Using guideline NG86 to improve outcomes and experience of adult social care

The aim was to work with the social care service to examine practice relating to NICE guideline NG86 and enable more of the recommendations to be better or more fully implemented. 

In addition to improving the experience of citizens in contact with social care it was hoped wider outcomes relating to people’s independence would also improve (with associated financial savings for both citizens and the local authority). 

Harrow is an ethnically and religiously diverse London Borough of about 250,000 people of which approximately 40,000 are aged 65 and over.  

A peer review conducted by London ADASS (Association of Directors of Adult Social Services) in February 2020 noted there “high performance / activity in many areas, yet citizens report low feelings of control and quality of life” (from a January 2019 survey of people who use services).  There was support from senior management for Jonathan to work with the service to look at how the NICE guideline could help improve user experience and quality of life.

In September 2018 a new operating model had launched with a new early intervention service supporting citizens at the first point of contact.  Initially Jonathan worked closely with managers and staff to look at the extent to which NICE recommendations were being followed and what it would take to implement them more fully, identifying and implementing a number of changes to practice. 

Within two months a comprehensive social care transformation programme was launched under a new director, bringing significant new investment and a series of new initiatives.  Jonathan was able to broaden his activities through membership of the Transformation Board and relevant sub-groups.  This ensured issues connected to user experience could be reflected in the design of new processes and staffing realignments.  For example, he identified opportunities to implement many aspects of the NG86 domain ‘Providing Information to Citizens’ through a re-design of the adult social care web pages by linking some of the recommendations to feedback from the annual adult social care survey and additional telephone interviews with citizens.

Jonathan concluded that working with the in-house early intervention and assessment teams could lead to measurable progress within the 12-months of the Scholarship and identified some immediate opportunities for change as well as longer term challenges, such as encouraging more co-production with citizens in recruitment and policy development (rec 1.1.9). Some of the recommendations were felt by social care managers to be too expensive to implement e.g. having a named worker during assessment (1.3.10).

As part of the transformation programme, Jonathan became closely involved with a strengths-based approach to social work practice termed “Three Conversations” (developed by Partners 4 Change).  A consultant guided the initial co-design with staff of an “innovation site” during the first few months to help build and sustain a new way of working. 

He worked in co-production to develop the new approach and associated data collection. Feedback from citizens via semi structured telephone interviews were delivered by a social care student working with Jonathan and combined with analysis of electronic case records to create an outcome dataset. 

Presenting the findings to weekly staff meetings influenced development of the new way of working with specific recommendations for practice changes from guidance NG86. Jonathan then continued to work closely with the consultant, staff and managers to expand the approach to more of the key contact points for citizens approaching adult social care for the first time.

Jonathan was also able to improve aspects of the NG86 domain ‘Providing information to Citizens’ by linking some of the feedback from the annual Adult Social Care Survey and telephone interviews with the recommendations, working with transformation programme colleagues to make changes to the council’s website. 

A final audit was then undertaken with managers to evaluate changes in adherence to NG86 recommendations.

Jonathan supported implementation of some no/low-cost changes such as improving consistency when offering copies of assessments to citizens (NG86 rec 1.3.9).  Work with the Three Conversations project enabled more of the recommendations to be implemented.  For example, social care specialists started taking phone calls directly (bypassing the contact centre) and continued to work with citizens instead of handing across to other teams as usually occurred.  This revised approach led to a reduced need for people to repeat their stories to different staff and in this way the recommendation considered “too difficult” to implement a few months earlier (1.3.10) was embedded.

By the end of the year an audit indicated 20 of the recommendations were more fully integrated into social care practice (see Table 1, below).

Table 1: Change in Adherence to Guidelines during Scholarship

*no recommendations were less closely followed by the end of the year.  The initial level of adherence to the recommendations varied (not shown in the table)

Most of the progress was achieved at the first point of contact, providing better advice and information to people, improving their access to support and personalising that support to a greater extent.

For example, feedback from a relative was received in relation to one elderly couple who were referred for possible residential care and supported by a social care worker to avoid this; “Both my parents would have been deeply distressed to have been separated from each other.  Tracy had taken time to understand my parents and it was clear that she wanted to explore all alternatives.  With hindsight it is easy to see just what Tracy’s bravery in standing up and fighting until all alternatives had been fully explored has achieved, in this instance it has probably saved two lives.  Lives that are now being lived out with a quality that Tracy believed was possible despite the views of others, including others in my family.” (Email, July 2020).

Impact was seen in the published activity data for Harrow and the London region.  Data for 2017-19 showed increasing requests for support but reductions in formal (including long term) support provided in both regions.  In 2019-20 the London region again received more requests for help but now arranged more formal support, the opposite of what occurred in Harrow.  Provision of long-term support continued to fall slightly in the London region but in Harrow dropped more markedly to below 10% of all new requests.

Table 2: Data from Short- and Long-Term Support (SALT) – Official Statistics for England

Sources: SALT data published by NHS Digital, combining Tables STS001 and STS002a

Further evidence of the impact of working differently at the first point of contact came from local measures from just the early intervention and assessment teams.  For example, the percentage of interventions where longer term social care services were not required rose from 75% to 93% between April 2019-March 2020.  The number of new citizens in the community going on to receive long-term support fell from 7.2 per week in April 2019, to 5.5 per week in March 2020.  The finance team estimated £696k of costs were avoided (part year effect) with potential full year cost avoidance estimated at up to £1 million.  ’Repeat referrals’ (where citizens make further requests within a year) fell from 33% to 25% - broadly equal to the reduction seen in new requests for support from 2019-20.   This suggests getting the initial interventions right was helping people to remain independent for longer.

The Scholarship evolved from being a standalone project to being part of a wider transformation programme.  The audit findings, feedback from citizens and full year results are suggestive of the benefits of better implementing the recommendations in NG86 in this context. 

Jonathan believes the transformation programme provided additional opportunities for change that would have been otherwise difficult to achieve so quickly.  The NICE Guideline provided an evidence-based, focussed way of influencing change in some of the projects.  In particular, the adoption of the Three Conversations approach by social care staff was helpful in enabling implementation of many of the NG86 recommendations concerning assessment.  Jonathan believes that it may be possible to make more impact with embedding NICE recommendations if they can be linked with other organisational change programmes taking place.