Little MiraclesUsing Communities of Practice to Improve Front Line

Collaborative Responses to Women with Complex Needs

The Road to Recovery for Women and ChildrenBrighton 5th September 2013

Michelle Cornes & Jill ManthorpeSocial Care Workforce Research Unit, King’s College London,

Catherine Hennessy & Sarah Anderson, Revolving Doors AgencyJo-Anne Welsh, Brighton Oasis Project

A Community of Practice is a group of people who share a concern, a set of problems, or a passion about a topic and who want to deepen their knowledge and expertise by interacting on an ongoing basis (Wenger, 1998)

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Health and Social Care Housing Related Support

(22.12.10) Bob is admitted to an acute in-patient mental health unit. Diagnosis: mental and behavioural disorder due to multiple drug use, and social anxiety problems. Depression and attempted suicide.

DISCHARGE PLANBecause Bob is homeless he is referred to a housing support project. A locum consultant psychiatrist supports the referral with a letter which is intended to “expedite the tenancy”.

In the letter it is noted that any discharge plan will include initial support from the Crises Resolution and Home Treatment Team. His CPN will then provide regular monitoring and review. It is noted that the drug and alcohol team are involved and that he has a drugs worker allocated to him.

8.3.10 Bob is accepted into a Supported Housing Scheme and discharged from hospital

Bob’s Timeline

Health and Social Care Housing Related Support

23.10.10 Bob has taken an overdose of anti-depressants. Said it was an impulse thing as he felt bad about shoplifting… food parcel given.

Care Plans

Support Plans?

On-going support provided by a housing support worker...

Bob’s Timeline

Cartoon from Community Care on Line June 2013

Community of Practice Development Programme

To explore if ‘communities of practice’ might:

• Help us move beyond ‘sequential handovers’ toward more meaningful collaboration

• Support workers by providing ‘shelter’ in what is an emotionally pressured and stressful job role

Fo

Theory of Collective Capability

The hypothesis...By building a network of mutual interest (a Community of Practice) in which participants view themselves as owning the ‘same problem’ practitioners will engage in renewed conversations about their practice, build their knowledge about how things work, and adjust (improve) their practices accordingly...

for achieving this.

i‘A learning process akin to what happens in jazz ensemble’ (Soubhi et al., 2009 p53).

Maximising Collective Capability to Improve Outcomes

• Agree a shared ‘work priority’• Flatten hierarchies (shared leadership) • Ensure frequent and timely communication• Promote trust, mutual respect and appreciation of others’ roles and

responsibilities• Faciliate crossing of professional boundaries and moving beyond habitual

practices toward an openess to experimentation • Promote sharing of knowledge (explicit and tacit) and task integration

Psychologically Informed Environments (PIES)

‘To make the team the focus of attention is to pay due respect to pervasive (dis)organising social defences and potentially traumatising group dynamics that are at the heart of all work with difficult people in difficult places’

(Scanlon, 2012 p214)

Community of Practice Development Programme (Mar 2012- Feb 2013)

Mental Health Worker

Drug and Alcohol Worker

Social Worker

Housing Support Worker

Expert by Experience

Employment and Training Advisor

Knowledge Broker

Facilitator

6 Communities of Practice established inWorkington, Halifax, Stoke, Brighton, Tower Hamlets, Colchester

plus a small scale (in house) evaluation -Survey (n=33/54) and

Focus Groups with Community of Practice Members (n=34/54)

Criminal Justice Worker

Evidence of Enhanced Collective CapabilityExample 1: Sharing Knowledge Across Agency Boundaries

“I found it very useful. Just the fact of coming here and talking with other professionals about best practice and reflecting on best practice. We don’t often do that in our work... [It] makes you look at your own practice and how you’re working and why you’re working like you are and it gives you ideas about how other people are working... It’s just been really valuable. A really good experience”

Member CP 1

Evidence of Enhanced CapabilityExample 2: Task Integration

Little Miracles

Over 90% of survey respondents agreed:

• I have increased my networks and contacts through my membership of the community of practice

• My knowledge of the role and function of other agencies has increased

• My skills and competencies in working with people facing multiple needs and exclusions has improved

Nice process but did it change anyone’s life?

“From an outcomes point of view, having them stabilised for a period of time is an outcome but it’s not one because they’ve not progressed but they’ve not got any worse and actually that’s a bloody big achievement for some of the customers that we’ve been discussing” (Member CP4)

Integration“The Challenge of Endings”Emily - Outcomes (2008-2012)

Stability FragileHappy TearfulContent LowSelf-esteem DistressedAbstinent LapsedMade changes Suicidal

Weight lossFragileSelf harmPanic attackChild into careDistressedDistraughtHelplessStressDebtsOverwhelmedVulnerableEviction NoticeNot engaging

Reality Check

‘We argue that social policy directives that optimistically envisage a future where all [socially excluded] people will be ‘socially included’ involve an equally stubborn and dangerous refusal to face up to the reality of these problems; a denial of their essential complexity... Such belief systems are setting-up socially excluded people and the workers charged with trying to reach out to them to fail’

(Scanlon and Adlam, 2011 p131-132)

Not just a talking shop: sustaining the workforce in an emotionally challenging and stressful job role

‘The value of this [Community of Practice] is not necessarily moving the customer on, it’s keeping the staff engaged and motivated to continue to do what they’re doing on a daily basis for the customer that’s presenting with the same problem day in day out for three years. That can be quite draining on the staff but actually to sit and talk about it and get that collective support that we’re all going through the same thing gives you a bit more energy and motivation to carry on doing whatever it is, for a longer period of time’ (Member CP4)

Doing More for Less

Discussing the value of PIEs...

‘So our answer to the commissioners’ request, “can you do more for less” is yes we think so. As long as commissioners are flexible and allow clinical staffing as part of teams that are funded for housing-related support’

(Peter Cockersell, 2011)Communities of Practice... Clinical advice for free!

“I remember thinking at the time that’s so simple why didn’t I think of that ... It was the simple thing of asking [the client] what are the positive things in your life? ”

(CP 1: A ‘Housing Support Worker’ reflecting on the ‘solution focussed’ advice given freely by a fellow Community of Practice member, a Community Psychiatric Nurse [CPN])

Can Communites of Practice provide intelligence for local commissioners?

• Dual Diagnosis Pathway (often inaccessible to women)

• Personality Disorder (lack of provision for women)

Policy Implications

• Managers and commissioners need to nurture front line collaborative practice. It will not just happen on its own. For a small financial investment communities of practice can reap many benefits in terms of delivering on the integration agenda.

• In times of austerity, accommodating the interplay between organisational, educational and psychological factors may yield additional benefits for both workers and service users when pursuing outcomes linked to integration (collective capability)

• There is a need to be realistic about what outcomes can be achieved through collaborative and integrative practice such as that found within communities of practice. Maintenance and prevention outcomes linked to resilient and continuous practice over the longer term should be valued just as much as recovery (change) outcomes.

Reports• Cornes, M., Manthorpe, J., Hennessy, C. and Anderson, S. (2013) Little Miracles:

Using communities of practice to improve frontline collaborative responses to multiple needs and exclusions. London: King’s College London and Revolving Doors Agency. Download at: http://www.revolving-doors.org.uk/documents/little-miracles/

• Hennessy, C., Anderson, S., Cornes, M., and Manthorpe, J. (2013) Toolkit: Developing a community of practice. London: King’s College London and Revolving Doors Agency Download at: http://www.revolving-doors.org.uk/documents/toolkit-for-developing-a-community-of-practice/

Contact UsMichelle Cornes and Jill ManthorpeSocial Care Workforce Research Unit, King’s College London, Strand, WC2R 2LS michellecornes@aol.com

Catherine Hennessy and Sarah AndersonRevolving Doors Agency, 4th Floor,291-299 Borough High Street, SE1 1JGCatherine.hennessy@revolving-doors.org.uk