1. A workforce fit for integrated settings: working and learning in integrated teams across the UK. THE SOCIAL CARE WORKFORCE: EVIDENCE FOR CHANGE Project findings showcase, 17 November 2009, Dr. Guro Huby, Dr. Pam Warner, Dr. John Harries and Dr. Eddie Donaghy. University of Edinburgh Professor Peter Huxley, Dr. Sherrill Evans, Dr. Chris Baker, Ms Jo White, Ms Sally Philpin, University of Swansea Wales

2. Modernization of UK NHS and Social Care: new demands on health and social care staff Modernization of UK NHS and Social Care: new demands 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 care Carers The Kaiser Pyramid: new relationships between and within occupational groups delivering care.

3. Responses to challenge: top down and bottom up Service change and transformation Service change and transformation Integration between health and social care Integration between health and social care –Wholesale structural change / incremental change by local collaborations? Governance Governance Quality, safety, equal standards, performance management against targets Quality, safety, equal standards, performance management against targets Impact on the ground? Impact on the ground? Workforce development Workforce development Registration, mapping of skills to roles, accreditation, provision of educational facilities Registration, mapping of skills to roles, accreditation, provision of educational facilities Roles shaped in negotiation among professional and occupational groups Roles shaped in negotiation among professional and occupational groups

4. Different integrated settings Three UK health and social care economies Three UK health and social care economies England: market driven competition. Joint commissioning key mechanism of integration. England: market driven competition. Joint commissioning key mechanism of integration. Scotland: local co-operation centrally supported and performance managed. Local Community Health Partnerships key mechanism for integration Scotland: local co-operation centrally supported and performance managed. Local Community Health Partnerships key mechanism for integration Wales: the best of both worlds? Local partnerships embedded in Health Boards with LA representation. Joint commissioning through Health Boards key mechanism of integration. Wales: the best of both worlds? Local partnerships embedded in Health Boards with LA representation. Joint commissioning through Health Boards key mechanism of integration. Care for older people and people with mental health problems Care for older people and people with mental health problems Both care groups key social work responsibility Both care groups key social work responsibility Integration of health and social care in sectors between acute and primary health services Integration of health and social care in sectors between acute and primary health services Different policy drivers and guidance -similar (health driven) organizational pressures Different policy drivers and guidance -similar (health driven) organizational pressures Needs of client groups constructed differently Needs of client groups constructed differently What models of integrated care emerge in different settings, and what are the implications for social care roles? What models of integrated care emerge in different settings, and what are the implications for social care roles?

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

6. Workforce implications: the evidence Existing evidence refers mainly to single staff groups within health care Existing evidence refers mainly to single staff groups within health care Evidence is lacking about changing relationships between several professions and occupational groups in specific contexts. Evidence is lacking about changing relationships between several professions and occupational groups in specific contexts. What is happening in social care? What is happening in social care? –What new roles are emerging? –How 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 social care staff?

7. The study 1. To capture key patterns in (social care) work-roles in integrated health and social care services in English, Welsh and Scottish settings, 2. To investigate local contingent factors which shape these patterns and compare their constellations in different settings, 3. To identify practical implications in terms of the management, support and training of social care workers in integrated settings, focussing on English settings.

8. Three stage mixed methods design Aim 1: Survey of integrated older people and mental health teams in England, Scotland and Wales Aim 1: Survey of integrated older people and mental health teams in England, Scotland and Wales –Team composition and size –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 –Team members and managers interviewed –How different team members and managers talk about How roles are defined, how staff understand their own and colleagues work, what skills are seen as needed, and their development, perceptions of support and place within organisation. How roles are defined, how staff understand their own and colleagues work, what skills are seen as needed, and their development, perceptions of support and place within organisation. Aim 3: Structured feedback questionnaire and workshop. Aim 3: Structured feedback questionnaire and workshop.

9. Some findings (mainly) from case studies Patterns of teamwork and 4 different role types Patterns of teamwork and 4 different role types –2 Positive types: coming together –2 negative anti-types: pulled apart Learning new skills: Learning new skills: –individual and professionally owned skills –governance implications Management Management – supporting the provision of care – supporting the management of provision of care? Implications: balancing top down and bottom up Implications: balancing top down and bottom up

10. Case study sites EnglandScotland MHOP MHOP Big City Industrial City Northern city Rural Town Seaside City Fishing Town Small citySuburb Town

11. Analysis What respondents said: ideal types What respondents said: ideal types Themes identified Themes identified All interviews coded All interviews coded Themes explored across setting and professions Themes explored across setting and professions Analytical constructs from themes Analytical constructs from themes Checking hunches:exploring theories across settings, survey data, feed-back exercise, workshop Checking hunches:exploring theories across settings, survey data, feed-back exercise, workshop

12. Dimensions of roles Health CareSocial Care Care delivery Care management Grey area X X X X X X X X X X

13. Movements Towards grey area: Towards grey area: –From division between health and social care Away from grey area Away from grey area –Towards division between care management and care delivery

14. 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 in team members expertise as needed key worker organising and delivering care, drawing in team members expertise as needed Health vs. social care Health vs. social care Mental health teams Mental health teams Model 2: Collaborating from distinct roles. Model 2: Collaborating from distinct roles. key worker organises a care package which is delivered by other workers. key worker organises a care package which is delivered by other workers. Care management vs. care delivery Care management vs. care delivery Older peoples teams Older peoples teams Anti models: Anti models: –Anti model to 1: Individual worker isolation – hanging on to a case –Anti model to 2: Occupational Siloes

15. Learning: the gap between skills and role Moving away from professionally defined roles and skill sets to learning in grey area on the whole seen as up-skilling Moving away from professionally defined roles and skill sets to learning in grey area on the whole seen as up-skilling Moving from grey area to care management seen as de-skilling Moving from grey area to care management seen as de-skilling Differences among professions Differences among professions –Holding on: minority professions OTs, Psychologists OTs, Psychologists –New roles; interface health and social care.

16. Informal learning in grey area Informal learning Informal 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)

17. Talking about learning Just listening, just seeing what was going on, working with people and you know going into appointments with them when theyre in with the doctor and listening to you know, what theyve 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 whatevers 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.

18. ROLES and NON-FORMAL LEARNING How 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 by service Older Peoples' Mental Health Informal, on- the-job 6 33 Professional education 21 27 Specific skills training 1524

19. Understanding skills –Model 1: Role blurring and interchanging of tasks (MH teams) Skills belong to individuals Skills belong to individuals Training an individual project Training an individual project Moving from roles where skills are defined by profession or occupation seen as up-skilling Moving from roles where skills are defined by profession or occupation seen as up-skilling Innovation, energy and creativity – but governance? Innovation, energy and creativity – but governance? –Model 2: Collaborating from distinct roles (OP teams) Skills belong to profession or occupational group Skills belong to profession or occupational group Training a professional or organisational project Training a professional or organisational project Care management/care delivery distinction seen as deskilling Care management/care delivery distinction seen as deskilling Control, regulation and oversight – but innovation and energy? Control, regulation and oversight – but innovation and energy?

20. Management and support Factors working against integration Factors working against integration –Protection of professional territory Concerns among minority professions: OTs and psychologists Concerns among minority professions: OTs and psychologists Nurses and social workers : varied with context Nurses and social workers : varied with context –Organisational pressures: targets, budgets, performance management Delayed discharges in older peoples services. Delayed discharges in older peoples services.

21. The impact of governance requirements Paperwork: the impact of governance requirements Paperwork: the impact of governance requirements –Paperwork: needed for communication and co-ordination needed for communication and co-ordination –bloody paperwork Separates the doing of care from the accounting for the doing Separates the doing of care from the accounting for the doing Management and alienation: Management and alienation: –Care in interaction between workers/users alienated from system –Management opaque and unhelpful –Relationships to individual managers important for satisfaction

22. Service change and workforce development Training: Training: –Service change and learning – what comes first? –Who directs change? Governance: Governance: –Management embedded in governance systems – Relationships? what is the role of the manager? Balance between Balance between –Innovation/regulation –Autonomy/oversight