The Ten Essential Shared CapabilitiesSupporting person-centred approaches

A learning resource for health care staff

Module 1

Module 1: The Ten Essential Shared Capabilities

© NHS Education for Scotland 2012. You can copy or reproduce the information in this document for use within NHSS-cotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

Welcome to Module 1This module introduces you to each of the Ten Essential Shared Capabilities (10 ESCs) and acts as the foundation for all other modules.

The 10 ESCs framework provides the fundamental building blocks for the education, training and continuing development of all health workers to deliver values- and rights-based and person-centred care. It is designed to be applicable to all people involved with delivering health care in practice and support roles, regardless of setting.

The 10 ESCs are shown in Box 1.1.

service or professional definition. We care for each other as “persons” whatever role we perform, either in work, at home or in social settings.

We will work through each of the ESCs in this module, defining what they mean and using reflective activities to help you think about them in relation to yourself and your experiences in practice.

Learning outcomesAfter completing this module, you will be able to:

• describe the 10 ESCs and how they relate to health work

• reflect on yourself and your practice in relation to the ESCs

• understand how the ESCs relate to and support the delivery of health and social services policy and legislation in Scotland

• start to think about further developing your practice in line with the ESCs and recognise how they can help you to improve your experience of health work and the experiences of the people you work with.

Box 1.1 The 10 ESCs

1. Working in partnership2. Respecting diversity3. Practising ethically4. Challenging inequality5. Promoting recovery, well-being and self-management6. Identifying people’s needs and strengths7. Providing person-centred care8. Making a difference9. Promoting safety and risk enablement10. Personal development and learning

On a surface reading, all capabilities will probably seem sensible and may reflect your current attitude and practice. Reflecting on yourself, your role and your practice in relation to the ESCs can be challenging, but it will provide you with a greater insight into, and enable you to explore and reflect on, health work and the care provided. We use the word “care” here in its fullest sense, not in a narrow

Working in Partnership

Working in partnership is about the engagement of all those involved in receiving or providing health and social services, maintaining helpful and productive working relationships and bringing them to an appropriate end. It is about viewing people who use services as partners in care rather than passive recipients of services. And it is about multidisciplinary team working, cross-boundary working and working with wider community networks.

Working in partnership involves:

• valuing individuals as equals in their care and treatment

• acknowledging the positive part that families, friends and carers can play in the person’s support network

• engaging people as partners in care in a way that maximises their role in decision-making and making choices.

Activity 1.1

Reflecting on this, think of a personal experience you have had of using health or social services. This could be a consultation with your GP or a social worker, going to a hospital appointment or supporting a family member or friend who is using health or social services.

How did the professionals with whom you came into contact take steps to “work in partnership” with you?

What positive steps did they take?

What could they have done differently to make you (or your family member or friend) feel you were an equal partner in care?

Working in partnership involves developing and maintaining constructive working relationships with people who use services, carers, families, colleagues, lay people and wider community networks.

It also involves working positively with any tensions created by conflicts of interest or aspiration that may arise between partners in care.

Working in PartnershipThink about the responses you have made to your own experience. How do you think individuals and carers you work with would respond to the questions above?

What changes could you make in your own practice to develop partnership working?

To work in partnership, you need to be able to explain in an understandable way your role in health work and the boundaries within which you operate. You also need to understand your role in relation to the other people with whom you work within a multidisciplinary or multi-agency team setting and know how your role contributes to the wider health and well-being of individuals, carers, colleagues and others you come into contact with.

Activity 1.2

This activity could be usefully carried out in the team in which you work.

Imagine you have started a conversation with a stranger who knows nothing about health work and is interested in what you do. How would you describe your role – what are the main things you

do, and what is the purpose of the service in which you work?

Who are the key people you work with and alongside?

How does the team or service you work with link with other health or social services and agencies and wider community networks?

Partnership working is key to delivering safe, effective and person-centred health care, in supporting people to participate fully in their care and in working effectively with families and carers. Benefits of active partnership working include the following.

Relationship building Positive outcomes are much more likely to occur if you have a firm base for your relationship with people who use services and, when relevant, their carers and family members. Relationships are built from listening and responding to other people’s points of view and

Working in Partnershipvaluing the other people within the partnership as equals with valid opinions.

Needs-based services These develop from a willingness to listen to the needs of the person and their carers/families, responding appropriately to expressed needs by family carers and making this the focus of the professional intervention.

Care decisions To be effective in the long term, care decisions need to be based in the “real world” and need to consider what is achievable in particular settings. It may be reasonable to expect professional staff to respond in a certain way, but this may not be a reasonable expectation of a parent or family member.

Conflict resolution Conflicts can and do arise whether we work in partnership or not, but partnership working gives us opportunities to build relationships, understand each other’s point of view and resolve conflict effectively.

Activity 1.3

What issues have you come across that present barriers to partnership working?

Gates and Barr1 suggest that issues that may pose barriers to partnership working include perceived difference in interests, differing understanding, different values, different styles and differing opinions.

Activity 1.4

Think back to the issues you identified that could be barriers to partnership working and, using the headings from Gates and Barr, see if your issues fit within this framework

Heading Issues you identified

Interests

Understanding

Values

Style

Opinion

We will continue to explore working in partnership while looking at the other ESCs. Several of the modules in this learning resource will also help you to reflect on and develop your capability in “working in partnership”, particularly:

• Module 2 – Values-based practice • Module 3 – Involving people• Module 5 – Inclusion, assets and outcome-

Respecting Diversity

Delivering equitable, person-centred care requires culturally competent health and social services that aim to eliminate discrimination and promote equality of opportunity for everyone. Most professional frameworks acknowledge the importance of respecting diversity.

Equality is about creating a fairer society in which everyone can participate and have the opportunity to fulfil their potential and no one is unfairly disadvantaged.

Diversity is about valuing people’s differences and addressing their needs and situations.

Respecting diversity means you need to be aware of, and take steps to challenge, inequalities and ensure that the care you provide takes account of the unique background and life experiences of each individual.

Activity 1.5

How are the specific needs of diverse service users identified in the service in which you work?

What processes are in place to support this?

How does the service respond to these needs?

What is your role in this response?

Respecting diversity is about working in partnership with people who use services, carers, families and colleagues to provide care and interventions that not only make a positive difference, but also do so in ways that respect and value diversity, including age, culture, disability, gender, gender identify, race, religion or belief and sexual orientation.

Respecting DiversityConsider the following statement: “Our service is equal because we treat everyone the same”.

What do you think about this statement? Record your thoughts here so that you can reflect on them as we explore diversity in more detail later in this resource.

The other modules in this learning resource will help you to reflect on and develop your capability in “respecting diversity”, particularly Module 4 – Equality and diversity: respecting difference.

Practising Ethically

Practising ethically means:

• recognising the rights and hopes of individuals and their families

• observing codes of practice and good practice guidelines

• working within the law.

Activity 1.6

Identify what guidelines are relevant to you and enable you to practise within an ethical, legal, honest and non-judgemental framework.

Are these guidelines straightforward and easy to follow?

What opportunities do you have to discuss such guidelines with colleagues or supervisors?

When you complete the learning in Module 2 – Values-based practice, you will recognise that a range of complementary (and sometimes competing) frameworks direct our behaviours and actions as people involved in health and social services. They include:

• the law – for example, the Human Rights Act (1998), the Adults with Incapacity Act (Scotland) 2000, the Mental Health (Care and Treatment) (Scotland) Act 2003, Patient Rights (Scotland) Act 2011, the Equality Act 2010 and other relevant pieces of legislation

• codes of conduct and professional values statements for professional groups such as nurses, allied health professionals (AHPs) and social workers

• importantly, our own individual values and beliefs.

Practising ethically involves recognising the rights and aspirations of individuals and their families and carers, acknowledging power differentials and minimising them whenever possible. It also focuses on providing care and treatment that is accountable to individuals and carers within the boundaries prescribed by law and professional, national and local codes of ethical practice.

Practising EthicallyThe principles underpinning legislation and professional ethical codes, standards and codes of conduct may use different language. Increasingly, these are being informed by the human rights agenda. We are going to focus on one example.

The Scottish Government launched Standards of Care for Dementia in Scotland [http://www.scotland.go.uk/Publications/2011/05/31085414/15]and Promoting Excellence − a framework for all health and social services staff working with people with dementia and their families and carers [http://www.scotland.gov.uk/Publications/2011/05/31085332/12] in June 2011.

The Standards of Care for Dementia in Scotland were developed to help people with dementia and their carers understand their rights and how they can help to make sure that they are supported and are listened to. The Promoting Excellence Framework is designed to ensure staff have the knowledge and skills to work in a human-rights based way.

The main sources underpinning the standards and the Promoting Excellence framework are:

• the Charter of Rights for People with Dementia and their Carers in Scotland [http://www.dementiarights.org/]

• what people with dementia and their carers in Scotland have identified as being important to them and what they want from services

• quality of life (QoL) outcome indicators for people with dementia.

Practising EthicallyActivity 1.7

Consider the standards areas and QoL indicators in Box 1.2

Box 1.2

Standards of care for dementia domains QoL outcome indicators• I have the right to a diagnosis• I have the right to be regarded as a unique individual

and to be treated with dignity and respect• I have the right to access a range of treatment and

supports• I have the right to end-of-life care that respects my

wishes• I have the right to be as independent as possible and

to be included in my community• I have the right to have carers who are well supported

and educated about dementia

• People with dementia have access to a timely and accurate diagnosis of dementia

• People with dementia feel empowered and enabled to exercise rights and choice, maintain their identity and to be treated with dignity and equity

• People with dementia maintain their best level of physical, mental, social and emotional well-being

• People with dementia have access to individuals, groups and organisations that can support their spiritual or personal beliefs and reflect their cultural wishes

• People with dementia have access to quality services and can continue to participate in community life and valued activities

• People with dementia feel safe and secure and are able to be as independent as possible

• People with dementia are able to maintain valued relationships and networks and have the opportunity to develop new ones, both personal and professional

• People with dementia and their family, friends and carers have access to information, education and support that enhances the well-being of the person with dementia and those who support them

Practising EthicallyImagine you have a long-term health problem. Which of the standards or QOL indicators would you consider to be of particular importance to you in your care and treatment, and why?

Reflect on a person you know who is using health or social services. To what extent are the standards and QoL indicators like those outlined above being applied to shape his or her care and treatment?

What are the successes in applying concepts such as human rights-based standards and QoL outcome indicators in your team or service?

What are the barriers to applying concepts such as human rights-based standards and QoL outcome indicators in your team or service?

What could you do to influence this?

Activity 1.8

Spend some time considering ethical codes or codes of conduct for your profession. What elements of the code/s emphasise protecting human rights or enhancing people’s quality of life?

Several modules in this learning resource will continue to help you to reflect on and develop your capability in “ethical practice”, particularly:

• Module 2 – Values-based practice • Module 3 – Involving people• Module 4 – Equality and diversity: respecting

difference.

Challenging Inequality

Challenging inequality is about helping to overcome the unfair treatment and unwelcoming attitudes that affect some people. It is important to recognise that some people face significant barriers and that these can not only have a significant impact on their health, but can also create a sense of exclusion. Barriers can relate to attitudes and stigma associated with particular conditions or life choices, backgrounds, personal characteristics, social position and/or access to health and social services.

There are two important and inter-related aspects to inequalities:

• inequalities related to individuals by virtue of their individual characteristics, which can lead to discrimination and exclusion

• health inequalities that may be linked to social, economic and environmental factors.

These two issues may often be related. For

example, in their 2010 report, How Fair is Britain [http://www.equalityhumanrights.com/key-projects/triennial-review/full-report-and-evidence-downloads/],2 the Equality and Human Rights Commission (EHRC) notes that Pakistani, Bangladeshi and Muslim people have worse than average health outcomes, which may be related to their relatively poor socioeconomic position. They also comment that research suggests an association between harassment and poor mental health.

Tackling health inequalities is a key objective of the Scottish Government. Poor physical and mental health is both a cause and a consequence of social, economic and environmental inequalities. The World Health Organization defines health inequalities as differences in health status or in the distribution of health determinants between different population groups. In Fair Society, Healthy Lives [http://www.instituteofhealthequity.org/],3 the strategic review of health inequalities in England, Sir Michael Marmot characterises health inequalities as avoidable differences in health, well-being and length of life and notes that they are inextricably linked with differences in social circumstances. Inequalities can cross generations, with children born and brought up in disadvantaged families being more likely to experience poor health in later life.

There is strong evidence of health inequalities across Scotland [http://www.scotland.gov.uk/Topics/Health/health/Inequalities/inequalitiestaskforce],4 with key populations

Challenging inequality involves addressing the causes and consequences of stigma, discrimination, social inequality and exclusion for individuals, carers and services. It also focuses on creating, developing or maintaining valued social roles for people in the communities in which they live.

Challenging Inequalityhaving much lower life expectancy and higher morbidity. Sources of inequality in health are broad ranging and include:

• life circumstances/social and economic determinants – for example, socioeconomic status, homelessness, asylum status, skills and qualifications

• differential access/care – geographic location, literacy, culture, physical access, attitudes, communication

• health behaviours – smoking and poor diet contributing to excess morbidity and mortality

• discrimination – on the grounds of ethnicity and culture, disability, gender, gender identity, religion or belief, sexual orientation or age.

To challenge inequality, you need to understand the effects of exclusion and discrimination, particularly in the way they can affect health and well-being.

Example: older people

Concerns have been expressed that older people can face discrimination in accessing NHS or social services as a result of their age. AGE − The European Older People’s Platform drew attention to some of these issues in 2004, citing examples such as access to health screening having an upper age limit, the frequent exclusion of older people from clinical trials (which may be significant given that it is estimated that one third of cancers occur in the over 75s) and low priority being given to services that are used and valued by older people (such as podiatry).

The fact that age discrimination in the NHS has been forcefully challenged by bodies such as Help the Aged and Age Concern has led to a range of policies effectively outlawing such discrimination and demanding evidence from health services that this is being addressed. Indeed, the Department of Health reported in 2008 that there had been greater action by hospitals in providing surgery for older patients following the issuing of specific directives. Between 2000 and 2002, for example, breast cancer surgery for patients aged 85 and over rose by 13% and coronary artery bypass grafts increased by 16% for 65s and over (the increase was 32% among patients aged 75 or over and 65% in the 85-plus age group).

Challenging InequalityActivity 1.9

Often the language used in a society reveals stigma and discrimination. This can be the case in describing people with mental health problems, where we know that derogatory and negative terms are often used. It can also be the case with other health issues such as obesity or diseases associated with alcohol dependency. Consider the following two examples.

Here are some statements made by health and social services workers to describe Jackie.

Here is what some health and social services staff had to say about Sheila.

Jackie

Jackie is an obese non-compliant diabetic who does nothing to help herself.

Jackie requires significant support with her lifestyle choices to attain optimum management of her diabetes and weight.

Jackie is the proud mother of a two-year-old daughter and has a supportive family. She aspires to go to college to study child care. She has lived with diabetes since she was 14.

Sheila

Sheila is an ageing woman with a learning disability who is almost totally dependent on her mother.

Sheila has severe learning disability but functions reasonably well with her mother’s support.

Sheila works in a café. She has a wide range of friends and an active social life. She lives with her mother and has a learning disability.

If you were Jackie or Sheila, which of the descriptions would you prefer was used about you. Why?

Look back at your responses to Activity 1.2. What language did you use to describe your role and the people you work with? Is there anything you would change in the light of this exercise?

Challenging InequalityActivity 1.10

Identify someone you know or have worked with whom you think might experience inequalities.

What is the nature of these inequalities?

What is the potential impact of these inequalities?

Why should it matter to you as a health worker?

Why have you identified this person as potentially experiencing inequalities?

What did you know about his or her background, life circumstances and aspects of identity?

How does this knowledge help you to provide care for the individual concerned?

People who experience mental health problems may be particularly at risk of experiencing inequalities as, unfortunately, stigma is still associated with mental health problems. Mental health service users and carers have identified stigma as a key problem that contributes to the inequalities they face. Challenging stigma and stereotyping is therefore an important part of challenging inequalities.

One of the best ways of countering stigma and encouraging people to be more open about mental health in general is through providing relevant information. For example, you should be aware that:

• one in four people in Scotland will experience a mental health problem at some point in their lives

• depression and anxiety are the most common mental health problems – most people recover fully from both

Challenging Inequality• almost three-quarters of people in Scotland

know someone close to them who has been diagnosed with a mental health problem at some point.

The National Programme for Improving Mental Health and Well-being was launched in October 2001 and ran until 2008. Its vision was to “improve the mental health and well-being of everyone living in Scotland and to improve the quality of life and social inclusion of people who experience mental health problems.”

To help inform the work of the National Programme, the-then Scottish Executive commissioned the first National Scottish Survey of Public Attitudes to Mental Health, Mental Well-being and Mental Health Problems in 2002. The survey was repeated in 2004, 2006 and 2008, with minor changes made to the questionnaire on each occasion.

Findings from the 2008 survey, Well? What do you think? [http://www.scotland.gov.uk/Publications/2009/09/15120147/0],5 indicate:

• a quarter of those who had experienced a mental health problem had experienced difficulties in terms of other people’s attitudes

• one in ten had been discouraged from participating in social activities, and roughly half this proportion had experienced discrimination at work or had been refused a job

• a quarter of those who had personal experience of a mental health problem had chosen to avoid a social event because of the way they thought people would react to their problem; this is significantly higher than the proportion who said they had actually been discouraged from participating in a social event, suggesting that self stigmatisation is an issue

• for the most part, attitudes towards mental health problems in Scotland were unchanged from 2006

• significantly, the proportion of people agreeing with the statement, “If I were suffering from a mental health problem, I wouldn’t want people knowing about it”, remained stable, despite decreasing gradually over previous waves of the survey

• attitudes tended to be more negative than average among older respondents (aged 75 and over), people with no qualifications, people living in the most deprived areas and those with no personal or proxy experience of a mental health problem

• with regard to public attitudes to mental health problems, the findings indicated that positive trends identified over previous waves of the survey may have at best plateaued.

Challenging InequalityActivity 1.11

Reflect on the issues outlined above. Many people experiencing physical health problems may also experience mental health problems. How open is your service to recognising and responding positively to people’s mental health issues?

How would you feel about disclosing that you had a mental health problem to your work colleagues?

If your response indicated that you would feel uncomfortable about this, what things do you think need to change?

We have many drivers to help challenge inequality in Scotland. One of the principles of the Mental Health (Care and Treatment) (Scotland) Act 2003, for example, is “non discrimination”, meaning people with mental health problems should, wherever possible, retain the same rights and entitlements as those with other health needs.

If a service user believes he or she has suffered discrimination (that is, has been treated less favourably than a person who does not share a particular characteristic like race or gender, or does not have mental health difficulties or other impairment defined legally as “disability”) in employment, education or in the provision of goods or services, he or she may be able to pursue this in law under the Equality Act 2010 [http://www.equalities.gov.uk/equality_act_2010.aspx].

Activity 1.12

On an individual level, think of a situation in which you have been able to challenge inequality and discrimination within your organisation. Describe the situation briefly:

On which key strengths did you need to draw to act in this way?

Looking back on the situation now, is there anything you would want to do differently?

Challenging InequalitySeveral modules in this learning resource will help you reflect on and develop your capability in “challenging inequality”, particularly: • Module 4 – Equality and diversity: respecting

difference• Module 5 – Inclusion, assets and outcome-

focused practice.

Promoting Recovery, Well-being and Self-management

Although the notion of recovery grew out of the area of mental health, the description above can clearly have meaning for many people with physical health problems, mental health problems, or both. In some instances, the word “recovery” itself may not always feel appropriate (where there is life-limiting or terminal illness, for example), but the underpinning ideas about working together, hope and valued lifestyle still apply.

These are the same beliefs and values that underpin self-management and an assets-based approach (we discuss this in detail in Module 5), which have clear relevance to working with people with long-term conditions (LTCs). When we speak of recovery within the ESCs, we are therefore also speaking about well-being and self-management.

The concepts of self-management and recovery may have come from different origins, but they share many common ideas and underpinning philosophies. The Long Term Conditions Alliance

Scotland (LTCAS) says that self-management is about people living with LTCs being “in the driving seat”. Like recovery, self-management is not an individual action, specific treatment or service, but is about supporting and encouraging people living with LTCs “to access information and to develop skills to find out what’s right for their condition and, most importantly, right for them”. To explore this in more detail, visit the LTCAS website [http://www.ltcas.org.uk/what-we-do/self-management/what-is-self-management/].

Focusing on recovery and well-being and supporting people to self-manage enables people to “be all they can be” and to maximise their quality of life. Recovery, well-being and self-management are about much more than the absence of symptoms – they are also about giving people the tools to become active participants in their own care and about having a belief, drive and commitment to the principle that people can and do recover, or maintain, control in their lives, even where they may continue to live with ongoing symptoms. Fundamental to this is the belief that individuals (and communities) are part of the solution rather than passive recipients of care. They have assets and resources that can be maximised but which may often be missed or not fully utilised in more traditional models of health and social care.

The word “recovery” may more traditionally be associated with the idea of getting back to “normal”. However, whatever the nature of an illness, it may not be possible (or even desirable) to return to a previous state. Recovery is about a way of living

Promoting recovery, well-being and self-management involves working in partnership to provide care and treatment that enables people to address health problems with hope and optimism and to work towards a valued lifestyle within and beyond the limits of any health problem.

Promoting Recovery, Well-being and Self-managementa satisfying, dignified, hopeful and contributing life even with the limitations caused by illness. Recovery may therefore involve the development of new meaning and purpose in one’s life.6

The Scottish Recovery Network (SRN) reinforces the idea that recovery is a uniquely individual process. It is not something that health or social care providers “do” to people; nor is it a service or programme. Box 1.3 [http://www.scottishrecovery.net/Key-themes-of-recovery/key-themes-of-recovery.html]7 identifies some of the common themes of recovery.

Box 1.3

A recovery and well-being focused approach and supporting self-management requires that we learn as much as possible from the experience of people. This sounds like an obvious thing to do, but it can lead to asking some pretty fundamental questions about our roles as professionals and to examine the knowledge, skills and values we bring to our supporting role.

Activity 1.13

Think of a time in your life when you have “recovered” from something (remember how we have previously defined “recovery”). It could be an illness, a loss, bereavement, or the end of a relationship.

What things helped your recovery?

What things hindered it?

Common themes of recovery7

Recovery as a journey

has ups and downs, a process rather than an end point

Hope, optimism and strength

hope is key, a better life is attainable, focus on strengths and assets

More than recovery from illness

not just about symptoms, about life and identity beyond experiences of illness

Control, choice and inclusion

being actively involved, sharing decisions

Self-management

people living with LTC being “in the driving seat” and supporting people to live their lives better, on their terms

Finding meaning and purpose

unique to the individual but often about contributing, having valued roles, reciprocity

Relationships supportive and helpful relationships are vital

Adapted from http://www.scottishrecovery.net/Key-themes-of-recovery/key-themes-of-recovery.html

Promoting Recovery, Well-being and Self-managementThink about the things you did for yourself or the things you did with support from family, friends, service providers (if relevant) or other people in your environment. What impact did they have?

Discuss your answers with others. Are there common themes and issues?

Do you think the helpful things you identified are also relevant to the people you work with?

It is important to note what recovery and promoting well-being does not mean. It is not:

• cure• something health workers “do” to people• a new word for “rehabilitation”• a model• “something we have always been doing

anyway”.

The keys to working in a recovery and well-being focused way include:

• HOPE, one of the most important factors in recovery

• a belief in recovery and knowing that recovery happens

• holding and demonstrating values and practices that reflect this belief

• working from people’s strengths, assets and abilities rather than focusing only on problems and deficits

• developing support so that people can increase their role in directing their own care and treatment

• recognising that people with experience of health problems are “experts by experience” with unique knowledge and insights to contribute

• recognising that while there are common themes, recovery is a unique and individual experience − consequently, our support must be person centred and holistic

• being creative and flexible in our approach and considering the role of risk enablement (explored later in this module)

• the importance of relationships – how practitioners communicate and behave can significantly impact on people’s recovery and well-being

• the use of tools such as person-centred planning and strengths-based approaches.

Promoting Recovery, Well-being and Self-managementActivity 1.14 Look back at the common themes of recovery (Box

1.3). In what ways (if any) did Dr Matheson draw on these in his conversation with Derek?

Imagine you were a participant in the conversation described above. What could you have said or done that might have meant Derek did not feel so despondent or hopeless?

You cannot work in a recovery and well-being focused way unless you involve individuals and carers, practice in a values-based, inclusive and asset-focused way, respect diversity and address inequalities. All of the other modules in this resource and all of the other ESCs will therefore help you reflect on and develop your capability in “promoting recovery, well-being and self-management”.

Derek’s story (1)

Remember Derek? He is the OT who works with his local authority and has been having problems with back pain.

Derek has been visiting his GP over the past few months because of his pain and has been receiving medication and physiotherapy. Things are still not going well for him and his pain is impacting on his life both physically and mentally. He has had a number of spells of sick leave from work and is feeling very low in mood. He is worried that his work colleagues are beginning to think negatively about him as he feels he is constantly letting them down and his manager has suggested he needs to be referred to occupational health. He attends his GP again to discuss his situation. During the consultation, Dr Matheson, Derek’s GP, is very sympathetic and agrees to review Derek’s medication, but explains that there is a certain degree of inevitability about the deterioration in his back. Derek is getting older, Dr Matheson explains, and the physiotherapy assessment suggests he has a long-standing injury that isn’t amenable to more invasive treatment. The GP suggests that Derek may have to consider lifestyle changes, including the option of possibly changing his job, and suggests he might want to discuss this when he see his occupational health services. Derek feels quite despondent and hopeless after the consultation.

Identifying People’s Need and Strengths

This is about working with people to help them identify their needs, priorities and strengths in all areas of their life, keeping in mind the way people like to live and the things they, their family, carers and friends hope for.

There may be a tendency in health services to define certain circumstances in people’s lives as “problems”, instead of working with people to support them to identify what is positive and what is negative in their lives. Rather than focusing on problems, we need to see people’s needs and strengths, recognising assets in the community in which the person lives and encouraging a self-management approach. It is about focusing on positives on which the person can build.

To identify people’s needs and strengths, you need to:

• carry out (or contribute to) assessments that focus on the strengths and needs of the person

using services and family, friends and carers who support him or her

• work in a way that acknowledges the personal, social, cultural and spiritual strengths and needs of the person

• work in partnership with the person’s network to collect information to assist understanding of the person and his or her strengths and needs.

Activity 1.15

Think about your own strengths and talents and list the three or four of which you are most proud.

Now think of a person who uses the service with which you are associated – preferably someone you are working with.

What needs does the person have? Be descriptive and positive rather than presumptive in answering this question.

Note: Please ensure you anonymise any information you write down.

Identifying people’s needs and strengths involves working in partnership with people to gather information to agree their needs, priorities and desired outcomes in the context of the preferred life circumstances and aspirations of individuals, their families, carers and friends.

Identifying People’s Need and StrengthsWhat strengths does the person have? Consider all the person’s abilities, interests and talents – everyone has strengths and talents.

What about the person’s support network? To help with this task, perhaps spend some time talking with the person and other members of his or her support network. It may also be helpful to think about your own support networks (friends, families, colleagues) when answering this question.

Several modules in this resource will help you reflect on and develop your capability in “identifying people’s needs and strengths”, particularly: • Module 3 – Involving people • Module 5 – Inclusion, assets and outcome-

focused practice.

Providing Person-centred Care

Person-centred care recognises and responds flexibly to each person as a unique individual, builds trust and empathy, and fully engages them in decisions that affect their health care and well-being. It is an approach which recognises that the quality of communication and human engagement with the person will underpin the effectiveness of the encounter and therefore impact on the person’s healthcare and outcomes [http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/1010492/9.%20Person%20Centred%20Care%20Key%20Messages%20_3_.pdf].8

Person-centred care has many definitions, but at its heart is a focus on providing care that is respectful of, and responsive to, people’s preferences, needs and values and ensuring that their values guide all health care and treatment decisions. To explore this concept more, visit the King’s Fund website[http://www.kingsfund.org.uk/topics/patientcentred_care/index.html].

This means working towards identifying goals and outcomes that fit with the person’s, family’s and carers’ aspirations rather than focusing on what health and social services think people need. It then focuses on helping to work out what needs to be done, who will do what and how progress and success will be measured.

To provide person-centred care, you need to:

• support the person using services to describe his or her wants and needs in a way that is meaningful

• support the person using services to identify and use his or her strengths to achieve goals and aspirations

• work with the person to identify the strengths and resources within his or her wider network that can play a role in supporting goal achievement.

Providing person-centred care involves working alongside people to identify meaningful goals and outcomes from their perspective and, when appropriate, their families and carers. It also involves influencing and seeking the means to achieve these goals and outcomes and clarifying the responsibilities of people who will provide help, including evaluating outcomes and achievements.

Providing Person-centred CareActivity 1.16

The story below helps us reflect on the most basic things we need to deliver to start to achieve person-centred care.

Imagine you’ve been admitted to hospital for an overnight stay. Complete your own “Lauren’s List”.

Let’s now move thinking about this issue on a bit further.

Activity 1.17

Identify anybody, or anything, you found helpful or supportive at a time in your own life when you were distressed (this may be because of illness or other events that have happened in your life).

If you were going to be accessing health or social services for any reason, what are the main things you would want the staff to think about to make your care person-centred?

Lauren’s story

When Lauren Sampson was only seven years old, she had already been hospitalised more than 50 times. With her mother, Sally, by her side, she had spent a large part of her life with health care professionals. The two watched teams of physicians barge into Lauren’s hospital room and pat her stomach because they were curious about her pancreatitis. They watched nurses deliver shots and say “This won’t hurt” when, in fact, it did. They watched all kinds of caregivers explain what was going to happen, but not explain who they were.

Frustrated with her care and the loss of control she experienced with each hospitalisation, Lauren taped to the door of her hospital room a piece of paper that listed some requests for any caregiver who came to see her. In time, Lauren, Sally and the hospital’s child life specialist refined the original list and changed the way those health care providers interacted with their patients.

Ultimately, with guidance from Sally, the hospital adopted Lauren’s idea to be used for all patients: it created a placard placed around the door handle to patients’ rooms that lists four simple instructions:

• please knock on my door• please introduce yourself• please explain why you are here• please tell me if something might hurt.

Reproduced from: http://www.ihi.org/offerings/ihiopenschool/resources/Pages/LaurensListAnInterviewWithSallySampson.aspx.

Providing Person-centred CareThink about how some aspects of health and social services, and public expectations, have changed in the past few years. What opportunities do these present to make your care more person-centred?

To explore this issue more, we will again draw on some lessons from mental health. The Scottish Recovery Network (SRN) undertook a major narrative research project that aimed to further promote understanding of the lived experience of service users in recovery in Scotland. The research involved over 60 individuals living in Scotland who identified themselves as recovered or in recovery from mental health problems. Recovering Mental Health in Scotland, Report on Narrative Investigation of Mental Health Recovery [http://www.scottishrecovery.net/Narrative-Research-Project/narrative-research-project.html]9 was published in 2007 and details the findings of this major research study. This original research is now being revisited and you should check out the SRN website [http://www.scottishrecovery.net/] to read the new report when it becomes available.

Some of the key issues from the 2007 report are highlighted in Box 1.4.

Box 1.4 Key issues from Recovering Mental Health in Scotland9

Recovering identity • Confidence• Hope and optimism • Self acceptance,

responsibility, belief and esteem

• Self-efficacy • Self-awareness• Growing beyond the

label • Reclaiming power and

self-determination • Belonging – cultural,

social and community identity

• Activism • Spirituality

Engagement and finding meaning and purpose• Being valued – giving

back • Meaningful roles • Volunteering,

employment and education

• Learning about self and condition

• Community and social engagement

• Communities and housing

• Exercise and creativity

Relationships• Friendships • Supportive family

relationships • Intimate relationships:

partners • Parenting • Peers • Pets • Service professionals

– a critical friend • Mutual trust and

recognition • Hopeful relationships

Treatments and supports• Feeling informed and

in control • Continuity and

flexibility• Treatments and

therapies• Security • Peer support • Relationships,

attitudes and power • Housing and

community supports • Financial security

Pacing and turning points • Coping • Other people’s

experiences • Taking control • Changes in thinking

and being • Narrating your story

Providing Person-centred CareYou can see from Box 1.4 the range of issues that were seen to be helpful. Some are offered by mental health services, but many more are beyond the current scope of most services.

Activity 1.18

While Box 1.4 relates specifically to mental health, reflect on its contents from the perspective of your own area of practice and the people with whom you work.

What similarities and differences exist?

What does that mean for person-centred care?

Remember to think broadly when supporting people to help them to describe goals, identify strengths and develop their own recovery strategy.

All of the other modules in this learning resource will help you reflect on and develop your capability in providing person-centred care.

Making a Difference

This is about delivering safe, effective and person-centred care that draws on the best clinical evidence and values base to help you deliver what people want and need.

“Making a difference” means making sure that people, their families and carers have access to a range of high-quality care and treatment options that work well for them, are delivered appropriately and meet their needs and hopes for the future.

To make a difference, you need to understand the notions of both evidence-based and values-based “best practice”. Values-based practice is explored in detail in Module 2.

What evidence should be informing practice? Basically, we are looking at:

• research• clinical guidelines• best practice statements• integrated care pathways (ICPs).

The former NHS Quality Improvement Scotland (NHS QIS) (whose functions are now part of Healthcare Improvement Scotland) was a special health board that led on improving quality of care and treatment delivered by services across NHSScotland. NHS QIS produced a number of clinical guidelines and best practice statements relevant to a range of health services, including paediatric, maternity, acute care, learning disability, mental health and care of older people. It also developed a programme of work on ICPs.

There are many definitions of an ICP. ICPs embed guidelines, protocols and locally agreed, evidence-based, person-centred best practice into everyday use for individual service users. They also enable differences from planned care to be recorded in the form of variances, which enable us to compare planned care with care actually given.

In simple terms, an ICP aims to have the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome − all with attention to the individual’s experience. The Health Care Improvement Scotland website [http://www.icptoolkit.org/] contains a wealth of information on clinical guidelines, best practice and ICP work.

Evidence into Practice [http://www.evidenceintopractice.scot.nhs.uk/home.aspx] is a resource launched by NES in 2010. It helps NHS staff to find, share and apply evidence to practice to deliver the best-quality care. It aims to equip NHSScotland with the knowledge and tools to deliver a world-class health service and facilitate

Making a difference involves facilitating access to and delivering the best quality, evidence-based, values-based and person-centred health interventions to meet the needs, goals and aspirations of individuals, their families and carers.

Making a Differencechange in practice at the front line by providing:

• access to the evidence base for safe, effective, person-centred care

• tools and support for creating, sharing and disseminating knowledge through communities and networks

• tools and outcome measures to support, record and monitor improvement in practice

• learning resources and guidance for quality improvement science.

Of equal importance is the evidence provided through “expertise by experience” that people who have experienced and live with health problems bring, including the experiences of their families and carers, their experience of receiving health and wider social services and their experience of the service provided to them by health care professionals.

Alongside evidence generated by scientific research studies such as clinical trials, it is also crucial to attend to what individuals, families and carers say makes a difference. Many health and social services organisations now seek to find out about experiences of care through the collection of “stories” (either patient, relative or staff), which can provide rich information.

Excellent examples of the quality material that is available online are shown in Box 1.5. This type of evidence can highlight factors that make a difference to individuals and carers that are somewhat different from the factors outlined in

clinical guidelines, such as specific treatments or medications.

Box 1.5

Useful websitesBetter Together[http://www.bettertogetherscotland.com/bettertogetherscotland/23.html] is Scotland’s Patient Experience Programme, which aims to use the public’s experiences of NHSScotland to improve health services. The website contains a section where patients, carers and staff are able to share their stories (both positive and negative) of their involvement with the health service. You can search the collection by health board or condition.

Health Talk on Line [http://www.healthtalkonline.org/] and Youth Health Talk [http://www.youthhealthtalk.org/] are charitable organisations that allow patients, families and professionals to share their experiences of health and illness. Through the websites you are able to watch or listen to videos of interviews, read about people’s experiences and find reliable information about conditions, treatment choices and support. This type of evidence is increasingly being recognised as important to the evidence base and can highlight factors that make a difference to service users and carers that are somewhat different from the factors outlined in clinical guidelines, like specific treatments or medications.

The Little Things Make a Big Difference [http://www.knowledge.scot.nhs.uk/making-a-difference.aspx] resource has been developed by NES to support the enhancement of patient experience. It gives access to resources and literature that will support continuous professional development or can be used with patients and carers.

Making a Difference

Activity 1.19

Reflect on one person you have worked with for whom you believe your care and interventions made a real difference.

Bearing in mind we are defining evidence broadly here, what “evidence” helped guide your decisions around the support and interventions you undertook with this person?

What values influenced your choices?

Did you use any evidence-based clinical guidelines? What sources of evidence did you use to inform your practice?

It is essential for best practice in health services that we always seek the views of the people we are working with to gauge how helpful our support and interventions are to them.

Activity 1.20

What means and processes are currently used in your team or service to gain feedback from individuals and carers about their experiences of the quality of the service?

What are the strengths and limitations of the approaches currently used?

Useful websitesA key Scottish Government Joint Improvement Team (JIT) priority has been to combine service user and carer involvement with an outcomes approach to planning, delivering, evaluating and improving services. The JIT-led Talking Points project and website [http://www.jitscotland.org.uk/action-areas/talking-points-user-and-carer-involvement/] provides a wealth of materials and resources that will support service user and carer involvement and personal outcomes-focused approaches.

Making a DifferenceHow do you gain feedback about your support and interventions from individuals and carers you work with?

What steps could you take to enhance opportunities for people to be involved in giving feedback about their experiences of the quality of the service you work in and what you provide for them as a worker?

All of the other modules in this learning resource and all of the other ESCs will help you reflect on and develop your capability in “making a difference”.

Promoting Safety and Risk Enablement

The concept of “positive risk taking” has its source in mental health and in this section we draw on thinking from this field. The concept of “risk enablement” has more recently evolved in relation to supporting people with dementia and people with a learning disability. Whichever term is used, “positive risk taking” or “risk enablement” are not about neglecting risks and compromising people’s safety. Rather, it involves:

• weighing up the potential benefits and harms of exercising one choice of action over another

• developing plans and actions that reflect the positive potentials and stated priorities of the person

• using available resources and support to achieve the desired outcomes and to minimise potential harmful outcomes.

Short-term heightened risk may need to be tolerated and managed to secure longer-term

positive gains. Sometimes the achievement of truly person-centred care demands that we take informed risks and adopt new ways of thinking to ensure individual needs, preferences and choices are at the heart of what we do. Such adaptation is not considered or undertaken lightly, but is progressed in the context of person-centred assessment, consultation and appropriate planning, delivery and monitoring.

Risk is often defined in terms like “danger”, “loss”, “threat” and “damage”. In health and social services contexts, this perception could be associated with taking risks with sexual health, engaging in substance misuse (alcohol, smoking or drugs) or indulging in behaviour that affects the management of an established health condition, such as a person with type 1 diabetes running a marathon without taking his or her dietary and insulin requirements into consideration. It has been suggested that one of the problems with such negative loading of risk is that it can dissuade us from considering positive aspects of risk, such as accepting a challenge or an opportunity to gain something.

Activity 1.21

Taking risks is something we all do frequently in our lives, sometimes to develop, because we see the potential for opportunity rather than failure (learning to swim, for instance), and sometimes to respond to issues outwith our control, such as making changes to your life after a relationship has ended.

Promoting safety and risk enablement involves working with people to decide the level of risk they are prepared to take with their health and safety. It encompasses taking a proportionate, measured and enabling approach to risk in the context of personalisation, meaning prioritising choice, control and independence for the people you support.

Promoting Safety and Risk EnablementThink of a time when you have taken a risk in either your personal or working life. What factors enabled you to take this risk?

The issues you identified in Activity 1.21 might have included:

• having enough information to exercise choice and make decisions

• holding some control over the direction of your destiny

• having a degree of power and control• being able to work with others positively to

inform your decisions • having options to make constructive use of

opportunities• having autonomy• having opportunities to learn from experiences.

These are no different from the opportunities the people we work with need to be offered through risk enablement.

Often health professionals feel that their job is to protect the people they work with – protect them not only from physical harm, but also from failure. But if any of us are to do the things we want to do, we have to risk the possibility of being unsuccessful. For example:

• none of us would have friends or partners if we had not risked the possibility of being rebuffed

or rejected• none of us would have qualifications if we

had not risked the possibility of failing our examinations

• none of us would have jobs if we had not risked the possibility of being turned down.

Steve Morgan has written extensively on these issues from a mental health perspective, but the issues raised also apply to other areas of health and social services. Morgan [http://practicebasedevidence.squarespace.com/blog/category/positive-risk-taking]10 suggests that there is often a culture that prevents positive risk taking, or risk enablement, in health services:

“‘Tick the box and cover your back, after all you are working in the culture of blame’. In this scenario, risk assessment seems less concerned with formulating good clinical judgement, and more focused on providing ‘defensible’ decisions. Risk assessment seems overly preoccupied with completing the paperwork, and less on the activity of risk management.”

Activity 1.22

Does the quote from Morgan tally with your experience in the service in which you work?

Promoting Safety and Risk EnablementIf your answer was “yes”, give examples of how and why this is still the case.

If your answer was “no”, what has enabled any positive changes to happen?

Morgan also identified factors that need to be in place to enable risk enablement to happen in mental health services, but these are likely also to apply to the service you work in. They involve the following.

• A focus on people’s “strengths” This provides a more positive base on which to build potential plans. It involves considering the strengths and abilities of the service user, of his or her wider network and social systems, and of the wide-ranging services potentially available (statutory and voluntary sectors and other resources).

• Partnership working This involves a clear understanding of the responsibilities that service users and services can reasonably hold in specific situations, providing opportunities for people to take chances, learn from their experiences and understand the consequences of different courses of action.

• A willingness on behalf of all people involved in a team or service to engage in positive risk-taking and risk enablement If parts of the wider network are not signed up, confidence in being able to sustain risk enablement becomes undermined. Fears associated with a “blame culture” are more likely to permeate thinking and threaten the implementation of creative ideas.

• High-quality supervision and support This must be in place as it is essential for discussing and refining ideas.

• The development of appropriate crisis and contingency plans These will aid prevention of some harmful outcomes and will minimise others. Risk-taking needs to be undertaken in a context of promoting safety, not negligence.

• It should become part of the culture of training Risk-taking should not be seen as a one-off experiment. It should be a natural line of thinking. Whole-team training will be essential if the approach is to be fully understood and practised by all team members as a routine part of its culture.

• Adequate resources to enable creative work Creative work should take precedence over “what usually just happens”. Resources are never open-ended, but true innovation needs organisational support to sustain its development and positive impact.

• Limiting the duration of the decision This means working to shorter timescales and with smaller goals broken down.

• Having team and service mechanisms These should be in place to check on progress. They

Promoting Safety and Risk Enablement• provide an ability to quickly change previous

decisions when needed, including intervening in a more restrictive way when necessary.

• Individual and collective accountability and responsibility is clearly defined Individual practitioners can reasonably be expected to be accountable to the standards of conduct set out by their professional body and for the roles they play in local implementation of guidance and legislation. But there are also collective responsibilities for information sharing, decision making and care planning that belong more with the team than with the individual in isolation. This includes the need for positive and efficient systems of verbal and written communication being in place.

• The “organisation” also holds responsibilities It must ensure adequate support and set the tone for the development of a culture that will enable all the above points to happen.

Activity 1.23

Some of the factors above are clearly influenced by organisational and whole-team commitment, but some could be influenced at individual worker level.

What changes could you influence to create a climate that supports positive risk-taking and risk enablement?

Activity 1.24

Remind yourself of Jackie, who we introduced at the start of this learning resource. We build on Jackie’s story here.

Jackie

Jackie is 22 years old and is unemployed. She recently broke up with her boyfriend. She struggles to keep her weight down, is a smoker and has type 1 diabetes. Jackie has a two-year-old daughter, Tracey, to whom she is devoted. They live together in social housing but Jackie has difficulties in paying the rent, despite receiving benefits. Jackie’s ambition is to complete a college course to enable her to work with children. Her mother, Helen, is very supportive to both Jackie and Tracey.

A friend is getting married. Jackie wants to go to her Hen Night and is determined to have a good time. She mentions that this involves alcohol but is worried: last time she was at such a night, she became incapable with drink and ended in hospital. She is nevertheless determined to drink on the night out.

Reflect on Jackie’s story above.

What are the risks to Jackie if she goes and enjoys herself at the Hen Night as planned?

Promoting Safety and Risk EnablementWhat are the benefits for Jackie of going to the Hen Night and enjoying herself as planned?

The concepts of positive risk-taking and risk enablement are based on the idea that the process of measuring risk involves balancing the positive benefit from taking risks against the negative outcomes of avoiding risk altogether.

To inform Jackie’s situation, an example of guidance provided to a young person with diabetes is provided below.

How do feel about the idea of providing information to Jackie that may be seen to support “risky” behaviour? Do you think it compromises your professional practice or any of the other ESCs in any way?

All of the other ESCs will help you reflect on and develop your capability in “promoting safety and risk enablement”. Other modules in this learning resource will develop this, particularly: • Module 2 – Values-based practice• Module 3 – Involving people• Module 5 – Inclusion, assets and outcome-

focused practice.• Eat carbohydrates before you go out − toast,

cereal, pizza • Drink in moderation • Avoid Alcopops − they are very high in sugar• Drink water or sugar-free juice as well• Always east something en route on the way

home or when you get home − toast, cereal, pizza

• Check your blood glucose when you get home/before you go to bed

• Wear ID or carry ID indicating you have type 1 diabetes as hypos and drunken behaviour can be confused with each other

• Stay with your friends and make sure they know how to deal with a hypo

Personal Development and Learning

This means:

• keeping up to date with changes in the way services are delivered and the policies, strategies and legislation that inform service developments

• taking part in learning activity throughout your life

• making sure you (and the people you work with) can access advice and support through supervision, regular reviews of progress and opportunities to think about the way things are done.

To promote your personal development and learning, you need:

• access to education, training and other personal development opportunities

• a personal/professional development plan that takes account of your hopes and aspirations and which is reviewed regularly

• to understand the responsibilities of the service in supporting you in meeting goals set out in the development plan

• to understand your personal responsibility to achieve the goals set out in your development plan

• to recognise the importance of supervision and reflective practice and integrate both into everyday practice

• to be proactive in seeking opportunities for personal supervision and personal development and learning.

“Supervision” is a term used to describe regular meetings with a supervisor in which workers are able to discuss and reflect on the work they do and their own learning and development needs. The person supervising the worker listens, advises and helps the worker to develop his or her practice. Other forms of support, such as mentoring, coaching and group meetings with colleagues, are provided in some settings in addition to, or instead of, individual supervision sessions.

The supervision process includes evaluation of specific pieces of work with service users and carers. This helps to ensure that workers are using effective, evidence-based approaches and have the skills, knowledge and experience they need to cope with changing demands. If you do not have opportunities to engage with support or supervision in relation to your practice, you should talk to your manager or a senior person in your organisation as soon as possible. It is very difficult to put new learning

Personal development and learning involves keeping up to date with changes in practice and participating in lifelong learning and personal and professional development opportunities for self and colleagues through supervision, appraisal and reflective practice.

Personal Development and Learninginto practice without the help of a supervisor, and you need the opportunity to discuss any difficult issues that arise from the work you do.

Activity 1.24

If you receive supervision that helps you reflect on your work with people, what qualities of the experience make it positive and helpful?

Action into PracticeWhat are your first thoughts about the ESCs? You may want to look back on this when you finish the programme.

Think about and note down the kind of support you might require to complete the 10 ESCs learning and take your learning forward to develop your practice in a positive direction.