5 Fast-Forwards for Social Care

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.

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.

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.

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.

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.

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.

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.

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: