Mental health, social care – complex, not complicated

Thanks to @pubstrat I came across this excellent post on complexity and government by Mark Foden (@markwfoden).

Mark draws out nicely the difference between stuff that’s complicated and stuff that’s complex.

Complicated is something like putting a man on the moon:

There was a clear objective – success was easily measured. The laws of physics pertained and sending a rocket to the moon did not change those laws. Effect can be predicted from cause. It is possible to make big, long-term plans and be reasonably certain of achieving them – London 2012, Channel Tunnel, Crossrail etc.

Complexity, however, is a different beast:

Dealing with something like poverty is complex. Poverty is hard to define meaningfully. It is difficult to measure improvement. It is subject to changeable human behaviour and action is persistently met with unintended re-action. Effect can be deduced from cause, but only in retrospect.

In complicated problems, Mark notes that the “build” mindset works, whereas in complex situations it’s the “grow” approach that works best.

The bit of Mark’s analysis that hit home for me was this:

The problem is not in plans, people or methods – it’s in mindset. Trying to build things that really need to be grown just won’t work – no matter how they are managed.

He also notes that we shouldn’t necessarily just abandon “programmatic approaches” but ensure we understand when complexity is at play and change our approach accordingly.

His thinking is mainly applied to IT infrastructure, but the applicability of this thought to social care or mental health is clear.

Both are significant systems with large amounts of money, buildings, providers, commissioners, wider stakeholders and, most importantly, users and families. Neither are particularly well-defined or have a particularly clear idea of what their end goal is (for mental health: better mental health of the population? More cost-effective services? More people with mental health problems in work? Less stigma? For social care: more money? More integration? Less integration? More care homes? More community provision?). And, goodness me, human behavior and action within the mental health and social care systems is changeable!

Indeed, I’ve always thought the mental health and social care systems are a bit like a Jackson Pollock painting:


To this end, it’s always been clear that the mental health and social care systems are complex. But plans to try and improve them have always tended to rely on top-down, “build” solutions.

Whilst equally not calling for the abandonment of good programmatic approaches in social care and mental health, what we do need to do is recognise the complexity at play and update our approaches accordingly. In these cases, such adaptations include: (1) distributing power amongst all stakeholders through all aspects of co-production; (2) putting people at the centre of their care and support, through personalised approaches and money more directly in their hands through Personal Budgets; and (3) creating a more equal playing field for a wider variety of providers based in across a range of settings.

If people like Mark are clear the “grow” mentality needed by complexity applies to the (supposedly) deterministic world it’s easy (but wrong) to assume government IT is, then it’s pretty obvious that the equivalent “grow” approach is needed for the future of the mental health and social care systems.