Health and social care case studies

“Stop Fixing, Start Listening!” Meet the people training healthcare workers to hand power over to patients - and transforming lives in the process. It all began with curiosity. Twenty-five years ago, a physiotherapist asked a simple question: why do some stroke patients manage to find their way to a fulfilling life more speedily and completely than others? Obviously, the severity of the stroke plays a big part but even those with similar neurological and physiological impacts had very different experiences. Determined to find the answer, Fiona Jones decided to speak to stroke patients in depth. What she found was surprising: the key was the nature of their relationships. And the relationships that mattered were not just those between the patient and family and friends but, crucially, that between the patient and the healthcare workers trying to help them. Too often stroke patients felt disempowered by the way professionals interacted with them. Out of the very best of intentions, those professionals wanted to ‘fix’ their patients by taking control of their recovery, failing to fully acknowledge the complexity and diversity of their lives. The stroke patients that did better were those that helped to play a bigger role in their own care by managing their medication, rehabilitation regimes and pace of recovery independently of their clinicians – what is often termed ‘self-management’ A Bigger Story But extensive further research revealed something deeper. The secret to a truly fulfilling change in a stroke patient’s life was self-efficacy. Those who felt more in control of every aspect of their recovery also began to feel more in control of the lives that had been so disrupted by a severe medical condition. That meant moving beyond self-management’s focus on medicines, exercise and training and instead allowing the patient to shape the underlying methods, goals and style of recovery. This was radical stuff. As Fiona puts it: while self-management requires the patient to change their behaviours, an approach based on self-efficacy and empowerment requires the healthcare professional to change theirs. It means shifting mindset and practices away from any sense that the health worker knows best with ready-made solutions at hand. Instead, they need to act as expert collaborators led by the expectations, hopes and challenges identified by the patient themselves. It’s an ethos that originates with the heartfelt recognition that when it comes to their own lives, the person in front of you is the world-leading expert. Fast forward to 2013 and, after further research, Fiona founded Bridges Self-Management (with the support of City St. Georges and Kingston Universities) - a social enterprise designed to help health workers play that empowering role. This is far from easy. Health workers sometimes feel they are abdicating their responsibility by not coming up with quick solutions, not being in the lead. And when they do recognise the need for self-efficacy, the skills, strategies and language to enable that are often undeveloped. In addition, what they see around them is countless colleagues - often very highly regarded ones - doing things to rather than with their patients. Breaking down these personal and cultural norms requires lots of self-reflection, self-questioning and gradual, careful introduction of new approaches. But the impacts speak for themselves. Bridges’s work training staff who support people with Long-Covid was recently the subject of a randomised control trial. Called, appropriately enough, ‘Listen’, the project was found to have improved patients’ ability and confidence in managing their symptoms and doing everyday tasks. It also improved their sense of self-efficacy and emotional well-being. Most significantly, that greater sense of self-efficacy was directly related to the improvements in patients’ recovery. It is research that endorsed the findings of Fiona’s own initial enquiries all those years ago and the knowledge the Bridges team has accumulated through research and experience since it started work. Workers’ Liberation The impact of this way of working extends beyond the patients. Call it ironic, call it counter-intuitive, but it seems that by stepping back, listening and empowering the patient, the health worker actually ends up feeling more empowered themselves. Liberated from the strictures of routinised interventions and the pressure of taking sole responsibility for fixing their patients, health workers report being able to build much more fulfilling human relationships focused on helping people build a self-defined, decent life for themselves rather than achieve a set of externally set, medicalised milestones. It gives them more time. And most importantly, of course, they can see that working in this “Bridgey” way is better for the patients and their recovery. Again, the data speaks for itself. Of over 250 NHS staff trained by Bridges in the last 6 months alone, 84% said they are now listening more and ‘fixing less’. 94% said that Bridges was having a positive impact on their day-to-day work and 60% said working in the Bridges way had already increased their job satisfaction. Ultimately, the ethos of Bridges is a challenge not just to the professionals they work with but to a whole healthcare and public service system that is still built around doing to rather than doing with. Of course, there are many occasions when the enormous expertise of health workers must operate unhindered with little immediate regard for co-designing a solution - no-one undergoing cardiac arrest or a major trauma wants anything other than to be fixed by experts as rapidly as possible. But too much of this acute mentality has leached into every other aspect of healthcare - often reinforced by time pressures and lack of empowering skill sets. So, the question now is how we can make the training Bridges provides utterly normal across healthcare rather than something so out-of-the-ordinary that it can almost feel like a process of deprogramming for those seeking a better way of working. Given the theme, the final word should go to Jeremy - a patient with Long Covid. His testimony shows what happens when a health worker takes the time to really listen and co-design ways forward. His words speak with far greater eloquence of the power of patient empowerment than anything written here. Do find the time to listen! By Adam Lent This case study forms part of a series we are producing together with the healthcare consultancy Baxendale and think tank King’s Fund, to demonstrate the innovation shown by social enterprises delivering health and social care.

North East Lincolnshire is pioneering a radical model of mental healthcare that is improving outcomes and cutting waiting times. The key: empowering patients and treating them holistically. The data tells its own story: 94% of emergency mental health referrals seen within four hours compared with just 50% across England. 81% of patients in settled accommodation compared to 24% nationally. Older patients at risk of harming themselves or others are restrained over 50% fewer times than the English average. 80% of staff say they would be happy for a friend or relative to be treated by Navigo compared to the 64% average for mental health providers nationally.* Clearly, Navigo - the social enterprise that delivers mental health services for the NHS in North East Lincolnshire - is making breakthroughs that elude many other providers. What are they doing differently? Jobs, homes, human connection That question is answered succinctly by Simon Beeton - Navigo’s Chief Executive. While conventional mental health services seek to “diagnose, treat, and discharge”, Navigo takes a holistic approach, not only helping people address their mental health condition but also working with them to find “somewhere to live, somewhere to work, and someone to love (or, at least, really get on with!)”. It’s an approach rooted in three transformational observations that fundamentally challenges how healthcare is currently delivered by the NHS. People are complex wholes - treating any medical condition, let alone a mental health one, without understanding the wider context of factors affecting patients’ lives will always be limited in its impact. There are very often social and economic drivers behind poor mental health which simply cannot be ignored when trying to help a person recover: debt, poor housing, unemployment, poverty. Mental health care should be as much about helping people regain a sense of agency and control in their lives as treating the condition. Approaches that reinforce passivity or helplessness can exacerbate as much as ameliorate mental ill-health. For Navigo, that means adopting holistic, empowering treatment frameworks but it also means going much further than conventional mental health services in supporting people. Nowhere is that more apparent than in Tukes. Named after William Tuke - the pioneering mental health campaigner and innovator - the initiative uses Navigo’s resources to help patients secure employment, develop skills and, maybe most importantly, form the human connection that comes from having a job. This is why Navigo - unlike any other NHS mental health service you may have come across - owns a garden centre, a cafe and a cleaning service to provide a job, income and training for their patients. It’s also why Navigo operates as a social landlord, as well as working closely with other social landlords, to provide the affordable, decent accommodation that so many with mental health conditions struggle to find and retain. Lighting a beacon for Barbara That principle of giving people agency and self-efficacy by addressing the wider conditions of their life runs so deep in Navigo that it has shaped its whole corporate structure. Navigo is effectively run as a co-operative that not only gives employees a major say in the organisation but also gives the same rights to patients who can get deeply involved in the running and shaping of the service. Indeed, you are just as likely to hear the people helped by Navigo being referred to, and referring to themselves, as ‘members’ than as ‘patients’. It’s also why Navigo is often described by its people as a ‘community’ or even a ‘family’ rather than a healthcare service or organisation. It’s a model that helps create that crucial space for human connection but is also credited with generating a culture of openness to innovation that drives so much of what Navigo does. Patients inevitably know best what needs to change to improve their experience and hasten their recovery. They also have little tolerance for the usual organisational obstacles placed in the way of necessary improvements. Thus Navigo is always looking to do things the best way they can and, if necessary, cut through the institutional noise that stops that happening. Barbara is a perfect illustration of this principle. Deeply unhappy with the fact that her husband who had severe dementia was being placed in a care home many miles away due to lack of appropriate accommodation, Barbara needed, and demanded, change. Always proactive when the wider system generates a problem, Navigo decided to act. Three new centres were set up providing forty places for older people with dementia and/or mental health conditions all located within North East Lincolnshire. One of the facilities was named Barbara’s Beacon to honour the key role Barbara played in making the change happen. And, of course, the same holistic and empowering approach that runs through all of Navigo’s work underpins the care provided at Barbara’s Beacon and the other new centres. So, Navigo is proving that compassionate, holistic, empowering care for patients need not be sacrificed in the pursuit of a more responsive, efficient service. In fact, the stats quoted at the start of this article show precisely the opposite: that the key to delivering a more responsive, efficient service is precisely that compassionate, holistic, empowering approach. But, after all, those are just stats and abstract principles. Far better to hear how Navigo’s ethos changes lives in practice by listening to Jemma. Jemma came to Navigo as a profoundly shy and fearful person with borderline personality disorder. But over time she changed: increasingly helping other Navigo members deal with their challenges, she ultimately set up and ran a support group for people who self harm. Her story provides an eloquent insight into the “big family” that is Navigo and the way it transforms lives. You can find plenty of other testimonies from staff and members alongside Jemma’s on the same YouTube channel. *Data sourced from What Makes Us Navigo. By Adam Lent This case study forms part of a series we are producing together with the healthcare consultancy Baxendale and think tank King’s Fund, to demonstrate the innovation shown by social enterprises delivering health and social care.

A pioneering social enterprise in northern England offers a vision of what the NHS could be like if it took prevention seriously Why would a healthcare provider fund a cafe in a primary school? Or support a confidence-building youth club? And why on earth would the same organisation provide cash to help its employees repair their car, fix a leak, even set up their own tattoo business. From the perspective of conventional healthcare, this is all very puzzling. Until that is you understand the ethos animating FCMS - a social enterprise operating across northern England. The idea is simple: keeping and making people happy and healthy not simply delivering healthcare. In practice, that does mean providing some demanding healthcare services: urgent treatment centres, emergency dental care, the 111 helpline, diagnostic services, and many others.  But what makes FCMS different is its determination to set this work in a much wider context of health inequalities and the social conditions that lead to either good or bad health and well-being. Put simply, FCMS doesn’t think it’s enough to just patch people up who come through their doors - they also aim to stop people coming through their doors in the first place. And that means intervening elsewhere. Tea and cake The school cafe is a case in point. Based in Flakefleet Primary School in Fleetwood and set-up with funding from FCMS, the Strive cafe serves a number of purposes. It creates a very pleasant place for human connection in an area facing deep poverty and isolation. It acts as a welcoming hub where people can come to seek help from local public services and the voluntary sector. It gives pupils and their families a relaxing space to speak to school staff about challenges they may be facing. And, of course, it also serves excellent but affordable coffee, tea and cake. Is Strive a health intervention? In the conventional healthcare world, it most certainly is not. Getting a ‘business case’ to fund Strive approved within an NHS Trust would be a challenge to say the least. But from the point of view of FCMS, Strive is very much an investment in health. It is a direct way of providing the things that create good health and well-being: human connection, living in a friendly and supportive place, having easy access to local services and sources of help. And when such an intervention occurs in a place like Flakefleet, it is a direct response to the inequalities that damage health and well-being. The same can be said of FCMS’s other activities such as backing The Boat House Youth - a voluntary organisation designed to develop young people’s confidence, funding free breakfasts and holiday activities for school children, helping adults develop basic maths skills, and supporting Flakefest - a summer festival for the Flakefleet community. These and many other similar investments now total over £1 million into communities, largely, but not exclusively, across the Blackpool and Fylde coast. Oompf! Importantly, this spirit of using resource to address the underlying and holistic causes of good and bad health also informs FCMS’s own services. In recent years, the organisation has focused heavily on making sure healthcare can get to some of the most marginalised communities. Taking a highly flexible approach to how, when and where their services are delivered, FCMS has made it a goal through its Complex Lives programme to take healthcare to homeless people, asylum seekers and those removed from GP registration. But this holistic approach doesn’t stop at patients and service users. It is also committed to the health and well-being of its own team. An approach that includes a fund called Staff Wishes which offers hard cash to make the lives of team members a little bit better, or sometimes a lot better. That might mean helping repair a broken down car or troublesome plumbing but, in one case, it meant helping a staff member follow their dream of setting up their own business by funding the purchase of tattoo equipment. Not many organisations would pay to lose a valued member of staff but it simply displays FCMS’s commitment to placing health and well-being ahead of everything else. If the NHS is to become truly focused on prevention of ill-health rather than just its treatment, as the Government claims to want, then it has much to learn from an organisation like FCMS: working closely with the voluntary and wider public sector; developing highly flexible services designed around the reality of people’s lives; investing in community-based solutions to local challenges. These are all important but perhaps there is one lesson that overrides them all: doing whatever it takes to keep everyone as happy and healthy as possible. Staying true to such a principle means thinking and working well outside the boundaries of conventional acute healthcare. It also means always being ready to ask tough questions of one’s own organisation about whether it is using its resource in the most effective way to address the things that make people ill and unhappy. Such self-reflection, if done honestly, would certainly upend many of the practices across an NHS that seems unable to break out of its acute focus, overcome its aversion to frontline innovation, and respond adequately to a pressurised and unhappy workforce. A good place to start that learning is by looking at FCMS’s core values. The language, simplicity and the values themselves say something about the fundamentally different culture nurtured at the social enterprise: being awesome, having fun, remaining humble, having the courage to challenge norms, being go-getting, and my personal favourite, displaying natural, infectious “oompf”! These are values that speak to a culture that esteems creativity, collaboration and sheer damn impact above everything else. It’s an ethos of oompf we desperately need to spread rapidly across the NHS and whole public sector. By Adam Lent This case study forms part of a series we are producing together with the healthcare consultancy Baxendale and think tank King’s Fund, to demonstrate the innovation shown by social enterprises delivering health and social care.

How one clinic in Hull cut emergency admissions for frail people by 50% Health nerd quiz question! What common condition increases an individual’s likelihood of attending a GP surgery by over 50%, undergoing emergency care by 216% and adds almost £6 billion pounds to the NHS bill each year? Diabetes? Heart failure? Cancer? It’s actually something that is barely recognised as a medical condition: frailty. So, when a frontline innovation manages to cut emergency admissions for the most severely frail people by 50%, it’s worth paying attention. This outcome was achieved by the Jean Bishop Centre - a unique initiative of the City Health Care Partnership (CHCP), a social enterprise working in Hull, and led by two remarkable physicians: Anna Folwell and Daniel Harman. Anna and Dan will tell you that the key to their success is flipping the usual model of care on its head. The CHCP and its workforce are committed to the idea that it should be the individual who shapes the support they receive rather than the public sector body. As such, their assessment of a person’s needs begins with a very detailed conversation about their experiences, their hopes, their needs. Armed with that understanding, the clinicians and others working at the Centre can work out exactly what is needed to maintain the health and well-being of someone with frailty and their care-givers and provide it in as effective and flexible a way as possible. And that regularly involves bringing in wider community and voluntary sector support from organisations, often located in the Centre themselves, enabling immediate connection to the people looking for help. Pete’s story* Pete’s story is a case in point. A care home resident in his seventies, Pete’s health had worsened significantly in recent weeks. Severely frail with advanced dementia and multiple conditions, he was eating far less, wandering more and at growing risk of falling and hurting himself. The residential home felt it could no longer offer appropriate care. Under normal circumstances, a situation that would often result in an emergency hospital admission followed by a lengthy stay, draining hospital resources and often leading to a further deterioration in the individual’s overall health and well-being. Luckily, Pete was referred to the Jean Bishop Centre. The staff there first undertook a very detailed medical review which resulted in Pete being placed on a more humane and effective regimen. Some of the medications he had accumulated in recent years and which were now doing more harm than good were removed while other underlying conditions that had gone undetected were treated for the first time. Most importantly though, the Centre spoke with Pete and his wife, Joan, in detail about what they really wanted - and the key thing was for Pete to stay in a care home where he felt supported and connected to others. So, working with the Alzheimer's Society in Hull and their own knowledge of the local residential care network, the Centre was able to find a new care home place for Pete while also offering greater support to his wife. The result: a healthier and happier Pete, a relieved Joan and a long hospital stay avoided. Doing with, not doing to Pete’s story exemplifies a spreading approach that seeks to ‘do with’ people rather than ‘do to’ them. Most fundamentally that means doing with the person or family in need of support or care as well as working closely with organisations and people outside the public sector institution, particularly those in the voluntary and community sector. But it also involves senior leaders ‘doing with’ rather than ‘doing to’ frontline professionals by trusting them to make the right decisions both in the radical redesign of a service and in its day-to-day delivery. This is often overlooked when frontline innovations are analysed but ask the City Health Care Partnership what enabled them to develop and deliver such an effective approach at the Jean Bishop Centre and they are clear. As an independent social enterprise, they have been able to break away from the hierarchy and bureaucracy of the mainstream public sector and free up their clinicians and other employees to think for themselves, take risks and focus on impact and outcomes rather than targets and processes imposed from above. A mindset summarised in a phrase one hears a lot at CHCP: “say yes before you say no”. And it’s an approach that has had an impact across the whole of Hull. When it first opened its doors, the Centre set itself the goal of reaching as many of the 3,000 people with severe frailty in Hull as it could. Within two years, it had worked with 90% of that population. That led not only to the 50% reduction in emergency admissions for the most severely frail in that group but also a 10-25% reduction in GP visits for the rest of the group. Work with a wider cohort with less severe frailty has led to  an overall reduction in A&E admissions for people over 80 by 13.6% and for residents in care homes by 18% and reduction in medicine costs of £100 per person per year. The human impact Of course, reduced admissions and innovative ideas are only ultimately tools to achieve the one thing that matters: meaningful improvement in the health and well-being of individuals and their loved ones. An independent evaluation found that the Centre significantly improved the overall wellbeing of older people living with frailty at 2-4 weeks and at 10-14 weeks after the intervention. In contrast, the evaluation control group experienced a decline in well-being over the same time-frame. And you won’t find a clearer example of what a ‘do with’ approach can mean in human terms than taking five minutes to watch this film about Ray. What he needed to massively improve his life was far less complex than Pete - an electric wheelchair and a ramp - but the simple fact that the Jean Bishop Centre really listened to his needs, treated him with respect and then did everything in its power, as quickly as possible, to respond is impactful beyond any quantitative measure. Get ready to shed a tear or two! *Names have been changed in Pete’s story. By Adam Lent This case study forms part of a series we are producing together with the healthcare consultancy Baxendale and think tank King’s Fund, to demonstrate the innovation shown by social enterprises delivering health and social care.

How do you encourage some of the most traumatised and disempowered people in the country to access healthcare? The Butterfly Project shows the way How can my team connect and work with the most marginalised people and communities in society? It’s a question that is asked repeatedly within the public sector.  And as we become increasingly aware of how inequality damages health and drives up pressure on public services, it is a question asked with ever greater urgency.  There is perhaps no more marginalised and ignored group than female prisoners. The vast majority have suffered layer upon layer of disempowerment. Many come from poor and excluded communities. Over half have experienced further disempowerment and trauma in the form of domestic violence, sexual violence, and abuse as a child. Then, of course, there is imprisonment itself which is very deliberately a form of marginalisation and disempowerment which has a disproportionately negative impact on women.  The proportion of female prisoners self-harming is seven times higher than male prisoners, while alcoholism and drug use is twice as high. In short, trauma, exclusion and distrust of authority are part of the everyday lives of female prisoners. This is not a group that is likely to engage positively with the state in any of its forms no matter how benign.  So, when a frontline innovation manages not only to engage but generate measurable positive outcomes with female prisoners, it is probably worth the rest of the public sector paying attention.   Releasing the Butterfly  That initiative is The Butterfly Project run by a social enterprise called Spectrum. The Butterfly Project set itself a simple but challenging goal: to increase the cervical screening rate to 90% for the 500 prisoners held at HMP Styal in Cheshire. This was ambitious. The screening rate at the prison was only 64% when the initiative began in 2020. The rate for the English population is not much higher at 69%. So, this would mean encouraging one of the most excluded groups in the country to massively exceed standard screening rates.   The Butterfly Project secured its goal. 92% of women at HMP Styal underwent cervical screening between 2020 and 2022. An achievement that has proved sustainable with a 91% rate by 2024.  So, how did The Butterfly Project do this? There are four key principles to their work. Principles that have wide applicability beyond engagement with prisoners.  1. Go where the people are  It may not sound radical but one major innovation was conducting cervical screenings at the prison itself. Most medical procedures occur outside the prison walls requiring prisoners to be escorted, often in handcuffs and prison vehicles, to a hospital or clinic accompanied by a prison officer. A process that reinforces stigma and inevitably adds considerably to the anxiety of any medical procedure. Conducting screenings in the prison eliminates that barrier.  This goes to the heart of an assumption underpinning much of public sector activity, namely that people should come to us. Vast swathes of the public sector’s work is conducted in buildings and places that suit the public sector rather than the people and communities they are serving. This inevitably creates an immediate barrier for engagement requiring people to invest time and money and to overcome mental and physical health barriers to interact with the public sector. It is telling, for example, that the Community Led Support initiative that has had such a positive impact on social care invests a great amount of time and energy into finding the right venue for their service.  Indeed, the principle has been taken a step further at another prison, HMP Low Newton, where a colposcopy unit has been set up so that any abnormalities identified during screening can be followed-up on site.  2. Let trusted people with relevant lived experience do the engagement  Peer mentors are at the heart of The Butterfly Project. These are prisoners who play a vital role not just in spreading the message about cervical health but also in discussing directly with those who may be anxious or doubtful about undergoing screening.   The mentors bring two vital aspects to the engagement. Firstly, they are far more likely to be a trusted source of advice and connection than a public service professional particularly when the population in question will have all been in conflict with the state and may have suffered mistreatment and discrimination at the hands of the public sector. Secondly, they bring an inherent and profound understanding of the lives of their fellow prisoners because they lead that life themselves.  There is clearly a lesson here for the public sector as a whole. Many public sector organisations assume that public sector staff or elected representatives are the best people to lead engagement. In fact, this assumption should be turned on its head in the case of marginalised groups by understanding that the public servant may well be the worst person to lead engagement. Instead, find those from the community who have the trust and shared experience of the community to act as connectors and conduits.   3. Take time to listen and understand  The role of The Butterfly Project’s peer mentors is not to meet targets or to push people into screening but to listen to their fellow prisoners and understand their fears and hopes. That can take a long time, particularly when working with people dealing with profound trauma. But it is time well spent for it enables trust to be built and allows mentors to develop a deep appreciation of the barriers preventing the women at HMP Styal accessing healthcare.  It’s an approach that extends to the Project’s medical personnel as well, who will often take considerable time to explain the screening procedure alongside the mentors and help address any concerns.  This is not an easy message for much of the public sector to hear. Time is a very scarce resource in a world shaped by constrained finances, rising demand and an obsession with top-down targets. The emphasis too often is on processing people as quickly as possible rather than taking time to listen and understand. But if any public sector body is serious about engaging with excluded individuals and groups, then ways must be found to carve out the time to build the necessary connection and trust.  4. Keep it friendly and welcoming throughout  Finally, and perhaps most obviously, The Butterfly Project places a premium on friendliness and providing care in a welcoming environment. Those who undergo screening often comment on the kindness of the doctors and nurses in the unit at HMP Styal. The necessity of this is obvious, particularly when engaging with people who may have suffered mistreatment and trauma. It is not only the most human approach but clearly it is the best way to ensure ongoing engagement and trust.    What The Butterfly Project teaches us is that with the right practices, enough time and a considerable dose of humility, it is possible to transform engagement with even with the most excluded people and communities. As health inequalities rise and demand pressures keep growing, this is a lesson the public sector needs to learn as quickly as possible.  By Adam Lent This case study forms part of a series we are producing together with the healthcare consultancy Baxendale and think tank King’s Fund, to demonstrate the innovation shown by social enterprises delivering health and social care.