People not systems

How Innovation Unit’s approach to power and relationships has transformed adult community mental health in three pilot sites.

Over the past four years of the Living Well UK programme, Innovation Unit is proud to have supported nearly 6,500 people with their mental health and unlocked more than £10 million in new investment.

Our pioneering partners in Tameside & Glossop, Salford and Edinburgh have marked new territory in mental health provision, with Innovation Unit helping people and practitioners take the journey together by:

• forging a powerful shared vision for change

• facilitating co-design and co-production

• testing and scaling of new integrated teams

• supporting practice development and leadership

• coaching leaders and building collaborative leadership.

At the release of our evaluation report, we asked partners what has been unique and inspiring about the Living Well approach. We asked particularly about their new teams, the people they help and their path to transforming services.

Three core themes have emerged: firstly, how Living Well systems transform relationships; secondly, how co-production embodies power and involvement; and finally, a focus on people, not systems.

Transforming relationships

Our leaders identified relationships - between practitioners in and across services, those coming to them in need of support, and between the Living Well sites - as critical.

Judd Skelton, Assistant Director for Integrated Commissioning, from Salford, acknowledges "existing good relationships in Salford" but describes the stand-out achievement for their site as "the strengthening of local relationships across people and systems.”

For Judd, the co-creation process of service design, testing, and feedback between those using the service and practitioners is "a true partnership approach, with providers, primary care, people with lived experiences and commissioners all working together to explore solutions.”

For Linda Irvine Fitzpatrick, Strategic Programme Manager from Thrive Edinburgh, true partnership is about multi-disciplinary and multi-skilled teams across the statutory and voluntary sector “respecting one another’s skills and strengths to support people and hold shared values.”

All sites commented on the importance of shared values in 'holding' the work's success. Lynzi Shepherd, Living Life Well's Head of Mental Health, Learning Disabilities and Ageing Well (Tameside & Glossop), said: "staff tell us the approach, vision, and values of the offer are conducive to a positive working environment."

As a result, our evaluation report, covering May 2019 to March 2022, finds "statistically significant improvements in people's satisfaction with relationships with friends and family.” Also, staff employed in the core Living Well delivery team experience high satisfaction levels through sharing skills and expertise across agencies: “... peer workers and third sector staff were pleased to be part of a professional network with the NHS and statutory sector staff."

So what is it about co-creation that enhances relationships and, therefore, the effectiveness of the services?

Co-creation and power

Living Well UK systems focus on meeting people's needs. All the sites talked about the importance of storytelling and co-creation in anchoring their work - especially in how it transformed power relationships and enhanced empowerment.

Lynzi says: “It was empowering for staff and people who have lived experience. Usually, they don't get to be part of the process or have their say in a meaningful way."

Judd and Linda also talk about equal empowerment. Linda said Innovation Unit's unique approach was "inspiring people to collaborate and be involved, treating everybody equally and listening to our local needs and context.” Judd added that "the co-creation process has embedded the flattening of hierarchies across all partners and people with lived experience.”

Anchoring service design in stories is another unique feature of Innovation Unit’s approach. Says Judd: “The most inspiring element was to centralise the ethnographic research in the programme. This approach to lived experience and understanding someone's journey has revolutionised our approach to co-design and co-production. It has created a ripple effect, with influence being felt in wider programmes of work relating to mental health."

People not systems

As our evaluation report outlines, each project dedicated time and space to allow an iterative process between lived experience, prototyping and developing a service model.

A system of 'collaboratives' involving all stakeholders was held every one to three months to diagnose progress, set a vision, hold the broader system to account, and centre the person at the core of the work.

In talking about dedicated time and spaces, Judd says: “The framework for co-design focused our approach and provided an opportunity to build prototyping/testing/learning spaces which could then support innovation and testing. The ‘critical friend’ challenge provided by Innovation Unit was extremely helpful in developing alternative approaches to existing challenges.”

Lynzi talks about the power of story across the design process, noting how they were “bringing real stories of experience to life in every session and using this evidence to appropriately challenge the traditional systems/services and ways of thinking."

Linda recognises that the Innovation Unit approach taught “the value of deep listening, sharing experiences, bringing alive adaptive leadership.”

Judd talked about how the IU's approach – co-creation, co-production, testing and being a 'critical friend' – meant that practitioners felt empowered to innovate:

"Holding a safe space around the vision challenged Living Well Salford partners to think outside of the traditional service approaches and to consider how people's strengths and needs could be approached differently."

This upending of traditional ‘top-down’ approaches is valued by our site respondents, with Linda commenting: “We are opening conversations with people that begin with ‘how can we help you?’”

Looking at the person not the system to create an authentic person-centred approach was critical to the success of Living Well.

Why does it matter?

Demand for mental health support is increasing, particularly after Covid and the rising cost of living. According to the Royal College of Psychiatrists, there were a record 4.3 million referrals to specialist mental health services in 2021. The Care Quality Commission has estimated that up to 10 million people, including 1.5 million children, will likely need additional mental health support due to the pandemic.

Services are characterised by long waiting times, poor collaboration, confusing and inconsistent thresholds leading to people falling between the gaps, ineffective discharge processes, no way to share best practice and an inability to harness the strengths of those seeking support. Reform has focused on improvements to aspects of the service rather than the system as a whole.

Judd, for example, talks of around 4,500 to 5,000 Salford adults who previously fell between the gaps in provision and who would "bounce" around the system and "not get their needs met".

Our evaluation report, covering May 2019 to March 2022, shows that Living Well helps people get the support they need much sooner - with first conversations being offered between 14 and 25 days after referral.

The success of our four-year programme, funded by the National Lottery and evaluated by Cordis Bright, continues to influence our approach. We currently support adult community mental health transformation across Derbyshire County, Greater Manchester and York, in line with the 2019 NHS England Community Mental Health Framework for Adults and Older Adults.

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In the New Year, Innovation Unit will publish a learning report so that everyone can benefit from what has been a remarkable programme.

Contact us if you are looking for new solutions to improve community mental health and wellbeing in your area.

How do we mobilise and sustain transformation? Let's talk about the power of story

Over the past four years, we’ve been creating new systems of community mental health in Living Well sites across the UK including Edinburgh, Salford, and Tameside and Glossop, thanks to the National Lottery Community Fund. So far the programme has supported some 2,500 people who might not otherwise have been helped and generated over five million pounds of additional investment in local mental health systems.

For these pioneering sites, transformation has meant developing new processes, creating new roles, building new services, and developing different ways of operating.

Such transformative change in any system - especially mental health systems - is deeply challenging. Mental health systems in the UK are highly complex and it’s difficult to understand how they work currently let alone to change how they work in the future.

The human response to change

When faced with such high levels of complexity, it is a very natural human response to feel overwhelmed. We are hard-wired to avoid such feelings and so our response is to find ways back into a state of stability and equilibrium - and we often attempt to simplify, to separate, even to detach:

• We try to simplify people’s needs and we try to avoid too many parts of our system being dependent on others
  

• We seek to separate elements of the system from one another, often creating silos and lines of separation
  

• We even find ways to detach ourselves and others from the responsibility for the overall purpose of the system, opting instead for being accountable for a technical function or measurable output.

Such responses, although understandable, have inhibited many attempts to transform our mental health systems so far.

Through our work in Living Well systems over the past decade, however, we have learned how to hold and navigate complexity, to embrace connections and dependencies and to maintain a deep relationship to our purpose. We place the power of people’s stories at the heart of our approach.

We’ve explored what we’ve learned from people’s stories in our previous blogs - firstly understanding the needs of people with lived experience, then reinvigorating shared purpose among professionals and practitioners and finally changing leadership practice.

In this blog, we’ll share how this culture of storytelling can help accelerate and sustain transformative change.

The power of stories

Stories can hold within them high levels of complexity. People’s shared experiences help us to build and maintain relationships and connections while bringing life to what we value and motivating us to take action.

Since our initial work in Lambeth, South London, we’ve used stories as our foundation - as a means to both understand the existing challenges in the system and to create a new desired way of working.

In 2010, Denis O’Rourke, a trailblazing Commissioner in Lambeth’s CCG, developed Vital Link to support and train people with lived experience to gather stories from other people using Lambeth’s services and their carers.

For our part, Innovation Unit trained people to collect and then tell stories from acute mental health hospitals. These stories united people with lived experience and practitioners around the shared values they held for what good support should be and revealed the gap between these aspirations and the reality of provision. Stories from the acute wards, along with stories from other services, became an engine for the transformation of community-based support that Lambeth would go on to pioneer.

Such power of stories has long-been evidenced as a potent means to transform complex systems. Marshall Ganz, Senior Lecturer in Leadership, Organising and Civil Society at the Kennedy School of Government, Harvard, describes how stories connect our values to our actions. Over the past four years in Living Well, our application of Ganz’s theory has revealed three learnings:

1. Stories connect people’s roles to their purpose People working in mental health systems often have an identity that is defined by the technical role or function they play in the service or system. Such identities can deepen a sense of detachment from the real purpose and sense of responsibility for outcomes for people. As Wendy, Chief Executive of Health in Mind Edinburgh in our second storybook book Working for Something Better described: “There were days when we came away thinking - this machine is too big it will never change. I can’t hold the responsibility of making this difference.” Living Well has created spaces, like our national community of practice, for people to talk about why they are here, what motivates them and what they care about. These spaces enable the opportunity for people to begin to reconnect with their own personal story - or their ‘calling’ - for why they are working to support people’s mental health. Marshall Ganz describes this as a story of self, and it is by exploring this story that he says we can each “understand the values that move us to act”.
   

2. Stories connect people with one another The ‘machine’ of mental health systems that Wendy described can feel very disconnected and alienating. Teams and those in them can feel isolated in the system. As Linda, Strategic Manager for Mental Health and Wellbeing, Edinburgh shared in Working for Something Better: “How do you connect with someone when that is just so far beyond your experience of where you’re coming from?”. When we share stories about our own motivations and cares with others, we reveal the values that underpin them. When we feel we hold shared values with others we can feel a powerful sense of ‘us’ - as a collective or community. In our blog about building shared purpose, we explored how creating this sense of community requires developing and communicating what Ganz calls a “story of us”. This is the way we can create a stronger shared identity and purpose in a system that moves beyond the siloed and disconnected teams, services, functions, agencies, etc. As Judd, Commissioner in Salford, said in Working for Something Better: “Being in a room where everyone was speaking the same language, and everyone’s getting it, and I guess coming away, chatting with some of the people with lived experience who came with us and them saying, ‘God, you know, we’re doing some really good stuff here.’”
   

3. Stories build movements that motivate people to act By acknowledging our stories of self, we can create and foster a story of us. However, Ganz argues it is only by acknowledging and communicating both the possibility for better if we act, alongside the risks if we fail to act, that we motivate people to take action. Ganz describes this as the “story of now”. It is by developing this story in conjunction with stories of self and stories of us, that Living Well’s pioneering sites have been building movements for change across mental health systems.

At the heart of our learning in Living Well, is that when we start to tell a new story, transformative change feels very urgent, very difficult, but quite possible. Our support for sites has taken them on a journey to understand and value the power of stories in the transformation of their systems.

By fostering this culture of storytelling - and by guiding our sites in how to establish this culture through new practices, processes and policies in the system - we help ensure that our sites can continue to inspire, mobilise and maintain people in an ongoing process of transformative change.

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If you’d like to talk to us about Living Well, including developing a programme in your area, then please email lwuk@innovationunit.org and we’d be delighted to start a conversation.

Living Well UK Programme is funded by The National Lottery Community Fund, the largest funder of community activity in the UK.

How to say yes: over-coming risk in ACMH

How do you say yes when you’re conditioned to say no? Let’s talk about managing risk

Managing risk is an important part of designing and implementing new services. So when it’s time to transform existing services to better meet the needs of both the people who benefit and the professionals who deliver, how do you overcome long-standing real and perceived barriers to saying yes?

Stacey Hemphill has been working in adult community mental health for 20 years, taking up her most recent role as Practice Lead with Innovation Unit’s Living Well Systems programme in 2019. Over the past four years, thanks to The National Lottery Community Fund, Stacey and colleagues have been creating new systems of community mental health across the UK.

Inheriting a culture of risk aversion

Working as a practitioner, Stacey experienced first-hand the culture of saying no, and now she works with Living Well sites across the UK to help professionals understand, challenge and embrace risk so they can say yes to more people.

As Stacey says: “Whenever I talk about risk, I’m always reminded of the story about the monkeys in a cage who get an electric shock every time they go for a banana. Over time, the monkeys stop reaching out and - as monkeys left and new ones arrived - the received wisdom became that touching the banana is bad and no monkey attempted to take it.

“Within complex health systems, there’s an anti-risk culture which gets handed down and is rarely scrutinised. As a result, risk influences decision-making and, particularly when people present with mental health issues, we find workers frequently refer people to a psychiatrist or a psychiatric team to move the responsibility from themselves.

“These practitioners are not willfully neglectful but, firstly, they don’t recognise that what’s presenting as mental health issues are often compounded by life problems and, secondly, they worry about blame and their ‘professional registration’ should their intervention not work out.

“This fear really limits professionals from saying, as a human being: “I've met this person, I'm worried about them, I want to help regardless of their diagnosis.” Instead they think: “My organisation might not support me because this person doesn't meet our criteria. I’ll end up in the coroner's court being held accountable for decisions that were made and how they were made.”

Shifting from checklists to conversations

In Living Well, multidisciplinary teams take collective responsibility for supporting people who seek their help. We begin by replacing lengthy assessments and checklists, which often justify moving the person along and/or provide a paper trail for worst case scenarios, with conversations between the people and the professionals, using short, open questions which elicit as much if not more information.

As Stacey describes: “We focus on simple questions like: “How’s your life at the moment?” and “Do you worry about your safety or the safety of someone else?” to start a dialogue, rather than loaded questions like: “Have you had thoughts about killing yourself?” or “Is there any domestic violence?” which sometimes scare people and close engagement down.

“Often our final questions like: “What else do you think is important to mention?” prompt the most useful and in-depth responses.

“Then, instead of moving the person on to another practitioner, we talk about what help they hope to find and what strengths and resources they can draw upon, before we make plans for what they are going to do next, what the practitioner’s going to do next and what they’re going to do together.”

Embedding a culture of co-creation

Changing professionals’ practice is hard. One of the most powerful ways to inspire new ways of working, however, is to co-create these conversations with people with lived experience, where professionals hear, respond to and are inspired by the wisdom of people who have used services.

Stacey says: “We give professionals lots of opportunities to practice these conversations out together in a safe way. And we take colleagues to see each other holding those conversations in real life before they practice again.

“We know there's a growing body of evidence now that's been talked about by NICE and NHS England that tick boxes as a way of assessing risk are not worthwhile because they're so often framed in the wrong way - asking people to guarantee they won't hurt themselves tells you nothing about the person in the moment, what resources they have, why they're feeling the way they're feeling, what things could help.

“We also know, of course, that there is always going to be a day when someone is sitting with you and you think: “I'm really worried about this person, there's lots of stuff going on and they might act, or have acted, on these thoughts. This person is really unsafe.”

“At this point, the conversations focus on listening and drawing out people's strengths and resources and building together what other support can be brought in. For some practitioners, this is the hardest part, because they’re conditioned to document everything because, if something goes wrong, there’s going to be blame.”

Managing the discomfort

In secondary care in particular there’s a desire to quantify risk in order to help people avoid risk. In Living Well, we’re asking practitioners to take the brave step to lean into risk, and we help them manage that initial discomfort.

Stacey explains: “We know confidence comes from empowering the practitioners - they have to design and test their conversations, they have to be ready to hold those conversations. People with more years experience already know what to expect when they have conversations, people who are newer feel worried about what they might hear and how to handle difficulty.

“We create safe spaces, therefore, for practitioners to talk about what’s not working for them - so we can figure out whether the conversations need adjusting or whether there’s a skills deficit. There's no perfect right way to have this kind of conversation, we’re constantly learning what works.”

Empowering leaders

A key part of Living Well’s success comes when leaders create a culture of safety around trying new ways of working.

Stacey continues: “We know governance and leadership attitudes make or break practitioners’ confidence.

“There’s a difference between giving permission to explore new ways of working and allowing 50 different approaches - so we help leaders learn what good looks like, and they can guide practitioners rather than demand every single employee works in the same way.

“This leadership commitment to culture change helps make sure new ways of working endure after we’ve gone - and the risk to slip back to old routines are minimised. We also build in mechanisms to hold leaders to account, by involving people with lived experience in strategic planning, governance, developing and testing the offer.”

Making a difference

From the very start of our transformation work, we give practitioners the confidence to take the work forward themselves and we leave the tools for them to keep learning.

The impact of Living Well’s work is captured by Linda, Strategic Programme Manager for Mental Health and Wellbeing, Edinburgh: “The teams were small and part-time, but they have worked with over 300 people. Only about six of these people needed to be referred to formal therapy.

“For us, that was like Wow! If we can extrapolate, what does that mean for our whole system?”

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If you’d like to talk to us about Living Well, including developing a programme in your area, then please email lwuk@innovationunit.org and we’d be delighted to start a conversation.

Living Well UK Programme is funded by The National Lottery Community Fund, the largest funder of community activity in the UK.