Dr Carl Purcell is a Research Fellow based in the NIHR Policy Research Unit in Health and Social Care Workforce, part of the Policy Institute at King’s College London. He is also part of the team working on the SASCI project led by Dr Juliette Malley based at the Care Policy Evaluation Centre at the LSE. This is the second of two blogs on Shared Lives. (1,315 words)
In a previous blog we considered the successful spread of Shared Lives (SLs) schemes as an alternative model of care that seeks to replicate ‘ordinary’ family life for adults with care needs. This model has long enticed national and local policymakers’ attention and SLs schemes are now established in most English local authority (LA) areas. However, it remains a very small model accounting for just 1 per cent of those drawing on local authority funded adult social care and less than 0.5 per cent of the workforce. Furthermore, SLs continues to be used predominantly for the care and support of people with learning disabilities (LD) despite efforts to promote its wider use for a more diverse range of people. This prompted us to investigate the challenges faced by local schemes trying to ‘scale-up’.
As part of our wider case study on the development of SLs nationally, we examined the development of four schemes of varying sizes. Two schemes had grown over recent years (Rural Counties and Northern County), but the other two (London Borough and Metro Region) had struggled to do so. Interestingly, each of these pairs comprised one LA run scheme and one voluntary sector run scheme. The voluntary sector schemes were run by the same long-established adult social care provider but commissioned by different LAs. We focused on four aspects of the innovation process (see Zigante et al 2022) to help identify the challenges encountered in trying to grow SL schemes and how these might be overcome.
First, SLs schemes must work collaboratively with a range of different professionals and agencies both inside and outside of their own organisation. This is important for the management of established SLs arrangements but also in establishing a wider understanding of what SLs can offer and to encourage professionals, usually social workers, to refer individuals in need of support. Collaborative working can involve formal and structured processes – in the voluntary sector run Rural Counties scheme regular meetings between LA commissioners and the scheme manager, and between scheme staff and LA social work teams, took place. Social workers specialising in work with people with learning disabilities were also required to consider SLs as the ‘default option’. On the other hand, the success of the Northern County scheme rested in part on long-established but less formal relationships connecting scheme staff and co-located LA social work teams. Social workers here appreciated the day-to-day support offered by scheme staff and felt confident in referring new people in need of support. Interestingly, the manager of the voluntary sector run Metro Region scheme considered lack of regular communication with LA commissioners and social work teams as the main obstacle to generating new referrals. However, relationships connecting this provider organisation with other adult social care agencies, including NHS teams, explained why this scheme was still able to support people with a more diverse range of care needs compared to the other three schemes which focused almost exclusively on supporting people with learning disabilities.
Leadership is a second theme identified previously. The evaluation of the ‘SLs Incubator’, a pilot programme involving investment in four local schemes, concluded that the leadership of an ‘outstanding scheme manager’ was necessary for schemes to grow (Kewley and Jupp, 2019). Consistent with this, we found that the scheme manager in Northern County had played a pivotal role in driving this innovation forward. Drawing on decades of knowledge and experience, combined with a strong personal commitment to SLs, this manager had been central to the establishment and maintenance of the collaborative working already described. They also played a key role in promoting the innovation to senior LA managers and elected Councillors leading to financial investment in the scheme. On the other hand, we must be careful not to overlook the leadership sometimes played by others. In Rural Counties it was one of the LA commissioners who had pushed hardest for growth, working to establish collaborative working, but also not shying away from ‘strong conversations’ with the scheme provider. We also heard examples from lower down organisational hierarchies where individual social workers promoted SLs to colleagues and experienced carers acted as ‘champions’ supporting the recruitment and induction of new carers.
A third area of organisational capability relates to the use of knowledge and evidence and its contribution to the process of organisation learning. Across the four schemes there was a strong awareness of the small body of research on the cost-effectiveness of SLs compared to other models of care (Todd and William 2013; PSS, 2017), and this had been used to support business cases made by scheme managers and commissioners seeking additional LA investment. In Northern County scheme staff also worked alongside finance colleagues to demonstrate the extent to which SLs was delivering positive outcomes and cost savings to support the case for further LA investment. However, knowledge and evidence relating to the operation of local schemes is more diffuse. The manager of the London Borough scheme found a regional network of scheme managers, facilitated by Shared Lives Plus (SLP), to be a valuable way to learn how their peers overcame operational challenges. On the other hand, the managers of the two voluntary schemes were more likely to engage with colleagues in their own provider organisation running schemes in different parts of the country. Schemes can also pay for consultancy support from SLP to address gaps in their own knowledge and experience. But, as in the case of Northern County, successful schemes are also often willing to support SLs colleagues elsewhere on a more ad hoc basis.
Collaboration, leadership, and the use of knowledge and evidence are three features of the innovation process that are, in essence, about the deployment of finances and staff. Of course, this begs the question about the availability of these resources. The growth of the Northern County scheme followed an initial investment of £650k to pay for new SLs officers to lead on carer recruitment, the matching process, and the ongoing management of care arrangements. The creation of a dedicated post for carer recruitment was key to the expansion of the Rural Counties voluntary sector scheme. In contrast, in the small London Borough scheme the priority for SLs officers was to recruit enough new carers to replace those who were approaching retirement or wished to step down. Added to the day to day demands of managing established arrangements, there was very limited capacity to support growth.
We can also learn from the carers we spoke to, some of whom had varying experiences of working for different schemes. Efforts to recruit and retain carers must address the increased workload and financial pressures facing this self-employed workforce. Even the two schemes that had grown had started to find carer recruitment more challenging. During the COVID-19 pandemic carers faced a significant increase in workload as day centre services and other external support were withdrawn, which in some cases have not been fully reintroduced. At the same time, subsistence allowances to cover food and utilities have not kept up with increases in the cost of living. On the other hand, most carers emphasised their commitment and enthusiasm for SLs. Moreover, it was evident that carers felt more appreciated and positive about SLs when they had a good relationship with their scheme including the support of an established SL’s officer.
Dr Carl Purcell is a Research Fellow based in the NIHR Policy Research Unit in Health and Social Care Workforce, part of the Policy Institute at King’s College London. He is also part of the team working on the SASCI project led by Dr Juliette Malley based at the Care Policy Evaluation Centre at the LSE. See the first blog in this series by Dr Purcell.
References
Kewley, K. and Jupp, B. (2019) The Shared Lives Incubator, London, Social Finance.
PSS (2017) Social Impact Report: Shared Lives and TRIO, Liverpool, PSS.
Todd, R. and Williams, B. (2013) Investing in Shared Lives, London, Social Finance. https://www.socialfinance.org.uk/insights/investing-in-shared-lives
Zigante, V., Malley, J., Boaz, A., Ferlie, E., and Wistow, G. (2022) ‘How can the adult social care sector develop, scale and spread innovations? A review of the literature from an organisational perspective’ CPEC Working Paper 8