Beyond bureaucracy: Emerging trends in social care informatics

Abstract

Existing information technology systems in much of UK social care have been designed to serve the interests of the bureaucracy rather than supporting professional practice or improving services to the public. The ill-starred Integrated Children’s System in statutory children’s services is typical. The Integrated Children’s System is a system for form-filling, micro-managing professional practice through an enforced regime of standard processes and time scales. In this article, we argue against this dominant design. We provide several examples where technology has enabled alternative modes of support for professional work, based on socio-technical principles. One such system is Patchwork, which describes itself as a ‘Facebook for Social Work’; its aim is to support multi-professional teams working with vulnerable families.

Introduction and policy context

Managers provide day-to-day management of child protection services. However, they also exercise leadership to challenge and bring about change and improvement. Leadership is much more than the authority of key figureheads. It is essential that local leaders fundamentally consider whether their service is configured optimally to meet the needs of children and families (Munro, 2011, pp. 106–107). ¹

In order to appreciate current trends in ‘Social Care Informatics’, it is necessary to go back to November 2008 and the trial of the mother, and two co-accused men, found responsible for the tragic and brutal death of a 17-month-old child (known subsequently as ‘Baby Peter’) in the London Borough of Haringey, the previous year. Press reports drew attention to the deficiencies of a national computer system, the Integrated Children’s System (ICS), and the role that it had played in undermining safe professional practice. The ICS embodied a prescriptive bureaucratic regime imposing immutable time scales for handling cases and complex forms for data capture; as a result, social workers were spending an excessive amount of time ‘feeding the beast’. The urgent need to review the design of the ICS was subsequently designated as a key priority for the Social Work Task Force, a body set up by the government to review all aspects of social work in response to Baby Peter’s death. ² Reporting in 2009, the task force called for major improvements to make the ICS ‘more straightforward and effective for frontline social workers in children’s services’ (p. 10). ³

The ICS was first conceived around 2000. ⁴ It does not refer to a particular computer system or software package but is a national specification, comprising a process model rigidly defining the social work ‘business process’ in terms of a branching sequence of tasks and time scales. It also includes a reference set of electronic forms, called the ‘exemplars’, which enforce a standard method of case recording. After a period of consultation and testing, the ICS was ‘rolled out’ nationally in 2007. Its deficiencies have been well chronicled in research by the authors and colleagues.^4,5 Our research involved intensive ethnographic observation of working practices as well as interviews with ICS users. From this evidence, we ascribed the flaws of the ICS to two major problems: first, the excessively complex forms which social workers were obliged to complete; second, the rigid ‘workflow’ regime it imposed, requiring tasks to be carried out in standardized sequences, enforced by management sanctions (‘Targets and terror’ ⁶ ). Such micro-management of professional practice had squeezed out discretion and vastly swelled the bureaucratic load.

Although some improvements in the design of the ICS have ensued as a result of the task force’s recommendations, such changes have been relatively marginal, and the ICS remains, at bottom, a system serving the managerial interest in a command-and-control bureaucratic paradigm. The design of information and communication technology (ICT) systems was taken up as part of the Munro review of Child Protection ¹ instigated in the summer of 2010. Munro’s final report called for further streamlining and loosening up of the restrictive work regime imposed by the ICS, urging that the future development of information technology (IT) systems should focus primarily on supporting and enhancing social work practice. As our epigraph shows, the report prefigures a new role for managers, emphasizing direct responsibility for the design of the services under their stewardship, including the engagement of all those impacted, professionals and indeed service users.

Design and the managerial role: ‘managers as designers’

As we have intimated, the last few years have seen a remarkable transformation in UK social work, with traditional paper records now universally supplanted by electronic ones. The ICS has been the main driver of this ‘electronic turn’. ⁷ Good design for such electronic documentation systems is critical, given the intrinsic limitations of the digital medium, such as small screen size, the lack of depth and structure of the two-dimensional (2D) display and other absent affordances, such as the ability to manipulate files physically and so on. These limitations are especially problematic, given the complexity of social work records. Gorman et al. ⁸ designate such complex files as ‘bundles in the wild’ – they are made up of many heterogeneous documents written by different authors, often over an extended duration. Medical records provide the epitome of the genre; social work files are much the same. For the most difficult of cases, a row of volumes can take up a whole shelf of filing space. It is not surprising that the economic impulse to ‘electronify’ social care records has been a strong force, given such physical storage requirements.

To embark on such a profound, technological change, you would imagine that the necessary design work had been carefully and diligently done. If nothing else, our natural predilection to ‘print out’ electronic documents would seem to invite such a careful approach. This propensity is especially strong when the files are lengthy and contain complex information and argumentation. Rather like social care records! However, the research reported in our articles indicates the opposite, with policy seemingly driven by an article of faith that ‘electronic is best’. ⁴ The emphasis throughout has been on recording and form-filling rather than reading and comprehension. How social workers could best find their way around complex bundles of electronic documentation has not been the central concern, if it has been considered at all. Yet, the ability to ‘make sense’ of cases is central to the professional task; if social workers are ‘lost in hyperspace’, their judgement and decision-making can only be impaired, perhaps with catastrophic results.

In our critique of the ICS, we argued that the ‘root cause’ of its vicissitudes was the paucity of careful design work, with lack of managerial leadership and user involvement being the primary failures. We argued that had a socio-technical systems design (STSD) approach been followed, a much better outcome could have been achieved.^2,4 We accentuated STSD’s core principles of user participation, minimum critical specification (i.e. to specify work processes in the minimum essential detail, thereby creating flexibility and avoiding rigidity) and the optimization of local autonomy. The latter is achieved by devolving discretion to those carrying out the work to deal directly with disturbances and contingencies; teams built around this principle are referred to as ‘Autonomous Work Groups’. To these precepts, we would add the crucial need to observe how work is actually accomplished (as an artful and often improvised performance) in the workplace through ethnographic observation, as we had done in our ICS research. STSD is not some arcane engineering framework; its practices and principles are well within the reach of managers and other professionals. Like other similar methodologies, ² it provides operational help for managers seeking to put into practice their new design role.

There is an alternative: four vignettes

Munro’s final report extols the virtues of good design and cites several examples of what can be achieved when the shackles are loosed of the ‘electronic iron cage’, giving managers the freedom to develop ‘work systems’ based on local conditions and methods of work. We will look at several vignettes to illustrate what may be achieved when the design role is embraced, the first two being derived from Munro’s report.

In Hackney’s ‘Reclaiming Social Work’ programme, the design work was led by two senior managers who took direct operational charge of all key aspects. The initiative is radical, involving the dismantling of the traditional hierarchical structure of ‘the team manager and seven social workers’, replacing it with Social Work Units in which professionals function in small multi-skilled autonomous teams, a concept directly corresponding to the Autonomous Work Group, the hallmark of traditional STSD. Independent evaluation of the programme has found many advantages, including the fostering of reflective practice and the refocusing of social work on the family, allowing professionals to spend more time with children and families. ¹ Results have shown lower rates of children on Child Protection Plans and fewer looked-after children, at an overall cost saving of 5 per cent.

In Cumbria, a ‘systems thinking’ approach has been followed. A small team of senior practitioners led by a service manager carried out a thorough analysis of how referrals to statutory social care were handled. From this, they identified that nearly 60 per cent of professional activity reflected ‘failure demand’, ² caused by the real needs of service users not being effectively met. Redesign efforts focused on increasing the time staff spent with clients, emphasizing early intervention and prevention and the development of meaningful performance measures. Early results pointed to the need for fundamental change in the role of managers, with a much greater focus on operational involvement, so that they know exactly how the current system is working and can intervene effectively when small adjustments, or more radical changes, are needed to the design of the service.

We have been directly involved in the third of our examples. To help design an electronic documentation system that supported its innovative team model, Hackney embarked on a user-centred design project, in which we operated as ‘action researchers’. Action research involves academics and practitioners working together on problems of mutual interest, aiming to deliver benefits to the organization as well as contributing to relevant theory; action research is a popular approach in the field of information systems. ⁹ Much of our research involved ethnographic observation of professional practice, complemented by a programme of user-centred design workshops, attended by front-line staff and line managers. We facilitated these workshops and we now consider some of the main themes to emerge, using quotations from participants as illustrations. A longer account of this exercise may be found in Wastell and White. ¹⁰

Resentment of the prescriptive workflow regime imposed by the ICS was a dominant motif, especially its curtailment of discretion. The remarks of several social workers exemplify their strength of feeling. One worker remarked, ‘I don’t like the idea of it setting me on a pathway, of it deciding what happens next – I want to decide’. Another trenchantly concurred, ‘We know what we need to do. It’s all too much having a computer that tells us what to do, flashing red lights giving us red eyes’. The impoverished nature of the electronic medium was another important theme. Not only is the screen small, but it is intrinsically two-dimensional and sensually limited; in comparison with paper files, there is no ‘tactile experience’. As one worker commented, ‘A computer is a flat screen. … A file is something you get hold of, the tactile experience is needed. You need to be able to hold the file’. Another pointed out that paper files provide important visual cues: ‘you could tell by the degree of yellowing how old it was’. Ideas for improving the visual design were plentiful: ‘A 3D experience is needed. Some computer games have rooms – cabinets, drawers. An organizational filing system for a family should be like their house’. Another commented, ‘It doesn’t have to be colour-coded but a different visual feel for types of documents, financial files, reports – you could show these types with icons. You need a front screen with tabs, like the paper file’.

The primary requirement of the social workers was the need to ‘make sense’ of the case files, in particular, to produce summaries called ‘chronologies’. Their importance is attested in the following quotation: ‘You need to create longitudinal histories, chronologies, to follow a problem, e.g. chronic abuse – it’s very hard when there are 15 different files. A chronology is just the critical incidents, births, moves, divorce’. The ICS was seen a major impediment to making sense of cases:

Trying to make sense of history is much harder with an electronic system – it can take a whole day to get a sense of a case. It was far easier to do a paper chronology – you can see where you’re up to with a post-it. It’s much easier than to read off a screen, you can highlight, scribble and all that.

In response to the workshops, we have produced a simple prototype to help practitioners work with electronic files. E-table^™10 provides the user with a set of virtual workspaces. The aim is to provide an area where documentation can be searched for meaningful patterns, by allowing spatial grouping according to common themes. Social workers often tell of taking files home, spreading their contents across the surface of the dining table, grouping documents into piles and so on. E-table attempts to mimic this process. Source documents can be pulled out of the case file and placed on the electronic tabletop, where they are represented by a simple link. The links can be moved around and grouped spatially reflecting semantic associations (an analogue of the physical pile). For instance, all documents of the same type could be clustered, or perhaps a more complex pile of heterogeneous material could be assembled around a particular ‘risk theme’. Yellow post-it notes can also be ‘pasted’ onto the tabletop to label these piles or for other purposes.

E-table overcomes a major limitation of current systems, which only allow one document to be open at a time. In such a situation, keeping track of what was read, where and what it signified, is a very difficult task in a typical case file, which may have tens or hundreds of documents. The realities of the busy social work office show up this limitation starkly. Assume a social worker is working with one case file, and the telephone rings regarding another; the first must be closed completely, and the new one opened obliterating all traces of the former. On the contrary, workspaces in E-Table are persistent. Switching to another case file and then returning to the prior one, the user will find the tabletop exactly as it was left. Moreover, more than one tabletop can be associated with a single case file, allowing the user to explore different investigative avenues for the same case.

Patchwork – socio-technical thinking in action

Although crude, we believe that the initial design work of E-Table affords a promising starting-point for the development of a ‘social care workstation’, designed around the needs of practitioners and the families with whom they work, not the bureaucracy. We conclude with another example of such socio-technical thinking, namely, the Patchwork project, carried out by FutureGov, an innovative UK organization set up in 2008. (Much of the empirical material presented in this section has been extracted from the Patchwork website – http://patchworkhq.com/ – The site includes detailed description of how Patchwork operates and the functions it provides, including a video showing the system in use.) Its web pages proclaim its distinctive credo as follows: ‘We are not your usual consultancy. We have our roots in local government and will always care passionately about doing what’s right for the sector, committed to improving and innovating local public services’. Although they do not describe themselves as socio-technical, FutureGov’s methods are intrinsically so, for example, working closely with users (including service users) and studying professional practice and social interaction ethnographically. In a recent brochure, they describe their ‘co-design’ approach as follows:

We believe that design should be done with and not done to people … involving staff allows them to both design something that meets their needs and more easily adopt new and sustainable ways of working, quite different from the traditional approach.

The aim of Patchwork is to support multi-professional teams working with vulnerable children. Being innovative with technology is FutureGov’s watchword: what is so disappointing about the ICS is its total want of imagination; it is like a throw-back to the data processing systems of the early days of computing, a bureaucratically driven system for form-filling. The Patchwork project shows this is not the only way and that new technology can augment social work in innovative ways. Patchwork describes itself as a ‘Facebook for Social Work’:

Patchwork uses social technology to join up the team around the family – leading to earlier interventions and better outcomes … When we started out, front line staff told us a huge barrier to working collaboratively was that they simply didn’t know which local organisations were also involved in their clients’ lives. In response, we worked directly with practitioners to design an application that allows them to see exactly who else is working with their clients … revealing previously hidden professional social networks around a family.

Patchwork is a relatively simple web-based application, enabling individuals involved with families to identify other professionals who are also engaged, to raise concerns and to make contact. It has been piloted in two UK local authorities, Staffordshire and Brighton, and an evaluation has recently been completed. ¹¹ While it is early days and there have been problematic issues regarding information governance and interfacing with extant IT systems, the evaluation is generally positive. The report highlights ‘the great potential of Patchwork as an application and process to engage practitioners with information sharing and multi-agency working outside of more traditional policy rhetoric’. The co-design methodology has been warmly received at both sites; participants felt that a bottom-up approach was useful in that it made them feel ‘worked with rather than done to’. ¹¹

Conclusion

We write at an important conjunction: the coming together of what may be called the ‘design imperative’ for managers in the public services ² and the recognized, but largely unexploited, potential of ICT to enable innovative modes of technological support for service design and professional practice in social care. The ill-starred story of the ICS demonstrates the limitations of a management regime based on standardization, targets and command-and-control. There is, sadly, nothing new in the failure of systems based on the ‘process paradigm’; studies have found that as many as 80 per cent of Business Process Management (BPM) initiatives fail ¹² even in the private sector. In this article, we have demonstrated that there is an alternative to the incumbent paradigm, illustrating the different design potentialities this opens up. We have made the case for the socio-technical approach to the design of systems for social care and provided several cameo examples of such an approach in action. Above all, these examples highlight the need to involve users in the design process and to base design on careful ethnographic observation in the workplace. They emphasize the need to prioritize practice over process, seeking solutions that augment autonomy, retaining the local flexibility (‘requisite variety’), which is essential to getting the job done.

The ICS serves the interests of the bureaucracy; it is driven by the need to fill in forms to show that procedures have been followed, to create an electronic audit trail. Our examples serve to illustrate how socio-technical thinking produces a shift in mindset, opening up a radically different design space from that exemplified by the ICS. Systems such as Patchwork and E-table have been expressly designed to help practitioners to work more effectively, and ultimately, to improve the services delivered to their clients. A paradigm change is needed, and we are in the process of setting up an Open Source Project to help accomplish this, much like better established initiatives on electronic records in healthcare. The proposal for an open source project was recently endorsed in Munro’s progress review of her report, and this seems a sanguine note on which to end:

There is a compelling case for an open source project for children’s and indeed adult social care. We need to harness the design expertise of the sector and produce a sustainable adaptable, iterative system with potential to increase creative capacity and technological expertise in the sector. ¹³ (p. 40)