using person-centred information for commissioning · commissioning, in some cases are planning to extend its use into other service areas, and are considering what it might take

Working together for change:using person-centred information for commissioning

Working together for change: using person-centred information in commissioning

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Working together for change: using person-centred information in commissioning

Foreword 3

Executive summary 5

Working together for change: what is it? 6

Why is it important? 7

Co-production and personalisation 7

The Joint Strategic Needs Assessment 9

Measuring the impact of personalisation 10

Information sources for commissioning 12

The Working together for change process 15

Process Diagram 15

Preperation: Clarifying the purpose and people 16

The six-stage process 19

Data presentation and comparison 28

Evaluation 30

Conclusion 34

Appendix 1: Worked through examples 35

Appendix 2: Feedback template 43

Authors: Sam Bennett and Helen Sanderson

Contents

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Working together for change: using person-centred information for commissioning

The vision of Putting People First can only be realised byempowering people who use services, their carers andfamilies to play a leading role in shaping and driving thechanges they want to see. This means at all levels, fromthe individual directing their own support to people’sengagement in decision making and planning for the

health and wellbeing of their whole community. It means finding ways toenable people to design, deliver, and evaluate services so that they becomea shared responsibility between citizens, councils and their partners.

Working together for change is a simple process for putting people using services at the heart ofcommissioning. As an innovative approach to community engagement and an active method forplanning change that will help us to put people first – I commend this report to you.

Phil HopeMinister of State for Care Services

Foreword

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Working together for change is a structuredapproach to engagement with people usingservices to review their experiences anddetermine their priorities for change. It is asystematic process for planning change withpeople, which provides powerful insights intowhat is working and not working in their livesas well as their aspirations for the future. Itcan be used to ensure that co-production withlocal people and families is at the heart ofsocial care transformation programmes, as avehicle to improve community engagement inthe Joint Strategic Needs Assessment and as atool for strategic commissioning.

It is compatible with work conducted by theDepartment of Health in parallel to thisproject to design an outcomes-focused reviewprocess that works for people and providesperformance information for councils, i.e. it isthis information in individual and aggregateform that drives the working together forchange process.

Helen Sanderson Associates (HSA) designed thesix stage process that has been built upon inthis work.1 The Department of Health’s PuttingPeople First Implementation Programmeworked with HSA and several Local Authoritiesin early 2009 to test and refine this methodfor collating and analysing person-centredinformation for use in strategic commissioning.

Whilst this is not a detailed evaluation, theexperience of testing working together forchange with four councils has shown theapproach to be flexible, transferable andeffective. Commissioners have begun toidentify ways in which it can improve localcommissioning, in some cases are planning toextend its use into other service areas, and areconsidering what it might take to embed theapproach within council systems.

The following sections explain what working together for change is, why it isimportant and what it can add to the current range of information sources available to commissioners.

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Executive summary

This report describes a simple six-stage process that uses person centredinformation (for example from person centred reviews, person centred plans or support plans) to drive strategic change and commissioning.

1 'From Individual to Strategic Change – driving change with person centred information' Sanderson et al (2009)

Working together for change is a simple, six-stage process that uses person-centredinformation taken directly from individualreviews, support plans or person-centredplans to inform strategic planning andcommissioning. A full explanation of thesestages is included later in the report.

Briefly, the six stages are:

1) Gathering the person-centred information– e.g. from individual outcomes-focused reviews

2) Transferring the information into a usableformat – involves transferring statements toindividual cards which captures the top threethings that are working and not working inpeople’s lives and the three things mostimportant to them for the future

3) Clustering the information into agreedthemes – this happens during the course of afull-day workshop and includes naming eachcluster with a first-person statement to bestdescribe the theme of the information

4) Analysing the information – this also happens during the workshop and includesanalysis of possible root causes for things that aren’t working in people’s lives and aconsideration of what success might look like if people’s aspirations for the future were realised

5) Action planning – conducted on the basisof the clustering and analysis, differentstakeholders plan what they will do differently

6) Sharing information – information aboutthe process is shared with others, particularlythe actions that have resulted

The process should be conducted cyclically –perhaps annually, so that the impact ofprevious action is understood, further actionscan be taken to change the things that arenot working for people and people’saspirations for the future can continue todrive local strategy and commissioning.

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Working together for change: what is it?

This section explains why working togetherfor change is important in relation to: Co-production and current policy, the JointStrategic Needs Assessment and measuringthe impact of personalisation. Collectively,these illustrate that working together forchange provides:

i) A proven, effective approach to ensuringco-production with people using services insocial care transformation

ii) A model for ensuring effective communityengagement in the Joint Strategic NeedsAssessment

iii) A way of understanding and measuringthe impact of personalisation, especiallywhen taken in conjunction with theoutcomes-focused review process.

Co-production and personalisation

‘Putting People First highlights the importanceof co-production in the transformation ofadult social care:

“It seeks to be the first public service reform programme which is co-produced,

co-developed, co-evaluated and recognisesthat real change will only be achievedthrough the participation of users and

carers at every stage.”

Putting People First, DH, 2007.

This means at all levels – from the individualdirecting their own support, to effectiveengagement with local people in decisionsabout the health and wellbeing of the wholecommunity. While co-production isunderstood in a number of different ways,there is broad consensus that at its heart co-production refers to a shift away fromprofessionally led and process orientatedpractices towards systems that support theactive engagement of local citizens in thedesign and delivery of public services.

The New Economics Foundation gives a useful description of co-production being: ‘not about consultation or participation –except in the broadest sense’ but ‘aboutbroadening and deepening public services sothat they are no longer the preserve ofprofessionals or commissioners, but a sharedresponsibility.’2 Put another way, co-production requires more of services andcommissioners than ensuring there areeffective mechanisms for feedback – it isabout creating shared ownership and workingcollaboratively to produce better outcomes.

This is no small aspiration. The value of co-production in the design and delivery ofcertain municipal services and theimprovements that have resulted have beendescribed in academic circles since the 1970s.It seems clear that some services are naturallymore predisposed to co-production thanothers dependent on the possibility and

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Why is it important?

2 Co-production: A manifesto for growing the core economy, New Economics Foundation, 2008

perceived benefits of active user engagement.In social care, where service solutions areincreasingly personalised and mediatedthrough ongoing dialogue between users andprofessionals, the opportunities for co-production are correspondingly strong. Indeed,the emphasis personalisation places on treatingpeople as experts in their own care rather thanpassive recipients of services makes the currentpolicy landscape particularly conducive to co-productive approaches.3

Co-production is inherent to self-directedsupport (SDS). By exercising choice and controlover the supports required in their lives, peopleusing SDS are on an increasingly even footingwith professionals. The emphasis within PuttingPeople First on the importance of social capital,conceived as the informal support, socialnetworks and community resources available topeople in addition to or instead of formalservices, ensures this is about more thansupported consumerism. SDS is genuinely co-productive as it mobilises all available resourcestowards achieving better outcomes.

How does co-production apply tocommissioning?

The recent Local Authority Circular,Transforming Social Care notes that councilsneed to ‘ensure that people and theirorganisations are much more involved in thedesign, commissioning and evaluation ofservices and how their needs are met.’4

At the individual level, some innovative practice has lately emerged that puts people and families at the heart of thecommissioning process. This has involved using anonymised support plan information in tender documentation and enablingindividuals and families to play a leading role in determining successful bids to deliversupport. It has also involved the developmentof individual service funds, which empowerpeople to work directly with providers todetermine how their budget is used to achieve their agreed outcomes.5

It has proved more difficult for localauthorities and their partners to developsuccessful models of co-production instrategic commissioning. Local people arerarely able to drive organisational change andshape the availability of supports and servicesin their area. Working together for changeoffers a simple approach to using informationcollected from person-centred reviews in astructured, co-productive environment, toaddress this problem.

There are additional reasons to use workingtogether for change discernable in the current policy landscape, particularly inrelation to Learning Difficulties. Thesystematic use of person centred planning to inform community and servicedevelopment was one of therecommendations in the first Valuing People implementation guidance (2001).

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3 SCIE’s recent briefing on co-production for a far fuller investigation of the academic research on co-production and itsapplication to social care, CCoo--pprroodduuccttiioonn:: aann eemmeerrggiinngg eevviiddeennccee bbaassee ffoorr ssoocciiaall ccaarree ttrraannssffoorrmmaattiioonn, SCIE, March 2009

4 Local Authority Circular, Transforming Social Care, LAC, DH, 2009

5 Flexible contracting for personalised outcomes, DH (forthcoming 2009)

Although there are some examples of thishappening, it has not become widespreadpractice. We are yet to see significantnumbers of community and serviceorganisations using person centred planningas a way to inform and direct their strategicplanning. Valuing People Now strengthensand restates this requirement. For example, it makes specific reference to using personcentred planning to directly inform thechanges needed regarding what people doduring the day.

Valuing People Now requires learning from person centred planning to make change at an individual and strategic level,and states that:

“Services will have person centred plans for everyone they support. They will use

this to review and improve the support they provide to individuals to ensure that

agreed outcomes continue to be met”

And;

“The Office of the National Director willwork with the Putting People First Team to

explore how person centred information canbe used to inform strategic commissioning

and will demonstrate good practisethroughout their regions”

Valuing People Now, DH, 2008

The Joint Strategic NeedsAssessment (JSNA)

The Local Government and Public Involvementin Health Act (2007) introduced the statutoryrequirement for upper tier Local Authoritiesand PCTs to jointly undertake Joint StrategicNeeds Assessments (JSNAs). The Departmentof Health (DH) guidance on JSNAs (December2007) describes the process as designed to‘identify the current and future health andwellbeing needs of a local population,’ toinform Local Area Agreements andcommissioning across health and social care. It also sets parameters around the collection of a minimum dataset on needs. The coreprinciples of JSNA are described as: partnershipworking, community engagement andevidencing effective ways that needs are met.

The DH guidance gives particular attention tothe importance of community engagement atall stages throughout the process, ‘fromplanning, to delivering and evaluating.’6

While the suggested minimum dataset forJSNA includes domains on ‘service users’ and‘public demands’ and identifies residentsatisfaction surveys as possible sources, theguidance is explicit that these ‘should besupplemented by information gained throughactive dialogue with local people, service users and their carers.’ LINks and CitizenPanels are possible forums, thoughPartnership Boards and specific referencegroups could be equally appropriate.

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6 This reflects the emphasis strong and prosperous communities’ places on recognising that citizens and communities knowwhat they want from services and what needs to be done where they live. It also reflects the first of eight steps to effectivecommissioning the DH identified in the JJooiinntt CCoommmmiissssiioonniinngg FFrraammeewwoorrkk ffoorr HHeeaalltthh aanndd WWeellllbbeeiinngg –– ppuuttttiinngg ppeeooppllee aatt tthheecceennttrree ooff ccoommmmiissssiioonniinngg.

The importance of finding methods thatsupport people to work together effectively isalso stressed in the guidance, though practicalexamples are thinner on the ground.

In practice, at least anecdotally, ensuringmeaningful community engagement in theJSNA has presented a significant challenge.This is perhaps unsurprising given the scopeand complexity of the issues involved, butfinding better methods for involving peoplewill be critical to their lasting impact. Manyareas have now identified more effectivecommunity engagement and better use ofqualitative information as key improvementareas for their second JSNAs. Workingtogether for change is one approach thatLocal Authorities and their partners may wishto consider (and that some are alreadyemploying) to achieve these aspirations.

Measuring the impact of personalisation

Measuring the impact of social care has longbeen a preoccupation and a statutoryrequirement for those involved in deliveringand commissioning it. The ultimate ambition –ensuring better lives for people by understandingthe outcomes of social care interventions andensuring value for public money.

The Department of Health’s work on the newNational Indicator Set for Local Governmentdescribes three types of evidence necessary todemonstrate outcomes in health andwellbeing – activity, results and experience.‘Activity’ refers to the volume and type ofinputs and outputs involved in a particular

intervention, for example the time spent andthe tasks completed during a domiciliary carevisit. ‘Results’ refers to the measurable impactof an intervention, such as the reduction inhospital readmissions as a result of re-ablement. ‘Experience’ refers to the self-attested experience of the user, such aspositive feedback about a service obtainedthrough a satisfaction survey. None of these is evidence of an outcome taken on its own,but a good indication of the outcome can be obtained by considering them incombination. Therefore:

Activity + Results + Experience = Outcome

Current work to revise the NIS is identifyingmetrics for ‘activity,’ ‘results,’ and ‘experience’in line with the outcomes described in thesocial care white paper, Our health, our care,our say. These are overarching measures fornational benchmarking, performanceassessment and understanding progresstowards key policy objectives. At a local level,councils need additional information tomeasure their own performance and that ofcommissioned services and to understand theoutcomes for local people.

The transformation agenda means that many previous measures are becoming lessuseful and councils are having to developnew ways of understanding outcomes. Someapproaches focus on identifying “objectiveoutcomes” (such as improved health or lower residential care admissions), whileothers focus on “subjective outcomes,” which concern what is important to individualpeople. Both are important.

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Mapping these against the NIS equationillustrates the point:

Objective Subjective(Activity + Results) + (Experience) = Outcomes

The Department’s work on outcomes-focusedreviews (available elsewhere in thepersonalisation toolkit) focuses on“subjective” outcomes. One benefit ofoutcomes focused reviews is in providing abetter source of “subjective” information thanis available through satisfaction surveys.Arguably, the information gathered fromthese reviews is significantly more than“experiential” in the way that satisfactionsurveys are. The use of open rather thanclosed questions to probe the outcomes of asupport plan means that while describing

“experience,” these reviews also describe“results” from the individual’s perspective.

This potentially changes our understanding of the NIS equation, where reviews aresubjective measures of both results and experience:

Objective Subjective(Activity + (Results) + Experience) =

Individual Outcomes

Outcomes focused reviews provide“subjective” data about individual outcomes.Using this same information in aggregateform to drive the working together forchange process provides the opportunity todraw wider conclusions about outcomes for a group of people, or population.

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Commissioning is often described as a seriesof activities that occur in a cycle. This startswith an identification of need and analysis ofthe market and available resources,progresses through the specification ofsupports or services, leads to procurement ofa service and monitoring of the resultantcontract and continues through reviews ofthe contract to ensure it meets the needsintended to the quality expected.

At strategic level, commissioning is less directlyinvolved with the tendering of contracts andmore acutely engaged in shaping theavailability of services for the medium-longterm, in conjunction with partners and inpursuit of strategic objectives.7 Increasingly,commissioning at all levels is shaped by theoutcomes that commissioners and individualsidentify as important, rather than the volumeof activity expected.

Commissioners draw upon a range ofdifferent information so that the services andsupports they directly commission and themarkets they seek to shape by other means,reflect the needs of their local populace;support the strategic direction of thecommissioning authority and ultimately leadto improvements in the lives of local people.Some of the information sourcescommissioners draw upon reflect statutory,regulatory or performance requirements while

others reflect an accumulation of experienceof what works locally.

While developments like the JSNA aresignificantly improving the scope and qualityof information that commissioners work with,it is still possible to identify limitations withthe common dataset. The table belowillustrates some possible limitations:

Data source Possible limitations

Socio-demographic data Highlights needs rather than aspirations

Strategic needs Can be overly assessments mechanistic and

process led

Analysis of available Tends to exclude resources social capital

Performance and Historicalregulatory

Market intelligence Distorted market view

Previous experience Imaginative constraints

Frontline staff Often limited input

Consultation Often occurs after development of the strategy

Satisfaction surveys Often closed questions

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Information sources for commissioning

7 For a thorough description of the activities associated with strategic commissioning see CCoommmmiissssiioonniinngg ffoorr PPeerrssoonnaalliissaattiioonn, DH 2008.

The table highlights some recurrent themes inrelation to the paucity of qualitative andperson-centred information available tocommissioners, especially if co-production andcommunity engagement are consideredincreasingly important goals. Some of theselimitations require further explanation in thiscontext:

1) Highlighting needs rather than aspirations: Formal processes for collectingcommissioning information tend toconcentrate on identifying needs within alocality or specific demographic, whether atmacro level and in the medium/long term,or at micro level and reflecting immediateconcerns. This kind of information,including the modelling of future need anddemand on the basis of demographictrends, is a vital reference but it doesn’treflect the whole picture of whatcommissioners need to know. The missingelement often relates to the aspirationslocal people have for the future, forthemselves, their families and theircommunities. At a strategic level, wherecommissioners are planning for the longerterm, a clear view of what people want forthe future is important. Assembling thiskind of information systematically has oftenproved difficult.

2) Can be overly mechanistic and process led: A general criticism levelled at the firstround of JSNAs has been that the process

has sometimes become the end in itself.This means that once a JSNA has beenproduced (often a substantial document,dense with quantative data) it has beenplaced on a shelf where it is destined toremain until there is a pressing requirement to update it. This has rarelybeen the starting intention, but it has beenthe reality in some cases. Arguably, theproblem can be attributed to the abstractnature of much of the information whenseen from the public’s perspective and thewider challenge of making commissioningmore accessible and understandable – what does this tell me about mycommunity and what has it got to do with me? It is unquestionably difficult todevelop JSNAs that both inform dailycommissioning activity and are recognisedas valuable by local people – but this has to be the aspiration!

3) Tend to exclude social capital: Anycommissioning process will include ananalysis of the resources that are availableto meet the needs that have beenidentified. Almost universally this tends tofocus solely on the financial and otherresources available within thecommissioning authority (or authorities).For co-production to be effective,community resources should be factoredinto any resource analysis and subsequentservice design from the outset.

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4) A distorted market view and imaginativeconstraints: These two limitations can betaken together as they represent two sidesof the same coin. The implication is notthat commissioning wilfully distorts themarket, rather that ones perspective of‘what’s out there?’ is often built upthrough experience over time ofcommissioning certain types of services, incertain ways and from certain providers.This knowledge is undeniably valuable(especially when taken in tandem withperformance information), but when thetraditional designation of services (intodomiciliary care, daycare and residentialcare for example) begins to fragment andchange as seems likely under thepersonalisation agenda, this informationand can also serve to reinforce a outmodedhabit. Even where there is recognition thatcurrent patterns of investment in servicesmay not remain applicable, it cansometimes be difficult to ‘think outside thebox’ about the different ways people maychoose to meet their agreed outcomes.This is also true for people using supportwho may find it equally difficult to thinkoutside of traditional service boundaries.

5) Consultation and satisfaction surveys:While consultation and satisfaction surveyscan be useful sources of qualitativeinformation, in practice they are too oftenlimited by the use of closed questions andby the timing of the exercise. Consultationoften happens once the plan or strategy

has already been written rather than aspart of a process to develop the plan fromthe bottom up. This tends to mean thatconsultations ask about agreement ordisagreement with a particular course ofaction. In such instances the scope ofpossible action and more importantly, theidentification of the problem that thestrategy is trying to solve, have alreadybeen determined. A genuinely co-productive approach would stress the valueof meaningful engagement with peopleusing services at all stages, in design,delivery and evaluation, rather than as‘feedback,’ however useful.

While working together for change is not apanacea for all of these limitations, it doesoffer a practical solution to many of them. It provides a means of generating andanalysing qualitative information forcommissioning. It serves to highlight people’saspirations as well as their needs. It recognisesthe value of engaging people from the outset,involving them in setting the direction forstrategic change.

One result of the limitations outlined above isthat it is often extremely difficult forcommissioners to demonstrate any direct linkbetween what they have commissioned andwhat local people have said that they wantand value. More than anything else, workingtogether for change seeks to provide thisgolden thread, the transparent audit trailbetween what people said was important andwhat was commissioned as a result.

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Process diagram

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The working together for change process

The diagram above is a summary illustration

of the working together for change process.

On the left hand side is the individual person-

centred review, or outcome-focused review.

The review results in ‘actions for individual

change.’ This means that for each individual

review, actions are agreed that change

what is not working for the person and

respond to what they have identified as

important for the future.

At the same time, the person is asked toprioritise certain information from their reviewto be taken forward into the working togetherfor change process. This diagram shows thisinformation, combined with other reviews,being thematically clustered during theworking together for change workshop.

These clusters are then analysed so that thegroup develops an understanding of thethings that are working that can be builtupon, the things that are not working thatneed to change for people and the things thatwill guide further change in the future. Thisinformation informs changes in local actionplanning (the red line) and changes instrategic commissioning (the blue line), wherethe information can be used alongside other

information sources, or as part of the JointStrategic Needs Assessment.

Preperation: Clarifying thepurpose and people.

The PURPOSE of the process is to listen to what people are saying about their livesand the services they receive through personcentred information, and to think about thechanges necessary to enable people to getmore of what’s working in their lives, and to change what’s not working throughstrategic commissioning.

The PEOPLE who should be involved arethose with the power to make and influencestrategic decisions.

At the beginning of this process it is essentialthat commissioners, strategic decision makers.and people using services come together toclarify exactly what information they wantand how they will use this to inform strategiccommissioning and decision-making.

The different elements of person centredinformation can be aggregated to providespecific information.

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Here are some examples:

Person Centred Information When aggregated can provide information on

What is working from the Best practices in persons perspective (or the service.parents/carers perspective) With this information

we can explore: • what it would take for

this best practice to become widespread

• what we can learn fromthis success to make itmore likely that it willbe come typical practice.

What is not working from What needs to change?the person’s perspective This may relate to(or parents/carers service levels that areperspective) insufficient, or services

that are ineffective. With this information we can explore:• what it would take to

change what is not working

• what the root causes might be

When collected routinelyand analysed cyclically this information provides a way of checking whether previous actionshave had the desired effect in changing things that were not working for people.

Person Centred Information When aggregated can provide information on

What is important to the What people may wantperson for the future in the future. With thisThis section can provide information we can:specific details about: • map this against what• activities is already present• support • explore any market• community locations. development

requirements.

Other consultation and listening methods cansometimes be accused of using closedquestions and leading to pre-determinedoutcomes. Because the questions ‘what isworking in your life?’ and ‘what is notworking in your life?’ are entirely neutral andnon-proscriptive, the answers provided willtend to reflect people’s genuine concerns andpriorities from their experiences of day-to-daylife and the services that support them.

Key decisions for the introductoryplanning meeting:

1) What specific information do we want togather from the person centred support plansor reviews?

The suggestion from the DH project is that asa minimum you should consider collecting thetop three things that people said wereworking and not working in their lives as wellas their top three aspirations for the future.Doing this requires that individuals are askedto prioritise this information as part of theirreview (either specifically for this process or aspart of all reviews). A template for this whichwas used during the project is attached inappendix 2.

2) Who will we do reviews with?

• What size sample?

• Within a geographical area?

• People who use a particular service?

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The DH project and other testing of thisapproach would suggest that the minimumdataset you can work with effectively isinformation from 12 reviews while there islimited value in considering more than 60,after which the clustering and analysis tendsonly to reconfirm existing themes.

The DH project tested the approach in anumber of different ways – defined by ageographical area (in Lancashire), by users ofa particular service (in Wigan) and across awhole locality (in Richmond on Thames). Itwould seem that the process is equallyapplicable whichever way you choose to cutthe cake, though the type of actions thatresult will be correspondingly different. Forexample, if focused on a particular provider(such as a supported living provider), actionsmay result to make immediate improvementswhere specific issues are identified (seeLancashire example below). Alternatively, ifcovering a whole locality (e.g. older peopleacross a whole council area), longer-termactions may materialise that shift the wholedirection of commissioning for older people’sservices. Both are valuable, one at anoperational and one at a more strategic level.

The project tested working together forchange in two learning difficulties services,one older people’s service and one olderpeople and physical disability service. Thechoice arose from the funding split for theproject (between Putting People First andValuing People Now) and the pragmaticintention to test usage with older people –

more than 70% of the customer base forsocial care. We believe that the approach isequally applicable and transferable to otherservice areas (e.g. mental health and sensoryimpairment) with the major determinant ofsuccess being the ample representation ofcommissioners/local decision makers andthose using services at the workshops.

3) How will we gather the information?

• Will we use person centred reviews, personcentred plans or support plans?

• Will we use our existing facilitators if wehave them?

• Will we use this as an opportunity to trainnew facilitators and coach their first plan or review?

• Will we bring in independent facilitators?

• How will we manage the logistics of the process?

To some extent, the answers to thesequestions will be predetermined by youranswers to question two. For example,choosing to focus on LD services may leadyou to use existing facilitators already trainedand versed in person-centred approaches,while choosing to focus on older people maylead you to include a training element in theproject if there are no existing facilitators inthe service. (Note that facilitators may meancare managers but can also mean employeesof user led organisations or providers whohave taken on these roles).

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4) Who needs to be at the workshop?

• Who needs to be part of looking at thisinformation to be able to use it to informstrategic decisions?

• Who else would find this helpful?

Again, answers to these questions will tosome extent be determined by your answersto question 2. In general, experience from thisproject suggests that the workshops shouldnot be too large or too small – no more than25 and no less than 15. Critically, there shouldbe good attendance from the people whoseinformation is being analysed and a full rangeof perspectives represented for the event tobe genuinely co-productive.

This does not necessarily mean the inclusionof people whose reviews are part of the data,rather that people or groups should attendthat are able to reasonably reflect their views.For example, none of the older people whohad been reviewed in Gloucestershire wereable to attend the workshop, but there werefive delegates from the Gloucestershire OlderPeople’s Assembly in attendance whichworked very well. Likewise, in Wigan threelearning disabled self-advocates and theirsupporters, as well as parents of learningdisabled young adults were present.

The six-stage process

Step 1: Gather person centred information

Person centred information can be gatheredfrom person centred plans, support plans orperson centred reviews. Each of theseprocesses typically use the questions ‘what isworking and not working’ and ‘what isimportant for the future.’

Where other information is required, theperson centred review process can be adaptedto provide this.

What are outcomes-focused reviews?

An outcomes-focused review is the processthe DH has developed with people, families,carers and councils for reviewing a person’sindividual support plan. It is a way of carryingout person-centred reviews that measuresprogress towards the goals set out in theirplan for people using personal budgets.

It can also be used to collate performanceinformation about individual outcomes (seepage 8) and to provide the informationrequired for working together for change,though other methods can also be used.

Moving towards a different review process ispart of the challenge of introducing self-directed support. While there willundoubtedly be local differences, theexpectation is that all such reviews should beperson-centred and there is good evidence tosupport the efficacy of this approach.

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The critical point is that you can’t do workingtogether for change without doing person-centred reviews!

Step 2: Transfer the information into ausable format

The next step is to make sure that theinformation is in a format that can be usedduring the workshop. The process for doingthis depends on the number of people whohave provided person-centred information,and is either done before the meeting if thereare more than 30 reviews, or at the meeting ifthere are less then 30.

You need to decide whether to use all theinformation provided under each heading(‘working,’ ‘not working’ and ‘important forthe future’), or to prioritise and select onlyone or two statements for each heading.

There are different ways of recording theinformation to share at the Workshop:

• In East Lancashire, they had information from over 90 reviews. They had printed the information using a very large font andcut the paper into strips so that each stripcontained a statement from the person about something that was working or not working in their lives or was important for their future;

• In Richmond, 12 reviews had beenespecially conducted. Delegates worked inthree mixed groups to transfer thisinformation onto colour-coded cards forthe three headings as the first exercise atthe workshop;

• In Wigan, the information was presented intables from the reviews and thentransferred at the workshop to green(working), red (not working), and blue(important for the future) cards.

There is some benefit in transferring some orall of the information at the workshop as thishelps stakeholders to appreciate the integrityof the data. If transferred in this way it ispreferable that the individual reviews areanonymised.

This information is then clustered at theWorkshop.

Step 3: Cluster and Name

(This stage takes place at the full dayworkshop.)

The individual information, either on cards or on paper strips (see above), is arrangedwith similar information to form thematicclusters. This is done separately for“working,” “not working” and “importantfor the future” information, using a separatepin board for each.

The facilitator helps the group to do this using a card call technique, i.e. each piece of information is read to the group whojointly decide whether it is similar toinformation that has already been read outand should join an existing cluster, or whetherit is different from the other information andshould form a new cluster.

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It is perfectly OK for some clusters to containlots of information and for others to containsingle statements. It is important that everyonehas an opportunity to contribute and tochallenge the clustering of this information.

Each cluster, or theme, is then given a ‘name’agreed by the whole group. The names mustbe as short as possible and written as firstperson, or “I” statements.

For example, the three person-centred statements:

“I have only one friend,”

“I only have staff in my life” and;

“I don’t see many people during the day”

might reasonably be clustered together andnamed by the group:

“I am lonely.”

Where the group is working with informationfrom 30 reviews or less the clustering can bedone by the whole group working together.Where there are more than 30 reviews it maybe preferable for two or three people toarrange initial clusters on several boardssimultaneously, and for the group to revieweach other’s work and come to agreement onany changes.

This step can be time consuming but is veryimportant because the themes that the groupidentify will form the basis of further analysisand action planning – so it’s worth spendingthe time to get it right!

Step 4: Analyse

(This stage also occurs at the full day workshop)

Once you have arranged all of theinformation into named clusters, the next stepis to make sense of the information andanalyse it as a basis for action. The processesused here depend on the specific person-centred information that the group hasdecided to use.

Here we show how “what is working?” and“what is not working?” might be analysed,what the purpose might be and what processyou might follow to do this during theworkshop.

What is working?

This information can tell you about goodpractice to celebrate. You can use thisinformation to:

a) Identify specific situations that are workingwell for people, so you can ‘drill down’ tounderstand the key components of this andthink how it can be replicated.

In East Lancashire three of the success themes were:

• I live as independently as possible

• I feel better (health)

• I stand up for myself.

The group talked about what had happenedto achieve these outcomes for people. Thecommissioners talked about the ‘provider

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Not working

Working

Important for the future

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pathway’ that had been used, and the impactthat this had had. The providers talked aboutthe work that they had done to create personcentred change with people. They agreed thatkey elements of the provider pathway processfor developing individual service funds hadmade a large contribution to these changes.This confirmed for the commissioners thattheir plans to expand this approach werelikely to be beneficial for people.

There are a range of approaches from‘Appreciative Inquiry’ that can be used here.

b) Identify success stories to share morewidely across the organisation.

One of the ambitions shared by Jean in the‘important in the future’ section, was to domore public speaking. The group thoughtabout how they could help Jean to achievethis and share success stories. One suggestionwas that Jean helped in the training of otherstaff in person centred outcome focussedreviews, as well as finding other opportunitiesto be a speaker at local events.

What is not working?

This information creates an agenda forchange. You may decide to consider all of theclusters, or to focus on those you considermost important to change – determined byvoting where everyone has a say. As with the“what is working?” clusters, you can use thisinformation in different ways:

a) Generate immediate actions

Sometimes the information is so straightforwardthat there is an obvious action or range of

actions indicated. At individual level youshould find that the person’s review has putright much of what was not working, butaction may also be required at anorganisational level.

b) Consider the underlying causes and what success would look like if the issuewere resolved

Often, it is useful to spend time thinkingabout the root causes of something that is notworking, and to understand these fully beforedetermining what action to take.

A simple process that can be useful here is the‘5 Whys.’ This means working in small groupsto interrogate an issue by brainstorming asmany reasons why this might be the case. The trick is to think as broadly as possiblewithout resorting to financial answers until allother possibilities have been explored.

Example A: In Gloucestershire one of theclusters was:

“I am not treated with respect or as anindividual by my paid carers”

The group who worked on this cluster came up with the following list of possibleroot causes:

• Paid carers are too task focused and notoutcome focused

• Poor quality and caliber of the paid carer

• We do not match paid carers to older people

• Paid carers get poor quality training and supervision

• We don’t know the older people well or

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Analyse

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understand them. Information is notrecorded for carers to use.Once the rootcauses have been identified, then look atwhat success would look like if these wereaddressed. In Gloucestershire the groupdecided that if the root causes wereaddressed, then success would mean thatolder people would say:

“My carers listen to me and understand whatis important to me”

“I look forward to my carer visiting me”

The staff supporting older people and theirmanagers would say:

“I love my job”

“I get good training and support”

“It is easier to respect others when you arerespected yourself”

“I have all the information I need – we havewritten information about what matters tothe person and how best to support them”

Example B: In Richmond, one of the clusters was:

‘I feel lonely’

Possible root causes for this are:

• We do not put enough emphasis onrelationships when we contract services

• Staff don’t know how to connect people

• Staff don’t see this as part of their job.They do not have time to do this

• We are not paying staff to help peoplewith their relationships

• Providers don’t see this as a priority

• CQC does not inspect on this, so Providersdon’t see it as important

• It is not part of induction training – or anytraining staff get

• This is not thought about when we thinkabout housing – we do not think aboutlocality and supporting relationships

• Staff don’t support people to think abouthow they can meet people and developrelationships or support existingrelationships

• Care managers do not see this asimportant when looking at placements.

Here is what success could look like if thesewere addressed:

For people:

“I have friends in my life”

“I feel supported to meet new people if I want to”

For staff and managers:

“Supporting people with relationships and helping them meet new people is

part of my job”

“I am supported to do this – through trainingand by my manager”

“ There is time to do this as part of my work role”

“I am pleased that I can make a difference to people by helping them have friends”

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“ We know that supporting people to make and keep friends is important to

those who commission our services”

“This work is costed into our contracts”

“We are evaluated and monitored on how well we do this”

“We are proud of how we are making a difference to people, and that people have friends”

Step 5: Action Plan

This is the “so what?” part of the process.You will have identified some commonthemes and issues from the person-centredinformation, you will have considered possibleroot causes and you will have thought aboutwhat success would look like should the issuebe resolved. In short, you will have developedsome insight and some shared understandingabout the things that are important to people.So what actions will you take as a result?

The process of action planning depends onthe decisions made at the beginning aboutpurpose and people. The different groups ofpeople will need to either plan how they willuse the information, or action plan directlybased on what the information shows them.

It is important that all groups represented atthe workshop are involved in action planning– commissioners, providers and user groups.Wherever possible, actions should be specific,realistic, tangible and measurable. Critically,they also need to be ‘owned’ so thatsomebody is held accountable.

In Wigan one of the ‘not working’ clustersthat the group worked on was “I don’t likewho I live with”. After considering possibleroot causes and thinking about what successmight look like, providers committed to thefollowing actions:

• Ensure that staff know people well (what isimportant to them and how to bestsupport people) and record what they learnin a person centred plan.

• The person centred plan includes‘matching’ information to help peoplethink about who they may want to livewith (if anyone) and information aboutdecision making (communication chart anddecision making agreement)

• Review the processes that are used formaking decisions about who lives togetherand ensure that these are as personcentred as possible

• Use person centred reviews to ensure thatthere are opportunities for people to saywhat is not working in their life (includingwho they live with)

• Continue to support people to move fromgroup homes into individual tenancieswhere they want to

• Work with the Commissioner to developindividual service funds.

Commissioners committed to the following action:

• Review the block contract tenderingprocess to develop a new frameworkwhere people can opt out of the blockcontract and have a personal budget.

‘They can use their personal budget to staywith their existing provider if they choosethrough and individual service fund.

Wigan People First committed to:

• Hold an event with other people withlearning disabilities to see how many otherpeople this was a problem for.

There are further illustrations and examples of action planning included in Appendix 1.

Step 6: Share information

A crucial final step is to share the information– most importantly the actions that haveemerged, with the people who shared theinformation with you through their reviews,and with other people who need to know orwould find it useful.

A simple ‘Who’ needs to know ‘What’ and‘How’ action plan for sharing informationshould be created at this stage.

In East Lancashire the Commissioners decidedto work with their providers group to sharewhat had been learned from this process.

The individuals decided to form a Tenants Association to share the actions from the process with other people who used the service.

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Data presentation and comparison

Richmond’s “working” data:

Wigan’s “working” data:

Richmond’s “not working” data:

Wigan’s “not working” data cross-referenced against the priorities thatdelegates set for action:

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Bar chart illustrating geographicalcomparison of mock “not working” data:

Bar chart of Wigan’s “important for thefuture” data:

Bar chart illustrating comparison ofmock “important for the future” dataacross different user groups:

This section describes a number of keyconsiderations when using working togetherfor change based on a “light touch”evaluation of its application by four councils.The evaluation at each event used thefamiliar questions of “what worked?”, “whatdidn’t work so well?” and “what needs to beconsidered for the future?” The primaryintention was to record people’s experiencesof using the process and their ideas forimprovement, rather than to apply academicrigour to evaluating the resulting actions –which will take longer to become fullyapparent. The comments and observations ofdelegates from events in Lancashire, Wigan,Richmond on Thames and Gloucestershireare drawn upon throughout.

This section should be read in conjunctionwith the specific pointers given for each ofthe six steps in the previous section. There isalso a list of facilitators “top tips” below toguide planning for the workshop/s.

Make it part of your programme

While working together for change can beused in isolation, there may be added valueintegrating it into a wider work programme tomaximise potential cross-benefits. The mostobvious value may be to commissioning workstreams, as part of the JSNA or the basis of aspecific service review, but the information

and analysis generated can be useful in otherways – for workforce development, systemsredesign or corporate planning for example.

Most obviously, the process requires that youare doing person-centred reviews. It isimportant that any parallel work you aredoing to design this process locally takes intoaccount the information requirements ofworking together for change. Introducing theprocess alongside changes to your reviews willensure you are extracting information forcommissioning from the very outset.

“Not just talk, we developed a clear action plan with a range of functional

and strategic outputs”

Get the right people there

This seems an obvious point, but it is worthstressing! For working together for change tobe effective, it is imperative that the rightpeople are in the room for the whole event orseries of events. The process allows multipleperspectives to be heard and it is the diversityof different stakeholders’ views that makesthe process valuable.

The ‘right people’ will obviously depend on the scope you have set for your projectbut the bare minimum is strategic decisionmakers from commissioning, people using services and/or their representatives

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Evaluation

and managers from provider services –especially if these are under specific review.

Other possibilities might include colleagueswith corporate responsibilities, people fromother statutory organisations, user ledorganisations and local advocacy groups –anyone who might reasonably be able to take action and/or influence change relevantto the project.

“It was good to have people fromcommissioning, providers, users and carers ina room together working to a shared agenda”

“I valued the opportunity to discuss withcolleagues from different disciplines”

“It would have been good to have Healthcolleagues represented”

Spend time on the positives

While there may be a natural inclination fordelegates to gravitate towards informationabout what isn’t working it is worth spendingthe time to dwell on the things that areworking for people. There can be as muchvalue in recognising and learning from successas there is in problem solving.

Delegates remarked that celebrating successwas not something their organisations wereparticularly good at doing and thought thatworking together for change events could beused to highlight best practice.

Experience has shown that finishing for a midmorning coffee break after the clustering andnaming of information about the things thatare working in people’s lives helps to buildpositive momentum and ownership of theprocess from the outset.

“It was good to finish with positivestatements about what success should

look like”

Don’t jump to analysis

There will naturally be a temptation toquestion and interrogate the informationabout what is not working and to startthinking of solutions as you go but it is betterto work through the process systematicallyand delay action planning until later.

It will not always be possible to fullyunderstand the context of certain statements,in which case the information should be takenat face value rather than explained away.

The richness and power of this informationsource is that it relates to real people’s lives intheir own words. This can be compromisedand diluted if statements are qualified ordismissed by the group, so any lack of clarityor specificity should be tolerated!

“Clustering statements in people’s own wordswas the most useful; the person-centred

reviews were very powerful”

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“It was good to have a diverse set of people looking at the data – statements arevery powerful when they are in the serviceuser’s words”

Make enough time for action planning

While we believe that working together forchange is a useful approach to analysing dataand identifying themes to inform strategicplanning, it will not directly determine theactions that should result. It is worthconsidering covering steps 1 to 4 in a one dayworkshop and making additional timeavailable for the subsequent action planningthat you do – a further half or whole day.

Since the action planning is done instakeholder groups (rather than mixed groups)it would be possible to integrate this into pre-existing management meetings. The importantthing is to ensure there is an opportunity forothers to comment on proposed actions –particularly those whose review informationhas been used for the process. As with anyaction plan, accountability for making ithappen, senior commitment and recognisablemilestones for implementation will make realchange more likely.

The Department of Health is planning further work to test a range of approaches to action planning with this information.

Meanwhile, some examples of actionsresulting from working together for changeare included in appendix 1.

Replicate and integrate

For working together for change to be effectivein driving changes in organisations and incommissioning it will need to be repeated andembedded rather than remaining a discreetproject within a particular service area. It will beimportant to revisit person-centred informationto determine if the changes you and others haveplanned are being felt by individual people andhaving the desired effect on their lives. Equally,the things that people identify as important forthe future may change over time and will needto be updated with sufficient regularity.

There are various considerations forembedding working together for changewithin systems, including:

• Making sure that all reviews are person-centred and extract the right information

• Ensuring that electronic systems canroutinely collate this information so that samples do not have to be amassed manually

• Considering software that can analyse andgroup a wider range of information – e.g.from all reviews

• Linking working together for change to thelocal cycle for JSNA

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• Using working together for change inshared services and with a wider group ofstakeholders – e.g. Health, the Police

• Establishing other “objective” performancemeasures alongside data from workingtogether for change so that outcomes canbe fully understood.

Facilitators Top Tips

• Ensure people know what they are coming to

• Allow enough time for effective pre-planning

• Allow enough time on the day – this caneasily overrun!

• Make sure you think about what it willtake for everyone to participate, forexample we had induction loops andmicrophones in Gloucestershire

• Involving people who have actuallyexperienced the reviews adds an extradepth to the process

• Use ‘rounds’ to ensure that everyone’svoice is heard

• Make sure that there is great wall space or use/hire pin boards

• Agree how you will feedback to everyone about the impact of the day on commissioning

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This report has illustrated how person-centredinformation can drive strategic change inorganisations and effect improvements incommissioning. It has also described how thissimple process can be practically useful tocouncils who are undertaking joint strategicneeds assessments and/or are seeking tobetter understand and measure the outcomesof personalisation.

When used alongside other data sources, theinformation from this process can helpcommissioners to engage people in shapingthe local availability of services.

The Head of Commissioning in one of the sites for this project described the process as “the very heart of goodcommissioning,” because it demonstrates the “golden thread” between what peoplesaid was important and what wascommissioned as a result. While the full co-productive potential of personalised socialcare will take time to realise, working togetherfor change is a flexible approach with tangiblebenefits that can be used now to move us inthe right direction.

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Conclusion

Working together for change is a potentially powerful tool that councilscan use to ensure that the current changes in adult social care are co-developed and co-produced with people and families. It is a tried andtested method for generating and analysing qualitative data forcommissioning which can improve the linkages between strategic decision makers and the people that they serve.

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APPENDIX 1: Worked examples

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Review for: Date of review:

Review facilitator:

People attending review:

Location of review:

1) What are the three most significant things that are important to the person from theirimportant to me now sheet?

2) From the person’s important for the future section, what are the three most significant things?

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APPENDIX 2: Person centred review feedback

3) What are the person’s main priorities in the whats working section of the review?

4) What are the person’s main priorities in the whats not working/what needs to changesection of the review?

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Documents

using person-centred information for commissioning · commissioning, in some cases are planning to extend its use into other service areas, and are considering what it might take