How do innovations spread? What we can learn from Shared Lives schemes and the role of Shared Lives Plus?

Carl PurcellDr 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 also the second blog in this series by Dr Purcell. (1,129 words)

Innovation, or doing things differently, is commonly promoted by policymakers as a response to social challenges in the context of increased pressure on public services and stretched resources. Policy announcements on adult social care are testament to this, but we know surprisingly little about how innovations emerge and are developed, sustained, and spread. The Supporting Adult Social Care Innovation (SASCI) project – an ESRC funded study investigating innovation in adult social care in England – was set up to address this. The spread of Shared Lives (SLs) schemes across England has provided an intriguing case study.

SLs schemes seek to replicate ‘ordinary’ family life by matching adults with care needs with self-employed people (known as carers) willing to provide accommodation and support in their own homes as part of family life. Much of the early development of what were originally called ‘adult placement’ schemes followed the closure of long-stay hospitals in England for people with learning disabilities in the late 1970s and early 1980s. A mixture of local authority and voluntary sector now run SLs schemes that cover most of England, and outcomes from Care Quality Commission (CQC) inspections are very impressive with nearly all being rated as ‘good’ or ‘outstanding’. An important finding from our research is the pivotal role played by Shared Lives Plus (SLP), a membership organisation for schemes and carers, in helping to develop and maintain an ‘infrastructure for innovation’. This infrastructure has been developed and maintained over three decades and incorporates a whole range of activities, systems and processes including many of the ‘boring things’ which can go unnoticed but which SLs schemes rely on.

The first component of this infrastructure is a network of expertise connecting SLP and local schemes. When it was established in 1992, as the National Association of Adult Placement Schemes (NAAPS), the organisation provided a formal route for scheme managers to come together to share ideas and offer mutual support. Today SLP brings scheme workers and carers together through a variety of routes including national conferences and regional network meetings. Nearly all schemes continue to subscribe to SLP giving them access to advice and technical resources, and additional bespoke consultancy services can now also be purchased. SLP also places a great emphasis on co-production and its role as a network facilitator. As this model of care has become more established SLP has worked to bring together the expertise now spread across a more diverse range of organisations delivering or commissioning local schemes.

A second essential role performed by SLP relates to the development and maintenance of regulatory standards and best practice guidance. The focus of NAAPS’ early work was the development of a set of standards for adult placements that formed the basis of a system of self-regulation. However, these were later superseded by the introduction of the Care Standards Act 2000. This legislation effectively treated the homes of carers in the same way as care homes, leading to a loss of carers across many schemes. Following the appointment of Sian Lockwood as its first Chief Executive Officer (CEO), NAAPS successfully campaigned for the introduction of new regulations introduced in 2004 which shifted the regulatory burden on to schemes and away from carers. This paved the way for the establishment and growth of SLs schemes across England. Over subsequent years SLP has continued to work with central government policymakers and the CQC to ensure that any changes in policy or regulations take account of the unique way in which SLs care is provided. The role SLP plays in making sure SL schemes can continue to work as an alternative model of care was particularly evident during the COVID-19 pandemic when, like other parts of the sector, it was responding to weekly, sometimes daily, announcements from central government.

Thirdly, SLP has been very successful in promoting SLs as an alternative model of care to national and local policymakers. Since the appointment of Alex Fox as its second CEO in 2010, SLP has worked to raise awareness of the model and emphasise its compatibility with national policy priorities around ‘personalisation’ and ‘independent living’. The impact of this work is evident in the promotion of SLs in the 2021 White Paper People at the Heart of Care. Importantly, these efforts to market SLs have been underpinned by work with partners to build-up an ‘evidence-base’ and demonstrate the cost-effectiveness of SLs. Moreover, amongst participants in our research (including SLPs’ CEOs, local authority directors, commissioners, scheme staff and carers) enthusiasm for SLs and it potential was striking. This has helped SLP to attract significant grant or charitable income – money it has used to recruit new staff and provide more support to schemes and carers. It has also helped individual schemes to make the case for local authority investment.

Our findings are consistent with a wider body of research that points towards the importance of focal organisations such as trade associations, technical committees, or campaign groups within both the private and public sectors in driving innovation. SLs has undoubtedly grabbed the attention of central government policymakers and local leaders working in adult social care in large part because of the campaigning of SLP. But another lesson for innovators in adult social care is to pay attention to the ‘boring stuff’. It is hard to imagine the spread of SLs across England without the ongoing problem-solving work led by SLP.

Yet it may not be easy to replicate the work of SLP in other areas of adult social care in a very challenging financial environment. The future of SLP itself is never guaranteed – the organisation has to direct significant effort to fundraising with only about a quarter of its annual revenue of £2m coming from scheme and carer subscriptions – and SLP still has work to do to grow the model. Notwithstanding the successful spread of SLs schemes this remains a very small model of care accounting for just 1 per cent of those drawing on adult social care and less than 0.5 per cent of the workforce. But the impact that SLP has had over its first three decades gives cause for optimism. In the coming years, and now under the leadership of Ewan King, SLP looks set to continue to play a central role in developing and maintaining the infrastructure that makes SLs happen.

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 also the second blog in this series by Dr Purcell.

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