Your next steps

• 6. Addressing and overcoming barriers

  Pinpointing barriers and mitigating issues will be vital in developing your new model. There is a step-by-step guide in our previous resource, Thinking differently, setting out how to go about working in partnership with stakeholders and experts by experience to co-produce the model, along with tools such as an expert by  experience role advert.

  However, time is short to deliver this redesign, and you may have experienced a number of challenges when trying to complete these steps. You are not alone and common barriers exist across many areas trying to enact this level of change. Through our webinars, interviews and meetings with STPs we have identified these particularly common roadblocks:

  • Scepticism and resistance to change

  Some staff, particularly those who have been involved in change processes previously, may feel cynical about the possibility of real transformation – and understandably so, as past ‘transformations’ have often been prompted by funding cuts. Others may resist change, perhaps because they are concerned about the risks involved, or that such a move will make their work more challenging or workload heavier.

  • Limited notions of what is possible

  Many of those responsible for this transformation will have spent years working in the existing under-funded system – with such familiarity with the way things have been within significant financial constraints, it can be hard to imagine how they could look different.

  • Concerns about the cost or difficulty of delivering better care

  Some believe that better care will ultimately be more
  expensive to deliver!

  • COVID-19 pandemic

  Of course, the pandemic has taken vital time, resource and attention away from many members of staff, reducing capacity to focus on this. Clinicians and commissioners are also telling us they are seeing increased demand and more complex cases.

  • Hierarchy

  This redesign involves dismantling long-held notions by
  some that the medical model of care is superior to other forms of mental health support. People have told us that respect doesn’t always exist between different
  professions, and different sectors frequently use language that can exclude others.
  We have also heard about significant concerns regarding sharing power, decision-making and funding with other sectors.

  • Lack of trust

  Poor levels of trust can hinder the early, relationship-building stages of this transformation. It may be that historically poor relationships exist between one or more of the agencies instrumental to the transformation process, or that those with lived experience lack trust in the direction of the
  transformation due to previous negative experiences of support or attempts at co-production.

  • Prevalence of single organisation agendas

  • VCSE organisations are, in particular, used to operating in a competitive funding environment – this will be particularly prevalent with the COVID-19
  pandemic significantly impacting on the sector’s funding.

  • Putting off involvement of certain groups until later in the process

  We have heard some STPs considering delaying working with other groups, whether that’s experts by experience, VCSE organisations, or the local authority, until their own house is in order first. However, this goes against what the Community Mental Health Framework is trying to achieve and ultimately will not lead to joined up support that improves outcomes for the local population. 

  We have also heard some areas considering delaying engaging with certain populations or communities until further down the line. For example, delaying
  co-producing a model for older adults because commissioning processes with other older adults services aren’t aligned, or finding certain BAME community groups ‘hard to reach’.

  Tips for overcoming these barriers

  1. Use evidence to articulate positive changes that can emerge as a result of the transformed system

  Demonstrate the cost and demand within the current
  system, versus reduced costs possible by providing more proactive care and investing in expanded teams and services that can reduce pressures.

  2. Demonstrate what is possible

  Share case studies included in this guide and elsewhere and consider working with a person
  or organisation to facilitate co-production with experts by experience to innovate and think
  outside the existing system. Engender a culture of positive risk-taking and willingness to
  make and learn from mistakes.

  3. Appeal to what motivates staff

  Encourage leaders to reflect on what motivated them to get involved in this area of work in the first place, particularly moral and emotional motivations such as overcoming injustice and ensuring public value.

  4. Actively dismantle the hierarchy

  Host collaborative groups involving people at all levels - commissioners, CEOs, clinicians from across primary and secondary care, service users - but ensure "lanyards are left at the door." Encourage "human-to-human" interaction and use the space to develop beliefs and values that the group share as citizens, rather than as services, service users or decision makers. Commit to using language that people understand.

  5. Create buzz and momentum around the transformation

  It is important to generate excitement - this is a once in a generation chance to use a large pot of money to get community mental health right. Connecting with staff elsewhere in your region and beyond can support learning and help staff to feel part of something bigger.

  6. Building trust

  Reflective practice is vital in recognising what has and hasn't gone right in the past. Good governance and agreeing ways of working that promote transparency and accountability are all key for bringing down walls between agencies.

  7. Be open and honest about how people may feel and address barriers head on 

  Sweeping issues under the carper could ultimately hinder your transformation process in the long term - be real with staff about how they are potentially feeling about the proposed changes. Strong leaders at all levels of the partnership have a role to play in doing this.

  8. Bring people together digitally

  Due to the COVID-19 pandemic, many early implementer sites have had to make use of technology to bring together transformation partners. In Somerset, they have found that this has made it easier for all parties, particularly smaller VCSE organisations, to find the time to participate. Ensure that digital inclusion is considered when recruiting expert by experience leaders.

  9. Think about how everyone can be involved from the start

  To ensure balance and avoid gaps further down the line, it is important to involve a range of partners from the off and consider how you reach the entire population. Its worth taking a moment to reflect from the perspective of those in need of care, support and treatment. 

• 7. Measurement and evaluation

  It will be vital to measure and evaluate the efficacy of your model, without rigid targets undermining the person centredness of what you are trying
  to achieve. Ensuring sufficient resource now should result in evidence on what works and what doesn’t in the community to secure resources beyond the three year transformation.

  Measurements should include service user experience, recovery metrics, time-to-access metrics (such as four-week waiting times), and system focused measurements (e.g. reduction in A&E admissions). These will enable the model to work for service users and carers, as well as helping organisations demonstrate its effectiveness and identify where further work is needed. It is important to consider how different treatments (including evidence-based psychological therapies) are resulting in clinical improvement and progress to recovery. Of course, to deliver this in practice, your evaluation will need to be co-produced.

  It is crucial in the new joined-up local system that all providers involved, including local authority providers and those from the VCSE sector, share measurements and are able to input into the same system. Ensure that the administrative commitments with regard to outcomes are manageable for all sizes of provider – this will encourage inclusion of micro-organisations and support groups within your VCSE alliance as it continues to evolve.

  You may consider investing in additional resource within your system to support data collection.

• 8. Commissioning and contracting

  At the heart of the Community Mental Health Framework is a shift away from solely clinically-run services to VCSE-led services. This requires giving away some leadership, power and funding for the greater good!

  The commissioning process is important in ensuring that this funding and power reaches the right places, including VCSE providers who may be small but very much represent their communities. In Somerset, this has been achieved through the development of a VCSE alliance – more details on this are available within our first guide.

  It is vital also that a co-produced model is in place to provide a strategic foundation for funding and power-sharing that is based on an agreed future direction between partners.

  Other benefits of alliance-contacting:

  1. Aligns providers on outcomes - providers are collectively accountable for the delivery and achievement of outcomes. All providers are working to a single performance framework, meaning risks and rewards are shared based on performance across providers.

  2. Flexibility in terms of outcomes - unlike traditional bilateral service contracts where outcomes are usually strict and predetermined, chane and innovation in delivery is both expected and encouraged.

  3. Active role of commissioners - unlike other models (e.g. lead provider), in which the majority of responsibility is handed to one provider, commissioners are an active and equal member in alliance structures and can influence change during the contract.

  Successful alliance contacting relies on he VCSE sector working in a united way. Commissioners being clear from the early stages of transformation that they will be looking to procure services via an alliance model providers both permission and impetus for VCSE providers to begin engaging in a different, partnership focused way.

  This aligns with the direction of travel of Integrated Care Systems and the role of VCSE partners within them, as set out by NHS E and I in their recent publication 'Integrating care: Next steps to building strong and effective integrated care systems across England.'

• 9. Recruitment and skills development

  Those with lived experience of moderate to severe mental illness make it clear that when they have received good support, it has rarely been the responsibility of a single person or service. A number of varied roles and wrap-around support from a joined-up team are vital components of keeping people well. Community support should complement, not replace, clinical care.

  Your workforce requirements will be based on the co-produced model of care. It is likely they will include a much-expanded multidisciplinary workforce, including new roles such as peer support workers and embedded staff members employed by VCSE organisations.

  Health Education England's mental health programme sets out these new and expanded existing roles in more detail.

  Social prescribing and care navigation

  It is important to link up with other local priorities, such as the social prescribing roll out within Primary Care Networks (PCNs) and ICSs. Social prescribers can play a role in linking people to the broader range of local, non-clinical services identified in your earlier asset-mapping exercise which should be available and integrated in a new community mental health system.

  Training

  A transformed community model of care will involve a culture change in how support is delivered. Training and learning opportunities are imperative in ensuring that staff are equipped with the necessary knowledge, confidence and ethos to successfully deliver your new model of care.

  For example, even if dedicated link workers exist within your staff team, it is important for all of those on the front line to be aware of what is available in the community. This is particularly important for staff who frequently serve as a first point of contact for those entering the system.

  Building understanding of mental illness is particularly important for staff in services who do not traditionally specialise in mental health, whilst tackling stigma and removing preconceptions, particularly those which relate to certain diagnoses, remains crucial to the delivery of holistic, person-centred care.

• 10. Co-delivery of your new model

  Having successfully navigated the previous steps, your partnership should now be ready to start delivery.

  Your co-production group should continue to meet and communicate to keep developing and evolving your mode, assess its efficacy and address any blockages that arise during the early stages of delivery.

  Spreading the word about your new model

  It is crucial that you not only spread the word about your new support offer, but do so in a way that is accessible and will reach those in need both in and outside of the system. For the aspirations of the mode to truly be realised, all of those with moderate to severe mental illness must be made aware of what is available and what they are entitled to.

  Work with experts by experience and the VCSE to co-produce communictions around the model with consideration of how these communications will reach different groups with particular needs, such as older adults, BAME communities and those facing digital exclusion.

  Experts by experience can help to share plans for change with their networks to begin to raise awareness amongst existing and potential service users.

  Providing support during the COVID-19 pandemic

  This transformation is taking place on the backdrop of the unprecedented circumstances created by the COVID-19 pandemic. It is understandable that the agencies involved in this transformation may be concerned about capacity and, indeed, about how joined-up, person-centered support can be delivered in this context.

  However, given the increased mental health need emerging during this pandemic, the Community Mental Health Framework provides the solutions to address the challenge ahead.

  Many early implementer sites and other areas spearheading good practice have found that the pandemic has provided impetus for them to spring into action in terms of delivery, to meet the demands of the crisis.