACT Demonstrator Coach was able to deploy a range of interventions, improvement methods, evidence and facilitation approaches that supported collaboration towards common goals and diverted from the kind of “problem-talk” which can be a risk during transformation projects. Staff at various levels were introduced to a range of methods that helped support their understanding of ways in which they could adopt improvement approaches to demonstrate the changes in operational delivery.

By scaffolding enhanced workforce experience through supporting practitioners and leaders, and fostering collaborative working between the commissioners and statutory, voluntary and private sector stakeholders, the IMPACT Demonstrator added value to the adoption of the new model and the move towards embedding. Challenges remain about the future embedding of the improvement work carried out during the Gwynedd Demonstrator project, since the Partnership had intended for the IMPACT Demonstrator resource to aid in the embedding process before the need to pivot was identified.

The Gwynedd Demonstrator was able to pivot to the Organisational Development requirements in the change programme at speed due to the specific skillset and experience of the Demonstrator coach, who has many years’ experience as a consultant strategic change agent in large organisational transformation processes, as well as a wealth of experience in leadership development coaching and training at different operational levels. The culture, openness and the vision of the Supporting Health and Wellbeing transformation team also allowed for trust to be quickly built and expertise shared without fear or closed-mindedness.

The ongoing risk to the transformation of homecare is lack of resource for embedding the change, as well as sector financial instability and serious challenges in the external environment. However, the biggest challenge remains achieving and embedding cultural and operational change in the day-to-day running of these services and avoiding slipping back to business as usual. The project was able to maintain focus on shifting mindsets towards person-centred care and collaboration between those delivering care.

Further senior leadership embedding funding would add to the drive and stability of the transformation work and much needed culture change, enabling true embedding of the new way of working within the culture and operational reality of delivery in the community. The Demonstrator coach role enabled additional effort and resource to hold the focus on this process with the senior leadership across organisations and to allow those working on the front line to feel truly supported and listened to. The initiatives and feedback-loop processes put in place by the Demonstrator project will leave a practical legacy over the upcoming 12 months which should aid embedding; in particular – the fully resourced regular Community of Practice sessions in each of the five operational regions specifically for those at care supervisor level, culminating after 12 months in a full-day Shared Learning Event for all homecare supervisors across Gwynedd will build collaboration, develop skills, support learning and enhance support for this highly under-pressure cohort. The challenge for Gwynedd now is to find ways to ensure the benefits of this work endure and are realised in positive outcomes for those in receipt of care, and those working with them day-to-day.