Other barriers to, and facilitators of, effective functioning and outcomes As well as the analysis of the ‘ five simple rules ’ , we also identified additional factors of relevance to the

In document Improving care for older people with long-term conditions and social care needs in Salford : the CLASSIC mixed-methods study, including RCT (Page 113-116)

implementation of the ICC.

Colocation

Staff from all three services were colocated, interspersed within two banks of desks. Physical proximity helped them learn informally about colleagues’work:

. . . you, kind of, want to listen to what their call is because you know you’re going to be dealing with those calls so you want to pick up and see what they do but most of the time you’re on the phone anyway.

ID 10474, ASCCT

Ultimately, staff felt that the integrated approach would improve responsiveness:

. . . eventually when it’s one number that will be even better because sometimes they do ring through and they’ve got a social care query and they might have a district nurse query as well so we will be able to deal with that all at once . . . I’ll just ask the person next to me rather than giving the number to ring somewhere else you’d just deal with that yourself and ask your colleague or leave a message with them.

ID 10474, ASCCT

Staff felt that colocation was essential to support the SIRP administrative team in call management:

I think it works at the moment for social care staff. I don’t think it’s working as well for the district nurse staff. And if we are integrated they’d have to put more professionals with us, and they’d maybe then need to rotate them, I don’t know. But it would need people here so that you’ve got some back up.

ID 10474, ASCCT

Central integration versus fragmenting existing local teams

Although part of the SICP, administrative staff were employed by different employers (adult social care by the council and DNs by the trust). When located separately, the fact that SIRP staff were employed on different pay scales and bands did not cause issues. Since July 2016, the employer of council staff working for the SICP has been the ICO (seeChapter 10), with human resources undertaken by the trust as‘lead provider’:

. . . the other problem we’ve got at the moment is we’re persistently talking about three groups of people doing the same job, and them three groups of people are all on different pay grades, and how do we move that forward?

ID 10479, manager

Administrative staff from NHS services contrasted their experiences with those of their social care colleagues who had been in place for 5 years and who had managers within the same open-plan office, providing regular opportunities for team and one-to-one meetings. District nursing and intermediate care managers were based off-site. This meant that staff often sought advice from social care managers:

. . . they’ve got their bosses, they’ve got four bosses on the floor . . . We’ve nobody, and we feel a little bit hurt and deserted really. I know they’re contactable by e-mail but it’s not the same . . .

ID 10477, DN administrator

I get a lot of hostility at the moment as well because they’re rushed off their feet . . . they’re not fully aware and understand what we do really. We were taken for granted when we were with them [in the locality bases], we were always there; also part of the team. I don’t feel a part of any team now, I don’t feel . . . I hope I make a difference but I don’t feel . . . I’m just a faceless person looking at a screen now . . .

ID 10477, DN administrator

Centralising the SIRP created difficulties for services elsewhere. Removing DN administrative staff meant that new‘housekeeper’posts had to be created at each locality base to replace some of the functions that were too costly for band 5 nurses. Having at least one DN within the SIRP supported administrative decision-making and enabled calls to be dealt with in-house, but was viewed as unsustainable in the long term:

. . . there was a district nurse based here with a very specific role and purpose for triage . . . She’d already stopped about three or four calls going through to the team at like half nine, quarter to ten in the morning, which might not sound a lot, but she’s probably done a lot more by then, and that was really successful . . . I think there was the will, but there wasn’t the staff to dedicate a district nurse from here.

ID 10479, manager

Loss of a sense of‘team’was also true of intermediate care staff when community rehabilitation, the SEP administrative team, rapid response and the intermediate care units were in separate locations:

. . . even though we’re based with the Salford council, and integrating with them [at SIRP], . . . from our point . . . we’re merging more with Salford council team, but our own team seem to be separated quite a lot.

ID 10476, intermediate care administrator

Similarly, for intermediate care, relocating the clinician away from SIRP meant that administrative staff could not physically pass on messages. As the clincian spent a large amount of time on the telephone, it was difficult for staff to relay messages. Although other SIRP administrative staff relayed messages via e-mail, the consensus was that it was easier to give out direct numbers and suggest that people contact staff themselves, contrasting with the ethos of SIRP. Staff felt that, over time, this might mean that calls that should be routed through the SIRP would bypass them:

. . . we’ve found it a bit harder taking messages, because she likes phone call messages . . . because she’s on the phone so often, she can’t check her e-mails as often, so it’s not great really, with her not being here, for that reason . . . so I’d rather just give [her] number out to that person . . .

ID 10476, administrator

Centralising the contact service aimed to make access easier, but it also created issues when people were referred for multiple assessments: a person might require an occupational therapy and social work assessment and their carer might require a carer’s assessment. This was recorded as three separate referrals. The process was being streamlined to ensure that, to avoid duplication, a single assessment was conducted by the most appropriate person:

I was thinking,‘hang on a minute, this one person has been contacted three times in 2 days by three different people in the same office.‘. What that person on the end of the phone must have been thinking’s going on here I’ve no idea, because if it was me I’d be like,‘hello, are you talking to each other?’. So we’ve worked on changing that now and it does work a lot better.

A 3-day test of change was conducted to try to rectify this. It found that colocation of a DN or intermediate care clinician alongside their administrative counterparts from SIRP was helpful in providing clinical advice and led to more calls being dealt with in-house, although this was not sustainable because of staffing shortages. One proposed solution was for clinicians to work on a rotation basis, enabling them to gain experience of SIRP work:

. . . a good mentor is being with nurses . . . I’ve picked up an awful lot of information. I don’t give clinical information out, but I do understand what their procedures are, and what they do now, it’s invaluable that.

ID 10477, DN administrator

Mental health involvement

A lack of representation from mental health within the SIRP created issues. Concerns about mental health were raised with social care via the ICC, either through referrals or through welfare notices from the police or ambulance service:

. . . if something comes through here and it’s mental health we can’t simply say‘oh, well, we’ll assign that to mental health’because it doesn’t work, and if we just sent things to them via their generic inbox which may or may not be manned you’ve got no guarantee that’s going to be picked up . . . all we can do here is notify the GP and see if they want to consider referring them to mental health . . . an awful lot of people have said,‘well, why don’t we just triage mental health here’. . .

ID 10479, manager

Two main issues seem to have influenced this: (1) the contractual agreements concerning what the mental health trust would provide and (2) the fact that, although the team will assess people, any mental health issues attributable to functional illness are discharged back to GP care without the requirement for the mental health trust to provide any intervention:

I had a meeting with the commissioners and the managers in the old person’s mental health teams and it soon transpired that historical agreements of what GMW were going to provide in terms of social care, with GMW restructuring over the years, agreements no longer were fit for purpose. They no longer fit the service like it is today.

ID 10479, manager

Although the mental health trust was one of the four integrated organisations, its staff were not transferring across to the ICO and it was undergoing its own organisational change.

Complex information technology systems

An issue faced by the SICP in general, but which particularly affects the ICC, is that the NHS and council each invested in different IT systems. Although integration of health and social care services was the primary aim, call handlers were required to work with multiple IT systems.

The trust had developed a system enabling its electronic patient record (EPR), which held hospital data to link with data from primary care via the Salford integrated record interface prior to the SICP. This was then used to develop the shared care record (SCR), which supported the sharing of information at MDG meetings. Although facilitating the MDG meetings, the summary SCR was not available to staff within SIRP. Meetings in spring 2016 showed that links between the SICP on a wider level were being considered, with a suggestion that, if a person known to MDGs telephoned SIRP and consequently had a SCR, their care co-ordinator could be contacted and updated with any relevant details. Subsequent to this, plans were discussed that ICC telephone triage would be used to manage telephone referrals from patients and carers wishing to self-refer to MDGs.

In document Improving care for older people with long-term conditions and social care needs in Salford : the CLASSIC mixed-methods study, including RCT (Page 113-116)