Adult social care eligibility criteria - innovations and developments: report

Findings of this project

How we think and talk about social care

The language associated with social care was a frequent concern for many participants in our project. This is important because language shapes how social care is viewed, with a strong sense that it needs to be framed more positively, and particularly recast as an investment in people's lives, rather than a societal burden. This was emphasised by the People Led Policy Panel (PLPP) who referred several times to the importance of 'supporting people to thrive.' Another person who had experience both of accessing support and of working in services added the following:

It comes back to how you view social care, its purpose and the value we place on it. Until it's seen as an economic investment, then we won't progress. People may need support, but they are still valuable. Social care is an investment in quality of life and wellbeing for people. We will replicate problematic systems until we change how it's viewed. (Interview, voluntary sector)

We will return to the theme of language below, particularly in relation to access to social care, and to equity.

Access to social care

Alongside the question of the need to reframe social care was the question of access in general terms. While examples were provided of people being able to get the support they needed, others described multiple barriers when seeking support. Much of the discussion around access to care involved supported people and carers. Some identified the layers involved to get through to access support:

It's not easy for people to access information and support. They don't know how to access it or who to go to. (COCIS group two)

We were also able to draw on the learning from a project which concluded in 2022, focusing on new models of learning disability day support (HIS 2023a, HIS 2023b). This work by HIS and the ihub included collaboration with People First to produce a version of Snakes and Ladders which illustrates the complexity and challenges involved in accessing support.

Linked to this project, the PLPP was asked about their experiences of accessing social care via key routes of social work, community-based and GP services. The accessibly written report emphasises that most panel members had accessed support via advocacy services and/or the third sector rather than more formal routes. While there were some positive references, they identified several ways in which more formal routes could be challenging:

• A need for more accessible information about support and how to access it, preferably a central access point
• Finding it difficult to admit to needing help
• Concerns about losing control of your life
• Over reliance by formal services on unpaid carers

Some comments here suggest the need for a more proactive approach from statutory services, as well as a more relational, co-produced approach when contact is established:

It's about access – about what you need to prove to gain that access and it's about exclusion – what happens to those who don't qualify. (Interview, steering group)

This complexity was also highlighted by people 'inside' the system. As noted above, that means that practitioners struggle to stay on top of rapidly changing processes and mechanisms. This layers onto existing complexity which can be difficult to explain to people in crisis and to carers under pressure:

We have built such a complex set of processes which vary depending which route you follow. It's a bit like a tree with multiple branches you can go down, and there is variation within the branches. It makes it very difficult to influence change. (Interview, SDS practice lead)

In addition, for practitioners, there was a sense that they learn to manage their own expectations about what is possible within cash strapped, bureaucratic systems. This filters in to both statutory and voluntary sectors:

Some staff say they feel they have to go under the threshold or it won't get agreed and that is not right. (SWS PF)

For carer centre staff that whole bit about managing expectations – you are already expecting a downgrade and that effects relationships and morale of staff too. You are looking at outcomes and what would make the carer role manageable – but the temptation is to exaggerate the difficulties. (COCIS group six)

Language is important for access; you need to know the right language at different steps in the process. In the COCIS event, someone used the phrase 'selling trauma to get support.' Another contributor linked challenges with access to language barriers and trauma:

People are often refused assessments. They often don't know the secret code (and may struggle to convey the true level of need). This process can be traumatising and it causes harm (interview, change organisation).

We return to the theme of language and access when considering assessment below.

Eligibility criteria

It's like turning off the fridge/freezer to save on electricity bills. (Interviewee, third sector)

It is heartbreaking to repeatedly have to tell people how terrible your life is. (PLPP)

People identified harms caused specifically by eligibility criteria as well as through trying to access the system in general. It was emphasised that there is a need for understanding and acknowledgement in the system that the criteria are not just a neutral decision-making tool. Their existence changes how people in the system interact with people trying to gain access:

It is assumed that eligibility criteria are a separate thing, a prioritisation mechanism that sit away from practice to be applied remotely, when in fact they are driving practice (Interview, steering group).

A couple of contributors within services thought that eligibility criteria, ironically, tended to focus assessments on formal supports and services, and to take the focus away from the assets of the person. If needs were assessed as critical, that could lead to community-based resources being overlooked: 'they take us back to being resource led' (interview, HSCP).

In the case study from Midlothian, the presenter considered the case for eligibility criteria,with attention given to some of the key questions to consider if looking to replace them, particularly with regard to specific aspects of budget (see appendix B). Alongside this, the case study / presentation from Gateshead shared important learning about what happens when eligibility criteria are switched off, albeit in a very specific service context.

Other contributors are working to find ways to be more inclusive and responsive, to enable to access that bit of early support, through increased partnership:

In Dundee our view is that everyone meets eligibility criteria. If the person meets critical or substantial criteria, they might need a package of care. If medium and low, there are still support options and we are developing/upgrading our front door system in that sense of more of a multi-disciplinary team. We have commissioned third sector roles where they will sit with us and be part of that team, in the front door team. Or practitioners will be coming to them and they will look to the community and third sector, so we are hopefully trying to strengthen prevention. It is very early stages, the funding is there, posts have been agreed (SDS PF).

Community Led Support (CLS) is a model promoted by the National Development Team for Inclusion (NDTI), a partner in this project. This has been running for over nine years across the UK. Many core principles promoted by NDTI are consistent with key themes in this project, focused on tackling systemic and cultural issues around speed of response, ease of access, changing the nature of 'assessment', reducing waiting times, turning eligibility criteria on their heads and making the best use of local resources for people:

Evidence from areas adopting CLS demonstrates that by implementing a preventative approach, embedding strength-based conversations and identifying outcomes at an early stage with the person, many resources can be found in local communities. Because this way of working is effective, eligibility should only be considered later in the process at a point when formal support is being considered. It is critical not to screen out advice and support to people even before an assessment has started.

NDTI have also worked in recent years to progress their ability to evidence the value of prevention, and are making progress with in this endeavour.

An additional key mechanism: the Resource Allocation System

As noted earlier, Resource Allocations Systems (RAS) were introduced in the UK as part of the personalisation agenda. In this project, they were frequently referenced alongside eligibility criteria, particularly in engaging with statutory sector colleagues, including the SWS practice network. The following two comments came from supported people:

The RAS omits the participation of the person – but it should be nothing about us without us. (Group conversation – supported person)

The Resource Allocation System denies disabled people the right to be involved in decisions about their own lives. (PLPP)

Many parallels were drawn with eligibility criteria. As raised with regard to eligibility, several people mentioned a concern that SDS is resource driven, in interviews and in the practice forum, again leading away from working with people's assets and community resources:

I don't particularly like the RAS as I think it is resource led. (SWS PF)

Also as with eligibility criteria, the intention to try to facilitate fair and open decision-making was an important principle that a mechanism alone can't achieve. In Angus, the SDS lead reported that they produce a minute of the meeting where decisions are made about resource, as a way to make the decision-making more transparent.

Another parallel with eligibility was the tendency to prioritise a focus on risk:

And the RAS, I've worked with our IT on trying to put RAS systems together. It's a percentage game; how much do we put to risk, how much do we put to enabling, how much to assessment. And risk always takes a bigger part of that function. (SWS PF)

In discussions with HSCP staff, participants frequently mentioned work underway to 'overhaul, review or tweak' their RAS. One HSCP practice lead noted of their RAS:

The worker defines the budget then it goes to a panel then to a finance panel. Workers don't know how and why budgets are decided. For people with lower level needs we've had to continuously refine the budget process because budgets are coming in too low. We also need to factor in that rural costs are higher (HSCP).

Another HSCP representative noted that they were one of several local authorities in Scotland using an alternative model which calculate budgets based on equivalent costs of services, rather than the RAS. While they thought it still had its limitations they noted that there were fewer instances of social workers being refused at screening panels. The case studies from England and Wales in the appendices also point to different ways of framing and alternative mechanisms for allocation of resources.

Equity, consistency, transparency

In all of our events we mentioned that the original intentions of eligibility criteria were to improve equity, consistency and transparency. These themes were picked up to various extents in the discussions. In the SWS practice forum our discussion was framed more explicitly around this theme, with most references below coming from that setting.

Equity

In broad terms there were two main concerns about achieving equity with access and with allocation of resources. One set of concerns was around avoiding situations where more articulate people with greater social capital are more enabled to get what they need from the system. The other related to perceptions of ingrained and more widespread systemic inequalities. Regards the first area of individual articulation of needs:

Carers who can 'speak the right language,' who are more educated and most often from higher socio-economic groups are more likely to be able to navigate through the snakes and ladders to access support. (COCIS group four)

Who shouts loudest tends to get. Some carers who are in very challenging situations will step back and say oh no, there are others in greater need than me. We have to fight to get them respite. At the same time it can be the easier path with those that shout loudest to avoid the protracted battles. (COCIS group six)

The term 'postcode lottery' was referred to frequently by carers and supported people and their representative groups. There is understandable frustration that conditions vary markedly between and within areas. For a minority of participants, there was a view that more rigorous and consistent application of eligibility criteria could resolve consistencies.

While at least one PLPP member thought that national eligibility criteria would promote consistency, others wanted to end eligibility criteria altogether. While the discussion in the SWS practice forum focused primarily on ensuring that people are not excluded from information, advice and preventative support, there was also a concern to promote equity through ensuring that people obtain resources commensurate with their levels of need. This led to a suggestion that a framework for 'defensible decision-making' was required while resources remain limited.

However, there were also challenges to the idea that eligibility criteria themselves, or an alternative similar mechanism could counteract deeper and longstanding systemic factors influencing equity. Differentiated provision across care groups was identified as a significant concern, particularly at the practice forum, where several people identified differential budgets, for example between older people and people with learning disabilities or between children and adult services. While there were complex reasons for some of this variation, there was a sense that eligibility criteria do not resolve systemic inequity:

Thinking about equity…As our staff have identified, we have different age groups, different care groups – with different support decisions getting made and different budget allowances, different PA and provider rates – all of that creates an absolutely different playing field. (SWS PF)

The conversation highlighted the limited extent to which any mechanism can achieve equity against a backdrop of embedded inequities in the system. This also links to suggestions (below) that more open conversations are needed with the public about fairness. In the final example here from Edinburgh short breaks service, a manager explains how they try to rebalance budgets which don't reflect underlying levels of need, to try to achieve equity:

The budgets for breaks are based on four different set rates depending on which care group it is. The budgets don't usually match the cost of support so we have to be very creative. For learning disabilities we find that people with moderate needs get the same as folk with higher level needs. One way around it is to encourage shared support. We have our own properties now for respite. They are run like air b and b, are fully equipped and providers can book them. In disabilities the budget is capped at £202 a night where the cost is closer to £400. We also need a kinder model. Savings can to go people with higher support needs. Higher levels of support should reflect carer needs too.

Consistency

The question of whether eligibility criteria promote consistency generated discussion about a wider need for consistency. This centred on the need, especially given increased remote working and fragmentation, to promote consistency through bringing people together to develop consistent values, practice and ways of working:

I've moved to a new local authority recently and I'm new to adults services, SDS and carers. The Consistency issue is so prevalent. What I'm seeing is lack of culture, dissemination, norms like we had in the olden days. And the workforce turnover is vast…I'm in HQ and there is always that tension with localities… And I keep asking what is the norm, and I can't find answers. (SWS PF)

The need for consistency was emphasised across stakeholder groups. The following comment from the PLLP reflected views of carer and practitioner representatives:

Training needed for social work staff on SDS options (PLPP)

There are already efforts underway in some HSCPs to address this:

We held SDS focused events involving our workforce learning and development team in Edinburgh, and we had over 60 people participate online from both children and families and adult services. This was the first time with a joint focus on SDS across the Local Authority. We asked-

• what do you understand about SDS
• what works well and what doesn't work well
• what would improve your understanding of SDS and help put this into practice.

We then have used this information to form our new training modules which will be rolled out this autumn. The plan is then to hold further focus groups early 2024 to review practitioners' knowledge and experience and then to look at what further steps are needed to embed SDS Into practice. We are also planning to have a joint adult and children's SDS policy to ensure consistency across the different areas (SDS PF).

There was also a view within the practice forum that training, while a vital component, will not be sufficient on its own to embed the changes required. Organisational culture and leadership is also critical to effective implementation, as suggested by the leader quoted above who is struggling to find the organisational norms.

Transparency

In both the COCIS forum and the SDS practice forum there were references to the 'layers of decision-making' about allocation of resources, with a shared sense that each additional layer reduces transparency. In the practice forum, there was a focus on meaningful engagement with families as the best means of promoting transparency:

I don't think it's mechanisms that promote transparency. It's how we interact with individuals and families, and from that perspective I think the question [about whether eligibility criteria support transparency] is out of kilter (SWS PF).

An earlier example from this report is also relevant here, whereby a minute of decision-making meetings about resource allocation is provided to families.

On balance, there was a strong focus on challenging the idea that decision-making about risk, needs, outcomes and allocation of resource could be a mechanical process, with reference to a 'veneer of objectivity.' The need for transparent decision-making could be supported by working more with principles than mechanisms. Good conversations were often linked to assessment as a potential place to enable these conversations to take place.

Assessment, good conversations and relationships

Someone who doesn't know you and maybe never even met you is making decisions about your life (PLPP)

The concept of assessment was an important theme, with the majority view that assessment should present an opportunity for dialogue, learning and co-produced decisions within a relationship-based approach to practice, rather than being a tick box exercise. Discussions often touched on the highly skilled nature of the conversations underpinning effective practice. The focus on good conversations included emphasis on the importance of building trust and rapport, and paying attention to what is not said. One manager reported:

We visited a carer last week. We knew she was caring for her daughter with complex disabilities. We were just leaving when she mentioned she was also caring for her mum who had significant mental health issues and dementia, and the urgency of a break became clear. It's not unusual for a carer to be holding on to all of their struggles so you have to build the trust. (Interview, short breaks service)

The extent to which diverse stakeholders in Scotland referred to the importance of 'good conversations,' was notable, particularly given this wasn't reflected in some of the policy literature. The importance of meaningfully engaging with people about their lives was associated with a concern to ensure that decisional mechanisms and formula do not undermine the potential therapeutic benefits, and opportunity for effective decision-making. Returning to the important theme of language in social care, the need to speak different languages in assessment was identified by social work practice leads:

When you are with the family, your conversation is person-centred, it is outcomes focused. It is based on strengths and assets. And then you come back and typing up the assessment or review…in a slightly different, almost more professional language, but still being mindful that the person is going to read it. And when you come to your resource request, you are writing in a completely different way to evidence that you are meeting eligibility requirements. As a social work practice educator that was always something that my students always really grappled with. (SWS PF)

In addition to the emphasis on good conversations, there were example of processes around assessment evolving to increase the benefits of information exchange, between agencies and with the person, with both of the following examples referring to carers:

Carers don't want to continually re-tell their story, there should be the ability to share this with agencies, with the carer owning the information. In Lanarkshire a system called 'Carer Space' does this. Practitioners and carers can both add to the record and it can be shared between agencies (COCIS group four).

A practitioner at Voice of Carers Across Lothian (VOCAL) informed that staff there use adult carer support planning to prepare carers for engaging with the statutory sector.

When supporting Carers to create an Adult Carer Support Plan it provides the carer with not only an opportunity to consider and plan their own support but also helps carers prepare for engagement with the statutory sector. Carers often have not had an opportunity to reflect on their situation and to work out how things could be better. We use those ACSP conversations to help them work out what matters to them, what the impact of caring is and the language they need to use to explain things in ways that can be heard (Interview, voluntary sector manager)

In both statutory and voluntary sectors, current pressures are making it difficult to avoid waiting lists, both for assessments and subsequently for services. One HSCP participant commented that even if "more social workers were out there, drafting in more in the same

way will not work".Similarly, the following participant described their evolving approach. This example is longer than others to illustrate the dynamic nature of the crisis, and the need for agencies to constantly adapt to survive and keep improving outcomes:

We've had to change our approach to adult carer support planning (ACSP). Escalating eligibility criteria have increased our referrals. The level of complexity has increased too. Due to increasing waiting lists, the starting point of an adult carer support plan for all carers is now impossible.

We did a lot of research to find all the resources in our local community and now send out a welcome pack with universal services. Within ten days, we offer an introductory chat to discuss it and find carers have identified several resources of interest. After another ten weeks we follow up and offer an ACSP. At that point most carers don't feel this is necessary, know the carer centre is there and are better informed about other supports. They know the ACSP option is there if things change.

When we checked back with the carer centre in advance of publishing, they told us:

As statutory eligibility requirements go up, the level of complexity of people we support increases too. We are now developing our own internal eligibility system of traffic lights, so that those who are in the red category get priority access to our support. We feel we have to do something to make sure those most in need access our limited services.

(Perth and Kinross Carers Centre)

Overall discussions with carer centres indicated a concern to ensure that support planning with young and adult carers was viewed as an important right, but that there needs to be a proportionate way of doing this. Underpinning statutory guidance includes a lot of information requirements which can lead to lengthy form-filling, which can detract from the desired conversational approach. Further to this, it was emphasised in the steering group that preventative work should be recorded, both to improve understanding of the impact of early intervention, and to avoid people getting lost without tracking their progress. While there is potential value in building evidence around prevention, given the pressure identified above, any additional recording requirements must be as light touch as possible.

Role of social work

Findings here concern the role of social work with regard to eligibility criteria. A recent Scottish Government paper (2022a) acknowledges the complexity of the social work role. This identifies the requirement to balance holistic and relationship-based practice, reducing inequalities, upholding human rights, promoting social justice and ensuring public protection. This is already a challenging set of principles containing inherent tensions. The previous sections also speak to the primacy of understanding individual circumstances and needs, and the tensions between securing supports for individuals and the gatekeeping requirements that eligibility criteria and the RAS have introduced. This all adds to the complexity underneath, with emphasis arising again here on an enduring and shared concern to focus on relationships,

The importance of relationships

Relationships matter. When a carer has a good relationship with the social worker or team supporting them or their cared for person it can often lead to better outcomes for all and is a much more positive experience for families. (COCIS group one)

There was reference to how this is hampered by social worker shortages, and in some areas the need to phone a central line to try to contact your social worker, with the effectiveness of the phoneline in one case likened to a 'chocolate teapot'(interview, voluntary sector).

Alongside the recognition of the expressed desire for greater early intervention and preventative work, some carer frustrations were expressed about leaving it too late:

We need to shift our thinking to how we fit into the carer's journey, not the other way around. The most powerful tool is listening, letting people tell their story. But it should be from the point of diagnosis etc. If you try to do this in crisis, good luck! (HIS breakout room)

Social work and communities

There was identification at a strategic level of a need to rethink social care and eligibility criteria in the context of the wider system, with specific reference to community assets, the role of community planning partnerships and community hub models. There was also an appetite to progress community social work:

Our Chief Social Worker is keen to progress community social work, and is frustrated by eligibility criteria. We know we need to change relationship with providers (interview, HSCP)

Examples of good practice in progressing this agenda were also highlighted:

We need social workers in the High Street. There is a lot to learn from the work that has been developed in the Fife community based model – there is a very strong focus on strengths there and acknowledgement that we all need support at some points in our lives. (Interview, change organisation)

Social work autonomy

Alongside rethinking where social workers would be best placed to carry out all intended aspects of the role, throughout discussions, there was general support for and appreciation of the merits of greater social worker autonomy, as the PLPP succinctly expressed it:

We want a better system for our workers- our lives are tied to theirs. (PLPP)

This view was also expressed by carers:

Social workers should be able to authorise low level interventions. They make decisions that help family and problems can be easily fixed. Social Workers would be happier and should be allowed to do their job. (COCIS group five)

There was frustration with "social workers undertaking their assessment and forming a view based on their analysis, essentially for the computer to say no" (SWS PF).

To counter this, steps were being taken in some areas to look at how to promote worker autonomy and move to delegated budgetary decision making. These included considering the viability of frameworks setting out delegated levels used in other localities, discussions with finance and service managers regarding appropriate thresholds and pilot initiatives where workers were using their professional judgement in work within small budget limits. The importance of ensuring consistency of practice was again recognised, with varying emphasis as to whether that was best promoted by 'auditing, checking and quality assuring' and/or through more qualitative and relational approaches to practice development.

The need to build culture, values and norms through dialogue

Several contributors referred to the need for a shift in mindset to find sustainable and human rights-oriented ways forward for social care. This means using language that does not exclude people on the basis of points-based systems (with several contributors using the phrase: 'computer says no'). There is also an urgent need to rebuild connections with the public to reset mutual expectations, as well as within and between organisations, where connectedness and shared understandings have been disrupted through the pandemic.

Conversations with the public

People with experience of using services who contributed to this project, including at our event in June 2022, were keen to be part of the conversation and to positively influence the future of social care. They also wanted to continue these conversations:

Should have joint meetings with social workers and people with lived experience to discuss moving forward (PLPP)

It was notable in the New Models of Learning Disability work that key learning identified across eight Health and Social Care Partnerships centered on a need for more effective ways of engaging with supported people and their families and for more collaborative spaces. Similarly, contributors to the SWS practice forum advocated for more collaborative conversations with communities, which would help to 'set more realistic expectations' and develop "a growing shared understanding" which would also help to change the language.

Discussion with the public was important not just to build a shared understanding, but also to draw in all types of human resources to navigate the challenges faced.

This needs to include making more of the third sector and communities. The Feeley review highlighted that. The roles of communities and the third sector during the pandemic was exemplary and we need to get that back. They were able to adapt, respond and be flexible. We need to keep that focus on how to keep people well fed and stay connected. (Interview, voluntary sector)

Conversations within organisations

The importance of building (or maintaining) relationships between different groups of staff within organisations was highlighted as necessary to ensure that what matters to people, or value demand, remains in focus, and to promote consistency of practice:

We have been really lucky in Falkirk because our finance colleagues from the start have been sitting alongside us. They will sometimes ask questions but they won't just say you can't do that. They have been part of the process from the beginning in terms of understanding what social work does and why we might spend money on certain things. As long as we can demonstrate the intended outcomes…. (SWS PF)

Underlying this view was a sense that staff within one part of an organisation can benefit from engaging with and understanding the perspective of others, with different roles, which in turn benefits the public. In another example from Moray, auditors had spent sufficient time with staff to understand how they were having to 'speak different languages' to navigate the system, whilst gaining a better understanding of the work they do, and wanted to maintain connections between their team and practice (SWS practice forum).

Similarly, there was a view that managers in their role can easily become disconnected from the realities of frontline practice, and that different approaches might be necessary to enable them to engage with and learn about experience on the ground:

You need to start the change on the ground with managers – it's a normative learning process. You need to encourage them to approach the organisation as a citizen and with genuine curiosity – and from that perspective they will find that the process rarely matches the need. Managers need to leave the forms behind and just ask open questions. Show curiosity. How do we engage differently – get past being a protector of the current system - then look again at specification, planning and delivery. (Interview, Vanguard)

Our case study from Wales (appendix C) shows an understanding within social work in Neath and Port Talbot that promoting good conversations in practice requires modelling this way of working in the organisation as whole.

Conversations between organisations about values and thresholds

With relevance to the wider system, our carer centre case studies show that centres are facing increased demand following the pandemic and staff shortages. They are adapting their own systems to try to ensure that everyone gets a response and that those who most need one to one support can get it. They also identify that due to pressures across the system, referrals to statutory services might get held up, or as one participant noted can 'drop off a cliff' (COCIS group four). A couple of carer centre staff spoke about an increased tendency for inappropriate referrals from social work. There was some understanding that this was fuelled by limits in the wider system. The need to regularly revisit referrals and flow between organisations was raised repeatedly. Our case study from June 2022 shows how strong partnership between the carers centre and HSCP in Dundee has helped to progress a well-founded locality-based approach (appendix D).

The following example from a children and family focus in Wales illustrated how building shared understandings across agencies had resulted in improved preventative work:

We need to remember the role of our partner agencies. This is in relation to children's services and is not obviously relevant to eligibility, but it is about thresholds for intervention. In recent years we have worked more closely with primary schools in our area. We have worked to change the thresholds there too and work with schools so that they are doing some of that preventative work. We compared five years of data for two neighbouring primary schools – and see the clear difference and impact of prevention in the one we did the work with. (N&PT)

Further to this, the same local authority has for several years now organised a conference for partners where priorities can be exchanged, and again with a focus on building shared understanding of values and ways of working:

One of the motivations for our annual partner conference is so that we can share with others what it is we are trying to do and how we want to do it, as well as hearing from partners about their priorities. It is also partly about promoting our outcome focused strengths-based approach so that there is that wider understanding (N&PT)

There was considerable emphasis on the importance of partnership working in promoting prevention in Scotland too, through engagement with the third sector and community supports. There were great potential benefits from avoiding people becoming "lost in service land" (COCIS group 4). There was also a widespread view that prevention should not be viewed simply as avoiding greater resource use, and that keeping people well and connected is itself valuable.

It's about how we promote opportunities for a conversation with carers too. We learned through the pandemic, more than ever, the importance of early intervention with carers. Carers usually say – what is the point of that. We gently persuade them to try the conversation. I'm thinking in particular of one parent who worked in the NHS and was very doubtful. He came back and said it was super helpful. (HSCP interview)