ETAPA II: ESTUDIO DE ALTERNATIVAS

CATWOE was applied to the different organisations involved in order to ensure that their subsystems of the whole system of care were considered in their entirety, from multiple worldviews. The root definitions are built from this CATWOE Table (Table 4), which considers the overall focus of each organisation/service. Reablement and care both currently fall under the remit of Social Services in Conwy.

Table 4: CATWOE for organisations involved

CATWOE Health Social Services RSL Wardens Clients People who

are ill

People who are assessed as having a

substantial/critic al need for care

Tenants His/her wards or charges Actors Hospital, Health Boards, GPs, District Nurses Social workers, care providers, carers, councillors, clients Board of Directors, staff, Local Authority Tenants, RSL Transformation Good health/no need for healthcare Independence- client given the care necessary to continue living at home Quality homes, good communities Independence- client given the support necessary to continue living at home

Worldview People get ill and they need to be fixed for discharge It is best for people to maintain independence as long as possible Affordable, long-term homes for people with low incomes

It is best for people to maintain

independence for as long as possible in their own home

Owners Central and devolved governments

Local Authority Self RSL

Environment NHS, austerity, Social Services integration Austerity, care provider guidelines, Personalisation agenda, Health integration Social value, austerity, Government (policy and funding) Supporting People funding, EU working time directives, austerity

122 The development of Table 4 highlighted two main issues. Firstly, Health's worldview is short-term and thus has a specific, quantifiable end date i.e. when the patient is discharged. Whereas the other three have long-term worldviews as they are community-based services, distinguishing Health from the rest of the system. It is difficult to measure the impact of preventative, community based services, as it is not possible to say what would have happened without this intervention. Health commonly has established links to community-based services through Social Services and reablement; in Conwy there are multiple joint Health and Social Care buildings to encourage integration. However, Health does not commonly deal with Housing as an entity in Conwy. This is despite the fact that unsuitable housing can be a barrier to discharge, causing an average delay of 27 days and costing an average of £11.2 million a year in England alone (Age UK, 2014; NHS England, 2014).

Secondly, there are numerous similarities between Social Services and wardens in terms of the CATWOE. Their transformations are extremely similar, both focused on maintaining independence in the home, with Social Services using care and wardens, support. Currently, wardens only provide this service to tenants. However, with changes to Supporting People funding, this will no longer be the case in the future and 'clients' will be a more appropriate word to describe the users of support. Therefore, the only significant difference between the transformations is the level of help that they provide. Social Services' and wardens' worldviews are also extremely similar, both focusing on independence. However, the wardens currently have the boundary formed by the specific type of housing. Whilst care provided by Social Services can follow the client to a new home, support provided by a warden cannot. Again, this will change due to the changes in Supporting People funding, further increasing the level of similarity between the two services.

Taking this information into account, the focus of the discussion then shifted from the transformation of housing not being integrated into the whole system of care, to housing being integrated. Root definitions and purposeful activity models were developed by the researcher for this transformation, based on numerous worldviews, following the method described earlier in this chapter. Within the boundary of the models there are the operational activities required to make the transformation;

123 outside of the boundary are the monitoring activities defined to ensure that the transformation is effective (Checkland and Poulter, 2006:48). These were used as 'sense-making tools' by the researcher, in order to improve her understanding of the whole system of care and develop discussion within the Steering Group meetings. It was found that the different organisations involved in the integration would all benefit from it, but in different ways. For example, integration would enable Housing to better support their tenants, reducing the possibility that their health would deteriorate to the point that they would have to move into a care home. For Social Services, integration would enable Housing to fill the gap left by tightened Social Services funding, by providing support to people who are not eligible for care under the new criteria. For Health, opening up the lines of communication with housing providers would enable improved flow of older people from hospital discharge to their homes, reducing bed blocking. Figures 10 and 11 (pages 124 and 125) illustrate the differences when integrating from the perspective of Health and Social Services. Consistently across all purposeful activity models was the issue of how to integrate. The rich picture highlighted three feasible integrating functions based on the identification of services that visit the client in the home, namely: support, reablement and carers. Each of these options was examined against the multiple purposeful activity models to see if any raised issues, or fit particularly well.

Using carers as the integrating function created an issue for Social Services, as their Unified Assessment dictates that they are only able to tender for the care of people with substantial or critical care needs following cuts to funding. This means that anyone who is assessed as having low to moderate care needs will not be provided with a social care package. Social Services was clear in its view that the benefit of integrating Housing would be that housing related support could pick up these clients with lower level needs, in order to stop their health from deteriorating further, as demonstrated by Social Service's root definition. However, this benefit could not be achieved if carers were responsible for integration, as they only visit people with high level care needs. There is also the issue that care is outsourced and Social Services do not have the power over the multiple care agencies that they work with to ensure that each individual carer is working to close the gap between Health, Social Services and Housing.

124 Root Definition for Health

A system that reduces bed blocking in hospitals, by enabling older people to heal in their own homes, through integration wit h housing, in order to improve efficiency.

CATWOE

C – patients of health A – steering group

T – housing not integrated with whole system -> housing integrated W- integration would reduce bed blocking

O – health, social care and housing

E- budget cuts and the ageing population resulting in pressure on health to move people on Purposeful Activity Model

Reduce bedblocking in hospitals Home made appropriate Heath inform housing of needs Relate to Analysis 1,2, 3 Identify integration models Monitor and review- reducing bedblocking? Integrate Signpost preventative services

Monitor and review- higher uptake of

preventative services?

125

Figure 11: Purposeful Activity Model from Social Care's perspective

Root Definition for Social Care

A system that improves preventative services, through integration with housing, by spotting deterioration in the home early and addressing it by signposting existing services

CATWOE

C – clients with low to moderate health needs (not met by SS) A – steering group

T – housing not integrated with whole system -> housing integrated W- integration would pick up clients not eligible for social care O – health, social care and housing

E- budget cuts have led to a reduction in preventative services, must have critical or substantial needs to receive care

Purposeful Activity Model

Improve preventative services Housing offer support

Refer those with low level needs to

new service Relate to Analysis 1,2, 3 Identify integration models Monitor and review- support more people? Integrate Signpost preventative services

Monitor and review- higher uptake of

preventative services?

126 Reablement is a potential integrating function as it is provided in the home over a period of time, enabling relationships to be developed. The reablement team in Conwy is already multidisciplinary, comprising of employees from both Health and Social Services. Currently, it is a highly specialised, skilled team responsible for re- abling, or re-teaching, the client to do daily tasks on their own following deterioration in health or recovery. This service lasts for a six week period so it is short term intervention. This team could be given responsibility to inform the client of other services available to them in the local area, and liaise with Housing and support following the period of reablement. It has been suggested that closer working between housing providers and reablement could improve the impact of reablement, by using ‘light touch’ support to continue the work of the reablement team following the short-term intervention (Wood and Salter, 2012). However, on closer inspection, reablement was a newly evolving service in Conwy and was not yet a functioning service in all areas of the county. This meant that it was not possible to get access to shape the service, due to the strict implementation guidelines that had already been established in the pilot phase. Although reablement was not deemed to be a viable integrating function in Conwy, it should not be disregarded in counties with a well established reablement team, who are looking to develop the service further.

The Social Services representative highlighted that changes to the support service would help them to fill the gap left by cuts to Social Services funding. The representatives from the RSLs felt that the support role was at risk due to reductions in funding, so were keen to add value to the service. Therefore, the group decided that support, provided by wardens, was the most appropriate integrating function. The root definition for this system is to integrate Housing into the whole system of care, using support, in order to improve access to the system, and communication within it, for older people. The CATWOE and purposeful activity model is included in Figure 12 (page 127).

127 Root Definition for Steering Group

Integrate Housing into the whole system of care, using support, in order to improve access to the system, and communication within it, for older people.

CATWOE C – clients

A – steering group

T – housing not integrated with whole system -> housing integrated

W- integration is necessary in order to improve access to the whole system of care and communication within it O – health, social care and housing

E- changes to SP funding mean support must be needs-based Purposeful Activity Model

Develop options for structure of integration RSLs monitor internally Establish subgroup to implement Cabinet approve OPHS Write model into OPHS Steering group choose appropriate model Steering group to monitor subgroups against action plan Compare

against current system

Consult with older people

128 The ‘Finding Out’ section of this SSM study highlighted that one of the main issues with the whole system of care was its complexity, resulting in difficulties accessing the system, especially when a person is in crisis. The Steering Group's discussion about potential integrating functions emphasised that access into the whole system of care is a significant issue that the integrating function should aim to address. There are multiple points of entry into the whole system of care for older people. When comparing this concept to the real world, it is clear that this is causing problems for Health, with current media attention on unacceptable Accident and Emergency (A&E) waiting times, caused by an increase in admissions (BBC News, 2015; NHS Wales Informatics Services, 2015). This increase in admissions can be partially attributed to the fact that the care system is fragmented and confusing, leading to people making the wrong decisions such as going to A&E for minor issues. A benefit of using support, as an integrating function for housing, is that support workers could help control entry into the whole system of care by providing advice and guidance to clients, helping them to make the right decisions.

The issue then arose of who should own the support function if these extra pressures were to be placed on support workers. Currently, support is owned by the RSL's, all of whom operate slightly differently in terms of their services. For support to bring housing into the whole system of care, closer ties with Health and Social Services are essential, in order to ensure that the wardens have access to the information they require to effectively signpost other services within the whole system of care.