Transforming social care starts with the smallest pieces of the jigsaw

Fundamental changes are needed in the way we commission, plan and deliver health and social care. That’s what the Five Year Forward View is asking for. The responsibility for making this happen falls on the shoulders of local services at a time of unprecedented financial challenges and growing demand.

It’s no surprise, then, that some areas are struggling. We recently spoke to a county struggling to deliver reforms to care and support. While the area had delivered pockets of real improvements, such as GP practices working closely with social care and mental health colleagues, the vision for transformed care hadn’t really left the drawing board. This is far from an isolated example.

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Wicked problems

To be fair to areas such as this, they are trying to tackle problems that are immense – issues so complex, so multi-faceted, that they are often difficult to define, never mind solve. In policy parlance, such situations are called wicked problems. Now everyone, from clinical commissioning groups and care providers to local people themselves, are tasked with tackling these problems.

There are also challenges that will need to be overcome if we are to deliver the forward view: major service reconfigurations; co-design of new systems and processes; establishment of integrated and multi-disciplinary teams; and above all shifting behaviour towards preventative, self and family care.

These challenges are multi-causal, complex, require a multi-agency response and are almost impossible to build consensus around. When confronting them, organisations on their own cannot test the success of their interventions other than by developing crude targets and proxies. In fact, the problems are probably impossible to actually solve. That’s because we like to tame the problem with clear plans and processes. We like to diagnose, treat and cure.

Clumsy solutions


When faced with the complexity and unpredictability of these changes, many public professionals feel anxious. They may interact with others as anxious people often do: defensively and sometimes with hostility. This can undermine the conditions necessary for tackling wicked problems: the building of constructive and trusting relationships. But the skills and behaviours required for good quality interactions are ones that we often call soft.

Moreover, they can even be called inelegant or clumsy. Paradoxically, this is because these skills are challenging to develop in a technocratic health and care workforce. And yet having these skills in health and care organisations is essential if we are to overcome the challenges we face.

Ongoing work

The Health Foundation has commissioned us at the Social Care Institute for Excellence, PPL and the Institute for Government to research how local health and care systems can create the space for more meaningful and effective interactions or constructive conversations. We are working closely with the Dudley and Nottinghamshire vanguard sites to study the issues related to the development of new models of care, testing when and how constructive conversations can be used to tackle these problems.

We’re also involved in Devon, where care homes are coming together to develop a quality kite mark. We will make clear recommendations for policymakers on how we can encourage professionals to stop acting tough and start embracing their “clumsiness”.

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Deep listening

We are learning that local communities can be a big part of brokering these conversations. Clenton Farquarson, co-chair of a recent event on this issue and expert by experience, says: “It is no longer acceptable to foist large-scale change on to local communities without their involvement in developing the solution.” We will have to relearn, in the view of professor Paul Corrigan, another contributor to the event, “those social work skills that are about deep listening”.

Harder still, we need effective constructive conversations. These are likely to involve leaders having to let go, whether that’s power, money, or ownership of risk. Constructive conversations will involve everyone at the table surrendering something in order to gain something.

The challenges faced by our colleagues are considerable; we all know that. But what can be done? In life, good conversations often help us overcome some of the most difficult situations we face as individuals and families. Could they also have a role to play in solving the problems we face in improving our health and care system? We hope our research will help us find out.

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