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Adult Social Care Demand Management and Cultural Change in Bristol

Maximising Independence through Demand Management and Cultural Change in Adult Social Care

March 2017

The Challenge

Like most local authorities, Bristol City Council faced a significant financial challenge towards the end of 2015/16. There was a determination to meet that challenge as well as creating a more sustainable service post-Care Act implementation, and to use the principles within the Care Act to support this. The People Directorate had also identified an overspend in excess of £4m in Adult Social Care in 2015/16. The Council were also faced with additional steep savings targets for 17/18 and beyond, forecast demand pressures and increasing complexity of conditions. Despite this situation, their desire to deliver the Care Act well was resolute, leading the Council to acknowledge that a completely new offer and cultural mindset was required to address the challenge.

IMPOWER were invited to work with the council across two phases of activity:

1. To provide support to the Council’s cultural change ambition with behavioural science support for the introduction of a new 3-Tier Model across ASC, which was designed to help more people to live independently.

2. To conduct a demand management review, identifying insights to help prevent, reduce or delay demand, before developing an agreed target demand scenario, financial analysis and supporting implementation plans.

“It was and remains vital that our work with IMPOWER was spearheaded by the People leadership team for Adult Social Care. Building on our passion to get into the culture change that was needed, IMPOWER brought expertise, challenge and insight when it was most needed. The ambition to provide more people with better information as early as possible in their care journey was the prize. Whilst we remain focussed on the budget and meeting the financial targets, developing this approach is just the right thing to do. Working closely with operational managers and organisational development staff, IMPOWER have helped the leadership team get into a position where, whilst there is much to do and the challenges continue, there is an excellent, evidence- based platform from which to develop further.”

Mike Hennessey , Director of Adult Services

The Chemistry

The council knew that they needed to do something very different. There were examples of really innovative practice, but there was a determination to make this the norm. During Phase 1, the council revisited their overall narrative. Together with citizens and staff, they co-created a new approach to care – the ‘3-Tier Model’ – ‘help to help yourself, help when you need it and help to live your life’. It was also understood that these words needed to be backed up with a new approach, a brand new culture. The leadership team recognised this, the Heads of Service wanted to spearhead the work, and the Council wanted a legacy to share across the wider Council. They also recognised that they needed specialist support to make it happen.

IMPOWER brought experience and capability in the following areas:

  • Impetus, innovative behavioural insight techniques and evidence to help identify the right areas of cultural change to target.
  • The deployment of a test and learn (trial) approach using Innovation Sites which provided a safe environment for embedding the 3-Tier Model. Staff could build their confidence and skills in having a very different conversation with clients using a supporting behavioural change toolkit.
  • A focus on evaluation and measurement of the impact of the new ways of working, leading to quantification of associated potential benefits.
  • The training of a cohort of managers to embed the insight, tools, knowledge and skills required to continue this approach and roll it out across care and support.
  • Changing the conversation at first point of contact to influence and steer people towards support and services that build independence and away from traditional and expensive council assessment and service.
  • Redesigning the 3 Tier and RAS assessment forms, and supporting social workers, occupational therapists and practitioners to think about approaching conversations differently drawing on service users assets, strengths and networks.

In Phase 2, the council wanted to further embed the 3-Tier Model whilst undertaking a broader review of demand management opportunities. IMPOWER conducted diagnostic work to understand demand and cost flows across the customer journey, and identify the opportunities to prevent, reduce or delay demand within ASC. IMPOWER then developed:

  • An understanding of the level of demand reduction required (‘target demand’) to achieve financial sustainability in 3 to 5 years;
  • A range of demand management and behavioural intervention opportunities that would help realise the target demand model;

Financial analysis and implementation plans to provide confidence in the delivery of the proposed demand reductions.

The revelation

The Phase 1 deployment of the 3-Tier Model proved to have a positive impact on both clients and front line staff. Some of the key insights were as follows:

  • 63% of Practitioners ‘strongly agreed’ or ‘agreed’ that they had changed the way they had conversations with clients.
  • 64% of call handlers felt that they had changed the way they dealt with calls.
  • The new Support Conversation Record showed citizens were being directed to Tier 1 & 2 services.
  • Not all Support Conversation Records resulted in a RAS assessment. This suggested that practitioners were successfully diverting / directing citizens to Tier 1 & 2 services.

Staff also provided the following feedback:

  • ‘’Starting with the positive has really lifted everything, even I feel lifted…it’s been really positive.’’
  • ‘’It’s a whole mind-shift…starting with the positive.’’
  • ‘’I have been able to change the conversation in the middle of it [using the new practice tool], to focus on a support conversation…clients take this seriously’’.

During Phase 2 the project discovered that further embedding the 3-Tier Model and new demand management interventions could help the service become financially sustainable over the medium term. Through identifying where the demand pressures were in the system – and most importantly where there were opportunities to prevent, reduce or delay demand – the joint team co-designed a new target demand scenario for Adult Services.  Evidence for the viability of the new scenario was gathered (and cross-checked) from a range of sources, including:

  • Quantitative current demand and cost analysis
  • Experienced practitioner reviews of current cases
  • Staff observations at different stages of the customer journey
  • Benchmarking of data

Although 50% of 3-Tier support conversations were now resulting in an outcome other than a RAS assessment, the following new insights were also identified:

  • 67% of calls to the contact centre were being passed on to area teams for further investigation
  • In 75% of younger adults’ and 50% of older adults’ cases, more could have been done to prevent, reduce or delay needs
  • 50% of transitions could have reduced levels of need

The analysis highlighted opportunities to manage demand at every stage of the customer journey, and helped to quantify the potential for demand reduction.

The scenario analysis gave the council an agreed target to aim for, but also helped the team to transition from a conceptual picture of financial savings, to a set of tangible demand metrics that front line staff and managers could relate to in their jobs.

The results

The results of the Innovation Sites in Phase 1, where the 3-Tier Model was deployed, were dramatic:

  • 40% of new clients avoided the need for a RAS assessment
  • Clients accessing Tier 3 services (Home, Residential or Nursing Care) dropped by 18%

These evaluation insights helped provide the confidence to begin to implement the 3-Tier Model across all front-line staff in Phase 2. This led to:

  • 2268 new support conversations (using the 3-Tier Model) with both new and existing clients
  • Financial Q3 data showing 100 fewer new clients accessing Tier 3 services
  • A predicted financial outturn position showing in-year benefits of £6m coming from a reduced spend on Tier 3 services

The additional work in Phase 2 also led to:

  • A desire to continue to stretch the level of ambition and truly maximise citizen’s independence
  • The identification of a range of new demand management and behavioural interventions
  • A strong evidence-based case for change which will deliver financial sustainability in the medium term – ranging from 10% (£11m) to 15%  (£17m) in financial savings
  • Confidence in delivery through a robust implementation plan and delivery governance approach

The Impact

As a result of the project, Bristol are now well on the way to achieving the step change in culture that they realised was so important at the outset. There is still more work to do, but the next steps are clear and will build upon the positive story to date.

The 3-Tier Model is now recognised as a key enabler of this cultural change. The council is looking to build upon this success and embed the approach across other departments, putting demand management and behavioural change at the centre of its corporate transformation agenda.

Within Adult Social Care, Bristol have already done much to improve the independence of its citizens and start to meet the funding challenges given to them. Within the management team, there is a clarity of vision coupled with an understanding of practical next steps. With IMPOWER’s support, there is a clear direction of travel together with the required capability and plans to get there.

Further information

To discuss this case study, or our wider work in Adult Social Care, please contact Ralph Cook

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