Enabling partnerships for change

We live in a simultaneously challenging and encouraging time. It is challenging as economic austerity impacts on public services and we are faced with growing social and health problems which cannot be simply diagnosed or easily solved. These problems have multiple causes and complex inter-relationships. It is encouraging as we see new energy, ideas, movements and initiatives emerging as innovative ways forward. In this era of constant challenge and change we must keep positively focused on seeing new possibilities and co-creating new futures. Fundamental to making this happen is the notion of effective partnerships. hence our reference to 'co-creation' of new futures. How can we bring together existing expertise and services in effective, authentic and supportive partnerships to make the difference?

This post is co-authored (partnership working in action!)  by Professor Ieuan Ellis, Dean and Pro-Vice Chancellor at Leeds Beckett University and John Walsh, Practice Manager at York Street Health practice, part of the Leeds Community Healthcare NHS Trust (LCH). In this post we outline some elements of partnerships established between York Street Practice and Leeds Beckett University, and reflect of how partnership working has happened and the dynamics that stimulate its work and life.

Leeds Beckett is a modern, professional regional university with a population over 2,900 staff, 28,000 students and with a firm commitment to be a catalyst for social and economic progress in and for the region as well as making its contribution and impact nationally and internationally. The university has been estimated to contribute over £450m to the local economy every year. The Faculty of Health and Social Sciences is one of the four university faculties and plays a key role in establishing and enabling partnership working 

Leeds Community Healthcare NHS Trust is a family of 65 community health services. This includes services  such as community dental, prison healthcare, district nursing and health visiting. Within the trust, York Street Health Practice is the health team for people who are homeless and in the asylum system.

The partnership between our two organisations has grown over the past two years. It embodies a number of different facets, themes and partnership links with other organisations which include the following examples;

  * A partnership between York Street and academics from social work, social care and youth and community studies to create best theory and practice in working with the marginalised, vulnerable and bringing street work perspectives. This is part of a wider international partnership with the universities of Amsterdam, Prague and Barcelona and involving Leeds Adult Social Care Services and so has an integrated care approach to the teaching and development of the work. Last year colleagues from Leeds Beckett, Leeds Adult Social Care and York Street attended a conference in Prague with students and colleagues from these universities and offered teaching and joint collaboration on academic perspectives. This partnership has resulted in funding for research into York Street Practice and its model of care and how adult social care works in addressing homelessness from a street perspective in Leeds.

* Funding has been acquired to hold an international conference in Leeds on new themes in inclusion. This conference will bring together managers, academics, organisational development specialists, practitioners and service users to look at how we create best culture for staff and best care for patients and carers. The conference will highlight international, national and local ideas and practice.

   * The development of a new undergraduate course at Leeds Beckett on youth, communities and society has York Street as key advisory partner. York Street is presently talking to key NHS figures and organisations about ensuring this course achieves recognition for best innovative practice and transformational change.

   * York Street is working with Alan White, Leeds Beckett Professor in Men's Health, looking at how we reach out to some of the most vulnerable people in the city. This partnership work was celebrated during Men's Health week last year in partnership with St George's Crypt. This brought wellbeing practice and health intervention to homeless men. It offered a move away from traditional model of health consultations to one of health conversations over food and dialogue. Health workers from LCH and other health services took part in this holistic and co-delivered event.

   * York Street is presently discussing some mental health and wellbeing research work with Professor White. York Street is also in discussions with Michelle Briggs, Professor of Nursing and Jane South, Professor of Healthy Communities at Leeds Beckett, to develop ideas and map out joint-working for the future

   * Paul Mackreth, a senior lecturer in community nursing at Leeds Beckett, is working with York Street. The team will be offering teaching on leadership this year for student district nurses.

The tripartite partnership of Leeds Beckett, York Street and St Georges Crypt has helped inform the work of CommUNity, a Leeds Beckett community campus partnership. This is an initiative that builds sustainable partnerships between voluntary/community organisations and Leeds Beckett with an emphasis on projects focused on health and wellbeing. The overarching goal is to find new, more effective ways to improve health and reduce health inequalities in communities. Combining the resources and knowledge of community organisations with those of the university creates benefits for both partners: it improves knowledge exchange and gives staff from both sectors access to different sources of expertise, widens participation and opens up opportunities for students and research.

In reflecting how and why this work happens, a number of key elements come through, three of them described here.

To start with there is a shared purpose and vision. The key people involved have moved beyond 'silo' thinking and working to what Kate Cowie, the social change specialist, would term 'a world centric view'. This view is panoramic. This vision is one that respects different disciplines and seeks to create a meeting point for them to develop and learn together. It is an explicit recognition that we work better together and can only deeply learn from and each other in listening dialogue. It looks outward and is open to the new. This provides the framework and field for the work and ideas to appear. The focus has always been on something bigger than ourselves. It has been what can support best health and care interventions with homeless and vulnerable people.

The second key to this successful partnership is that it is capable of creating positive and creative space. We may all have attended meetings where there is no freshness or innovation or inspiration. The joint meetings between Leeds Beckett and York Street have been places of trust, openness and clarity. They have been where it is possible to test and sift ideas and options. We would venture that one key ingredient here has been that the participants haven't seen partnerships as what we can get but more about what we can all contribute to the common good.

A third key aspect of this fruitful partnership has been the human element. Support, kindness, humour and respect have marked the work and tell us that partnerships are fundamentally not just about what we do but who we are. They offer the possibility to bring our best gifts to the present.

As this new year of 2015 starts we will continue on this road of trying to create a health and education partnership that makes the difference in our city and beyond. This post is a sign and witness to that commitment. We believe we are only at the start of a journey that offers potent and engaging models of how we can all work and learn together. This offers something for all of us. It also offers a future. 

John Walsh, Practice Manager, York Street Health Practice

john.walsh@nhs.net @johnwalsh88

Professor Ieuan Ellis,  Dean Faculty of Health and Social Sciences & Pro-Vice Chancellor, Leeds Beckett University

i.ellis@leedsbeckett.ac.uk  @Prof_IeuanEllis

Inspiration and the way forward

The NHS and social care along with other services face major challenges. There are financial, economic and social issues affecting the care people need. In this difficult period we are faced with different views and options for the future. In this post, myself and Pria will reflect on two themes which seem to us so vital. They are our vision and the tools to help us make it real.

The future will be decided not only by what we do, it will be shaped by what we see now. Our vision will create what appears and generate the ideas to realize it. The author, Joel Barker, says it well: "Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world." We need to elaborate a vision of how social care, health and other sectors can come together to create new ways of working. How silos can fall and new integrated solutions be created to meet need in the fastest and most effective caring manner. This vision would enthusiastically embrace co-learning and co-work with patients and carers. It could in alliance with people and communities work on a holistic approach to those in need. The Maori people speak of well being. This is a fascinating word as it is not well arm or well house or well mind but the whole person. The Maori vision sees well being as a house with four walls; the physical, the mental / emotional, the social and the spiritual ( in terms of meaning and purpose ). This holistic vision offers the possibility of circular care where all the four walls reverberate and work off each other. It is also circular as it can only be delivered by different people and services working together in a circle with and around the person. This vision could focus on the person first and foremost. The phrase 'person centred care' is used a great deal today and rightly so. However, we can only really have people centred care if we move away from seeing people as problems. The challenge is to look through the problem to the person and their gifts. This is a move to the person and their potential.

We live in a complex period. The words of Charles Dickens in 'Tale of Two Cities' about another historical period has an echo with us today. He writes, "It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness....it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us." This period includes austerity but also great opportunities to really breakthrough old system thinking and make a shift to better more humane perspectives and practice. Today is not a time for despair but vision and action. The road will not be easy but we can build or rather grow cultures and care that offer best solutions for all. However we can only do this by thinking and doing what's needed in new innovative and potent ways.

There are many tools to support this journey. We will touch on two key skills that support the way forward. The first is to see that the future lies all about us in the present. It is found wherever people care and have passion. This folk represent what the future of our services could be. Recently I met an inspirational Doncaster GP who works in a poor area. He shared the work that he was doing. He said he shook hands with everyone who came into his surgery to welcome them and connect. He said one Saturday a month he would have clinics for carers to reach out and be there for them. The GP also shared that he visited the well as the sick. This was well being work. This GP was creating the forms of the future. These positive practices of really connecting with patients, making space and support for carers and promoting wellness in the community are a sign of what could be done and is being done. We need to capture these wonderful innovative works and share them and ask what they say to us.

The second help is the use of creative space and dialogue. This is where people come together and develop a safe space where trusting and listening discourse can occur. From these transformational hot spots come ideas, inspiration , actions and positive changes. Are the meetings we attend or set up creative dialogical spaces? If we are not learning in them or finding creative energy and visions there then probably not. We need to develop the art of dialogical exchange. Our good NHS colleague, Dr Maxine Craig, speaks of dialogic change. This is where change and creativity occurs in the locus of authentic and open sharing. It's amazing how fresh thinking and practice flow from deep dialogue and connection. When we experience it we feel inspired and caught up in possibility.

The future offers us many challenges and openings. We believe that the need of a vision that positively infects us all and calls forth clear and courageous actions is central to where we need to go. We also affirm that people of passion and vision and the power of dialogue are mechanisms for the vision to become visible. To us the choice seems pretty clear. We are will either be people of purpose and passion who make a great future that works or we won't. That's the crossroads we stand at.

John Walsh, York Street Health Practice, Leeds Community Healthcare NHS Trust  
Pria Bhabra, Leeds Adult Social Care Commissioning, Leeds City Council 

Elevators and services

We live in a world where most of us want to move away from what we call 'The Elevator Effect'. The Elevator Effect is where people get in a lift and look away from those in the lift with them. We will look at the ceiling. We will look at the lift numbers intently as if we expected them to go somewhere else. Where just two people are in a lift they will often stand as far away as possible from each other. We understand that this is an enclosed space and we want to give others as much as space as possible. But there is something else. When we speak of the Elevator Effect we means where people together will not speak or connect. We are often glad to get out of a lift. That might be to do with the enclosed space. It is also to do with a group of people together but not together. In the closed in elevator it is somewhat understandable. In life, work and business it is less so.

We have integrated care services and programmes across health and social care. We have partnerships between the third sector and the statutory services. There are also moves to involve patients and carers more fully.  We also have work with the faith communities. These are all initiatives we support as it brings us all together. It means new understanding, work and co-operation may occur. For patients and clients better, faster and more inclusive services are the planned outcome. This bringing together of all for the common good should be welcomed, nurtured and developed. All of us have so much to learn from each other. It gives us a great opportunity to hear and grow.

There is however a concern for us in this process. The worry has a name and that name is silo. It's easy to work in a silo. We work in our own space and never look up or out. We are like goldfish in a bowl going round and round. We may occasionally look outside the glass and see the world working and moving. We, however, keep on moving. Even in teams with different sections people will sometimes have not team work but section work. This focus on looking at our work but not around and beyond is not the way to create the best services for clients or the best cultures for the future. If the glass of the goldfish bowl breaks the poor fish dies. However if our glass breaks we have the opportunity to live in new and creative ways.

Silo work is a result of a silo consciousness. Silo consciousness always lives in a black and white world of separation. It is always us and them. Our concern is that unless we deal with this consciousness we will bring it over in our efforts to create new joined up approaches, partnerships and services. If we do this we will have elevator meetings where people are not connected or even talking in an engaged way. Silos leave their mark and moving on involves a transition. Silos also go two ways. They go across and up / down. They go across where different services work separately rather than together. This is where we see each other as units that can be called upon when needed but not core and essential partners and co-creators of best care. Silos work up and down where in the same organisation people work as if other sections did not exist. This can be fed by illusions and judgements some people hold of each other. This leads to non-contact and hence non-understanding of roles and struggles. It's so sad when we don't listen to the other. It should be so commonplace for the doctor and social worker to really listen and learn from his patient and for different agencies to meet and co-learn together. There may be some parts of an organisation where silo work is what is needed. That would be fine. It's the silo consciousness that we see as the problem.

The opposite of the silo consciousness is the relational approach. This is a fancy word for something very simple and rich. It means that relationships are what our work is all about. We are social beings and need each other. We live in communion and communication and it is this context that we flourish and grow. At York Street Health Practice we talk in our presentations of 'Circular Care' where all should work together with the client ( in our case homeless people and people in the asylum system ). The symbol of a circle is used as it co-joins us all. It can't be complete until we are all there. It also means that we can't do this alone, we don't want to to do this alone and we don't do this alone. This relational approach is also expressed as a circle where the circumference is the practical work we do - the GP writing the prescription, the nurse bandaging the wound, the support worker making the phone call. The centre of the circle is and has to be the call to rapport, connectivity and relationship. This relational cannot and should not stop at our service door. It needs to extend across services and cities. It is the dissolver of silo consciousness. This post is an example of where Leeds Adult Social Care and Leeds Community Healthcare NHS Trust meet to see what we can do and write to bring together people and communities for change and connection. The Migrant Access Project is another example. It is chaired by the Head of Adult Social Care Commissioning and has statutory and voluntary sector as its members. It exists to support networking across different communities.

Relationships are what will offer the most authentic integration,partnership work and patient engagement work. It is in relationship that we understand others and grow ourselves. It is here where we can jointly see solutions and create change. There is a price here too. That price is that relationships to be genuine need certain features. For the best relationships we have to be our best. Respect, kindness, equality, humour, giving as well as taking and mutual support are all needed. If we grow these seeds great things can happen. We see this in our own city where positive relationships are bringing forth positive results. We have so much to give and learn from each other. We can only receive this in lasting ways when our minds are set on the greater good and open to others. We know that Social Care and the NHS face major problems. Our words will not solve them. What the words point to may offer the best context and bond in which they can be addressed. This is our hope.

John Walsh. Support Manager. York Street Health Practice

 Pria Bhabra. Commissioning Officer (Migrant Access). Leeds Adult Social Care 

The case for care navigation

Health and social inclusion is a priority. Inclusion work around health and social inequalities usually takes two forms. The first is that we attempt to support people and communities access services. We open new clinics, change times and offer new aspects of the service to support this. The second form is to take services to people and communities - to have outreach clinics and workers. Both forms are valuable and powerful options that can make a real difference. The authors of this article believe that there is a third way which builds on the previous two forms but offers a radical orientation for genuine involvement and change. 

Leeds GATE (Gypsy and Traveller Exchange) is a member led organisation which exists to improve quality of life for its members and the wider Gypsy and Traveller communities. It describes itself as ‘value-based’ and these values include such things as ‘helping people to help themselves’ and ‘keeping people safe’. Leeds GATE has developed a reputation for community led approaches to improving health and well-being. Mutual understanding of the impact of social determinants of health, including structural inclusion makes natural bed-fellows of Leeds GATE and the York Street Practice.  This blog post arises from discussion between our organisations in which the proposed role of ‘Care Navigators’ has played a central part.

What is a ‘Care Navigator’? When we speak of care navigators we are proposing a new role which sees trained members of communities acting as a bridge between individuals with health needs and providers of healthcare. This could include services as wide ranging as dentistry, diabetes, maternity, or end of life care, to name but a few.  Our model of navigators is not intended to replace any clinical role, nor to gate-keep direct access to services. The role is better understood as providing a fast track to understanding and increased, effective dialogue between isolated community members and the professional healthcare support they need. A navigator would be the ‘go to’ person for community members needing additional support to understand and work their way through what is often a very complex care system, and for professionals seeking to ensure that their services are effective and don’t exclude groups of people traditionally regarded as ‘hard to reach’.

We imagine navigators spending time in their own communities, generating conversations and sharing information, and in clinical settings doing the same.  It’s not that navigators need to be ‘the expert’ but they would know who ‘the expert’ on any given topic is and would be able to effectively link patients and experts together whilst supporting developing trust and good communication. This care navigation approach, which has been successfully adopted to ensure that homeless people leaving hospital are navigated into services which assist in avoiding rapid re-admission, places people  at the heart  and action of services.  Care navigators can make significant impact on service access inequalities and can work with care providers to create viable, caring and realistic services that people actually need.

The vision of NHS England aims for people to have greater control of their health and wellbeing, supported to live longer, healthier lives by high quality health and care services that are compassionate, inclusive and constantly improving. The Health and Social Care Act 2012 introduced significant amendments to the NHS Act 2006. The Act introduces two legal duties, requiring clinical commissioning groups and commissioners in NHS England to enable:

• Patients and carers to participate in planning, managing and making decisions about their care and treatment through the services they commission
• The effective participation of the public in the commissioning process itself, so that services reflect the needs of local people.

The Marmot Review (Fair Society, Healthy lives) drew attention to the financial and social costs of health inequalities. It might be fair to suggest that many busy service providers and the infrastructure behind those services can find including marginalised people in commissioning, design and delivery of their services difficult to achieve. There is credible evidence available that proper inclusion significantly reduces cost and delivers real health improvement but for service providers making change happen, even just knowing where to start, can be easy to say but hard to achieve.

Care navigators could play a vital role in supporting community involvement and ensuring that the high values and vision of the NHS, and the social and financial savings associated with good care outcomes, are available and meaningful to all groups. Their position at the heart of their communities but, importantly, located as colleagues within professional care settings would enable effective dialogue to address outstanding healthcare inequalities. We believe there is potential to improve health of current and future generations via focus on developing community wide initiatives and individualised care plans on issues as mortality rates, long term conditions, mental wellbeing, etc. Navigators would look at prevention and early spotting of illness and conditions, promoting confidence in early intervention, raising awareness on key issues and, critically, advising clinicians on programmes of follow up action.

Care navigation represents person centred care in which the person and community are at the centre of the care provided. It supports best care in recovery after illness capitalising on tremendous care and support which already operates within communities. The care navigators can explore with the community how people can best manage their own conditions. They could look to develop 'health cell' groups in the community - small groups of community members - each devoted to a different health aspects such as men's health, depression and suicide, etc - the care navigator would help these groups learn, share and link to professional expertise - these cells would be centres of knowledge, accurate information, good signposting and support.

Another benefit, especially in light of the Francis Report findings, is that care navigators could act as barometers for measuring clinical effectiveness and safety, catching and reporting community and individual experiences of health care. The need for health and other services to be transparent and honest with patients would be enabled by care navigators supporting clinicians and providers to find appropriate language and methods to share information.

Care navigation offers a real innovation as it is a new paradigm for working with people from the different marginalised communities which will place the community at the centre of health and wellbeing. The care navigators would be co-located - in the community (understanding the community and relating to its gifts, issues and hopes) and within services. Co-location alongside professionals, as well as within community settings, would assist in linking to other relevant service sectors such as housing, social care, aiding awareness and practical responses to social determinants of health.

There is tremendous potential social and health value and impact present here. Care navigators would promote the dissolution of health inequalities, promote a culture of health inclusion, address in a practical and living way the stereotypes that people from communities face on a daily basis, promoting local community involvement and building potent links between services and people. Critically, it presents the possibility of a real culture of trust and hope to emerge, creating real access for the community to health and celebrating successful good practice and good service models.

We believe that this navigator model is based on a fundamental truth - communities and people have answers and assets. A meeting between these gifts and existing services is needed and holds tremendous promise. Inclusion from, with and for the community may be the greatest hope for health and wellbeing of communities. Health and social work would be based on and flow into communities and become enriched by the assets of the community. We hope this option can be seriously discussed, examined and tried. Care Navigation potentially offers a powerful key to dissolving some of the worst health and social inequalities people in this country face. We believe it is an idea whose time has come. We commend it to you.

John Walsh, Support Manager, York Street
Helen Jones, Chief Executive Officer, Leeds GATE  Health Practice