What's That Coming Over The Hill?

Earlier this week, NHS Highland ran a seminar to discuss and develop a new programme. It is called Getting It Right for Every Adult (GIRFEA).

From the name it is obviously an outgrowth of GIRFEC, Getting It Right For Every Child, The Scottish Government’s unlawful answer to all issues facing children from conception to adulthood. This new programme is extending the concept further. So then, what is GIRFEA and who will it affect?

Last weekend, we received our first information concerning this new programme in the form of an agenda for a meeting, In full this read:

Getting it Right for Every Adult (GIRFEA)

​​Monday 23 January 2017

Aim of event:

This event will bring together developments from across NHS Highland on an Adult Practice Framework, Getting it Right for Every Adult (GIRFEA) and role of Lead Professional. By the end of the day there will be an agreed Adult Practice model for NHS Highland to roll out, test and fine tune over the next twelve months.

Intended participants:

AHP, SW and Nurse Professional Leads and managers involved in supporting, managing or working within integrated District Teams.


0900​​    GIRFEC: what works well & lessons learned​​   Bill Alexander

0930​​    GIRFEA: update on developments​​​ Pat Tyrrell

1000    ​Lead Professional Role: update & explanation 

1030    Adult Practice Framework​​​​​  Joanna Macdonald

1100​​    Community Planning Partnership/ Lead professional​ Jan Baird

1115​​    Break

1130   Setting the Direction: Agree 3 priorities each for GIRFEA, Adult

        Practice Framework & Lead Professional ​​Clare Wood/Pat Tyrrell  

1245   ​​Lunch

1330​​   Working with others: Group feedback​​​  Joanna Macdonald​

1415​​   Achieving Outcomes: Agreeing ‘the plan’. Managing resources,

          people, performance and risk    ​​Pat Tyrrell

1500​​   Self-leadership: Leading the change​​​   Alison H/ Kate PQ

1600   Finish​​

Immediately it is apparent that this is the progeny of the GIRFEC approach to the child and family, with the apostle of GIRFEC, Bill Alexander, making the opening address. (I wonder what lessons he has learned?) 

But what is the "The Plan"? What does this new scheme involve? We have only a few clues at present.

A pilot programme was run from 2012 to 2014 in Dumfries and Galloway. It was called “Putting You First”. Some snippets of information reveal themselves in the published minutes.

PYF Seamless Care Workstream Wednesday 3 July 2013 10.30am Meeting Room 4, Crichton Hall

4 Getting It Right For Older People

Graham Abrines provide an update advising that it has been difficult to agree the wellbeing indicators for older people and that this may take some time. GA is also looking to see if there is capacity within his team to assign this to some. I was noted that a single point of contact for older people (as for the GIRFEC model) would be of great benefit. Action: GA to provide update in August

So defining wellbeing "may take some time". This is hardly surprising when one bears in mind that one of the leading advocates of wellbeing defined it thus:

Well-being is not a beach you go and lie on. It’s a sort of dynamic dance and there’s movement in that all the time and actually it’s the functionality of that movement which actually is true levels of well-being.

- Nic Marks, Radio 4, 7 January 2012.

"Single point of contact" is the "Named Person" of GIRFEC, We learned during the No to Named Person campaign that the important question is "point of contact for whom?" Is it a means of providing improved service and communication to better deliver care chosen by the patient, or is it, as was the case for the Named Person, a single point of contact for the state about, not for, the individual?

PYF Seamless Care Workstream Wednesday 8 August 2013 11.30am Lochar South, Crichton Hall

5 Getting it Right for Older People

GA advised that the correct term should be “Getting It Right For Every Adult” [emphasis added]. Scoping has begun and GA advised that there would be a need for £25k to release Social Work resource for up to 6 months to develop the concept and also to release up to £5k for resources for support the work of the individual such as meeting accommodation, travel expenses with GA approving any costs over £250. This funding was agreed on the condition that this project would outline a model that followed the SHANARRI principles: • Safe • Healthy • Active • Nurtured • Achieving • Respected • Responsible • Included

Thus, one month after the difficulties in defining wellbeing were acknowledged, the SHANARRI indicators are adopted straight from GIRFEC and this was a condition of funding. In other words, a diktat from the Scottish Government. This against a background where the UK Supreme Court, in its judgment concerning Named Person, looked specifically at wellbeing and SHANARRI. Their conclusions were damning:

“Wellbeing” is not defined. The only guidance as to its meaning is provided by section 96(2), which lists eight factors to which regard is to be had when assessing wellbeing. The factors, which are known under the acronym SHANARRI, are that the child or young person is or would be: “safe, healthy, achieving, nurtured, active, respected, responsible, and included”. These factors are not themselves defined, and in some cases are notably vague: for example, that the child or young person is “achieving” and “included”.

Why, one wonders, has the Scottish Government ignored this finding? Why is it pushing these vague and undefined concepts as the core ideas for a new scheme targeting "Every Adult"? And what of the name change? It is no longer for "Older People" (75+) but "Adults" (18+).

We have no indication why this change. It seems to open up the whole of society to the early intervention agenda: action by the state before problems arise at the say-so of a state functionary who considers the individual's behaviour or choices to be problematic. But that is experience of GIRFEC talking, for there is no explanation of the name change despite the enormous implications. It simply IS. Another edict from on high, another government requirement adopted willingly by the bureaucracy, whatever the logical inconsistencies.

Some of the concerns driving this policy are mentioned in the few documents currently available: 

The Scottish Government has established a Change Fund, (attached to the ‘Reshaping Care for Older People’ Strategy), to enable health, social care and third and independent sector partners to implement local plans that seek to making better use of their combined resources for older people’s services and change the way in which we deliver health and care services.

It's about care for the elderly (or at least it was to begin with), scarce resources and "change":

In order to provide safe, effective, person centred care and communicate the same throughout the Multi Disciplinary and Partner Agency Teams, we must change the way in which we all record, share and thus communicate patient care.

Information is key:

Understand the need for pace. This challenge is not in the future, it is now. We are already starting to see and feel the effect of the predicted demographics, disease profiles and financial pressures in the system. Again, contrary to the way in which we traditionally apply service improvement we need to find new ways of quickly gaining momentum and escalating the pace of change. We need to do this by re-imagining ways of introducing, scaling up and rolling out change across complex systems that cross organisational and professional boundaries.

It is urgent and radical:

Make difficult decisions. In order to transform services, ultimately, ‘difficult decisions’ will need to be made. Difficult decisions include a service reduction or change that will have a significant impact on people or groups of people, major reduction or cessation of an established clinical procedure/treatment due to new evidence or application of thresholds, a service reduction or change that is or may be controversial..

It will involve "difficult decisions". Exactly what difficult decisions are is unclear. One thing we can be sure of, they are difficult because they are not freely consented to and endorsed by those most directly affected.

So the components of GIRFEA are familiar enough: early intervention, explicitly seeking cost savings, and operating a change agenda.

There are signs that "small tests of change" and other Deming management techniques borrowed from manufacturing will be employed. Most strikingly we have the "single point of contact" and the use of wellbeing as the defining metric, all borrowed from the disastrous GIREFC agenda.

What does this combine to create? It is too early to be certain. The GIRFEC approach was rolled out across the whole of the public sector in this fashion. A few, such as the Home-school community, sounded the alarm but generally people did not know what was being installed. Only when there was an attempt to commit the process to legislation (and to use force of law to compel compliance) did the full horror of the scheme become apparent. We now know that an explicit decision was taken to install GIRFEC in all of the professions – teaching, healthcare social-work etc - before telling the people. It seems that Getting It Right For Every Adult is likewise being deployed by stealth

The justification for change is the manifest failure of the existing system. Twelve percent of patients decline in ADL function (Activities of daily living, a term used in healthcare to refer to people's daily self-care activities) between admission and discharge. Delirium after admission runs at 4-29%. 500 patients per year fracture a hip in hospital in England and Wales. The hospital acquired infection rate is between 5-10%. There is one or more adverse drug reaction in 19% of inpatients. And always and everywhere the unaffordable nature of the welfare state creates financial pressures that demand urgent action.

The direction of this change is being set in secret. It does not allow people a chance to make an informed choice and ultimately it treats those people, be they children, the elderly or perhaps all adults, not as a customer to be served but as a product to be improved. This is the core error in thinking; the collectivist mindset at work, This is what is likely to turn GIRFEA, as it grows, into a monster every bit at threatening to human thriving as the hideous GIRFEC from which it has spawned.

And we must be watchful for remember how Max Weber praised the civil servant:

'The honour of the civil servant is vested in his ability to execute conscientiously the order of superior authorities, exactly as if the order agreed with his own conviction. This holds even if the order seems wrong to him and if, despite the civil servant's remonstrances, the authority insists on the order'. This kind of behaviour means, for a civil servant, 'moral discipline and self-denial in the highest sense'.

So there will be no resistance from within the system. As we saw with The Children and Young Peoples Act which brought in the Named Person Scheme, there will be little help from political sources. It will be up to the people to slay whatever comes over that hill.


Main image: WorldSkills UK (CC BY 2.0)