Skip to navigation Skip to main content

5 Fast-Forwards for Social Care

The fundamental shifts leaders in adult social care need to make to transform the system

Why is it so hard to fix the adult social care system?

The focus of debate about reforming adult social care is often reduced to two key themes: insufficient funding and a lack of integration with the health system.

We believe that this is an unhelpful narrow-framing of the problem. Even if a magic money tree delivered additional financing and it was possible for integration to happen overnight without any unintended negative consequences, this would still not lead directly to a sustainable model of adult social care. While these are both significant issues, resolving them would still not address the inherent complexity within the system.

As this paper will explore, the adult social care system is complex, not complicated; the two are very different, and solutions that are designed for complicated systems cannot produce lasting results in a complex world. In a complex system, inputs do not directly lead to predictable, repeatable outputs and outcomes. Increasing funding for adult social care or making structural changes to increase integration do not therefore automatically result in better outcomes. A different approach is needed.

Strategic challenges

To successfully navigate the complexity within adult social care, our view is that the sector must confront five key strategic challenges:

  • There is no agreed approach for achieving ‘good’ adult social care, despite broad consensus over what the key elements are.
  • Saving money has in some cases become the primary focus, rather than helping citizens live a better life.
  • The quality of frontline practice is inconsistent, with change management activity focussing too much on structures and processes rather than behaviours.
  • Differences between organisations and services can lead to an adversarial culture which keeps service leaders from looking beyond their limited span of control.
  • Service leaders often lack the data they need to make effective decisions.

Seizing the day

Every week, we see headlines and stories about the future of adult social care. There are myriad political, fiscal, social and moral arguments for and against injecting more public funding, and the expectations of an ageing population are high. This is a key challenge of our time, and local government leaders know that while national politicians avoid making difficult decisions, they must plan and deliver a sustainable and affordable service for their local citizens.

As the environment for delivering adult social care services becomes ever more challenging, the risk of not acting now far outweighs the risk of moving forwards despite the political ambiguity. Without action, the ever-increasing pressures on the system will result in a growing number of suboptimal outcomes for vulnerable people.

More positively, it is also the case that the scale of opportunity for reforming the system is enormous: our analysis shows that between 50-70% of support provided by the adult social care system can be prevented, reduced or delayed.

Strong central government leadership and courageous decision making would still be welcome. A long-term funding solution, a clear policy framework, and honest and frank engagement with the electorate all remain important components of delivering a sustainable future for adult social care. Whether the new Prime Minister grips these challenges or not, services will still need to be delivered on the ground by service leaders and frontline staff. Delivering a sustainable future model for adult social care will only happen if those leaders resolve the challenge themselves; they must take the initiative. Many leaders recognise this and have already begun the journey. Others must now join them.

This paper sets out five actions that leaders in adult social care could take in response to these challenges, moving the sector closer to better social care for all who need it within a more sustainable and more affordable system.

Towards a better model

The key elements of good adult social care are not in dispute. Most people working in the sector have a shared vision of what this  would look like, based around:

  • a focus on the person and their outcomes;
  • the person remaining as independent as possible and living in their own home for as long as possible;
  • spending much more on prevention and alternative provision for complex needs, and switching away from residential homes and nursing beds;
  • frontline staff excelling at strengths-based practice, being empowered to be creative and taking positive risks; and
  • organisational interfaces working seamlessly together and not being visible to the person.

Undoubtedly, leaders and frontline staff want to deliver the best outcomes for vulnerable people in their communities, based on the vision above. But their ability to do so is constrained by the current delivery model of adult social care which focuses on service and budgets rather than on the person and their outcomes. And while many people agree that there is a need to move towards a better model, there is a lack of consensus on the best way to get there.

In IMPOWER’s view, the first – and essential – step is to understand that adult social care is a complex system and therefore requires a different way of thinking that runs counter to traditional approaches.

Understanding complexity

Systems or problems can be complicated or they can be complex. Complicated and complex problems are different from each other, and solutions that are designed for complicated systems do not apply in a complex world.

Building a plane is complicated: it requires expertise and skill, careful planning, and there are many parts and processes. But if you follow the linear instructions you will build a plane that flies, and, while difficult, the process is repeatable.

Public services are entirely different. Even if you use the best available expertise and careful planning, doing the same thing twice, even in the same location, won’t necessarily lead to the same outcome. Power is distributed, meaning both that no single organisation or individual has complete control and that many people exert influence over the actions of others. Small decisions made by individuals – including the users of public services – skew the outcomes. Taking a linear approach to problem solving in this environment does not work.

Bringing about sustainable change in a complex system such as adult social care is therefore extremely difficult unless those within it recognise the complexity and look at it in a completely different way. It requires solutions that have been co-produced across organisational boundaries. At IMPOWER, we call this EDGEWORK®. EDGEWORK is our unique way of understanding and navigating complex systems, and helping leaders in local government deliver better outcomes  that cost less.

Complexity in Adult Social Care
Logically, the needs of vulnerable people must be addressed by the entire system as they are likely to require the support of more than just a local authority adult social care service to live more independently and fulfil their personal aspirations.

The current  model does not reflect this reality. The adult social care system is set up to work in silos of individual services with their own defined budgets and statutory obligations. This complexity will be amplified even further over the coming years, by a growing range of new challenges including the disparity between urban and rural areas, the use of robotics and other technology, and the increasing prevalence of complex health conditions.

In this challenging environment, service leaders are often forced to narrowly frame problems and therefore only deal with the aspects of adult social care that they directly control. This is understandable because it provides confidence and certainty which are welcomed by anyone whose decisions affect real people and come with real risks attached. But the consequences of looking inwards rather than across the whole system are poorer outcomes for the public generally and vulnerable people in particular, along with higher costs for the taxpayer.

Making an impact within a complex system requires moving beyond what can be controlled to what can be influenced, as shown in the following diagram.

Children’s services – if young people’s care is not transitioned effectively either into independent living or into adult services, it can lead to long-term high cost placements in adult social care.

Housing – strategies and plans for affordable housing and alternative provision are often not aligned with the needs of vulnerable people. This undermines opportunities to improve independence and reduce long-term placements.

Service Providers – the market is at breaking point because of a relentless focus on unit cost efficiency. Some councils aspire to move towards outcomes based commissioning, but in a complex system this is unlikely to work; providers have limited control over the outcomes achieved.

Health – the challenges here are focused on structural integration and delayed transfers of care. IMPOWER research has highlighted the existence of a trust gap and cultural disconnect between health and social care.

Technology – while the potential benefits are huge, most new technology projects within councils are led from the corporate centre rather than focussing on the needs of a people-based service such as social work.

Voluntary and community sector – under austerity, most councils have significantly reduced investment in local
voluntary and community groups even though they know prevention is better than cure.

Police – the interface with police forces is becoming increasingly critical as they spend more of their time addressing the symptoms of social issues such as mental health and drug and alcohol misuse.

People – the most important interface of all is with the people using the council’s services and carers. Understanding lived experience is not currently given the focus it requires; genuine co-production of new services is very limited.

A new approach for adult social care

The problems within adult social care are clearly not a result of bad intentions or inadequate leadership. Managing complexity is difficult. As set out above, one of the fundamental challenges is that service leaders are required to work across multiple interfaces where no-one has complete authority and where human behaviours and decisions are unpredictable.

Despite this reality, other consultancies working in the sector offer solutions that focus on:

  • Structures (such as target operating models)
  • Processes (operational process efficiency and digital)
  • Technology (new systems and devices)
  • Costs (aggressive performance management)

None of these solutions take into account the fact that the adult social care system is complex. As a result, they are unable to resolve the challenges set out above; while there may be a short-term positive impact, it is not sustainable over time. Ultimately they cost the sector a lot of money but do little to help it deliver better adult social care.

We are therefore advocating a new approach that:

  • Gives service leaders confidence to reach beyond what they can directly control and begin to influence across interfaces and boundaries
  • Shifts the focus onto preventing and managing demand for services rather than simply accepting it as an inevitable part of their service
  • Defines how to measure what ’good’ adult social care looks like, setting clear expectations around “value” – the outcomes achieved for the money spent

Some adult social care services have already taken steps towards this new approach, and there are impressive examples of great practice in some authorities – but nobody has yet successfully met all five strategic challenges set out at the start of this paper.

Reframing the problem: not just money and integration

As set out earlier, the problems facing adult social care go beyond insufficient funding and a lack of integration with the health system. Resolving these issues by themselves would not address the underlying challenges of operating in a complex system.

As a reminder, the five key strategic challenges facing the sector are:

  • There is no agreed approach for achieving ‘good’ adult social care, despite broad consensus over what the key elements are.
  • Saving money has in some cases become the primary focus, rather than helping citizens live a better life.
  • The quality of frontline practice is inconsistent, with change management activity focussing too much on structures and processes rather than behaviours.
  • Differences between organisations and services can lead to an adversarial culture which keeps service leaders from looking beyond their limited span of control.
  • Service leaders often lack the data they need to make effective decisions.

In the second part of this report, we recommend five actions that respond to these challenges.

5 fast-forwards to transform adult social care

There are 5 fundamental shifts that leaders in adult social care need to make to change their systems for the better and create a sustainable model.

1. Reframing ambition

Due to the difficulties of operating in a complex system, service leaders default to working within the boundaries of what they can control through their own individual organisations or services. While this minimises risk, it does not put people first or necessarily improve their outcomes. The ambition of service leaders should be reframed, in order to create the space in which system leadership can occur.

Today – what we frequently see…

While everybody in the system wants to improve outcomes for people, their good intentions are undermined by having to work inside the boundaries of their own organisation or service. Strategies are narrowly framed down to what service leaders believe they can control, and the level of ambition is driven by budgetary requirements rather than a true focus on a person’s needs or outcomes.

Tomorrow – how we think the future state could be…

Service leaders move away from what they can directly control to what they can influence. To facilitate this, they invest time in developing stronger relationships and building trust across different organisations and departments, and use different tools for analysis, governance, direction setting, and for involving people and organisations beyond the DASS’s direct control. They also build an inclusive ambition around value, focusing on the outcomes they can collectively achieve for the money they each spend.

Clear strategic priorities (which recognise the context within which individual organisations are working) are agreed between service leaders. Service leaders commit to supporting the goals of the wider system even if they do not benefit from them directly. Priorities are broken down into meaningful goals for frontline staff that can be tracked on a weekly and monthly basis through the development and use of Primed Metrics.

2. Delivering at the frontline

The success of change in complex systems is largely determined by decisions taken on the frontline where the services are delivered. It is the everyday choices made by staff which cumulatively impact on outcomes for citizens and on the council’s finances. But social workers, care workers and council staff are very unlikely to list ‘saving money’ as a career aspiration: by and large, they chose their profession because they wanted to help citizens in their community live a better life. Delivering sustainable and affordable services at the frontline therefore requires empowering the workforce to focus on outcomes and enabling them to make choices on the basis of both social purpose and system performance.

Today – what we frequently see…

Changing the behaviours of frontline staff to embed new ways of working is critical but challenging. Change overload means that ‘transformation’ is a word met with a level of apathy; some staff think they have seen it all before and often don’t buy into the need to change in the first place. New technology is seen as counter-cultural rather than helpful. The staff who do aspire to improve outcomes are often under pressure due to long waiting lists and excessive caseloads, making it hard to invest time in shaping a new future. Their initial focus is often to provide support so that the person is ‘settled’ or ‘safe’, and care packages are often driven by what is available rather than being tailored to the outcomes being pursued. Once support is in place it can be hard to find time to review the appropriateness of support in a timely manner, which ends up creating dependency, and delivering poorer outcomes at higher cost.

Tomorrow – how we think the future state could be…

Frontline staff understand the need to change in order to deliver a new model for adult social care and recognise the importance of their role in fulfilling that ambition. They are inspired by leadership that works at a system level to improve outcomes. They feel supported and empowered to work creatively and to take positive risks to ensure the best outcomes for the people they are working with. Packages are innovative, unique to individuals and are focused on the person’s goals. Innovative solutions related to housing and technology have been created, and represent a step change in terms of their effectiveness at solving emerging issues. Frontline staff have become digital practitioners and welcome the use of new technology. Transformation is seen as having a positive impact because it frees up staff time to do things differently, and in particular to invest more time in having different conversations with vulnerable people and their carers.

3. Understanding and changing behaviours

For leaders to successfully change culture and behaviours at the frontline successfully, they must recognise and then understand the motivations of staff and the root causes of their behaviours. Behavioural science provides us with vital tools that enable new ways of working to be successfully embedded and sustained over time.

Today – what we frequently see…

System interventions are heavily biased towards a focus on processes, systems and structures, when the crucial elements for driving change are improving the quality and consistency of frontline practice. Designing new systems, processes and operating models is the easier option, but the reality is that these solutions are only effective in complicated systems – not in complex systems. Interventions of this kind can sometimes have a short-term positive impact, but the lack of change in underlying frontline practice as a result of failing to change culture and behaviours undermines their sustainability.

Tomorrow – how we think the future state could be…

The importance of understanding and influencing behaviours is recognised and is applied through all stages of transformation across the person’s journey: within diagnostic work to identify key frontline practice challenges and opportunities; within design work to make sure frontline practice challenges are addressed; and through implementation to make sure that the improved quality and consistency of frontline practice is embedded and sustained. At the frontline, strengths-based practice is the norm and has truly shifted from a conceptual understanding to consistent new behaviour. Council communications with staff and the public use behavioural techniques to improve their impact. All touchpoints across the person’s journey are framed using behavioural science to maximise the positive impact on people’s lives. Staff from service leaders down to team managers understand and influence behaviours to optimise the impact of all change activity.

4. Managing interfaces

As set out earlier in this paper, control and influence are distributed within complex systems, and no single element has complete control over outcomes. Different organisations and services have varying responsibilities, objectives and incentives. This has led to adversarial system cultures and keeps service leaders from looking beyond their limited span of control. Sustainable solutions must therefore cross the boundaries between organisations, people and processes, and manage the interfaces between them.

Today – what we frequently see…

Service leaders in adult social care are inclined to focus on what they can control. Where there is ambition to improve working across the interface of services or organisations, structural changes are the default solution, but don’t have the desired impact. The misalignment of cultures, strategic priorities and operational objectives between services or organisations can lead to adversarial and hostile relationships. This results in services which are not focused on the person, and therefore lead to poorer outcomes and a higher cost to the taxpayer.

Tomorrow – how we think the future state could be…

Service leaders have the confidence to look beyond what they control to what they can influence. They invest time in building relationships and trust across interfaces, are able to work effectively across them, and are proactive and flexible in building inclusive ambition across the system. This has resulted in the co-production of innovative solutions in areas such as housing and technology that are helping to resolve the most critical issues facing adult social care. The outcomes of vulnerable people at a system level are valued above the individual objectives of an organisation or service. Investment is focused as much on improving culture and behaviours as it is on changing structures, systems and processes.

5. Managing trajectories

Successfully delivering and embedding change within complex systems requires a different type of performance management and governance. Solutions to ‘complicated’ problems don’t work when trying to manage complexity, and systems leaders therefore need new types of data and insight which facilitate fundamentally different conversations to those we experience in traditional programme management approaches.

Today – what we frequently see…

Organisations and services attempt to understand the impact of change activity through service and spend data. This data is reported separately and after the event through project status reports, so operational managers are forced into reactive firefighting. Service leaders are exposed to vast amounts of data, which is rarely turned into helpful insights or a coherent narrative. This makes it difficult to make effective evidence-based decisions in real time, and results in the implementation of new interventions that are grounded in anecdote and gut feel.

Operational firefighting also means leaders and staff cannot lift their heads to think beyond the short term.

Performance metrics are focused on activity rather than outcomes. Budgets are often overspent with little understanding of the reasons why. As overspends are hard to explain, it is also hard to predict if they will happen again. There is no understanding of value (outcomes achieved for money spent).

Tomorrow – how we think the future state could be…

There is a focus on outcome productivity – triangulating demand, cost and outcomes data to provide new performance insights. There is a clear articulation of what success looks like and how it is measured, providing
transparency and confidence in the journey towards the future model. There is also a clear line of sight between the strategic vision and the behaviours required of frontline staff.

Leaders are armed with new information in real time, to facilitate fast evidence-based decision making that counters delivery issues before they have chance to escalate. There has been a shift away from reactive project status reporting to proactive approaches such as Trajectory Management and Primed Performance Management.

Adult social care is able to build confidence in the service across the wider system leadership, as they can demonstrate much greater financial and transformational grip. All key roles from the DASS to frontline staff understand how success is being measured and their individual responsibility in delivering it.

What next?

These five actions in response to the five strategic challenges might seem too aspirational, optimistic or unachievable. In our view, that’s the wrong approach. It is not unreasonable to set a solid, achievable ambition and vision, and work to deliver it. Our clients have proven getting this right leads to better outcomes: better outcomes for council coffers and better outcomes for people.

If those working in the social care sector can agree what ‘good’ looks like, work together to reframe ambition, tackle culture and behaviour change (not just redrawing the organisation chart), work collaboratively across interfaces, and take a new approach to management performance in complexity, the benefits would be multiplied. And the sector would have a new model for adult social care.

More money would certainly help. Councils could invest in greater pay for their staff, provide better training, and invest in the provider market to improve quality of care.

They could invest in new types of housing, technology and community services that facilitate greater independence. But even if extra funding was made available, creating a sustainable adult social care system isn’t that simple. As we keep saying, adult social care is complex.

Integration with health has proved too difficult to achieve, continues to deliver poor outcomes, and potentially risks removing the one check and balance between a national health service focused on the system and a local adult social care service with statutory responsibility to focus on the person.

Delivering a new model for adult social care must start by reframing and widening the problem. Service leaders need to acknowledge that they are working within a complex system and move from a position of control to one of influence. They need to come together to build trust and inclusive ambition, take a system-wide view and work across boundaries. The sector must focus on defining good as ‘outcome productivity’ – the outcomes achieved for the money spent – and must ensure that vulnerable people are always at the centre of the system.

Have you started to make the 5 fast-forwards for social care?

Where are you on the journey? A checklist

Some adult social care systems have already made progress towards the five things which need to change, but no area has yet done it all; the checklist at the end of our downloadable report enables you to assess the progress made by your service.

Complete the checklist (or ask us to guide you through it) and we will share some comparative analysis and further insight into your progress compared to the national picture. Get in touch to learn more.

What is EDGEWORK?

Drawing on 20 years of insight and impact, EDGEWORK is IMPOWER’s unique approach which helps our clients understand complex problems in order to solve them. Public services can be effective, affordable and sustainable; the key is understanding complexity.

Many might argue that lasting change comes down to robust business cases, strong project management and clear planning. A traditional approach like this is logical and it gives directors and leaders the feeling that they have control. But year after year, research shows that a majority of change projects fail to deliver their promised benefits.

This is because of an illusion that public services are ‘complicated’, and that they can be controlled if the right processes are put in place. At IMPOWER, we reframe public services as ‘complex’ – non-linear systems, where responsibilities are distributed and where success depends on creating the right relationships across and between system boundaries. This reframing enables our clients to achieve better outcomes at lower cost.

IMPOWER’s solutions are cross-boundary, as the distinctive and game-changing work is done at the edges between organisations, people and processes. We therefore call our approach EDGEWORK.

EDGEWORK comprises a set of defined and flexible inventive methods which are deployed as appropriate to local circumstances. Inventive methods are grouped under five competency areas:

Related content

Read more related content from across the site, including in-depth reports, project case studies and articles.

Setting Inclusive Ambition: why, who and how?

In my current project with a local authority, I have the privilege of working with professionals across Children’s Services, applying…

November 4, 2019

5 Fast-Forwards, 3 months on: how is it being used?

Since the July launch of our report ‘5 Fast-Forwards for Social Care’ which reframed the problem for delivering a sustainable…

November 4, 2019

What we learned about transitions from our Shared Learning Event

A few weeks back, IMPOWER brought together representatives from 13 different local authorities for a Shared Learning Event on transitions…

October 29, 2019
Close
Close