‘Who is Helping Who?’ – Co-Production and Professional Boundaries within Social Care services.

By Nick Andrews

I have been working in education and social care for thirty years, and have seen various new initiatives and buzz words come and go, whilst the fundamental principles of humanity remain the same. ‘Co-production’ in its truest senses is grounded in these principles. However, as with the concepts of ‘personalisation’ and ‘reablement’, there is a real danger that the term  ‘co-production’ is misused for hegemonic purposes to cover up what is essentially a cost cutting exercise. Under this scenario, individuals and their communities are expected to take on more responsibility for their own well-being whilst the machine of impersonal and ‘professionalised’ public services carries on as it always has done, albeit it with a few less staff employed. In my opinion, this would be a travesty and missed opportunity to restore warm humanity as the driving force for public services, not compliance with increasingly centralised and de-personalised processes and systems.

One of my favourite quotes by the theologian Martin Buber is ‘all real living is meeting’. Please note that Buber’s understanding of the term ‘meeting’ is much richer than the idea of putting a group of people together in a room or placing nurses and social workers in the same office, which is commonly assumed to result in integrated practice. I am sure many people will share my experience of being in meetings where no one actually met, where each person had their own agenda and the purpose of the meeting was to get this across – to win the argument.  For Buber, ‘meeting’ is about genuinely connecting with other people and being changed in some way by the process. In order to explain this process, he talks about two ways of relating to people and the world, which he calls ‘I-It’ and ‘I-Thou’.

In ‘I-it’ relationships, the person is detached and unaffected. In ‘I-Thou’ relationships, the person is attached and vulnerable. Tom Kitwood, in his seminal book ‘Dementia Reconsidered – The Person Comes First’ talks about his experience of seeing how people living with dementia were dehumanised through receiving emotionally detached task based care:

‘A man or woman could be given the most accurate diagnosis, subjected to the most thorough assessment, provided with a highly detailed care plan and given a place in the most pleasant of surroundings – without any meeting of the I-Thou kind ever having taken place’ (Kitwood, 1997)

By contrast, I believe that genuine co-production facilitates and nurtures the development of ‘I-Thou’ relationships between all parties, which in so doing begins to challenge the prevailing understanding of professionalism and professional boundaries.  In relation to this, I am currently co-ordinating a NISCHR and Joseph Rowntree Foundation (JRF) funded project in Wales, which is focused on the use of evidence from their ‘A Better Life – for older people with high support needs’ programme, along with other forms of evidence in social care service and workforce development.

The ‘A Better Life’ programme has identified that relationships are key and ‘Often it is the simple things that bring the most pleasure (and the lack of them can bring a sense of sadness and loss) and services do not always seem to be very good at delivering ‘the ordinary’’. (Blood, 2013 p13)

The research challenges also call for a different way of working, which is often alien to the world of emotionally detached and compliance focussed task based care, which is summed up nicely in the following quote by Edgar Cahn:

‘The world of helping others in need is now built around one-way transactions…. and with the best of intentions, one-way transactions often send two messages unintentionally. They say: “We have something you need – but you have nothing we need or want or value.”’  (Cahn, 2004).

In a series of recent focus groups and learning events involving older people, carers and frontline staff, I have been struck by how many people feel that current regulation and guidance is risk averse restrictive and at worst destructive of human relationships. For example, workforce regulation states ‘the inappropriate use of touch is not permissible’, rather than ‘the appropriate use of touch is fabulous and to be encouraged’. This is a particular issue for people living with dementia, who often have to express themselves and connect with others through feelings and emotions. Frontline staff talk have talked about feeling guilty when they do little kind things that are not written in the Care Plan or receiving small gifts of appreciation, older people have been ‘told off’ (in the name of health and safety) for pouring tea for others in day services, and carers have been made to feel that they no longer have a role when the person they love goes into a care home.

At the heart of co-production, is an understanding that everyone has something to contribute and that exchanging these contributions is enriching for everyone concerned.  I am reminded of the work of Jean Vanier, who established the L’Arche Communities in learning disability services. Vanier did not see his role as caring for people with learning difficulties, but rather sharing his life with them and being open to receive and learn from them as much as to offer them support.

I am reminded of one of my earliest experience of working in social care services. It was 1984 and I had started my first job as a residential support worker in a children’s home. I thought I was the ‘sorted one’ who was employed to help others. I worked hard to form good working relationships with staff and children in the home, but one boy, who had experienced a lot of hurt in his life, kept his emotional distance. As anyone who knows me well can tell you, I am not gifted in DIY or anything that involves fixing something mechanical. One day, I was trying to repair my bicycle (I did not drive at the time) and was getting nowhere fast. The boy walked past me and said ‘I’ve got a book about repairing bikes, do you want to borrow it?’. I am pleased to say that I took up his offer and our friendship took off from that day. He is now a happily married 43 years old who lives on the other side of the country, but we still keep in contact via Facebook and phone and offer each other support and encouragement whenever we can.

Jean Vanier once said, ‘I am struck by how sharing our weakness and difficulties is more nourishing to others than sharing our qualities and successes’. This is an important message for social care practitioners and agencies. We need to open our ears, our eyes and our hearts to the people we work with, which might involve sharing our vulnerabilities and concerns and allowing ourselves to be changed by genuinely ‘meeting’ with them in truly co-productive relationships.

 

References

Blood, I. A Better Life – Valuing Our Later Years, York, Joseph Rowntree Foundation, available at: http://www.jrf.org.uk/publications/better-life-valuing-our-later-years

Cahn, E. (2004), No more throw away people – the co-production imperative, Washington, Essential Books

The Right to Assistance – The Public Duty to Assist by Jane Krishnadas

The Hands of the CLOCK; Rights as the Intersections

Since the Legal Aid Sentencing Punishment and Offenders Act, 2012 – ‘The Government’s evisceration of Legal Aid leaves those of us involved in the court system feeling a bit like the  inhabitants of an island about to be hit by a tsunami… (Saunders, The Lawyer, 2013).  Having lived, worked and researched in a post-disaster situation, the comparison may seem extreme. However, one year after LASPO, the collaborative efforts of the Community Legal Outreach Collaboration Keele, (CLOCK), have been just in time to assist more than 100 litigants a month facing the loss of livelihood, property or families, which replicated across the UK reaches the disaster scales of 100,000’s of people.

Theoretically, the comparison of the post-disaster sites lies in Arendt’s framework of diminished agency and a declining state (The Human Condition), within which I’ve explored the role of rights within different ‘Scales of Justice’ (Fraser), as a transformative rights strategy; reflecting voices, revaluing resources and relocating sites of justice; (Rights as the Intersections, A Transformative Methodology).

CLOCK

CLOCK Logo

The CLOCK logo presents a visual and practical blueprint of the interrelation of rights and duties within the local justice system (see CLOCK partner leaflet). The Community Legal Outreach Collaboration, Keele (CLOCK) was formed as an umbrella of professional public, private and third sector organisations, to develop a new role ‘the Community Legal Companion’, premised upon the McKenzie Friend principles,  to safeguard the litigant- in-person’s rights to assistance and access to legally-aided and affordable legal services, within the shared commitment to access to justice.

The Community Legal Companion is centred within CLOCK, reflecting Crenshaw’s principle ‘that those concerned with alleviating discrimination’ should begin with ‘addressing the needs and problems of those who are most disadvantaged… for which placing those who are currently marginalised in the centre is the most effective way to resist efforts to compartmentalise experiences’ (‘Demarginalising the Intersection of Race and Class’, Crenshaw, 1989; 167).

However the Legal Companion presents a different starting point to Martha Fineman’s ‘Vulnerable Subject’ (2008). The Legal Companion is an assistant to the legal subject, premised upon the right to reasonable assistance which is embedded within the McKenzie Friend Practice Guidance, July 2010. The text clearly affirms ‘The Right to Reasonable Assistance’. Critically the right of assistance is the right of the litigant. It is not a right of the gratuitous, commercial or politically motivated McKenzie Friend.

The Legal Companion cannot act as an agent for the individual and has no authority to act or speak or advise in any way on behalf of the individual. The litigant’s voice therefore remains their own, as does their actions and decisions- in the words of a litigant, the legal companion is ‘My Calm in the Storm’ (BBC Radio Stoke Discusses Legal Aid and CLOCK).

It is the duty of the court to grant the right of assistance, or provide sufficient reasons why the litigant should not receive assistance. The decision of the court is based upon procedural fairness, the right to a fair trial and the efficient administration of justice. The Chair of the Civil Justice Council Working Party on Access to Justice for litigants-in-person states ‘It is impossible to overstate how important it is for people to have access to justice in a free society”, and calls for ‘concerted leadership to drive collaboration’ (Civil Justice Council Calls for Action).

The CLOCK dial represents a collaborative shared duty to the right of assistance. The Courts provide training on the court forms for suspending evictions, debt, divorce and Children Act applications. The Police and CPS provide training on bridging the civil and criminal processes. The Charitable organisations, circle the CLOCK, providing supporting evidence for legal aid applications, and holistic support; the first quartile, housing and complex needs, Brighter Futures, ASPIRE; the second, family relations, YMCA Family Services, Arch, Savana, Voices of Experience;  the third, community safety, Savana and the fourth, welfare and discrimination, Staffordshire North and Stoke-on-Trent Citizens Advice Bureau, SNCAB. The inner circle of the partner law firms Nowell Meller, Salmons, Young and Co, Lichfield Reynolds and colleagues within the North Staffordshire Law Society‎, and Regent Chambers and Rowchester Chambers,  ensure the companion acts within the professional duty to refer to mediation, legally-aided and affordable legal services. (See: Law Society Litigant in Person, Practice Note; and Bar Society: Guide to Representing yourself in Court).

The legal companion, provides a holding hand, the hands of the clock, to pivot the range of public, private and third sector services, which intersect the complex nature of shattered lives (see Intersectionality and Beyond) for which legal companions have assisted clients to trace multiple legal pathways through criminal, civil, welfare, immigration and domestic violence services (BBC News, Keele students help legal aid gap).

The daily presence of the legal companions in the court, presents a mechanism to draw together evidence to satisfy legal aid criteria, monitor the scope and impact of LASPO on the local community and highlight cases to challenge the fairness of s.10, LASPO, as recommended in the R.1, R.3, and R.4, of the Low Commission Report, Jan 2014.

The hands of the CLOCK  reached the hour, when the Head of Legal Aid visited the domestic violence refuge and listened to ‘Voices of Experience’, to contribute their perspectives on access to legal aid to the  Parliamentary Debate on Baroness Scotland’s Civil Motion to Regret (Head of Legal Aid Commends Legal Companion CLOCK initiative, as “a really positive initiative and could provide a model for similar programmes across the country”).

The endorsement of CLOCK as: an ‘imaginative scheme’ from the Stoke-on-Trent Judiciary; ‘a strategic development in legal education’ (the HEA, Strategic Summit, 2014); an ‘excellent service which epitomises the practical implementation of several of the Working Party’s recommendations’, (Civil Justice Council) and a case study of ‘good practice’ within the Legal Services Consumer Panel Fact Finding Visit, has secured the interest for wider collaboration from Birmingham, Birmingham City and Wolverhampton Courts and Law Schools.

CLOCK has maintained its momentum via the pendulum of in-kind resources, exchanging the costs of court, police, CPS, solicitor barrister and local council time with the experience of the legal companion assistance to navigate the most direct and supported pathways to meet unmet legal needs.

As the past President of the Law Society concludes ‘Sadly the cuts are inevitable’ it may be important to remember the Public interest litigation (S. Krishnadas v Government of Maharashtra). Filed by the, then, law student who initiated the Social Legal Information Centre, Omerga, to fact find information, and with the support of the independent judicial inquiry on the constitutional right to equality won a High Court order for the State to provide financial compensation, housing and basic needs to the earthquake-affected population (see with Krishnadas Sukumaran, Reclaiming Rights, Pluto Press, forthcoming).

Twenty years on, the comparison may seem a travesty, with in effect, “the cessation of the ‘Legal Aid’ programme as it was and its evolution into a new mutation with centralised and commercial controls run from regional centres”, yet the provision of a local service (CLOCK) with “access to citizens in the community will become a resource of huge importance for those who rely on the use of the national legal system. The City which holds the ‘signed’ Magna Carta should also seek to set an example of the standards of performance expected of that document” (David Hallmark, CBE, Worcester Law Society, Visiting Fellow, Oxford. See 2015: Unification of the four surviving original copies of the Magna Carta, celebrating the 800th anniversary of the issue of the Charter).

It is at this intersection in time, where the hands of the CLOCK may indicate a potential for ‘remaking and restructuring the world’, (Crenshaw, 1989; 167)… or at least to bridge our constitutional rights and duties within local spheres of justice… time will tell.

Please note that with due regard to the wider CLOCK partnership, this is a personal narrative of my experience and views. For further information please contact j.h.krishnadas@keele.ac.uk

‘Preceptorship’ – helping newly qualified nurses ‘thrown in at the deep end’

Preceptorship is support for newly qualified nurses (NQNs) as they transition from studenthood to the demands, and responsibilities, of being a qualified nurse. Preceptorship refers to ‘a period of structured transition for the newly registered practitioner during which he or she will be supported by a preceptor, to develop their confidence as an autonomous professional, refine skills, values and behaviours and to continue on their journey of life-long learning’ (DoH 2010: 11). It is underpinned by a range of government policies and good practice guidelines, including A High Quality Workforce: NHS Next Stage Review which states: ‘A foundation period of preceptorship for practitioners at the start of their careers will help them begin the journey from novice to expert’ (DoH 2008: 72). Preceptorship aims to address how knowledge acquired in nurse training is recontextualised in practice (Evans et al 2010) and how newly qualified nurses (NQNs) adapt to the ‘real world of practice’ (Houghton 2014).

In addition to needing support in developing their clinical skills and self-confidence in their own nursing judgements, many NQNs find time-management in busy clinical contexts a challenge (O’Kane 2012) and, in parallel, experience difficulties in relation to delegation skills. Inability to delegate can lead to NQNs feeling overwhelmed, which can result in burnout and high staff turnover of NQNs. However, despite the need for registered nurses to be competent in delegating and supervising unregistered health care assistants, research suggests that their nurse education does not always equip them with the necessary skills (Hasson, McKenna and Keeny 2013). Preceptorship then becomes a vital means of supporting them in acquiring those skills.

Even though research repeatedly affirms the importance of preceptorship, it is not consistently available to NQNs cross the UK, nor, even if offered on paper, is it always reliably delivered in practice (Higgins Spencer and Kane, 2010) particularly at times where there are considerable restraints upon nursing budgets (Avis, Mallik and Fraser 2013). This means that many NQNs feel they find themselves in ‘Sink or Swim’ situations (Hughes and Fraser 2001). While many will swim, some inevitably will sink. This is a terribly waste not only of training, but also of people who want to be, and could be, competent and confident nurses, provided they are given sufficient support during their transition from student to qualified nurse. Investment in preceptorship can have huge benefits in supporting and retaining NQNs (Whitehead et al 2013) and as such should be made consistently and robustly available to nurses during their initial post-qualifying period.

References
Avis, Mark, Mallik, Maggie and Fraser, Diane M. (2013). ‘”Practising under your own Pin”–a description of the transition experiences of newly qualified midwives.’ Journal of Nursing Management 21(8): 1061-1071
Department of Health (2008). A High Quality Workforce: NHS Next Stage Review. London: Department of Health.
Department of Health (2010) Preceptorship Framework for Newly Registered Nurses, Midwives and Allied Health Professionals. London: Department of Health
Evans, Karen, et al. (2010) ‘Putting knowledge to work: A new approach.’ Nurse Education Today 30(3): 245-251.
Hasson, Felicity, Hugh P. McKenna, and Sinead Keeney (2013) ‘Delegating and supervising unregistered professionals: the student nurse experience.’ Nurse Education Today 33(3): 229-235.
Higgins, Georgina Spencer, Racheel Louise and Kane, Ros (2010). “A systematic review of the experiences and perceptions of the newly qualified nurse in the United Kingdom.” Nurse Education Today 30(6): 499-508.
Houghton, Catherine E. (2014) ‘”Newcomer adaptation”: a lens through which to understand how nursing students fit in with the real world of practice.’ Journal of Clinical Nursing: Advance access, http://onlinelibrary.wiley.com/doi/10.1111/jocn.12451/full
Hughes, Anita J., and Fraser, Diane M. (2011). ‘”SINK or SWIM”: The experience of newly qualified midwives in England.’ Midwifery 27(3): 382-386.
O’Kane, Catherine E. (2012). ‘Newly qualified nurses’ experiences in the intensive care unit.’ Nursing in Critical Care, 17(1): 44-51.
Whitehead, Bill, et al. (2013). ‘Supporting newly qualified nurses in the UK: A systematic literature review.’ Nurse Education Today 33: 370–377.