Creative Best Practice (a four-part trilogy!?)

Working as a case manager I am fully aware of the importance of skillful care coordination for the most successful clinical and social outcomes for people needing health and social care services. This is also why I published 'The Art of Coordinating Care' in 2009, to promote a values-based approach to the creative thinking required in this role.

Contact with different types of teams reinforces my appreciation of the need to carefully consider how we assess, manage and take risks for positive outcomes... in our own lives as well as our work with others. This is also why I published 'Risk Decision-Making' in 2013 as guidance for promoting best practice in making carefully reasoned and defensible risk decisions.

Working with people in teams, in organisations, and with those in need of services has reinforced my long-standing belief in the importance of developing strengths rather than overly focusing on fixing weaknesses. This is also why I published 'Working with Strengths' in 2014 to draw together the evidence, influences and guidance for keeping us focused on excellence rather than driving mediocrity. 

The weekly podcast show 'The Strengths Revolution' commenced in April 2014 to reinforce all of the above messages about genuine strengths-based person-centred ways of working and being. Creative coaching and practice development is also available through the Practice Based Evidence consultancy.

Values-Based Practice

In 2013 Oxleas NHS Foundation Trust commissioned a piece of work from Practice Based Evidence and the Mental Health Foundation to explore ways in which ‘values-based practice’ can be practiced and evidenced more in the day-to-day work with service users and carers within the Adult Mental Health Directorate. So far, the programme has engaged with six pilot teams and produced a set of draft guidelines. In 2014 the programme will seek to explore innovative ways of implementing the ideas, and spreading ideas to staff in other directorates. Any page references will be referring to the draft guidelines document produced for the Trust, and as such will not be available in full here.

Why focus on Values-Based Practice?

They influence everything we think, decide and do in day-to-day practice, though often in a more sub-conscious way rather than overt statements and discussions. Good practice is not about adhering to one set of right values, we should respect and embrace values diversity. Values can be very personal, professional or organisational statements, but the focus here is on the values that underpin the day-to-day language of focusing on the needs and priorities of the individual service user. Practitioners need to be supported to be able to work where values of the service user, organisation, or professional may differ or conflict, See p.3 for a guide to the process of good values-based practice. A recent high profile report highlights the need to put this approach to values-based practice into context:

Francis Report into Stafford Hospital “People must always come before numbers. Individual patients and their treatment are what really matters. Statistics, benchmarks and action plans are tools not ends in themselves. They should not come before patients and their experiences. This is what must be remembered by all those who design and implement policy for the NHS.” Excerpt from press release statement by Robert Francis QC in Stafford (5/2/13)

Click here for the introduction to the guidelines document.

Click here for the report to Trust Managers.

Playing with numbers

I am often mindful of the need to criticize the quality of leadership and management in health and social care services; particularly the obsession with numbers, the tick-box mentality, and the blind faith placed in targets for driving change and daily practice across services. I am surely not a lone voice in this critique, but is it valid or just a reaction against the sound of the pips squeaking?

I do believe that an absence of targets or defined outcomes, and a failure to establish high standards for provision of services only leads to inconsistencies between practitioners and teams… what is often referred to as a postcode lottery. Service users don’t deserve to be on the receiving end of either stressed out practitioners fearful of constant criticism, or laid-back practitioners doing their own thing. Audit and regulation have a place, but surely they need to be clearly joined up to practice, not existing in a vacuum somewhat disconnected from the realities within which good practice has to operate.

The ever-growing chasm between person-centred practice and business-focused managerialism does little to promote a culture of organizational collaboration that may encourage a more engaging form of audit and regulation across services. My solution would be to eliminate most of the current audit requirements imposed on practitioners and teams, particularly that which they experience as wholly time-consuming and unhelpful. So far so good, say the practitioners amongst you; please do share your thoughts, but read on before you do…

Over the last 12 years, through the Practice Based Evidence initiative, I have been developing tools designed specifically for use by practitioners and teams. These tools have flexible uses: personal reflection, individual supervision, team development and team evaluation. Used diligently they should be able to provide a host of qualitative and quantitative data, which in turn should offer useful feedback to practitioners and teams for practice development purposes. The Risk Decision-Making publication includes examples of these tools, and a specific example of data emerging from their use in a specific organization to help identify good practice and priorities for further development.

So, the sting in this tail is that practitioners and teams need to own the processes of audit and regulation if they are to reflect and develop good practice. For those auditors and managers fearful of losing their jobs if Practice Based Evidence emerged as the norm, you could always make use of the data to tick your boxes; better still, you could prioritise your time more effectively by getting in and alongside practitioners and teams to support a quality revolution. You might then be in a stronger position to challenge and inform the thinking of the inter-galactic warlords from distant planets a.k.a. commissioners, Department of Health, Care Quality Commission…

These are just a few thoughts I am passing on as I reflect on years of connections with so many people who are desperately trying to do good work despite rather than because of their masters. Do feel free to offer your thoughts and ideas (with an accompanying dictionary from those of you who find ordinary language an alien concept… with all due respect to the demands of the Plain Language Association).

Practice Based Evidence for Risk

Surrey and Borders Partnership NHS Foundation Trust recently engaged the Practice Based Evidence consultancy to undertake an organisation-wide programme of Working with Risk training. By identifying a large cohort of senior clinical staff in ‘Leadership’ roles the Trust is establishing a positive commitment to working as constructively as possible within all teams. My role was to devise a training workshop that would reflect the principles and practice issues identified in the initial Leadership workshops. In addition to adopting their locally agreed set of principles and edited filming of Leadership discussions, I used my own materials on ‘Positive Risk-Taking’ and ‘Risk Decision-Making’ to facilitate reflective practice discussions as a main focus of the workshops. With the help of colleagues in ARW Training the cumulative evaluations across 50+ workshops were overwhelmingly positive. See the following two summaries for the numerical ratings of the workshops (the narrative comments cover too many pages to include, but broadly reflect the ratings).

Cumulative summary of workshop responses

Cumulative responses of additional workshops

The summaries represent 1252 and 72 responses respectively. The main lessons to be learned are that practitioners respond best to relevant and practical content that enables them to reflect on and develop their practice. Successful training workshops start with close attention to design and detail.

Coordinating Care: Art or Science?

Being a care coordinator and managing the care programme approach has become a challenging function of our care and support services, attracting more than its fair share of negative connotations. A genuine tension exists between the passion and artfulness of human relationships on the one hand, and the pursuit of a scientific basis for interventions on the other. The science of research seeks to impose a sense of reassurance by means of consistent results when defined sets of circumstances are observed or applied. By contrast, the quality of an artful endeavour may be measured more by its emotional characteristics and the feelings it engenders in those involved or observing. In reality, the experience and practice of mental health and learning disability services is primarily a study of people’s emotional experiences, feelings and behaviour patterns. So we should be wary of any attempts to understate the elements of artfulness and passion; and we should recognise the potential impact this may have on our enjoyment of the work, as well as our motivation for doing it.
 
Arguably, one of the most crucial effects of the evidence-based practice focus of research is that it undermines the art of relationship-building. The pursuit of a rigorous scientific rationale places a clear priority on the cult of numbers. ‘How many?’ and ‘How frequently?’ and ‘How quickly?’ become the valued quantitative outcomes of an efficient service. But what is the cost of this, in terms of an effective, good quality experience for the individual service user within this wider research picture? Or, indeed, what is the cost of its impact on the qualitative experience of the work that, for many practitioners, is their motivation? Ideally, we need to strike a careful balance between art and science in the delivery of good quality care and support.

Find out more on these views from the published manual The Art of Coordinating Care