Leeds Transforming Home Care Project

Leeds City Council had appointed a transformation programme Director who was a senior leader in the sector, to provide governance, accountability, and strategic change leadership. This role enabled mobilisation of links to national and international projects to enhance the need for the change business case. This also supported local business case development for the initial pilot (2020-2022) and its evaluation by Leeds Beckett University (LBU), as well as commissioning of Healthwatch Leeds[1] to undertake an initial Citizen Panel.

In 2023, just prior to the IMPACT Demonstrator, a Statement of Common Purpose was published between Leeds City Council and Leeds Community NHS Trust, which aimed to develop a common programme of service development, with governance sitting under an Alliance Board. This provided wider system leadership and alignment of strategic priorities for change, such as the Active Recovery at Home service, part of the Home First programme. In addition to this, the leadership provided a sense check for political and other issues relating to the social care context.

The initial pilot, captured in the LBU evaluation, had clearly engaged staff and people drawing on care and support. Quotes regarding their experiences were cited in the report and used during early information gathering for the Demonstrator project. A limitation of the report was that it was carried out during the pandemic and had limited access to people.

The Healthwatch Leeds report, co-created with people who had used home care services, and their carers, provided further evidence of engagement. However, dedicated funding for Healthwatch ended in 2022. The co-ordination of the citizen’s panel was taken on by the Project Team, and no further external facilitation had been commissioned. Community health staff were aware of changes via a range of communications sent from the Alliance partners but largely, teams were under significant pressure and staying focused on what was presenting to them day to day. Operational Managers were juggling the ‘day-job’ and the need to engage with and influence where possible, plans for change coming from the senior leadership, who in turn were under pressure as budget cuts became more intense.

The commissioners were fully immersed in the procurement process for most of the twelvemonth Demonstrator project, due to its complexity and sensitivities relating to changes in the provider landscape which may impact staff. Nonetheless there was full engagement with the Demonstrator and the coach was welcomed into the team.

The Demonstrator was deployed into this context, actively supported by the senior leadership and commissioning team. It quickly became apparent that there had been no 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 had changed. The procurement for the new home care providers to deliver the new service (the Community Health and Well-being Service) was ongoing. The strategic improvement coach used the IMPACT Engage-Understand-Reflect-Evidence-Change/create – Assess model to work with local stakeholders to prioritise change support.

It was agreed that there was a need to re-activate the Citizens Panel to maintain their voice and influence in the next stage of the process to implement a new way of working in home care. The pilot was underpinned with a range of practitioner, lived experience and published evidence, but the voice of people using services were not present at the table when deployment planning was ramping up.

The IMPACT Demonstrator coach recognised that, due to delays in the procurement, the change process was not at mobilisation (as originally expected when the EoI was submitted) but was still at a pre-planning phase. This enabled a pivot to engage citizens and staff in the preparatory work to identify issues, ideas and innovations. One gap here was access to the provider organisations, due to the procurement, and therefore proxy partners were used – Leeds Care Association.

The Demonstrator project was focused on practice changes which would underpin the success of the new model. Care staff were to be paid for their whole shift, not work on a time and task basis, their professional opinion being valued and care workers were to have more flexibility to use their time in a smaller geographical patch, focused on wellbeing and promoting independence.

Driven by the need for team developments across health and care, the IMPACT Demonstrator viewed the citizens and their carers as part of that integrated team.

Over the year, key areas of focus became evident such as training and the implementation of Delegated Healthcare Activities. This sought to optimise care staff and regulated health professionals’ expertise, releasing resource and enabling both improved citizen outcomes, and career development for care workers. The cost of care was also a driver for system improvements but was not an area prioritised for the demonstrator work as this was subject to a longer term, commissioned evaluation planned to start just prior to the new home care service.

Leeds has a long history of utilising co-design. As a community, the city services are good at strategic thinking for its internal services, but commissioning has perhaps lagged behind in terms of innovation due to a number of factors including the requirements of the commissioning cycle, market stability and capacity to implement significant and rapid change programmes. Leeds has a range of centres of excellence and embedded service improvement teams. The Demonstrator brought additional capability and capacity to the system, which was under significant pressure, and financial resource to support the work. The co-design work aimed to test a rapid change accelerator model using a re-convened Citizen Panel. The panel was reoriented to a service improvement way of approaching issues, to generate ideas and emphasise specific areas of practice that needed change. For example, training for the new care workers. The panel members flagged the need for people to be part of the sign off for training in situ, and using real life scenarios in classroom training was essential. Discussions helped to refocus some improvement ideas in a really practical way. This was subsequently discussed at a strategic delegated healthcare activities workshop and with the citywide training team.

The IMPACT Coach was able to deploy a range of improvement methods, evidence and facilitation approaches that supported change and avoided problem-processing which can be a risk during transformation projects. Staff were not familiar with some of the methods used so it was a good way to support their understanding of ways in which they could adopt improvement approaches to demonstrate change during the mobilisation.

A final co-design workshop was held, bringing all participants together to share in the findings of the Demonstrator and define actions needed to embed the learning.

The Leeds Demonstrator was able to deploy the rapid change accelerator at speed due to high trust in the coach as a member of the city health and care system for many years. This local knowledge enabled the coach to work with staff who were initially unsure of the value of the work. The coach was also a regulated health professional which allowed for open conversations with health colleagues enabling reframing of issues/ideas to promote stakeholder buy-in. Shared understanding is a key aspect of preparedness for change.

The ongoing risk to the transformation of home care is the instability of the senior leadership funding and serious challenges in the external environment. The scale and nature of the dedicated commissioner resource in Leeds is unusual, and has provided long term positive benefits end to end in the development of the new home care model. However, the biggest challenge remains achieving cultural and operational change in the day to day running of these services and avoiding going back to business as usual. The project was able to:

keep the focus citizen centred when so many operational considerations were being negotiated that could have easily strayed into ‘what’s easiest for us’ without focussing on ‘what’s right for the person

Further senior leadership funding would add to the drive and stability of the transformation work and much needed culture change, taking the work through the mobilisation into benefit realisation. The work Leeds is ambitious to deliver, will require a team effort in the long term, with additional resource being sought and won already. The opportunity is immense and in the words of a stakeholder, reflecting on this projects’ outcomes:

A good range of contributors has been excellent ie service user, professionals, and providers all working together for a common cause. Wow!

The Demonstrator coach role enabled additional effort to hold the focus on this process with the senior leadership and national networks. The challenge to Leeds now is to find ways to ensure the benefits of this work endure into the mobilisation and beyond.

Exciting times ahead but the journeys a long way from over