Wicked issues and constructive conversations in health and social care

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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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Systems Leadership in practice

I was kindly invited by Debbie Sorkin to attend an event on Systems Leadership last week. It was held at the University of West of England’s business school, and was part peer support, part theory and part sharing findings on how Systems Leadership works in practice.

I’ve highlighted before why I’m so taken with what Systems Leadership seeks to do – see here and here – and it was great to hear directly from people who have been explicitly putting this approach into practice through the Local Vision programme.

The Local Vision programme is run by the Leadership Programme and supports 25 areas with Systems Leadership at the moment. An interim evaluation (pdf) of how this has been working so far is now available, and there’s lots of good stuff in there to look at and consider. I’m particularly taken with the importance of the Enabler role – a person who:

• Builds a safe space, relationships and trust
• Surfaces hidden themes and patterns
• Fosters recognition and ownership of what needs to change
• Creates shared purpose and collective connection
• Explores and fosters recognition of the nature of systems leadership
• Brokers/acts as independent arbiter; encouraging reflection and learning.

As if to highlight this is a way of working that deserves more attention, the King’s Fund also last week published a fascinating report about the practice of Systems Leadership and “being comfortable with chaos”.

One final point: it was rightly noted at the UWE event that Systems Leadership isn’t the only answer. I agree wholeheartedly with this: we cannot and should not dogmatically take a Systems Leadership approach to every problem we face, if not for the sole reason that not every problem will be suited to such an approach.

Links and reading on (1) achieving change, and (2) organising work

I’ve been thinking and reading a lot lately about different ways of doing stuff. By ‘stuff’ I mainly mean (1) ways in which change is achieved, and (2) ways in which work is organised.

I thought it might be useful to put the most influential things I’ve been reading in one place – partly for my own reference, and partly for others to have a look at the source information if they so wish – so that’s what I’ve done below. It’s arranged into two lists (achieving change, organising work) and I’ll update it as and when.

Achieving change

• Beyond belief – towards a new methodology of change (Matthew Taylor)
• Collective Impact (SSIR) – “The social sector is filled with examples of partnerships, networks, and other types of joint efforts. But collective impact initiatives are distinctly different. Unlike most collaborations, collective impact initiatives involve a centralized infrastructure, a dedicated staff, and a structured process that leads to a common agenda, shared measurement, continuous communication, and mutually reinforcing activities among all participants.”
• Channeling Change – making Collective Impact work (SSIR)
• The dawn of system leadership (SSIR) and my own reflections on how system leadership helps us move beyond ‘just’ top-down and bottom-up change
• Systems leadership – synthesis (overview) paper (pdf) (Virtual Staff College) and “A view from the bridge” (Sue Goss)
• Complex isn’t the same as complicated (Mark Foden)
• The basic principles of strategy haven’t changed in 30 years (HBR)
• Charismatic, chameleonic or institutional ideas? (Chris Hatton)
• Anarchists in the Boardroom: more like people (Liam Barrington-Bush)
• Scaling across, not just up – “Locality does scale via network, rather than via hierarchy”

Organising work

• How to become a soulful organisation (Frederic Laloux) (see also his book Reinventing Organisations)
• Misperceptions of self-management and Five crucial components of self-management (closely linked to systems leadership above)
• Rebooting accountability: from top-down to AA (Cormac Russell)
• Making absolutely boring and absolutely needed meetings better (HBR)
• The paradoxes of organisation – “Paradoxes can be clues to understanding deep and abiding conflicts, and confronting them directly may sometimes help in the search for resolutions.”
• Skills in flux (David Brooks) – “People with social courage are extroverted in issuing invitations but introverted in conversation… They build not just contacts but actual friendships by engaging people on multiple levels. If you’re interested in a new field, they can reel off the names of 10 people you should know. They develop large informal networks of contacts that transcend their organization and give them an independent power base…. [Other types of people] possess negative capacity, the ability to live with ambiguity and not leap to premature conclusions. They can absorb a stream of disparate data and rest in it until they can synthesize it into one trend, pattern or generalization.”
• Invisibles: the power of anonymous work in an age of relentless self-promotion (David Zweig)
• Two cultures in public services 
• We can’t know everything and should act accordingly