Intermediate Care

On 11 March 2009 I attended a conference sponsored by Department of Health and attended by commissioning officers from across Britain, and afterwards wrote the following.

Thank you for inviting me to this fascinating day. My apologies for the length of this but the subject is critically important. There is the following structure to what follows.

• About me
• About my understanding of this subject

The following contains information I have copied and pasted over the years from various sources and is not formally referenced.

About me

I have nearly forty years experience of health, social, and housing services with local authorities, hospitals and housing. My first degree is in Social Administration from the University of Manchester and includes a Diploma in Social Studies. I am a Fellow of the Chartered Institute of Housing and I have an MSc in Urban Policy from South Bank University. I got a distinction for my housing dissertation Ecosystems, Shelter and Society and my MSc dissertation was about quality systems in Housing Associations. As I am nearing retirement I am considering a part time PhD looking at disability and design.

I am the former chair of a Housing Association and have worked as a senior manager in a Housing Association. I proved to a Social Security Appeal Tribunal that a married couple was not a married couple for benefit purposes. I have managed both residential and sheltered schemes for older people including those with very high dependency, including Alzheimer’s, learning difficulties and enduring mental health problems, and been involved in detailed change management processes.

I understand care homes, nursing homes and hospitals to be total institutions like nuclear submarines and therefore their only justification is on a temporary basis or in extremesis. The phrase feeding the beast is justified.

My understanding of institutions is informed by Goffman and Macpherson. I had not realised Nightingale had made similar comments, but thinking about it this is a critical enlightenment issue of freedom, justice, power and equality. When Adam delved and Eve span, who was then the gentleman? There is in fact a strong argument to extend the philosophy of intermediate care into the criminal justice system and prisons and all examples of institutional behaviour.

I would wish to see a key measure of directions of travel being away from institutional solutions through deregistration, closing of homes, moving towards popp models. A key measure must be do the systems enable equality, participation and co-operative emergent behaviours – together we solve. Budgets must be joined up across organisations as a basic starting point. Integrated systems cannot be achieved if it is not possible to define clearly where the money is going – follow the money!

I will never forget a Housing Association sheltered scheme with an identical wing that was registered as a care home. If someone was deemed to need a certain level of care they were actually moved from an identical flat to another in another part of the same scheme – and no one realised there may be a problem or two with that!

Of course the issue may be with the NAA 1948 which as I understand it means anyone with any care needs must be in a registered care home!

I am hard of hearing and probably undiagnosed dyspraxic and on the high functioning Aspergic continuum. My sister in law – a Health Visitor noted the fact that I walk on my toes is a symptom of learning difficulties!

The phrase “nothing about us without us” is very valuable.

I have experience of:

• Strategic and change management, business planning, risk analysis, quality, audit training
• Sustainable neighbourhood management and renewal
• Residential care and supported housing, young offenders and family social work
• Supporting people, disability law and Welfare Rights, need and resource assessment

Governance

Twelve years ago now at the dawn of the Labour Government, Demos wrote in Holistic Government:

“The core problem for government is that it has inherited from the nineteenth century a model of organisation that is structured around functions and services rather than around solving problems.

Budgets are divided into separate silos for health, education, law and order and so on.

The vertical links between departments and agencies in any one field and professional groups such as the police, teachers, doctors and nurses are strong.

The horizontal links are weak or non-existent.”

The Audit Commission has noted three common weaknesses:

• A lack of integrated planning and decision making
• A tendency to give a low priority to the housing aspects of community care
• Operating reactively

(Home Alone)

A life like yours

Asked what he wanted from his social worker one disabled man replied:

‘I want a life like yours. One where I don’t have to battle every day to get the basic things done. A life where I can do the fun things in life not just bump along the bottom all the time. ’

Social Services Inspectorate Annual report

What is to be done?

Leading Change summarises the issues excellently:

How can organisations fit to house the human spirit be created and sustained such that they meet the needs of individuals, communities and society at large?

They discuss in depth whole system working, but first I wish to look at the law.

The Disability Equality Duty

The aims of the law are:

• To take action before discrimination occurs
• Not just fairer but better public services
• Should be proper continuing engagement well beyond consulting about what you were going to do
• Across impairments and ethnicities.

The Office of Disability Issues is responsible for driving forward Equality 2025. There is a clear duty of reasonable adjustment – have to do something positive.

They are creating a cultural shift in the way public sector thinks about disability. The positive duty to promote equality – general duty – due regard – means treating disabled people more favourably.
It is a legal requirement to involve disabled people from first principles. (For example, the hotel we met in is very poor in terms of accessibility and should not be used by government bodies)

Every 3 years each Secretary of State is to report across their “policy sector”. I would wish to be involved in the disability equality impact assessment of this refresh.

The Courts have set out the general principles:

• Must be aware of the due regard duty
• Conscious approach
• Must be exercised in substance and with rigour
• Not delegatable
• Continuing duty
• Adequate record

The Disability Equality Impact Assessment is critical.

Judges are saying all public authorities including Central Government departments, the NHS and local authorities will be called to account that they are taking into account the Disability Equality Duty.

This culture shift is hugely ambitious – equality is at the heart of how public sector does business. The Disability Equality Duty is for life, not just for Xmas!

There is extremely patchy implementation – a stock transfer lost £90million because got 2 stars because of weak Disability Equality plan.

Why?

Ideological reasons – Public bodies still do not understand this – see it as an add-on, something they have to do.

Not seen as one of the key ways to improve services and engage communities.

Operational reasons

Public duty does not yet fit into the performance framework so becomes add on. Measurement systems must also prove they are enabling.

Meaning of participation

What does involvement mean? Change from paternalistic to working together attitudes

Knowledge

Equality impact assessments are the key tools to drive the public duty. Must be part of training of every public officer. There is not enough access to good practice.

Procurement

It is critical to encourage public bodies to work together to implement the duty.

The Equality standard for local government in April is tied closely to the local government performance framework.

Failure to carry out an equality impact assessment

R (Kaur) v London Borough of Ealing the High Court has ruled that Council acted unlawfully in failing to carry out a racial equality impact assessment of a change to its policy on the provision of financial support to organisations dealing with domestic violence.

The implication of this judgement is that a decision that is made without first having carried out a proper equality impact assessment may be quashed and declared legally null and void.

Whole Systems

How can organisations fit to house the human spirit be created and sustained such that they meet the needs of individuals, communities and society at large?

Many organisations are still based on machine like and territorial assumptions where:

• Change is equated with restructuring, with the attendant dangers of moving the chairs around the deck of the Titanic and, in the process, setting back progress to improve services;

• Managerial attention is focused on internal silos to the detriment of a coherent approach to stakeholder needs;

• Territory is defended against the demands or wishes of partners and residents, and even against the ‘unreasonable’ demands of staff;

• The attention span is short and of the ‘let’s fix it’ variety, rather than taking a longer-term and sustainable view.

Such organisations are not usually populated by bad or even incompetent people. People, we believe, are the product of the circumstances, the system, in which they find themselves. Firing the key people will not change these design assumptions; equally, developing individual competencies alone will not change the way things work.

On the brighter side some people and organisations are:

• Working creatively with local residents to improve services;

• Asking different questions about ways of organising that support improved delivery

• Seeing structural change as only one ingredient of sustainable development; putting greater emphasis on learning from experience – individual, team, intra- and inter-organisational – and taking action as a result

• Trying to take a longer-term view, while at the same time understanding the imperatives, particularly from the government, about shorter-term improvement.

This is not comfortable territory. The notion of organisation as machine gives a superficial, and illusory, sense of control and action that fits with our task-fixated culture of performance targets and indicators. Equally, organisation development approaches have implicitly emphasised the notion of single organisations with clear territory and well-defended walls.

The landscape we chart here is more uncertain, being composed of phenomena that cannot be reduced to simple cause and effect. It also requires a capability to work with paradox and a tolerance of ambiguity. Magic bullets or quick fixes will not deliver change.

Given a sense of humility, a willingness to listen and learn, and the other values we advocate, they can provide an antidote to the sorts of action hero performances sometimes erroneously equated with leadership. Public learning, working with diversity and finding ways of meeting differently all encourage the development of processes that will bring people together across the barriers and boundaries of organisations and communities. Follow-through emphasises the need to see whole systems development as a long-term process of change whose path can be mapped by the sketching of

‘change architecture’

Ten core values in whole systems development

(1) Optimism – that people and organisations have the capacity to learn and the commitment to tackle dilemmas and intractable ‘problems’.

(2) Empathy and humility – in the face of the tough challenges faced by those who are charged with, or voluntarily take on, a whole systems development agenda.

(3) Tenacity and courage – to question assumptions and current ways of working.

(4) Learning – putting learning at the heart of what we do and a recognition that it is as important to honour what is and what works as it is to encourage new ways of thinking and acting.

(5) Relationships – that are founded on the pursuit of mutual understanding and preparedness to negotiate, sharing learning and experience from elsewhere and working through problems.

(6) Whole system perspective – resisting fragmented and ‘one size fits all’ approaches and seeing organisational and community issues within the wider environmental context.

(7) Local knowledge for local solutions – a bias towards the use of local knowledge, held by individuals, communities and organisations, to create locally invented solutions.

(8) Building social capital – an active appreciation of the personal qualities and experiences of the people with whom we work and a determination to involve them in designing processes that will strengthen learning and build capacity and social capital.

(9) Celebrating small steps – a welcoming of the small improvements that demonstrate the practical posssibilities and potential for learning in whole systems development.

(10) The long view – being there for the long haul rather than the quick fix.

There are interesting issues of language – arguably the terms “service user” and “broker” belong to the discriminatory institutionalised siloworld.

Emergence

All theories of organisation and management are based on implicit images or metaphors that lead us to see, understand and manage organizations in distinctive yet partial ways … the use of metaphor implies a way of thinking and a way of seeing that pervade how we understand our world … One of the most basic problems of modern management is that the mechanical way of thinking is so ingrained in our everyday conceptions of organization, that it is often very difficult to organize in any other way.”

The basic problem with these metaphors when applied to a complex adaptive system is that they ignore the individuality of agents and the effects of interaction among agents. Or worse, they simply assume that all this can be tightly controlled through better (read: more) specification. While there are many situations for which the machine and military metaphors might be useful – for example, routine surgical processes – there are also many situations for which these metaphors are grossly inadequate. When we view our system through the lens of complexity, we take on a new metaphor – that of a Complex Adaptive System CAS – and, therefore, are using a different model to determine what makes sense for leaders to do.

To see life as a whole – to observe what all life has in common – requires a shift in the way we normally look at things. We must look beyond the individual insect or tree or flower and seek a more panoramic perspective. We need to think as much about process as we do about structure. From this expanded viewpoint, we can see life in terms of patterns and rules. Using these rules, life builds, organizes, recycles and recreates itself.

Build a good-enough vision

Provide minimum specifications, rather than trying to plan every little detail.

Since the behavior of a CAS emerges from the interaction among the agents, and since the detailed behavior of the system is fundamentally unpredictable, it does little good to spend all the time that most organizations spend in detailed planning.

Most organizational leaders have participated in very detailed planning, only to find that assumptions and inputs must be changed almost immediately after the plan is finalized. Complexity science suggests that we would be better off with minimum specifications and general senses of direction, and then allow appropriate autonomy for individuals to self-organize and adapt as time goes by.

The principle of min specs [minimum specifications] suggests that managers should define no more than is absolutely necessary to launch a particular initiative or activity on its way. They have to avoid the role of ‘grand designer’ in favor of one that focuses on facilitation, orchestration and boundary management, creating ‘enabling conditions’ that allow a system to find its own form.

In contrast, we often over-specify things when designing or planning new activities in our organizations. This follows from the paradigm of “organization as a machine.” If you are designing a machine, you had better think of everything, because the machine cannot think for itself. Of course, in some cases, organizations do act enough like machines to justify selected use of this metaphor. For example, if you are having your gall bladder removed, you’d like the surgical team to operate as a precision machine; save that emerging, creative behavior for another time! Maximum specifications and the elimination of variation might be appropriate in such situations.

Most of the time organizations are not machine-like; they are complex adaptive systems. The key learning from the simulations is that in the case of a CAS, minimum specifications and purposeful variation are the way to go. This principle would suggest, for example, that intricate strategic plans be replaced by simple documents that describe the general direction the organization is pursuing and a few basic principles for how the organization should get there. The rest is left to the flexibility, adaptability and creativity of the system as the context continually changes. This, of course, is a frightening thought for leaders classically trained in the machine and military metaphors. But the key questions are: Are these traditional metaphors working for us today? Are we able to lay out detailed plans and then just do it with a guaranteed outcome? If not, do we really think that planning harder will be any better?

“Managers therefore cannot form a vision of some future state toward which the business can be moved; the futures open to the system are too many, and the links between a future and the actions leading to it are too obscure. Chaotic dynamics lead us to see strategy as a direction into the future that emerges from what managers do. In chaotic conditions, strategy cannot be driven by pure intentions. Instead, it represents the unintentional creation of order out of chaos.”

Again, we can look to biological sciences for a dramatic illustration of this principle. Dr. Ary Goldberger is a cardiac specialist at Harvard Medical School who has done much research in the role of complexity in physiologic systems such as the beat-to-beat record of a healthy heart. It shows an irregular, wrinkly appearance – not a smooth, regular tracing. Furthermore, when this tracing is magnified, there is even more wrinkly detail. This complex pattern of irregular fluctuations is a fractal. Surprisingly, if you were to view an equally detailed heart-rate tracing of a patient before cardiac arrest, you would probably not see more chaotic activity, as you might expect, but rather virtual consistency and regularity. Thus, predictable and regular activity can lead to a heart attack; unpredictability and fractal (chaotic-like) variability are associated with health and stability. (Note that this pattern can also be observed in other biological systems: in sleep, chaotic patterns have been shown to produce restful sleep and extreme regularity may indicate a coma; and in muscles, chaos indicates healthy functioning and stability indicates seizure or degenerative disease.)

Of course, the trick in a human CAS lies in gauging the “right” amount of information flow, diversity, connectivity, power differential and anxiety among the agents. Since the predominant metaphors of organizational life are those of a machine and military operation, most organizations today have too little information flow and diversity, and too much power differential.

You can have more – or less-correct intuitions, and some sense of general direction, but that’s inherently the best you can do. You’ll just have to try tuning up or down the various factors and reflect on what happens.

Reflection

Reflection is a key skill for anyone in a CAS. Good leaders in a CAS lead not by telling people what to do, but by being open to experimentation, followed by thoughtful and honest reflection on what happens.
Uncover and work with paradox and tension.

Do not shy away from them as if they were unnatural. Because the behavior of a CAS emerges from the interaction among agents, and because of nonlinear effects, “weird” stuff seems to happen. Of course, it is only weird because we do not yet have a way to understand it.

In a CAS, creativity and innovation have the best chance to emerge precisely at the point of greatest tension and apparent irreconcilable differences. Rather than smoothing over these differences – the typical leadership intuition from the machine and military metaphors – we should focus on them and seek a new way forward.

An organization in which tension and stresses are quickly smoothed over or even denied is one that isn’t learning or adapting very efficiently. Consider an organization embroiled in internal conflict over some kind of change, in which one group wants radical change and the other is holding steadfastly to the status quo. There may be a temptation for leaders to compromise, try to deliver to both groups, or prematurely stand by one position while discounting the other. How might you work with paradox and tension in this case? The approach one leader took was to mix the two warring factions (the “radical change” people and the “status quo” people) into a single group and give them the task of finding a “radical way to hold on to the status quo.” This is a paradox; it makes no sense according to the prevailing mental models.

However, working on it placed the group at the edge of chaos and increased the likelihood that creative approaches would emerge. Here are some other paradoxical questions to consider. Can you think of others that are relevant to your context?

• How can we give direction without giving directives?
• How can we lead by serving?
• How can we maintain authority without having control?
• How can we set direction when we don’t know the future?
• How can we oppose change by accepting it?
• How can we accept change by opposing it?
• How can a large organization be small? How can a small one be large?
• How can we be both a system and many independent parts?

Another way to uncover paradox is to ask “wicked questions.” These are questions that have no obvious answers, but expose our assumptions. For example, in an organization that was trying to build a more-enabled environment, one leader asked, “Are we really ready to put responsibility for the work on the shoulders of the people who do the work?” Perhaps you can sense the discomfort in such a question. But challenging the sacred cows is an activity that can put you at the edge of chaos, and begin to reveal the hidden assumptions.

Go for multiple actions at the fringes, let direction arise.

You don’t have to be “sure” before you proceed with anything. In a CAS it does little good to plan the details. You can never know exactly what will happen until you do it. So, allowing the flexibility of multiple approaches is a very reasonable thing to do. Of course, such a flexible approach is unreasonable when we view the situation through the metaphor of a machine or military organization. A machine can work only one way, and an old-style military organization must follow procedures and regulations.

“A healthy fringe speeds adaptation, increases resilience and almost always is the source of innovations.”

When we do find ourselves in situations far from certainty and agreement, the management advice contained in this principle is to quit agonizing over it, quit trying to analyse it to certainty. Try several small experiments, reflect carefully on what happens and gradually shift time and attention toward those things that seem to be working the best (that is, let direction arise). These multiple actions at the fringes also serve the purpose of providing us with additional insights about the larger systems within which every system is inevitably buried.
“Successful experiments can go a long way in creating a foothold in a new reality. In particular, they offer important insights on the feedback loops and defensive routines that sustain a dominant attractor pattern and what can be done to help a new one to emerge.”

Listen to the shadow system.

Realize that informal relationships, gossip, rumour and hallway conversations contribute significantly to agents’ mental models and subsequent actions.

Every organization actually consists of two organizations: the legitimate and shadow systems. Everyone in an organization is part of both. The legitimate system consists of the formal hierarchy, rules and communications patterns in the organization. The shadow organization lies behind the scenes. It consists of hallway conversation, the grapevine, the rumour mill and the informal procedures for getting things done. Most traditional management theory either ignores the shadow system, or speaks of it as something leaders must battle against (as in, “overcome resistance to change” – it’s that military metaphor again).

Because the shadow system harbours such diversity of thought and approach, it is often the place where much of the creativity resides within an organization. While the legitimate system is often focused on procedures, routines and the like, the shadow system has few rules and constraints. The diversity, tension and paradox of these two organizations that coexist within one can be a great source of innovation if leaders could just learn to listen to, rather than battle against, the shadow.

One health care executive entered the shadow system when he joined a group of doctors and nurses talking in the cafeteria one day. He was so fascinated by their discussion of improving the process for delivering anti-coagulants, he soon became part of this underground ad-hoc team. In doing so, he quietly sidestepped the difficult, formal process for approving quality improvement projects instituted by the hospital. The resulting work was so successful, it led to a close re-examination of the approval process that had been unintentionally discouraging such innovation.

When we see our organizations as CASs, we realize that the shadow system is just a natural part of the larger system. It is simply more interconnections among agents, often stronger interconnections than those in the legitimate system. Leaders who lead from an understanding of CASs, will not have a need to discredit, agonize over, or combat the shadow systems in their organizations. Rather, they will recognize and listen to the shadow organization, using the interconnections it represents as another avenue for tuning information flow, diversity of opinion, anxiety, and power differential.

Grow complex systems by chunking.

Allow complex systems to emerge out of the links among simple systems that work well and are capable of operating independently.

Who built the Internet?

No one. Not Bill Gates or any other computer genius. The Internet is our most visible and oft-cited example of emergent phenomena, an elegant case study of how a complicated and vastly diverse system can self-organize … in this case, almost overnight. On close examination, we see that the Internet evolved in chunks – like a set of building blocks – with components being integrated into the system only after they had been individually refined, proven and accepted by a collective, systemic jury.

Complex systems are … well, complex. They are not easily understood or built in detail from the ground up. Chunking means that a good approach to building complex systems is to start small. Experiment to get pieces that work, and then link the pieces together. Of course, when you make the links, be aware that new interconnections may bring about unpredicted, emerging behaviors.

“A scan of history shows that technical innovations almost always arise as a particular combination of well-known building blocks. ”

Applying this principle to teambuilding in a mid-sized organization, for example, would suggests that leaders should look for and support small natural teams. We might provide coaching and training for these teams. Then, when these teams are functioning well, look for ways to get the teams to work together and involve others. These new links may result in weird behaviour; with a CAS, this is to be expected. The leaders should be open to doing some adapting of their own. Rather than insisting on pressing forward with the training, ground rules, or procedures that worked so well in the first teams, the leaders should understand that the interconnections among teams has resulted in a fundamentally new system that may need new approaches.

Continual reflection and learning are key in building complex systems. You cannot reflect on anything until you do something. So start small, but do start.

Mix cooperation with competition.

It’s not one or the other.

Nature competes. If you have ever glimpsed a lion stalking and devouring an elk on a PBS program before quickly changing the channel, you know this to be true.

Nature cooperates, too. Observe members of an ant colony working together to produce intricate ant-mound societies.

These dynamics are not mutually exclusive. Natural and biological systems display both cooperation and competition. And so can corporate, business and sociological systems.

A good leader would be one who knows how to, and prefers to, cooperate, but is also a skillful competitor when provoked to competition (that is, a nice, forgiving, tough and clear person). Note that this strategy rejects both extremes as a singular strategy. While much is said these days about the importance of being cooperative and positive-thinking in business dealings, the always-cooperative leader may find his or her proverbial lunch is being eaten by others. Similarly, while sports and warrior metaphors are also popular in some leadership circles, the always-competitive leader may find himself or herself on the outside looking in as alliances are formed.

Conclusion

Our existing principles of leadership and management in organisations are largely based on metaphors from science that are hundreds of years old. It is time that we realized that science itself has largely replaced these metaphors with more accurate descriptions of what really happens in the world. Science is replacing its old metaphors not because they are wrong, but because they only described simplistic situations that progress has now moved us well beyond. Similarly, our organisations today are not the simple machines they were envisioned to be in the Industrial Revolution that saw the birth of scientific management. Further, people today are no longer the compliant “cogs in the machine” that we once thought them to be. We have intuitively known these things for many years. Management innovations such as learning organizations, total quality, empowerment and so on were introduced to overcome the increasingly visible failures of the simple organization-as-machine metaphor. Still, as we have pointed out, the metaphor remains strong.

The emerging study of complex adaptive systems gives us a new lens through which we can now begin to see a new type of scientific management. This new scientific management resonates well with more modern, intuitive notions about what we must do to manage increasingly complex organizations today. More importantly, the new thinking in science provides a consistent framework to pull together these heretofore intuitive notions. Now, for example, advocates of open communications and empowerment can claim the same firmness of ground that advocates of structure and control have been claiming exclusively. Science can now say rather clearly that structure and control are great for simple, machine-like situations; but things such as open communication, diversity and so on are needed in complex adaptive systems – such as those in modern organizations. The new scientific management will, no doubt, revolutionize organizations in the coming decades much as the old scientific management changed the world in the early decades of this century.

All Components of Edgeware Principles Copyright © 2000, Curt
Lindberg, Complexity Management, VHA Inc. Permission to copy for educational purposes only. All other rights reserved.

Whole Systems Thinking

Systems thinking, much of it derived directly from Deming, fundamentally challenges the management attitudes that he regarded as outdated in the 1950s yet which still underpin the prevailing wisdom that targets, incentives and managing the performance of people are the main levers of improvement.

Systems thinking challenges the notion that thinking can be separated from doing; that good ideas about re-designing for improvement can be arrived at remotely by superior brains and that improvement can then be delivered by using ‘carrots and sticks’ to make people do what is required.

Systems thinking embodies a number of key concepts, including:

• Improvement has to start with understanding what the individual customer/user wants – in their terms

• There will be variety in what customers/users want – especially in relation to services

• An effective production or service delivery system must be capable of absorbing variety and changes in what customers/users value

• What the customer/user wants constitutes what is of value to them – they must be the arbiter of value

• An efficient and successful production or service organisation must focus on delivering only individual customer/user value

• To deliver only customer/user value, a production or service organisation must be able to view and understand its own system “end to end” – from the customer/user’s perspective

• The system can, and often does, extend beyond the immediate organisation

• Only those activities and parts of the system that are essential to delivering customer/user value constitute “value work” – everything else is waste

• Any failure to do things right first time tends to create waste in the form of “failure demand” e.g. repeat user contacts or repeated processes that consume available capacity

• Simple is best – complexity tends to create waste

• The people working inside the system, especially the people working closest to the customer/user, are best placed to identify waste and potential improvements

“The performance of anyone is largely governed by the system that he works in.”
Deming From Vanguard Consulting and Advice UK.

Summary

Wigan is an excellent example. Dorset’s mapping of services is very valuable.

http://www.wiganpopp.org/

I would wish to see local and regional co-operative structures evolve. Existing institutions like the government offices and strategic health authorities must move away from checking performance of their “junior” partners to enabling and solution orientated roles.

In fact, the whole idea of external audit is old fashioned management and quality thinking – the quality manager at the end of the production line – in comparison with – are we working excellently with our partners is the responsibility of every partner – the auditors need to move to an enabling learning role. The audit and quality systems are also hierarchical and institutionalised!

The law in the areas of Community Care, Housing, Equality, Disability equality impact assessments and natural justice is very interesting and is very likely to force significant change, but really everyone should be mapping the local issues together from an explicitly person centred perspective. What is your local ecosystem? What does it cost?

If we are not careful we will achieve pretty silos.

Where is the complete system redesign on extra care, care and repair, Disabled Person’s Housing Service, community staff models with explicit strategies to close nursing and care homes except for clear temporary use? Is emergence embedded? Are services citizen led, participatory, open, equal, based on the social model of disability?

Do we know the costs of decisions – track the life time costs of putting someone in hospital, then nursing home. What are the costs of alternative pathways? The Japanese are retiring to the Philipines because they have surplus trained carers and good services at low costs. May I use my individual budget anywhere in the world? Why not?

What is the WHO definition of health?

Are the structures enabling not suffocating?

Nancy

Nancy is 19 and has lived in residential homes since she was 4. Nancy has many labels:

• Physical disability
• Learning disability
• Challenging to support

Nancy needed to move on. Nancy agreed to try person centred planning and decided to involve her parents, her grandmother, three of the six support staff, one ex support worker who she is still in contact with, the home manager and one of her friends from college.

The meeting was amazing, Nancy had thought really carefully about what she wanted. She told us about having her own house, about how she could have friends to visit, about where she would work. Everyone was really impressed by Nancy. She seemed to have thought about everything. She had realised that she would need staff to assist her and so she wanted to know how to work out rotas. She wanted to learn how to iron, she wanted a social life which had nothing to do with disability, a boyfriend, and a job.
This doesn’t sound unusual for a woman of 19 but was unusual for someone with Nancy’s labels. Nancy’s parents were thrilled that she was so competent and had a plan although some elements of it scared them!

Nothing much seemed to happen after that, for a few weeks people helped Nancy to work on learning what she wanted and she started looking for a job but then people slowed down. No one has been looking at housing with Nancy, no one has helped her meet up with her social worker about funding. Staff have been saying that Nancy’s expectations are too high and now, nine months later, people, not those at the meeting, are starting to wonder if Nancy can live alone because she is more challenging in her day to day relationships with staff. It may seem as if the planning did not help change to happen.

Did change happen? It’s an interesting question because I think it did. In the room at the time of the planning people saw Nancy differently and she too saw herself differently, she believes she is worthwhile and she has a dream about having her own home and she is not going to give up on that. The service has not changed to meet Nancy. The people in the service are not bad or being difficult they just don’t know the next step and how to treat this changing and growing young woman. They don’t know how to help Nancy get a social life, or to alter their service enough to offer what Nancy wants. I asked Nancy what she thought? She’s glad she planned but is frustrated with people not acting more quickly, she can’t understand why some simple things like going to the pub get complicated. But at least she now thinks that she can and should go to the pub. Her grandmother has asked the staff to meet again and review progress on the plan, so something has changed for Nancy’s family, they perhaps feel more empowered to intervene on her behalf. So from the outside little has changed but the small changes that have started cannot be reversed and will, over time, cause more change to happen.

The issue now might be how can we help the organisation change faster so that Nancy does not have to wait for them to catch up with her. What changes will result are not predictable. Families and people who use services often begin the process of change more quickly than service providers after person centred planning. (JRF)

Bridging the Gap

I don’t lie in too late. I get up about half past twelve. I get up and walk round to Kathy’s house. She’s my mate. She has a wee baby so sometimes I help her with the shopping.

Most times I watch TV or go to someone’s house and just hang around. In three months time I’ll probably be doing the same thing.Work experience was only for the teacher’s favourite kids. They didn’t want anyone doing it who might show the school up. You need money to support yourself. If you travel to Leeds, half your wage is gone on buses.

Unintended Consequences (2007)

The Government’s efficiency drive is undermining the pursuit of effective public services… based on… assumptions or myths about how to create efficient public services.”
New Economics Foundation

The commissioning and funding methods being adopted by central and local Government would not achieve better advice services:

“In our view, the top-down approach to achieving the objective of improved access to integrated advice and legal services is fundamentally flawed.

We expect it will lead to unnecessary disruption, waste and… a poorer service to the public. In our view, service design should be “front-to-back” and it must involve the people who are providing the service.

Vanguard was founded in 1985 by Professor John Seddon, an occupational psychologist.

http://www.systemsthinking.co.uk/home.asp

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One thought on “Intermediate Care

  1. Nice piece – your comments about the delivery of public services echo exactly my experience of working with Vanguard in that space. Nancy not only needs person-centred planning, but person-centred work design as well, everything (including the money) flowing from what Nancy needs to make progress. To do that organisations everywhere need to unlearn the flawed assumptions that govern them before they can relearn better, systems ideas.
    JC

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