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The Living Well Dialogues

Introduction

Introduction
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Our journeys of transforming mental health systems across our pioneering sites have revealed a range of tensions that appear to underpin many of the challenging experiences within our mental health systems. We explore these tensions through a series of recorded conversations between people with lived experience, practitioners, managers and strategic leaders.

 

In 2018, we began our Living Well UK journey with four pioneering sites in the UK inspired by the approach developed in Lambeth in south east London. Today, the Living Well approach is shaping mental health systems for tens of thousands of people in Edinburgh, Salford, Tameside, Derbyshire County and York. From the outset, the Living Well UK programme has drawn on inspiration and learning from Lambeth in order to shape a collective journey towards a more co-productive approach to mental health systems and the support it delivers.

At the heart of this, is to value and honour the stories of the human experiences in mental health systems. In our first collection of stories, Waiting for Something Better, we explored stories of lived experience of mental health to reveal different ways of understanding the challenges and opportunities for mental health systems.

 

In our second collection of stories, Working for Something Better, we examined the experience of practitioners and system leaders in striving to develop their Living Well systems. For our third and final collection of stories, we have brought together people from across the UK to have intimate and revealing conversations about the tensions that underpin our mental health systems, and how the journey of Living Well has uncovered new learning and created new opportunities.

Under the surface

The tensions shaping our mental health systems

Whether you are receiving support, delivering it, or striving to develop and change it, mental health systems are fraught with tensions from different perspectives. For example: we might feel paralysed by whether we place our trust in a more clinical form of expertise or a more social one; or we can feel caught between investing in prevention or directing resources to those with the most acute needs; or we might feel we need evidence to determine what support to offer whilst also feeling feeling we need to design support with the people receiving it. These tensions are often experienced as polarising conflicts. They can feel like you have to be on one side or the other; that you are either with us or against us, that you are an ‘us’ or a ‘them’. In short, they shape our identity; the story of what we stand for and who we are in our mental health system. Although these conflicts are so powerfully experienced, strangely they are rarely explicitly expressed or acknowledged, but instead appear to sit below the surface, too daunting to bring into the light of day because of the discord and disruption that might ensue. When experienced in this way, it appears to us that the only way to find common ground is to resolve the tension; either to identify a technical solution - an answer to the problem that the conflict appears to present - or to compromise - for both sides to make concessions on their beliefs. For mental health systems around the UK, striving to resolve these conflicts through solutions and/or concessions has been at the heart of the experience of initiatives for change. Our work across mental health systems has revealed how this approach has led to a deep fatigue for transformation and in many cases a complete lack of confidence that it is even possible. We might be able to reflect on how these kinds of polarising decisions show up for us in our individual lives. To be a parent, we are both there to protect our child, whilst also there to enable often through the taking of what we perceive as risks. To be in community requires us to both care for the wellbeing of ourselves, whilst also caring for the wellbeing of others. As in our mental health systems, we can feel exhausted and impotent when seeking to find solutions to tensions that appear to fail one side or another and ultimately we lose confidence in our ability to be the 'good parent' or the 'good friend'. But what if we didn’t seek to resolve these conflicts? What if instead we sought to acknowledge the tension that is created in order to better understand the beliefs and intentions underpin it? What if by doing so, we could find a new and more shared space where the tensions act to energise and amplify our effort, rather than diminish and corrode it?

Finding the third way

Taking inspiration from Lambeth

During Lambeth’s journey to developing the original Living Well approach, one tension above all was experienced; that of whether we should have a system led by medical expertise often held by clinicians and doctors, or whether we should have one led by social expertise often held by those in the community and in the voluntary sector. For Lambeth, this tension was played out time and time again; both when trying to make strategic decisions for the long-term change Lambeth wanted to achieve and in the day-to-day decisions on people’s mental health support and how resources were prioritised. So how did Lambeth resolve this tension? They didn’t. Instead of setting out to resolve the conflict, they sought to connect with different perspectives and deepen their understanding of the problem. This revealed that it was not the expertise that was polarising, but the way in which the expertise was used in a relationship of support. In fact, both perspectives in the polarity believed that each other’s expertise was not just valuable, but essential for a person to experience good support. The current way the system was organised appeared to put each expertise in competition with each other, creating a dynamic where each felt the need to prove its legitimacy over the other. The effect of this was to package expertise as stand-alone interventions that could be prescribed to an individual. What was required was a more collaborative form of support that placed the person experiencing a mental health challenge at the centre, so that each form of expertise could be tailored and combined. What first appeared to be an impossible and polarising choice between two forms of expertise, became about a choice to move away from a prescriptive to a co-productive approach. This ‘third way’ became the shared story at the heart of Lambeth’s transformation, connecting and energising a system around a previously unthinkable possibility. So how did Lambeth manage to find this third way? Well, the answer is simple; by creating opportunities for people across the system to have human conversations and relationships. From connecting around stories of lived experience, to regular Collaborative meetings, to large scale events bringing together diverse stakeholders- the purpose was always the same - to connect people with each other and create the means for a deeper, more collaborative conversation. In fact, this simple idea was not only in the ways in which they managed the transformation of their system, but in the ways in which they delivered support to people in communities. What this led to was the pioneering Living Well approach, underpinned by a set of new relationships in the system that prioritised collaboration - from new ways of commissioning to contracting in services.

Human conversations at scale

Living Well UK

For the past four years, our Living Well UK sites have been growing new systems of mental health support for their people and communities driven by the same simple principle. Like in Lambeth, by enabling human conversations, our sites have been able to deepen their understanding of the tensions that exist in their systems, find new ways to understand them and to bring into reality new possibilities from the ‘third way’ they have uncovered. However, like in Lambeth, the polarities our sites have been exploring run deep. They are woven into the deep dark matter of their systems. They have shaped the identities of practitioners, they have been cemented in the ways in which power and authority is organised and they have influenced the ways in which people think about their own mental health and the possibility for leading a bigger and better life. The process to acknowledge them, understand them and work to reveal a different way of navigating them takes time. Although Lambeth has arguably been able to influence national policy (such as the Community Mental Health Framework), it has faced the challenge of driving such transformational change as a single area of the UK. As a national programme, we have brought places across the UK together through our national learning events, communities of practice and other activities. This has enabled us to draw together the insight and learning of this collective endeavour, in order to identify a powerful set of tensions that we understand to be fundamental in how mental health systems are shaped and that require continued exploration and learning in order to understand and reveal new ways of navigating.

About

About the Living Well Dialogues

 

Recorded over the summer of 2022, each tension has been explored in dialogue by two people from different parts of the UK who hold a unique perspective.

 

These conversations have been compiled* with narration that draws out the key learning that helps deepen and extend our understanding of the tension. The result is the Living Well Dialogues, a series of podcasts of intimate conversations between people striving to understand how their mental health system is shaped and seeking to find new possibilities to continue to grow their Living Well systems in places across the UK.

 

We would like to thank our funders National Lottery Community Fund. 

 

You can listen to the episodes in any order you like.


Under each episode below is a link to a series of questions we have compiled from each dialogue that you might find useful prompts for wider conversations in your teams or organisations around these issues.

 

You can also find links to the participants of the dialogue.


Participants recordings have been made in situ - in their homes, offices, hospitals, and services. This means that sometimes the sound quality can be affected.

An overview
The tensions we explore

Introduction

Welcome to the Living Well Dialogues.


You might find listening to this Introduction episode useful as a guide to why and how we have created a series of dialogues on these tensions in our mental health systems.

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What do we value?

NHS Foundation Trust lead social worker and trained mental health nurse Paul Blakeman and Edinburgh’s Strategic Programme Manager for Health and Social Care Linda Irvine Fitzpatrick, have a big picture dialogue that explores what we should value and invest in when thinking about the transformation of our mental health systems.

 

They examine the drive for decisions to make best on evidence-based practices that meet the needs of people today that often sits in tension with investing in practices with promising potential to meet people’s needs in the future.

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Where do we place our trust?

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.

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What story matters most?

In this dialogue, mental health consultant Tricia Nicoll and practice lead at Innovation Unit Stacey Hemphill - who were both at the heart of developing Lambeth’s pioneering Living Well approach - explore the tension of what story is understood as being of more validity and importance in our systems: that of the subjective individual person’s experience, opposed to more neutral, perhaps objective, measures and assessments. 

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Whose risk it it anyway?

When speaking with anyone working mental health services, one of the challenges that will be surfaced quickly is how to effectively manage risk.

 

Tameside & Glossop based GP Vinny Khunger and Occupational Therapist in the High Peak Living Well Prototype in Derbyshire Megan Shenfield explore how when considering risk, there is a tension between managing the risk of a specific action for the person and the service, with taking in account the risk within the bigger context of the person’s life.

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Where should the power be?

We listen to poet and Salford Healthwatch trustee
J Ahmed and mental health trust deputy director Becki Priest, reflecting on the conflicts that arise when considering the equity of power in decision making.

 

They explore the tension between the belief that decisions should be driven by people and communities, with the belief they should be made by those with best perceived professional expertise.

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The Dialogues
Introduction au

The dialogues provide a powerful range of learning and insight into the power tensions that exist within our mental health services in England and Scotland. The detailed learning from these dialogues will inform a wider Living Well Learning Report, that will also draw together learning from across the 4 year programme. This will be published in early 2023. 

Together, the dialogues help illuminate learning, not solely on what the response to these tensions might be, but importantly how we might work with these tensions in our systems. 

 

Rather than set out to diminish or compromise these tensions in our systems, these dialogues demonstrate the potential held in human relationships to be in a more generative conversation. Throughout the dialogues we listen in to moments where the tensions are acknowledged and excavated in ways that reveal possibilities that can both shape the day-to-day practices of mental health support, and the future of our mental
health systems.

7 things we have learnt about how to explore these tensions in our mental health systems

1

Keep the
tension
alive

X

5

Create environments where we can hold others and be held

2

True dialogue is about “taking part in each other’s thinking”

6

Nurture the courage to investigate what lies below the surface

3

Diversity of perspectives is a necessity, not a luxury

7

Dialogue is a practice that needs to be developed and supported

4

Trusting relationships are the foundations we need to progress

Learning
7 thing
Credits

Narration

To help guide us through our dialogues is narrator Jo Harrington. Jo is senior associate at Innovation Unit. His involvement in Living Well started in 2010, when he led the design of the original Lambeth Living Well approach and in recent years he has been supporting sites across the Living Well national programme. Jo works across Europe on projects promoting deeper forms of democracy to respond to today’s global urgencies.

Audio and Music

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Special thanks

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Acknowledgements

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Introducing our dialogue participants 

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Jo Harrington

Narrator

To help guide us through our dialogues is narrator Jo Harrington. Jo is senior associate at Innovation Unit. His involvement in Living Well started in 2010, when he led the design of the original Lambeth Living Well approach and in recent years he has been supporting sites across the Living Well national programme. Jo works across Europe on projects promoting deeper forms of democracy to respond to today’s global urgencies.

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Paul Blakeman

NHS Foundation Trust lead social worker

Paul has practised in the NHS as both a mental health nurse and social worker since 1995. He has also been an academic in the fields of mental health nursing, and more recently, social work. Paul is currently the Professional Lead for Social Work in an NHS Foundation Trust in the East Midlands of England.

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Linda Irvine Fitzpatrick

Edinburgh’s Strategic Programme Manager for Health and Social Care

Linda has worked for the NHS for over 25 years and is currently leading on development and implementation of Edinburgh Thrive – the city’s ambitious mental health and wellbeing strategy, which has been the focus of the Living Well programme in Edinburgh. Linda is also a Senior Research fellow at Queen Margaret and Strathclyde Universities. 

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Vinny Khunger

GP

Vinny is a GP Principal in Tameside and Glossop and the clinical commission group governing body lead for mental health. He is also a clinical lead for projects across the greater Manchester area. Vinny has been involved with the Living Well programme in the area since its start 4 years ago.

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Clare Mayo

Integrated commissioning manager for Salford

Clare works for Salford Council and Salford CCG, as an Integrated Commissioning Manager, focusing on adult mental health. She has been involved in Living Well Salford since the beginning of our work around 4 years ago. Clare’s background is as a CBT practitioner and counsellor as well as engagement worker for mental health.

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Stacey Hemphill

Practice Lead at
Innovation Unit

Stacey’s background is as an occupational therapist specialising in mental health and she has worked as a practitioner in a variety of different settings. In her role as programme manager she was at the heart of developing the Lambeth Living Well approach that inspired our national Living Well programme. Today, Stacey is the practice lead for the Innovation Unit and has been working across the UK to develop Living Well systems.

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Tricia Nicoll

Mental health Consultant

Tricia was central to developing the Lambeth Living Well approach, working with commissioners, practitioners, managers and people with lived experience to develop, prototype and establish the approach in Lambeth. Tricia herself has experienced mental health services and works across the UK to support people, organisations, systems and policy makers to grow new approaches that hold an inherent belief in the capacities of people.

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Becki Priest

Mental health trust
Deputy Director

Becki is a deputy director in a mental health trust and the clinical lead for implementing a community health framework. She is a qualified Occupational Therapist and has worked in several areas of mental health. In 2015 she was invited to New Zealand, where she led OT and vocational services both regionally and nationally. She is a keen walker, proud mum and devoted dog owner.

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Megan Shenfield

Occupational Therapist

Megan is an Occupational Therapist by training, with a background largely working within Community Mental Health teams. Megan currently works in the High Peak Living Well prototype team, in Derbyshire. 

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Trudy Griffiths

Mental health nurse and network coordinator for Luton Live Well

Trudy has been working as the network coordinator 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-19 pandemic. Trudy’s background is as a registered mental health nurse, and she has had experience working in all areas of mental health services for over 20 years.

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J Ahmed

Poet and Salford
Healthwatch trustee

J is a poet. He studied economics and marketing management at university before becoming unwell and receiving a mental health diagnosis in 2005.  J has been a trustee at Healthwatch, a representative on advisory and scrutiny boards, and a member of the Independent Mental Health network for the Greater Manchester Transformation Board. J describes himself as someone who has experienced poor mental health but who is proud to have successfully challenged his situation to overcome his illness.

Acknowledgement, credit and thanks

Narration

To help guide us through our dialogues is narrator Jo Harrington. Jo is senior associate at Innovation Unit. His involvement in Living Well started in 2010, when he led the design of the original Lambeth Living Well approach and in recent years he has been supporting sites across the Living Well national programme. Jo works across Europe on projects promoting deeper forms of democracy to respond to today’s global urgencies.

Music and Audio

Music for the dialogues is brought to you by Purrple Cat Creative Commons Attribution-ShareAlike 3.0 Unported Living Well is a dynamic and ‘living’ programme. This means that each dialogue is a recording of a virtual conversation with each participant recording being made in situ - be that their homes, offices, hospitals, and services. This means that sometimes the sound quality can be affected.

Special Thanks

Special thanks goes to Tally Daphu and Dr Jean Harrington for leading and managing the dialogue process. We would like to thank all of our generous participants, who have given their time, energy and insight to make a compelling series of conversations that shine light on the challenging, promising and hopeful possibilities of mental health support in England and Scotland.

Acknowledgement

We would like to thank the Living Well programme funders the National Lottery Community Fund.

*(in partnership with our participants)

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