Wicked issues and constructive conversations in health and social care

wicked-musical-movie1
Image via Screenrant

The Social Care Institute for Excellence is working with the Health Foundation and Institute for Government on a fascinating project about how “constructive conversations” can help with “wicked issues” in health and social care.

I was lucky enough to be invited to a discussion about the project and hear a wonderful summary of the literature on both constructive conversations and wicked issues from ICFI, and wanted to quickly reflect here two key parts of the useful information that was shared.

(I stress that the information below is taken directly from the really excellent work by ICFI, to whom all plaudits should absolutely go!)

First, what is a wicked issue?

The concept is taken from social planning (Rittel and Webber, 1973) referring to problematic social situations where: there is no obvious solution; many individuals and organisations are involved; there is disagreement amongst the stakeholders and there are desired behavioural changes. Public policy problems are ‘wicked’ (Clarke and Stewart, 1997) where they go beyond the scope of any one agency (e.g. health promotion strategies) and intervention by one actor not aligned with other actors may be counter productive. They require a broad response, working across boundaries and engaging stakeholders and citizens in policy making and implementation (Australian Public Services Commission, 2007).

Wicked issues therefore have the following typical characteristics:

  • Are multi-causal with connections to many other issues
  • Are difficult to define – so that “stakeholders understand the problem in different ways and emphasise different causal factors… The way the problem is approached and tackled depends on how it is framed, so there may be disagreement about problem definition and solution.”
  • Are socially complex – “Decisions about how to tackle them are unavoidably political, values based and may raise moral dilemmas. They cannot be tackled as technical challenges with scientific solutions; there is no point at which sufficient evidence will be gathered to make a decision.”
  • Require a whole system, multi-agency response – they do not sit within the control or authority of a single organisation, making it difficult to position responsibility.
  • Have no clear or optimal solution – they are not right or wrong, but better, worse or good enough
  • Have no immediate or ultimate test of ‘success’.

Against these characteristics, questions of social care, health, promoting disability equality, and public service reform are all obvious wicked issues.

Second, what is a constructive conversation?

The phrase “constructive conversation” itself is perhaps not well known, but its attributes are becoming increasingly familiar since they reflect much of what the approach to system leadership calls for.

A constructive conversation engages in what area known as “clumsy solutions”:

  • Questions not answers: seeking a deep understanding of the problem
  • Relationships not structures: engagement as the primary vehicle of change
  • Reflection not reaction: resisting the pressure for decisive action at too early a stage
  • Positive deviance not negative acquiescence: ignore, or look beyond, conventional culture and wisdom
  • Negative capability: the ability to remain comfortable with uncertainty
  • Constructive dissent not destructive consent: seeking consent is often destructive and illusory
  • Collective intelligence not individual genius: WPs are not susceptible to individual resolution
  • Community of fate not a fatalistic community: collective responsibility to underpin action which is likely to involve risk-taking
  • Empathy not egoism: seeking to understanding how other people see the problem, and the wider context”

As a result, a conversation is constructive if the following are in place:

  • A commitment to be open and honest
  • A conscious effort to foster and maintain trust
  • Clear information, provided at the right time
  • A focus on relationships not methods, underpinned by the goal of collaboration
  • Well-defined roles and clear expectations
  • The involvement of all stakeholders, fostering a whole-system approach
  • The ability and willingness to be flexible, wherever possible”

What a wonderful though subtle rejection of “heroic leadership” or CEO-itis this is, and what an obvious parallel with co-production it produces!

As I read through the slides of the summary on wicked issues and constructive conversations I found myself scribbling “YES!” and “Absolutely!” all the way through, so well did the findings tally with my feelings about what’s needed for change, especially in health and social care, and disability equality. They clearly tally with the ideas of system leadership and collective impact we’ve written about here before on many occasions (1, 2, 3). Though I could understand it if people were to tire of yet another set of terms that could be used and abused, for me the value of the above is in having something further to point to, consistent with what we’ve been talking about before, that further articulates the how I feel we need to go about change.

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rich_w

Man of letters & numbers; also occasionally of action. Husband to NTW. Dad of three. Friendly geek.

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