A few years ago while preparing for interview for my job at Rutland, the point where most of us catch up on some meaningful reading about around our roles, an interesting article caught my eye.
Please don’t think for one minute that I normally sit down of an evening to read Harvard Business Review but, following a quick Google search on culture, the title of an article piece from that publication caught my attention.
The title was, “To Change the Culture, Stop Trying to ‘Change the Culture’”.
The article was by Robert H. Schaffer and it struck a chord with me. I have always been of the view that culture change is overthought, made overly-complicated and, most importantly, is horribly over-planned.
That said, I think most of us can agree with Schaffer that sweeping, large-scale culture change efforts, despite having some useful impact, rarely cure those aspects of culture that were so frustrating in the first place. Stay with me, though, because, as Schaffer suggests, there is another way and one that has been successful in changing Rutland’s health and social care services for the better.
In 2014, a strategic review of Rutland’s adult social care services identified that some improvements were needed. Despite the best efforts of those delivering care, there were lengthy processes for assessments and a waiting list. Services were reactive and prevention was rarely the focus of initial contact. Reviews of individual care packages were backed up and we were not responsive enough to changing needs. Unplanned hospital admissions were rising and there were long adult social care and health discharge delays. There was little integration between health and social care and care services created dependence, rather than enabling or encouraging people to continue living independently.
What’s more, although the situation was clearly making the service’s managers and staff miserable, they felt unable to change it and stuck waiting for something to improve. Some seemed so resistant to change that it was like they were wearing their misery as some kind of comfort blanket.
Three years on, however, a new attitude and a revised approach to care in Rutland has taken hold and this has had a transformative effect on services, yielding some outstanding results for the county council, its partners and, most importantly, our service users.
To achieve this we did not invest in a large-scale cultural or transformational change programme. Instead, we started by focusing on three manageable but key problem areas that we could empower staff to tackle.
These were: increasing reach into the community to support needs earlier, including addressing safeguarding issues; reducing the number of people we were putting in care homes; and reducing the number of delays in hospital discharges.
Multidisciplinary teams were established around these issues and managers provided teams with expectations around the types of solutions we were looking for. From there, the role of our management team was to support teams to overcome barriers and ensure quick decisions were made when potential solutions were found.
Trusted to take unique action
One key element to our success here was the absence of political interference; cabinet gave their trust and supported the approach, challenging us on outcomes rather than models of delivery or activity. They made sure there were no political barriers put in the way of the solutions our teams identified. These included solutions such as shifting some social care resources towards support for non-eligible citizens, to prevent escalation of issues; or the council taking the unusual step of underwriting the cost of care at discharge so assessment could be undertaken in the destination care setting. This meant not waiting to see which agency was responsible before discharge; financial responsibility for those people’s care was addressed post-assessment.
Empowering the workforce
After each barrier to positive outcomes was addressed teams were encouraged to learn from this and develop the next phase of their transformation, setting more ambitious next steps. This gradually established a culture of empowerment, practitioner collaboration and innovation.
As a result, Rutland now has professionals at the very first point of contact with service users, leading to the majority of new contacts now being resolved without a social care assessment and any potential for crisis identified early and addressed quickly. Rutland also now has full integration across both health and social care to offer holistic support to people with complex health needs and has a more personalised approach to long-term care, helping people to stay put in their own homes wherever possible. People also receive robust support for a smooth, timely, therapy-led discharge from hospital back into the community.
Having been a driving force behind the change, staff have had a greater ownership of increasingly more complex change. Now, instead of being passive, held back by fear and apprehension about new or different ways of working, they embrace change, focusing on the opportunities it brings and benefits it offers.
Using this approach we have succeeded in developing a service that is exciting to work in, with creative, motivated and collaborative colleagues who are having a significant positive impact on the lives of Rutland people.
The data reflects the success of the approach:
- Numbers of people entering permanent residential or nursing reduced from 522 per 100,000 population in 2014-15 to 118 per 100,000 population in 2016-17; a decrease of 77%
- The proportion of adults with learning difficulties living in their own home or with family rose from 55% in 2014-15 to 71% in 2016-17
- Delayed transfers of care from hospital reduced between 2014-15 to 2016-17; social care delays are down 85%; and 34% for all delays including health. That’s 1,893 fewer days of delay per 100,000 population
- People receiving post-hospital re-ablement services, who were still at home three months after discharge, increased from 67% in 2014 to 97% in 2017
- Community safeguarding alerts increased fourfold from 2014 to 2017, with over half of all alerts now coming from the community
- At one point in 2014-15 we had 46% of our social worker posts unfilled and covered by agency staff; in 2017 we have just one vacancy
- Care Quality Commission ratings of the care homes in Rutland have increased from 38% ‘requires improvement’ to 100% ‘good’ in 2016-17
The challenge is still formidable in this changing world. However, with a new approach, developed and delivered by passionate and dedicated staff, we are confident we are now well placed to continue meeting the changing needs of our local communities.
Schaffer’s way is simple and based on addressing a few problems and incorporating the successful ideas into subsequent steps. You start with small successes, which then provide a basis for expanding. So, if you think your organisation’s culture still needs to change, maybe try this ‘other way’ and one day, like us, you will wake up and discover that you are working in a radically new culture.
Mark Andrews, deputy director for people, Rutland CC