How do you transform a service like mental health at a time of ever-increasing demand? This is exactly the sort of ‘wicked' issue which Camden and Islington NHS Foundation Trust is facing.
The council is trying to involve service users through what it calls ‘evolution' groups, to develop a new clinical strategy and redesign frontline services. It's a tough ask.
Earlier this year, there were some collective groans from the care sector when the Government announced it wanted to produce a green paper for social care. ‘Yet another', people complained at the time. But this is in some way understandable, as we face so many problems which are so complex that they seem to defy solutions.
The current challenges facing the NHS, social care and others are arguably the most wicked yet. There is a danger the new models of care, discussed in the Five Year Forward View, will be implemented in ways which fail to recognise their inherent complexity.
We have just published a report on this – working in partnership with PPL and the Institute for Government and funded by the Health Foundation's Policy Challenge Fund – which has sought to explore how we might go about addressing some of these challenges through more effective engagement with communities.
Meaningful engagement
Change on the suggested scale cannot be ‘done to' local communities – it needs to be negotiated through co-production. So, we want to encourage in-depth dialogues between people who commission and provide services and patients, service users and the public.
In order to build visions and plans that are more likely to be sustained, it is critical to have service user, patient and carer involvement in service design, commissioning and delivery. That is co-production.
Creating an innovative care pathway in North London
Camden and Islington NHS Foundation Trust wants practice-based teams which work locally with GPs and other services in primary care. It wants to offer people rapid assessments near to where people live, conducted by senior clinicians who can make decisions about treatments, access services in the community or, if needed, refer to their specialist care pathways. This means radically changing the model of care from one dominated by acute and hospital-based care to a much more community-based one.
Brokering constructive conversations needs to happen at a whole system or service level. However, they also need to happen at an individual, care-planning level. For the former, one key message from the report is that there isn't a one-size-fits-all answer. Genuine co-production, deliberation and negotiation take time and resources. For the latter, a key recommendation is that frontline health and care staff need to be supported to have challenging conversations and to articulate the benefits of new ways of delivering care in the community.
Co-production is top of the agenda
Camden and Islington NHS Foundation Trust is a good example of how users and carers can be central to design, delivery and the evaluation of services. The Clinical Strategy 2016–2021 says: ‘Instead of services "doing for" they will "do with" service users'. People who use services can, through being helped and supported, become participants in their community rather than dependent on services.
Ultimately, the Trust's ambition is to create the freedom to give service user groups their own funding, plus their own agenda and accountability. This would mean users and carers can co-design services which will advance the aims of the organisation and also empower service users to be co-production ‘public servants'.
Constructive conversations
Along with the Islington example, our report shows constructive conversations which are taking place in Mid Nottinghamshire and Dudley. All three of the case studies describe how citizens are being involved in developing new models of care, including using co-production.
We need to get away from what can be described as old-fashioned linear planning. It is far messier and more complex than that.
Creative approaches to problem solving are risky because they involve trial and error, but constructive conversations, taking place between service providers and service users and communities can help broker these solutions, enabling hard-pressed service leaders to use the expertise, assets and experience of citizens to help guide their decision-making.
Ewan King is director of business development and delivery at the Social Care Institute for Excellence (SCIE)
SCIE's report, Brokering constructive conversations, can be found here
