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Transforming Care in Bristol

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This is the story of how Bristol City Council is changing its approach to delivering care to vulnerable people.

Presented by Amy McGuinness of cxpartners alongside Tracy Dodds and Sonia Moore of Bristol City Council at Service Design in Government 2016.

Published in: Government & Nonprofit

Transforming Care in Bristol

  1. 1. Transforming care services in Bristol
  2. 2. 2 189m 106m 40m c. Diminishing LA budgets Life expectancy Connectivity 6% above the national average 6% Care Act Better Care New legislation Partnership working group 65% 35% Adult social care cost 
 35% of BCC total budget spend Care Direct Increase calls to care direct 50% 2011/12 2015/16 2019/20 Funding split central vs local gov Increasing Tracy Dodds, Digital Services Manager talked through BCC’s service change programme Why are we doing all this service redesign? Diminishing budgets from central Gov alongside an increased demand for services such as Care and higher expectations from citizens about how they engage with BCC has led to a complete rethink about how we shape and deliver services.
  3. 3. Bristol’s vision for a Citizen Platform “Give me the information I need to help me deal with events in my life” “Enable me to apply, report and pay for things online 24/7/365” “Remember me and relate to me intelligently as a single organisation” “Let me progress openly online” “Give me the tools that enable me to assess my own needs” “Let me tell you what services are performing well and how they can be improved” “Connect me to people who have similar needs and engage with us to help 
 re-design services” This is our journey. Starting with making sure people can access information and guidance wherever they are and building our capabilities service by service, working towards a truly digital platform where people can assess their own needs and connect to others with similar needs. 
 BCC is trying to remove the silos so that the citizens of Bristol can engage with us as one council.
  4. 4. Improved IAG on new website Digital services Citizens account Waste tracking Homelessness self assessment Feedback online User centred design approach Bristol’s vision for a Citizen Platform We’ve made the greatest progress on simplifying our info and guidance on the new website as well as delivering a whole range of end to end services. We’ve also delivered some basic assessment tools around rehoming and homelessness and have plans to build on these in the future. Now our focus is on delivering a citizen account. All of these changes have been driven by user need.
  5. 5. January 2015 Residents Parking Concessionary Travel Complaints Registra7ons March 2015 Taxi Licencing June 2015 Response Repairs Pest Control September 2015 Local Tax Moving Home Waste Cancel a Job New Web Site Housing Bens Evidence Upload New end to end digital services
 delivered 2015 We’ve delivered more than 10 digital services delivered in as many months focussing initially on those services used by most by residents (parking) and then looking at services needed by more specific groups such as older people, taxi drivers, tenants, benefits claimants and so on. 
 We’ve involved real people, built reusable digital patterns and plan to build even 
 further on what we’ve learnt so far in 2016.
  6. 6. June 2016 Further Ci*zen A/C work Residents Parking Verifica*on Concessionary Travel Verifica*on Cohort 4 – Internal Support Processes Sept 2016 Landlord A/C January 2017 January 2016 Repairs – communal jobs Local Tax A/C Transac*on Rent A/C Transac*on Benefits A/C Transac*on Waste forms Local Tax – General Form, Student Discounts Mayoral Correspondence Evidence upload Cohort 4 – Internal support processes March 2016 Loca*on Based Repor*ng C/A Further Transac*ons Govtech – automa*on Local Tax Enforcement Repor*ng Online Feedback Cohort 3 – IAG, Self assessment Cohort 4 – Internal Support Processes End to end digital service pipeline 
 planned for delivery Jan ’16 – Mar ‘17 Our ambition for 2016 Many more digital services – reusing and exploiting what real people have told us so far, reusing the lego bricks to expand our digital offer. A focus on a citizen account which will allow people to log in and see all of their services in one place.
  7. 7. Context Our role is to put customers at the centre of the design Designing digital services so good people prefer to use them Whether we are rewriting a piece of website content or rebuilding a digital transaction we ask Who is the user here? What do they want to find out or do? How can we best meet their needs and what might get in the way? We then solve it and check back – does that work? Did we get it right?
  8. 8. We’ve been inspired by GDS, and have followed several of their guiding principles Bristol City Councils digital design principles Feb 2014 Look for ways to delight people Use familiar patterns Create accessible services Don’t just design a pretty front door Measure and improve Free data from its silos Look for relationships Strive for consistency and efficiency Create simple, clear experiences Digital services so good people 
 prefer to use them
  9. 9. The new Agile The old Waterfall We’ve significantly changed our approach to projects and delivery. The Old Waterfall - gathering requirements, a long time building specifications with the risk that the end result wasn’t quite right. 
 The new Agile - getting user feedback upfront and building minimal viable services then getting them out there and improving them based on feedback.
  10. 10. Developing a clearer picture service by service
 by sharing and building on insights January 2015 Residents Parking Concessionary Travel Complaints Registra7ons March 2015 Taxi Licencing June 2015 Response Repairs Pest Control September 2015 Local Tax Moving Home Waste Cancel a Job New Web Site Housing Bens Evidence Upload = It hasn’t been an easy ride BUT… We are seeing a benefit to our approach. The more we learn from our user engagement the more patterns we spot and the more we can draw and learn from the things we have done so far. Building up a picture of the Citizens of Bristol and their needs.
  11. 11. Infrequent engagement Low need High propensity to self-serve Frequent engagement High need Low propensity to self-serve ‘Universal citizen’ ‘Group 1’ ‘Stable’ ‘Precarious’ Universal 
 citizen Higher 
 need Higher needs describes citizens with a tendency 
 towards higher engagement, complex needs and multiple service use One council, 
 differing levels of engagement It helps when we visualise who we are dealing with on a scale of need and vulnerability. 
 This came out of a piece of research with benefits customers and homelessness. We found out that people moved up and down this scale (they wanted to be stable and in control of their lives, didn’t necessarily trust the council to get things right but wanted to use digital services to save themselves time and money)
  12. 12. Martha is a mixed-race woman, 45 years old and with physical and cognitive disabilities. She has a daughter, who lives with her on and off. He life is intricately entwined with BCC: housing benefit, council tax, concessionary travel, and previous experience of Home Choice and homelessness. She lives in social housing and works as a receptionist. Martha has lived just above the breadline for years, and is regularly in and out of debt to payday lenders. Her attitude to BCC arrears is both fearful and resigned - it’s happened before and it’ll happen again. She is quick to admit that she makes bad choices, particularly when in a panic, but feels that the council could do more to understand her circumstances. At the same time, she feels that she knows a few workarounds - helpful individuals, ways to get attention - although she doesn’t like having to do it. ‘I don’t want to be that angry person’, she says, of turning up at the CSP and making a fuss. At the same time, she’s found that it’s worked in the past. Anything that happens to Martha has a knock on effect on her other services: a missed Housing Benefit payment uses up her council tax money, which means she has nothing for food. She can’t understand why different departments don’t communicate with each other ‘it’s just the council owning the council money, at the end of the day’. At its worst, letters from BCC just get thrown in the bin - she panics, and buries her head in the sand * All citizen stories are composites based on several interviews. Real names have not been used. Citizen story: Martha * “I don’t want to have to be that angry person” ‘Stable’ ‘Precarious’ We also found the concept of a compound profile really helpful. Here we have collated the features and views from a range of individuals into a single profile which we have used as a persona against which we can build a service (both digital and non digital).
  13. 13. 1313 Redefining 
 Adult Care Services So that was all going swimmingly and then we turned our attention to services in adult social care. Bristol had completed some immediate and important work to ensure we had responded to our duties of the care act by April 2015 but we knew we needed to look beyond that.
  14. 14. Test and refine the three tier model Help to Help yourself Accessible, friendly, quick, information, advice, advocacy, 
 universal services to the whole community, prevention Help when you need it Immediate short term help, reablement, intensive support to regain independence, minimal delays, no presumption about long-term support, goal focussed, integrated Help to live your life Self directed, personal budget based, 
 choice and control, highly individualised Safeguarding Rightskills,rightpeople Promoting wellbeing Early help and prevention, enabling people to live more independently 
 for longer Directing people to 
 lower cost options 
 and solutions Delaying or avoiding 
 the needs for more intensive, 
 higher cost care and support The team wanted to test Bristol’s version of the three tier model of care and support. 
 A major concern: how do we do all of that? Would our Bristol approach (which was 
 quite a well oiled machine for some fairly transactional services) really work here? These are potentially quite vulnerable people with a complex set of needs.
  15. 15. How do we find people who are seldom heard and will they want to get involved? How should we engage these service users (will our current practices / process work?) There is so much to find out and fix – We don’t want to boil the ocean Will they worry that we will take the opportunity to cut their entitlements or support ? Is using partners who are not subject matter experts a good idea? Can we do this in project time scales and how do we optimise use of limited budget? Initial concerns We were convinced by our user centered, agile approach – it has worked so far BUT… There were concerns about whether it would work for something as complex and sensitive as Care Services.
  16. 16. Amy from cxpartners talks about how the approach was tailored cxpartners have been working with Bristol City Council throughout their change programme supporting them to become a people led organisation who do user centred service design. 
 This picture was taken from a customer vision workshop back in 2013.
  17. 17. We worked to deliver a number of services using a people led approach. This means gathering insights about what services are currently like and then finding out how people would like them to be in the future. We had a established process that had been used across parking, council tax, waste…
  18. 18. ?Care Services We knew that this approach had worked well for these other services but when it came to care there were concerns about whether it would be appropriate to work in this way and the Better care team had some concerns. So we needed to tailor our approach.
  19. 19. We don’t want to risk upsetting a vulnerable group of people
  20. 20. Organisation Customers Promise Value Feedback live|work This is a promise value diagram. An organisation gives a promise to it’s customers and in return the customer gives that organisation value .The whole thing is underpinned by a feedback loop. In this case Bristol city council offer a promise of care to it’s citizens and the citizens provide value in the form of taxes.
  21. 21. Organisation Customers Promise Value live|work But if we don’t have a feedback loop then we don’t know how effectively the promise is being delivered or even if it’s the right one. ?
  22. 22. Organisation Customers Promise live|work And if we don’t know that the promise is right then we risk disrupting the value.
  23. 23. 65% 35% Total BCC budget spend on Adult Social Care which is spent on less 
 than 10% of Bristol’s population. 35% It’s important that we understand the needs of people who are cared for and carers in order to decide how we can make services fairer in the future. So although there was a concern about involving a vulnerable group of people we knew it was vital to do so. We were mindful of this when we went about recruiting who we were going to speak to and how we would structure the research.
  24. 24. How do we avoid hearing the same things from the same people?
  25. 25. There were worries that only the same or loudest voices would be heard. We needed to objectify what was being heard at support groups to see whether these views represented those people who don’t normally have a voice. 
 We needed to distill the truth of people’s experience.
  26. 26. How do we avoid boiling the ocean? There’s too much to find out
  27. 27. 18 yrs + When we talk about Adult Care Services typically this is delivered to people over 18yrs +. That covers quite a large group of people with differing needs. 
 We didn’t want to risk diluting what we uncovered by trying to cover everything.
  28. 28. 55 yrs + We narrowed the lens by focusing where there was the highest demand (the older population). We decided to talk to Service users over 55 and Carers who look after people who are over 55.
  29. 29. Infrequent engagement Low need High propensity to self-serve Frequent engagement High need Low propensity to self-serve ‘Universal citizen’ ‘Group 1’ ‘Stable’ ‘Precarious’ Universal 
 citizen Higher need Scale of vulnerability We needed to make sure we were representing a broad spectrum of people. Both those who are considered to be nearer the stable end of the scale - someone who has MS, people who have had a stroke, People with early stage Dementia as well as those at the other end of the scale who might be experiencing all these things coupled with a disability, mental health issues or alcohol and drug issues. Within in the carers group we made sure we spoke to younger carers (people in their 30’s) right up to older carers (people in their 70’s).
  30. 30. How do we find people who are seldom heard and will they want to 
 get involved?
  31. 31. Because of the nature of the research we recruited through social workers and community organisations. We took a lot of time to find the right people and make sure they were both happy to talk to us and aware that we were NOT reviewing their care package.
  32. 32. Is using partners who 
 are not subject matter experts a good idea? Shouldn’t we do it ourselves?
  33. 33. We don’t need to be 
 subject experts we just need 
 to be able to ask the right 
 questions, listen and feedback 
 to the right people We involved the whole team in creating the discussion guide so we knew we were asking the right questions. Being from outside the adult social care team allowed us to assess what we were hearing without bias and feed back the truth of peoples experience.
  34. 34. The research consisted of one-to-one sessions. No surveys, no shallow views but a deep dive into how people felt. We carried out sessions both in our offices and peoples homes. The wider team were able to view these sessions which was invaluable in helping them understand peoples stories.
  35. 35. NowRecent experience The future Our discussions were based around 3 areas. • What life is like now for people • A recent experience involving a review of their care or change in situation • And peoples thoughts and feelings on Bristol City Councils ideas for the future and the three tier model of support and care which looked at independence, well being and choice.
  36. 36. The structure of the sessions were printed out to make it transparent to participants what we are going to ask them. There were no secrets and no surprises. We used a talk and draw approach so we could share what people said with them and check that we had got it right.
  37. 37. We began to group what we were hearing into themes and then plotted this onto experience maps for both carers and service users.
 During the research sessions post it notes were annotated by the whole team (including social workers, people from public health and service managers.)
  38. 38. Service User Carer A difference in experience for service users and carers
 For service users they was an over whelming feeling of passiveness. Many could not remember how their care had been arranged or who by. Carers were at the other end of the scale - bombarded with appointments, people they had to liaise with and decisions they felt ill equipped to make on behalf of their loved ones. It was highly stressful, overwhelming and disjointed experience.
  39. 39. Lesley John CARE PATHWAY The importance of taking a 360. view
 If we’d of only talked to service providers, or just service users or just carers we would’t have got the full picture of what was happening. We may have misinterpreted key pieces of information. In the example of someone who experiences Bipolar, their carers are often key in supporting their independence and well being and the carers needs have to be recognised so that they can keep providing this vital role.
  40. 40. We grouped people with the same needs together and created compound profiles to tell their stories. Compound profiles allowed us to reframe the problem. To tell the rich narratives of peoples experiences whilst protecting peoples identity and removing the biases that might come from using real cases.
  41. 41. Here’s an example of a compound profile for John. He has been caring for his wife Lesley who has Bipolar for the past 50 years.
  42. 42. Service usersCarers We had to make sure we had captured the nuances of peoples needs, so that we could appropriately stress test any ideas for Care Services in the future. From someone like Sarah who wanted to be actively involved in the planning of their care to someone like Bill who had been in care his whole life and was terrified by words such as Independence and choice.
  43. 43. Organisation Customers Promise Value Feedback live|work What we heard It’s a very complex and disjointed experience. People are not sure who they should go to for what. It was hard to distinguish who is from where e.g NHS, voluntary, Council and people didn’t understand why they had to repeat their story all the time.
  44. 44. Organisation Customers Promise Value Feedback live|work With such a complex system of services working together there is the opportunity for things to get lost in translation. If people weren't sign posted to the right services and support at the start of their journey it could lead to an escalating series of events which meant they were more dependent on care services than they needed to be.
  45. 45. Co-design workshop We used the experience maps and compound profiles in a co-design workshop with the Better care team (a multidisciplinary team including front line workers, partners and service delivery teams). We asked teams to use the profiles to plot out the services and people they engaged with, their questions and pain points.
  46. 46. Rewriting 
 people’s stories We then asked the teams to imagine they had no budget or infrastructure constraints and think about how they would improve each of the compound profiles stories. This allowed them to remove themselves from the day to day and imagine what could be in the future. It was really exciting to see people from different disciplines working together to think how they could improve peoples lives.

  47. 47. 47 Sonia Moore, Care act lead from BCC talks through the value of involving carers and service users from the beginning 
 This process was really valuable for us and was the cause of several ‘eureka’ moments although there were some hard messages for us to hear.
  48. 48. How complex? This is one of the two final ‘maps’ that cxpartners produced for us. There is a lot of information on there. But what this shows us very clearly is quite how complex the customer journey is for people who access social care services. Being able to see it mapped out like this really hit home in a way that we wouldn’t have experienced without seeing it in this format.
  49. 49. There were some key themes that emerged from the compound profiles.
 
 The health and social care system is very complex. Even those of us who work in it don’t always know our way round the whole thing – we know our specialist areas and the ones that touch them. If we find it complex imagine how convoluted it is for the public. Key messages Being informed 
 & guided through options Holistic assessments for carer & cared for Having a single 
 point of contact Transparency about what’s happening Make me feel like I matter - familiarity to 
 my old life Keeping the person I care 
 for happy Consistency; Choice; Control; Trust Carers: being able to self-refer; time for me Receiving information at the right time
  50. 50. The key messages that we need to embed are all about how we communicate with our citizens. People need to know their options, and be supported through them. People need to know exactly what’s going on – if there’s something we can’t do we need to be upfront about that. And people need to feel that they are in control of their own lives – the way to do this is by giving people consistent messages, that they can trust and use to inform their own choices.Key messages Being informed 
 & guided through options Holistic assessments for carer & cared for Having a single 
 point of contact Transparency about what’s happening Make me feel like I matter - familiarity to 
 my old life Keeping the person I care 
 for happy Consistency; Choice; Control; Trust Carers: being able to self-refer; time for me Receiving information at the right time
  51. 51. Help to Help yourself Help when you need it Help to live your life Safeguarding Rightskills,rightpeople Promoting wellbeing Early help and prevention, enabling people to live more independently 
 for longer Directing people to 
 lower cost options 
 and solutions Delaying or avoiding 
 the needs for more intensive, higher cost 
 care and support The three tier model of care and support
 The Care Act has given us the biggest change to social work practice in 30 years. The focus on wellbeing and prevention underpins everything that we need to do differently, while balancing reducing resources and increasing demand. We need to change from social care as an assessment factory, to social care as an enabler of solutions. 
  52. 52. Self Assessment Carers Pathway Information, Advice and Guidance Reviews Pathway Direct Payments Prison Pathway Care act / Children and Families Act Charging Policy Safeguarding Pathway Market Shaping and Commissioning Culture change LAS / ContrOCC Development Discharge to Asess First Contact Resource Allocation System We have a range of projects that we are working on in order to deliver this wholescale change to how we deliver Social Care for Adults in Bristol. Each of these are important, but allow us to highlight the foundation projects.   All of these projects are part of the bigger national picture, considering things like the Integration agenda under Better Care Bristol.
  53. 53. Self Assessment Carers Pathway Information, Advice and Guidance Reviews Pathway Direct Payments Prison Pathway Care act / Children and Families Act Charging Policy Safeguarding Pathway Market Shaping and Commissioning Culture change LAS / ContrOCC Development Discharge to Asess First Contact Resource Allocation System 3 critical areas to focus on Self Assessment Tools to help people assess their own needs. Information and Guidance Enabling people to find their own solutions through effective and timely IAG.
 Culture Change Fundamentally changing the culture within our front line practitioners so that they can have very different conversations with people.
 Key challenges for us are: • Transforming 30 years of social work practice. • Heading back to basics of social work training. • Managing expectations of current and future users of services.
  54. 54. Photo courtesy of LinkAge Bristol We have some really valuable insight that we are actively using to inform the most fundamental change to Social Care for Adults in decades, with a vision for the future that works towards supporting our most vulnerable citizens and ultimately not just changing services but improving people’s lives. We’ve been doing things better for a while and now its time to start doing Better things.
  55. 55. 55 Tracy Dodds Service Manager 
 Bristol City Council Sonia Moore Care Act Project Manager
 Bristol City Council Amy McGuinness Senior UX Consultant cxpartners

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