By Greg Fisher
I was recently given two papers to read on the nature of “Multiple Exclusion Homelessness”, which is about people with multiple care needs e.g. housing, drug addiction, unemployment, etc. The papers covered (i) Tackling homelessness and exclusion: Understanding complex lives i.e. need and (ii) Implications for Workforce Development and Interprofessional Practice i.e. the attempted satisfaction of need. In this article I’d like to consider this subject from a “complexity perspective”.
The reports painted a picture I had feared was probably true, given the tension between (i) how we run our government services in a silo-based way; and (ii) the idiosyncratic nature of human nature. In summary, the first paper noted how those with multiple and acute needs (e.g. a combination of drug addiction, homelessness and mental health) are “complex cases” involving inter-dependence of need; and the second paper noted that by and large the delivery of care is silo-based. The papers did highlight some rays of hope, including interdisciplinary co-ordination but I was left with the impression these were rare. As should be obvious, a silo-based system is most likely to fail those with the most complex of complex of care needs, which can only be described as tragic. I am not blaming care workers here: this is a problem of organisation and the management of resources, and the location of authority and responsibility.
An enormous amount of work has been done in this area by people who are much more familiar with the problems than I. But here I would like to offer a “complexity perspective” on these most complex of care cases. I think this perspective could add a lot of value. The challenge is best represented by quoting one of the case studies in the first report cited above:
“Sharon was 34 and living in shared accommodation with support when interviewed. She was kicked out when she was 12 after the man her mother had married sexually and physically abused her. She stayed with a street sex worker for a while, before being taken in to local authority care. By the time she was 14, Sharon was a sex worker herself and on drugs, moving between squats, punters’ flats and rough sleeping, with brief periods in hostels. She started sniffing gas and glue, but she was groomed by a pimp who got her on to crack cocaine. Other drugs quickly followed.
Sharon had four children by various men, all of them taken into care and three now adopted. Relationships were brief affairs, normally ending in her being subject to violence and needing to leave for her own safety. There might then be a period in accommodation before she was drawn back into her street lifestyle of drink and drugs, maintained by sex work. There were periods of imprisonment when, for instance, she was violent to a social worker trying to take her children into care. It was the prospect of getting custody of her fourth child that eventually led Sharon to seek help to stabilise her life and get a place in supported accommodation.”
There are two principles I would like to emphasise in this blog post. The first is that human psychology is relatively “plastic”, which is to say that our own values and actions in part shape the values and actions of others; and vice versa – we are shaped by the values and actions of others. The principle that bears on this in complex systems is co-evolution: in effect, we evolve together, simultaneously. This principle highlights another important point, that a person’s character is path-dependent i.e. it will reflect the combination of their life experiences, including (and most importantly) their interaction with other people.
The second principle is that every person is unique when viewed close enough. Idiosyncrasies tend to be emphasised in complex systems more than in other approaches.
We can contrast these two principles with how public policy has typically been delivered in the UK and many other countries. Silo-based systems are the organisational manifestation of reductionist thinking. In simple terms, what I mean is that with a reductionist mindset, people are viewed as the sum of their parts and this is also true of care requirements. If someone has a drug problem, is homeless and has a mental health problem, then they will need to access specialists in these separate fields. That’s true –but there is an additional point that reductionist approaches miss: the interdependence of need means the provision of care needs to be cohesive and appropriate (i.e. tailored) to each unique individual.
As noted in both papers, quoting a housing support worker:
“everyone has got snippets of the individual but no one is collating it.”
I will emphasise this again because it is so important: it is those most in need of cohesive, tailored care that will suffer from support services supplied by silo-based departments.
So what are the policy implications? It is tempting to suggest that in light of the care needs of ultimately unique individuals, everything should be devolved to the individual level. However that would be to under-emphasise the importance of patterns in complex social systems. There are clearly a lot of people with very specific care needs e.g. a mentally healthy person without a drug problem who just needs housing. The needs of such people can be satisfied by a system that provides “buckets” of focused care (although this is not to argue for the highly centralised system we now have at the moment – I am merely arguing that specialisms can align with specific patterns of need).
The studies behind the two summary papers mentioned at the beginning included a pattern recognition exercise to identify “typical” Multiple Exclusion (ME) needs. These patterns (highlighted more in the first paper referenced above) illustrated the high “complexity”, or interconnectedness, of ME but with noticeable “paths” that many people follow. The policy conclusion I would draw is that those with ME needs require a single representative to appreciate the “whole need” of specific individuals, who could draw on the plethora of statutory resources available as befits an individual. The metaphor is that of a GP being the gatekeeper of the general public’s access to health care services: those with ME needs require tailored support. I should emphasise that the two papers referred to an increase in emphasis on bottom-up approaches, noting the idea of personalisation, which seems to be the same as what I am talking about here. A complexity perspective supports such an approach to ME cases, in my opinion.
When it comes to policy recommendations, it is important not to offer unfunded advice i.e. that which simply says “the government should spend more”. Here my policy conclusion is purely organisational – under a care budget of given size, a part of it should be allocated to a cadre of people who in effect specialise in being care generalists. This fits nicely in to the Big Society agenda because it is about devolving power.
Judging by the two papers cited in the first paragraph, a change in primary legislation would probably not be required because the 1990 NHS and Community Care Act appears sufficiently flexible; and the Department of Health has sufficient discretion over interpretation via its guidance notes.
As might be obvious to many readers, a key area I have not touched on in this blog is “causation”. I have taken for granted some ME need but, as with any problem, ex ante prevention is better than ex post fixing it after the fact. That’s an entirely different kettle of fish.
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