The right sort of messy

Thanks to the Guardian for publishing these thoughts on 2016 and the year to come (Social Care Network article here):

2016 was a year of sudden, unpredicted change. Some certainties unravelled overnight, as polls turned out not to reflect votes. Others have been building for some time.  The crisis in health and care services is being dangerously accelerated by cuts, but you can trace its roots back to decades-old failure to take seriously the ever-growing gap between what our current services can deliver and the growing demands upon them. It is easy to believe that the only future is simple one: an absence of the public services we have now, and little else. But in public services, as in everything else, the future will be whatever is made by those who choose to make it.

There is a time for tweaking and refining the existing model, but perhaps the middle of the widespread collapse of health and care services is not that time. We need significant central government investment to avoid crisis becoming catastrophe, but then what?

The NHS’s Strategic Transformation Plans, which have been the big headline of NHS ‘change’ in 2016, are for the most part prime examples of how we lack a model for radical change within public services. They are the system responding to crisis by doing what we always do – just faster, at bigger scale and with more anxiety. The more urgent and important the work, the less leaders feel able – or obliged – to involve a wide group of organisations, let alone people who use services and their families.

So most STPs express what leaders were already intending to do, with little of the involvement of new people which would have led to new aims, new approaches, new behaviour. Lack of collaboration has bred suspicion, but they are not the ‘secret cuts’ plans they have been dubbed: they are more likely to avoid talking about cuts which have been inevitable for years. Where they say the right things about community-based care or prevention, they lack the model for the culture, power and economic changes needed. There is much talk of scale in public service delivery, but nearly always this is the industrial age’s need to operate in large units. Our large organisations, silted up with the governance requirements which must accompany any big budget, are not the place where change will happen.

The real scale challenge is to scale those bureaucracies down to be human and family sized again. Personal budgets, Shared Lives, community enterprise, Buurtzorg, Local Area Coordination, Homeshare: the lesson of these successful models is that we avoid the prototype-then-replicate approach and instead create enough infrastructure for people to form similar but entirely individual relationships everywhere. This is the scaling model of the internet age.

The only kind of change you can make happen suddenly, on a large scale, is destruction. Whereas creation of anything real and valuable starts small, but ambitious. For real change to take hold, you need to involve people who don’t always agree with each other and you need a tolerance for messiness: the neater the plan, the more fictional it is. There many kinds of people who care about each other and who already change the world around them: hundreds of Homeshare households, thousands of community entrepreneurs, 10,000 Shared Lives carers, tens of thousands of timebankers and millions of unpaid family carers. Can those overlooked groups join together, gradually and messily, to become a national movement which chooses to build a better, more human future? Do we still have time?

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