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.

Follow us on Twitter to see what developments health, social and community care are interesting our research team.

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

 

The power of personal budgets

Image by Tristan Martin via Creative Commons

Image by Tristan Martin via Creative Commons

Described by supporters as having revolutionised the way the social care system in England is organised, personal budgets have developed to become the norm in social care commissioning in England.

One of the ideas underpinning personal budgets is the development of a new relationship between people who use care services and the organisations who provide them. The new approach was designed to move away from previous prescriptive services towards more bespoke, personalised models of care, where service users are directly involved in planning and deciding what care they receive, and how they receive it.

Within the personal budgets model an allocation of money is given to a specific person from their local authority, following an assessment of need. Money is allocated to the individual, who then works with a professional to work out the most appropriate support. The idea is based on the ideas of transparency, empowerment and personalisation of care.

There are 4 options for service delivery which recipients can chose from to best suit their care needs:

  1. Managed council budgets – where councils arrange the care that is needed following an assessment and an agreed set of outcomes to go alongside a pre-agreed care plan;
  2. Individual service funds – marketed as a more flexible option than local authority led management, this allows recipients to select an alternate organisation to manage an individual’s care budget, and deliver the required services;
  3. Direct payments – this option sees the money paid directly into the account of the person in need of support and allows them to buy care services from an agency or to employ their own carer, or a mixture of both;
  4. Mixed package – a combination of any of the options above, where recipients of support may give some of their budgets to a care provider (either a charity or local authority) but may get a portion of the budget paid directly to them so they can pay, for example, for additional carers to visit during the night.

Seniorin mit Pflegerin

Those in favour of personal budgets point out that the model promotes the personalisation agenda within health and social care in a way that no other policy does. It gives control of spending directly to the person in receipt of the support and has been heralded as a new age for transparency, increasing choice and control, reducing bureaucracy and cutting costs. Personal budgets have also become a key part of the health and social care integration agenda, as well as being highlighted within the recent reform of SEND (special educational needs and disability) care and provision.

Supporters also argue that one of the best and biggest changes between personal budgets and the original direct payment pilots are that personal budgets are designed to produce outcomes, not pay for a service. They are co-produced with the person in receipt of care, as well as professionals from a number of sectors, care providers and family, if appropriate, to ensure that care plans and agreed outcomes are established when the budget is allocated and that the payments achieve those outcomes.

pregnant carer giving pills and medication to her elderly pacient

However, studies have shown that there are big variations in service provision, choice can be limited and poor practice and processes can have a big impact on personal budget delivery and effectiveness. There has also been criticism of the high level of support within government for the model, despite the limited number of pilot roll outs and reviews into outcomes.

In 2016 a National Audit Office report was critical of the way that public services have monitored the impact of personalisation through personal budgets, as very little evaluation of their long term benefits and efficacy have been completed. The report stated that the Department of Health needed to “gain a better understanding of the different ways to commission personalised services for users and how these lead to improvements in user outcomes.” It is clear that there is a lack of evidence as monitoring does not allow service providers to understand how personal budgets improve outcomes.

Critics also argue that personal budgets are ineffective and cannot provide suitable care for everyone in need. They argue that there has never been, and never will be adequate funding to implement personal budgets properly. The principle is only effective, they argue, if there is an unlimited supply of both funds to pay for services and service providers delivering high quality service, which under current conditions of austerity there is not. Supporters counter however, that the concept of “self-directed support” is fundamentally a good one, but admit that poor delivery can deter some people.

Conclusion

Personal budgets can empower people in receipt of care, allowing them to take control of how their care is delivered. This recognition that care should be individualised is a big step forward for people who rely on care services on a daily basis.

However, reduced budgets, inconsistent service provision, and a lack of information for recipients has meant that some people have missed out on the benefits of personal budgets. In practice, services are patchy and evidence of actual benefits, in terms of improved outcomes, is lacking due to the limited number of research studies.

In order to fully realise the power of personal budgets for everyone in receipt of care, the provision, implementation and understanding of the model must be improved. Support for people to help them make the most informed decisions about planning their care packages should also be increased.

Social prescribing – just what the doctor ordered?

blue toned, focus point on metal part of stethoscope

By Heather Cameron

It is widely acknowledged that wider social, economic and environmental factors have a significant influence on health and wellbeing. According to recent research only 20% of health outcomes are attributable to clinical care and the quality of care while socioeconomic factors account for 40%.

With increasing pressures on GPs and lengthy waiting times a real issue for many, particularly those with mental health conditions, social prescribing could represent a real way forward.

The government clearly recognised the importance of social prescribing in its new deal for GPs announced earlier this year, which made a commitment to make social prescribing a normal part of the job.

In response to a recent Ask-a-Researcher request for information on different approaches in social prescribing and evidence of what works in the UK, it was interesting to find that despite the recognition of potential value, there has been little evaluation of social prescribing schemes to date.

Much of the material found focused on specific interventions and small-scale pilots and discussion around implementation. A new review of community referral schemes published by University College London (UCL) is therefore a welcome addition to the evidence base as it provides definitions, models and notable examples of social prescribing schemes and assesses the means by which and the extent to which these schemes have been evaluated.

So what is social prescribing?

Social prescribing means linking patients with non-medical treatment, whether it is social or physical, within their community.

A number of schemes already exist and have included a variety of prescribed activities such as arts and creative activities, physical activity, learning and volunteering opportunities, self-care and support with finance, benefits, housing and employment.

Often these schemes are delivered by voluntary, community and faith sector organisations with detailed knowledge of local communities and how best to meet the needs of certain groups.

Social and economic benefits

Despite a lack of robust evidence, our investigation uncovered a number of documents looking at the social prescribing model and the outcomes it can lead to. Positive outcomes repeatedly highlighted include:

  • improved health and wellbeing;
  • reduced demand on hospital resources;
  • cost savings; and
  • reduced social isolation.

According to the UCL report, the benefits have been particularly pronounced for marginalised groups such as mental health service-users and older adults at risk of social isolation.

A recent evaluation of the social and economic impact of the Rotherham Social Prescribing Pilot found that after 3-4 months, 83% of patients had experienced positive change in at least one outcome area. These outcomes included improved mental and physical health, feeling less lonely and socially isolated, becoming more independent, and accessing a wider range of welfare benefit entitlements.

The evaluation also reported that there were reductions in patients’ use of hospital services, including reductions of up to a fifth in the number of outpatient stays, accident and emergency attendances and outpatient appointments. The return on investment for the NHS was 50 pence for each pound invested.

Similarly, the Institute for Public Policy Research (IPPR) has recently argued that empowering patients improves their health outcomes and could save money by supporting them to manage their condition themselves.

IPPR suggests that if empowering care models such as social prescribing were adopted much more widely throughout the NHS we would have a system that focused on the social determinants of health not just the symptoms, providing people with personalised and integrated care, that focused on capabilities not just needs, and that strengthened people’s relationships with one another.

Partnership working

With a continued policy focus on integrated services and increased personalisation, social prescribing would seem to make sense. In addition to providing a means to alternative support, it could also be instrumental in strengthening community-professional partnerships and cross-collaboration among health, social and other services.

The New Local Government Network (NLGN) recently examined good practice in collaboration between local authorities, housing associations and the health sector, with Doncaster Social Prescribing highlighted as an example of successful partnership working. Of the 200 referrals made through this project, only 3 were known to local authority and health and wellbeing officers, showing that the work of social prescribing identified individuals who had otherwise slipped through the net.

And with the prospect of an ageing population and the health challenges this brings, a growing number of people could benefit from community-based support.

As Chair of Arts Council England, Sir Peter Bazalgette, notes “social prescribing is an idea whose time has come”.

Follow us on Twitter to see what developments in policy and practice are interesting our research team.

Further reading: if you liked this blog post, you might also want to read Heather’s earlier post on the health and wellbeing benefits of investing in public art.

Giving service users a say: how self-directed support is shaking up social care service delivery in Scotland

Image courtesy of Time To Change campaign

Image courtesy of Time To Change campaign

by Laura Dobie

Back in 2010, the Scottish Government and the Convention of Scottish Local Authorities (COSLA) published a ten year self-directed support (SDS) strategy, with proposals to give individuals real choice and control in the health and social care services that they receive. The strategy is part of a broader reform agenda, and supports current health and social care policy to deliver improved outcomes for individuals and communities.

Halfway through the ten-year strategy period, it seems timely to consider the impact that implementing this transformation in service delivery is having on local authorities in Scotland.

What is self-directed support?

SDS allows individuals to choose the way in which their support is provided, and allows them as much control as they would like over their individual budget. It is not the same as personalisation or direct payments. SDS is a means of delivering personalisation, while direct payments are one of four options for delivering SDS:

  • Local authorities make direct payments to individuals which they can use to arrange their own support;
  • The local authority allocates funding to the provider of the individual’s choosing;
  • The local authority arranges a service for the individual; or
  • A combination of all three.

The benefits

An advantage of SDS is that it gives individuals the freedom to purchase the support that is best suited to their requirements. Some of the benefits highlighted in a review of self-directed support in Scotland are:

  • Flexibility, control, choice and independence;
  • The sustained delivery of personalised, quality, hands-on care;
  • Enabling clients to continue living their lives as they wished, such as by remaining in work or keeping up long-established activities, instead of conforming to rigid routines of care;
  • Helping families to stay together and family carers to continue in their caring role.

Implementation and impact on councils

SDS has required considerable change from service providers, who have had to alter the way in which they design, deliver and market services. Challenges in the implementation of SDS include training for social workers, dealing with the loss of economies of scale associated with personalisation, and achieving a greater degree of consistency in the approach employed by local authorities. There have also been concerns about costs and administration.

An Audit Scotland report last year, which reviewed local authorities’ progress in implementing SDS, has noted that SDS will have a considerable impact on social care at a time of growing demand and financial pressures. Professional staff are required to work in partnership with service users and their families, where appropriate, to identify services that will meet their needs. This approach is sometimes called co-production. The report found that council staff meet regularly with users, carers and organisations providing care, but have not always worked together with them in planning SDS.

The SDS strategy is a ten-year strategy running from 2010 to 2020, and it is not anticipated that councils will change the way in which they plan and deliver social care immediately. The Audit Scotland report found that councils have started to make substantial changes to social care, although progress has been slower in some areas.

Its case study councils expect to take between one and three years to offer the SDS options to all eligible individuals. They expect that fewer people will opt for day care centres and respite care but it will be challenging to shift away from this form of service provision – some people will want to continue to receive this form of support, however lower uptake may threaten the financial viability of these services.

The Audit Scotland report also found that some councils have underestimated the extent of cultural change required and the need for effective leadership. SDS is also changing the way in which councils are managing their social care budgets, and it is necessary for them to manage financial risks when implementing SDS.

Achieving successful co-design

The Institute for Research and Innovation in Social Services (IRISS) Pilotlight project has explored effective pathways to self-directed support (SDS) and ways of achieving successful co-design. The project website launched in May and contains useful SDS resources, lessons learned and a toolbox for successful co-design.

One of the project’s objectives was to explore how services can be delivered differently, in particular by engaging goups of service users and their families who can be excluded from participation. These groups could include people with mental health problems, vulnerable adults, disabled people of working age, and young people with additional support needs.

The project found that co-design could help councils develop more effective pathways to self-directed support for people who previously faced barriers. In a case study of the project, one service manager reported:

“Seeing the service users who have been involved in the process, I have known a lot of them for a long time and to see them take control and flourish and for their ideas to be taken on board has been a great success.”

Looking to the future

It is clear that self-directed support has required councils to make significant changes to the ways in which they work and deliver services, and that this transformation has occurred at a time when social care services are facing challenges related to demand and budget pressures.

Projects such as Pilotlight offer lessons and resources which can help councils and providers to plan and deliver support in conjunction with service users.

In June, the Scottish Government announced the award of funding to continue building the capacity of provider organisations to provide self-directed support, help develop the workforce and to ensure that support and information is available to individuals throughout Scotland to assist them in making informed choices. This three-year funding programme should help continue the major culture shift in the way health and social care services are delivered.


The Idox Information Service can give you access to a wealth of further information on social care services – to find out more on how to become a member, contact us.

Further reading

Self-directed support, Audit Scotland (2014)

Self-directed support: preparing for delivery, IRISS (2012)

Self-directed support: a review of the barriers and facilitators, Scottish Government (2011)

 

Let’s get personal: top tips for using our information alerts

Personalised infoBy Heather Cameron

With the abundance of information available these days and with time becoming ever more valuable, finding the information you need when you need it can be an arduous task.

Whether you are interested in a particular topic in general or need to be kept abreast of latest developments, having tailored information sent to you at times that suit you is invaluable.

This is something the Idox Information Service can help with. As highlighted in our previous blog showcasing the service, current awareness services are a large part of our offering.

Current awareness tools

In addition to our weekly bulletin providing a selection of the latest policy, research and comment added to our database, and our more subject-specific fortnightly topic updates which include 29 topics to choose from, we also offer the option of information alerts that allow for an even greater degree of personalisation.

With the Idox Information Service’s email alert service, our users can create a customisable schedule of alerts on topics of specific interest. So if co-housing is an area of particular relevance but you don’t want to receive items covering the wider topic of housing (which you can find in our housing topic update) then an alert on co-housing will pinpoint only those items of interest.

Setting up an alert

If you are a member of the Information Service, all you have to do to set up an email alert is log in, run a search as normal and click on the ‘Save as alert’ link at the top of your results: alert1

This will then provide options for saving your search as an alert so that you receive an email update whenever any new content that matches your search criteria is added to the database. You can choose a name for your alert and decide how often you would like to receive it. Alerts can be sent to you either weekly, fortnightly or monthly. Alternatively you can run the saved search whenever you choose from the My alerts page:

Alert pageIf you have selected a daily, weekly, monthly or fortnightly alert, you will receive emails with a list of records that match your search as below:

email alert2If there are no items in the selected time period that match your results, you will not receive any emails. And if you are going on holiday, you can also suspend the alert while you are away and reactivate it on your return – no need to worry about your inbox being clogged up!

Editing your alerts

These tailored updates allow you to receive focused information on the specific subjects that you need for your work, and you can adapt your search criteria to reflect your changing information needs as often as you like.

For example, if you think you receive too many or too few records, changing your search terms in order to broaden or narrow your search may help.

To do this, click on the ‘Edit’ link on the relevant alert on the My Alerts page which will take you to the ‘Edit Alert Schedule’ page. Then simply click on ‘Edit Terms’ and you will be taken back to the main search box, where you can change your terms. To update your alert, run the search with the edited terms, click on ‘Save as Alert’, then use the ‘Update Existing Alert Schedule’ option:

updateMeeting changing information needs

We cover a variety of topics on our database ranging from economic development, regeneration and planning, to social care and health. Some recent alerts that have been set up include:

  • Local welfare
  • Disguised compliance
  • Children and families social work
  • Child poverty
  • Safeguarding adults
  • Youth crime
  • Scottish tourism
  • Poverty and social justice
  • Benefit cap
  • Business and development
  • Land value tax
  • Community engagement
  • Community safety/involvement
  • Sustainable development

Our information alerts provide an efficient way for users to receive the tailored information they need and expect. Hopefully this article has shown how easy they are to set up.


If you’d like to find out more about our email alerts, or any other aspect of the Idox Information Service, you can contact us.