June 2015
LIVING WELL
PENWITH PIONEER
How does change happen?
A qualitative process evaluation
Written by
Prof Catherine Leyshon, Dr Michael Leyshon, Dr Kathi Kaesehage, University of Exeter. http://geography.exeter.ac.uk/cges/ Funded by
NESTA -­‐ Nesta is an innovation charity with a mission to help people and organisations bring great ideas to life. http://www.nesta.org.uk/ Produced for
Age UK Cornwall & Isles of Scilly – the leading independent charity working to improve the wellbeing of people in later life. http://www.ageuk.org.uk/corn
wall/
Executive Summary
1.1 Background to project The following report was commissioned by NESTA to provide a qualitative process evaluation of how Living Well has been operationalised through the Penwith Pioneer programme. Penwith Pioneer uses the Living Well philosophy of care to deliver health and social care in Cornwall through encouraging social innovation and energising cohesive, sustainable and resilient communities. The growth in Britain's aging population, coupled with the significant financial pressures on the country's health services mean that new (better) approaches to delivering public services are needed. Living Well was developed through a unique partnership between Age UK Cornwall, Volunteer Cornwall, and the NHS to provide bespoke support for older people with long-­‐term health conditions who are at risk of repeat non-­‐elective hospital admissions. A combination of paid staff and volunteers provide a tailored package of support that is unique to each person, helping them to manage their health conditions and re-­‐engage with their communities. The Living Well philosophy of care seeks to position volunteers as integral to the co-­‐production of care for older people. 1.2 The Purpose of this Living Well evaluation The purpose of the evaluation is threefold: first, to explore critically the processes through which Living Well as a philosophy of care has been operationalised and embedded in Penwith. Second, to examine how change has been achieved in the delivery of health and social care for older people; and, third, to ask what has been learned about developing the Living Well approach elsewhere. We examine how a specific configuration of statutory and voluntary organisations, charities, health and social care practitioners, volunteers, and older people have come together under Penwith Pioneer in order to operationalise the Living Well philosophy of care. In so doing we examine how change has been achieved and – crucially for the commissioning process – how Living Well can be operationalised elsewhere in an iterative, emergent and contingent way. 1.3 Aims and objectives The overarching aims of this evaluation are: i) to understand through what processes Living Well as an approach has been operationalised and embedded through Penwith Pioneer; and ii) to understand lessons learned that for the implementation of this approach elsewhere in Cornwall. The specific questions we answer in this report are: ● How have the outcomes of Living Well in Penwith been delivered? ● How has change been achieved in the delivery of health and social care for older people? ● What are the impacts of the change on practitioners working in the system? ● What are the impacts of the change on people and their carers? 1 ●
●
●
●
●
How has this change been achieved? How does the involvement of volunteers reduce dependency and build confidence? How will the change be sustained? How could the programme have been improved? What were the key factors for success, are there any significant barriers to delivery? 1.4 Headline Findings Our headline findings are structured around change to three aspects of health and social care delivery: Referral: an easy, simple, direct referral process is the best way to introduce older people to Living Well. Relationships: in Living Well, strong relationships between and within groups of healthcare practitioners, GPs, older people, volunteers, community groups, and Living Well Coordinators are key. Routine: establishing the Living Well philosophy of care into the working routines of GPs and other healthcare practitioners will secure its sustainability in the long run. 1.5 Principal Recommendations We make 20 recommendations and 3 follow-­‐up recommendations which are listed below in the order in which they appear in the report. We present these findings without prioritising one recommendation over another. We have deliberately done this, as the evaluation should be viewed as a holistic overview in which the recommendations should be seen collectively and not as separate components. Consequently, there is some overlap between some of the recommendations. We recommend that: 1. the co-­‐location in GPs surgeries of Living Well Coordinators in surgeries as this is critical to maintain the visibility of Living Well in the healthcare community. 2. contact lists, opportunities at Living Well, and some good news stories about outcomes for older people are regularly updated and conveyed to GPs/practice managers and cascaded to all staff. 3. communication to and the with Living Well coordinators and other health and social care providers involved in the Living Well approach is kept as easy and straightforward as possible. 4. a modern data-­‐sharing platform is developed holds the latest patient data on the older person. 5. Living Well Coordinators are enabled through co-­‐location to develop continuous face-­‐to-­‐
face contact with GP Surgeries. 6. clear lines of and pathways of progression are co-­‐formulated and informally recorded for older people so that they are able to reflect on the changes in their lives. 2 7. roles within the team are clearly defined with greater specialisation – for example, between administrative jobs, volunteer management, and promotion. 8. Living Well explores new ways of recruiting volunteers 9. all volunteers understand their role within Living Well. 10. a regular review of volunteer skills sets is undertaken by facilitators and training adapted appropriately. 11. reorienting volunteers and volunteering to the concept of ‘Your Volunteering Neighbourhood’. 12. Living Well explores mapping local volunteers skills and desires against the needs of older people. 13. Living Well downplays a reliance on adverts in the local press 14. the Living Well team explore ‘viral-­‐networking’ techniques for recruiting volunteers. 15. roles within the team are i) clearly defined with greater specialisation – for example, between administrative jobs, volunteer management, and promotion; and ii) clearly communicated to all partners. 16. before Living Well as an approach starts recruiting older people, each Living Well team must be given time to establish a network of individual volunteers and volunteer community groups. 17. the same referral process is implemented across those different practitioners. 18. Living Well is consistently branded by and for all partners; and ii) Living Well posters, flyers, and other material such as customised pens should be handed to the different health and social care partners. 19. the training needs of volunteers should be evaluated regularly 20. investing a small amount of time at the time of the launch of Living Well in a new area in auditing the local arrangements for co-­‐location, technology, skills, and capacity. Final Recommendations: 1. A follow up stage in the evaluation, outlined above, which: i) addresses operational issues; ii) seeks opportunities to disseminate and embed learning; iii) continued monitoring of Living Well; and iv) develops the concept of ‘Your Volunteering Neighbourhood’. 2. Longitudinal research on the long-­‐term experience of older people in Living Well. 3. Further evaluative work on inter-­‐agency working. 3 Contents Page
1.0 Introduction ..................................................................................................................................... 1 1.1 Living Well ................................................................................................................................ 1 1.2 Progress ................................................................................................................................... 2 1.3 Purpose of the Research .......................................................................................................... 2 1.4 Methodology ........................................................................................................................... 3 2.0 Findings ............................................................................................................................................ 5 2.1 How have the outcomes of Living Well in Penwith been delivered? .................................. 5 2.2 How has change been achieved in the delivery of health and social care for older people?
7 2.3 What are the impacts of the change on practitioners working in the system? ................... 7 2.4 What are the impacts of the change on older people and their carers? ............................. 9 2.5 How has this change been achieved? ................................................................................ 11 2.6 How does the involvement of volunteers reduce dependency and build confidence? ..... 11 2.7 How will the change be sustained? ................................................................................... 17 2.8 How could the programme have been improved? ............................................................ 18 2.9 What were the key factors for success, and are there any significant barriers to delivery?
22 3.0 Follow up ............................................................................................................................... 23 Research Team Contact Details: Prof Catherine Leyshon cbrace@exeter.ac.uk Dr Michael Leyshon mleyshon@exeter.ac.uk Dr Kathi Kaesehage Kathi.Kaesehage@ed.ac.uk Suggested citation: Leyshon, C, Leyshon, M and Kaesehage, K (2015) Living Well, Penwith Pioneer – How does Change Happen? University of Exeter/NESTA Research Report. Please cite this report appropriately. 4 Final Report – Living Well
Process Evaluation
Prof. Catherine Leyshon, Dr. Michael Leyshon, Dr.
Kathi Kaesehage
1.0 Introduction
1.1 Living Well
Living Well is a transformational philosophy that brings together a range of agencies and volunteers to provide care for older people. This philosophy was developed through a unique partnership between Age UK Cornwall and the Isles of Scilly, Volunteer Cornwall, Cornwall Council, the NHS, and other health and social care providers. It aims to deliver bespoke support for older people with long-­‐term health conditions who are at risk of being (re-­‐)admitted to hospital. A combination of Living Well staff and volunteers provide a tailored package of support that is unique to each person. Living Well was rolled out across Penwith, Cornwall UK, in January 2014 and awarded Pioneer status by the Department of Health. The focus in Penwith was to implement a programme that goes beyond meeting the health care needs of older people through promoting emotional wellbeing, financial stability, social connectivity and a sense of purpose. At the heart of Penwith Pioneer is an equal partnership between the community and voluntary sector, the local authority, and health commissioners and providers. The programme vision is to improve the quality of life for older people by providing practical support to help them to build their self-­‐confidence and self-­‐reliance, and achieve their aspirations. This should reduce the dependency of older people on health and social care, e.g. through reduced non-­‐elective hospital admissions. To date the Living Well philosophy has been applied in the Newquay Pathfinder project, Penwith Pioneer project, and in the Living Well East Cornwall project. At the time of writing this report, the Living Well approach is also being applied in the Isles of Scilly. This report focuses on Penwith Pioneer. Age UK Cornwall and other partners are now seeking 1 the commissioning of the approach across Cornwall and to communicate the approach nationally. 1.2 Progress
We have completed all the activities outlined in the original proposal on time and within budget, including: ● Contracts – completed and signed ● Reviewed research questions ● Data collection (see below) ● Assembled data already collected ● Analysed and coded data ● Assembled metrics ● Analysed data and writing up research findings ● Complete final report ● Populate the Knowledge Bucket In addition, we have completed the following activities: ● Impact and dissemination activities: o Social media – Twitter o Plymouth University Seminar Series Feb 2015 o Exeter University Seminar Series March 2015 o RSA Volunteering in Public Service Event June 2015 ● Securing the afterlife of the research o ESRC Impact Acceleration Award to March 20161 1.3 Purpose of the Research
The purpose of the evaluation is threefold: first, to explore critically the processes through which Living Well as a philosophy of care has been operationalised and embedded in Penwith. Second, to examine how change has been achieved in the delivery of health and social care for older people; and, third, to ask what has been learned about developing the Living Well approach elsewhere. We examine how a specific configuration of statutory and voluntary organisations, charities, health and social care practitioners, volunteers, and older people have come together under Penwith Pioneer in order to operationalise the Living Well philosophy of care. In so doing we examine how change has been achieved and – crucially for the commissioning process – how Living Well 1
The ESRC Impact Acceleration Award will enable the research team to share the insights from five years of research on volunteering and community resilience – including the research on Living Well – with project partners and stakeholders including Age UK Cornwall and Isles of Scilly, Volunteer Cornwall, the Voluntary Sector Forum, and others. 2 can be operationalised elsewhere in an iterative, emergent and contingent way. Evaluations are often linked to quantifiable targets and take place at the end of a programme. However, this research is somewhat less conventional in its approach. In keeping with the Living Well transformational philosophy of care, which places older people at the heart of the bespoke decision-­‐making and delivery, our process evaluation has been undertaken while Living Well is still on-­‐going, thereby gathering data while the project is ‘live’. This approach has avoided the problems of examining process retrospectively with the inevitable post-­‐
hoc rationalisation that occurs. 1.4 Methodology
3 Our evaluation was developed specifically to understand how Living Well, as a philosophy of care, is realised in practice and how it provides a framework for the engagement of communities and the delivery of services. Our research methods were designed to expose the bespoke, iterative characteristics of Living Well. We achieved this by looking at networks and relationships, social practices in place, and experiences of Living Well from a variety of perspectives and ways of working. The evaluation was primarily qualitative, and data was collected using one-­‐to-­‐one semi-­‐structured interviews, small group interviews, personal observations, and participatory tea parties. Collectively, these methods have enabled the research team to understand the geographical area and extant resources, test out process through role-­‐play, explore the relationship to existing ways of working, and understand how change has been achieved. Our sampling methodology was predicated on a non-­‐probability, purposive sampling method commonly referred to as snowball sampling. This method gathers research participants through the identification of subjects who are used to provide the names of other actors. It is a sampling method that takes advantage of the social networks of identified respondents, which can be used to provide a researcher with an escalating set of potential contacts. The point of snowball sampling is to reach as many of the population group as possible and it is a highly effective method in achieving wide engagement with a diverse but finite group of – in this case – healthcare practitioners, volunteers and older people. Our sample was drawn from front line health and social care practitioners from a range of specialisms including GPs, district nurses, community matrons, and Living Well Coordinators; those working in health and social care at the managerial and strategic level; volunteers; staff from both the main charities involved (Age UK Cornwall and Volunteer Cornwall); and older people. More specifically, this qualitative research approach consisted of: ● 19 semi-­‐structured interviews with volunteers who participated in the Living Well approach ● 6 semi-­‐structured interviews with older people who were part of the Living Well programme ● 8 semi-­‐structured interviews Living Well Coordinators involved with setting up and delivering Living Well at different stages. ● 11 semi-­‐structured interviews with strategic partners across a range of organisations ● 8 personal observations during coffee mornings and crafts group during which older people, volunteers and Living Well coordinators socialise with each other ● 4 signature ‘tea parties’ for volunteers, older people and Age UK staff and four tea parties ‘on tour’ in GP surgeries. Tea parties are a participatory research method, akin to focus groups but are different in that they are semi-­‐structured, place an emphasis on ensuring participants are comfortable, and allow people to speak freely about their ideas, concerns and aspirations in relation to the project. In the tea party setting, we used a series of interactive participatory exercises that included: 1. Mapping the Living Well Process – an interactive mapping technique used to draw out the Living Well process. This activity uses hypothetical scenarios to explore how the process is put into practice. 2. Stories of Living Well – this enables each individual’s experience of delivering or being referred to Living Well to be shared. This method focuses on personal accounts and enables people to reflect on different experiences and perspectives on involvement. 3. Networks of Living Well – this exercise plots the formal and informal networks that connect individuals that participate in Living Well and identifies key geographical features which have an impact on the way that the Living Well approach operates in the given area. Reflections on these connections help to identify the transformative effect of the Living Well approach on the community of practice associated with care and support for older people. It also makes visible some of the 4 informal connections that are difficult to identify and quantify but are integral to making Living Well a success. Over the course of an afternoon, the attendees completed the series of exercises outlined above. The events were warmly praised by attendees afterwards. We also took the tea party on tour to the GP surgeries in Hayle and St Ives and two GPs surgeries in Penzance. We also attended Living Well: Pioneer for Cornwall and Isles of Scilly Board Meetings and meetings of the Evaluation Working Group. The interview transcripts, field notes, and materials generated by tea parties were analysed using a combination of content analysis and discourse analysis. We combined the data collected in the last five months with data from our research into Living Well conducted over the last eighteen months. The findings from this are presented below. 2.0 Findings
In this section we present the findings of our process review. These are structured around our original research questions. 2.1 How have the outcomes of Living Well in Penwith been delivered? The outcomes have been delivered through change to three operational aspects of health and social care delivery: referral, relationships and routine. These three cross-­‐cutting themes run through this report and provide a convenient summary of a range of complex, subtle, and interconnected activities undertaken by a diverse group of healthcare practitioners, Living Well Coordinators, volunteers, and older people themselves. We outline them here and return to them at the end of the report. Referral: an easy, simple, direct referral process is the best way to introduce older people to Living Well. The unique change in the delivery of health and social care for the older people in Penwith has been achieved through the intervention of the five Penwith Living Well coordinators. The coordinators select the older person through a variety of referral routes, including one-­‐to-­‐one discussion with GPs and their surgery teams and scheduled monthly Multi-­‐Disciplinary Team (MDT) meetings in each surgery. Referral can also happen in an ad hoc way, which should be encouraged. Although Living Well has been introduced across all Penwith surgeries, some GPs and surgery staff do not 5 “I think that it’s probably alleviated maybe a bit of appointment pressure because elderly people that sometimes would have come to the doctors just because they’re lonely and you know for a chat or whatever and they get referred to Cally and she goes and sees them and then directs and takes them out or gets them involved so they’re not isolated you know” GP. participate in the described referral processes. GPs in this research frequently remarked on the complex bureaucracy of referral in general. Monthly meetings that identify older people at risk of repeat non-­‐elective hospital admission via a risk stratification tool and the Kaiser triangle are only one way in which referral to Living Well occurs. GPs pointed out that their own observation of a change in their patients – e.g. more frequent visits for more trivial conditions, a persistent mood change, or failure to rally some time after bereavement – trigger a referral to the Living Well Coordinator. GPs expressed some relief that they had something in their toolkit to offer patients who presented with issues for which no clinical intervention was appropriate. As we show below, in the case of Living Well, referral can and should also come from anyone in contact with an older person who would seem to benefit from being put in touch with a coordinator and volunteer. Relationships: in Living Well, strong relationships between and within groups of healthcare practitioners, GPs, older people, volunteers, community groups, and Living Well Coordinators are key. These are built and maintained through frequent face-­‐to-­‐face contact, conversations, information sharing, and activities. The particular configuration of these relationships is place-­‐specific, dependent on both geography and existing social networks. One of the most important relationships is between the Living Well Coordinators, the Living Well volunteers, and the older people. Our research has shown that the outcomes of Living Well in Penwith are delivered in large part through bespoke arrangements between these two groups of individuals. In each case, the coordinator and a volunteer identify the individual needs with an older person. The volunteer then helps to meet these needs through continuous and personal interaction with the older person. A close friendship between older people and volunteers can develop and older people eventually find it easy to trust and accept the help of the volunteer, though there may be some initial reluctance to join social activities often because of a lack of confidence. A small number of community groups, which existed before Living Well was introduced, have helped to meet some of older people’s needs. Routine: establishing the Living Well philosophy of care into the working routines of GPs and other healthcare practitioners will secure its sustainability in the long run. This requires improved branding and visibility in the healthcare community. 6 Routine is also important for older people who are less interested in a high frequency of contact but who value regular, dependable, and consistent contact. They report that this gives them something to look forward to, as one older person commented: “I am looking forward to things and [my time is] taken up now with this sort of thing because I am looking forward to the next meeting or whatever it is, you see”. “They [receptionists] probably get a few people, I expect they get the regular ones. And if they haven’t got anybody else, if they’ve got a problem and haven’t got anybody else, they’ll ring the surgery and the girls, the receptionists are very approachable so they won’t ever feel they can’t ring up, they’ll probably think oh I’ll just ring and ask you know so I would say in that respect having [a Living Well Coordinator] as somewhere we can direct people that are lonely to is you know, just eases some of the pressure on the surgery” – GP. 7 2.2
How has change been achieved in the delivery of health
and social care for older people?
One of the most important drivers of change has been co-­‐locating Living Well Coordinators with the participating GP practices. Co-­‐location is important for several reasons. First, the presence of a Living Well Coordinator in a surgery streamlines the referral process from GPs. Referral can take place by GPs through formal routes such as the monthly meeting or through a conversation. Second, when the Living Well Coordinator is present in the surgery, they are accessible to a greater range of practitioners and surgery staff who can refer older people. For example, a surgery receptionist reported that she often got telephone calls from older people seeking help and advice about things outside the surgery’s remit, like a broken boiler, because they had no one else to whom they could turn. The receptionist realised that such calls were symptomatic of older people’s lack of a wider support network. The receptionist was able to mention these concerns to a Living Well Coordinator on-­‐site. Such practice is not, however, universal, and some surgery-­‐based healthcare practitioners, such as practice nurses and phlebotomists who have frequent contact with older people, reported that they were unsure how to “get people into Living Well”. For this reason, we recommend the co-­‐location in GPs surgeries of Living Well Coordinators in surgeries as this is critical to maintain the visibility of Living Well in the healthcare community. 2.3 What are the impacts of the change on practitioners
working in the system?
One goal of Living Well is to reduce older people’s dependency on the participating GPs practices. Evidence from our interviews with GPs suggests that there are some reductions placed on the resources of the NHS as a result of Living Well. However, GPs and surgery staff do not always recognise Living Well even if they are part of a monthly MDT meeting. Even practitioners who recognise their participation in the Living Well approach sometimes struggle to describe the change that Living Well “It [Living Well] never comes into my head” GP. has brought to their everyday practices. Some practitioners report a reduction of workload while others report that their worries about not being able to meet social care needs of older people, such as loneliness and isolation, have been reduced. A common response from GPs was summed up by one who noted: “I think it [elderly care] works better than it used to”. The participating GPs recognise the value of Living Well in general and the co-­‐location of Coordinators in surgeries specifically. However, they also appreciate that they have incomplete knowledge of Living Well. For example, not all GPs considered that a monthly meeting, which they attend to identify patients at risk from repeat non-­‐elective hospital admission, was linked to Living Well. With competing demands for time and resources, one GP suggested that Living Well was “on the margins” of his radar. GPs tended to be more familiar with Personal Care Plans, which were often identified as the prime vehicle for determining health care needs in older people. Nevertheless, where GPs were referring older people to Living Well, having a Coordinator on hand was indispensable: “Well, knowing what to do with people [that is the issue]. Knowing where they can access certain things. You know we know about local day centres and perhaps the odd place where people can go and get a cup of tea or somebody would come and pick them up. You know basically but you’re not constantly up with all the latest knowledge. So I think they [Living Well Coordinators] have that knowledge. So you can comfortably pick up the phone, talk to somebody and they take that from you and they have the time then to cascade it out to where it needs to go”. GPs therefore understand that knowing when and who to contact in Living Well is paramount to the delivery of an efficient and effective service. This would also prevent Living Well being seen as ‘just another project’, which would disappear once funding ran out. One key to success, as noted above, appears to reside in the operations and practices of receptionists. They receive telephone calls from older people and see them every time they check in for an appointment. Reception staff can assist in redirecting them towards the Living Well services – obviously this should be under the direction of a GP. The ‘cascading effect’ requires receptionists to have a working knowledge of the programme and thereby act as an essential conduit between GP, patient and Living Well. There is still work to be done in developing a knowledge economy around the programme, but perceptively at least, Living Well is helping to reduce 8 competing claims on the limited resources of surgeries. However, a cautionary observation was offered by one GP: “I mean …you know it’s [elderly social care] very, you know quite dysfunctional in some ways but it works better than it used to but there’s certainly room for improvement”. To seek that improvement we recommend that: 1. contact lists, opportunities at Living Well, and some good news stories about outcomes for older people are regularly updated and conveyed to GPs/practice managers and cascaded to all staff. 2. communication to and the with Living Well coordinators and other health and social care providers involved in the Living Well approach is kept as easy and straightforward as possible. 3. a modern data-­‐sharing platform is developed holds the latest patient data on the older person. 4. Living Well Coordinators are enabled through co-­‐location to develop continuous face-­‐to-­‐face contact with GP Surgeries. […] have gone through that period of not having confidence […] are now […] having their own kind of creative ideas about what they’d like to do” Living Well Coordinator. 9 2.4 What are the impacts of the change on older people
and their carers?
The impact on the lives of older people who are involved in the Living Well project, although hard to quantify, is significant. Older people that are part of Living Well speak warmly of the benefits that they have enjoyed: greater confidence, new friends, something to look forward to, and reduced loneliness are just some of the benefits they describe. Probably the greatest impact can be characterised as building social capital and restoring self-­‐confidence. There is extensive qualitative evidence to suggest that the programme is making an important difference to the quality of life for older people. The following quote is a typical response from the older people that we interviewed: “What are the benefits? It’s provided a means whereby I can get out to do things … Meet other people and there’s other things that I could do. Like I could go and there’s a private library that I go to in Morab Gardens but that is, libraries are all very well but you don’t really have conversations with people in libraries do you?... Yes, so it’s better than that, a lot better than that”. For older people that are part of Living Well, establishing connections with ‘others’, be they coordinators or volunteers, serves to extend their insular personal geographic and social worlds. Meeting and being with others evidently has a profound effect on personal wellbeing, particularly on those who have experienced loneliness. However meeting new people “Well, it’s got me out and about meeting people, doing things… which didn’t happen before – I was just sitting at home just wondering what to do next with nobody coming at all but I am now seeing people, I’m going out to different places, just mingling, which is lovely… I’m looking forward to things.” after a period of isolation requires confidence-­‐building in the older person and can occasionally be met with resistance: “One of the actual helpers [volunteers] said to me ‘oh you can come and talk to this lady’ and I thought why the bloody hell are you getting me involved with her? I don’t want to talk to her. Didn’t like the look of her anyway. That’s telling you truthfully”. Challenging older people’s preconceptions about meeting others or just going outside their home is an essential component of being a volunteer. Helping to develop ‘soft-­‐skills’ in older people such as confidence, enhanced aspiration and hope (often referred to in interviews) is a process of encouragement and gentle coercion by volunteers. This has ultimately led many volunteers and older people to develop a great fondness and respect for each other as the following observation from a volunteer amply demonstrates: “I really feel they’ve become my friends, I’m really, really fond of them and I just think that’s that what communities should be about actually. It is that we link up with people who aren’t necessarily our immediate family and spend time together and become a support network. They really give me at least as much as I give them, you know. They’ve become really, really dear to me and they’re great fun, you know, they really are great fun. We have such a laugh most Mondays. I either get teased about my parking or maybe some joke about something or the other. We’re really familiar and we have a lovely time and I’ve learnt so much actually. I’ve learnt that the older are exactly the same as us, just as irreverent, just as silly, just as funny, just as vulnerable, just often a lot more wise with a lot more interesting things to tell from their long lives, you know”. Through a re-­‐engagement process a level of confidence can be returned to the older person. In this process the volunteers have a key role, as a volunteer stressed in an interview: “But I think confidence can begin to be restored a bit just by pointing out to people the positives in their life. And not concentrating on what they can’t do but pointing out to them some of the things that they can do. I mean it might be just a case of being able to sit over a cup of tea that this elderly person just may be able to sit over a cup of tea and chat to another elderly person. And together they could encourage each other”. A sense of belonging and being part of a community is fundamental to older people’s perception of their wellbeing. Re-­‐engaging with ‘life’, whether through social contact, extending geographical reach and/or 10 “I’m seeing people again. You can’t – well – you can’t put a price to that because if you’ve been lonely, which I have for quite a long time, you suddenly find you’ve got people you can talk to and mix with. It’s like heaven really. I’m so grateful for the fact that I was led into this. You’ve got me going and sorted me out and – well – here I am. Loving it” Older Person. engaging in activities, is a choice. Understanding how a choice is made requires volunteers to be able to comprehend both when to encourage, and when to refrain from encouraging older people to participate. This is often a fine line. As one older person reflected, “the biggest problem I’ve got is I have difficulty disengaging you know when I want to move on”. Re-­‐connecting is not always successfully achieved as other influences affect the lives of older people. As one older man stated: “The most amazing thing is for some reason it [Living Well] draws the ladies. Maybe it’s the ladies that are left on their own and they outlive the men. That’s what it looks like. But I quite honestly think, I haven’t got a computer but I think a lot of these old boys have got computers and they don’t want to leave their damned computers. I’m sure of it. They play games on their computers or something like that”. Achieving connection or re-­‐engagement is, like wellbeing, a relative concept. Personal levels of wellbeing can only be measured in terms of the effects to an individual and not the requirements of a clearly defined programme or a medical intervention. Living well appears to achieve enhanced wellbeing for individuals without recourse to clinical ‘assessment scales’. To further improve the work of Living Well we therefore recommend that clear lines of and pathways of progression are co-­‐formulated and informally recorded for older people so that they are able to reflect on the changes in their lives. 2.5
How has this change been achieved?
The role of volunteers is fundamental to the Living Well philosophy of care. The volunteers undertake activities associated with Living Well 1-­‐3 times a week and tend to have 1-­‐3 older people that they are responsible for. As the interviewee stated above, volunteers are integral to engaging, encouraging and facilitating a lifestyle change in older people. Evidence from our interviews with both volunteers and older people suggests that there is a strong relationship between both groups that is predicated on trust, reciprocity and conviviality. One of the key successes of the programme has been the participation of volunteers who care passionately about their roles and responsibilities. They are enthusiastic and inspiring people whose work is personally rewarding and has the power to be transformational and meaningful for both themselves and the older person. 11 2.6 How does the involvement of volunteers reduce
dependency and build confidence?
In this section we will consider the process of caring and the issues that arise from current practices and experiences. We do this by exploring the following four themes: i) building social capital; ii) reducing dependency; iii) on becoming an older volunteer; iv) and finally, rethinking volunteering and geo-­‐care spaces. “Well I am a volunteer and so I, what actually happens is you are supposed to sort of get these sort of people on track and then they make friends within the group and you can back off to a certain extent because they have made a friend, they have probably exchanged telephone numbers and then they can start sort of doing things on their own a bit more” – volunteer. Building Social Capital The desire to produce face-­‐to-­‐face contact and reintegrate older people within social groups is essentially a process of building social capital and empowerment. Our interviewees suggest that older people experience a rediscovery of community. In this way, social capital is generated through the society bonds that enable people to get by and get ahead, to challenge introspective senses of community, and to foster social attachments that cohere and link them to a sense of social belonging. One volunteer describes the formation of social capital: “It’s going really nicely actually, a lot of them, we’ve managed to create quite a lot of social capital I suppose through the groups because the clients who’ve come on board with us have kind of taken things into their own hands a bit by voting with their feet, said what they’d like to do, we’ve managed to develop four quite sort of good foundation groups if you like, we’ve got a craft group, we’ve got the knitter natter group, we’ve got a coffee group, we’ve got the cinema group, we’ve actually also got a reading group now which is lovely, perhaps you’d like to come along to that actually, you could actually sort of see that”. The above quote illustrates how, through reciprocity, confidence can be co-­‐produced between volunteers and older people. Social capital is also produced for volunteers by the simple virtue of volunteering. Their sense of being ‘connected’ is present in their reflections on becoming a volunteer: “I need it. In a way I look forward to these mornings as they [older people] do and I think it is just nice to sort of get out and help people. I mean people say to me, God, you must be a right mug, but I don’t think so, I enjoy it, you know?” The comfort of human connection within Living Well cannot be underestimated. Many of the volunteers we interviewed have themselves experienced loneliness – perhaps after a relationship break down or children leaving home – and this motivated them to ameliorate loneliness for others. As one volunteer said “I have been with people since I was eighteen and I know that if I don’t have that people factor in my life I get very depressed”. There are reasons to be extremely cheerful about Living Well as the group of beneficiaries goes well beyond the older people and 12 “And I thought well I’ve got to do something. I want to do something, I just feel I need, I need to, because I don’t work and just take the dog for a walk, and that’s about it, that’s my life really. And I’d like to, well okay, I go and play golf occasionally, but you know, I could do with the contact with other people” – volunteer. 13 their carers. The strength of the programme is that it draws on people’s resources and in particular their empathy, resourcefulness and fortitude. The older people that are part of Living Well reflected that they benefited through actively being connected to people outside of their close localities and were thereby able to chose who they spent their time with. One of the older people explained in her own words how Living Well expands her choices: “I’m quite sociable, but [before Living Well] I haven't actually met anybody in the village who has a similar interest to me, and I don’t meant totally similar but perhaps the same educational status”. Reducing Dependency As noted elsewhere in this document, GPs report a reduction in demand for appointments and a lessening of the load to the practice and to healthcare practitioners as older people enjoy the health benefits of improved wellbeing and are motivated to manage their long term conditions. Dependency on the Living Well coordinator and the volunteer is increased, however. Some structural issues, especially around transport in Penwith – a rural area characterised by small, dispersed villages with poor public transport – mean that Living Well Coordinators and volunteers take on some roles that lie outside their remit. The research team observed Living Well Coordinators completing shopping lists for older people, arranging times to drive them to activities and planning future visits. Although we commend the professional commitment, diligence, and generosity that this demonstrates, for the future sustainability of Living Well we recommend that roles within the team are clearly defined with greater specialisation – for example, between administrative jobs, volunteer management, and promotion. On Becoming An Older Volunteer The recruitment and retention of volunteers is crucial for the future success of the project. We believe the role(s) of volunteers within Living Well requires further thought. In this section we would like to reflect upon the recruitment of older volunteers. This is not to suggest that younger volunteers should be dismissed or discouraged from participating but targeting and enlisting the help of older volunteers may produce long-­‐term benefits for the individuals concerned and the project. Volunteers produce social capital and remake it through every visit or contact they have with an older person. Volunteers are not simply an available resource to be deployed in lieu of service retraction caused by “The doctor suggested Penwith Pioneers. After a couple of [coffee mornings] I said, I would like to become a volunteer because I am sure there is something I can do to help. […] I feel, shall we say, feel alive again” – volunteer. “So I've always dealt with people. I haven’t had a care background or a nursing background. But I have had a people orientated background. So I suppose from that point of view it seemed a natural thing to do” – volunteer. state restructuring in the care sector. Volunteers do not exist in a dormant condition waiting to be mobilised. They are often disparate groups of individuals with a diverse range of skills who have a common purpose in offering to ‘help’. Living Well has a proactive recruitment volunteer policy, notably through Age UK and Volunteer Cornwall, Volunteers are recruited through newspaper adverts, radio broadcasts, and through word of mouth, but there are challenges in recruiting in sufficient numbers. One volunteer summed the situation up: “Well, I think that volunteer numbers is a challenge; I think we need more volunteers because obviously the ideology of the Project is setting people up with volunteers and getting that voluntary support actioned and in place. And if there isn’t a volunteer, you know, you are left with, well what do you do?” The majority of the volunteers we interviewed are older, often recently retired individuals who are looking for new roles in their lives: “I’ve been working generally as a practice nurse but recently I semi-­‐
retired, so I’m still doing a bit of occasional practice work but I set myself up to do something in retirement. I decided to volunteer for Age UK. I had worked for Age Concern in the past monitoring people in nursing homes so I had a little idea of the set up. I volunteered for the Steady On side of things because I thought I could and that would utilise skills I already had, assessing people at home in terms of what medication they were on, what they needed, the safety of the home. It was sort of, it had a crossover effect and I used to work as a district nurse as well so I was used to visiting people in their homes. So that’s why I went for that side of it. There didn’t appear to be… once it got going it took about six months to actually, to get any referrals and then there weren’t a lot from Steady On so I got involved with Befriending as well, doing assessments for befriending because what I didn’t want, I didn’t want to commit myself to doing something regularly on a certain day of the week because I do still do some locum work and that comes and goes and varies. So I prefer to do something that was a one off visit here, there and everywhere”. Harnessing the skills of such volunteers is crucial to the future success of the programme for two distinct reasons. First, recently retired volunteers are frequently former professionals that have a skills match directly relevant to the project – thus reducing the need for extensive training. We also believe there is an untapped resource here for further co-­‐
production of producing care systems. From their professional backgrounds these individuals are passionate, skilled and importantly for Living Well, want to get away from the politics, administration and bureaucracy of caring, to just being carers (see two quotes below). They understand how social care systems can or should work and have the potential to feedback useful observations into team evaluations. 14 “And so my experience at Citizens Advice Bureau is very useful… Because I visit elderly people in their own homes to discuss benefits. I help them if they’re got money problems. I might write a letter for them. I help fill in forms. I don’t know you probably never met the application form for Attendance Allowance. It’s 30 pages long…” Secondly, they have time to give and are flexible. Amongst these volunteers there also appears to be a tacit social Darwinian recognition that if they give help now, in the future others will help them in turn to live a happier, longer life. This is not to suggest that older volunteers are a panacea for the care crises or that they are the only people who should be recruited to the programme. Rather it is to draw attention to their potential. Recruiting older volunteers may require a different form of recruitment strategy from current models – this is discussed below. We recommend that Living Well explores new ways of recruiting volunteers. Rethinking Volunteers and Geo-­‐Care Spaces Some of the most compelling evidence to arise out of our interviews suggests the need for a reconsideration of the ‘recruitment, training, placement, and retention’ of volunteers in the programme. This is because mobilising community resources is difficult, contrary to the impression given by romanticised accounts of the rural idyll as a place in which community self help is in evident and abundant. Living Well requires voluntary organisations to actively mobilise and share volunteers and cultivate and promote active citizenship within communities. As noted above, volunteers have to be nurtured through an on-­‐going process of recruitment and training. As co-­‐production lies at the heart of the Living Well programme the role of volunteers should be placed more firmly within this context. Volunteers cannot be viewed as belonging to one organisation or another: they are individuals who are highly altruistic, yet also gain from being part of the process. This includes being enabled to grow and personally develop through volunteering, as the following quote demonstrates: “I have just been involved with the actual Living Well, so that I can see what is going on basically, and then I will go from there. But I would prefer to do something like I did the other day with coffee mornings, being involved with groups”. 15 Whether there is such a thing as ‘pure altruism’ is highly contentious, but volunteers appear to benefit greatly from being involved in the project. However, we noted that some volunteers were not entirely clear on which organisation they represented. Confusion rests in organisational identity, for example, one volunteer thought they worked for Age Concern and not Living Well. We recommend that all volunteers understand their role within Living Well. The training provided to volunteers who enter the programme appears to meet current demands. However, future training should reflect both the aspirations of the volunteers and those they are helping, as well as meeting the statutory requirements of the Care Act (2014). Through providing systematic iterative feedback from volunteers and older people into the Living Well project, facilitators should be able to identify future training gaps and needs. Volunteers expressed in interview that they would like to develop their own skill sets to enable them to offer a ‘better service’ to the older people. We recommend a regular review of volunteer skills sets is undertaken by facilitators and training adapted appropriately. Future proofing volunteering requires a reflexive capacity within the programme to identify and respond to changing social contexts. In particular we recommend reorienting volunteers and volunteering to the concept of ‘Your Volunteering Neighbourhood’. Context is everything in volunteering: people volunteer for a huge range of reasons, but the majority of their volunteering is local to their home. This appears to be partly a function of ease but also that they have a strong sense of belonging and commitment to their home area and want to do something to make change happen locally. In recognition that building social capital occurs within communities, we recommend that Living Well explores mapping local volunteers skills and desires against the needs of older people. To produce a successful culture of volunteering requires an instrumental shift away from recruiting ‘ready-­‐made communities of practice’, those that always do, to creating a culture of volunteering that is co-­‐produced locally. This is a wider issue for the health, social care, and third sectors as a whole. We recommend that Living Well downplays a reliance on adverts in the local press as they may “come across as very intimidating to some” towards producing taster days. As one interviewee suggested, a number of volunteers had joined Living Well after “just coming along to an event to see what it was all about”. Other volunteers have joined the project because of their friends and family were involved – as discussed in the following quote: 16 “Originally I met [a Living Well Coordinator] and three of the participants that are still in the Project at a local sort of Art & Craft community space where I was helping a friend out. I really clicked with them and I found out about volunteering and just signed up. I was ready to do something as I had been off work with a young child for a few years so it was nice to test the water with some volunteering. And I really wanted to work with older people; that was always my interest. Yeah, so I started volunteering and I got to know three participants in particular that I would see every Monday and sometimes help them with travel, I would just be there and sometimes help them with some of the medical issues that cropped up, so attending appointments or helping with some clarification around things like that with one of the ladies”. We therefore recommend that the Living Well team explore ‘viral-­‐
networking’ techniques for recruiting volunteers. Viral networks will help identify local volunteers who can best respond to local needs. In manner Living Well can produce ‘geo-­‐care spaces’ that are identifiable units of facilitators, volunteers and older people. This may require the implementation of a new geographical information systems (GIS) tool. 2.7
How will the change be sustained?
In this section we consider how change in Living Well can be sustained through best practice. Based on the research findings outlined above we have the following recommendations: Living Well Coordinators are crucial for the initiation, development, and the sustainability of Living Well. As noted above, we recommend that roles within the team are i) clearly defined with greater specialisation – for example, between administrative jobs, volunteer management, and promotion; and ii) clearly communicated to all partners. It is important that Living Well Coordinators do not end up undertaking some of the tasks that are normally done by volunteers, such as driving or shopping. The sustainability of Living Well rests on: ● A funding stream that employs Living Well Coordinators. ● More GPs and surgery-­‐based healthcare practitioners participating. ● An increased focus on prevention, meaning that older people can be volunteers before they become (dependent) older people ● Improved volunteer recruitment and management. Living Well volunteers are at the heart of the Living Well approach. Without them, the potential benefits for older people and the health and social care services cannot be achieved. More time and effort 17 should go into the recruitment of individuals and community groups using a variety of techniques such as volunteer taster days, and actual enrolment into Living Well. We recommend that before Living Well as an approach starts recruiting older people, each Living Well team must be given time to establish a network of individual volunteers and volunteer community groups. Ideally, the recruitment of volunteers would keep pace with the numbers of older people being referred to Living Well Coordinators. ● An easy, simple, direct referral process. The referral process is the means by which older people are recruited into the Living Well approach. Currently, this referral process is time consuming and complex, especially for the GPs and other health and social care providers. We recommend that the same referral process is implemented across those different practitioners. Referral should be possible via a phone call to the Coordinators or through an online system that is to be developed specifically to for the Living Well approach. As part of this online platform an older person’s data (including contact information, outcomes from the Guided Conversation, and subsequent actions) is accessible to all the Living Well partners. ● A more consistent brand for Living Well. Currently the Living Well approach is often perceived, especially in the participating GP surgeries, as just as another project amongst many. Living Well should be understood as an approach that impacts all existing health and social care services. We recommend that: i) Living Well is consistently branded by and for all partners; and ii) Living Well posters, flyers, and other material such as customised pens should be handed to the different health and social care partners. 2.8
“It’s the everyday little things that make a difference” – older person. How could the programme have been improved?
As a philosophy of care Living Well does not come with a toolkit for delivery. Although this is innovative, it can also lead to some snags in operationalising the approach. Volunteers Volunteers are clearly at the heart of Living Well. Their time, care and commitment is highly valued by the older people and Living Well Coordinators. As one Coordinator noted, “I think we should make more of the volunteers. I feel sometimes that is the whole ethos of the process that is the whole cusp of it”. However, there are several aspects of the volunteer involvement and experience that could be improved. 18 19 Recruitment Activities that depend on volunteers can suffer from both low recruitment and high turnover of volunteers. The Penwith Pioneer team have noticed the effect of low levels of recruitment, summed up in this observation from a Living Well Coordinator: “Well, I think that volunteer numbers is a challenge; I think we need more volunteers because obviously the ideology of the Project is setting people up with volunteers and getting that voluntary support actioned and in place. And if there isn’t a volunteer, you know, you are left with, well what do you do?” Existing mechanisms for recruitment include adverts in the local paper and other local media outlets like Radio Cornwall. However, as noted above, the way Living Well is presented and promoted might be a bit off putting to some potential volunteers. As one Coordinator observed: “...the initial promotional material that was out there people were put off because it sounds quite scary, the Living Well, and if you are not from that sector or that background [e.g. health or social care] it is quite complicated”. A positive step has been to change the way Living Well volunteering opportunities are promoted to “simple things like ‘Mrs. Jones next door needs help to put her Christmas Tree up’ or ‘Peter wants a lift to go and do one of his talks’; it was small little things and I think yeah really concentrating on the volunteers because that is the whole idea of it. And I think sometimes that is the bit that is forgotten” (Living Well Coordinator). Meanwhile, low recruitment can be compounded by volunteers who like to work with a defined group of people. Although it is never intended that a volunteer remains permanently associated with an older person in Living Well, the strong bonds that are forged between older people and volunteers mean that some volunteers do not wish to stop helping individuals with whom they have become friends. This reduces their capacity to help new participants in Living Well. The volunteering life cycle means that people come in and out of volunteering. The natural turnover of volunteers sees the loss of skills, expertise and capacity in the system but this can be reduced by peer-­‐to-­‐
peer mentoring and succession planning. Recruiting, retaining and managing volunteers requires some input from someone with a specific job description. This need not necessarily be a paid member of staff – it could be a volunteer whose role is to manage other volunteers. The important thing is having the capacity to recruit volunteers and raise the profile of Living Well. As one Coordinator observed: “But sometimes it doesn’t seem like, I don’t know, it seems like maybe we should have somebody employed specifically for that role to really go out and promote”. This would also have helped to give a more accurate impressions of what is involved in volunteering in Living Well: “…so people in the communities understand what we are asking for volunteers because I think some people think, oh god, I am going to have to do three hours a week, I have got to get them to their hospital appointment, it is medical; it is not about that it is the every day little things that really make a difference I would say. So yeah really promote that and push that idea for the volunteers” (Living Well Coordinator). Training, Mentoring and Co-­‐production Training is not currently a significant part of the Living Well experience for volunteers. Understanding the skills volunteers need and what they bring to the Living Well is currently a neglected area of activity. Yet, as a Living Well Coordinator noted, volunteering with older people is not as straightforward as simply showing up: “Okay, well I think taking time is really important; you can’t go into someone’s life, certainly not the volunteer, and hey ho it is all fine. I think there needs to be a process, there needs to be time. I think research into empathy is really important so I think people who had either had an experience of depression or anxiety themselves or they have maybe had a sibling or a child or a parent with such a condition. Or there is some good training around because I think the Project works because all of us like and care about older people; we have all got empathy for the people we work with”. After an induction, we recommend that the training needs of volunteers should be evaluated regularly. Volunteers may decline the offer of training but it should be made. An assessment of the geographical coverage provided by the volunteer community should also be undertaken. Volunteers value speaking to each other and exchanging their insights 20 21 and experiences. This can be an important part of informal training and mentoring, but some volunteers have noted that peer-­‐to-­‐peer interaction is muted by concerns about data protection. Further, volunteers are not fully involved the in co-­‐production of care with healthcare practitioners because of similar concerns about information sharing and patient confidentiality. The primary channel of communication between the volunteer and the MDT and GP is the Living Well Coordinator. Voluntary Community Groups One way to overcome some of the volatility in volunteering capacity is to achieve a greater engagement with local volunteer-­‐run community groups. Lessons learned from East Cornwall show that actively engaging and enlisting existing community groups works well to offer a range of activities and opportunities to older people. Forward Planning Organisation on the Ground The bespoke nature of Living Well does not foreclose the need for a certain amount of forward planning on the ground. For example, one Coordinator noted that: “I think a lot of things needed to be laid down first and how it would work. Little things like, is there enough office space? Have you got the right technology to talk to other Agencies? Have you got the man power in place? I know they are silly little things but we did it all too quickly and had to work backwards really”. This can be achieved without impacting the innovative, bespoke, iterative nature of Living Well. We recommend investing a small amount of time at the time of the launch of Living Well in a new area in auditing the local arrangements for co-­‐location, technology, skills, and capacity. The job descriptions of Age UK Living Well Team Leaders and Coordinators currently encompass a wide range of high friction activities. Age UK staff may benefit from more focused roles and greater specialisation within the team. GPs and Referral As frequently pointed out by GPs, Practice Managers and surgery staff, GP surgeries are businesses and are incentivised by a business case. Whilst the co-­‐location of Living Well Coordinators in surgeries has been a successful innovation, Practice Managers and GPs have been drawn to Personal Care Plans because these have been incentivised by the commissioning process. Living Well can also become swamped by a plethora of different projects and programmes, which emphasises the need to a) brand Living Well consistently; and b) ensure it retains a high profile amongst GPs and healthcare practitioners. As noted above, referral should always be easy, simple and direct allowing anyone to refer or self-­‐refer into Living Well. However, this has implications for capacity within the volunteer group and the Age UK team. “The idea of getting people out and about is really good but (the issue of) transport is huge down here. We got ourselves in a rut because we were picking people up (...) so you try and use other transport but it is so expensive. Even now we could get people out and about so much easier if there was affordable safe reliable transport.” 2.9 What were the key factors for success, and are
there any significant barriers to delivery?
The key factors for success are: Referral, relationships, routine: The referral of an older person on to the Living Well approach is the first step towards improving an older person's life. We identify the referral as our first key factor for the Living Well success. This referral should be as easy and quick as possible. Referrals can and should come from anyone in contact with an older person who would seem to benefit from contact with a coordinator and volunteer. Relationships are the second factor for a successful Living Well implementation. The research findings clearly highlight the importance of relationships between the older people, GPs, volunteers, community groups, health and social care providers and Living Well coordinators. These relationships are very personal, reciprocal and mainly are established and kept afloat through regular face-­‐to-­‐face contact. We identify the routine as our third key factor for the Living Well success. The Living Well philosophy should be embedded into the everyday practices of GPs and other healthcare practitioners. However, this will require considerable work to overcome the barriers outlined elsewhere in this report. The challenge is making Living Well the ‘new normal’. The main barriers to the successful delivery of Living Well are: insufficient recruitment of volunteers, lack of links to and involvement with community groups, invisibility of the Living Well approach in everyday practices, and transport. Insufficient recruitment of volunteers: Living Well volunteers are at the heart of the approach. Currently, there are not enough volunteers assigned to Living Well and new recruitment of volunteers happens slowly. There is nobody in the Living well team who is solely responsible for recruiting and enrolling new volunteers. Lack of links to and involvement with community groups: The main idea 22 of Living Well is to reintegrate older people within their local communities. Thus far, there are only few links with people and organisations other than the Living Well partners, GP surgeries and volunteers. There is a clear lack of involvement with existing local community groups. Invisibility of the Living Well approach in everyday practices: Currently the Living Well approach is often perceived, especially in the participating GP surgeries, as just as another project amongst many different existing projects. Living Well should be understood as an approach that impacts all existing health and social care services. Transport: Transport is the most cited issue during our semi-­‐structured interviews and tea parties. Older people without transport are sometimes unable to join some of the Living Well coffee mornings and to visit other older people. Currently, many Living Well coordinators spend much of their time driving older people to and from such events. Even through local transport organisations cooperate with Living Well, the costs incurred need to be carried by the older people. If costs exceed the older people's budgets they can be left with no choice but to stay at home by themselves. Budgets: Coordinators, volunteers and GPs alike are concerned about budgets, with the end of the funding period looming. Sustainability can only be achieved when there is a degree of financial security for those employed in delivering Living Well. “It’s an Age UK thing.” GP.
3.0 Follow up
23 In this section we reflect upon the need for a follow up stage in the evaluation of Living Well, which: i) addresses directly, at all four Cornwall sites, some of the operational issues that we have identified; ii) seeks to disseminate and embed learning in other sectors – such as adult social care – and other operational contexts – such as other regions in the UK; iii) continued monitoring of Living Well’s emergent, iterative qualities and the experience of health and social care practitioners, Age UK and other voluntary sector organisations, volunteers and community groups, and older people themselves; iv) to explore the utility of the ‘Your Volunteering Neighbourhood’ as a functional tool for identifying and mobilising community capacity. Any process evaluation of the type we have conducted here benefits from a longitudinal approach. With an emphasis on centring care around the older person, one priority for future research is to track the difference that Living Well makes to older people over time, especially as participants’ needs change further because of the inevitable effects of aging – such as reduced mobility, cognitive impairment, new or worsening conditions, and so on. The Living Well philosophy of care also entails inter-­‐agency working amongst health and social care practitioners. Further evaluative work should examine the extent to which agencies, organisations and practitioners have embraced and embedded change or simply reverted to ‘business as usual’. Final Recommendations: ● A follow up stage in the evaluation, outlined above, which: i) addresses operational issues; ii) seeks opportunities to disseminate and embed learning; iii) continued monitoring of Living Well; and iv) develops the concept of ‘Your Volunteering Neighbourhood’. ● Longitudinal research on the long-­‐term experience of older people in Living Well. ● Further evaluative work on inter-­‐agency working. Prof. Catherine Leyshon Dr. Michael Leyshon Dr. Kathi Kaesehage June 2015
24