Radical Change Made Reality I Municipal Journal

The emergence of co-production as a credible approach to commissioning and delivering care has been a welcome shift in the way we approach the design and delivery of our public services. But how seriously has it been taken in practice?

Lambeth’s mental health care system has, for the past five years, been doing just that – taking co-production seriously by building a shared vision for radical change in the commissioning and delivery of services in the borough. But what do we mean by radical change?

Radical change is not incremental. It doesn’t represent the tweaking of established systems and most definitely doesn’t just happen on the surface.

It is a fundamental challenge to the status quo, not only in terms of structures, but also culture. It is the unravelling of embedded power structures and established assumptions, principles, practice and language.

The impetus for radical change can come in varying forms and from a myriad of sources. The Mental Health Care system is a prime example, with professionals, people who use services and extended carers of those with mental health issues calling for radical change, specifically in response to the failure of stagnant, overly-prescriptive and clinically- focused service approaches to overcome the issues of stigma and cycles of crisis.

In 2012, Beacon UK, along with Dr Martin Baggaley, executive medical director of South London and Maudsley NHS Foundation Trust, found that over 50% of the formal admissions to hospital were people already known to mental health services.

A review of 750 patients’ notes across South East England identified that over half of all in-patients would have been better supported in the community.

This reality is increasingly common and is contributing to a growing appetite and necessity for radical change within the Mental Health Care system.

There is no place where this is more prevalent than in Lambeth, which has more than double the average rate of prevalence of severe and enduring mental illl health in England, experiencing an estimated 53.5 new cases of psychosis per 100,000 population aged 16-64.

So how is Lambeth tackling these issues? For the past five years, we have committed to an agenda of radical change. We have built a shared vision and platform for transformation called The Collaborative, based on the principles of co-production as outlined by independent charity, NESTA, and the New Economics Foundation (NEF) and through an investment in relationships from across providers, professionals and patients.

Together, The Collaborative has undertaken a programme of development that has aimed to embed these principles not only in the delivery of support to people with mental health challenges, but in the wider system of structures and cultures

We have sought to turn the system on its head, creating more inclusive and bottom-up ways of working, both in terms of service delivery and decision-making.

Simultaneously, commissioners and providers have committed to a progressive vision of a network-oriented, relationship-focused, outcome-led model of services and support.

Providing more and better with less is a central tenant of this model, using a wider range of resources and assets, focusing on resilience of communities and growing people’s capabilities to care for themselves.

Hearing the voices and stories from people who use the borough’s mental health services and the staff that support them continues to fuel and clarify our ambition for a radical and sustainable change in Lambeth mental health.

In the past these stories existed, but were not told openly, nor to a room that contained the leaders and users of the whole system of care and support.

The stories help reveal moments in our system that lack structure, but which are key to enabling better outcomes – as people who use services move (and often get stuck) between primary and secondary care services.

Through co-design and co-delivery, those who use mental health services are able sit next to those responsible for leading them and creating new working relationships, while also describing the failings in the care they receive.

In addtion, service directors from once competing organisations are now working together to consider how they can achieve more with less to facilitate shared and overarching outcomes for all Lambeth residents.

The Collaborative provided the critical mass for a cultural movement using co-production as the central principle. This, in turn, created the platform and authority for sustained change; allowing for ongoing investment in new ideas and ultimately, new system models. For Lambeth, there was significant investment in relationships – engaging over 2,000 people in ongoing design and development of services to build a network model that better incorporates a wider range of the assets and resources available to people and their communities.

We feel we have established a momentum and platform for widespread change, but the wider Collaborative acknowledges that it is only just starting to see the signs of transformation. It is this honesty and transparency in our progress that we need to maintain if we are to deliver sustainable change – a healthcare system that really works for those who need it and one that speaks directly to the stories they share

Published 15 December 2014 - Jo Harrington is a partner at Innovation Unit, Denis O’Rourke is assistant director, integrated commissioning – adult mental health services, Lambeth CCG and Dr Adrian McLachlan is chair of Lambeth CCG and a Lambeth-based GP
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