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?”



 

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.




A key part of the Living Well approach is decentralising leadership and the work of change, and distributing it to the people who will eventually be asked to deliver what emerges. This is often called co-production and, in our experience, results in new services and new solutions that are far more likely to meet people’s needs holistically and effectively.



But distributing does not mean giving away all responsibility or letting others get on with the work on their own. By contrast, to be successful, leaders must distribute in a way that builds shared purpose and a common identity among and between people.


What is leadership?


Across the globe, there are perhaps hundreds of definitions of leadership - the ability to hold people towards a shared vision, to personally embody the values and mission of an organisation, to inspire others to follow you into the unknown, or, as the ability to help people recover from disaster. Whichever definition you choose, one truth always holds - there is no leadership without uncertainty. When things are going swimmingly, or when there is apparently no need for change, good management, rather than leadership, is required.


Uncertainty comes when you are faced with a challenge, or challenges, for which you are unprepared - for which you have no ready made template or well-rehearsed answer. The challenge creates a breach between the future you had in mind and a different, disruptive future that you can barely see or imagine.


Transforming community mental health


Thanks to The National Lottery Community Fund, since 2018 the Living Well UK programme has helped to create new systems of community mental health in sites across the UK. 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. Living Well is being scaled in Derbyshire, Greater Manchester and Edinburgh.


Living Well delivers on the NHS’s new vision for transformed community mental health. The NHS rightly describes its national three year investment programme (2021-24) as “an historic opportunity to … achieve radical change in the design of community mental health care by moving away from siloed, hard-to-reach services towards joined up care and whole population approaches, and establishing a revitalised purpose and identity for community mental health services.” (1)


Embracing complexity


Transforming community mental health is a complex leadership challenge and one that provokes uncertainty, because:


  • Mental ill health is complex in and of itself, and hard to address - as the Wellcome Trust suggests, globally there has been no improvement in outcomes over the past 50 years. (2)

  • In service delivery, there are many people, teams, workstreams involved, many expectations to meet and many perspectives to understand, embrace and influence

  • Change requires undoing what is already in place - dismantling the old

  • Change requires creation - imagining and building the new

  • Creation requires learning about the nature of the problems with which you are confronted, and this in turn requires dedicated energy and focus.


Creating holding environments


In Derbyshire and Greater Manchester, Living Well is creating new kinds of groups and conversations in which leaders from across different services can work collaboratively to confront complexity. In Derbyshire, a ‘transformation group’ of senior leaders from the mental health trust, local authority, VCSE and CCG come together to build around shared vision and shared purpose, to develop new ideas and to work through conflict honestly and productively. In Greater Manchester, a new ‘coordinating group’ does the same, in addition to trying to create the right culture in which trust and collaboration can grow.


In Derbyshire, we facilitated a ‘design team’ that gives practitioners working in Community Mental Health Teams (CMHTs) the time and space to co-create new principles, and co-design a set of new functions, to achieve the “revitalised purpose and identity” imagined by NHS England. Drawing inspiration from the work of world-leading leadership theorist Ron Heifetz, the design team is an example of a ‘holding environment’ that mobilises others to solve problems by placing the work where it belongs. In particular, Heifetz encourages leaders to consider ways in which they might be holding on to work that naturally falls to someone else.


Distributing leadership


Distributing leadership means decentralising power and enabling others to bring their direct experience and expertise to complex challenges. Handing over an element of control and responsibility can be challenging for many leaders.


Our years of experience in Living Well means we know how to hold leaders through change, helping them to build a shared purpose and a common identity among and between people, while maintaining accountability.


Building community


Marshall Ganz, the globally celebrated guru of storytelling in leadership, points out that leaders often focus narrowly on creating strong relationships between them and groups of co-workers, often through individual line management or leadership of team meetings. For Ganz, this misses entirely the crucial leadership task of actively building relationships among and between group members.


“It’s one thing for people to relate to you [as a leader], to respond to your need, it’s something else to relate to each other.”

Marshall Ganz


Ganz calls this the ‘us’ - a community who can relate to each other emotionally because they have been helped to draw out the values, experiences and ambitions that they have in common. In Living Well, we enable this, for example, by supporting our sites to gather and share stories of lived experience of mental health issues. The power of connecting emotionally with these stories - however senior you are! - of seeing oneself in them empathetically shouldn’t be underestimated. Stories help people answer the question of why they are here in the first place, why their personal call to leadership has brought them to mental health, and what they want to do about it.


In Living Well, it is this building of a sense of ‘us’ - between and among statutory, voluntary, primary and secondary leaders and practitioners - that has enabled trusting and creative collaboration and a sense of shared purpose, and which in turn has been crucial in successfully designing promising new services that have real potential to genuinely improve people’s lives.


Yet communities of ‘us’ are rarely nurtured by leaders in the public sector. Without them, teams and groups of people may co-exist, co-operate and even collaborate, but they won’t feel and act like a community, or bring their full selves, or their full commitment, to the work. They will continue to see themselves as separate, disconnected actors working in siloed teams and inward looking organisations, unable to think and work as a single organic system. They will continue to privilege their own priorities, power and resources, and so fail to deliver the flexible, integrated system that the NHS has imagined.


With more than 10 years experience in transforming adult community mental health, we have the knowledge and expertise to hold leaders through the uncertainty, and complex challenges of change. To address our country’s worsening mental health, we know how to support leaders with the foundational task to actively create a sense of community in the people who are best placed to do the real work of change.

 

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.



When we considered how to evaluate Living Well, we quickly realised the current ways of collecting and evaluating data wouldn’t meet our aspirations to understand how a person had experienced support or a change in their life - or how ‘healthy’ the system itself was in delivering that support.

We also realised that, just as we place people at the heart of deciding what they want from a new system, so too we must place them at the heart of deciding what they think is worth measuring.

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. 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.

Inspired by a model developed by Innovation Unit in partnership with Lambeth, South London, Living Well sites have been designing, testing and learning new ways to build different and better systems of support, thanks to funding from The National Lottery Community Fund, the largest funder of community activity in the UK.

Telling the whole story

Bringing together several systems to provide holistic support threw up many problems when it came to measuring impact:

Consistency: each system collected and evaluated data in different ways

Relevance: what systems chose to evaluate didn’t delve deep enough into Living Well’s new ways of working

Context: evaluation reports didn’t always cross-reference other sources of data or come with a narrative to tell the full story

Disruption: ability to collect data was hampered due to people’s time and COVID

Infrastructure: investment in technology to collect and analyse data hasn’t been made

Skills and capacity: investment in training and time on collecting analysing data and consider its impact hasn’t been prioritised

Rather than attempting to use or and improve current data that is collected, we decided to co-create a Living Well outcome framework by starting from our first principles - working with people who benefit from, and who deliver, the support.

Standard approaches to evaluation focus on counting undesirable outcomes - for example how many people attend A&E - and rarely cross-reference other sources of data to build a bigger picture or indeed come with a narrative to frame the statistics.

We decided that not only would we capture data which measured positive outcomes, we also wanted to listen to people’s experience of the system as key part of our evaluation.

Our ‘holistic’ framework aimed to tell the whole story of both the impact on the people accessing support and the ‘health’ of the system around those people - combining quantitative data in-depth feedback and ethnographic stories.

Creating an evaluation framework

Living Well Systems start with the people they are designed to benefit. Our research, conversations and work with people with lived experience, staff and system leaders help us understand the challenges in the current system and co-create our vision for a better mental health system.

We facilitate a collaborative space where stakeholders reflect on the story of their system, what is really happening now, and make an honest assessment of what needs to change.

Across our sites, Collaboratives were set up which included system leaders in multiple sectors, voluntary and statutory practitioners and people with lived experience and carers. These collaboratives held the vision on behalf of the wider systems - and crafted high level outcomes and some specific goals that matched their ambition for peoples’ experience and the impact of the new network of offers.

Lambeth Big Three:

From the high level outcomes and specific goals, we co-created outcome frameworks - detailed theories of change, starting with high level aims then evaluation outcomes before finally specifying what data and intelligence would be required to demonstrate success.

Every framework focused on two areas: system level outcomes describing the impact of the new offer on service usage; and person level outcomes that provided insight into people's experience of the Living Well offer and the impact in their lives.

Making data simple but meaningful

In our impact blog, we recognise the difficulties and barriers our sites faced with gathering data, and measuring outcomes and quality. We know data collection on the ground is hard to implement and takes time to analyse and act on findings.

Our practitioners were often primary data gatherers in addition to their daily work which, despite best efforts, often leading to incomplete data sets. COVID diminished opportunities for data collection, with heavy reliance on email communication, telephone and even post.

Our new ways of collecting data were underpinned by two principles:

  • limiting the number of questions we asked a person that were for the system’s benefit not theirs

  • providing only the data that would deepen working teams’ understanding of: who they were supporting and their needs; what they're doing well; and what opportunities exist for practice improvement and system development.

To evaluate impact on people who benefit from support, sites chose an option from a pool of standardised, co-produced and holistic self-reporting tools - e.g. REqol and MANSA - and viewed these results alongside data from people’s feedback on how they’d progressed against their own goals set at the start of their support and measured by a goal attainment tool.

Such integrated evaluation also allowed people and practitioners to understand their current situation, areas they may wish to focus on, a person's strengths and preferences and - if used at the beginning and end of support - a person can see their own successes and progress.

To evaluate the system - and to hold ourselves to account against our vision - we wanted to move from a numbers game of how many people we helped to truly understand their experience of support.

We balanced our mix of quantitative measures - including demographics, reasons for seeking support, who made the referral etc - with stories of people's experiences of support now and previously, eliciting the magic and miserable moments of their time with Living Well, their progress and, most importantly, insight into their strengths and aspirations, recommendations and feedback.

Wide-ranging continuous learning

Another important and intentional feature of Living Well’s evaluation culture was bringing data out of dry performance or contract management meetings with senior system leads and into the view of interested system stakeholders.

We began to build a three-dimensional picture of the system which we shared across stakeholders, helping them view the system as a ‘living’ amalgam of people and their collective endeavour and giving them confidence to design spaces to deal with issues such as responding to inequalities or handling the co-location of staff.

Such open, transparent warts and all approach to data aimed to give a shared and realistic understanding of the system - not simply to hold people to account but mainly to inspire continued learning, innovation and improvement.

What have we learned?

Like with almost everything in complex system transformation you are never the finished article - but what have we discovered so far?

System data is more useful for transformation and collaborative commissioning than team or service data alone. As we look ahead and consider what opportunities the development of Integrated Care Systems can offer, one can hope data collection and shared data will become the norm.

Data must be accessible, transparent and understood by multiple stakeholders including people using services and those with lived experience, warts and all, to enable system thinking.

If we want to move to true co-commissioning models in the future we need to demystify data and open opportunities for transparency and discussion. There are many myths and misconceptions about what happens in organisations or offers e.g decisions about ineligibility for services.

Holistic data considering activity and experience, can uncover practitioner and customer behaviour and unlock understanding of how we as humans drive demand and influence service usage.

Data at the fingertips of practitioners leads to increased understanding of real time opportunities for practice development and how the workforce can be shaped to meet local needs.

Data collection remains difficult. We need to prioritise data that measures what matters to people and bring data collection methods into the 21st century so that it is a valuable resource to support systems to put people at the heart of everything we do.

We’ve only just begun our journey to capture and lift marginalised voices as a means of uncovering and addressing pervasive inequalities in access, experience and outcomes.

We want to broaden our ambitions for local populations - so we need to start paying attention to multi-level data that describes person-centred outcomes, system level quantitative and qualitative data and puts it in the context of trends in wider determinants and population health indicators.

When done well, data provides opportunities to make better decisions, to improve outcomes and to make a real difference to people’s lives. We need the skills and capacity to know what to collect, how to analyse and draw insight, how to act on findings - and we need the tech to support our work. Let’s invest.

 

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.



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