Listening and Learning: Let's Start Talking Sense in Social Care

02nd Feb 2016

Social care is littered with language that doesn’t belong. Some of it has been copied from business, while other phrases come from the NHS – which can be equally inappropriate.

Some words have so many multiple meanings that using them renders discussion meaningless; they become those conversations that 10 people can walk away from thinking they have agreed 10 different things.

Those of us pushing for innovation in social care know that if you want people to work differently you have to support them to generate a new language – almost force people to say ‘what they really mean’ rather than using terms that are confusing and misplaced. This process of language building becomes crucial to the process of innovation itself. If you want someone to do something different you have to give them new tools.

Those of us who believe that the fundamental system of social care is broken beyond repair need to ensure that key terms belonging to that system are not allowed to recreate themselves in any new way of working.

A number of councils are now playing around with the idea that banning key terms is a crucial part of learning a different way of working. For example, the word ‘respite’  has become synonymous with the haphazard prescription of often inappropriate and sometimes damaging overnight care in an institution. Banning the word ‘respite’ forces people to have a proper conversation with a carer who needs to believe that their life matters too and that their health and wellbeing is crucial.

In banning the word, the service-led response is also ruled out. Instead, people can have real conversations about what would make a difference, what would give a carer a break, or a sense that their labour is not never ending. What happens is the carer starts believing that someone is interested in them, not just applying a ‘one size fits hardly anybody at all’ solution. (And we know that traditional respite is, for many people who receive it, very bad for them!)

Words to do with the way social systems work are fascinating and also ripe for abolition. These terms include ‘triage’, ‘allocation’, ‘referral’, ‘handoff’, ‘waiting list’. Ban them all and force people to imagine a new way of constructing an organisational response to people and families who need support (you notice I have not used the words ‘service user’, ‘client’, or ‘customer’).

It is instructive to work with a group of social care professionals and ask them to describe the worst aspects of any service experience they have had – with their mobile phone company, with their mortgage provider, with a plumber.

What is salutary is that when you have collected together the worst features of their worst customer experience, we appear to have built them all in to a default social care organisation and become dependent on them. Waiting lists, being handed off, being placed in an allocation system, are all bad for people and bad for us. They are more fitting in describing a sorting office that deals with letters and parcels. But we are dealing with people.

So ‘triaging’ someone from a professional point of expertise to decide which ‘channel’, ‘swim-lane’ or ‘pathway’ we push them down is probably the most dispiriting experience there is – for those subject to it (often in distress) and also those people working in it. The only thing that saves this system from the gutter is the principles, values and commitments and just about everyone who works in it.

Assessment is perhaps the key word we need never use again  It has become the badge for low value, process-driven behaviour where professionals ask a series of questions (50% of irrelevant, and 20% down right rude) to satisfy a mechanistic view of practice. The questions are nearly always deficit based and lead inexorably to the prescription of a service. Banning the concept creates a space where social care practitioners can design a new type of conversation based on assets and strengths of the individual and their community, and on a real understanding of what counts as a ‘good life’ and what will assist someone in continuing to live it independently.

Of course, these different types of conversations are much more Care Act compliant and proportionate  ‘assessment conversations’ than those mechanistic ones. We just can’t afford to call them ‘assessment conversations’ out loud otherwise the unwanted behaviour, culture and practice will follow through.

‘Commissioning’ is perhaps the most misunderstood word of all – and represents the biggest untruth of the system. The idea that ‘commissioners’ can properly understanding need through population analysis, gap analysis and then can, through a contracting process, ensure the market meets that need is ridiculous – can anyone tell me where that has actually happened? But how many people have ‘commissioning’ in their job title? The word has different meanings in a health and in a social care context; senior health and social care managers spend hours talking together about joint commissioning, or aligned commissioning. What do we really mean?

Of course, the concept of commissioning is indelibly connected to the word ‘services’. You might think it is difficult to imagine a world of social care without the word ‘services’.  But somehow, in the broken system we now have, we have been duped into believing that all that people want are ‘services’ and that services are solutions – even though all that we have to offer are services whose reputation, if we would only open our eyes, is damaged maybe beyond repair.

We have known for a long time that in residential care for elderly people you have a better than 50/50 chance of been given the wrong drugs.  We now know that you also have a 20% chance of being dehydrated – in ‘services’ that are audited and inspected on a regular basis ( I am not pointing the finger of blame at over-worked, minimum wage paid frontline staff).

We know that people with dementia suffer and they are likely to be medicated to control their distressed behaviour – yet we still persist in sending people to respite and other institutions that don’t know them well enough to do a good enough job.  Banning the word ‘services’ forces us to think about what would help someone live a better life, whatever their circumstances. And so innovation is borne.

The opportunity it creates, in banning these key descriptors of our broken system, is to build a new way of working around real conversations between real people – that is personal, community focused, and based on what kind of lives people really want to live.

By Sam Newman