Transformation

“Within the world of social care, there has been much talk about the ‘transformation’ of adult social care, but the actual pace of change has been not so much transformational as geological.”

Richard Humphries [1]

While much of the national narrative around social care is about ‘fixing’, at a local government level there’s a strong emphasis on ‘transformation’.

The dictionary definition of transformation is “a complete change in the appearance or character of something or someone, especially so that that thing or person is improved”. “A dramatic change in form or appearance”. “An extreme, radical change.” [2][3]

Sounds good doesn’t it, given the scale of reform needed? Ambitious. Hopeful. Revolutionary even.

Or not.

I’m all for radical change in social care, and I also firmly believe in the potential for fundamental, lasting change at a local – and particularly a ‘hyper-local’ – level. But I don’t believe we’ll achieve this change through ‘transformation programmes’ led by ‘transformation teams’.

I’ve looked at a significant number of councils’ social care ‘transformation’ plans and strategies, and I want to use this blog to unpick the language of transformation in relation to social care. I’ve included direct quotes from the documents I’ve read, but I haven’t included sources. I’m not pointing fingers. This is a snapshot to illustrate how and where I think we’ve got stuck in terms of local change, and why I think we’re trying to transform the wrong things, for the wrong reasons, in the wrong ways, with the wrong people, in the wrong places!

Why

“demographic pressures such as increasing numbers of older service users with complex health needs will add a significant burden to the already stretched and reducing resources.”

Most transformation plans begin with the stick, not the carrot.

It’s a little bit ironic that documents which inevitably reference ‘strengths-based approaches’ start with what’s wrong, not what’s strong.

The motivation for change is usually articulated in quantitative terms, and – like the national narrative – has a distinct undercurrent of blame.

Reasons include:

• “an increase in older adults suffering with Dementia”
• “an ageing population”
• “increased complexity of cases”
• “an increase in people suffering from a moderate or severe learning disability.”

The anticipated result of the ‘transformation’ is usually articulated in quantitative terms too.

• “to reduce people’s dependency on health and social care”
• “to reduce demand”
• “to save money”
• “to avoid hospital admissions”
• “to ensure ASC is as efficient and as cost effective as possible.”

Reduce.

Avoid.

Save.

So, while the local narrative of change may have a glossier and more ambitious headline than the national message, the nuance is still the same. Things are bad. We need to stop them getting worse.

There are of course some ubiquitous ‘buzz words’, like ‘modern’ – whatever that means!

• “the need for transformation arose due to services needing to be modernised”
• “the Transformation Programme is enabling the delivery of modern services”
• “to deliver services that are modern and accessible.”

(Note also the pervasive references to service delivery – despite the clear shift in the Care Act 2014 from ‘providing services’ to ‘meeting needs’.)

And numerous references to our old friend ‘independence’ weave their way through the papers.

• “to enable people to live independent and fulfilled lives”
• “to enable people to stay as independent and well as possible, for as long as possible”
• “to support people to live independently.”

But this is not independence in terms of ‘independent living’. This is about “increasing independence” to “reduce need for care”. “Enabling independence” to “divert those at risk of becoming vulnerable due to health and care needs away from dependence on formal care systems.” “Maximising independence” to “reduce need for ongoing support”.

Overall, there’s an absence of vision in these plans. There’s no sense of possibility, or hope. There’s little to grab our attention, pique our curiosity or motivate us to get involved.

“To create change we need a guiding vision, and the vision we must aim for is good lives well lived. This bold vision – which creates a sense of purpose, sparks our energy and sets a shared direction of travel – returns us to the original intentions of the welfare state and reinvents them for our time.”

Hilary Cottam [4]

How

“When we say we want ‘change’, all too often what we do is just train or re-train our frontline staff (I hate that term). We expect more from the people already doing the work. We don’t even question if leadership, our organisational culture and our power structures are standing in the way of change. And we don’t ask how these things can instead act as enablers.”

Ewan Hilton [5]

So how will this ‘transformation’ happen? Well, through programmes and plans of course, and largely – it seems – through ‘reviews’.

The plans I looked at mentioned reviewing:

• “our information and advice strategy”
• “our workforce strategy”
• “the front door”
• “our crisis response arrangements”
• “Direct Payment audit arrangements”
• “respite”
• “our day care offer”
• “reablement services”
• “high cost expenditure”
• “lower cost expenditure”
• “high cost packages”
• “low cost packages.”

Arghh!!

As well as reviewing literally everything there is to review, there’s lots of emphasis on the transformational potential of ‘strengths-based practice’. Plans mention “implementing a strengths-based approach to working with all service users”, “strengths-based assessment” and “embedding a strengths-based approach at every stage of the customer journey”. And if references to ‘service users’, ‘assessment’, ‘customers’ and ‘journeys’ aren’t enough red flags, it’s explicit in the plans I looked at that this emphasis on strengths-based practice is all about “reducing care expenditure”, “discouraging dependency” and “effectively managing demand”.

There’s no sense of any form of appreciative inquiry, of learning from and building on what’s working well (although maybe – hopefully – this forms part of all those ‘reviews’?). There’s little mention of codesign or coproduction (aside from the odd reference to ‘engagement’).

There’s no space, or permission, in the programmes and plans to experiment. Be curious. Share stories. Make mistakes. Try again.

There’s no sense of any kind of organic, evolutionary approach to ‘transformation’.

And as such we ‘deliver’ change like we deliver care, with plans and schedules.

Structured. Linear. Measurable. Reportable.

Done to and for, not with or by.

“Change is disturbing when it is done to us, exhilarating when it is done by us.”

Rosabeth Moss Kanter [6]

What

“Innovation tends to proceed without an explicit ethical foundation, too often focused on coordination, efficiencies, and the exploitation of new technologies… An app on its own doesn’t change the quality of the information collected, or who holds what kind of power, or the types of decisions that are made. If anything, it becomes one more system artifice that reinforces the way things are done.”

Gord Tulloch and Sarah Schulman [7]

“You don’t change the world by changing the form.”

Department of Health and Social Care [8]

So, what is this ‘transformation’ going to achieve?

There’s a distinct focus on “more and better use of technology”, to “enable staff to work efficiently”, “to support people more effectively and efficiently” and “to maintain people independently in their home”.

• “an e-marketplace”
• “a front-end chat bot”
• “an online self-assessment and screening tool”
• “a library of useful apps”
• “a new customer relationship management system”
• “a new resident focused performance dashboard”

Technology isn’t the only focus though. Social work practice, performance monitoring, financial management and reporting are all in the mix too.

But there’s no reference to any change in leadership style, or power dynamics, or decision-making. No mention of building trust, or compassion, or connections. No sign of liberating people from the stifling processes and forms and bureaucracy, of freeing workers up to listen and to learn. To share ideas, explore communities, remove barriers, build relationships, uphold rights.

If you ask – well, pretty much anyone seeking or drawing on care and support what they’d like to be ‘transformed’ about adult social care, you can pretty much guarantee that IT systems and performance monitoring won’t be on their list.

And therein lies the problem.

We don’t ask.

Who

“I’ve been involved in many change initiatives over the years, and mostly, that change was decided in one room, and then explained and trained in another set of rooms.”

Daniel Stillman [9]

The focus of ‘transformation’ is on what, not who. Process, not people. Efficient systems, not flourishing lives.

People seeking or drawing on social care, and the people who support them in both paid and unpaid roles, are largely excluded from discussions and decision-making. Instead, we have transformation teams. Heads of transformation. Transformation leads. Directors of transformation. Transformation managers.

The proliferation of these posts implies that ‘transformation’ is the remit of select individuals and teams, who will lead and manage and deliver and evaluate ‘their’ change.

This removes any sense of agency or influence from the very people who are most likely to know best what needs to change and how best to make those changes. It ignores – and in turn saps – their ideas and creative potential and energy and vision. And, because we’re “engrossed in only grand things, we underappreciate (and under-resource) the small things, which can be mighty. We leave changemaking in the hands of a few giants rather than vesting it in everyone.” [10]

Where

The majority of ‘transformation plans’ I read could apply anywhere, and everywhere.

There was little sense of place influencing or impacting on plans, and little sense that ‘transformation’ would change anything very tangible beyond the office walls.

When

“It is essential for effective change to be delivered and have an impact in a timely manner in-year.”

“Our transformation projects have key milestone dates for each outcome that are monitored through our project management system”.

“The Strategy sets out a comprehensive transformation programme which is to be delivered over four years.”

“Our recovery and transformation plan sets out how care services will be transformed over the next three years.”

“The majority of work is now complete and all outstanding deliverables are on track to be delivered by the end of the year.”

This is Chronos time change, with implementation dates and key milestone dates and delivery dates.

Scheduled. Controlled. Predictable. Measurable.

Impossible.

“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.”

Alex Fox [11]

So

So.. how will we know when we’ve ‘delivered’ transformation?

Well, “progress will be reported through the corporate performance management framework and business planning processes”. “We have built several performance dashboards that provide a picture of how we are performing on a range of indicators.” “We will have succeeded when.. performance in key areas is sustained in line with the targets we have set ourselves.”

“The targets we have set ourselves.”

Pretty much sums it up really, doesn’t it?

How about we ask people seeking or drawing on support if things have ‘transformed’ for them?

Ah no – sorry, we don’t have time. We’re too busy ticking the boxes to complete the forms to populate the dashboards to provide the evidence that things have changed.

Reimagining social care

“What’s needed is nothing less than a reimagination of what we do.”

Gord Tulloch and Sarah Schulman [12]

“My assertion is that nothing changes until someone feels something”.

Sue Robins [13]

Our approach to delivering change mirrors our approach to delivering care. (The concept that either can be ‘delivered’ doesn’t help!) We don’t start with what matters most to individuals and families. We don’t involve the right people in conversations. We have discussions in the wrong places. We make decisions about people without them. We make plans that lack imagination and insight, and impose inflexible and inhumane schedules. And we focus on and measure outputs, not outcomes.

Our deficit-based reasons for reform, and our ambitions to reduce and avoid and save, lead to transactional rather than transformational change. A focus on efficiency and processes, not wellbeing and better lives.

What is needed is nothing less than a reimagination of what we do.

And we need to begin with these four little words.

What. Matters. To. You?

What really matters to you?

Because if we make time for those conversations, make space to listen and to question and to learn, we’ll identify the needs and desires that we share and that connect us all. We’ll understand what good really looks like. And then we can start to work together to achieve it.

“Radical transformation [is] not possible until we look at the people we want to help, and we see ourselves; when we realise that their needs, out there, are our needs, in here.”

Don Berwick [14]

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References

[1] Ending the Social Care Crisis: A New Road to Reform, Richard Humphries, Policy Press, 2022

[2] Transformation, Cambridge dictionary

[3] Transformation, Vocabulary.com

[4] Radical Help, Hilary Cottam, Virago, 2018

[5] On bumpy but exciting starts, relationships and complexity, Ewan Hilton, Platfform, 26 January 2023

[6] Rosabeth Moss Kanter, GoodReads

[7] The trampoline effect: redesigning our social safety nets, Gord Tulloch and Sarah Schulman, Reach Press, 2020

[8] Strengths-based social work practice with adults, Policy paper, Department of Health and Social Care, 21 January 2017

[9] Minimum Viable Transformation: How many people does it take to change a culture? Daniel Stillman, Medium, 6 June 2022

[10] The trampoline effect: redesigning our social safety nets, Gord Tulloch and Sarah Schulman, Reach Press, 2020

[11] A new health and care system, Alex Fox, Policy Press, 2018

[12] The trampoline effect: redesigning our social safety nets, Gord Tulloch and Sarah Schulman, Reach Press, 2020

[13] Ducks in a row, Sue Robins, Bird Communications, 2022

[14] Ducks in a row, Sue Robins, Bird Communications, 2022