Arguments about language in the field of social care can often be dismissed as academic indulgence that we can ill afford when people’s lives are at stake. But language can really matter. It not only reveals our assumptions and prejudices, it actively shapes and re-enforces them. And this in turn can affect people’s lives.
Increasingly I struggle with the way ‘complex needs’ has become the standard descriptor for combinations of homelessness, debt, violence, mental illness and drug use.
‘Needs’ seems like a good plain English word but my concern is that it carries the strong implication that the harm experienced is exclusively inherent in the person and not in wider structural inequality. Needs can be ‘met’ or ‘addressed’ by bureaucratised systems, whereas structural inequalities require us all to change or give ground.
‘Complex’ is similarly troublesome. Whose complexity is this? The idea that needs or lives might be simple seems to be a relatively recent invention. Gertrude in Shakespeare’s Hamlet says: ‘When sorrows come, they come not single spies, but in battalions.’
Describing needs as ‘complex’ suggests there is something peculiar and different about them, rather than the inevitable consequence of human interdependence where one problem breeds another.
We see time and again that natural interdependence gets turned into complexity by bureaucratised systems that deal in single needs not in people. Complexity is generated by the way systems treat interdependent problems as if they were actually independent of each other. The reason we have service silos is because systems, whose core purpose is to deliver scale and standardisation, like to keep things simple for themselves. And so the complexity is projected on to the person who ‘doesn’t fit’. Rather than using the label ‘people with complex needs’, it would be far less stigmatising to say ‘needs that the system finds complex’ or more accurately ‘needs that the system makes complex’.
This is my model for public services: incredibly simple front end ideas
behind which all of the complexity has been sorted
out by customer-focused commissioners
LankellyChase and the Social Research Unit recently co-hosted a seminar on Housing First. We heard from colleagues from Denmark, Canada and the UK who described how the lives of people with the most entrenched patterns of homelessness had been transformed by the offer of accommodation of their choice with intensive support then wrapped around the individual.
A beguilingly obvious solution to homelessness, you might think, yet it has overturned decades of received wisdom which held that the more ‘complex’ a person’s needs the less likely they were to sustain a tenancy. In fact, Housing First has shown the reverse: that this approach works best for homeless people who face multiple challenges, people who had previously been stuck in the hostel system because they couldn’t prove their readiness for mainstream accommodation. Which goes to show that people can surprise you.
What Housing First highlights for me is that when you are dealing with complexity, the best thing you can do is try and fix one of the chief variables. If you nail down the housing variable (and it needn’t be housing), this in turn requires you to organise all the other variables behind it to make sure that it stays nailed down. So the role of all the other support services is get behind the housing solution and make it work.
The problem with most of our existing solutions to complexity is that they leave all of the variables completely in flux. So we create ‘system navigators’ whose job it is to spin all the plates on behalf of the client. It is now obvious to me why we favour this model: nobody has to compromise the precedence or priority of their own service domain.
How many commissioners and service directors are happy to place their resources at the service of another commissioners’ outcome, even where the evidence shows that their own outcome would also benefit? Fixing one variable creates an organising principle for other services that is an affront to their autonomy. And it requires service leads to give ground and listen to what people actually want. This is why the challenges faced by Housing First have not been with homeless people themselves but with all the other services and budgets. That is where the complexity has shown up.
Denmark and Canada are not some kind of utopia where enlightened solutions inevitably thrive. They have found it incredibly tough and complicated to make a simple solution work. They had exactly the same tensions over territorialism that we would face. It is just that they took the risk and believed it was worth it.
Translating complexity into simplicity is the job of twenty first century services. We don’t expect to have to get the manual out in order to turn on a computer, car or television any more. Yet we expect the most disadvantaged people in society to contend with unmediated complexity and to do so without a manual.
The iPod might be an incredibly complex product, but Steve Jobs knew he had to make it startling simple for the person using it. He knew that Apple’s task was to sort out the complexity so that it didn’t impinge on its customers’ enjoyment. This is my model for public services: incredibly simple front end ideas behind which all of the complexity has been sorted out by customer-focused commissioners. If we could realise this ambition, then we might suddenly find that we don’t need stigmatising labels like ‘complex needs’ any more.
I really like this piece. You are right that it is not people who have complex needs. It is the system that makes those needs seem complex. It is the endless complex cycles of assess, refer, assess, refer, offer something off a fixed menu, refer, sign post, send away, assess, refer etc. Some people cycle around in this complex system for years with very simple needs. The people working in this system don’t understand it, let alone those trying to get help from it.
Instead of the well meaning role of ‘system navigators’, we should be funding ‘life understanders’. This cuts to the chase. Life understanders would listen to people and find out what matters to them, their strengths and what a good life would be for them. They would pull in whoever is appropriate to help the person in front of them. They would do whatever it takes to help, as long as it was legal. No more referrals, assessment forms, eligbility criteria and sign posting. Just real help when people need it.
I agree that it is bizarre that we expect disadvantged people to wrestle with complex systems. A simple request called “My sister needs help taking her medication” gets turned into multiple forms, letters, referrals, criteria and multiple workers and organisations involved. This complexity wastes money and rarely helps people.
I like the iPod example. Imagine if every customer who bought an iPod needed an iPod Product Navigator to work out how to use it. And imagine if Apple thought it was a good use of money to fund these Product Navigators. This is exactly what we are doing in public services. It would be cheaper to design it right in the first place.