'Good' systems for whom?

‘Good’ systems for whom?

By 9am, Katie had dealt with 4 systems.
Her partner, Nick, was out drunk with his mates.
Her 10 kids were in various states of undress. If they were even awake.
The social worker was in the driveway, getting ready to drop in.
The school attendance officer was on the phone, asking about her older son’s whereabouts.
The pharmacy was texting to confirm her methadone appointment.
Katie just wanted a hot shower. And some peace and quiet.

I spent a week living with Katie and her 10 kids, in a spotless 3-bedroom house, in a leafy Australian suburb. From the inside, systems weren’t the abstract entities that descriptors like “dynamic” “interconnected” and “complex” seem to suggest. Systems were groups of people clumsily interacting.

They were a mum, dads, kids, aunties, uncles, mates, grandparents.
They were clients, social workers, psychologists, police officers, managers, policy advisors, ministers.
They were students, parents, teachers, a principal, school attendance officers, education consultants.
They were a patient, a pharmacist, a drug supplier, doctors, health care administrators, ministers.

Few of these people were getting what they needed, or wanted. Katie needed support from Nick. The kids needed attention. The aunties and uncles wanted to know what to do. The social workers needed to ensure the kids’ safety. The family wanted to stick together. The policy advisors wanted to avoid a headline. The teachers needed the kids to stop getting into trouble. The principal needed the kids to come to school. The pharmacist wanted Katie to show up.

We could diagnose these systems as strained & stressed; inefficient & ineffective; even perverse and pathologizing. There’s no shortage of solid analysis about the failures of our systems, particularly our public ones, clearly shown by the other blogs in the Nesta series. John Seddon identifies “corporate foci of targets and costs.” Jesper Christiansen talks about the lack of “coordination” “integration” and “continuity”. Halima Khan uses words like “out of synch” and “disenabling”. Zaid Hassan names “expert-planning” and responding to “symptoms” versus “root causes.”  Alice Casey describes “budgetary silos” “risk aversion” and a “deficit orientation.”

The technocratic problem
At the core of much of our collective analysis is a critique of technocracy. Of taking problems (say, family crisis), breaking them down into smaller and smaller pieces, and assigning professionals with increasingly narrow specialities to each puzzle piece. Katie regularly interfaces with attendance officers, family support workers, intake workers, social workers, cultural affairs coordinators, housing workers, pharmacists, nurse practitioners, and doctors.

Yet I would argue that many of our proposed solutions – be it personalized services, empathic professionals, learning networks, change labs – are open to the same critique. We focus on the technological means – on methods, processes, tools, approaches – and on instrumental ends: creating efficiencies, enabling collaboration, integrating services, empowering people, and being more human-centred. We neglect the ethics. We neglect to ask what is good.

Efficient, collaborative, integrated, empowering, strengths-based, human-centred systems aren’t necessarily good systems. Who are they good for?  

The master value
Richard Kraut, in his book What is good and why, convincingly argues that ‘good’ is the master value of practical life. Other values like collaboration or justice or virtue or autonomy are actually underpinned by whose good and harm are in view. He writes, “This way of thinking is not quantitative or reductive. It holds that it matters a great deal whether what we do is good or bad for this person rather than that; that the kind of good we create and the pattern according to which we do so, not merely the amount of good we do, are significant.”

Katie’s many workers regularly convened interagency meetings to share case notes and join-up their decisions. An ‘effective’ system might be measured by the amount of information exchanged, by the frequency of professionals calling each other to talk about Katie, by the percentageof paperwork reduced. But, I would argue a ‘good’ system has little to do with the system itself, such as whether it’s a seamless service experience or a satisfying interaction. And instead has much more to do with whether the system is good forpeoples’ lives. For Katie’s life. For Nick’s life. For their kids’ lives. For the social workers lives.

But what isgood for someone? Kraut concludes that, “What is good (for someone) is determined by what it is for them to flourish…A flourishing human being is one who a) possesses, b) develops, and c) enjoys the exercise of cognitive, affective, sensory, and social powers (p.137).”

You wouldn’t say Katie, Nick, or the kids are flourishing. Nor would you say the social workers and managers are flourishing. Ask Katie and Nick to talk about what is good, and they define it as the absence of bad. Not having welfare in their lives. Not having a dirty house. Not going hungry. That’s what the social workers told them was good. Ask the social workers to talk about what is good, and they also define it in terms of the absence of bad. Not having to remove kids or to get court orders. Not having to encounter abuse and neglect. Living in a clean house, with food on the table, and without abuse or neglect does not make for a good life. It just makes for a life.

Our beliefs about what is good matter. Behaviours follow beliefs. Katie spent 3 hours every day mopping floors, wiping down cabinets, doing laundry, making spaghetti Bolognese. She hated clutter: she packed up the kids’ books and toys and threw out their school work. Few of these behaviours facilitated living well: developing over time: receiving loving attention; forming close bonds; communicating with others; enriching and gaining mastery over emotions; reasoning and deliberating to make decisions, etc. Indeed, Katie, Nick, and the kids were always so busy reacting to the past that they didn’t have a language to talk about the future, about what was good and what they really wanted. What they really wanted was shaped by what they thought was possible – by what they had directly experienced. The same was true of the social workers, managers, and other professionals in the systems.

A few mechanisms for change
To make our systems better – be it our families, our schools, or our child protection systems – we have to understand, shape, and align lots of peoples’ conceptions of what is good. And then we have to learn how to apply these conceptions to our everyday circumstances. So if we were Katie, we have to decide what a good use of our time is: cleaning the house, playing with the kids, going out. Of course, how Nick and the kids and the social workers and her mates react will all factor into Katie’s decision. Changing Katie’s decisions, and increasing her capacity to act, means changing not only what she thinks but what others’ around her think.

This is not at all easy to do. Over the past 3 years, we (the Radical Redesign Team at The Australian Centre for Social Innovation) worked with families, social workers, older people, and care workers to co-design and prototype interventions that re-conceptualized ‘good’ families, ‘good’ older age, and ‘good’ care work. We had mixed success.

In 2010, we partnered with 100 families to co-design, prototype, and scale Family by Family: a network of families helping families to thrive. In 2012, we worked with 150 older people to co-design and prototype Weavers and Care Reflect. Weavers is a new kind of peer support for friends & family in caring situations. Care Reflect is a new source of ideas & know-how for care workers.

All 3 of these solutions draw on some common mechanisms for change. A mechanism is a specific interaction (or set of interactions) that shift what’s behind our beliefs and behaviours. They are the building blocks of interventions – whether with 2 people in a family home or with thousands of people across multiple workplaces.

Here are 3 of the mechanisms we often used for shaping peoples’ and professionals’ beliefs and behaviours.

Mechanism 1: Modelling
Seeingis (often) believing. To change your ‘stuck’ beliefs and behaviours, you have to be exposed to people who have different beliefs & behaviours, and see that those beliefs & behaviours enable flourishing. So in Family by Family, families like Katie and Nick are linked-up with families a lot like them. Families who are in a similar socio-economic class, or who have faced similar challenges, but who are living well. The closeness of their experiences is critical. So too is spending time together in each other’s daily environments – where the messiness is not shielded from view.

Mechanism 2: Space
It’s not often we make our beliefs explicit, and look at things from a few different points of view. Creating the time, space, and structure for people to air their values & beliefs can help to debunk assumptions or logical fallacies. In Weavers, we use a book of prompts to get carers to name some of their hidden beliefs (e.g. nothing can change, I just have to grin and bear it, etc.), first to normalize their way of thinking, and then to understand alternatives.

Mechanism 3: Feedback
Most of the time, it’s hard to know whether we are doing ‘good.’ Particularly where ‘good’ isn’t defined. Often, the hardest question for professionals to answer is: are you doing ‘good’ work? Care workers would say ‘yes’ if they got to their clients’ houses on time, or if one their clients expressed gratitude for their service. They knew very little about their client’s day after they showered them or gave them their medications. In Care Reflect, we developed a range of ways for care workers to get more direct, constructive feedback. To learn about their clients’ whole weeks, and to track their ups and downs. And ultimately, to generate ideas for conversations & experiences they could have with clients that might enable better living when they weren’t around.

Of course, these mechanisms are not a panacea. They didn’t prompt change with many senior civil servants, service delivery managers, and with lots of older couples like Gill and Martin. Perhaps they weren’t at the right intensity or dosage or directed to the right person or deployed in the right way. Or perhaps they aren’t the right mechanisms: not powerful enough to challenge deeply embedded norms. So, what mechanisms would be?

Gill and Martin came from a very close-knit Greek culture. They’d just celebrated their 30th wedding anniversary when Martin was diagnosed with early onset dementia. Gill often thought about putting Martin in a home. She was almost at breaking point. She never saw the grandchildren anymore. Martin, in his more lucid moments, cried at the thought of a nursing home and asked Gill to promise that she wouldn’t abandon him. Gill thought the situation was insoluble. Her ‘good’ life was at odds with Martin’s ‘good’ life. And she couldn’t be that selfish. We tried to give Gill (and other older people like her) time & structure to reflect; to expose her to different ways of organizing caring; to encourage her to do some small experiments, such as writing a letter to her children. But she thought it was hopeless. We also never found a way to engage Martin. Or the children and grandchildren. We weren’t able to help the family articulate a shared conception of good, and re-structure how they approached caring. Respite workers, in-home nurses, and cleaners came and want. They helped keep things as they were.

If we really want to shake up how things are, then, we’d start with a different kind of conversation. A conversation about what is good and what is bad for each person that makes-up the system. We’d take the opportunity to listen, to understand, to critically examine our lives from ethical angles. Not merely technocratic ones.

Sarah Schulman
More of her writing can be found at www.sarahschulman.com.