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9 September 2022

Supporting adult social care innovation: improving the conceptualisation of innovation in adult social care

Juliette Malley, London School of Economics and Political Science, United Kingdom
Gerald Wistow, London School of Economics and Political Science , United Kingdom
Jane Maddison, University of York , United Kingdom
Carl Purcell, King’s College London, United Kingdom

Abstract

As is the case elsewhere in the public sector and internationally, innovation is seen as a critical part of the solution to the adult social care (ASC) sector’s mounting challenges and features strongly in the English government’s recent proposals for reform. A major barrier to this vision, however, is the widely acknowledged difficulty of growing, sustaining and spreading innovations. Consequently, there is increasing interest in understanding how and why innovations grow, are sustained, and spread to improve policy and support for innovations in the field of ASC. The Supporting Adult Social Care Innovation (SASCI) project is a response to this research need. It aims to build evidence about how to support the ASC sector to develop, grow, sustain and spread affordable innovations that work well for everyone.

Although there is much interest in innovation in ASC, and a small but growing body of evidence about the effectiveness of specific innovations, scholarship addressing these broader organisational and system level questions lags behind. The first phase of the SASCI project therefore took an exploratory approach and aimed to better characterise and conceptualise innovation in ASC through mapping the field and a literature review. Subsequent work packages, including comparative case studies, witness seminars and a survey, are designed to explore key issues arising from the conceptual review in greater depth.

This session will share findings from the first phase of the SASCI project. The first presentation will summarise findings from the exploratory research and set out a research agenda for studying innovation in ASC. It will reflect on what we know about innovation in ASC, highlight gaps, tensions and contradictions in the evidence base, and set out the core research questions raised. Since the literature provided a somewhat limited basis for the conceptual review, we took an exploratory approach to the case studies and held conversations with stakeholders in order to improve our conceptualisation of innovation in the sector.

The remaining three presentations in this session describe how the case studies have helped us to refine our conceptualisation of innovation. These presentations examine case studies in different contexts. They will highlight where the case studies echo questions raised by the review and illustrate the insights that are beginning to emerge around these questions. They also identify where there are significant absences in the review, or a narrowness in the way the topics have been investigated. In such instances these presentations will illustrate how the case studies have helped us to reframe our questions and redirect the research agenda for the project.

We conclude the session by setting out how the findings from the first phase of the case studies and stakeholder discussions have led us to reframe and adapt the research agenda. Although we focus on the English ASC system, the research questions and agenda that emerges from the conceptual review has relevance for an international audience.

Presentation 1: Key concepts and the character of innovation in adult social care in England

Juliette Malley, London School of Economics and Political Science

Annette Boaz, London School of Hygiene and Tropical Medicine
Ewan Ferlie, King’s College London
Jasmine Mah, Dalhousie University
Gerald Wistow, London School of Economics and Political Science
Valentina Zigante, London School of Economics and Political Science

Background and aims: There is little evidence to directly inform policymakers and innovators about how to support or grow their innovations in ASC. The limitations of the existing evidence base are reflected in the Putting People at the Heart of Care white paper, which has few references to the academic literature to support either its assertions about why the sector struggles to grow, sustain, spread and scale innovations, or its proposals for reform. This picture stands in stark contrast to the vast innovation literature, which includes important theoretical and empirical contributions that could provide insights for the ASC sector. We drew selectively on this general innovation literature to characterise and conceptualise innovation in ASC. Our aim was twofold: to set out a research agenda for studying innovation in ASC, and to inform the direction for the subsequent SASCI work packages.

Methods: The research involved two elements. First, we mapped the field of innovation in ASC to understand better its character and start a conversation about the range of innovations in ASC. Second, we conducted a review of the academic and grey literature to improve the conceptualisation of innovation in ASC. As the literature was so scattered, we needed a theoretical framing for the review and drew on the resource-based view school of strategic management. This perspective focuses on the role of organisations and provides a good way of examining the capabilities and competences of an innovating organisation. The findings from the exploratory research are integrated and synthesised to set out what we know about innovation in ASC, highlight gaps, tensions and contradictions in the evidence base, and the research questions raised.

Findings: Innovation takes place in a range of contexts and has features of its governance that have not been the subject of research. What matters for innovation in ASC is similar to other sectors, notably collaboration is key, as is leadership, learning, and culture. The exploratory research provided limited insight into what organisations should be aiming for and how they could improve existing competencies in these areas. Although key features of the ASC system (e.g. regulation, commissioning) were largely missing from discussion, tensions were identified around dominance of the NHS, the framing of innovations as projects, and a lack of key resources for innovation (finance and workforce).

Conclusion: The case studies were chosen to capture three different contexts that had not been the subject of previous research: innovations focused on system change, innovative provider organisations, and innovations where there is a strong governance structure coordinating the instances of the innovation and driving its further growth. Emerging research questions, which form the key lines of enquiry for the exploratory phase of the case studies, revolved around three themes: evidence and innovation, which looks at when and how evidence is generated and used for innovation; explaining innovation dynamics at the organisational and system level, which focuses on resources for innovation, collaboration, leadership, organisational learning, culture and the governance of innovations; and innovating in a crisis.

Presentation 2: Opportunities, challenges and idiosyncrasies of introducing system-level innovations in long-term care

Gerald Wistow, London School of Economics and Political Science

Jose-Luis Fernandez, Joanna Marczak
London School of Economics and Political Science

Background and objectives: Long-term care innovations often affect the way in which the system is managed (e.g. markets, integration, information, regulation). Such system-level innovations frequently present challenges of design, implementation and spread. The presentation will discuss the opportunities, challenges and idiosyncrasies of introducing system-level innovations in long-term care, using as examples Thurrock and the LTC market in Greater London.

Methods: The analysis will build on in-depth, semi-structured interviews with managers and professionals as well as on a review of relevant documents in each site. Topic guides included questions around the historical journey of the innovations; ideas, evidence and philosophy underpinning the innovations; their infrastructures, growth and spread, and the impact of Covid19 pandemic. Informed consent was obtained from all respondents, and interviews were recorded and transcribed verbatim. Interview data was analysed using framework analyses and with the help of QSR NVivo 12.

Emerging findings: We anticipate that the analysis of data from all sites will follow a broadly common framework based on the SASCI Key Lines of Enquiry and Literature Review. The LSE case studies will provide evidence which will contribute to drawing conclusions across all sites. In addition, it will enable comparisons to be made between the two system level sites, themselves, as well as between innovation at the level of systems and projects, respectively.

Conclusion: Some of the issues important for successful design and implementation of system-level innovations involve topics around leadership, culture and collaboration between different stakeholders within the system.

Presentation 3: Going with the flow and navigating rocks: tales from journeys of three innovative social care organisations

Jane Maddison, University of York

Kate Baxter, Yvonne Birks
University of York

Background and objectives: The SASCI literature review found that what matters for innovation in ASC is similar to other sectors, with the key capabilities required being collaboration, leadership, learning, resources (knowledge, skilled workforce, finance) and an enabling culture. However, with existing research dominated by single projects, the review offered limited insight into how organisations develop and grow these capabilities in the ASC context.

The University of York case studies are three innovative provider organisations: two established care home groups and a new home care venture. Examining why and how these organisations evolved as innovative, and their innovation ‘journey’ to develop and deploy the key capabilities they require, will generate new, ASC-specific knowledge on process of innovation at organisation level. This evidence will contribute to SASCI’s overall objective to support the sector to develop, grow and spread successful innovation.

Methods: The data collection involved semi-structured, in-depth interviews with staff and document analysis. Topic guides covered the history of each case as an innovator, including the origin and rationale underpinning this focus, key elements which have built or blocked momentum on their innovation journey so far, perceived impacts of being innovative, and any spread of their innovations/approach. With consent, all interviews were audio-recorded and transcribed. Data were analysed thematically.

Emerging findings: The York case studies are generating rich examples of why and how ASC provider organisations seek to develop as innovators and their experience of navigating the innovation ‘journey’ in the particular context of the sector. Findings from each site, and comparisons between them, offer learning for other ASC providers seeking to innovate. Evidence from the York cases studies will also contribute to drawing conclusions across all the SASCI case studies, to support the sector to develop, grow and spread successful innovation.

Conclusion: While key capabilities required by innovative ASC organisations are similar to those in other sectors, the context of working in ASC – including its values, regulation and particular challenges -- affects how these capabilities are perceived, accessed and deployed by ASC organisations seeking to innovate.

Presentation 4: Unfulfilled promise? The development of Shared Lives schemes in England

Carl Purcell, King’s College London

Jill Manthorpe, King’s College London

Background and objectives: Over the past decade Shared Lives schemes have spread across many parts of the UK, offering an alternative model of care and support under which about 10,000 people with care and support needs live with, or (less often) regularly visit, their Shared Lives carers. In some areas these schemes are recently established, but elsewhere the major schemes have built upon more loosely organised ‘adult placement’ schemes that have been established for many years. This presentation will discuss the development of, investment in, and promotion of Shared Lives schemes as a model of innovative high-quality care and the challenges associated with establishing and growing local schemes.

Methods: Data are taken from documentary analysis and semi-structured interviews with individuals at national and local levels, including those working for, or with, four local schemes. Two of the schemes are local authority run, the other two are run by the same voluntary sector provider under local authority contracts. The interviews explored the history of Shared Lives schemes, the use of evidence, the infrastructure to support the development and spread of the innovation and the difficulties faced during the COVID-19 pandemic. With consent, all interviews were recorded and transcribed in full, and the data were analysed following a thematic approach organised with the help of QSR NVivo.

Emerging findings: Shared Lives Plus, the national body representing schemes and carers, has played a prominent advocacy role in collecting and creating the evidence relating to outcomes and possible cost savings associated with the model. It has used this to persuade several local and many national policymakers of Shared Lives’ value and cost-effectiveness. However, ambitions to grow and spread schemes beyond a predominant focus on long-term support and accommodation for people with learning disabilities who have eligible needs for care and support have generally not been realised. There has been much reliance on early funded pilot schemes as providing the evidence and less on what helps ‘cross the chasm’ to sustainability. Recruiting and sustaining carers (self-employed individuals) are major challenges and these need to be balanced against ensuring sufficient demand. Both require resources and it is evident that successful schemes have had to invest in their own workforce as well as addressing the limit numbers of people wanting to be Shared Lives carers with the precarity of their work/volunteer status, who have time, accommodation and flexibility to take on substantial responsibilities. Such tensions and contradictions may help understanding of the ‘steady state’ of Shared Lives’ provision.

Conclusion: Shared Lives schemes now offer a better understood and valued model of care with a national organisation that plays a central part in social care debates. However, the growth and spread of schemes locally requires continued investment in schemes’ own workforces and close working with commissioners and frontline practitioners. Ambitions to professionalise the care workforce are part of current government policy and the implications for this recent innovation on ‘carers’ who have a hybrid status of carer/worker have yet to be fully addressed.


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