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Service demand can be controlled

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We are often being exhorted to change others’ behaviour in order to manage demand, but I sometimes think it is we that need the treatment.

One of my epiphanies as a new director in inner London was on older people and residential care. The council had high numbers comparatively and the assistant director explained to me that this was a problem of demography and house prices; an ageing working-class population stranded when their children move away. As a result, poor old people were left isolated, with no support network, and needed the support of the council. This sounded plausible to me.

However, it was later discovered that the council had been filling in our statutory returns differently from other people. In fact, it turned out we had relatively fewer people in residential care. About six months later, I heard the assistant director explaining to members that the reason for our comparatively low numbers was that our increasing black and minority population meant residential care was not an easy cultural choice.

This story shows how the human ability to ‘make sense’ of any given state of affairs is very powerful, and can obscure the fact that we make our own history, even in social care. The numbers of older people in residential care, or the number of looked-after children, are not ‘natural facts’. They are the end points of complex systemic processes which we can influence but not control.

For at least a couple of decades, the relative rates of older people in residential care were best explained by the historic decisions of private providers when the benefits system paid for residential care, prior to the community care reforms (places with a lot of provision had high rates). Essentially, there was a supply-side driver that had nothing to do with the demographics or even the self-proclaimed values and objectives of social workers and their managers.

Nowadays there are different drivers. In my current authority, the numbers of older people being admitted to residential or nursing care has risen by about 10% every year for the past five years, and it seems this is not uncommon in my part of London. The system caneasily come up with explanations – older people are moving here in their retirement, dementia is increasing, longevity is rising, the number of older people with multiple long-term conditions is rising and so on – but my nerves are twitching.

How can these long, slow population changes be producing a trend that will double the numbers being admitted to residential care in seven years? Why is the number of self-funders in residential care apparently falling (as bed numbers reduce)? This is a system issue.

However, we must avoid jumping to conclusions. It might suit councils to think this was because of the emerging crisis in acute care, since the increasing demand of residential care fits with the period when pressure on social care to facilitate hospital discharge has also been increasing. But it could also be that the wrong community services have been cut, or because of changes to end-of-life care. 

Our impulse to find meaning does not mean facts are optional; merely that we have a bias for explanations that do not reflect badly on ourselves or that mean we don’t have to change what we do.

In this case, our values should tell us it is wrong that the state is ending up taking away people’s lives (and money) because we have created a system in which it suits us to increase the use of residential care.

Similar points can be made about looked-after children. Research on differing looked-after children rates (Inequalities in Child Welfare Intervention Rates, Bywaters et al, Child and Family Social Work, 2014) shows children from all social classes are more likely to be in the care and child protection system in areas of lower deprivation, but this is masked by the extremely high rate of involvement in the bottom two deciles, particularly from white families.

It is striking that these correlations are largely invisible in each local system. Most people believe they are working in a rational system where thresholds are applied and checked, courts provide oversight and there ‘must be’ good reasons for things to be the way they are. In wealthy areas there are ‘reasons’ that spring easily to mind: children with problems really stand out; close geographic proximity of rich and poor may reduce social cohesion; possible recent EU migration that the statistics have not caught up with; and/or possible forms of ‘middle class’ neglect or abuse.

But if these are post-hoc explanations, then they are no more than plausible stories.

Our values should tell us we do not want children to be in care or in the child protection system unnecessarily. We should not intervene more because we work in a rich area, particularly if our targets are the few poor people who live there. If black children were disproportionally in the care system (as they once were) we would ask questions and consider whether there was institutional racism or stereotyping going on.

The work of Kahneman and Tversky can provide an explanation as to why local systems believe so strongly that they are ‘normal’. We use what they called ‘heuristics’ for everyday decision-making, including professional judgements. These are ‘rules of thumb’ and are often based on previous experience. They can work pretty well most of the time, but often come unstuck when dealing with rare events, or where information is incomplete (as can be the case in child protection).

When heuristics are used in child protection decisions the process can be described as one of ‘recognition’ as well as risk assessment. If you see experienced workers at work in a multi-agency safeguarding hub it is impressive how quickly children are ‘sorted’ and the degree of consensus between agencies. They are using typology to recognise most children who meet or do not meet the threshold, and saving their thinking time for the hard cases.

Child protection systems aim above most things to be consistent. The system ‘trains’ referrers by simple reinforcement mechanisms, so that they learn which children are the business of social care and which are not. In poor councils where decision-making is not consistent, there is often conflict and real distress among referrers because they know that previously the council took a child who was ‘just like’ the one batting back this week. They are using ‘recognition’ too.

A local system, particularly if it is running well, can easily develop its own sense of what is normal, and settle into it. Some councils (like Leeds, Essex and triborough) have used new models of practice to reduce their looked-after children populations, using social work values to challenge the status quo.

We have to be alert to the powerful psychological processes that determine our own beliefs. Above all, we have to understand that we are in charge of demand, not facing it like a force of nature. Public services make their own customers, and always have done.

Simon White, senior consultant, currently working at Kingston upon Thames RBC 

This article was sponsored by iMPOWER. The essay was published first in Shining a Light, a collection commissioned by iMPOWER. For more information see LGCplus.com/guidelines

Olly swann

Olly swann

Olly Swann

Expert comment

We asked Simon to contribute to iMPOWER’s essay collection because of his knowledge of organisational culture, and expertise in getting complex systems to change. 

Simon highlights the psychological aspects of demand management, including our bias towards explanations that justify why we don’t have to change. He also offers insight into why local systems believe so strongly that they are ‘normal’. The calls for better and more sustainable demand management initiatives have never been louder, but does the sector really understand what this means? Are organisations ready to hold a mirror up to themselves and recognise that service-based behaviour, alongside organisational culture, is just as important for changing citizen’s behaviour?

Earlier this year – in our annual iNSIGHT survey – we asked local authority chief executives and directors the following question: “How prominent an influence is demand management in your council’s budgetary discussions?” Sixty percent listed it as ‘essential’, with a further 35% listing it as ‘significant’. Given its obvious importance, local authorities should be making every effort to understand its potential. It is much more than restricting service access or shunting demand and costs on to others; it is a fundamental design principle, and should be a universal mindset adopted by all. 

Local authorities, and the public sector as a whole, can affect demand. Given the current fiscal climate, they should be embracing the opportunity to do so.

Olly Swann, director, iMPOWER Consulting

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