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.”
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 firstname.lastname@example.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.