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).

Working With Risk

The 'Working with Risk' tools located here have been developed into a 2-day Risk Trainers Manual and an accompanying Practitioner Risk Manual and were published by Pavilion Publishing in Spring 2007.

The article below, written by Steve, gives an overview of the tools. It was first published in Mental Health Today in September 2007 and included here with their kind permission.

PDF: Working with Risk: Steve Morgan outlines a new training pack on positive risk management.



Strengths Assessment Tools & Guidelines

Click below to download this form as a PDF.

PDF: Strengths Assessment tool: for developing working priorities and care/support planning

To read the report above you will need free software called Adobe Reader. This software can be downloaded here.

Guidelines for developing strengths working

Click here to download these guidelines as a PDF document.

Purpose

To provide guidance for encouraging the identification of strengths as an essential part of all assessments in practice across the local services. Reflecting the need for a flexible approach that is individually tailored to service users needs on a case-by-case basis. It is intended to be a 'method of working' that supports client-led practice, not a service driven need for auditing standards. A strengths assessment tool may help the process, but is not considered essential for ensuring a unique picture of the person is being developed through a unique process. Strengths working forms a radically different basis with which to resolve problems and work with risk.

Who is it for?

• Everyone who comes into contact with all services should have a balanced assessment that includes recognition of their 'strengths and abilities', not just a summary of 'problems'.
• All service users should have an assessment of their strengths at least in a process of completion, documented in whatever way is most appropriate to ensuring they strongly influence the on-going work of the team.
• Wants, aims, and aspirations are important anchors to drive plans forward, to clarify what resources are needed from whom in order to achieve them, and to identify what barriers or difficulties may need to be overcome.

When is it used?

• From the first point of referral, direct contact and thinking about a person determined to be in need of the local services.
• It is not a specialist assessment only to be drawn on in special cases.

How is it used?

• There is no single way of doing it, or documenting it; but the outcome should be a positive inventory of achievements, resources and aspirations individualised to the experience of the person themselves.
• In many cases a tool may simply act as the prompt for this aspect of assessment to take place, and to influence decisions in plans.
• 'Strengths working' is a continuous process that develops over time. It is not something that is done to someone, but rather an outcome of mutual dialogue. Circumstances change, as may the service user's aspirations; therefore the assessment is not fixed, and new facets of a person continuously emerge.
• The ultimate aim is for the assessment to be completed collaboratively, with or without an example of a form being introduced into the conversations. Paperwork in meetings can have a habit of formalising the situation, and thus getting in the way of the intended purpose.
• In rare instances, the whole process could be described to the service user, and where appropriate, a strengths assessment format left with them to ponder and complete in their own time. This may then form a basis for the service user to lead a subsequent discussion of their strengths and aspirations with the practitioner.
• The assessment is best conducted in an informal, conversational manner, rather than a structured interview. It is best conducted so far as is possible on the client's own 'territory' and in places where the user feels comfortable, rather than in formal service or institutional settings (e.g. the service user's home).
• It develops at each service user's pace and comfort level, and adapts to change.
• As 'strengths working' will be developed in response to the individual's circumstances, it is not relevant to set a standard time period for monitoring when it is completed and reviewed. Some assessments will be completed relatively quickly, and can reasonably be reviewed on a regular basis e.g. 6-monthly timescales. Some assessments will take many months or years to build up, and therefore do not fit a regular review cycle.

Structure of the process

• The assessment is focused on gathering information relevant to a range of 'life domains' e.g. housing, finance, health, occupation, social relationships, cultural and spiritual beliefs. Therefore, it should paint a holistic picture of the service user's life.
• It should be a positive, hopeful, and constructive process - the act of looking at strengths, possibilities and motivations is in itself constructive.
• It provides the essential positive information and resources needed to work constructively with risk.
• The format fits well with the local training on WRAP (Wellness Recovery Action Plan), and with Brief Solution Focused Therapy.