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The thermostat in the system. Can Local Authorities learn anything from systems thinking?

I can’t make up my mind whether this title appears tedious or stimulating.

Nonetheless, the ideas proposed under the title in a systems thinking approach to social care could actually be very exciting.

 

Provision of social care in Kent has conventionally been strictly top-down driven activity. A budget was set and contracts would be tendered on the basis of standards to be achieved, measurements to be reported upon, activity to be strictly avoided and all of this interaction with our fellow citizens to be based upon an assessment of need calculated through matrices which very quickly would cease to respond with any alacrity to real, varying client need.

Judgements relating to compliance would then be made by representatives of the local authority who would only infrequently have contact with the client. Sometimes experienced care managers would recognise that social care providers knew their client, their client’s family, the nature of the client’s disability, the neighbourhood and the local resources much better than they did. As a consequence an experienced care manager would very frequently permit and even encourage the social care provider to do whatever was necessary in order to improve the client life experience.

However, it’s unfortunate that the opposite has also often occurred to very great detriment of our clients’ well-being. Preoccupied with management protocols and budgetary driven anxieties, some care managers would present as the omniscient professional and demand action or restriction of action which social care providers knew with certainty would lead to deterioration and, very likely, much greater contingent demand upon other costly public services.

Of course, the development of such a contractual arrangement ina the first place was subject to the normal consultation process. Avondalecare have long understood that this type of commissioning, whilst it offers a sense of control to budget holders and commissioners, undermines the insightful use of innovation and saps the energy of those who truly want to make a positive difference - the art of making things work in the way that the client desires it to work.

Underpinning this philosophical dislocation of client need from local authority provision has been the concept of “time and task“. Unresponsive to social care providers during the consultation process and their pleading for some practice latitude, time and task, target driven commissioning would have been catastrophic had it not been for the ability of some case managers, social care providers and service users along with their families finding ways to make a dysfunctional system less dysfunctional.

John Seddon encapsulates the problem:

"Subcontracting care organisations are paid per hour of provision, so there is no incentive to reduce amounts of care. Local Authority managers operate with the assumption that the subcontractors can’t be trusted, so resource is allocated to control and inspect their work. This not only adds to costs, but also prevents contractors being treated as part of the system. Care workers should be a useful source of information - the thermostat in the system. But because the contract is based on hours worked, not the degree of independence/improvement achieved (and assessment is deemed to be the province of local authority staff), improvement is not the focus."

Feeding the machine

As currently constituted it is the system that stands in the way better adult care because it is designed as a bureaucracy to feed the machine, not as a service to meet people’s needs. 

Seddon states the ‘regime constrains the method. It is a bureaucracy of call centres, functional specialisation, activity targets, budget management, form filling and counting, designed according to the requirements of the regime.

The result is the consumption of resources to feed the reporting machine, instead of doing the value work’. 

Adult social care is crying out for experimentation with method to find out about what works and how to account for all needs, not just substantial and critical ones. However, it is noteworthy that mental health provision is severely impacted by low volume but high cost service provision (especially with out of area services). There are effective approaches which can diminish the costs attributed to these relatively few service users.

There is benefit if a different approach is adopted in respect of both modest and substantial needs. This ought to be about value and values-based commissioning. The JCPMH state something about cost and value. What our clients want is values in mental health commissioning.

‘The committee conclude that value-based commissioning, maximising outcomes ... is desirable; and return on commissioning investment is a good thing’.

However, they point out that 'this value for money approach goes hand-in-hand with values-based commissioning-commissioning what service users, patients and families think is important -courtesy, company, compassion, information, empowerment and employment - less so than what service providers consider important-equipment, buildings, technology, medication'.

So, let contracting reflect real customer demand and not a wholly unproductive preoccupation with controlling every single activity without the insight to know what really matters.

Listen to and trust your social care providers. Command and control, time and task approaches merely disable and disorientate those who have the greatest levels of insight, fail to improve client and community experience and certainly do not offer value for money or create the sorts of improvements which really ought to be possible.

It is time for a change.

Les Jeffs 
CEO @ Avondalecare Ltd
Board Member @ KICA

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