The belief in the need to place trust in staff to be able to make difficult decisions and tailor support to people’s needs is often in tension with having clear standards and rules to make it easier for staff to make good decisions.
Mental health nurse and network coordinator for Luton Live Well Trudy Griffiths and integrated commissioning manager for Salford Clare Mayo explore this tension and seek to find a third way.
‘We need to trust our people and services to adapt support to meet people’s needs’
‘We need clear standards and rules to make it easier for people and services to make good decisions.’
Trudy: I think for me it has been such a journey, being such a clinical profession to work with so many wonderful organisations and communities and it’s opened my eyes up amazing, and actually having that trust with them, knowing that we are trying to go in to the same direction for that individual to provide that support.
Jo [Narrator]: Welcome to the Living Well Dialogues a series of podcasts of intimate conversations between people striving to understand how our mental health system is shaped and seeking to find new possibilities to continue to grow their Living Well Systems in places across the UK.
Where do we place our trust? We might think about trust as a cornerstone of public services. In its simplest form it is about the contract that we, the public, make with our public institutions to provide the best possible expertise and support for us, our families, and our wider community. One way that we have tried to build trust is to provide continuity in the public services that are provided, try to meet expectations, and ensure that everyone receives the same level and quality of support.
Our approach in public services to achieving this is to drive a greater level of standardisation and to have clearer and more actionable guidelines and rules for public service delivery. Now this logic makes sense to us because it has been at the heart of some of our big stories of success in the business world. For example, we know we can trust that when we go to a McDonalds in Southampton that we are pretty much going to get the same burger that we would in Aberdeen. However, the risk of standardisation has been that it can struggle to work when facing high levels of complex needs. When needs are complex, it isn’t simply about having lots of different needs placed one on top of the other that will require different kinds of support.
A complexity of needs often means that each need impacts the other in ways that are hard to predict or rationalise. This can be particularly true for people’s mental health challenges. So, when working with complexity then we often need to adapt support and combine it in different ways to make sure that it is appropriate and effective, and this requires a great deal of skill and flexibility of those delivering the services and means that people might well receive different levels or types of support, and this can sit in tension with that logic of standardisation. Can we trust our services to work in this way? Or should we trust in good levels of standardisation instead. This is the tension that Clare and Trudy help us explore today.
Clare Mayo works for Salford Council and Salford CCG as an Integrated Commissioning Manager focusing on adult mental health. She has been involved in Living Well in Salford since the beginning of our work around 4 years ago. Clare’s background is as a CBT practitioner and a counsellor as well as an engagement worker for mental health.
Trudy Griffiths has been working as the Network Co-ordinator for Luton Live Well Network since August 2020. Although they started at the beginning of 2020 work in the Programme was postponed due to the Covid Pandemic. Trudy’s background is as a Registered Mental Health Nurse and she is experienced working in all areas of mental health services for over 20 years.
So, how has the understanding of trust developed through the Living Well Programme in Salford and Luton?
Clare: I guess the first thing that came to me, that first tension, we need to trust our people to adapt support to meet people’s needs … was about the work we did around the ethnographic research, so speaking to people about their experiences and what their journeys were like, what their strengths were and what they needed to support them. And one of the things that people told us was that people were often trying to access help and support but were either told they weren’t poorly enough, so they needed to come back because they weren’t able to access the service, or they were too poorly for a service thy were trying to access and often fell between those two gaps.
And I guess that element of trust for me, really made me think about trusting our population to know when they need support and to be able to trust that if people are reaching out for that help and support that they have assessed what they need themselves and that we need to be trusting of that and work with people as and when they present rather than having that conversation about whether they fit a certain criteria of service.
That feels quite challenging because we’ve got service criteria and to be able to help and guide us about who accesses which parts of the system. But there is something about recognising that when people come forward that they are the experts in their own experience, and we need to be trusting of that and work with people and meet as and when they come forward for support.
Trudy: Absolutely, I agree, 100%. One of the main problems is when people access services they do get turned around and they are not offered any alternative. It’s like, ‘No, you’re not for us, go back to the GP’, which is really frustrating. Really, we should be saying, well, actually, this service may not be suitable, but here’s another service that will cater your needs. And it is about having those frank conversations … and I think us as professionals need to take that on-board, how we respond to individuals.
Clare: … something about that tension of what the service describes as what the needs might be and what the person describes as what the needs might be and feeling that when you are able to share your story that you are trusted in what you are sharing. So almost holding the conversation around somebody’s strengths, that somebody has been able to cope and manage and has lots of resilience and they are bringing all of that with them when they are having the conversation when asking for support - but there’s also that discussion from a service perspective where some of the barriers might be to different parts of the system and sometimes that tension can lead to people feeling that they have not necessarily been heard or that their experience hasn’t been held by those two different parts of the system. So, there is something about how we support the system to be able to hold that conversation and build trust that the person has been listened to, whilst understanding where the best part in the system is for that person to have the support - and it might not be about the system, it might be about the wider community as well.
Trudy: … it’s about having that conversation with that person and being truthful - hear what you’re saying, here are the needs and sometimes, some goals can be unrealistic and again it’s about having that conversation … to explore what goals can be met out of their vision.
Jo: So, trust might start in how we hold the relationships in services with people so that we might better connect with both the person’s expertise in their own needs and strengths and the expertise of those delivering services to help understand and set achievable expectations for their support journey. So, what kinds of conditions might we need in our services in order to hold these kinds of relationships of trust?
Clare: One of the conversations we had around trust was very much about the partners that are involved in the support offer, in terms of the things that people were saying that they needed and wanted to be able to support them and how do we make sure that working as a system and working as that partnership we’ve got the trust to be able to offer that flexibility.
Trudy: In our team it was a learning and reflection once a week talking about our own organisations, how we view risk, frank conversations
Clare: That’s very interesting about that conversation about the learning element of it - a space in the team to learn from each other to share information and I guess there needs to be that trust in place between everybody in the team to feel comfortable enough to be able to share those discussions about what the learning might be and how things might need to change and flex from that learning. … a bit of a learning practice to have a framework that enables you to think about the different ways to supporting people, but to be very flexible … to really think about the different ways people’s needs can be met and not being restricted by having to deliver that in a specific way.
Trudy: Also, I think the trust element, you build that on respect for each partner - the relationship you can build together will enable that. Respect people’s conversations with service users … respect their views, respect how they do assessments or risk assessment and explore together.
Clare: That’s an astute reflection … sitting in the commissioning part of the system and reflecting on the way in which the team works together and what I see in how that team interacts, it’s really positive to see everybody with that same level of trust .. and the relationship between the team being positive. What is really interesting is the trust within the team is making sure you’ve got the right framework and support in place to hold the team, to enable them to have that level of flexibility and trust and autonomy about the way in which they work. We talked a little bit in Salford about the psychology input that needed to be there to help and hold the team and provide a framework about how some of those conversations take place and how people are supported …
Trudy: … that’s why it was important that once a week we had a psychologist and a psychiatrist that we had open discussions with during our reflections. People were called by their names, not by their professions - they were there just to do some case discussions and explore the way that we work … reflect on what worked, what didn’t work … what we could do better, what new ideas we developed ourselves as part of a team …
Clare: … which enables the work force within a team to be a bit more flexible about the ways of engaging with people and the types of interventions that they might put in place. … there is something there about the structure as well as the flexibility and how the two things need to work together.
Jo: The process of learning and reflection sees key to be able to foster the trust within a team to work together in more responsive ways with people. Clare and Trudy describe how respecting one another and drawing on expertise in psychology and psychiatry can help create this holding of the teams. Again, we hear this idea of holding in connection to trust, both Trudy and Clare underline the importance of the ways that relationships are held, describing how creating the right ways of holding a team with both structure and flexibility can create the right ways of holding relationships of support with people. This concept of holding is one that connects with wider theory, like that of psychoanalyst Donald Winnicott who describes the importance of holding environments that balance both creating feelings of security and connection whilst also creating the ability to take risks and to have confidence. But what kinds of foundations might we need to create in our wider system relationships in order for teams to hold each other and hold people in more trusting relationships?
Clare: The conversation about that way of working and the trust in co-production is an interesting one. … in Salford we thought we were doing co-production in a really good way. What we then learnt throughout the process with Innovation Unit and throughout the journey of Living Well, we learnt that actually we could be doing it much better and that we needed much more time to be able to do that, but also much more in depth conversations with people with lived experience to be able to fully co-produce something and co-own what that offer looks like … for us it was very much about developing - almost re-defining what that relationship looked like between providers, commissioners, the voluntary sector, people with lived experience to ensure that we could have that honest conversation and that people felt that they were being listened to as part of the design process.
Trudy: Absolutely … one of the things we tried to do was knock down that hierarchy … you had partners of all different sizes from our main mental health providers to the small voluntary organisations, trying to make an equal partnership for the people, the carers, the professionals, and it gave them that freedom to speak. It was very hard knocking down the hierarchy. People like to be called their qualifications etc, but we made sure everybody was called by names, not by status.
Clare: … we did the same thing. When we first started our design team meetings, our collaborative meetings we had a rule that people would not be coming in business attire, we would be coming in our normal clothes. We were not allowed to wear our lanyards because we were coming as … me coming as Clare a citizen of Salford, rather than someone coming with their professional title or with whatever hierarchy it might bring with it. It was a really interesting first couple of meetings. Some people felt comfortable introducing themselves with their title, some people felt really comfortable just introducing themselves with their name, but it really did challenge that hierarchal traditional way of working and it enabled us to hopefully feel like we were all on the same level, with the same - different types of experiences - but with the same value given to our experiences regardless of which part of the system or part of our life that might link back to. From the start that really helped to embed the way we were hoping to work on this piece of work and really embedded some of those values about how we would respect each other and … each other’s views in the process. That then led to a greater sense of being able to have that trust in the room to challenge each other later down the line.
Trudy: … it’s the simple essence of co-production. People coming together … meeting of the same minds, sharing solutions and also challenging each other, feeling comfortable enough to challenge somebodies’ perspective. You learnt so much through that simple co-production and trust. And it is knocking down the barriers. Some people had a hard time - but we got there.
Clare: And that helps to set the roots and the foundation for when it does become time to do some of that helpful challenge with each other. It feels like it then comes from a place of respecting where each other is. Starting from and respecting the aims that we’ve all got jointly - but with a different perspective. Those initial sessions where those ground roots were embedded … enables you to have the conversations about why something may not be possible or why your perspective might be different and then to work together on a joint solution rather than it being more of a combative discussion about something can’t be done or done in a specific way …
Trudy: Exactly I think it is also changing that language that provided that trust as well. It’s not about what we do, it’s about what can we do as a team, and it opened so many doors.
Clare: It does take time to do that partnership working … to build that trust with different parts of the system. I think there is something about the journey that you need to go on together to be able to feel that you all come from the same place and that you have all travelled that same road together. And to try to bring people in at later stages of the journey can feel a bit more difficult. So there’s other parts of the system that we might want to have conversations with, that we need to keep at the forefront of our mind, and that not all the parts of the system have been through the same journey that we have with Living Well. And so we shall need to make sure that we are going at a pace that enables us to have those conversations … about where we started from and what our vision was and how we have trod that path to ensure that we can bring people together when we come along that same journey together.
Jo: To start with, bringing the conversation back to a human level, coming as a citizen rather than as a professional title, Clare and Trudy described how that simple act helped overcome some of the immediate challenges of the established hierarchy that existed in the system and created the foundations for trust. We hear how trust is not only important to bring people together but to create the conditions for helpful challenge and conflict when it is needed. But Clare and Trudy highlight that building these foundations is a process, a journey and one that takes time. The challenge then is how the wider system responds when it’s not been on this journey with us. How do we engage those who haven’t been part of building these foundations? So, what did we learn from Living Well about what we might need to pay attention to in order to take the rest of the system along with us on this journey?
Trudy: I would say within Luton Live Well I think the trust was quite powerful within our team. We trust each other, we trust each other’s skills, knowledge, the reflection we had, we felt we were able to approach each other. So, within the huddle, the network, the trust was very, very - very, very good. It was quite powerful really. The outer organisations, I think it was more to do with they weren’t sure what was going on, so it’s about trying to bring them in.
Clare: I guess there is something about the leadership within those conversations holding that vision - and holding the space for those conversations about different parts of the system and what those different agendas might be, what those different challenges might be and how we understand each other’s perspective, to be able to build those relationships up. And recognising that historically throughout services we’ve had to have quite strict criteria around services - quite strict inclusion/exclusion criteria for example in terms of accessing services and to then have the conversation about what that might that look like if it was different can feel quite scary and quite uncertain to be able to work through and I think those of us who have been part of that Living Well journey and explored some of that in a bit more detail probably need to keep in mind that that’s quite a scary conversation and that we need time and space to be able to unpack that together.
Whereas if we have the discussion from the beginning and are able to take people through that journey and work through it together so that we can understand what the challenges are in the other parts of the system - then it enables us to come to a shared understanding and hopefully a shared solution.
I think otherwise you are enforcing something on a part of the system that you might not know the detail about or might not understand the detail of Living Well. And I guess we had a lot of conversations and am still having lots of conversations about how we manage that. So, thinking about our governance arrangements to ensure that the trust that we have as partners and as commissioners is held and supported by a framework.
Trudy: I think for us the Lived Well was put to one side and therefore people stopped focusing on Luton Live Well and focused more on the transformation work. In fact, it should have come together. And so, there is a little bit of distrust from some organisations feeling overwhelmed that a larger organisation may be taking over - well, it’s about having that clear conversation that it is going to be built in, it is going to be part of the transformation, and it was more about communicating effectively and I think sometimes some people just went in too fast - “this is what’s going to happen. These are the changes.” Yeah, but it’s like - we’re here. We’re still here. Where are we going to be sitting? And again, it is about communicating effectively.
Clare: I would agree with those challenges around communication - that’s where we can have the impact potentially on trust. And I think we need to think really cautiously and carefully about the process that we go through when we are establishing something like Living Well, or wider Community Mental Health transformation to ensure that we are communicating with the right bits of the system at the right time and we’re communicating with our communities at the right time, because without that, I think that is where some of those challenges come in around understanding peoples motivations, understanding the wider vision. I think that can cause quite a significant challenge around the trust.”
Trudy: … and reflecting on what we have already learnt and bringing that forward into the new ways of working.
Clare: And I think the beauty of this work is that we’re holding that learning space so we can continuously keep coming back to what have we learnt, how does that shape what we do next, where have some of the things that we’ve done not worked so well, so that we can tweak that and make that different for the future and I think that learning process supports the element of trust because people can see that you’re learning from that and it’s not just a case of “we’re steam-rolling through with a vision that is going to be implemented regardless”, it’s something that we have developed together.
Jo: Clare raises the importance of leadership in holding these relationships. Central to this leadership is the importance of communication. Too often we believe that good communication is about giving people strong direction, but Trudy and Clare describe a form of communication that is about inviting others into a process of learning. This means that rather than asking them to commit to a pre-baked vision of how things will be, it invites people to make something together. How do we nurture this kind of working that calls the systems together to learn and to make the way forward?
Trudy: Sometimes it’s really hard to explain what we do when its multiple organisations coming into one team, working together with the individual with the needs. It’s very difficult to write it down on paper. Sometimes they have to come in and visually see what goes on and actually hear the conversations that we have.
Clare: I think describing to other people what Living Well offers can sometimes be a little bit challenging because it is working in a different way, so other parts of the system might need to see it to understand what that work looks like.
Trudy: It’s about being open with each organisation and also trusting. The majority of the organisations I have worked with throughout my years in mental health nursing have been outside the mental health services, but I know full well that they have worked with my clients over the years. They know what they are talking about. And it’s about having that trust with them that we can work together.
Clare: And I guess as we look at wider community transformation that just exacerbates the conversation, about how we’re open and transparent about the different things that might influence different parts of the system and the other things that we need to consider as part of the individual organisations. Because there will be visions that sit for each organisation, there will be priorities that sit for each individual organisation and they might be very, very different. But it’s about that transparency to be able to have those conversations and think about that joint way forward together - that’s potentially a very different space to be in than where things might have been previously.
Trudy: It’s using the best resources that we have in our community together and it builds a much stronger community and I think that’s what people need to understand and co-producing, trusting organisations, working together, using all the resources that we have, together, rather than individually, because that is just a waste.
Clare: And I think as well, the ownership of that type of way of working across the community so that it doesn’t feel like the outcomes are owned by one part of the system, it’s a shared ownership across the whole system. From a commissioning perspective, I guess it’s about understanding the outcomes that you want to achieve as part of the wider system. So not just looking at a service, but the community and the wider network that people might get their support from or be engaged with and thinking through very clearly what the shared objectives might be and what the shared outcomes might be, to guide some of that work but not to put a limitation on it. And not to put too strict of a structure around it, because that can sometimes stifle that ability to adapt and evolve to be able to meet the needs of what people are sharing. We’re talking about a system and a community that really supports people. It’s about recognising that that is everybody’s busines and we have to have that connectivity to every part of the system and it’s not the responsibility of a mental health service it’s about the wider network that sits around that.
Trudy: Absolutely, absolutely …
Jo: Mental health is everybody’s business. Clare and Trudy call for our mental health systems to see themselves as a bigger system that holds a shared vision with shared ownership and better outcomes for people. They have described how this requires a radical form of transparency where people at every level of the system can be in a relationship that invites them to reflect, learn and collaborate. This relies on trust as a foundation, and building this trust requires creating the ways of holding people in honest, open, and respectful relationships at every level from the relationships between those receiving and delivering support, to the relationships within teams to the relationships between partners and agencies and to the relationships of system leadership. Clare and Trudy’s conversation reveals that providing better support for people’s mental health challenges requires investing in our relationships at all these levels. It is only by seeing ourselves as part of this system of relationships that we can truly realise the power of our collective capacity and resources to improve people’s lives.
The Living Well Dialogues is brought to you by the Living Well UK Programme, funded by The National Lottery and delivered by the Innovation Unit. For more information visit livingwellsystems.uk.