If the public sector is to achieve the task of innovation, integration and improvement in social services, we must learn from our social policy experience, writes Dr Pradeep Philip, secretary of the new Victorian Department of Health and Human Services, and his chief of staff, Dr Vishaal Kishore.
The Victorian government has signalled a time of ‘mega-departments’, of service integration, and of radical innovation in our policy approaches.
The new Department of Health and Human Services sits across service systems that on many metrics rival Toyota in size. We are charged with:
- tackling some of the thorniest problems in public policy, of individual wellbeing, active living, socio-economic participation, and vulnerability;
- integrating social services for Victorians, building on functions and relationships with private and community sectors that have over time rendered extensive service to the public; and
- overcoming — simultaneously — some of the known barriers and dis-locations that have plagued our systems, to the detriment of our populations.
As we strive towards these goals, we have a timely moment to consider afresh, on the one hand, abstract but profound questions of social justice — of inclusion and equality, of participation and of flourishing — and, on the other hand, of intensely practical and urgent problems of social services — their quality, their effectiveness, their connectedness, and their focus.
Systems and governments across the globe are grappling with similar challenges, but it is fair to say that the nut has yet to be cracked — health and human services remain areas in which new models and ways of thinking are demanded, but have not yet clearly emerged.
Here in Victoria, an ambitious new government and new structures put us in an enviable position to take a lead in thinking about these issues.
But if we are to achieve the task of innovation, integration and improvement in social services, we must first learn the lessons of the history of our social policy experience, and second, confront anew fundamental questions of principle, of purpose and of role — for it is only from such an encounter that a new, contemporary and practical approach to social justice will emerge.
Three key lessons stand out, taught to us by bitter experience:
- The tyranny of complexity that hides the human face of social policy
- The need for a focus on wellbeing as the way to make social policy ‘real’ and ‘human’ and as a bridge between services, and towards values
- And the harmony — rather than the contest — of economic and social policy spheres.
Lesson 1: complexity reigns — and masks the personal face of the social
The domain of social services — of social policy — is one in which complexity reigns supreme. Nothing is simple. Few problems can be solved in an isolated way. Connections are rife. Problems are compounded by other problems.
All too frequently clients accessing human services have multiple needs. The majority of clients in one service stream will also access other service streams. For example:
- A survey of young offenders in custody revealed that:
- 35% of offenders had previous child protection involvement,
- 34% presented with mental health issues
- 55% were victims of abuse, trauma or neglect prior to incarceration; and
- in 88% of cases the young person’s offending was exacerbated by alcohol or drug use.
- In 2013-14, around 30% of people accessing homelessness services cited family violence one of, or the main, reason for seeking assistance.
- Alcohol has been estimated to be involved in 50% of all violence between partners in Australia.
Indeed, if the literature on the social determinants of health tells us anything, it tells us this: social, health and economic inequality make gleefully happy bedfellows.
Despite our constant efforts to force regularity and certainty on our social domain, the problems of social policy stubbornly refuse assimilation — the social world is not one of mechanical, clockwork laws of motion. The insights of every form of behaviouralism scream to us that people — their actions, their preferences, their desires and their dreams — simply cannot be predicted reliably. And any time our policy and service frameworks imagine that they can be, our efforts run aground.
Indeed, the problem of mechanical thinking in public policy is not some abstract matter. If you look around at our public sector structures, we can see the consequences of mechanical frameworks in play:
- Discrete service units that manifest as fragmentation
- Department and divisional structures that manifest as silo-ism
- Accountability directed at specific business lines that manifests as disconnection.
As we increasingly seek to recognise and deal with holistic dilemmas, this mechanical, Newtonian, frame becomes less and less ‘fit-for-purpose’. Each day we are confronted with the practical failures of this mechanical approach.
The false sense of security that linear thinking gives is partial — and for all of our rushing for data, for evidence, for logic maps and process engineering, for percentages, for touch points and services — we risk losing sight of the human face of social policy.
Analysis is crucial, but only when connected to purpose. We must never forget that social policy and social services are about more than just figures, providers or even abstract outcomes. They are about human benefits and human costs. About pain and laughter, personal freedom and individual dignity. About years spent with family and friends. About suffering and about happiness.
In short, social policy is about people, or it is about nothing at all. As we recognise and learn more about the human condition, interventions based purely on mechanics are the enemies of progress.
Lesson 2: wellbeing — bridging the divide in services and in values
This brings us to a second lesson — a lesson that teaches us a little about how to make our social policy more ‘human’ and less mechanical.
We must not, amongst all of the KPIs, all of the services and all of the funding lines, lose sight of the underlying and unifying purpose of social policy which is — or at least should be — individual and collective wellbeing.
Our aim must be to maximise as much as possible each individual’s ability to participate in social, economic and community life; put another way — to vouchsafe as much as possible the ‘good life’ for the publics that we serve. We are in the business of individual and collective aspirations, and this focus on wellbeing represents the next stage of a movement:
- In economics: from wealth and output maximisation to considering the effectiveness of that wealth in satisfying human wants
- In human services: from focusing on vulnerability, given pre-existing factors and history, to focusing on capabilities and resilience — an adaptive and evolutionary notion
- And in health: from a focus on illness to one on ‘wellness’.
Wellbeing is the currency, in a sense, in which we should now trade across all of social policy. It embodies aspiration and progressive, continual improvement. It is deeply personal and experiential, reconciles the individual in the context of the population, and recognises that the history and geography of individuals and populations matter.
Wellbeing necessitates bringing values into our debates about social policy in ways in which they have perhaps been absent in recent times. A world of efficiency and of social-policy-by-engineering becomes less able to grapple with questions of values, of purpose, of the components of the ‘good life’, of how things should be.
To this, a wellbeing focus can be an antidote, bringing to the fore ‘the normative’ and putting the citizen — as she always should have been — at the heart of the economist’s social welfare function.
Make no mistake, a focus on wellbeing takes us beyond the physicality of illness or indeed of deprivation. It gives us a glimpse not only of the ‘good life’ for our people, but of the ‘just society’ for our entire community. It is the bridge from where we are to the place where justice itself demands that we go.
A focus on wellbeing also starts to help us grapple practically with some debates that have long distracted attention in social policy. A good example of this is the debate about equality and inequality.
Philosophers have long sought to understand the value of equality, manifesting in different ways of thinking about what kind of equality we want. Equality of income? Of resources? Of outcomes? Of the so-called ladders of opportunity? Social policy has not well-assimilated these debates, finding it hard, perhaps, to make the concepts tangible.
Importantly, a focus on wellbeing can help us to understand what is wrong with inequality in quite practical ways.
To be sure, measuring wellbeing and its improvement is hard. But when significant gaps in wellbeing confront us, we recognise them and feel a compulsion to act. Inequality of wellbeing is fundamentally about:
- unbalanced burdens of suffering
- differentially crimped life-chances
- unequally tainted standards of living.
Inequality of wellbeing is about some people living in misery, hardship and ill health, while others do not.
- An aboriginal child is 10 times more likely to experience an out-of-home care placement than a non-aboriginal child.
- About 1 in every 20 Victorian adults reported having run out of food at some time in the previous year, and was unable to buy more.
- Here in Victoria, those living in the 3% most disadvantaged postcodes are 3 times more likely to be experiencing long-term unemployment or to have been exposed to child maltreatment.
We know inequality in wellbeing when we see it and we feel a compulsion to act.
It is surely not beyond our analytical powers to develop approaches to measure that which we can certainly recognise.
So — lesson 2? Focus on wellbeing as a way of humanising social policy, integrating effort, increasing impact, of bringing pragmatism to debates that have long-haunted social policy, of truly placing the citizen at the heart of public policy.
Lesson 3: harmony of the spheres — the flawed priority of the economic
Now for the third lesson — which concerns how to think about social policy and wellbeing in the context of public policy more broadly.
There will be some amongst our economist friends who may say to us: ‘wellbeing is fine, but if you want to improve wellbeing, you should improve the economy.’ Social policy, in this kind of model, takes a back seat to economic policy.
This common attitude is also the basis for the idea — very popular in our public debate and policy practice — of seeing health, education, social services as being a ‘drag’ or ‘drain’ on the economy or on the Budget. These areas are seen as parasitic on — rather than contributing to — overall economic performance.
This notion of the priority of the economic and the subservience of a parasitic social policy is simply wrong as a way of thinking about public policy. Let me give you some very simple examples of why:
- if you have hepatitis you will be significantly constrained in your ability to work — provision of health services is in this case a condition to your economic participation;
- or consider that the labour force participation rate for people with 2 or more health conditions has been found to be about 52%, as compared to 75% for people with 1 condition;
- or note that — unsurprisingly — domestic violence perpetrated against children has been associated with welfare receipt, unemployment, and reduced productivity as an adult.
What these very simple examples tell us is that social policy and social services are importantly constitutive of the health of our economy. In this sense, wellbeing is both a cause and an effect of economic performance and social vibrancy. It points to what microeconomics has long known, but public policy has lost some sight of: what matters is the rate of social return.
And indeed — social returns are the very reason that wellbeing and social policy should matter as much to the private sector as the public sector. It is from social returns that grow:
- law, order and social resilience;
- vibrant labour markets, enhanced skills and capabilities, and strong economies; and
- conducive environments for investment and for economic growth.
So caring about individual wellbeing — and prioritising social policy and services — are not a matter of bleeding hearts and emotional policy development, they are intrinsic to our economic and social health. Hard heads can very happily unite with soft hearts for the collective good.
Economic capital, human capital and — critically — social capital are not perfectly distinct spheres that stand in linear priority, but rather we find a need for mutual action across each of these to create a simultaneous ‘musica universalis’ — a harmony, rather than a priority, of the spheres.
A new approach to social policy
What do these lessons teach us about the necessary contours of a fresh and contemporary approach to social policy — and indeed to social justice?
In my view — we find that such an approach must embrace four key elements.
New principles: wellbeing and its improvement — ‘living well’
First, we need to embrace some new values to guide our thinking about social policy — and by implication — social justice. Social policy needs to tell a story of a brighter future for all Victorians.
For me, a starting point can be found in the new department’s mission: to improve the wellbeing of all Victorians.
Focusing on wellbeing teaches us to focus on the needs and aspirations of the person in front of us, to prevent harm, to intervene early and to attack underlying causes:
- Illness must be treated, yet it is better that it be prevented
- Vulnerability must be recognised, but it is better that it not be ‘compartmentalised’
- Remedying disadvantage, dislocation and alienation is important, however we must chase their elimination, not just the softening of their blows.
More than anything else, wellbeing forces us to confront and grapple with the aspirations and the dreams of actual Victorians. Implied in this is also the notion of improvement for all: irrespective of starting point, irrespective of where on Fate’s Wheel blind chance and pure luck has placed someone. For as we know:
- economic ruin does not discriminate between social classes
- cancer and stroke do not attack only the complacent
- family violence does not wrap its poisonous tentacles exclusively around the disadvantaged.
It is wellbeing that is the value beyond vulnerability and illness, and improvement for all the goal for which we should strive. And wellbeing is about more than just the avoidance of ill — it is also about a more flourishing, more intense, more free immersion in communal life itself. Sports, active living, the enjoyment of recreational pursuits are as much part of this story as health care, resilience and avoiding disadvantage.
Call it: all Victorians ‘living well’. This is the task of social policy and the mission of social justice.
A new perspective on services
To realise these values in the real world of public action, we need also a second element — a new perspective on services.
To deliver on the goal of individual and collective wellbeing, we must embrace a person-centric approach to services with an eye to outcomes and experience. If our service systems are to be genuinely ‘for the people’ we must find new ways of grasping the experience of people who encounter our system, and constantly, continually, rapidly, recalibrate our systems around that experience. We must focus not just on widgets, or even outcomes, but rather on the outcomes that matter to people.
We must leverage what have been silos in housing, health and mental health, disability and youth services in order to provide integrated and multidisciplinary care delivered across pathways and over life-cycles. We must find new ways to keep our people active, engaged and participating in social life — not only through classic ‘welfare’ programs, but also through sports, community institutions and recreational participation. Our systems must be linked to place where they should be, with an unerring eye on the experience of the people we serve.
And this new perspective on services will cause us to renovate the platforms and mechanisms that we use to deliver those services — a third element to a new approach to social policy.
We will need to embrace and indeed create new access points, new integrated service delivery across health, housing, youth services — located in hubs close to where people live, targeting people where they are.
And we will need:
- New approaches to triage based upon risk and trauma,
- New approaches to data and its sharing between agencies,
- New ways of planning for pathways and case-management,
- New multidisciplinary professionals and care deliverers.
But all of these must be infused with a new rendition of purpose — wellbeing — and refreshed with an understanding of the person and their primacy in everything that we do.
A new mode of engagement
But none of this will be possible without one last element: a new model of engagement in the policy domain.
It is undoubtedly the case that there are those in the bureaucracy who have long held the conceit that it — and it alone — has the tools, understanding and role to address the most demanding issues of public policy, of social justice. This conceit is false. We must create a new and inclusive policy development dialogue with providers, users and our workforce if we are to genuinely achieve the goal of ‘living well’ for all.
We must make more porous the walls of the public sector and embrace notions of co-design and collaboration, respecting and leveraging insight, irrespective of where it comes from. But with this must come a new ethic of collective ownership and responsibility across those who would seek to be part of that conversation.
Government, consumers and their representatives, the not-for-profit-sector, the private sector, workforce groups, peak bodies all have a role to play in bringing forth this new future, but with that role comes responsibility. We must consign to the past the model of government telling, and those outside either throwing stones or withholding their trusted voices from public debate, making it all the poorer.
Together we must address problems of wellbeing and its improvement, and form real coalitions for change in which these problems are jointly confronted and action jointly taken.
So — four limbs of an approach to social justice and to social policy:
- New principles,
- A new approach to services,
- New platforms, and
- A new engagement model.
It is important that these four be simultaneously held in the mind: our efforts in social policy will run aground if we lose sight of one in fervent pursuit of others:
- Jumping to service platforms like one-stop-shops, place-based integration and the like without clarifying first principles and purpose will largely amount to recalibration of what we already have — more of the same, as it were
- Without a different model of engagement, our policy thinking about services and models may forever be off-base, ineffective, and lacking of traction
- Meditation on principles or on ‘becoming more person-centric’ alone will lead to little change at all in the real world without changing also our service platforms.
We must take social policy beyond tag lines and slogans — a new, contemporary and real-world approach to social justice demands nothing less.
Together or not at all
Social justice is about building and delivering to our people a quality of life that they undoubtedly deserve, blind to chance and the vicissitudes of Fate.
And that quality of life depends on building social capital in our communities. It depends upon strengthening connections between people, and creating institutions that keep people well, engaged and resilient, that diminish isolation, reduce disadvantage and tackle vulnerability.
The history of our public policy and our social services has taught us:
- That although complexity rules, the human face of social policy must be not be hidden
- That our underlying purpose must invariably be the reduction of life-crimping inequalities in wellbeing that can persist like chasms across our populations
- And that social policy itself is a precursor to the kind of economic participation and flourishing that we seek.
A new approach to social policy will demand that we learn these lessons well and seek new principles, a new approach to services, new platforms and a new engagement model.
More than anything else, the future — that brighter future, that more just future — that we seek for our people will be brought about by all of us — together as it were, or not at all.
Public sector, private sector, not-for-profit sector — we are all invested in our own ways:
- We all benefit from a peaceful and harmonious society
- We all seek people that contribute economically and we all desire a thriving economy
- And as individuals, we are each moved to ensure that we, and those we hold dear, are happy and free from suffering.
Wellbeing is our collective dream — it is our common task.
And while there may always be inequality in wellbeing, and suffering may ever persist, striving to diminish these is — at the end — the most fundamental and noble of human pursuits: the purest of hopes that we can have for each other and for ourselves.
This is an edited extract of a speech delivered by Dr Pradeep Philip to the Trans-Tasman Business Circle in Melbourne on July 28, 2015.