A Project To Support More Effective Involvement Of Service Users in Adult Support and Protection Activity

Chapter Four: Key Findings

Introduction

4.1 This chapter pulls together the learning from all the teams about trying to improve service user involvement in ASP processes. It is divided into three parts starting with the common learning around ASP work. The second part reviews the learning from the work done to develop the tools themselves. The third part explores co-production lessons, drawing on expertise that contributed to the national workshop days, as well as lessons generated by the locality teams. The chapter concludes with reflections on the methodology of the project as a whole.

Learning about ASP work

4.2 Teams identified a wide range of factors that meant that service users were not as involved as they could be. These views reflected the findings from the research undertaken so far in Scotland. These can be summarised as follows:

• Much of the development to date has focussed on procedures and raising awareness about ASP in their locality
• As a result there is a need to start looking in more depth at service user experiences and what can be done to improve their participation
• Whilst information sheets about ASP can be helpful, for some they are too detailed and cause anxiety
• The service user actually gets very little written information along the ASP journey and as a result their understanding can be limited
• There appears to be an underlying presumption that if you have told someone something then they will retain that information but emotions and stress can get in the way
• Mis-communication is at its greatest in the early stages and there is a need to slow things down, not everything is a crisis
• There is a need to spend more time establishing an open dialogue and building an effective relationship that allows both practitioners and service users to express views, ask questions and discuss different perspectives and options
• There is an overreliance on traditional interview methods
• Even where practitioners have learned what works best for someone to participate, this is not often clearly recorded, accessible and shared
• Case conferences need attention in terms of preparing people for them (if they wish to attend), getting their views heard and receiving feedback about the meeting

Framing change within different perspectives

4. 3 A useful way of looking at how ASP work has developed and what needs to change is to look at the different perspectives of those involved. It also became a useful dynamic within the project teams.

The local authority

4.4 ASP work is still relatively new and local authorities have been getting the policies and procedures in place, training staff to identify and investigate situations where adults may be at risk of harm and raising awareness in their local communities, setting up adult protection committees and cementing inter-agency working. As a result it can feel very procedural. This is exemplified by one team member commenting that they considered doing away with all ASP paperwork and starting again as a means of improving participation. This leads to a concern that whilst there may now be clearly a defined 'scaffold' (to adopt a word used by Lois Cameron of Talking Mats) in which ASP work and narratives take place in each local authority, these narratives can become dominant ways of working and may not leave space for different approaches to engage with service users to emerge.

Local authority practitioners

4.5 Those that carry out inquiries and investigations have an ASP 'script' that they follow. They are concerned with gaining information, separating fact from fiction, imparting information, making judgements and relaying this back to managers. This work is often done under pressure of time and there are occasions where immediate responses are required to crises.

Service users

4.6 Service users, on the other hand, unless they have experienced ASP work, have no scaffold within which to place an inquiry or investigatory visit, case conference etc. Whether there is harm taking place or not, theirs may be a more emotional reaction: anxiety, anger, fear or a mixture of all. It may be hard to understand what is being said and to make sense of something called adult support and protection. Being left with information about the ASP in general does not really explain the who, what, why, and how of the concerns uppermost in the person's mind.

Advocacy workers

4.7 Advocacy workers often meet service users for the first time when they are in the midst of an investigation. They are often asked 'what's this all about?'. These workers will have little information about the person they are meeting and yet may have only a day or two before supporting that person to attend a case conference or going to represent their views on their own. Much time is spent explaining what ASP work is about before then being able to explore with that person what their wishes and feelings might be. Not everyone will have an advocacy worker.

Developing a different scaffold

4.8 It is clear that currently a procedural scaffold dominates ASP work. Much of the work of the locality teams involved exploring how the agency scaffold and scripts could be adapted or rebuilt from a shared perspective.

Learning from developing the tools

Common Themes

4.9 The common themes across the teams were:

• Appreciating differing perspectives of practitioners, advocacy workers and service users on the same process
• Good communication as a platform on which to build participation
• The importance of tools being used as part of a process rather than a tick list or as a form to be filled in.

Lessons across the process

Lessons also emerged that are relevant at different points within ASP processes.

Information

4.10 Information is part of the platform on which to build communication and then hopefully participation. As noted above, standard information leaflets can raise more questions and anxiety than they aim to solve. A better approach for some would be to take a stepped approach to giving and discussing information as needed and as relevant to the service user and their own particular situation. What started as an inquiry visit information sheet for the Perth team became a tool that might be useful at all steps of the process, because at each step the practitioner should sound out again with an adult what it would be most helpful for them to know, to agree action together and to have this in written form

Symbols and pictures

4.11 There was also learning about use of symbols and pictures. On their own they can be of limited value. Symbols need to be in regular use within the group or setting familiar to an adult and be part of everyday communication to be most helpful in times of stress or crisis. It is also important to be aware that symbols and pictures can develop a negative meaning and then their effectiveness is limited. These observations about standard symbols apply to both paper based tools and any developed for phones and computers. Another approach in one-to-one work is for the service user to select their own symbols or pictures to convey their own specific meaning and for people around that person to learn that language.

Focussing change work where it has most impact

4.12 Some aspects of ASP work seemed better starting points than others for beginning to achieve change. In the early stages of ASP mis-communication of various kinds is more likely to occur. Reducing misunderstanding in the early stages will make for more effective involvement later on. The tools together suggest ways in which service users' participation can become more meaningful by ensuring practitioners quickly find out how best to communicate with the person, help the person to understand key information about what is happening and why. This should open up service user-led ways of recording and presenting their views and wishes.

Individual participation needs

4.13 The Dundee City tool sets out to try to ensure that practitioners keep a wide appreciation of how someone's participation can be supported or limited. Their tool assesses the many ways in which a service user's participation can be diminished. It goes beyond the obvious issues of sight and hearing impairment, and intellectual disabilities to include where interviews take place and who helps the person to express their views. Once the most effective ways of communicating with someone have been established, it is important that this knowledge is shared, facilitating greater involvement in the rest of the ASP process. It also puts the onus on the practitioner to consider referral to other resources that might help strengthen a person's inclusion more broadly.

Supporting understanding in an on-going basis

4.14 The Perth and Kinross tool aims to address the uncertainty and confusion that service users are often left with after an ASP initial visit. Even where practitioners feel they have given a person space within a visit, it can become apparent later on that they are still trying to understand and process the information received. Leaving a straight forward written record with the person will help them to process the who said what, why and what might happen next. Whilst the focus was on ASP inquiry and investigation visits, if the tool was used as part of all service contact, it could help the service user build up an on-going record of their contact with social work. The key learning here is that records are not just for case files, records help service users remember, understand and make connections too.

Creating space for service users' views in agency IT systems

4.15 East Ayrshire, in piloting the pre-existing tools and working towards making them compatible with IT systems, are addressing the issue that agency paperwork and processes around ASP do not yet really allow for service users' own stories, views and wishes to be recorded in their own words; and therefore tabled at any meeting where decisions are made. These tools are available yet are rarely used. There are questions about how practitioners view IT tools and how an agency may respond to service users taking more control over how their views and wishes are recorded.

Learning from doing co-production

4.16 The national workshop days provided important learning opportunities in and of themselves, as well as allowing learning that had already taken place within teams to be shared.

Lessons on Co-production from previous work:

4.17 It is useful to start with a summary of co-production lessons shared on the first national workshop day by Andy Millar, Angela Henderson, and Angela Halpin from SCLD about their experiences of co-production. Angela Halpin explained that "Co-production means working as a team". They explained that if co-production is working, you see a shift in power and it's clear it's working "when it feels like a family". It is important that the same people work together over time to build trust and relationships. As Angela explained the SCLD experience it worked well because "We all started together and learnt each other's feelings". People involved in SCLD co-production groups often have a capacity building plan to support their involvement. An approach, we agreed at the national workshop day that should be taken up more widely.

4.18 SCLD top tips for co-production:

• Involve people early
• Discover and use people's gifts
• Help people to develop new skills
• Make sure there is enough time and money to do it properly
• Celebrate what you have achieved
• Think about what you have done - learn from it

4.19 The SCLD team also discussed the importance of doing planning beforehand to ensure there is an agreed focus for the work, having shared goals and shared values, and capturing all views.

Lessons on co-production from the project process

4.20 The local authority teams' work generated lessons which were brought together in the second workshop day. Factors that helped the teams work together were:

• Being given permission by managers to spend time away from their usual work so they could be part of this project
• Taking time to build up understanding and trust in a group can lead to powerful partnerships
• Taking a 'nothings off limits approach' helped team members to speak their mind, be open to other people's ideas and be creative
• Acknowledging we can make progress but we are not going to 'fix it' once and for all
• Having deadlines as a mean of pushing their ideas on
• Humour was a key thing: being able to laugh and relax together
• Viewing the project work as a journey: sometimes of discovery, sometimes the way forward was not clear but a lot of valuable learning had taken place

4.21 The co-production approach was new to all teams and they at times experienced some confusion, particularly early on about what they were doing and why. This however was part of the democratic process as no one person was driving the agenda.

Making problem solving happen

4.22 Comparing experiences across working groups on the national workshop days generated further lessons. Frequently discussions that examined how tools or approaches would work for the intended group opened out into an examination about how to adapt or modify them for other groups or contexts. This service wide scanning and comparison was very valuable, all the more so because teams were able to do this in a context that provided multiple perspectives from service user, advocacy and social work.

When perspectives clash

4.23 The second workshop provided a good example of what happens when different people view the same thing through their own lenses. It revolved around the summary contact sheet which was designed to give accessible information to the service user at each contact and therefore a better understanding of what was happening and why. The agency lens was in evidence through discussion about whether workers should be making decisions that are recordable at that point. The advocacy lens viewed it as potentially helpful in helping to unpick with a service user what was happening and their views about it. Those with experience working with service users raised questions about the pronouns used in the form: should the form only say what the social worker had told the service user? Or should it be about what was talked about together and use the pronoun we?

4:24 However, because this debate took place away from everyone's own daily routines we were able to work through these different lenses in a way that led to better tools but also improved understanding of why we take the stances we do. A key element of working through differences was graphic facilitation, where key points were written up for everyone to see and briefly illustrated. When we read back through key points at the end of each session, people could hear their own and other's points read out in an impartial voice and could revise together the learning that came from them.

Making communication easier

4.25 Lois Cameron, from Talking Mats, attended both national workshops and her reflections are recorded here as a summary about how communication can be better structured. Lois shared a lesson from marketing strategy: start with the buyer. In ASP this translates to starting with service user instead of the service.

Clear Communication

4.26 Keep written documents simple and easy to read. Using bullet points makes communication easier for everybody because they are:

• Easier to read
• Clearer
• More concise

4.27 Ways of writing things up that are not helpful are:

• Serif Fonts
• Underlining
• CAPITALS.

Using Symbols

4.28 Visuals can help, can give a person another way to grasp what is at issue, but it is important to remember a symbol by itself can be misleading. Symbols shouldn't be a test. They work better with the story they are meant to visualise and can also help a person tell the story from their view. They should be used as a gateway to discussion not a replacement for it.

4.29 The Scottish Government with the Royal College of Speech and Language Therapists (see resources list) has developed some symbols they would like everyone to use in relation to ASP work. The intention is that if these are used often people will become more familiar with them.

4.30 It is always good to have prompts for remembering. Anyone stressed needs help remembering. Visual symbols can help do this.

Translating Legal Language

4.31 Law uses circular language. One term refers to another which refers to another and then back to the first. It can be difficult to break into the circle. It is important to keep this in mind because people who may be facing harm are often on the outside of this circle and find it difficult to begin to make sense of the terms used within decision-making processes. For this reason it is important that practitioners step out of their main role to look at how their language and ASP concepts are actually perceived and work to develop a more common language.

Recognising other influencing factors

4. 32 There are many other factors that can make it hard for a person to take in what is being said and to get their point across, like being worried they will miss their bus if the meeting goes on too long, or the impact decisions may have on cherished routines or on loved ones.

Making change happen

4.33 A conclusion all teams came to was that tools are not checklists. Tools developed shouldn't become tick boxes. The intention is that they are used as prompts for better conversations between practitioners and service users. This in turn should aid the relationship and trust-building that people need to do. We are not seeking to replace that work with a quick short cut but hope the tools will help to avoid barriers or detours.

4.34 Tools should help to put the person first so that arrangements, decisions and plans should always have consideration of the person at the forefront, rather than the other way around. Whilst developing a phone app might suggest the service user does the risk planning on their own, the reality is that all these tools are for sharing and discussion. Time spent building relationships, relating to the person as a person, looking at the work they have done to solve problems can save time later on, lead to less stressful meetings, more beneficial processes and mean harm is not compounded by the process. As one service user said: "Sit down and do it together".

4.35 It's useful to remember that there is a wide spectrum of people, situations, problems and resources. Ways of doing things are always going to need to be adjusted and mean a variety of different ways to engage need to be possible. This also suggests choosing the approach or adjusting an existing one is something best done in collaboration with service users.

Making dissemination happen

Claire Lightowler with the Institute for Research and Innovation in Social Services (IRISS) was involved in the project due to their expertise in project working with local authorities and other care agencies.

4.36 IRISS has done a great deal of work multiplying the effect of pilot projects and helping the learning from them to percolate across the sector. From this experience they have distilled some pointers that all teams in the project felt they could benefit from:

• Remember there is strength in numbers
• Find natural allies to introduce your innovation to first. Their recommendation can be more powerful than claims you would make by yourself
• Highlight what you have found to be successful (rather than what is wrong with current practice)
• Use stories to help people envisage how what you are proposing works in action and what kind of benefits it has for the people involved
• Consolidate learning into key points that are easy to follow

Value of the national network

4.38 The value of gathering the teams into a national network was that it enhanced each other's learning by:

• Looking at each other's work
• Hearing from subject experts
• Discussing common themes and challenges

Summary

4.39 In this project, teams have developed some very practical ideas about how to improve participation. What helped these teams to make such progress was that the teams were small and made up of local people with different perspectives. The co-production approach was new to all teams and they have demonstrated its potential. The workshops also helped to capture important learning about the process of developing tools co-productively that otherwise would have got lost. Sharing experience is particularly important in the development of co-production. It benefited the teams significantly and they modelled how this might be relevant to other service development areas.