Imagining a healthy system
November 2019

What the day was all about?

Purpose of the day: To imagine what a healthy system supporting those facing severe and multiple disadvantage and complex needs may look like, and what we can do individually and together to make it a reality.

This is the live blog of the day. Thank you to everyone who took part.

9:03 am - Welcome to the live blog!

We’re setting up and our guests are arriving. In the beautiful surroundings of the Friargate Meeting House

9:32 am - Getting busy

People are arriving and the music’s on…

9:49 am - Welcome and introduction

Paul Connery and Catherine Scott introduce the day. And then the check-in–turn to the person next to you and ask:

  • What’s the one thing you’re looking forward to today?

  • What do you want to contribute?

9:55 am - Who we are and why we’re here

 

Catherine talks about the York multiple complex needs network. It came together to look out how to improve the outcomes for people.

Questions include – who are we talking about? What can we learn from other areas of the country? What can we learn from people with lived experience.

 

Today is bringing a lot of that together, and taking the time to make sense of what’s going on in the system – and how we can use what we learn to take the system forward.

9:57 am - Different voices

We’re going to hear from lots of different voices today, including a drama from a peer research group, the Systems Changers group participants, the network and more, says Paul.

You can sit with each group to hear what they have been doing. Then there’s time to reflect and feed back.

9:59 am - Introducing the peer research project

The CERT at York St John University group were commissioned to go out and hear from the people in York with multiple disadvantage. The report was truly a collaborative project.

One of the first things we wanted to get right was the language. We did six in-depth interviews, some short interviews in the community.

Our findings. The top need was access to good and timely mental health report. Safe places to recover, quicker response and shorter waiting times, issues around stigma and respect, knowing where to get help were also important.

10:06 am - Nick on In The Moment

Nick Rowe  introduces In The Moment theatre company, who will be presenting a drama based on people with lived experience. In their research people talked about ‘the open wound’ that had to be healed, and the feeling sometimes that people sometimes felt the were being ‘thrown to the wolves’.

10:08 am - Language and label

A member of the group discussed the labels placed on people and the stigma they can bestow.

Are they suitable in a professional environment?

“We are all individuals with needs… It has been my experience time and time again that the people we are talking about are some of the most wonderfully creative, sensitive… resilient and funny individuals you will ever have the privilege of knowing.”

10:14 am - In The Moment performs

A powerful performance by In The Moment theatre company, based on lived experiences. We will be posting videos of the performance shortly.

In The Moment are part of the Out Of Character Theatre Company, who say on their website:

“We make challenging work for inquisitive audiences with the aim of transcending the boundaries of modern theatre and your perceptions of mental health, claiming the territory between inspiration and medication.”

10:28 am - What people were saying on the streets

Another member of the group told us:

“I conducted interviews with people with lived experience… suggestions included:

– people assume what homes people need rather than interacting with them

– a better dialogue to find out what services were available and ways to interact with homeless services

– access there is to things like GPs is hard for people without an address

– clubs and events: support with travelling costs would be helpful

– clothing is an issue especially in the winter, and property being thrown away

– outreach with vulnerable people and finding out their needs

– a dedicated team of homeless workers who can navigate the system to find out what’s needed.

10:37 am In The Moment: a response

People are feeding back on the theatre performance by In The Moment:

“it’s accurate”

“we need more dual diagnosis”

“if you were choosing for yourself you wouldn’t choose 12 weeks intensive treatment and then it drops off”

“the individual person being given the time to recover… I’d had 14 re-referrals before I got the PTSD order waiting list. The timescales of people when they present to agencies needs to be reduced dramatically”

10:43 am - In The Moment: What was missing?

Responses to this question:

“solutions” one of the main things that came out of our research was the difficulty in finding what support was out there

“the drama was fantastic… but charitable and statutory services across York could almost put forward their own drama in the pitfalls and challenges in responding – and it’s heartbreaking to see some of this. Services want to respond”

“when you get discharged from the community mental health services you’ve got 12 months. If you go over the 12 months you have to go back to your GP”

– “there are some great services in York like the Local Area Coordinators who offer rounded support… we have a model in York, what we need people to do is for people to expand it”

11:08 am Lots to talk about

Coffee break! A chance for guests to talk about what they’ve seen and heard so far, and their responses.

11:22 am Joe Gardham: Social Sofa

 

Joe runs Social Vision, “a consultancy made up of a group of friends who want to make the world a better place”. He was asked to do some work with the non-statutory services on multiple and complex disadvantage in York.

He begins by telling a little of his own story. Joe was born and raised in York. “I was in care as a child and was brought up in a white single parent family.

“I went to work in prisons on the pathways like mental health, housing and so on.

“I was working with lads with the same upbringing as me. I had made one of two decisions which had stopped me going down that path. Having a positive male role model helped.”

11:26 am Outside the walls

York is a beautiful city. But outside the city walls there are problems, Joe said. Children are going to schools hungry, there are families with three or four generations of unemployed.

One of the biggest issues is housing. People’s tenancies are being dropped to three or six months. Student accommodation is displacing.

11:33 am The Social Sofa

Joe is explaining his idea of the Social Sofa. Other consultations weren’t necessarily talking to people in Bell Farm, Tang Hall, Acomb, Haxby and similar areas.

Social Vision took a sofa out to these areas and asked:

  1. What do you love about York?

  2. What would you change?

11:36 am The film

 

Joe screens a film where he had invited people both with lived experience and with a professional interest to an exhibition about multiple and complex disadvantage, and asked them to talk about the issues including: “Why is there homelessness in York?” and “how do you solve homelessness?”

11:52 am Responses to York’s homelessness problem

After the film, Joe asked what we can do about homelessness in York. Some responses:

  • The cost of social housing in York doesn’t add up. There’s an illusion that the city is affluent

  • Benefits and Universal Credit are a problem

  •  Affordability is a big problem – trying to find accommodation here is awful, it’s not welcoming

  • There’s a lack of council properties. But why are we taking two or three months to make a flat safe for someone to move in?

  • Early intervention is critical. Kids get messed up. We need to break the cycle

  • York is the 15th least affordable city for housing. There are so many people who are just managing. There’s no resilience in the system. It only takes one thing – ill health, relationship breakdown, job loss – to tip people into homelessness

  • We need to try to understand why people are on the streets – they may feel they can’t cope with the benefits system

  • There are enough types of accommodation for the needs that are out there

  • If York’s such a flourishing city, build houses rather than selling land for luxury development

  • I’ve experienced homelessness in the past. A lot of people are still lost in the system. Direct communication could be improved. I speak to a lot of homeless guys and they are a bit lost, they don’t know where to turn

  • There’s some big structural stuff we can’t control locally. We can’t control rents locally, that needs to be a national change – perhaps we need to find a voice to demand that political change. Housing should be a right

  • In Finland, when they approached a vulnerable person, the first thing they did was give them a home. That was demonstrably effective

  • It’s easy to demonise services, like the council. We need joint accountability. It’s not a problem that sits with one service

  • I’ve seen how much work has gone on in areas like Tang Hall and Acomb which have made a big difference. But getting social housing through the planning system is very difficult and time consuming. It’s about a system that has individual care at its heart

  • When we’re in rooms who work in the system, who get up every day and try to make things better, we forget there are people who think homelessness is a choice. Not everybody believes housing is a right. We should tell the stories, that’s the best way to make the case

  • York adopted a Housing First policy in 2015

  • Finland started its approach in the 1980s. And only now are they able to house everyone. And they have had sustained political will supporting the programme.

12:07 pm An introduction to Systems Changers

Paul Connery introduces the Systems Changers programme, which he facilitated with Oliver French, and which finishes today.

Systems Changers has been developed by Lankelly Chase to take people in a system through a process. York is the first city where the system is the same for all the people going through Systems Changers programme. There are three parts to it:

  1. Seeing the system – tools and approaches to identify issues

  2. Finding the flex – some things are too big for one city or group to change, what are the areas you can influence

  3. Experimenting with change – techniques to try to do things differently

The group began with 14 and finished with 11. The group has bonded well, and in some ways are a microcosm of the system.

Over a number of weeks we identified about 50 different barriers or challenges in the system. We talked about power – of the individual and the system; we did Deep Democracy; we did some prototyping of things that might make a difference.

It’s been a real journey. Having that time and space over six months to reflect has opened up a lot of things, and to see what creativity is there ‘locked-in’ the system.

We were only together for 11 days – in some ways we’re just getting started. The Systems Changers want to use what they’ve learned, share what they’ve discovered, link in with other initiatives and harness the collective.

1:22 pm We’re back!

The afternoon is back on, with Catherine Scott from Healthwatch York introducing. People have ten minutes per table to talk to the group on that table, then move on. It’s shift and share!

1:30 pm Station 3 – Power:

There is an issue around power within the system. Somehow we need wider conversations around who wields the influence. There are obvious centres of power – council, certain charities with large contracts.

Power starts at the top and comes down. In a ideal spread of power it would start with people’s lived experiences. Is there a way to change the decision making process to involve people who use the services.

 

These issues are so complex and interrelated you want elected members to be immersed in it and have these conversations. Trying to distil two years of experience into three bullet points is frustrating.

 

Councillors need to be shadowing officers and organisations.

 

We discussed the idea of building better relationships. In Systems Changers we came together. There was tension in the group because of the misconceptions about each other’s services so we set up shadowing one another.

1:39 pm Station 4 – Causal loops

One thing we spent our time on the Systems Changers programme was how these loops affect the systems we work in. It’s a very practical way of looking at something because you can see the issues in front of you.

Jennie Cox from LAC: A feedback loop is something where something gets really stuck. You can use a causal loop at an individual level, or an organisational level, or system level.

Example of a causal loop: Behavioural responses in the system with BPD/EUPD diagnosis. It demonstrates a self-fulfilling prophecy of a person labelled in a certain way who then gets angry and isolated which results in the practitioner’s behaviour being reinforced – and you are stuck in the loop.

You can’t address these problems from one place. You need a collaborative approach. The more places you can break the loop, then the bigger the impact. So in the example above, you try to work on the individual’s behaviour and the practitioners behaviour at the same time.

Question: trying to tackle several loops at once, is there a danger you will be biting off more than you can chew?

Response: We will be concentrating on the challenges we’ve identified in commissioning challenges. And some of the easier wins are things like sharing stories more widely, which we can do right now.

It’s easy to get overwhelmed by the scale of it, but the more you break it down the more manageable it becomes.

Response: You need buy-in. It would be good to share this with my team, and think about how we can apply this.

It’s a really good visual to see where the problems are – to say this is the merry-go-round we’re stuck on, how can we change it? The more repetitiveness in the system, the worse the arrangements get.

1:52 pm Station 5 – Drawing a solution to ending homelessness

2:06 pm Station 6 – the Network

Kelly Cunningham: The network was an opportunity to create a meeting that was different – not operational or strategic. But a space for everyone – people with lived experience, those with day to day work on the front line, commissioners – to discuss change. It has been challenging at times, people have come with different agendas. But someone of the tangible things that came out of the network include peer research, Systems Changers, a trip to Trieste to look at their system. So it is having an effect but what next?

Paul Connery: Some of the network responses coming through include getting people’s voices heard, which is starting, including with today’s event. Have we got the right people in the room? There’s been a tension over the network aiming for specific goals, and having an open space for discussion. At one meeting we had people from Exeter and Gateshead talking about their journey. Out of that came the feeling that there are people with creativity ready to be unleashed.

Responses:

– Could you pilot some schemes based on good practice? Could there be joint working, for example?

– It is having an impact. I take things from Network meetings and feed them into the work I do. But the fact I do come back means it must be useful to me. We should keep it going. If we can identify some small prototypes, and have a concerted push on this, that would be brilliant.

– In terms of multiple complex needs, homelessness has been identified as the only tangible issue that stands out. Working in homelessness we seem to be taking a lot of flack, but we need to recognise the limited resources.

– It’s about more than putting a roof over their head. It’s about building their confidence and resilience which takes time.

– One challenge to the network might be, in your daily experience bring in the voice of lived experience.

2:20 pm Station 1 – Theming the questionnaire answers

These are all answers to the answers to the statutory sector and commissioned service survey questionnaire. Can you put them into themes?

2:35 pm Station 2 – Additional improvement suggestions

People studied two lists – suggestions by people with lived experience, and suggestions from Carecent and Food Not Bombs. They were then asked to choose the most important one to them.

The suggestions that got the most votes were:

  • Lived experience: access to appropriate help and / or diagnosis for people with mental health difficulties; quicker responses and shorter waiting times

  • Carecent and Food Not Bombs – asking the person what they want help with, rather than assuming you know what they need most; more and better accommodation; and better communication between agencies, raising awareness of services available

This led to a discussion about the housing stock in York. What was social housing was being switched to student accommodation by private landlords who could make more money that way.

“It’s a goldmine for them, but not good for the people who live there.”

“In York the rents are unusually high.”

 3:35 pm Feedback on these questions

  • Emphasis on a person-centered approach

  • People who are missing: with policy-making functions and funding

  • Better pathways to housing to give people choice

  • So much comes out of a session like this it can be bewildering; focus in on the priorities set out at 2:35 pm

  • Visiting other people’s teams to try to practically connect more – so a housing key worker could go into a mental health team monthly meeting and vice versa

  • an app so we could share ideas which could feed into what to do next

  • an explicit commitment for organisations working together

  • bringing together funders and commissioners

  • a number people can ring to find information

  • going out to private landlords, employers and others who are not here but who should be part of the response

  • is it a good idea to stop looking for a single unifying leader but do it for ourselves then inviting people to our party

  • tackling stigma through increased understanding of people’s lived experiences

  • embracing the power of stories without removing that person’s right to move on

  • can we keep working together, build our support for one another, and not blame each other and not undermine the system

  • a consensus for collaboration, and how we could implement experimentation

  • the creative culture that exists in York is under utilised in how we can engage people in art, music, theatre, poetry – people can be brought together through creative experimentation

  • the stories of the human beings of York – relating everything we do back to the individual, the story they have, and the agencies working together with the individuals in mind

  • there’s a need for strategic buy-in to some of these ideas, not least within the council

  • based on the collaborative energy in the room, how can we take this forward through the network – via a hub, maybe?

  • practical things – a hub; frontline staff and the constant monitoring and funding challenges they face, the need for self-care; make KPIs more realistic, question who they are benefiting, do we really need them?; permission to be more flexible – who does it come from, senior leaders, frontline managers, this room?; how do we incentivise people to work together, would that be a better KPI? 

3:57 pm Summary of themes

In summary, the themes picked out by Catherine:

Sharing lived experience

  • More choice

  • Strategic buy-in, the people who aren’t in the room, private sector

  • Commissioning and funding conversations

  • Collaborations – the hub, shadowing

  • Permission and self-permission

  • Who is missing – how do we invite them in?

  • Creativity for social change

 

4:01 pm Check out

Two questions:

  1. What’s hit home for you today?

  2. What would you like to be involved with going forward

 

Responses:

  • How important connections are – and they are key to us moving forward

  • If it was easy, we’d be doing it already. We’re all doing a bit of it already we need to build on that

  • However disenchanted and discouraged we get, we need to keep going with this

  • It is big, but we can all do small things, break it down into something that’s tangible

  • There’s a lot of talk in the room about things that don’t work, but there’s also a lot that does work – we need appreciative inquiry

  • How people in this room need to look after themselves

  • A lot of people want to collaborate – we need that courage to experiment to fail – try to make connections with others

  • I have felt a real sense of collective ownership – a big shift from talking about services to people, and what a thriving York would look like

  • Relational culture and the power of relationships