Creating a new landscape for mental health - with
co-production at its heart
Living well collaborative
With Lambeth Clinical Commissioning Group & Lambeth Council, London, UK
Over the last 7 years Lambeth has been radically transforming mental health services, driven by a shared goal to help everyone who is experiencing mental health difficulties to recover, stay well, make their own choices and participate on an equal footing in everyday life.
Led from the start by a small but determined collaborative of commissioners, providers and people with lived experience, Lambeth has:
- Crafted and kept alive a compelling vision for the whole of adult mental health provision – that “every citizen, whatever their abilities or disabilities, can flourish, contribute to society and lead the life they want to lead”
- Defined a set of system-level outcomes for all service users
- Co-produced a set of cutting-edge services that are helping many more people get help when they need it in primary and community settings
- Moved to an alliance model of commissioning that is driving collaboration among providers and integration of services
- Used innovation, service design and system change to manage significant budget pressure.
Lambeth’s story has important lessons for commissioners and providers who want to reduce cost and activity in secondary care, and, in line the Five Year Forward View, put early intervention, prevention and co-production “at the heart of commissioning and service design.”
average waiting time to get help and support on mental health, with high thresholds and eligibility criteria stopping people getting help until they were very unwell.
Up to 3/4
of referrals into secondary care could have been managed in primary and community settings.
Support available not helping with practical and social problems affecting mental health (housing, debt, social exclusion).
Service users telling their story many times because of fragmented care, repeated referrals and handoffs.
The Lambeth Living Well Collaborative is a coalition of local stakeholders (service users, carers, voluntary sector providers, primary care, social care, commissioners and secondary care), who first came together in 2010 to start to drive change in the mental health system. They recognised the existence of long-standing challenges that weren’t being addressed by ‘business as usual’: poor service user experience and disjointed care pathways, secondary care services struggling with high caseloads, over capacity in hospital wards and reducing budgets.
They wanted a new system that could shift investment from secondary to primary and community care, make it a lot easier for people to get help where and when they need it, focus on people’s assets and strengths and blend medical/clinical support with social offers that address the wider determinants of ill health.
The Collaborative has:
- Provided legitimacy and authority for change
- Supported co-production at the heart of the change process, and encouraged professionals, service users and carers to work with, not against each other.
- Maintained energy for change among local stakeholders and kept things going when momentum has slowed.
- Held each other to account in achieving the vision.
NEW SERVICE MODELS
Three innovations lie at the heart of Lambeth’s new system:
- The Living Well Hub – the “front door” to mental health services, delivered by a multidisciplinary team from primary and secondary care and the voluntary sector. The Hub is an open access offer, with no thresholds or eligibility criteria, to help people who are experiencing a ‘wobbly day’.
- The Living Well Network – a community of providers, support agencies, statutory organisations and people who help citizens of Lambeth live well by resolving problems that trigger mental ill health, including housing, employment, debt, benefits and isolation.
- The Integrated Personalised Support Alliance – an alliance contracting model that has helped 200 people with complex mental health needs move out of rehabilitation wards into community settings. The IPSA is recovery focused and supports people to improve physical and mental health and work towards goals in education, employment and training.
“The Living Well Network Hub in North Lambeth was launched in 2013 as a large-scale prototype for Lambeth’s ‘new front door to mental health’. The launch marked a key milestone in Lambeth’s ambition to turn the system on it’s head and start to redistribute resources and practice toward mental health prevention and in support of the primary care services striving to reduce the number of people experiencing mental health crisis.” Jo Harrington
Outcomes and impact
supported by the Living Well Network Hub each month, many of whom would not previously had any support at all.
reduction in waiting times for support in secondary care (down from 1 month to 1 week).
reduction in referrals to secondary care teams.
average cost per person - a low cost to alternative secondary care.
THE CHANGE JOURNEY
In the early stages of working with Lambeth, a series of storytelling and co-design sessions over three to six months helped set a bold and shared vision change. The sessions brought together individuals from different parts of the local system and used service design tools (such as stakeholder maps and personas) to bring to life a vision for a system that was poised for prevention rather than crisis.
The creation of a resource map identified the imbalance of funds in the current system – with very little resource going to services designed to help people live well in their communities – and this map was brought to life by peer researchers so they could tell rich stories of distress that had previously existed only as anecdotes of system failure and tragedy. Capturing the words of people with lived experience highlighted the humanness of the system failings and, in combination with the resource map, provided a clear case for radical change.
At the same time Innovation Unit worked alongside Lambeth colleagues to start to build a culture of co-production. A series of workshops generated insights from professionals and service users on how to shift responsibility from the professional to service users, helping to evolve co-production within Lambeth’s workforce.
“Working with the staff has enabled me to build up my confidence in dealing with day to day issues, and coping when things get difficult. I also feel better equipped to make confident decisions and when I am well I enjoy every moment playing with my son.” Hannah
As part of the borough-wide expansion of the Living Well Network Hub in 2015, the Collaborative invested in a practice development hub for professionals. The aim was to support professionals to co-produce new practice built from a foundation of people’s experience, as well as building the capacity for more proactive leadership. By bringing stories of people’s experiences of the Living Well Network Hub, professionals have identified ways to do things differently, and carry on doing more of the things they do well.
Building on the work of the Lambeth Collaborative and the Integrated Personal Support Alliance (IPSA), Lambeth’s Alliance leaders are now planning for further transformation to mental health services for working age adults.
New services will be easier to access (for both service users and professionals) with an integrated ‘front door’. This front door is expected to comprise of:
- Three (subject to further work) Living Well Centres, aligned with formation of Local Care Networks publicly available 24/7, and with mobile teams that reach out to those who need support but are not currently engaging with services.
- A single telephone number and email address, available 24/7, that can be accessed by users, families, carers, professionals and colleagues from other services such as the police and housing.
- A website (and related social media platform), providing information, advice and guidance, self-assessment and other support as technology matures
The services themselves will be integrated, co-located and organised in multi-disciplinary teams that work with users, their families and carers to develop single asset-based support and development plans. Those who need it can also expect a Key Person to build a trusting, mutual relationship with them and support them to navigate the help they need from a menu of targeted support.
There will be genuine 24/7 crisis response with alternative safe options to hospital admission. Hospital support for those that need it will only be as long as clinically required. People can expect asset-based housing options that work flexibly to support them within a home of their choosing. People who previously may have been supported in more restricted settings can expect to be supported through a community rehabilitation pathway.
The aim of the new system is to shift the focus from expensive, overlong and sometimes inappropriate stays in hospital and similar settings to community and home-based services that are joined up and easier to access. A crucial aspect of the proposed system is a ‘Key Worker’ – not necessarily a care, social work or health professional – who will provide trusted and consistent support for the person and help them to navigate the system.