A workforce fit for integrated settings: A workforce fit for integrated settings: working and learning in integrated teams working and learning in integrated teams

across the UK.across the UK.

THE SOCIAL CARE WORKFORCE: EVIDENCE FOR CHANGETHE SOCIAL CARE WORKFORCE: EVIDENCE FOR CHANGEProject findings showcase, 17 November 2009,Project findings showcase, 17 November 2009,

Dr. Guro Huby, Dr. Guro Huby, Dr. Pam Warner, Dr. John Harries and Dr. Eddie Donaghy. Dr. Pam Warner, Dr. John Harries and Dr. Eddie Donaghy.

University of EdinburghUniversity of Edinburgh

Professor Peter Huxley, Dr. Sherrill Evans, Dr. Chris Baker, Ms Professor Peter Huxley, Dr. Sherrill Evans, Dr. Chris Baker, Ms Jo White, Ms Sally Philpin, University of Swansea WalesJo White, Ms Sally Philpin, University of Swansea Wales

‘‘Modernization’ of UK NHS and Social Care: new Modernization’ of UK NHS and Social Care: new demands on health and social care staffdemands on health and social care staff

• Bringing more care into the community

• Reducing pressure on acute medical services

• Managing long term health needs between health and social care

• Preventive, pro-active care

• Delivering personalization

Health care

Social care

Housing

‘Our Health Our Care Our Say’ (England)

‘Delivering for Health’ (Scotland)

‘Fulfilled Lives – Supportive Communities’ (Wales)

Vol. orgs

Self careCarers

The ‘Kaiser’ Pyramid: new relationships between and within occupational groups delivering care.

Responses to challenge: ‘top Responses to challenge: ‘top down’ and ‘bottom up’down’ and ‘bottom up’

Service change and transformationService change and transformation ‘‘Integration’ between health and social careIntegration’ between health and social care

– Wholesale structural change / incremental change by local Wholesale structural change / incremental change by local collaborations?collaborations?

GovernanceGovernance Quality, safety, equal standards, performance management against Quality, safety, equal standards, performance management against

targets targets Impact on the ground?Impact on the ground?

Workforce developmentWorkforce development Registration, mapping of skills to roles, accreditation, provision of Registration, mapping of skills to roles, accreditation, provision of

educational facilitieseducational facilities Roles shaped in negotiation among professional and occupational Roles shaped in negotiation among professional and occupational

groupsgroups

Different ‘integrated’ settings Different ‘integrated’ settings

Three UK health and social care economiesThree UK health and social care economies England: market driven competition. Joint commissioning key mechanism of England: market driven competition. Joint commissioning key mechanism of

integration. integration. Scotland: local co-operation centrally supported and performance managed. Scotland: local co-operation centrally supported and performance managed.

Local Community Health Partnerships key mechanism for integrationLocal Community Health Partnerships key mechanism for integration Wales: the best of both worlds? Local partnerships embedded in Health Wales: the best of both worlds? Local partnerships embedded in Health

Boards with LA representation. Joint commissioning through Health Boards Boards with LA representation. Joint commissioning through Health Boards key mechanism of integration. key mechanism of integration.

Care for older people and people with mental health problemsCare for older people and people with mental health problems Both care groups key social work responsibilityBoth care groups key social work responsibility ‘‘Integration’ of health and social care in sectors between acute and primary Integration’ of health and social care in sectors between acute and primary

health services health services Different policy drivers and guidance -similar (health driven) organizational Different policy drivers and guidance -similar (health driven) organizational

pressures pressures Needs of client groups constructed differentlyNeeds of client groups constructed differently

What models of integrated care emerge in different settings, and what What models of integrated care emerge in different settings, and what are the implications for social care roles? are the implications for social care roles?

‘‘Social care’?Social care’?

the wide range of services designed the wide range of services designed to support people to maintain their to support people to maintain their independence, enable them to play a independence, enable them to play a fuller part in society, protect them in fuller part in society, protect them in vulnerable situations and manage vulnerable situations and manage complex relationships. complex relationships. (Department (Department of Health 2006). of Health 2006).

Policy ideal – implementation?Policy ideal – implementation?

Workforce implications: the evidenceWorkforce implications: the evidence

Existing evidence refers mainly to Existing evidence refers mainly to single staffsingle staff groups within health caregroups within health care

Evidence is lacking about changing relationships Evidence is lacking about changing relationships between between several professions and occupational several professions and occupational groupsgroups in specific contexts.in specific contexts.

What is happening in What is happening in social caresocial care??– What new roles are emerging?What new roles are emerging?

– How are boundaries shiftingHow are boundaries shifting Within social care?Within social care? Between social care and other professions?Between social care and other professions?

– What are the implications for training and support for What are the implications for training and support for social care staff?social care staff?

The studyThe study

1.1. To capture key patterns in (social care) work-roles in To capture key patterns in (social care) work-roles in integrated health and social care services in English, integrated health and social care services in English, Welsh and Scottish settings,Welsh and Scottish settings,

2.2. To investigate local contingent factors which shape To investigate local contingent factors which shape these patterns and compare their constellations in these patterns and compare their constellations in different settings,different settings,

3.3. To identify practical implications in terms of the To identify practical implications in terms of the management, support and training of social care workers management, support and training of social care workers in integrated settings, focussing on English settings. in integrated settings, focussing on English settings.

Three stage mixed methods Three stage mixed methods designdesign

Aim 1: Survey of integrated older people and Aim 1: Survey of integrated older people and mental health teams in England, Scotland and mental health teams in England, Scotland and WalesWales

– Team composition and sizeTeam composition and size– Work patterns and satisfaction in teams.Work patterns and satisfaction in teams.

Aim 2: Eight in-depth case studies.Aim 2: Eight in-depth case studies.– England and Scotland: 2 MH and 2 OP team England and Scotland: 2 MH and 2 OP team – Team members and managers interviewedTeam members and managers interviewed– How different team members and managers talk aboutHow different team members and managers talk about

How roles are defined, how staff understand their own How roles are defined, how staff understand their own and colleagues’ work, what skills are seen as needed, and and colleagues’ work, what skills are seen as needed, and their development, perceptions of support and place their development, perceptions of support and place within organisation.within organisation.

Aim 3: Structured feedback questionnaire and Aim 3: Structured feedback questionnaire and workshop.workshop.

Some findings (mainly) from case Some findings (mainly) from case studiesstudies

Patterns of teamwork and 4 different role types Patterns of teamwork and 4 different role types – 2 ‘Positive types’: coming together2 ‘Positive types’: coming together– 2 negative ‘anti-types’: pulled apart2 negative ‘anti-types’: pulled apart

Learning new skills: Learning new skills: – individual and professionally ‘owned’ skills individual and professionally ‘owned’ skills – governance implicationsgovernance implications

ManagementManagement– supporting the provision of caresupporting the provision of care– supporting the management of provision of care?supporting the management of provision of care?

Implications: balancing ‘top down’ and ‘bottom Implications: balancing ‘top down’ and ‘bottom up’up’

Case study sitesCase study sites

England Scotland

MH OP MH OP

Big CityIndustrial City

Northern city

Rural Town

SeasideCity

Fishing Town

Small citySuburb Town

AnalysisAnalysis What respondents What respondents saidsaid: ‘ideal types’: ‘ideal types’

Themes identifiedThemes identified

All interviews codedAll interviews coded

Themes explored across setting and professionsThemes explored across setting and professions

Analytical constructs from themesAnalytical constructs from themes

Checking hunches:exploring theories across settings, Checking hunches:exploring theories across settings, survey data, feed-back exercise, workshop survey data, feed-back exercise, workshop

Dimensions of roles Dimensions of roles

Health CareSocial Care

Care delivery

Care management

Grey area

XX

X

X

X

X

X

X

X

X

MovementsMovements

Towards ‘grey area’:Towards ‘grey area’:– From division between health and social From division between health and social

carecare

Away from ‘grey area’Away from ‘grey area’– Towards division between ‘care Towards division between ‘care

management’ and ‘care delivery’management’ and ‘care delivery’

4 ‘Ideal types’4 ‘Ideal types’ Model 1: Role blurring and interchanging of tasks: Model 1: Role blurring and interchanging of tasks:

‘‘key worker’ organising and delivering care, drawing key worker’ organising and delivering care, drawing

in team members’ expertise as neededin team members’ expertise as needed ‘‘Health’ vs. ‘social care’Health’ vs. ‘social care’ Mental health teamsMental health teams

Model 2: Collaborating from distinct roles.Model 2: Collaborating from distinct roles. ‘‘key worker’ organises a ‘care package’ which is key worker’ organises a ‘care package’ which is

delivered by other workers. delivered by other workers. ‘‘Care management’ vs. ‘care delivery’ Care management’ vs. ‘care delivery’ Older people’s teamsOlder people’s teams

‘‘Anti’ models:Anti’ models:– Anti model to 1: Individual worker isolation – ‘hanging on Anti model to 1: Individual worker isolation – ‘hanging on

to a case’to a case’– ‘‘Anti’ model to 2: Occupational ‘Siloes’ Anti’ model to 2: Occupational ‘Siloes’

Learning: the gap between skills Learning: the gap between skills and role and role

Moving away from professionally defined roles Moving away from professionally defined roles and skill sets to learning in ‘grey area’ on the and skill sets to learning in ‘grey area’ on the whole seen as up-skilling whole seen as up-skilling

Moving from ‘grey area’ to care management Moving from ‘grey area’ to care management seen as de-skilling seen as de-skilling

Differences among professionsDifferences among professions– Holding on: minority professionsHolding on: minority professions

OTs, PsychologistsOTs, Psychologists

– New roles; interface health and social care.New roles; interface health and social care.

Informal learning in ‘grey area’Informal learning in ‘grey area’

Informal learningInformal learning– “not typically classroom based or highly

structured and control of learning rests in the hands of the learner” (Marsick and Watkins 1990: 12)

Incidental learning Incidental learning – the by-product of some other activity, such as

task accomplishment, interpersonal interaction, sensing the organisational culture, trail-and-error experimentation, or even formal learning.” (Marsick and Watkins 1990: 12)

Talking about learningTalking about learning

Just listening, just seeing what was going on, working with

people and you know going into appointments with them

when they’re in with the doctor and listening to you know,

what they’ve said. And knowing, through experience, that

if they do for a short period of time, take a bit of extra

medication, it will help with whatever’s you know, the

voices, their delusions, whatever, you know the anxiety,

whatever it might be, going on at that moment in time. So

just experience I would think, and reading. But I think just

being part of the team and seeing what goes on and

observing. Scotland Big City Social Work Team Leader.

ROLES and NON-FORMAL LEARNINGHow “talk” about non-formal learning relates to peoples’

understanding of their role in the team and service.

In services where work was distributed amongst roles that were clear, bounded and distinct from one another non-formal learning was not emphasised.

In services were roles were flexible, relatively unbounded and “blurry” non-formal learning was emphasised.

‘Formal’ professional/occupational training a pre-requisite for informal learning

Ways of learning Ways of learning

by serviceby service Older Older

Peoples'Peoples'Mental Mental HealthHealth

Informal, on-Informal, on-the-jobthe-job 66

3333

Professional Professional educationeducation 2121

2727

Specific skills Specific skills trainingtraining

1515 2424

Understanding skillsUnderstanding skills– Model 1: Role blurring and interchanging of tasks (MH Model 1: Role blurring and interchanging of tasks (MH

teams) teams) Skills ‘belong to’ individualsSkills ‘belong to’ individuals Training an individual project Training an individual project Moving from roles where skills are defined by profession or Moving from roles where skills are defined by profession or

occupation seen as up-skillingoccupation seen as up-skilling Innovation, energy and creativity – but governance?Innovation, energy and creativity – but governance?

– Model 2: Collaborating from distinct roles (OP teams) Model 2: Collaborating from distinct roles (OP teams) Skills ‘belong to’ profession or occupational groupSkills ‘belong to’ profession or occupational group Training a professional or organisational projectTraining a professional or organisational project Care management/care delivery distinction seen as Care management/care delivery distinction seen as

deskillingdeskilling Control, regulation and oversight – but innovation and Control, regulation and oversight – but innovation and

energy?energy?

Management and supportManagement and support

Factors working against ‘’integration’Factors working against ‘’integration’

– Protection of professional territoryProtection of professional territory Concerns among ‘minority professions: OTs and Concerns among ‘minority professions: OTs and

psychologistspsychologists Nurses and social workers : varied with context Nurses and social workers : varied with context

– Organisational pressures: targets, budgets, Organisational pressures: targets, budgets, performance managementperformance management

Delayed discharges in older people’s services.Delayed discharges in older people’s services.

The impact of governance The impact of governance requirementsrequirements

Paperwork: the impact of governance Paperwork: the impact of governance requirementsrequirements– ‘‘Paperwork’: Paperwork’:

needed for communication and co-ordination needed for communication and co-ordination – ‘‘bloody paperwork’bloody paperwork’

Separates the doing of care from the accounting for the Separates the doing of care from the accounting for the doing’doing’

‘‘Management’ and alienation: Management’ and alienation: – Care in interaction between workers/users alienated Care in interaction between workers/users alienated

from ‘system’from ‘system’– ‘‘Management’ opaque and unhelpfulManagement’ opaque and unhelpful– Relationships to Relationships to individual managersindividual managers important for important for

satisfactionsatisfaction

Service change and workforce Service change and workforce developmentdevelopment

Training: Training: – Service change and learning – what comes first? Service change and learning – what comes first? – Who directs change?Who directs change?

Governance:Governance:– ‘‘Management’ embedded in governance systems Management’ embedded in governance systems – – Relationships?Relationships?what is the role of ‘the manager?’what is the role of ‘the manager?’

Balance between Balance between – Innovation/regulation Innovation/regulation – Autonomy/oversightAutonomy/oversight