By Alex Fox, CEO of Mayday Trust.
Becoming Open Systems
Dr Jean Boulton of Bath University observed at a Northumbria University/ Centre for Public Impact conference on relational public services, that we are all ‘open systems’ not ‘closed systems’: we are impacted by what’s around us and impact what’s around us, in ways which are patterned and not random, but which are also not fixed and predictable. Boulton started academia researching quantum physics before studying the field of complex systems and is now working on the application of complexity theory to public service management.
Services don’t fully recognise the open-system, changeable nature of people.
Most start by categorising people and making a binary in/out decision. Most can recognise that people change over time, but they see those changes in one dimension: progress against whatever the service is there to achieve. Changes which happen in other dimensions are harder for services to recognise and if they do, it may be to the detriment of the person they support, if they no longer neatly fit a service’s boxes.
Some people are seen by services as completely unchangeable: they are given labels like hard to reach, disengaged, challenging, stuck, and revolving door.
But in reality, as Boulton pointed out, not only do we all change over time (through ageing if nothing else), we are all contextual: we are different people in different contexts.
My experience of many services is not only that they cannot see our contextual nature, but they are also unable to see that services themselves help to create and change those contexts. Some services create almost all of someone’s context.
So, if you put someone into a needs assessment, you will experience their needs. In my book I argued there is a paradox in assessments which is a little like (my layperson’s understanding of) the observer effect in physics: observing something or someone changes them and therefore what is observed, or even like Heisenberg’s uncertainty principle which says that we cannot know both a particle’s speed and its position: the more we know of one, the less of the other. In service assessments, the clearer someone’s needs are, the less can be known about their strengths, and vice versa.
If you put an 85-year-old in a hospital bed for longer than 12 hours, they will very often lose enough of their leg muscle strength to make the difference between being mobile and immobile. This is the context, created (perhaps unavoidably) by a (often entirely necessary) service, within which a person is assessed for their home-readiness.
There are people who have learning disabilities who have been locked in so-called Assessment and Treatment Units – closed, medical institutions – for years. In some cases, people have been locked in institutions, in near solitary conditions, for decades, based on a violent or risky incident from their youth. If their behaviour continues to be violent and risky – even if it only became that way once they were placed in such hopeless, isolated, arguably abusive circumstances – they will never leave. No professional will be willing to take the risk to the professional’s career by placing them in a different context to see who they are there. (But the risk to the individual of lifelong incarceration is not given the same weight.) The person is observed not to be changeable, by the service which maintains their unchanging context.
How many care assessments are able to say, “Sometimes this person is one thing, and sometimes another”? And to do that as a route to support, rather than to deny a person is eligible for support? How many assessments are able to recognise the impact of the service upon the person in anything other than entirely positive terms? This is not to say that services should be constantly self-critical – there is enough unjustified criticism of public services out there. But there is always a cost to interacting with services, and there are always risks of accepting support from an organisation, and if we fail to acknowledge that, we ignore a crucial dimension of what will impact the person supposedly at the centre of the assessment and therefore upon the success or harm of the work.
So every assessment must partly be an assessment of the organisation offering support, and of the support system as it impacts on the person being assessed. This may sound overly complex, or even pointless agonising. But the evidence that, for instance, large areas of the health system are systemically racist is overwhelming, in terms of service access, experience of support, what is offered and what the outcomes are. The impact and risks of that to people are huge.
But I wonder if there has ever been a mental health assessment that has stated that the individual being assessed has been harmed by racism in that mental health system, and a support plan that sets out how to end that and mitigate the impacts.
A constant challenge for organisations and the people they support is how to meet as equals. When we don’t meet each other as equals, the risk increases that support relationships contain harm and help, or even instead of help. The inequalities embedded in society make those power imbalances unavoidable, as does the asymmetric nature of any support relationship, and the fact that only one of the people meeting has the backing of an organisation. Recognising that we are contextual, complex and fluid, not just one fixed thing, feels fundamental to offering effective support (and fundamentally incompatible with basing entitlements and plans on snapshot assessments). To meet people as equals, and thus offer support services which work and which are equitable, organisations and the people who work in them will need to find ways to be able to see not just the individuality of people, but also their complexity. To recognise that people are ‘open systems’, and to aim to become more open systems themselves.
You can find out more about Mayday’s work here