People in power don’t think they have power

Power

Most people who are thought to have power don’t think themselves they have power.

Let’s look at those thought of as traditionally having power[1].

In the world of health, we hear about the “power” of the clinician over the “patient”; in care the “power” of the social worker over the “service user”. In the world of services the commissioner is the most powerful, and in the civil service we think that power resides with (Prime) Ministers or Permanent Secretaries.

Inevitably, the person at the top of any organisation is often thought to be the most powerful: the higher you go the more powerful the people get.

And, to some extent, this is true: their decisions affect larger and larger numbers, whatever those numbers happen to represent (people, staff, money).

So how can it be that the person thought of as the most powerful in the world can lament his own lack of power?

It goes back to my opening: if you ask those people listed above who are traditionally thought to hold power, I doubt very many of them would feel anywhere near as powerful as they are perceived to be by other people.

Take a social worker: from the point of view of someone who uses care services the social worker is incredibly powerful: they potentially determine what money you do/don’t get and what types of services you can access. But if we ask the social worker about their power they will talk about the pressure of their caseload, the policies they have to implement, the limited number of providers that exist on their patch, the pressure from their manager, and several other factors that all act to curtail their power to act.

Ask the social worker’s manager if they are powerful. They’ll probably laugh at you and say they have a team of social workers completely under the kosh who don’t fill out paperwork in the way they should do. They’ll be harangued by management for implementing lovely sounding changes there is actually little resource or appetite to put into practice. They’ll be getting phone calls from providers at all times about placements that are breaking down, and they’ll be pestered to complete monitoring data they’ll never see again by people they’ve possibly never met.

Commissioners in the same area will be thought of as having the power because they hold the purse strings. When they look up from reading the scant information about the latest priority they have to reflect in commissioning intentions with no new money, alongside the 78 other priorities they’ve been given, they’ll tell you that big providers call most of the shots, or that health commissioners are in the driving seat now. For what it’s worth, the supposedly powerful providers will tell you they’re being asked to do more and more for rates that are decreasing rapidly whilst under greater regulatory scrutiny.

At the top of the care staffing pyramid, the director of social care will tell you about the unrelenting pressure of upward demand, downward resources, their obligations under the Care Act, the threat of judicial review from any one of tens of families who have been treated poorly by their department, a recalcitrant workforce working in a culture that can’t be shifted, and the waffling politics of their portfolio holder and the local health and wellbeing board. They want to do good stuff in and for their local area, but the politics (big ‘P’ and little ‘p’) significantly curtails them.

And on and on it goes: “powerful” people for whom power is little more than juggling clouds.

What to do? The only reflection I can give is to try to recognise:

  • The person you think has power probably doesn’t think themselves they have power
  • Helping them in their relatively powerless position will probably help you as well
  • To someone somewhere in the system, you are the person with power.

[1] – There is, of course, a vast literature on all types of power in a variety of different settings. I’ve not gone into that at all here, but a useful starting point for the interested reader is Chapter 10 of Fred Luthans’s Organizational Behavior (pdf).

The Waste Land project (01)

i_land
The Triumph of Death by Pieter Bruegel the Elder

Today I am starting a new personal project: the Waste Land project.

I know very little about The Waste Land. It’s a Modern poem by T.S. Eliot and, well, that’s about it. It keeps cropping up in various other things I’ve read over the last few years, so it must be important in some sense or another; I just have no real feeling of what that sense might be.

And so the idea came to me to spend a set period of time reading The Waste Land and exploring it, its meaning, its references, its context and its place in (modern?) culture.

The idea is to spend the next 6 months – until Christmas – reading pretty much only The Waste Land and things associated with it. As much as possible I will explore it myself, by which I mean I won’t simply search straight away for what other people have said about it, nor buy the Norbury Critical Notes that achieves everything I’m seeking to do through this project.

This belies a final reason for undertaking this project: to create some space, focus and flow for myself in one tiny area of the physical and mental worlds. Physical, in the sense that I’ll do it mainly amidst the noise and selfishness of train journeys; mental, in the sense that it will be a focus away from the well-known sinks of time I’ve reflected on before.

I will try to document the project as I go. It’s worth noting that I don’t have any particular eye or training when it comes to poetry and literature; I’m also quite a poor completer/finisher. By making this project relatively public, then, there is both risk (of being stupid in public) and reward (a benign motivation that comes from the possibility people may be reading this).

Finally, you are of course very welcome to join in. Please do leave thoughts, links, questions, provocations in the comments or via Twitter – I tweet @rich_w and will try to use #wasteland throughout the project.

A mathematician’s view on integration in health and social care

Though the answer may be integration, we don’t always know what the question is.

Similarly, though we often say “integration”, it’s not always clear what type of integration we mean. There are at least four interpretations of what we meant when we talk about “integration”:

  • Integration across any of primary, secondary and tertiary healthcare
  • Integration across health and social care (and education and housing and etc.) boundaries
  • Integration of resources and processes
  • Integration at the level of the individual.

As a mathematician by training, integration has another particular meaning to me. I thought it would be useful to reflect on what integration means from a mathematician’s perspective and so what we might learn from this in the context of health and social care.IntegrationMathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.

Integration, on the other hand, gives you a bigger sense of the whole. It tells you not just about rates of change but the overall picture you have: the sum total of what exists in time or space.

Differentiation is easier. It’s exciting (think Mick Jagger swaggering around a stage) and has no room for anything but the most important stuff. If there are any ‘spare’ numbers floating around then the process of differentiation gets rids of them – they disappear.

Integration, as any mathematician will tell you, is far harder. It’s a slower, altogether more considered process that requires more sophistication (think Bjork). There are some tricks you can use to make it slightly easier – such as integration by parts – but the challenge of integration remains.

And because integration is the reverse of differentiation it adds in an unknown factor: the arbitrary constant (from which this blog takes its name). Where differentiation has no space or time for the arbitrary constant, integration very deliberately includes it and recognises it. This unknown factor – an unidentified ingredient – is a vital component of integration.

(Interestingly, the only time the added, unknown ingredient of the arbitrary constant doesn’t play a part in integration is if you explicitly define the boundaries within which integration happens. By specifying these limits so exactly the arbitrary constant is cancelled out.)

If we were therefore to try and summarise what we know about integration from a mathematical point of view we’d say something like this:

  • Integration is harder than differentiation – though there are limited tricks to make it easier
  • It gives a bigger picture across a wider area than a specific view of just one point in time or space
  • It has a secret ingredient – the arbitrary constant – which his fundamental to capturing this bigger picture
  • This secret ingredient disappears only if you define exactly the boundaries of what integration is trying to achieve
  • Integration is a subtle, complex process that takes time and understanding to do.

Thus, though you wouldn’t immediately think it, the mathematical conception of integration tells us everything we need to know about successful integration in public services, especially across health and social care and beyond.

Breadline or Left Behind: social work schemes for graduates from the university of life

Frontline and Think Ahead are new routes into children’s and mental health social work respectively for graduates with a 2:1 degree or better. The principle behind them – derived from Teach First – is to attract the “brightest and best” into a job / career they may not otherwise have considered.

My feelings about these social work training programmes have developed over time. Initially I wasn’t keen, but now I feel that anything which promotes social work as a good profession should be, broadly, welcomed.

How my feelings have developed have probably reflected the way the programmes themselves have been refined since their inception. Where before there was arguably an elitist, Oxbridge focus on who the programme’s participants might be, now it feels they’re much more interested in good graduates from a broader set of universities.

I wonder, though, if by focusing only on people graduating from university with 2:1s or above we’re missing an opportunity?

What if, as well as this, we had well-resourced and targeted recruitment campaigns focused on bringing people into social work who are likely to graduate cum laude from the University of Life?

These would be people who never made it to university; a high proportion of them probably wouldn’t have A-Levels. They will have faced adversity at many points in their lives and been used to navigating a whole host of difficult environments. But, despite the many challenges they will have encountered, their character, resilience and way of thinking has meant they have flourished.

If people like this became social workers, imagine the experience and perspectives they could bring to social work! Imagine the difference they could make to people whose lives they would truly understand!

We could call such programmes Breadline or Left Behind – anything that reflected the exact opposite of what Frontline and Think Ahead represents. Without denigrating these existing schemes, though, I think we’d find ourselves with another group of people whose contribution to social work could be significant.

Now, if only we could a think tank to take up the idea…

It’s person-centred, Jim – but not as we know it

We all have our favourite “I can’t believe that actually happened” stories in social care.

Mine relates to care and support planning: whilst observing a panel process (error number 1), a Head of Social Care instructed a social worker (error number 2) to change a support plan so that all sentences were “I” statements (error number 3) from the point of view of the patient [sic] (error number 4), without going back to the person themselves (error number 5).

It would be funny if it weren’t so normal.

But we hear variations of this all the time, summarised in the line:

Of course what I do is person-centred care – it always has been

If we are honest, relatively little of what currently happens in the care and support system is person-centred (though we’re definitely moving in the right direction).

This being the case, we should ask ourselves: if it isn’t person-centred, then what is it? I think there are at least four alternatives:

  1. Money-centred care: where what people get is what commissioners can either afford, currently buy, or have always bought
  2. Provider-centred care: where the primary objective is to ensure the ongoing feasibility of an organisation rather than the people it serves
  3. Process-driven care: where filling out the paperwork or keeping the IT system happy is the main driver
  4. Professionally-driven care: where the professional knows best and tends to think of the person in front of them as another one of their caseload or a walking set of conditions

Thinking of it in this way shows why the drive to person-centred care has been so difficult: it requires significant change on a number of major fronts – the flows of money, the role of providers, the supremacy and comfort of process, and the culture of professionals.

It’s why I’m personally so excited about person-centred care and what it means for the future. It isn’t just an optional variation of what we’ve always done; it flips public services as we know them on their head. To make this happen, though, we need to be clearer on the alternatives that being person-centred is replacing.

What politics isn’t

In recent posts we’ve noted what politics currently isn’t: neither civil nor balanced.

Chris Dillow also notes here what politics isn’t, through the eyes of people who are interested in what passes for politics:

Most of those who claim to take an interest in it are not really interested in how to govern the public sphere: if they were there’d much more interest in the social sciences. Instead, they’re mere spectators in a wrestling match who are booing baddies and cheering goodies.

I cheered – well, sighed – reading this.

This begs the question: what is politics?

We’ll need to go back to Plato, Aristotle, Hobbes and Locke to get started on this. At least, though, we’re asking the right question.

 

Obama’s civility in a polarised world

We wrote last week about political polarisation, through which we include two different-but-related things: (1) exaggerated debate about public services being the norm; and (2) the role of interest groups in polarising politics.

Then up popped a video comparing Barack Obama and Donald Trump’s ways of dealing with hecklers:

This echoed David Brooks’s piece reflecting on the civility of Obama’s presidency, and the fact we’ll miss it when it’s gone:

Obama radiates an ethos of integrity, humanity, good manners and elegance that I’m beginning to miss, and that I suspect we will all miss a bit, regardless of who replaces him.

What I note about Obama is that he always plays the ball and not the player. He engages in the debate and doesn’t resort to name-calling, ad hominem  attacks or the tone someone employs.

As you would hope, he engages at the upper scales of the Hierarchy of Disagreement:

DH0: Name-calling

DH1: Ad Hominem

DH2: Responding to tone

DH3: Contradiction

DH4 Counterargument

DH5: Refutation

DH6: Refuting the central point

Our polarised political debate means Obama’s civility stands out. Perhaps we can restore civility and try to engage in what people are saying and why, rather than who they are and how they say it?