Adapting for Change: evaluation

Chapter 3: Strategic leadership

AWG recommendation: Strategic leadership from the local housing authority, working in partnership with health and social care.

The AWG was clear that housing adaptations is, and should remain, a partnership service. However, it was also of the view that there needs to be clear responsibility for setting the strategy and priorities for the service. The AWG recommendation, made prior to the introduction of the Public Bodies (Joint Working) (Scotland) Act 2014, was that strategic leadership should unambiguously rest with the local housing authority, through the Local Housing Strategy ( LHS) and Housing Contribution Statements ^[13] developed as part of the joint commissioning strategies in health and social care. As noted earlier, responsibility for adaptations was in fact delegated to the Integration Authorities, meaning that they now hold strategic responsibility for housing adaptations.

This chapter explores the issue of strategic leadership and broader challenges associated with delivering change using a collaborative, partnership-based approach. Issues associated with making specific changes using a partnership-based approach are covered at Chapter 6.

Key research evidence

The Health and Social Care Integration setting for AfC

On the more general issue of a partnership-based approach, there was a broad consensus amongst key stakeholders from housing, health and social work that Health and Social Care Integration presents both an opportunity but also significant challenges when looking to make changes to how adaptations are being delivered. In terms of the opportunities offered:

• It was generally felt that the Scottish Government has sent clear and consistent messages about both the important role housing has to play and the paramount importance of prevention-focused services. Both of these elements were seen as helping to make the case for a partnership-based review of the housing adaptations function.
• More generally, there was a very broad, cross-sectoral recognition of the key role that a well-functioning approach to adaptations can play in terms of promoting independence, choice and wellbeing.
• Specifically, adaptations were seen as having a key role to play in preventing avoidable hospital admissions, including with the fitting of handrails, ramps and stair lifts helping to prevent falls. The potential to enable those having significant on-going medical treatment, including cancer-related treatment, to remain an out-patient was also highlighted, including through the client interviews.
• The importance of facilitating a timely discharge from hospital was also highlighted, with the potential resource savings associated with both timely discharge and preventing unnecessary admissions widely noted.
• Many interviewees felt that undertaking the AfC pilots in the early stages of Health and Social Care Integration provided very positive models of partnership working and enabled them to shape the agenda around integration processes. This view was often strongly-held by local authority stakeholders.
• Housing Contribution Statements were usually seen as having the potential to be a useful vehicle for setting out a clear strategic statement of intent regarding adaptations.

Although the potential offered by Health and Social Care Integration was widely acknowledged, it was also seen as presenting a number of significant challenges. These included that:

• The Health and Social Care Integration agenda has led to huge and on-going change. There were some concerns from across all sectors that the sheer scale and pace of change could result in housing-related issues being side-lined for the time being. This was not because they were considered unimportant but rather because other areas, and primary health care in particular, were expected to take precedence and receive more attention from the IJBs in the short to medium term.
• There was an associated concern that prevention-based strategic planning and service development may not be one of the early priorities for the IJBs and that this could also affect the priority placed on improving and developing adaptations services.
• The adaptation-related statements within Housing Contribution Statements could sometimes go further, including placing greater emphasis on adopting a tenure-neutral approach. Also, many felt that the statements are yet to function as fundamental drivers of positive change and have not had a significant impact on IJB thinking, to date.

There was a view - which tended to emerge most strongly from those with a responsibility for, or involvement in, housing-related strategic planning - that there is an adaptations-related information deficit. Issues related to data and information collection are discussed further in Chapter 7, but of note here is that the lack of available information on need and demand for adaptations was sometimes seen as making it more difficult to set out a clear case for adaptations within the Housing Contribution Statement and the LHS.

Finally, the work of delivering change at the same time as integration-related changes were in full swing led to practical challenges for the majority of test sites. Most significant of these were changes to staff roles, including being given additional responsibilities, or key staff being moved to other positions to take forward another Health and Social Care Integration-related area of work. Replacing staff sometimes also proved challenging, including because new integrated services arrangements meant more than one Human Resources department needed to be involved.

Building the multi-agency approach

Despite strategic leadership for housing adaptations being delegated to the Integration Authorities, the local authority's housing service was generally a key player, and sometimes the lead player, in the initial conversations and subsequent decision to apply to be a test site. Although there has been a significant degree of variation both between and within sites, the evidence suggests that a range of factors have helped or hindered the building of a multi-agency approach.

Those involved in the test site application process tended to be very clear that progressing the AfC agenda would require a robust and inclusive partnership approach. In two of the areas, work to improve the adaptations process had already begun when they applied to be a test site, and project groups had already been formed. However, in other areas, the work around building that partnership approach and achieving wider 'buy-in' to the process began after becoming a test site. This timing may have had an impact on the overall process. In a minority of the test areas, that buy-in from certain key stakeholders had been difficult to achieve or had occasionally been reluctantly given. This was not because adaptations were seen as unimportant, but it was sometimes felt that other service areas needed to be addressed first.

A few stakeholders, mainly from the health sector and/or those managing OT services, felt that the housing sector was 'trying to take ownership' of the agenda but without necessarily recognising the central roles of other services. However, it should also be noted that others in very similar posts were not only fully supportive of, and sometimes key players within, the process of change but also agreed that housing had a leading role to play. The most frequent view was that housing's position needed to be one of 'first among equals' with their colleagues in social care services and/or with those responsible for the delivery of community-based OT services.

Most of the staff taking part in the Project Boards were middle managers, and while some felt well-supported by senior staff who understood and championed adaptations, others expressed concern about the extent to which housing-related issues were being prioritised by the IJBs. Issues identified included:

• Most key stakeholders from across all sectors felt that it can be difficult to ensure that housing-related issues are seen as a priority. This was often seen as a consequence of the relative youth of Health and Social Care Integration and of health and social care issues dominating the early stages in the life of the IJBs. It was generally felt, however, that the housing sector needs to play a central role, particularly in the development of Strategic Commissioning and Locality Plans.
• There was some frustration, including from within their own ranks, that larger budget holders - namely health and social care - did not necessarily see the perceived lack of priority being given to adaptations as being at odds with developing a comprehensive and cohesive package of preventative services.
• A minority of the housing services acknowledged that they were struggling to find the resources to fully engage with the Health and Social Care Integration agenda, including ensuring they were represented on all appropriate strategy and planning groups.

As many stakeholders observed, the appropriate mix of key partners to form the AfC Project Board and/or Steering Group, was dependent on local structures and, to a lesser extent, the type of work on which the test site was concentrating. Nevertheless, a number of common themes did emerge, including that:

• Health was seen as a key partner although, other than health-based community OT services, they tended to be seen as less central to the AfC process than housing or social care. Stakeholders from the health sector occasionally saw the work of AfC as being something of which they should be aware and of which they were supportive, rather than as a priority for their own service. However, in one of the test sites, health sector representatives have been very actively engaged with the process and felt that involvement had been key to designing fully integrated services going forward.
• Although the support of senior management within statutory social care services is very important, clear and sustained 'buy-in' from those with direct responsibility for managing the community-based OT function is a powerful driver of change. Where this level of positive engagement does not exist, the pace of change can be slowed and change may even be blocked.
• Locally-based housing associations were generally fully involved and seen as central to the process, both by the associations themselves and by the other key partners.
• Other third sector organisations and, in particular, local Care and Repair Services, have also tended to be fully involved in the AfC process. This has generally been seen as of great benefit, both by the third sector representatives themselves and by those from the public and housing association sectors.
• The AfC Project Boards have sometimes also provided a vehicle through which other connected work or initiatives, such as that being taken forward through the Dementia Demonstrator Programme ^[14] , can be linked into and co-ordinated with the changes being made through AfC. Making these connections was seen as helping to support a whole-system approach that focuses on the individual and helps move away from a system which is driven by the specific responsibilities and priorities of different services.

In terms of ensuring that any planned changes continue to move forward and/or that the change process continued after the AfC initiative officially ended (in terms of being a Scottish Government sponsored pilot), there was a broad consensus that:

• The adaptations agenda, and other preventative services, need to be 'championed' by those heading up key services including, but not limited to, those leading housing services. Critically, this will need to include ensuring that the work of the IJB has a clear and on-going focus on prevention.
• This level of clarity and commitment also needs to extend throughout the management team for key services, including to those with direct responsibility for the management of key frontline services.

Key stakeholder interviewees acknowledged that many services have been working through a period of significant change. Stakeholders who felt some colleagues had been resistant to adaptations-related change often felt that the extent and pace of wider changes may have shaped their colleagues' outlook. This was generally seen as being most likely to apply to frontline staff but also extended to some in management roles. There was a view that, while it is very important to engage and work with these staff, not least because they will have a significant amount of knowledge and experience which can help shape services, it is also important that they are not allowed to block required changes. Ensuring this does not happen was usually seen as the responsibility of senior management.

Other factors influencing the process

As noted above, the test sites have tended to find the change process to be both more challenging and requiring a longer overall time period than originally anticipated. In addition to the issues outlined above, other points to note about taking a partnership-driven approach to adaptations-focused change included:

• The change process is likely to require a significant involvement from a small number of key players and from those driving the change process in particular. The tasks involved range from building relationships, arranging and minuting meetings through to leading on the development of policies, procedures or single pathway materials. Much of this work was seen as vital to moving the agenda forward but was also very time consuming.
• The key individuals who have been leading on much of the specific activity associated with taking forward AfC have been doing so as part of their existing posts/along with their normal workload. These other work commitments sometimes involved the delivery of front-line services and managing a client caseload. This has often proved difficult, with other work pressures or commitments having to take precedence. This has sometimes meant that these generally very committed individuals have not been able to keep AfC moving forward at the pace they would have liked.
• If one of these key individuals is either absent from work for a prolonged period or moves on to another post, the pace of change can be delayed significantly or change may even stall. The general view was that with current levels of staffing, there is limited if any potential to provide effective cover when a colleague is absent. It was also noted that when key staff have moved on (either to other posts or by leaving the organisation altogether) they may not be replaced - and their knowledge and expertise is also lost.

Outside the key individuals, many of those involved in the AfC Project Boards reported that being part of the Initiative had not been too onerous. This tended to apply particularly to those from the housing association and third sectors. They often felt that the time involved had been well spent given the importance of the issues being addressed and the 'knock-on' benefits in terms of building new working relationships. However, a small number of Project Board members did report that it had been difficult to find the time to participate fully; these small number of individuals tended to be local authority or health service staff.

Finally, it should be noted that the resource pressures sometimes experienced within the test sites have been despite the support being offered by the Improvement Associates for the ihub. In the light of particular resource challenges, the Associates have sometimes taken on specific tasks (such as drafting policies) which might otherwise have been taken forward by Project Board members. This support has been very much appreciated, particularly by those most closely involved in taking the work forward. These key individuals generally felt that the work in their test site would not have progressed as it had without their Improvement Associate's support and encouragement.

Summary conclusions

The AWG's view that a partnership approach would be crucial to meaningful change appears well founded. Although care needs to be taken in assuming that the experiences of the test sites would be mirrored elsewhere, the lessons to be learned around building or strengthening a partnership approach suggest that:

• When the partnership approach works well, and in particular where all the necessary services are round the table and are engaged and committed participants, the approach not only supports positive change in the field of adaptations but can radiate out and have a positive effect across a range of housing, social care and health functions. Building new working relationships and an increased understanding of others' roles was at the heart of this very positive outcome.
• A small proportion of key stakeholders were initially reluctant to fully engage with AfC, and particularly where that reluctance was sustained, this has created challenges. Most obviously, it has slowed progress and has contributed to test sites struggling to deliver their plans within the anticipated time-frames.
• However, even when progress has been slow, there have been some signs of attitudes changing even in the latter stages of the AfC initiative. These changes appear to represent a very encouraging shift in perspective and an increased willingness to step beyond professional boundaries and consider how all players can work together to provide a sustainable, high quality, person-centred package of services.

The building of strong, cross-sectoral partnerships committed to working together to bring about positive change could be seen as the single greatest achievement from across the test sites. Critically, it is an achievement which may well provide a foundation for driving positive change not only in relation to adaptations but also for other prevention-focused services. Conversely, where this has not happened, a genuine opportunity to influence and deliver improvement may have been lost.

A number of other factors have been identified as either supporting or undermining both the pace and depth of change. Ensuring that housing adaptations, and preventative services more widely, are seen as key and immediate priorities by the IJBs may be challenging. It will require a concerted effort not just by those leading local authority housing services but also by those leading other key services as well. The voice of housing must be heard around the IJB table, but it must not be a lone voice on this issue.