EDGEWORK Series: Trajectory Management in Adult Social Care

Introduction

IMPOWER has worked as a delivery partner with Bristol City Council on its ‘Better Lives’ transformation programme since October 2017. The programme is introducing a new demand management approach to adult social care to improve outcomes for service users and at the same time reduce costs.

We have used Trajectory Management to address two of the main challenges when introducing demand-led change: how to ensure successful delivery of the programme; and how to show that better outcomes have been achieved. Providing evidence of the results of demand management is challenging as the impacts are often felt far from the point of change or intervention. Our Trajectory Management approach shines a light, helping to deliver sustainable change.

What is Trajectory Management?

Trajectory Management provides a management overview of system performance and improvement by developing and tracking a series of ‘Primed Metrics’. Rather than just counting inputs and outputs, Primed Metrics capture outcomes and performance improvements over time to give a better picture of how specific activity leads to outcomes. The Metrics are identified and agreed at the start of a programme. This approach moves beyond traditional reporting practice to include qualitative measures, including improved outcomes for citizens and measures of staff engagement, as well as more traditional measures such as cost and volume. Agreeing these measures involves skilled negotiation between stakeholders with different priorities (eg finance departments and social care teams) to find common ground and develop ownership.

Reframing the problem

Using Trajectory Management, Bristol City Council reframed their central problem in adult social care.

Traditionally, change programme governance lacks information other than that related to individual services and costs. Using a top-down savings target with delivery monitored through milestones and traffic-light (red/amber/green) status reporting, it is only possible to look at data after the event. This means that insight into any current situation is limited, which contributes to reactive rather than strategic decision making. Since programme monitoring is of limited value, it is often reduced to a box ticking exercise.

Governance challenges are particularly acute in demand management programmes, where savings are by their very nature gradual, and can fluctuate upwards and downwards over the short term. As a result, many councils still rely on anecdotal evidence to inform the design of interventions and to determine whether transformational changes are having the positive effects intended.

In Bristol, introducing Trajectory Management enabled the combined delivery team to understand where demand for services was coming from, who the key cohorts of service users were, and how programme interventions could be deployed with a sharp focus to impact on outcomes and longterm costs. This led to a reframing of the problem once the team could properly understand some of the underlying dynamics and complexity.

What did the combined delivery team do?

The team used a four-stage approach to Trajectory Management.

1. Setting an inclusive ambition

What is it? Stakeholders across the system need to agree what success looks like so that they can envisage and articulate what the end point is that they are all working towards.

How do you do it? Stakeholders need to agree a baseline of demand, cost and service data from a range of different systems which should be cross-referenced. Workshops should be held to set project goals using this baseline as well as benchmarking and lessons learned from previous projects. Data should be presented in a way which shows its relevance for day-to-day programme management.

Why is it important? An inclusive ambition gives stakeholders a sense of ownership and a common goal. This enables prioritisation of efforts and ensures everyone is pulling in the same direction.

2. Developing a Primed Metrics tool

What is it? Primed Metrics capture outcomes and performance improvements, not just inputs and outputs. They should support the purpose of the transformation while also enabling and promoting managerial oversight.

How do you do it? Key success measures which include the impact on service users and demand are identified as well as financial savings. These measures might include data sources never previously used. The indicators should be presented in an engaging and easy to understand format.

Why is it important? Active monitoring of Primed Metrics will enable the programme team to be proactive in changing interventions or activities that are not delivering as planned.

3. Embedding

What is it? A structured and managed process for handing over at the end of a project.

How do you do it? Trajectory Management is co-developed from the beginning and Primed Metrics are gradually presented in more detail. The approach to converting data into real insights and actions (the ‘so what?’) is also gradually handed over.

Why is it important? Ownership of the product by the service department enables deeper insight and will ensure that knowledge is transferred.

4. Transfer to business as usual

What is it? At this stage, the programme’s Primed Metrics will set the agenda rather than being an item on the agenda, and will drive all discussions, actions and decisions. Data feeds will become automated in council processes rather than a manual monthly exercise.

How do you do it? Embedding a Trajectory Management approach in the culture of a local authority happens over time, as leaders become more familiar with it and can see how the new data and insights enable them to make more informed decisions. Embedding Trajectory Management operationally requires having dedicated owners for both the data and for the approach itself.

Why is it important? Moving to business as usual is critical to remove any long-term reliance on external support, and to build capability and a lasting legacy within the council.

Impact

By applying Trajectory Management with an inclusive ambition and Primed Metrics, IMPOWER and Bristol City Council are delivering better outcomes for users of adult social care services.

• It is now possible to prove the positive impact the programme is having on outcomes through tracking new data and insights. For example, by the end of March 2018 there were 21 fewer older people in residential beds than there would have been without interventions with an associated saving of £890,000.
• Culture, behaviours and conversations are changing. Leaders at all levels are managing the department differently and having new conversations among themselves as well as with wider stakeholders and service users. They now spot and address issues earlier, discuss and agree actions, and invest further in positive results.
• Political Members can clearly see and understand what their investment decisions are aiming to deliver. They are better able to communicate to their peers and electorate the purpose and outcomes that the service is trying to deliver.
• The corporate finance team has greater confidence that the programme will deliver. They can see clear links between the work on the ground and expected shifts in demand and cost. They are included in regular updates and are therefore able to influence the actions being taken to address identified issues.
• Engagement with operational staff has improved, in terms of understanding, buy in and accountability at all levels. Everyone from front line staff to project leads can clearly see and understand how their contribution matters to the programme, and to the service as a whole. This has led to staff suggesting their own service interventions which have then been fed upwards to the wider programme.
• Primed Metrics are providing new insights that were not previously visible. This is leading to problems and opportunities being identified earlier, and innovation happening more quickly, positively affecting the change journey

Conclusion

Successful delivery of demand management – and demonstrating its impact – is complex and requires an approach which is grounded in an understanding of more than just demand and cost. Primed Metrics underpin the importance of outcomes and impacts. Setting an inclusive ambition means that the myriad parts of the complex system share a common goal.

The Better Lives programme in Bristol shows that this complexity can be tackled successfully using EDGEWORK and Trajectory Management. The approach fundamentally changes traditional forms of management, away from the limitations of looking at service budgets and forecast spend to the use of Primed Metrics which can be monitored in real time and therefore be used in strategic decision making.

What is EDGEWORK?

Drawing on 20 years of insight and impact, EDGEWORK is IMPOWER’s unique approach which helps our clients understand complex problems in order to solve them. Public services can be effective, affordable and sustainable; the key is understanding complexity.

Many might argue that lasting change comes down to robust business cases, strong project management and clear planning. A traditional approach like this is logical and it gives directors and leaders the feeling that they have control. But year after year, research shows that a majority of change projects fail to deliver their promised benefits.

This is because of an illusion that public services are ‘complicated’, and that they can be controlled if the right processes are put in place. At IMPOWER, we reframe public services as ‘complex’ – non-linear systems, where responsibilities are distributed and where success depends on creating the right relationships across and between system boundaries. This reframing enables our clients to achieve better outcomes at lower cost.

IMPOWER’s solutions are cross-boundary, as the distinctive and game-changing work is done at the edges between organisations, people and processes. We therefore call our approach EDGEWORK.

EDGEWORK comprises a set of defined and flexible inventive methods which are deployed as appropriate to local circumstances. Inventive methods are grouped under five competency areas: