RIESGOS DEL PROYECTO HACIA EL AMBIENTE

3.5.1 Service provider staff17

People’s descriptions of the staff with whom they had contact were generally very positive. They described staff members’ interpersonal skills in very favourable terms, seeing them as ‘friendly’, ‘courteous’, and ‘charming’. They were impressed by how engaged staff were with them, how they listened, were sympathetic and caring, seemed genuinely interested in them as an individual, and did not judge or criticise them. They described staff showing concern for people’s health, through regularly asking how they were or actions such as rearranging furniture to meet clients’ needs. Although there were exceptions, people also talked about not feeling under pressure from staff to return to work. Simply finding someone who did not question whether they were ill or imply that they were malingering, and who engaged wholeheartedly with them, could be an enormous boost to people. For some it contrasted very sharply with the treatment they had received from employers and health care professionals.

17_{Research participants did not generally know whether the people they saw were}

employed by the provider organisation or worked in another capacity, and the term ‘staff’ is used here to refer to both employees and contractors.

There was also praise for the professional skills of those with whom they had contact. People were impressed with the detailed knowledge that staff members sometimes showed of particular conditions, the skill with which they provided particular therapies, and the time and commitment they gave. There were positive comments about people’s skills in organising, liaising and persuading, and about the appropriateness of the advice they gave. Again, there were exceptions here where people felt a staff member did not seem experienced, for example, in liaising with employers, where communication did not go smoothly, and where contact was not sustained (see Section 3.5.4).

3.5.2 Premises and accessibility

There were many positive comments about providers’ premises and the atmosphere people found. People responded positively where they thought attention had been paid to the impression that surroundings created, and there were positive comparisons with NHS premises. They also valued a warm welcome from other members of staff, and a friendly and relaxed environment. Some premises were described as cramped, and an office was seen by one person as not the right environment for therapy sessions. Some people faced long journeys to the premises, and bus journeys of over two hours were described which could be demanding on people with limited energy and, for example, back pain. It was generally appreciated where taxis were provided, or in a case where the client was visited at home. Overall, however, access had worked smoothly.

3.5.3 Pace

The speed at which different types of help were arranged, either following on from the initial assessment or in responding to circumstances as they changed, could be very impressive to people. One person, for example, was very pleased to be given physiotherapy at the first meeting with the provider. This speed contrasted sharply with long waits for NHS services. However, there were also examples where progress was slower. It could also be too rapid. One woman found the assessment traumatic and draining, particularly when she had to complete several questionnaires, including a mental health assessment she found particularly painful. She felt rushed and ‘railroaded’ when she was offered an appointment with a professional for the next day and appointments made with other professionals in the following fortnight, and decided to withdraw from the service.

People were generally happy with the pace at which services were delivered, in terms of the frequency of sessions. There were cases where people found a service too intense, such as twice-weekly sessions of cognitive behavioural therapy, or weekly contact from the case manager at a time when they felt their situation was simply not changing. Equally, some people would have liked more intensive help, such as where there several weeks between appointments for different therapies. It was important to people to know in advance that a particular type of treatment was coming to an end.

3.5.4 Communication and contact

As noted in Section 3.3.6, people placed a high value on regular contact from their case manager. Communication between provider staff and clients was generally seen as good although, as described below, clients were reliant on case managers to sustain contact and this did not always happen. There were some individual difficulties, for example, when a client was not told that a session of physiotherapy had been arranged. A more recurrent difficulty was where suggestions or plans for other types of help did not appear to be followed up with the client and such help did not materialise. The way in which provider staff communicated with employers and GPs was also generally seen as helpful. It was important to people to be kept informed, to know who was communicating what to whom, and that communication happened as they were expecting. There were again individual cases where people were not happy with this aspect of the service, where information had been passed on without them expecting this, or had not been passed on where they had wanted it to be.

There were also instances where it appeared that the client had not told their case manager about a change in circumstances, such as new health problems, new dissatisfaction with NHS services, or a worsening relationship with an employer. It was not always clear why they had not told the case manager about this, but uncertainty about what the services provide appeared to be relevant. People sometimes also described being asked specific questions by the case manager, such as how physiotherapy was going, which may not have provided the prompt for new information.

The picture that emerged was generally one of clients expecting provider staff to lead on communication with them. There were exceptions to this, where people saw it as their responsibility to keep in contact with their case manager. But on the whole, people described provider staff as having initiated each contact. This worked well where provider staff were in touch regularly, but where they were not it meant that contact could dwindle and cease without this being what the client wanted, and without the client themselves taking steps to resurrect contact. When people cancelled or missed an appointment they did not always get in touch to make the next one, assuming that the provider staff would contact them. Although people were not concerned about this loss of contact if they did not want any further help, they were less happy if they did.

In cases where people looked to the provider to sustain contact but where communication appeared to have fallen away, they could be left somewhat in limbo. Some people were waiting to hear from their provider and did not appear to be taking responsibility themselves for progressing health care or contact with the workplace, assuming there would be further contact in due course.

It was not always easy for people to explain why they had not been in touch themselves and they sometimes expressed themselves apologetically, vaguely or somewhat defensively in talking about it. But some possible explanations emerged.

Where there was a lot of other change or activity in someone’s life, for example, a lot of health care appointments, contact with an employer or a review of Incapacity Benefit (IB) entitlement, it could be hard for them to find the time or energy to contact the provider too. Some people simply felt too ill to be in contact or to use the services. Feeling very depressed or down could also make people reluctant to get in touch. One man, for example, telephoned the service when he had not heard from them for some time but felt too disheartened to talk when the telephone was answered and hung up. Someone who had no follow-up contact after the assessment said they were reluctant to get in touch in case it got a member of staff into trouble. If people had not been impressed by the help they had so far received, there could be a lack of confidence that getting in touch would lead to something useful. The patchy knowledge of the services and what they could provide also appeared to be relevant. Where contact had dwindled people sometimes found it difficult to know what help the service might be able to provide. It appeared that not being able to place their own needs within a wider framework of the help available made it difficult for them to see the value of getting in touch.

It also seemed to be easy for people to assume that they were not seen as a priority by the provider staff, or that staff had lost interest in them, particularly where people sensed that the services were busy and pressed. This was the assumption, for example, of someone who felt they faced particularly significant barriers and ‘would be a hard case’. One man felt he was not a priority because he had lost his job; another, perhaps more surprisingly, assumed he was not seen as a critical case because he still had a job to return to. Where people were told to get in touch when they felt ready to return to work, continued ill-health meant they did not feel it would be appropriate to be in touch.

There were cases where people’s circumstances changed without the provider services knowing about it, because contact had lapsed. There were examples of people returning to work, finding that contact with an employer which had been going well began to be problematic, being offered a job, starting to look for work, or experiencing new difficulties with their health or their NHS treatment. People did not always identify a need for help in these cases, and of course it is impossible to know whether the service could have intervened usefully.

However, the possibilities opened by a more proactive approach on the part of a service are illustrated by one case in particular. The client, in the workplace group, was off work with severe back pain. She had a good relationship with her employer, was disappointed to be put in the work place group and after the first meeting did not think she would be in touch again. Shortly before the second research interview, her case manager telephoned and asked about her pay situation, which triggered the offer of a session with a benefits adviser although this did not, in fact, take place. At the third research interview, she again had no plans to be in touch. Before the fifth interview she was planning to return to work. She was again contacted by the case manager, and the discussion triggered the offer of assistance with providing equipment. Before the sixth interview, she herself had telephoned the case manager

to talk about the possibility of other support for the return to work, and although this was not funded she was planning to get in touch again if the return to work did not happen.

Communication and contact strategies were not explored specifically with case managers, but they did not comment on difficulties in maintaining contact with clients.