Making Transformation Count

About the author

My name is Helen Gilburt and I am a Fellow at The King’s Fund, undertaking research and analysis on issues around mental health and mental health care (amongst other things!). I have a particular interest in the quality of mental health care and its ability to meet the needs of those who require support. This is partly informed by my own experiences of living with mental illness and using mental health services.

My favourite album is Tripomatic Fairytales by Jam and Spoon – a classic old skool trance album.

Those of us who have been around a while will know that mental health services are no stranger to transformation – moving out of the asylums, the national roll out of specialist community teams such as crisis intervention, assertive outreach and early intervention in psychosis, not to mention NHS trust-led initiatives to transform local mental health services. Some might say that mental health has mastered the art of transformation, but has it really delivered for people who need the care of those services?

Well, yes and no.

Arguably, since the days of the asylums, more people get access to mental health care, more people with severe mental illness live in the community, and the range of support that services provide has expanded. At the same time, successive transformations have led to fragmentation in services leaving people liable to fall through the gaps, some groups of people have been left behind and some areas of care have been neglected.

In 2019, NHS England and Improvement (NHSEI) launched the NHS long-term plan and mental health implementation plan. The largest component of the latter is a commitment to modernise community mental health services: enabling people with mental health problems to

1) access mental health care where and when they need it;

2) manage their condition or move towards individualised recovery on their own terms; and

3) contribute and be participants in their communities.

The Community Mental Health Framework provides a set of principles to guide that modernisation and 12 early implementer sites were selected to test-run putting this vision into practice. The King’s Fund were subsequently commissioned by NHS England and Improvement to facilitate and capture learning across those sites over a 12-month period.

So what have we learnt? Well first and foremost, a crucial and substantial part of leading

local transformation is about building relationships and trust across people and organisations, most notably between primary care, secondary mental health services, voluntary and community sector organisations and local authorities. That rhetoric is not new, but having conversations that are built on a vision of care and a commitment to developing and learning from shared solutions perhaps is.

That leads me onto a second component that we think is both important and shifts our

understanding of transformation.

This is the need for flexibility in design and implementation, and an approach which supports iterative change. Previous transformations have shown us that implementation of prescriptive models has often been met with a mixed reception, in part because they may fail to fit with local context and needs. At the same time, our analysis of quality in mental health highlighted the sometimes devastating consequences that driving a model of transformation can have without due attention to learning. So, while each early implementer site had to come up with a plan upfront in order to receive funding, being open to adapting that plan to accommodate and learn from feedback from frontline teams and service users, and adapt to new circumstances, has been important in navigating the messiness of change, while holding to the principles of the framework.

As a facilitator of these conversations, I witnessed how leaders working from a position in

which doing and learning are given equal attention, led to fundamentally different conversations. For instance, conversations between practitioners in primary care and secondary care mental health services, which began with how to bridge support for people with severe mental illness, have led to new understandings of ‘complexity’ which are more reflective of the wider issues that impact on people’s mental health and the impact of trauma, not to mention uncovering significant unmet needs. Not only have these conversations led to new insights of how the transformation can better meet individual needs, they are core to building a shared understanding and collaboration across health professionals and organisations.

As might be expected, transformation of this nature calls for strong and skilled leadership,

and passion and commitment were defining features of many of the leaders we worked with. Given the scale of this transformation however, the leadership teams were often relatively small, and tasked with leading change both out in the wider system, as well as internally within their own organisations. In managing the process, those leaders need to be able to engage stakeholders, manage expectations and uncertainty, contain anxieties and work with resistance. They also need to model the behaviours that transformation seeks to engender – openness to feedback and learning, advocacy and inclusiveness. Leaders in turn require support and management and it is notable that despite considerable operational pressures throughout the pandemic, transformation leads continued to provide each other with regular peer support to share learning and challenge thinking in equal measure.

Sceptics out there might say – what makes this different from any of the previous

transformations?

Looking over our back catalogue I’m struck by how many of the points above have been made before, and I have to say I hold a healthy scepticism. This transformation comes from a place of recognising

limitations in the care currently provided, but where the solution can’t be more of the same. For those whose access to care and treatment is currently limited, and for staff and services which are insufficiently resourced – that’s a hard message to digest.

If I was to sum up what we have learnt in the last 12 months, it’s that transformation is not a linear process which can be planned in advance, but a complex system of change in which the strength of relationships and shared vision is as important as the resources in driving change.

Furthermore, that change should have the needs of people with mental health problems at

its core and with service users and carers as partners in framing those needs and identifying solutions. Mental health campaigners and allies have done much to highlight the issues that underlie this programme of transformation, but ensuring due attention is given to the process without losing sight of the overall aims will be vital if we are to collectively make this

transformation count.

Helen Gilburt, Fellow at The King's Fund

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