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Building from the bottom up

Guy Dewsbury explores the benefits of building person-centred service delivery from the bottom up, the importance of equipping and valuing staff to have more control, accountability and to deliver the services everyone wants within current constraints.

Building efficient and quality care services from the top down can be tough. Staff work at the service delivery end and are a company’s most important asset. They can be the key to ensuring that service users receive good quality, person-centred care, whilst organisations increase their efficiencies. However this can be a step-change and it’s not always easy to build services from the bottom up.

Benefits of a bottom up approach

Rethinking how people are cared for is an increasing concern. Traditionally, health and social care are managed from a top down approach as advocated by the Care Quality Commission, employing strong management techniques. The Care Quality Commission’s State of Health Care and Adult Social Care in England 2013/14 report highlighted that, ‘Strong, effective leadership at all levels is vital. We have found in our more rigorous inspections that “well-led” drives up quality and safety…. Good leadership is vital’ in which ‘Leaders at all levels should develop a culture of support, openness and learning.’ The drive for a person-centred approach to care is central to common visions, as is the reduction on spending and other economic drivers which mean producing more output for less and with less.

If the person-centred approach is to benefit everyone, then it is required to be responsive to the ebb and flow of people’s needs which change regularly. Top down management techniques can make it more difficult to be person-centred as all changes require higher approval. This approach can be sluggish and can lead to extra health costs in the long-run to correct something that could have been prevented.

Frontline staff are the people that know about those who are cared for. The day-to-day management of the people in their care results in the frontline staff being the first people to be aware of small changes to someone’s condition. The accuracy of the report to senior staff could be the determining factor of whether the person receives further additional support.

The question for providers is how they allow care staff the ability to care and have control over the care process without diminishing the management role. The bottom up approach allows for flexibility to delivering care needs within an organisation.

Equipping staff with more control

Delivering care relies on care staff following each person’s care plan. Care plans should be regularly updated to reflect the current situation of the people in their care. Often though, in reality, care plans can be outdated. This can be due to many factors. One method of ensuring care plans are up-to-date is through the use of technology. Electronic care plans can be based directly on the observations and experienced assessments of frontline staff. This means that as a person’s needs change the care plan can be modified accordingly. Here, the frontline staff are, in many ways, the best people to manage day-to-day care.

The current state of mobile working or working with technology provides work stations where staff can access care data and update notes on the people in their care. These stations can be mobile but are often static in offices. Therefore, care staff must retain key information until they can get to a work station to upload it. The difficulty with this is that care staff are always busy and will often have numerous other things to do before they sit down and update records. In this time, valuable information could be lost and the new needs of a person might not be updated.

A further issue is that the care plan directs the care the person receives. If it is outdated, the frontline staff could be providing inappropriate care to a person with negative consequences. A system that provides real time care records which can be updated on the go by frontline staff is a possible new strategy that could be deployed. The solution is required to be easy to use by all staff and have a quick method of data entry and feature all the care plans. Laptops and iPads could be used to transfer this information but these are bulky. A possible resolution for this is the mobile smartphone.

Accountability and service delivery

When frontline staff are working they are accountable for all they do, including reporting change. They require a method to evidence what they have accomplished with the people in their care and what requires modification. Having the ability to note down changes whilst in situ means that information is recorded immediately and can be accessed by managers and other health or social care professionals.

Managers also need to know where their staff are and what they are doing, this is a relevant in large care settings as it is in home care and community-based support. Having a smartphone-based programme, in real time, allows the managers to be kept up-to-date on all their staff. The software could also help with reports and handovers ensuring the most up-to-date information on each person being cared for is available to the frontline staff coming on shift.

The use of a system like this relies on a new management style in which frontline staff are valued more and have a greater influence over the care pathway. As a result managers are provided with clear, current, accurate information on all the people in their care. This locates the frontline staff and the person being cared for at the top of the pyramid and the higher echelon lower down. Effectively it inverts the current care pathway, but potentially achieves a better quality of care, as frontline staff are not required to spend time updating records in an office because they are updated on the go.

Managing change

Managing change is never easy, and staff need to be valued and empowered in any change situation. The Care Quality Commission suggests that social care providers should, ‘Recognise and value excellence in all staff, especially those in professional or leadership positions. By recognising the contribution of, for example, registered nurses in nursing homes and excellent registered managers in any service, supportive systems can start to attract, and critically retain, excellent staff in these positions. Stability and professionalism will help to improve care.’

Whilst these values are excellent, they could be extended to explore the role of other frontline staff and the use of these staff in the maintaining health and care of people. This might appear daunting to providers as this means moving responsibility of real-time reporting and changes to care planning from the top to the bottom takes a high degree of trust. Through placing responsibility on the people in the frontline, the management are demonstrating their respect for the staff. It also ensures all staff are correctly trained to perform these duties.

Risk mitigation is a management concern with a bottom up approach and clear monitoring is essential to ensure any changes are authorised, highlighted by the system, followed up with case conferences, face-to-face or telephone conversations with the person to ensure they are in their best interests at all time. The core value of allowing people in the frontline to make alterations is that it saves time and money as well as adds a level of respect to the staff undertaking these duties.

The Care Quality Commission also says that, ‘Leaders at all levels should develop a culture of support, openness and learning. Welcome feedback on the service you provide and treat it as a free source of intelligence that can help you improve… Offer support to staff who are trying to do the right thing in often difficult and stressful environments, and enable them with the skills and the emotional support to do the job with compassion.’

The first steps include ensuring you have the correct systems in place.

Technology can help

Taking a bottom up approach to care in which frontline staff have the ability to modify care in situ is daunting to many but can be a step closer to making care person-centred. The correct technology can facilitate this change and enhance the care of people and ensure staff are better appreciated for the skills they demonstrate. Empowering frontline staff with technology can mean more appropriate, timely care and a more resilient workforce who are happier as their worth is valued.

Guy Dewsbury is an Independent Research Consultant working with Person Centred Software. 

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