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.

Follow us on Twitter to see what developments are interesting our research team.

If you enjoyed this blog, you may also be interested in our other articles:

Helping people with dementia to live well through good urban design

Planning for an ageing population: some key considerations

Co-production in the criminal justice system

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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If you enjoyed this blog, you may also be interested in our other articles on health care and reablement care

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.


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Zero suicide cities: learning from Detroit in the UK

Suicide is the biggest killer of men under the age of 45. Yet people still experience stigma when seeking help for mental illness, despite high-profile discussions of mental health issues such as those by members of the royal family and sportspeople. And a report into the Government’s suicide prevention strategy in March 2017, suggested that although 95% of local authorities now have a suicide prevention plan, there is little or no information about the quality of those plans, or whether adequate funding is available to implement them.

The lack of progress made on improving suicide and general mental health provision has led to a growing frustration among professionals and resulted in attempts to create new approaches to tackle mental health issues, and in particular to improve access to support for people in crisis or at risk of suicide.

The idea of a “zero suicide city” was first adopted in Detroit in the late 2000’s, with others following its lead in subsequent years. With reports finding that around 14 Londoners a week took their own life in 2015 (735 in total), an increase of a third from the 2014 statistics, a report in February 2017 by the London Assembly Health Committee suggested that London too should take this approach.

So what can London, and other areas of the UK, learn from Detroit’s approach? And how can services act to reduce the number of people taking their own lives?

Zero-suicide cities

Poverty and high unemployment in Detroit are contributing factors to high levels of depression among city residents. As a result of these high rates of depression and very high suicide statistics, Detroit-based mental health professionals adopted a new approach to tackle the stigma around mental illness and use identifiers to highlight cases of crisis, or potential crisis. The focus is on preventative care, encouraging professionals to act upon signs of mental illness before a suicide or attempted suicide takes place.

Patients attending health clinics for other illnesses, including diabetes or heart failure, are also now screened for depression and other mental health issues before they are released. This allows people deemed to be ‘at risk’ to be identified as soon as they come into contact with medical professionals, who can then refer the patient to a mental health specialist if needed, rather than reacting to mental illness once it reaches crisis point.

In order to support this approach, a centralised IT system was created which means results are traceable, and surveys and information are standardised so they can be used and accessed across clinics throughout Detroit. Coordination with non-medical practitioners, including social workers, employers and family members, has also been key in identifying people at risk and signposting them to help at every possible opportunity. There has also been additional training for staff to improve recognition of identifying factors. Patients can email their clinicians or liaising staff directly and attend regular drop-in appointments. Up to 12,000 patients using mental health facilities are tracked each year in the city and some statistics suggest that the clinics reduced suicides by over 80%.

There have been some criticisms of the system however, despite the reduction in the number of suicides in the city. Critics highlight the fact that many of the poorest and most severely in need of help are not reached as they do not have health insurance and so do not attend those clinics involved in the scheme.

Ultimately, however, the scheme seeks to provide better preventative, coordinated and targeted care to those who are at risk or show some signs of mental health crisis. And some in the UK have suggested there are lessons that could be learned from this approach.

Whole system approach to suicide prevention in the East of England

Four local areas in the East of England (Bedfordshire, Cambridgeshire & Peterborough, Essex and Hertfordshire) were selected in 2013 as pathfinder sites to develop new approaches to suicide prevention based in part on the Detroit model.

Since then, Mersey Care, Cambridge and Peterborough Clinical Commissioning Group and Teesside councils have also become aligned with the programme and are continuing with their approach towards improved suicide prevention. The Centre for Mental Health evaluated the work of some of the sites during 2015.

The evaluation found there were a range of activities that had taken suicide prevention activities out into local communities. They included:

  • training key public service staff such as GPs, police officers, teachers and housing officers
  • training others who may encounter someone at risk of taking their own life, such as pub landlords, coroners, private security staff, faith groups and gym workers
  • creating ‘community champions’ to put local people in control of activities relating to promoting positive mental health and signposting to help services
  • putting in place practical suicide prevention measures in ‘hot spots’ such as bridges and railways
  • working with local newspapers, radio and social media to raise awareness in the wider community
  • supporting safety planning for people at risk of suicide, involving families and carers throughout the process
  • linking with local crisis services to ensure people get speedy access to evidence-based treatments.

However, subsequent research also highlighted some of the challenges. The marketing of the pilots was seen to be damaging and misleading with regards to creating “zero suicide areas”, rather than suicide prevention areas. It has also been suggested that although the campaigns serve to raise publicity and awareness, there is little evidence that the schemes actually reduce the number of suicides in an area any more than “traditional campaigns” to better signpost people to available support.

In addition, many of the projects struggled past the initial implementation stage to have long-term impact, as the buy-in from local GPs and other service professionals was not as high as was expected.

Final thoughts

Widening and improving access to support and services for people at risk of mental ill health or suicide is a big challenge for health and social care professionals. Identifying those people at risk is one of the key barriers and taking inspiration from schemes like those trialled in Detroit is one way for professionals in the UK to adapt their approaches in order to overcome these barriers.

Providing more opportunities for people to get help, and better training for professionals who may come into contact with people with mental illness are some of the ways that current schemes are trying to address mental health and suicide in particular.

However, as many of the evaluative studies from test sites in the UK have found, going beyond that to take mental health into the community, in order to create whole system pathways of care across multiple settings and professions, remains a challenge.

As the London Assembly report pointed out, another key aspect is creating an open environment for people to talk about how they are feeling. This week is Mental Health Awareness Week 2017 and the theme is ‘surviving to thriving’ – and emphasising that good mental health is more than the absence of a mental health problem. Whether in the workplace or in the home; with friends, family or colleagues; it’s important that everyone feels that they have a space where they can talk, and to cultivate resilience and good mental health.


If you enjoyed this blog, you may also be interested in our other articles on mental health in the workplace.

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“Business is an act of citizenship”: using BIDs to promote inclusive economic growth in communities

The key to inclusive place based economic growth?

The principle of Business Improvement Districts (BIDs) is pretty straightforward, and the legislation in Scotland is flexible enough to ensure that pretty much anyone can create and act on a BID-based idea. There are currently over 30 live BID projects in Scotland, with BIDs Scotland stating in their latest annual report that they believe this number could almost double to 65 by the end of 2017 if upcoming and scheduled BIDs are also taken into account. The report found that, despite continuing tough economic conditions, there appears to be little evidence of a decline in interest in the BID model. If anything, more people are turning to BIDs as a way of improving local high streets using limited local funds, private investment from local businesses, and other local assets.

BIDs themselves can be seen as a cross section – a mix of the entire economic ecosystem of a place. They can encompass economic, business, local, political and social elements and bring them together in a strategic way to build revenue to support the different aspects of the BID area, including aesthetics, security and commerce. They are locally developed, locally managed, locally financed and locally delivered, giving a sense of authenticity which is becoming increasingly popular among consumers. This popularity is evidenced by the successful renewal of all of the BIDs in Scotland who have gone to reballot to date, with many actually increasing their majority in favour of the BID model.

Collaboration and embedding BIDS within their local communities

As BIDs have been developed, and new models, partnerships and ways of co- operating have been established, BID coordinators and councils in particular are thinking about how to ensure the legacy of the BID within their locality and, more importantly, how to ensure that the economic benefits of the BID are felt across the BID area, not just within the businesses.

This area-wide benefit can be created by for example, re-investing money in security, street lighting, Christmas lights, and flower baskets to improve the feel and aesthetics of a place – actions which are commonplace in BID areas. However, there are some who feel that BIDs could and should go even further in increasing their social value within a community, while not losing sight of the interests of levy payers. This balance, which requires recognition of the wider roles and responsibilities of BIDs, is something which will have to be carefully managed by BID managers in order to ensure that BIDs do not try to do too much, but at the same time act in a way which makes them a key part of their local community and economy. It is an interesting and, at times, difficult place for progressive BIDs to be.

In many areas, BIDs have provided an opportunity for increased community development, and it has been suggested that there could be a formal role for BIDs to play in the wider community development partnerships within localities. BIDs are now being developed to sit alongside existing community anchor bodies, helping to create strong local partnerships and independent communities.

Through collaboration and co-ordination, BIDs are working alongside other services and organisations to help develop sustained community empowerment, helping communities to lobby, providing work experience placements to local young people and acting positively in the form of events to promote increased community cohesion and empowerment, as well as continuing with “normal practice”- increasing footfall in their local area to benefit businesses.

Not all about the money

While generating additional income for the local economy is one of the biggest drivers of support for BIDs in communities, in some instances one of the biggest assets they bring to a community (especially once they are firmly established) is their leverage and collective bargaining power. They have the power to campaign and support other groups in the community on issues that are important to them, as well as offering greater bargaining power with local authorities or other businesses.

As well as commitment to the levy payers’ interest and to improving the local area for people living nearby, another of the potential roles of BIDs is not to act as direct income generators, but as catalysts or facilitators, to encourage new investment and wider growth beyond the BID area – to engage strategically with other partners to encourage investment.

 

Where next for BIDs

As we have already seen, the flexibility of the BID model in Scotland (there are some legislative differences in England) is such that groups may only be limited by their own ambition. Currently Scotland has what is thought to be the world first food and drinks BID and the first tourism BID this side of the Atlantic. Another innovation is the Borders Railway BID, which seeks to maximise the collective benefit to businesses that are located along the railway route.

It has been suggested that the BID model could be used in a more flexible way to generate income for other public service projects, including the suggestion of a BID for health and a BID for schools. Although the intricacies of how these would work in practice are still being considered, there is much that can be taken from how the existing models use community empowerment, and engagement between the public, third and private sectors to create sustainable and inclusive local economic growth in an area.

As well as their commercial enterprising side, BIDs are also realising their potential as agents of community development and improvement beyond that of economic input. The future currently looks bright for BIDs, which will hopefully mean that it also looks brighter for our local communities.


Business Improvement Districts Scotland is the national organisation for BIDs in Scotland, providing support, advice and encouragement to business groups, communities and local authorities considering and developing a business improvement district.

BIDs Scotland held its Annual Gathering on 28th March 2017 at Perth Concert Hall  with the theme of People – Place – Business: Business Improvement Districts – the key to economic growth.

Follow us on Twitter to see what developments in public and social policy are interesting our research team. If you enjoyed this article, you may also be interested in our other article on BIDs.

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World Social Work Day: promoting community and environmental sustainability

Tomorrow is World Social Work Day (WSWD), and this year the focus is on community sustainability. The theme is inspired by the third pillar of the Global Agenda for Social Work, which was created in 2010 to integrate the aims and aspirations of social workers across the world. It stresses the important role of social workers in prompting sustainable communities and environmentally sensitive development.

This includes:

  • working closely with other partner agencies – including those beyond social work – to create communities of practice, particularly in relation to environmental sustainability;
  • promoting community capacity building, through environmentally friendly and sustainable projects, where possible; and
  • responding to environmental challenges, including helping communities to be resilient to and recover from environmental and natural disasters, as well as in relation to “human disasters” which includes refugee families fleeing persecution or war.

But how does this play out in everyday practice?

Supporting integration

Across the world, social workers are being asked to address ‘human disasters’ as they seek to support and integrate refugee families fleeing persecution and war in conflict zones. Some of the biggest challenges for social workers today relate to refugee and displaced communities. As well as dealing with the effects of trauma, they also help integrate refugees successfully into existing communities and build bridges with others to promote cohesion, reduce tensions and help them make positive contributions to society. Social workers also have a responsibility to encourage all members of the community to help with this support and integration process.

However, in a UK context, supporting people to make positive contributions to their community is not limited to refugee families. It also relates to intergenerational work, valuing the experience of older people, developing the skills of vulnerable adults, or encouraging children to feel connected to a place and community so that they might better take care of it as they grow up.

Supporting sustainability

The role of social workers in supporting the sustainability agenda may not be so obvious. The ability of social workers to adapt and respond to the needs of communities which are experiencing environmental sustainability issues is of growing importance in developing countries. However, social workers in the UK can still contribute to this element of the global social work agenda.

This includes behaving in a way that recognises the need to protect and enhance the natural environment. In practice, this may mean social work departments having policies on going paperless where possible, recycling in offices, and reducing the use of cars, or car sharing (for frontline social workers, however, this is often impractical).

Social work practice can also consider how it supports sustainable social development outcomes within a community, and maintaining personal CPD, education and training levels to reflect this. There should also, as always, be an attempt to share best practice and learn from others.

Final thoughts

This World Social Work Day, let’s take a moment to reflect on the positive contributions that social work professionals are making to their communities as well as to the lives of individuals. It’s also a chance to consider what the future might hold for the profession and how it can continue to promote and support the growth and development of sustainable communities.


If you would like to follow the events going on to mark World Social Work Day or, share any of your own stories you can do so on twitter using the hashtag #WSWD17.

We regularly write on social work topics. Check out some of our previous articles:

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