Housing models for the future

Housing is one of the challenges of our time. The task for architects and designers is to create affordable, robust housing that can accommodate the needs of a rapidly growing, but also ageing population. And it’s not as easy as simply building. The demands and expectations on house builders to also be community builders and the architects of mental and physical wellbeing through design have led architects and designers to consider alternative ways to house us in the future. This includes innovative use of materials and construction methods, addressing the issue of financing through co-operative living models and using bespoke design to create lifetime homes which can be adapted to accommodate the changing needs of our population.

Large-scale development

One of the big challenges for urban areas is large-scale development strategies for designing and delivering housing to meet need. For developers and planners going forward there are a number of factors to consider: the type of investment introduced to an area; how the schemes fit with a wider development plan for the city; and the importance of engaging the community in any plans to develop or regenerate an area.

“Placemaking”, not just house building is central to large scale development discussions, emphasising to planners, architects and developers the fact that they are not just building houses, but creating communities. As a result, designers and developers should be mindful of their important role in community building, to build the right sort of homes in the right places, at affordable prices and with a legacy in mind. They should, create high quality, long lasting units, which will stand the test of time but that also can be easily adapted to accommodate people’s changing needs.

Alternative construction and design

Innovative models and options for future builds have been discussed for a number of years but they are becoming an increasingly mainstream way to build affordable housing that meets the current need, particularly of students and young professionals, and of older populations looking to downsize or move into assisted care accommodation.

Offsite manufacture or modular homes  Offsite manufacture of timber framed houses is becoming increasingly common, with the constituent pieces of the house manufactured off site, then transported to the site and constructed on a concrete block where foundations and services such as plumbing have already been created. Offsite housing can either be open panel, which requires the finishing such as bathroom and kitchen installation to be done on site, or closed panel which provide the entire section complete with decoration and flooring (this is becoming a common way to build cheap, efficient student housing).

Custom build  Custom build projects are similar to self-build in that they give clients flexibility to select their own design and layout, However, custom build provides slightly more structure and certainty which can make it easier when considering elements like financing and planning applications. In essence, customers select the spec of their house in the same way they might make custom modifications to a car.

Build to rent  This model has been adapted from the United States, where build to rent is popular. The model is based on self-contained flats, with central and shared amenities, entrance and communal space. Designed to attract graduates and young professionals, these are being increasingly designed using a “user first” approach. Developers identify the sort of person they want to live in the development, identify what sort of things they might look for in a development, including floor type, furniture, layout, amenities, gadgets, and then build the development around that.

Dementia friendly – Building homes that are safe and affordable, but allow for independence in old age, is one of the major demands on house builders currently. Housing stock is seen as not suitable for current need, but building bespoke sites for people with illnesses like dementia has been seen as a bit of a niche previously. Virtual Reality (VR) is being used by some architects and developers to try to help them understand the needs and requirements of people with dementia and how they can build homes suitable for them to be able to live as independent and full lives as possible. Building dementia friendly homes not only means making them accessible and open plan, but also adapting the layout, adding signage where appropriate and if possible locating the homes within a wider community development. Dementia villages like those seen in Amsterdam are being used as the model for this.

Co-housing

Co- housing offers an alternative to communities in Scotland, and while lessons can be learned from elsewhere in Europe, where co- housing models have been successful, there are also pockets of good and emerging practice in the UK too. More traditional examples include Berlin, where almost 1 in 10 new homes follow the Baugruppe model, and Amsterdam (centraal wonen) where some of the oldest co-housing projects originate. In Denmark, 8% of households use co-housing models.

Co-housing provides the opportunity for groups of people to come together and form a community which is created and run by its residents. Each household has a self-contained, private home as well as shared community space. Residents come together to manage their community, share activities, and regularly eat together. A “Self-build Cooperative Group” is a joint venture between several private households who plan and build their own house together. Usually they are supported by an architect. Often co- housing groups are able to realise high-quality living space at prices below local market rates, although it is not really considered suitable for large-scale development within the current UK market.

Opportunities for a new way forward

Practitioners are often challenged to push the boundaries of design and building in their field. Looking to new models for future building design provides an opportunity to think creatively about alternative uses of materials and space and to consider options for construction, funding and investment in the built environment that challenge the norm. Learning lessons and exchanging ideas from elsewhere, architects and planners have the opportunity to come together to consider how the built environment in Scotland can help to create places  not just buildings  and how this can contribute positively to the wider wellbeing and happiness of people living in Scotland in the future.


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Using an asset based approach to support people with learning disabilities into work

This blog is based on discussions from the Scottish Commission for Learning Disability conference, held in Perth in September 2017.

Introducing an asset-based approach

The term ” asset-based” is commonly used within community development and public health. It is used to mean an approach that identifies and emphasises the strengths and abilities of people within a community.

Instead of focusing on what people are unable to contribute, asset-based approaches instead focus on finding the value and potential of each individual, regardless of their background or personal circumstances.

At the SCLD conference in September, the audience heard examples of how asset-based approaches are being used within the field of employment support. A number of projects across Scotland are creating opportunities for people with learning disabilities to participate and contribute to their local community through meaningful work that recognises their abilities, and not the barriers created by their disabilities.

Facilitating a culture change

Research by Mencap found that although around 8 in 10 working age people with a learning disability have one that’s mild or moderate, fewer than 2 in 10 are actually in employment. Overall employment rates are also much lower than for the rest of the population or for people with physical disabilities – although recent data is lacking, in 2008 a study suggested that only about 17% of all working age people with a learning disability have a paid job.

Enabling people with a learning disability to enter employment is something that requires more than a change in policy or increased funding to improve skills and access to employment schemes (although that is also invaluable). To successfully integrate adults with learning disabilities into the workforce requires a change in employer attitudes. More generally it also requires a transformation in how we perceive learning disability within society.

One of the biggest barriers to participation in employment, are the attitudes and perceptions of other people. Increasing the understanding of how much people with learning disabilities can bring to a job and a workplace is crucial. This is where asset-based approaches can really help. They focus on identifying and making the most of someone’s abilities, and allowing individuals to offer these skills and abilities as a part of a positive contribution to their community through work.

Projects that put people at their heart

The Scottish Commission for Learning Disability (SCLD) has supported a range of projects for people in Scotland with learning disabilities. In September 2015, SCLD announced that the Scottish Government was seeking applications for development funding to support the refreshed delivery approach for The Keys to Life (Scotland’s learning disability strategy).

Of the projects awarded funding, two focussed specifically on tackling underemployment among the learning disabled population.

  • Wee enterprizers (a project that aims to increase employment opportunities for adults with learning disabilities) helped a group of aspiring entrepreneurs with learning disabilities to progress their micro business ideas. Events and workshops allowed participants to come together and share business plans, marketing ideas, and resource strategies. It also helped to identify suppliers and trading opportunities. The Yunus Centre at Glasgow Caledonian University conducted an evaluation of the project. It found that as well as helping business ideas to get off the ground, it also helped to encourage personal growth and independence in participants, improved communication skills and provided an opportunity for entrepreneurs to form a network of their own to help support each other.
  • Tayberry Enterprises provided creative art activities, volunteer opportunities and training placements in catering for people with significant health barriers to employment. The Multi-Storytelling Project offered adults with a learning disability, experiential training apprenticeships in techniques that would help them communicate effectively in a variety of different ways.

More than just work

What these projects had in common was their ability to promote the holistic benefits of training and employment. Like anyone else, opportunities to work allow people with learning disabilities to form new and engaging relationships, and to feel that they are making a positive contribution to their community. This in turn helps them to feel valued as people, not limited by their condition or circumstances.

The use of asset-based approaches adds an extra layer, as they often highlight the advantages of bringing people from different backgrounds together. For example, a project that helps to get people with learning disabilities into employment by offering training opportunities, could also double as a centre for older people who suffer from loneliness, with both communities bringing unique perspectives and contributions to the table. This enriches the experience for everyone and helps to create stronger and more resilient bonds within the community.

Final thoughts

Employment opportunities are limited for people with a learning disability. However, schemes which take into account and actively seek to make the most of a person’s assets, can go some way to reducing negative perceptions and prejudice within society.

Everyone should have the opportunity to learn, form relationships and live their dreams and aspirations, while demonstrating how they can thrive and positively contribute to their local communities.


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Highlights of the SPEL conference 2017

This year’s Scottish Planning and Environmental Law conference, held in Edinburgh’s COSLA building, focused on Anticipating and preparing for change and covered a range of topics from the impact of Brexit on planning and environmental law in Scotland to how planning and planners can help tackle the growing housing crisis. Delegates were given the opportunity to reflect on the challenges for planning and environmental law in Scotland as well as the great opportunities the next few years may present to the profession.

Bringing the planning profession together

The conference provided an opportunity for professionals from across the planning and law professions to come together to discuss some of the key challenges to their profession going forward. While Brexit was high on the list of discussion topics, the possibilities for reform, and the opportunities for practitioners to learn and share their experiences and knowledge with one another, for what is now the 26th year of SPEL, continued to be at the heart of the conference discussions.

Is planning fit for purpose?

Chaired by Stuart Gale QC, from event sponsors Terra Firma Chambers, the conference was opened by Greg Lloyd who addressed the issue of the “distinctiveness” of the Scottish planning system, asking the question, “Is planning fit for purpose?” In the context of Brexit and with the benefit of years of planning knowledge, Greg discussed the performance of planning and how its modernisation is equipping planners to deal with challenges in the future.

The Rt. Hon Brian Wilson, former UK energy minister, spoke next on the challenges energy targets are posing not only for environmental lawyers and practitioners but also for planners. He discussed how the drive to achieve energy targets both in renewable and traditional energy generation needs to be tackled as much by planners as environmentalists and politicians. He also highlighted the need to meet the growing demand for energy by helping to reduce energy use and tackle wider socioeconomic issues relating to energy in Scotland.

Brexit – the impact on planning

The morning session was brought to a close firstly by Laura Tainsh from Davidson Chalmers who spoke about the intricacies, expectations, challenges and potential opportunities for environmental law and practitioners in Scotland following the UK’s decision to leave the EU. She highlighted the importance of ensuring that the essential elements of environmental law are retained within any future UK or Scottish legislation and that a system is created which provides an opportunity for robust scrutiny and maintenance of standards, specifically in relation to the consistency of application. She also discussed some of the ways in which existing principles and policies can be future proofed. Following on from Laura, Robert Sutherland gave an overview of recent developments in community right to buy in Scotland.

The morning session also included a case law roundup which reviewed and discussed recent significant cases including: RSPB vs Scottish Ministers (2017); Douglas vs Perth and Kinross Council (2017); and Wildland ltd vs Scottish Ministers (2017).

Delivering new housing

The afternoon opened with a panel session, where speakers tackled the million-dollar question of whether planning reform will assist in the delivery of new homes to help tackle the growing housing crisis. Speakers from Renfrewshire council, the University of Glasgow, house builder Taylor Wimpey, and Rettie & Co. discussed a range of topics from barriers to the delivery of homes and infrastructure, to the setting of national housebuilding targets, as well as the challenge of building the right sort of housing, in the right place at the right cost, and the role of local authorities in meeting housing need.

The afternoon session included a second case law roundup which saw review and discussion of recent significant cases including: Taylor Wimpey vs Scottish Ministers (2016); Angus Estates (Carnoustie) LLP vs Angus Kinross Council (2017); and Hopkins Homes Ltd. vs Scottish Ministers (2017).

The role of planning in driving inclusive growth

The conference was closed by self-professed “economic agitator” Ross Martin, who discussed the role of planning more widely within Scotland’s economy and its role as an agent for driving inclusive growth. He stressed the need for planners and other related professionals to look at the “bigger picture” when it comes to planning, using the system as the engine for growth and development, rather than as a barrier, and challenged those in the room to think creatively about how planning can play a role in strategic, but inclusive growth in Scotland going forward.

Some of the key points of discussion to come out of the conference were:

  • Planners, and planning lawyers need to recognise the importance of the wider social and economic context on their decision making, even if that decision only relates to one single building
  • Brexit is providing a lot of uncertainty and raising a lot of questions about the future of planning and environmental law in Scotland and the UK as a whole, but it may provide an opportunity for practitioners to take the lead and shape the system in a way that better suits current needs
  • There is scope and appetite, following the UK’s decision to leave the EU, to create a specialist planning and environmental law court to help scrutinise decisions and fill the void left by the EU in terms of accountability and implementation of environmental law, practice and strategy going forward

SPEL Journal is a bi- monthly journal published by the Idox Information Service. The journal is unique in covering all aspects of planning and environmental law in Scotland. Each issue contains articles on new legislation, significant court cases, expert comment on key planning appeals, government circulars and guidance, ombudsman cases and book reviews. SPEL deals with matters of practical concern to practitioners both in the public and private sector. Please contact Christine Eccleson at christine.eccleson@idoxgroup.com if you are interested in learning more about the journal or our subscription rates.

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Going grey behind bars: meeting the care needs of older people in prisons

The population is ageing. People are living longer, and are in need of greater levels of care than ever before. But how is this increase in life expectancy and demand for care being met in prisons? Our prison population is also ageing, at a time when the sector is under increasing pressure, low staff numbers, higher levels of prison violence and disorder, and poor, crowded living conditions. In an environment which is largely designed to support young, able bodied men, how are prison staff and care teams liaising to help meet the needs of older prisoners?

A care plan for ageing prisoners

A report published in 2017 by the Scottish Prison Service called for a specific care plan for ageing prisoners to react to and provide planning to reflect the change in demographic of the prison population. The report found that between 2010 and 2016, the number of men aged over 50 in Scotland’s prison population rose by more than 60%, from 603 to 988. According to a Ministry of Justice report on prison population, the number of inmates aged over 50 is projected to grow from 12,700 to 13,900 by the end of June 2020, a rise of 9.5%, while the number of over-60s behind bars will grow by 20% from 4,500 to 5,400 over the same period.

In July 2017 Prisons and Probation Ombudsman produced the Thematic Review: Older Prisoners, which stated that HM Prison and Probation Service needs a national strategy to address the needs of the increasing numbers of elderly prisoners. It highlighted six areas where lessons still needed to be learned: healthcare and diagnosis, restraints, end-of-life care, family involvement, early release and dementia, and complex needs.

The difficulties older prisoners face on prison estates are far reaching. Not only are there physical barriers to moving around and living within a prison environment, but the increased mental health and social care burden is significant, as well as the potential need to begin end-of-life care. Many prison inmates suffer from multiple, longstanding and complex conditions, including addiction, and these conditions are exacerbated by a phenomenon known as “accelerated ageing”, which suggests that prisoners age on average 10 years faster than people of the same age in the wider community.

While some prisons have effective care plans which allow older prisoners to live with dignity, often older prisoners rely on the goodwill of officers and fellow inmates to meet the gaps in their care needs. And while in England and Wales the Care Act means that, a statutory requirement to provide care lies with the local authority within which the prison is located, this is not a guarantee. Calls have been made for care planning in prisons to become more robust, with minimum standards of care and a clear pathway of delivery, with accountability and responsibility of specific bodies being made explicit.

 

Prison staff, care teams and the NHS in partnership

Any care planning for older people needs input from a number of different sources, and care planning for older people in prison is no different. It will require input from professionals across health, social care, and housing and the criminal justice system as well as wider coordination support and legislative and financial backing from central and local government.

Prisoners with physical disabilities or diseases such as dementia need specialist care at a level that standard prison officers cannot give. Research has suggested that prison staff are being expected to shoulder this extra burden, often having to perform beyond their duty to care for and look for signs of degeneration in prisoners, particularly those who show signs of Alzheimer’s and dementia.

A number of research studies have looked at the provision of training and the use of additional, multi-agency staff to try to bridge the gap in care for elderly prisoners. In 2013 a review was conducted of multiple prisons, including some in England, the USA and Japan, which examined the training available on each estate for prisoners with dementia and similar conditions.

A number of schemes have been trialled, including extra training for staff, the allocation of specific wings or cells adapted to cater to the specific needs of older and vulnerable prisoners, and the use of peer to peer buddying or befriending services to help with care and support. Some prisons have also trialled the introduction of “dementia champions” to identify and support those with early signs of dementia or Alzheimer’s.

Extra challenges on release

As well as social care needs inside prison, specific rehabilitative needs of older prisoners being released from prison is also something that prison charities and reform bodies are keen to raise onto the agenda. A report from the Prison Reform Trust in 2016 highlighted the challenges of rehabilitative and parole needs of older prisoners, commenting that older people released from prison are being “set up to fail” by a lack of adequate provision to meet their health and social care needs on release. It highlights the limited and inconsistent housing, employment, debt and substance abuse advice available specifically for older offenders and suggest that their particularly vulnerable position puts them at risk of serious harm or reoffending.

Final thoughts

The population of older prisoners in our prisons is growing, and it is clear that a comprehensive strategy is needed to ensure that the specific, and at times unique care needs of these prisoners are met. This will mean greater cooperation from social care, health and criminal justice agencies, but will also mean reassessing how we think about social care, how it should be delivered and funded. The needs of older prisoners go beyond physical adaptations, to mental health, dealing with social isolation, the onset of chronic illnesses and at times the provision and planning of end of life care.

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Helping people with dementia to live well through good urban design

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Joining up housing and mental health

The role of housing goes far beyond physical shelter and safety. It introduces people to a community to which they can belong, a space which is their own, a communal setting where they can make friends, form relationships and a place where they can go for support, social interaction and reduce feelings of loneliness and anxiety. Housing  stable, safe housing  also provides a springboard for people to begin to re-integrate with society. An address allows them to register with services, including claiming benefits, registering at a local job centre, registering with a GP, and applying for jobs.

Housing and health, both physical and mental, are inextricably linked. A 2015 blog from the Mental Health Foundation put the relationship between housing and health in some of the clearest terms:

“Homelessness and mental health often go hand in hand, and can be a self-fulfilling prophecy. Having a mental health problem can create the circumstances which can cause a person to become homeless in the first place. Yet poor housing or homelessness can also increase the chances of developing a mental health problem, or exacerbate an existing condition.”

Single homeless people are significantly more likely to suffer from mental illness than the general population. And as a result of being homeless they are also far more likely to rely on A&E services, only visiting when they reach crisis point, rather than being treated in a local setting by a GP. They are also more likely to be re-admitted. This high usage is also costly, and increasingly calls are being made for services to be delivered in a more interconnected way, ensuring that housing is high on the list of priorities for those teams helping people to transition from hospital back into the community.

Not just those who are homeless being failed

However, transitioning from hospital into suitable housing after a mental health hospital admission is not just a challenge for homeless people. It is also the case that people are being discharged from hospital to go back into settings that are unsuitable. Housing which is unsafe, in poor condition, in unsafe locations or in locations away from family and social networks can also have a significant impact on the ability of people to recover and prevent readmission.

Councils are facing an almost constant struggle to house people in appropriate accommodation. However, finding a solution to safe, affordable and suitable housing is vital. Reinvesting in social housing is a core strategy councils are considering going forward to try and relieve some of the pressure and demand. Gender and age specific approaches, which consider the specific needs of women, potentially with children, or old and young people and their specific needs would also go a long way to creating long term secure housing solutions which would then also impact on the use of frontline NHS services (by reducing the need for them because more could be treated in the community). Suitable housing also has the potential to improve employment prospects or increase the uptake of education or training among younger people with a mental illness. It would also provide stability and security, long term, to allow people  to make significant lifestyle changes and reduce their risk of homelessness in the future.

A new relationship for housing and health

A number of recommendations have been made for services. Many have called for the introduction of multi-disciplinary teams within the NHS, recruited from different backgrounds, not only to create partnerships with non-NHS teams, but also to act as a transitional care team, to ensure that care is transferred and dealt with in a community setting in an appropriate way, and to ensure housing is both adequate and reflects the needs of those who are most vulnerable.

In June 2017 the King’s Fund held an online seminar to discuss how greater integration between housing and mental health services could help accelerate discharge from hospital and reduce the rates of readmission for people suffering from mental illness. The panel included Claire Murdoch, National Mental Health Director at NHS England and Rachael Byrne, Executive Director, New Models of Care at Home Group.

Final thoughts

Increasingly the important link between housing and health is being recognised and developments are being made in acknowledging that both effective treatment and a stable environment are vital to helping people with mental illness recover and re-integrate back into their community, improving their life chances and reducing the potential for relapse.

Housing can be an area of life which can have a significant impact on mental health. It can cause stress, and the financial burden, possibility of being made homeless, or being placed in temporary accommodation can have a significant and lasting negative effect on people’s mental health. However, safe and stable housing can also have a significant positive impact on mental health, providing stability, privacy, dignity and a sense of belonging.


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Opt-in, Opt-out? A new system for organ donation in Scotland

Guest blog by Findlay Smith

Credit: Soeren Stache / DPA/Press Association Images

The Scottish Government is in the process of bringing forward legislation to introduce a ‘soft opt-out’ scheme for organ donation. Public Health Minister Aileen Campbell stated that the move will be one step of many in a “long term culture change” regarding organ donation.

A ‘soft opt-out’ scheme operates on the assumption that lack of objection on an individual’s part can be considered ‘deemed consent’.

This means that people in Scotland will have a choice to:

  • actively opt in – being placed on the organ donor register; or
  • do nothing – which will now be treated as ‘deemed consent’; or
  • actively opt out – being removed from the donor register

 Current situation in Scotland

According to the British Medical Association, as of 6 March 2017 there were 530 people in Scotland waiting for an organ transplant, with more than 1 in 10 dying before receiving a transplant.

Scotland currently operates an ‘opt-in’ system – to be a donor, you must actively register with the donor card scheme.

Although support for organ donation is high among the Scottish public, and there are indications of support for deemed consent, less than half of Scotland’s population are registered organ donors, with 45% registered.

Aimed at increasing the rates of organ and tissue donation, a public consultation was held by the Scottish Government between December 2016 and March 2017. The results indicated that 82% of respondents supported the principle of a ‘soft opt-out’ system.

Comparison with Wales

One example cited by the Scottish Government of a successful ‘soft opt-out’ policy is in Wales. In 2015, following the passing of the Human Transplantation (Wales) Act in 2013, Wales became the first country in the United Kingdom to introduce deemed consent for organ donation.

Due to these changes being implemented very recently, it is too early to accurately assess the impact of deemed consent in Wales, as it can take several years for an observable change in donation rates.

However, despite the absence of concrete figures, there are some promising signs. The British Medical Association reported in December 2016 that 39 organs had been transplanted in Wales as a direct result of the change in laws.

The Spanish model

Looking elsewhere in Europe, Spain has the highest rate of organ donation in the world, at a reported 40 donors per million people in 2015.

Whilst they have a nominally similar system to Wales, in practice they operate in a different manner. Although Spain introduced an ‘opt-out’ system in 1979, the system itself is considered ‘insignificant’ when looking to explain their world leading donation rate, as in the decade following the change in legislation there was no substantial increase in organ donation. This may be due in part to the ‘opt-out’ process rarely being applied in practice, as family members always have a final veto.

Crucially, in addition to the change in system, Spain has also drastically improved the infrastructure used to identify and recruit potential donors. In 1989 the National Transplant Organisation (ONT) was established, and Transplant Co-ordinators were placed inside every hospital.

The role of the Transplant Co-ordinator is to identify potential organ donors as early as possible. What makes the Spanish model innovative (it has since been emulated elsewhere in Europe), is the widening of the pool of potential donors. Rather than focusing on people in intensive care, potential donors are also identified in accident and emergency rooms and hospital wards.

The role of family members in this process is also key. The early identification of potential donors allows a strong relationship to be built with family members. As they have the final say, getting them on board early can make a significant difference. The Scottish Government seems to be aware of this, having conducted a fact-finding mission to Madrid in 2015, consulting ONT Director Rafael Matesanz.

Final thoughts

The examples highlighted suggest that if the introduction of ‘soft opt-out’ legislation is to be successful, it may not solely be the result of the legislation on its own. Improvements in infrastructure, organisation, and dialogue with families of potential donors will also be crucial. Transitioning towards this change in practice will require a change in culture in the NHS around organ donation.

These steps taken in Scotland, which follow the lead of Wales and draw from the Spanish model, are also now being considered in England. Assisted by a lengthy campaign from the Daily Mirror, Labour MP Geoffrey Robinson’s Organ Donation (Deemed Consent) Bill was introduced to Parliament on 19 July 2017 and is due for debate on 23 February 2018.


Findlay Smith is currently in his final semester of study of the MPP Public Policy Programme at the University of Stirling. Findlay has recently completed a voluntary two week work experience placement with the Knowledge Exchange team in Glasgow.

Buurtzorg: reinventing district nursing in Scotland

Buurtzorg roughly translates from its native Dutch as “neighbourhood care”. The model, used extensively in the Netherlands, has attracted international attention as a novel way to deliver community based nursing programmes. Its positive reputation and recorded successes in areas of Holland are attributed to its innovative use of locally-based and locally-aware nursing teams to deliver high-quality person-centred, but low-cost, care.

Seeking to improve core health outcomes

In the Netherlands, Buurtzorg was designed to engage three key health priorities:

  • Health promotion
  • Effective management of conditions (in a community setting)
  • Disease prevention

It focused particularly on the elderly, those who move regularly between hospital and home, and those with long term, constant care illnesses. It has also been used with patients with progressive illnesses such as dementia, with some nurses within the teams being given training to become dementia specialists where appropriate.

The model includes the following key elements:

  1. Holistic and personalised care – where assessments of need are integrated into and form the foundation of agreed care plans
  2. Mapping networks of informal care, and assessing ways to involve these networks in treatment plans
  3. Identifying other formal carers and organisations who provide care services and coordinate their input
  4. Taking steps to support the client in his/her own environment
  5. Promoting self-care and independence on the part of patients.

A number of studies of pilot sites across the UK and beyond have identified the positives and some challenges of applying the Buurtzorg model in different contexts. Some of these are outlined in the table below.

Applying the model in Scotland

In a Scottish context, the model has been applied in a number of areas, with the initial pilots making way for a wider roll out of adaptations of the model. In March 2017, as part of a wider research project, nurses and management staff from NHS boards across Scotland met in Perth to discuss learning and exchange best practice around how the model could be adapted and further rolled out in the future.

It highlighted the different stages that many Buurtzorg areas were at in their roll out, with some like Aberdeen and the Borders far more established than Argyll, who were at the time only in the earliest stages of their Buurtzorg journey. The research and learning event gave practitioners the opportunity to engage and further cement both formal and informal learning networks, which have been identified as key to the success of the Buurtzorg model both in the UK and elsewhere.

The importance of information sharing and informal learning

Rolling out the model in test sites highlighted the importance of planning and learning, and of creating a strong sense of trust between practitioners and NHS management, but also between the Buurtzorg nurses and their service users and other professionals. This change in mindset regarding ways of working, and a change in the chain of accountability was something, which, according to those practitioners who attended the Perth event, many sites have found to be a significant barrier to effective implementation.

However it was also highlighted that promoting and facilitating the creation of formal and informal learning networks and learning spaces can be an effective way to generate conversation about best practice as well as allaying some fears that may persist regarding working culture and approaches, including partnership working with other agencies and understanding risk in the working environment.

In Scotland, approaches have varied, from encouraging nursing teams to create videos and then post them to an online forum, employing more formal training plans to incorporate multiple agencies and ensure that everyone is “singing from the same hymn sheet”, or holding informal drop-in or open space events where staff are supported in their role and given advice to alleviate and find potential solutions to issues.

Practitioners also highlighted that it is important to provide a space where teams can examine what did not work well, and why. Learning from mistakes can often be as beneficial as learning from good practice, as these can provide insights into issue management and resolution as well as how to implement the programme effectively.

It is also clear from feedback, that while a strong core network of nurses and other community based practitioners is vital to the success of Buurtzorg care models, the back team support is also just as important. Creating efficient and streamlined processes leaves nursing teams free to care for patients and allows them more time to develop and deliver the person-centred care which is a key element of the Buurtzorg model.

Final thoughts

Learning from the experiences of the trial projects in Scotland has provided invaluable insights on how the model can be applied and some of the challenges that can be encountered because of the differing context. This knowledge can then be used to shelter and steer newer projects away from danger areas toward best practice and innovative collaborative working. Applying Buurtzorg in Scotland gives the potential to create and implement new models of holistic person-centred care, where practitioners with local and specialist knowledge interact at a local level with other care providers, join up approaches and create a better care experience for service users.

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Maggie’s Centres: wellness through building design and the environment

In March 2017, the 20th Maggie’s Centre was opened in the grounds of Forth Valley Royal Hospital in Falkirk. Designed by architects Garbers & James, it is expected to receive 3000 visits in the first year.

Maggies Centre Forth Valley, Garbers and James

Maggie’s provides free practical, emotional and social support to people with cancer and their family and friends, following the ideas about cancer care originally laid out by Maggie Keswick Jencks and co-founded by her husband Charles, who is a landscape architect. Among Maggie’s beliefs about cancer treatment was the importance of environment to a person dealing with cancer.

She talked about the need for “thoughtful lighting, a view out to trees, birds and sky,” and the opportunity “to relax and talk away from home cares”. She talked about the need for a welcoming, reassuring space, as well as a place for privacy, where someone can take in information at their own pace. This is what Maggie’s centres today aspire to.

A number of high profile architects have designed Maggie’s Centres across the UK – from the late Zaha Hadid to Frank Gehry, Richard Rogers and Rem Koolhaas.

The Maggie’s Centre in Kirkcaldy, Zaha Hadid Architects

Promoting wellbeing through the natural environment and effective design

Drawing on research which considers the significant impact that environment can have on wellbeing, Maggie’s Centres are designed to be warm and communal, while at the same time being stimulating and inspiring. The interiors are comfortable and home-like. Landscape designers and architects are encouraged to work closely together from the beginning of a project as the interplay between outside and inside space, the built and the “natural” environment, is seen as an important one.

A building, while not wholly capable of curing illness, can act as “a secondary therapy”, encouraging wellness, rehabilitation and inspiring strength from those who move around it.”

Each of the centres incorporates an open kitchenette where patients can gather for a cup of tea, airy sitting rooms with access to gardens and other landscape features, and bountiful views. There are also private rooms for one-on-one consultations; here Maggie’s staff can advise patients on a range of issues relating to their condition, whether that is dietary planning, discussing treatment options (in a non-clinical setting) or delivering classes such as yoga.

Spaces to promote mental wellbeing as well as physical healing

Maggie’s Centres are also about offering spaces to people to help improve their mental wellbeing. As well as quiet tranquil spaces for reflection and meditation, there are also central areas, focused on encouraging the creation of a community between the people who use the centre. Wide-open spaces, high ceilings and large windows, with lots of opportunities to view the outside landscaping and allow natural light to enter are a key feature of many of the Maggie’s Centres.

The locations also try as far as possible to provide a space free from noise and air pollution, while remaining close enough to oncology treatment centres to provide a localised base for the entire treatment plan of patients.

Fresh air, low levels of noise and exposure to sunlight and the natural environment, as well as designs that provide spaces that promote communal interaction to reduce feelings of isolation and loneliness, have all been shown to improve mental as well as physical wellbeing. In this way, the physical attributes and design of the Maggie’s buildings are helping to promote mental as well as physical wellbeing of patients and supplement the care being given by the cancer treatment centres located nearby.

Interior of the Maggie’s Centre in Manchester, Foster and Partners

Award-winning architecture and design

In 2017 Maggie’s Manchester was shortlisted for the Architects’ Journal Building of the Year award. And many of the individual centres have won regional design awards for their innovative use of space and incorporation of the natural environment into their designs.

A Maggie’s garden was also featured at the 2017 Chelsea Flower show, highlighting the importance of environment, and the role of the natural environment in rehabilitation and promoting wellness among those who are ill.

Final thoughts

How design and landscape can aid and empower patients is central to Maggie’s Centres. They are a prime example of how people can be encouraged to live and feel well through the design of buildings and the integration of the surrounding natural environment. These environments are the result of a complex set of natural and manmade factors, which interact with one another to promote a sense of wellness, strength and rehabilitation.

They demonstrate how the built environment can contribute to a holistic package of care – care for the whole person, not just their medical condition. Other health and social care providers can learn from them in terms of supporting the wellbeing of patients, carers and their families.


You can find out more about Maggie’s Centres though their website.

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Read more about innovative building design in our other blog articles.

Creating sustainability in health and social care

The question of the sustainability of funding for health and social care services has been in the spotlight recently. The Conservative Party manifesto contained proposals around making individuals pay for more of their social care costs, to deal with the “challenges of an ageing society”. Meanwhile, figures suggest that NHS Trusts in England overspent by £770m last year despite a focus on efficiency savings.

However, creating and maintaining sustainability in health and social care is much broader than financial sustainability. It means considering other factors, including environmental, training and project management issues. This takes planning, commitment and an understanding of the aims and expectations of staff and senior management.

A research symposium earlier this year (hosted by Healthcare Improvement Scotland and partners) explored these issues further, looking at the evidence underpinning ways to create sustainable health and care systems.

Environmental sustainability

Environmental sustainability is something which all organisations are being asked to address and improve. The issue of climate change has led to a focus on behaviour change and a more sustainable use of resources.

  • Buildings – This includes the planning of new healthcare buildings, as well as adaptations to existing structures to make them more energy-efficient. Alternative building materials and designs have been used in new projects to improve energy efficiency, with some buildings even incorporating wind turbines, solar panels and geothermal capture centres. Reducing waste water and improving temperature regulation through heat capture and insulation techniques are also being adopted. While these may be costly initial spends for many, the long-term cost savings are also significant, as well as ensuring that the buildings meet minimum national requirements for energy efficiency and contribute to emissions reduction targets.
  • Resource, waste and recycling management – In many offices and clinical centres, individuals are encouraged to be personally responsible for their own reduction in waste and improved use of recycling facilities; however, this must also be facilitated at an organisational level. Clearly labelled recycling bins, promoting reduction in of the use of disposable water and coffee cups, and encouraging employees to use less paper when report writing (printing double sided for example, or going paperless where possible) are all simple ways in which environmental sustainability can be promoted in health and social care settings. Innovative techniques such as reusing water in internal plumbing, or creating bespoke recycling facilities to help reduce the amount of clinical waste incinerated, are being developed.
  • Remote monitoring and the use of technology – There have been major advances in the use of remote technology to host meetings, video-conferences, follow up appointments and assessments for those in receipt of reablement care via tele-health. Remote monitoring of patients, as well as the use of tele-health and other digital platforms can allow consultations and routine check-ups to take place without either party having to leave the house or office, thereby reducing vehicle emissions used in transport. In social care, remote meetings and cloud-based reporting can allow front-line social workers to remain out on visits instead of having to return to the office to fill out reports, again reducing vehicle emissions.

Sustainable resource management

In the face of more limited funding, joint working between health and social care is being heralded as a new way of cost saving, making the most of ever-depleting resources in the face of ever-greater demands. Being efficient with resources, through effective planning and management is one of the key ways to ensure resource sustainability in the long term, especially for the NHS and local authority social care teams.

Approaches include:

  • Making full use of the entire health and care ecosystem – This means using the entirety of the health and social care ecosystem, its capacity, expertise, resources and the end-to-end care it can provide. It means engaging carers, GPs, nurses, and pharmacists to improve efficiency, make better use of resources, spread the workload and improve satisfaction levels and outcomes for service users.
  • Using careful and well-managed commissioning models  This means making good decisions about commissioning and outsourcing to make best use of funding and other available resources. It also means allocating to appropriate projects, being mindful of the possible consequences of payment by result frameworks, and getting the best value possible.

Sustainability in practice

The final level of sustainability in relation to health and social care practice involves the sustainable implementation of programmes. This means finding ways to ensure that implementation is carried out in ways that ensure long term success and positive outcomes. It involves understanding context, and the culture of the organisation and makes reference to something discussed previously in our blog on implementation science.

Ensuring sustainability in practice requires multiple efforts including:

  • Making sure that practice becomes embedded into everyday work
  • Sharing best practice
  • Maintaining motivation among your workforce
  • Using robust, local evidence in a way that is clear and concise.

Understanding what kind of evidence leads to sustainable programme implementation is also important: economists prefer cost-based strategies, chief executives want one-page summaries, professionals want examples of other organisational based programmes and what was required to implement effectively, and councillors want case studies based around the positive impact on services users. Case studies can at times actually be the least helpful because even in a failing programme there is usually one example you can use to find positives.

Another issue with evidence is the reluctance to report on issues or challenges, or failed projects, when actually some of the greatest insight can be gained from this. All of the learning that can be gained from failures could be useful when trying to make programmes more resilient so they can be more sustainable.



Final thoughts

The concept of sustainability in health and social care cuts across many areas of organisational management and personal practice and behaviour. Encouraging and participating in sustainable practice can mean anything from being more environmentally friendly by digitising reports, recycling paper or changing to energy saving lightbulbs to promoting sustainability of resources through efficient and effective management, utilising the skills, expertise and resources of the entire health and social care ecosystem.

These approaches to sustainability should not only help health and social care as a profession to be less impactful on the environment but will also allow organisations to save money, improve efficiency and ultimately improve outcomes for patients and service users as a result.


* The 5th Annual Research Symposium: Evidence for sustainability – exploring the current evidence underpinning ways to create sustainable health and care systems was held on 16 March 2017. It was jointly hosted by Healthcare Improvement Scotland, Health Services Research Unit and the Health Economics Research Unit at the University of Aberdeen, and the Nursing, Midwifery and Allied Health Professions Research Unit at the Chief Scientist Office.

If you enjoyed this blog, you may also be interested in other articles on implementation theory and commissioning in health and social care.

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Learning from mistakes: reflective learning in social work

No one likes to talk about their own mistakes. They are an inevitable part of the human condition, highlight our flaws, inabilities and limitations and can place a spotlight on what happens when resources and people are stretched too thinly.

In certain professions, including frontline social work, mistakes – however innocent or unintentional – can have potentially life-changing effects for service users. Keeping them to a minimum is of paramount importance. And it’s important that if mistakes have been made that they are not only rectified but also analysed to consider what went wrong, and what can be done to avoid the same thing happening again. For social workers the stakes could not be much higher – people’s lives are in the balance. So how can social workers not only recognise, reduce and rectify mistakes, but also use them as learning opportunities to improve performance and decision making in the future?

Making the most of our mistakes

It is important that practitioners and their managers know which strategies are most effective for them and their team when it comes to extracting valuable insight from mistakes. This only comes from having a strong and secure working relationship, where people feel able to talk openly and reveal insecurities and inadequacies, as well as recognising the positives within their practice.

Working out the correct strategies for each occasion and for each team member will take time. However, some tools and strategies include:

  • learning how to generate effective questions to explore not only how a mistake happened, but why and what steps can be taken to prevent it from happening in the future
  • adopting a strengths-based approach, rather than a deficit-based approach to staff and any mistakes they made
  • reflective frameworks that can be formally incorporated into everyday practice
  • encouraging staff to find a “critical friend” to offer an external perspective and extend personal reflective capacity
  • encouraging staff to take up reflective writing (in everyday life, not just at work) including journals and diary entries
  • training staff on creative models of reflection and on how to give and receive constructive feedback
  • finding ways to feed back to an entire organisation regarding the lessons learned from mistakes and how they can shape practice in the future.

The reflective cycle

One of the traditional models of reflection for social workers is Gibbs’ cycle of reflection (1988).

Among social workers, reflective practice is often promoted. Personal experience and participation should be seen as a positive and an opportunity to develop new skills, learning or approaches. Reflection should be focused on professional errors, asking questions like “why”; “what went wrong”; and “what did I do wrong.”

Reflection can happen at three levels:

  • personal
  • one-to-one with another person (a supervisor, colleague or family member)
  • in groups (at organisational level)

It can be useful to reflect at all levels, where possible, in order to get the most out of the experience and have the biggest impact with regard to what can be learnt from mistakes and how this can be passed to others to avoid them making the same ones.

Taking and giving constructive feedback

Although it may be uncomfortable at the time, social workers and people from other professions should welcome feedback from colleagues and service users as they can be powerful sources to drive professional growth. However, it is important to distinguish constructive feedback from blame. Highlighting helpful advice and using it in a constructive way is not the same as finger pointing and fault picking, and managers must develop the ability to distinguish between the two.

Final thoughts

Mistakes happen, and although we don’t like to talk about them, they can sometimes provide some of the most useful insight for learning and improvement within an organisation. Beyond the organisational level, personal reflection on practice and taking time to consider how you approach certain situations is a vital aspect of the self-aware, continual improvement that social workers must strive towards, even if they don’t always meet the exacting standards all of the time.


If you enjoyed this blog post, you may also find the following article of interest:

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