Time to buck the system

September 10, 2004 in Social care leaders

Andy Bilson is professor of social work research at
University of Central Lancashire. He worked in a range of
managerial and academic positions in social work for 30 years. He
has written widely on systems approaches to organisational
change.

The concept of the whole system has become one of the key
elements of planning in health and social care. From initiatives
such as healthy communities to problems such as delayed discharges,
the idea that the whole system needs to be addressed is widely
recognised.

But the models used for understanding the systemic nature of
organisations and networks often appear to be more like a series of
sound bites than a coherent theoretical framework. Like Gregory
Bateson,¹ one of the founding fathers of modern systems
theory, I suggest that approaching the complex behaviour of systems
without properly understanding the theoretical basis for actions
will lead to frustration and in some cases harm.

In practice, the concept of the whole system is not used in any
coherent manner. It is used mainly in considering complex social
problems that run across the boundaries of organisations or
agencies. For example, the National Service Framework for Older
People states that problems in services are generated “Éby
allowing organisational structures to become a barrier to proper
assessment of need and access to care.”

This highlights a need to ensure responses to the needs of older
people are planned and co-ordinated between the agencies involved
and hence become a focus for a whole-systems approach. The NSF
calls for this planning to engage older people and their carers to
inform the “whole system” of care.

The attempted solutions to these problems have tended to focus on
better co-ordination of services and attempts to set up structures
between the different agencies, such as joint planning, health act
flexibilities, intermediate care, the charging of local authorities
for delayed discharges, single assessment processes, co-location of
staff and joint teams. These attempts to reduce barriers between
organisations are not based on systemic analysis but on the
command-and-control approach of successive governments.

The use of the whole-system idea does not necessarily lead to a
careful systemic analysis and the responses coming from it are
often common-sense, linear approaches. It has been long recognised
in systems thinking² that the behaviour of complex
systems is counter-intuitive and common-sense actions often make
things worse rather than better. So, in looking at the problem of
older people falling through gaps between services, the solutions
have focused on a common-sense idea that the effects of boundaries
can be reduced or changed by mechanisms such as joint planning and
joint assessment. As these attempts have failed, we have seen an
increased focus on reducing boundaries and producing a whole
system. A similar pattern can be seen in children’s services where
perceived failures have led to proposals for multi-disciplinary
structures such as children’s trusts, and the view that poor
communication is best tackled through structural changes aimed at
reducing boundaries between organisations.

This would not be such a problem if the outcomes were benign. But
this woolly thinking about whole-system problems has led to changes
that threaten the continued existence of social work as an
independent discipline. This was illustrated in a recent audit of
services for older people in a three-star local authority carried
out by David Thorpe and myself. Rather than social care offering an
additional perspective and range of services to complement the
medical services provided by the NHS, we found that, in this
authority, it had been subsumed by the culture of the medical model
to the extent that files and social care plans contained little
analysis of the social aspects of the service users’ lives and
instead focused on medical problems and the need for packages of
physical care. Despite the many strengths of the services, rather
than plugging gaps the changes in service provision had created a
chasm into which anyone with social rather than medical problems
would fall.

So how does systemic thinking differ from current approaches?
Systems thinking acknowledges that problems are framed within
multiple perspectives, recognises the validity of different views
and that effective change takes place through a process of
learning. Because human systems develop in local environments,
problem-solving needs to be local and is unlikely to be reducible
to a formula that can be applied across the country. Solutions
involve focusing on the local patterns of problems and discovering
how beliefs held by people in organisations and teams lead to
behaviour that maintains the patterns. Thus, in the case of the
council discussed above, the issue is how to challenge the
over-medicalisation of service provision – a problem that requires
the strengthening of the culture of social care, the opposite to
the current national direction of reducing boundaries, joint teams
and so on.

Solutions to this sort of problem require changes in local
professional culture that cannot be achieved through executive
order or by structural changes. They involve gaining commitment and
shared understandings and avoidance of the current tendency to
structural reform, which can be likened to forest clearing to solve
ecological problems.

Policies that espouse the use of the whole-system approach in
social work owe little to any form of systemic analysis and more to
a command and control management culture. The problems we face in
the complex interactions between health and social care agencies in
communities are amenable to methodologies drawn from systems theory
but this requires a change of approach.

We should avoid the chainsaw of structural reform and seek
responses that value learning and respect professional
practice.

Abstract

This article challenges current thinking and policy based on
whole-system concepts. It claims they are based on common sense
mechanistic thinking that may aggravate problems and threaten the
continued existence of an independent social work profession. A
fuller understanding of systems thinking would lead to a change
from top-down policies promoting structural change to a recognition
of the importance of multiple perspectives at the local level and
respect for the local ecology of professional practice.

References

¹ G Bateson, Mind and
Nature: A Necessary Unity, EP Dutton, 1980

² J W Forrester,
“Understanding the Counterintuitive Behaviour of Social Systems”,
in Open Systems Group (ed.) Systems Behaviour (3rd
edition), Harper and Row, 1998

Further reading

A Bilson and S Ross, Social Work Management and Practice:
Systems Principles, Jessica Kingsley Publishers, 1999
A Bilson “Guidelines for a Constructivist Approach: Steps
Towards the Adaptation of Ideas from Family Therapy for Use in
Organizations”, Systems Practice, vol.10 no.2 pp
153-178, 1997
PCheckland, Systems Thinking,
Systems
Practice, Wiley, 1999
GMidgley, Systemic Intervention: Philosophy, Methodology,
and Practice, Kluwer Academic, 2000