In the first of two articles looking at Lambeth’s mental health services, Tom Beresford and colleagues set out how commissioners played a critical role in leading radical change
The challenge of austerity has forced leaders to confront traditional ways of working and to adopt more proactive and innovative models - and the London Borough of Lambeth is doing just this. It is exploring new ways of commissioning mental health services, challenging traditional relationships and building a more inclusive, preventative delivery model that makes better use of all resources available, including those found in communities, and among peers and individuals.
The challenge of radical improvement with substantial financial savings is also an opportunity for disruptive change; a catalyst for a fundamental challenge to the structures and cultures at the heart of mental health services.
‘Commissioners are beginning to recognise that real change requires more active leadership’
Rather than simply managing markets to drive service quality, commissioners are beginning to recognise that real change requires more active leadership: shaping markets, convening stakeholders and facilitating a wider process of service redesign and innovation.
A number of characteristics of traditional commissioning practice can disable and inhibit this necessary shift. There is often a misguided anxiety about regulation, manifested in a set of key issues, concerns about “fair competition”, overly narrow and prescriptive procurement, and a binary and short term view of “value for money”.
These barriers manifest risk aversion in commissioning models and practice, leaving commissioners feeling they are unable to take measured risks. Ultimately, this reduces the opportunity for radical innovation and prevents the necessary shifts in structure and culture that are so desperately needed to face today’s unique challenges in public service provision.
Lambeth is at the coalface of mental health. The borough has more than double the average rate of psychosis in England, with an estimated 53.5 new cases annually per 100,000 population aged 16-64.
In May 2012, a review conducted in Lambeth by the Innovation Unit and South London and Maudsley Foundation Trust, found that 80 per cent of the formal admissions to hospital were people already known to mental health services, with bed occupancy stretched beyond 100 per cent.
Lambeth Clinical Commissioning Group realised that it needed a much more open way of commissioning which would deliver more sustainable services and support.
There was a need for a substantial shift in the participation of people who use services and their carers, and of the organisations that deliver that care. The CCG recognised that if these key stakeholders did not co-own commissioning intentions and outcomes, there would be no vision or motivation to carry them out.
Change through collaboration
Lambeth’s proactive and inclusive approach allowed commissioners to bring together those who showed an appetite for change, were open to collaboration and, most importantly, were eager to overcome the risk aversion that all too often holds back radical innovation.
The outcome - Lambeth Collaborative - has created a safe space for system leaders to have frank and challenging conversations that never really had a forum before.
There are a number of new complexities with collaborative commissioning, but as a more open and honest model that carries a whole system set of perspectives and user stories, it is more likely to deliver sustainable whole system change.
‘A more open model that carries a whole system set of perspectives is more likely to deliver sustainable change’
Opening up the process sounds a daunting task but the simplest of adjustments can have a profound impact on culture and ways of working. A monthly open invitation to breakfast in a local social enterprise cafe, run by people with lived experience of mental health issues, was the catalyst in Lambeth.
It provided those wanting change the opportunity to be a part of the conversation about challenges. This platform not only mobilised those committed to the new approach, but also afforded opportunities for simple service reorganisation to take place and resources to be better shared.
New offers like a peer support service and community options team were quickly established to support people out of secondary care and into sustainable community based support and services.
Committing to co-production
The breakfast meetings were just the start. And it was not simply about signing up to a set of principles, but creating a commitment to a wider culture and way of working: co-production, as outlined by Nesta and the New Economics Foundation. The foundation was a shared vision that is not just about outcomes but more of a declaration of “how we do things around here”.
Reminding ourselves and renewing our commitment to the principles of real co-production in conjunction with our shared vision is a critical feature of our sustained programme of transformation.
Having spent so many years entrenched in a system of need and delivery, as opposed to assets and facilitation, means a great deal of time is committed to co-designing what “different” looks like, so leaders do not go off into their separate areas of interest and fall back into old habits that perpetuate a stigmatising and inadequate system of care and support.
At the heart of the commitment to change, we explicitly redefined the commissioning framework and model Lambeth applied. Lambeth’s new approach actively seeks to embed processes of co-production, from generating insights into what is and is not working, to the detailed design and delivery of services.
It has begun to be widely recognised as a model approach, winning the 2013 London NHS Leadership Recognition Award for Patient Inclusivity and recognised as one of six sites for innovation across the country within Nesta’s People Powered Health Programme.
Lambeth Collaborative were committed to creating a more agile and reflexive response to the changing needs of the area’s residents. With so many features of the mental health system requiring change, as leaders intervene in one part, a new commissioning requirement evolves elsewhere. The new commissioning model needed to recognise this instability and facilitate a culture of learning and readiness for perpetual change.
Design thinking, which promotes the notion of prototyping (testing changes quickly and safely) and making continuous, small iterative changes to service and system design, is a central characteristic that generates a more responsive and efficient commissioning process.
‘The new approach is seeing real impact, with a significant fall on referrals to secondary care’
The next step for Lambeth was to tackle a core and central challenge that is shared across many mental health systems in the UK - shifting from a crisis led system to one that truly affords early intervention and sustains people outside of secondary care services.
The Living Well Network ambitiously builds on the Collaborative to transform the landscape of mental wellbeing support in Lambeth. It is asset based, and commits to community focused co-production as the focal drive in relationships between services and individual needs.
By applying the new co-production led commissioning model, people who use services in Lambeth, carers, community leaders, commissioners, providers, clinicians and health professionals have all co-designed, co-developed and now co-deliver a radical new model for mental health support.
The new Living Well Network approach in Lambeth is seeing real impact, with a significant month on month fall on referrals to secondary care.
Tom Beresford is a researcher and project coordinator at Innovation Unit; Denis O’Rourke is assistant director integrated commissioning - Adult Mental Health at Lambeth CCG; and Dr Adrian McLachlan is chair of Lambeth CCG
- In a follow-up article, the authors will set out how Lambeth’s approach to mental health service delivery was developed with communities, and the borough’s ongoing journey to see co-production delivered at scale.