Another successful co-production event: Stepping Up and Stepping out to meet our challenge on 12th September 2012 at The KIA Oval.
The Lambeth Living Well Collaborative held a successful co-production event on the 12th September at the Kia Oval. Over 160 people attended from NHS Lambeth CCG, including members of the Board; Lambeth Council, including Councillors, SLaM, Voluntary and Community Sector people who use services, and carers. The focus of the meeting was to discuss and develop the new ‘Living Well Network’ which aims to turn the current Mental Health system from one which focuses on crisis to one that focuses on early intervention and enablement. Lots of fantastic ideas were given as to how we could develop this network and The Collaborative will be taking these ideas forward in the coming months.
To download the presentations used on the day please click on the links below:
To download the ideas from the entrepreneurial workshop please click on the link below:
Feedback from the workshops:
My name is Joiss Soumahoro and I work for NHS Lambeth CCG. On our table were thinking about Llyod:
- Lots of the discussion was about medication issues – he should get a full medication review as may be on too high a dose or there may be a more suitable medication. It might be better for him to see his GP rather than medication clinic to reduce stigma and feeling ‘mental’
- We thought peer support to help with smoking, which we assumed referred to cannabis and a possible personal budget for gym membership, coaching qualification, CRB, equipment etc.
- If his medication is reduced, then find a way to re-direct the under-spend to support him specifically.
- Time Banking – he could offer coaching support in exchange for social resources like cinema tickets, or career advice etc
- Housing benefits advice in preparation for when he wants to move out. Although, he should be encouraged to consider moving out of Mum and Dad’s when he has a job, deposit and not be reliant on benefits
- Consider going to SHARP team as they can help in a more targeted way than the CMHT
Our big 3 ideas
1. More innovative ways of managing medication issues:
- Peer support medication group
- Improved support for primary care to take on medication clinics or have them located in general practice
- Start medication at much lower doses rather than using medical standards
- People with lived experience or expert patients used to up-skill/train/educate GPs, practice nurses and other practice staff, other medical staff, voluntary sector staff etc.
2. Peer support could be used to help people with substance misuse issues during the recovery process (in peer support hotels etc, wobbly days intervention)
3. Peer support groups to facilitate healthy lifestyle issues such as weight management
What does this mean for the system?
What should we stop doing?
OFFERING NO CHOICE
- Stop saying “This is for life”
- Stop considering risk above everything else
- Stop offering choices limited by service needs
What should we start doing?
BUILDING GOOD RELATIONSHIPS
- Ask what someone wants to achieve
- Offer more choices/more meaningful choices around medication
- Break things down into stages
What do we need more of?
- The person having more control
- More choice of locations where people can receive support with meds
- GPs more skilled in mental health and medications
What ideas could be prototyped to help understand better how it could work?
- Medication support groups including young people and peer supporters
The group discussed ‘the system’s’ approach to risk around medication, or lack of it, and how it can alienate people and prevent meaningful discussions and relationships with clinical staff. People stop taking medication regardless of what the system recommends, so if the system was to listen it might be able to offer choices that might seem risky (such as supporting a medication break) but that would build relationships that enable co-production and reciprocity.
My name is Rachel King and I work for SLaM on Personal Health Budgets. On our table were thinking about Mary
Overall the table found it quite hard to work out what they wanted from the system, and community for her but we got as far as agreeing:
What does this mean for the system?
What does this mean we need to stop doing:
- As much paperwork
- Stop slow IT systems
- Prescribing and telling people what to do
What does this mean we need to start doing:
- Have better linked up systems across GP’s/mental health services
- Better sign posting – have access to good, available up to date information (or know where to go for this)
- Have access to work with people at practical skill such as budgeting (possibility of peer support doing this?)
- Asking and providing people with time and space they need/want
What does this mean we need to do more of:
- Working collaboratively/co-production
- Enabling community access to services such a gyms (make funding available for a person to access this)
- Provide opportunities for people to earn money if they are in debt
- Look at creating more positive/welcoming environments (for our services and in the community)
- Look at improving peoples own home environments – and maintaining this
- To use empty spaces more creatively (such as nice corporate buildings outside of business hours etc)
- Make use of existing teams/systems (such as SHARP) and how to use them more effectively – one comments was made that SHARP could almost help Mary meet all her support needs
- Facilitating/enabling people to build positive and supportive relationships – there was a lot of talk about this being a ‘basic need’ alongside environment
What ideas could we prototype to help us think more about how it could work?
- Need to invest and cease the overlap in services between social care and health – spoke about a person to oversee this?
- Move and increase awareness outside mental health systems – use community resources as our ‘interventions’ rather than mental health specific
- Working collaboratively with physical health services
Our table also spoke about ensuring ‘basic needs’ (think Maslow’s hierarchy of needs) are met BEFORE we try other interventions (such as medication), as it seems many people are not getting these needs met.
My name is Zoe Reed and I am an Executive Director at SlaM. On our tableing we were thinking about Mary:
We thought that Mary had come to London from her home town of Manchester in search of work. As with many people the cost of living proved to be too high and she was now living on very little money – DLA. She had no family locally. Mary is sociable and chats with people like the local shop keepers and others on the allotment but has no one who could be identified as a close friend or carer.
Mary loves gardening and helps out at the local community allotment but she only feels up to going there 2 or 3 times a fortnight. There were concerns from the CMHT that Mary, whom they had been supporting for many years, tends to disengage from services, stop taking her medication and then her physical health [she had type 1 diabetes] and her personal care suffers. Mary describes her flat as ‘messy’ but we suspect from the CMHT concerns that it might be worse than that.
She identifies her main problem as “They are trying to get me to leave my flat and I’m not happy about that”. We decided as a Table that we would focus our efforts on keeping her in her flat.
We decided that the Mary needed support to
- Get back in contact with her family – she spoke of a cousin whom she had lost touch with but they were good friends as children
- Help her manage her flat and keep it clean and tidy
- Help her manage her money and e.g. prepare for her benefits review
- Help her look after herself physically including taking her medication, taking regular exercise, looking after her personal care
- Find a daily social contact opportunities e.g. helping out in perhaps a garden centre or the allotment
We thought peer supporters, expert patient, exercise referral and joining a timebank would all help. We did not however indentify exactly who was going to set up the Peer Support or introductions or ‘walk with’ Mary in solving her problems.
We had representatives from providers of:
- Community Services [NHS GSTT],
- Cyrenians supported housing – used to housing people straight from Forensic services so felt very able to deal with complex needs
- First Step Trust employment – providers and service users,
- Vital Link service user and Time Bank member
- a resident of supported housing
and we had really good conversation about how to address Mary’s wants and needs with a focus on non-statutory interventions.
However the solutions, when we realised that there was a possibility that Mary might lose her tenancy, became necessarily prescriptive (notwithstanding an NGO provider) due to the urgency of the situation, and we wondered whether they would in fact feel like co-production from Mary’s point of view. This all pointed to the necessity of setting up the networks and peer support to prevent the crisis happening.
My name is Sue Field and I am a Commissioner from NHS Lambeth CCG. On our table we were thinking about Magda
Magda is 53 and lives in Streatham Hill with her partner Sara. She has a daughter who is 13 who lives with her ex-partner.
She is a primary school teacher and loves it. It’s much more than a job – it’s part of who she is. She is passionate about getting the best start for the kids in her class.
What is working well? Her job: it is everything to her.
Key people in her life: Sara is her rock. She has lots of friends at school. However Sara is feeling neglected.
Magda has only just come back to work after the school holidays, and as her mum died in the holidays, no-one knows how to talk to her.
She is also estranged from her siblings and her dad.
What does staying well mean to her? She is not sure. She does not see herself as ill, but she does not want to feel like this anymore.
Assets: She thinks she is a good teacher, although it doesn’t always feel like that at the moment. She loves singing, and is a member of a local choir but has not been there for a while. She likes watching Eastenders. She has a cat.
What would she like to change? Since her mum died 4 months ago, she seems to have lost all the joy in her life. Her mum’s birthday is coming up and she is worried how she will feel. She is also getting pressure from work as she is not performing as she once did. She also used to regularly go running but has no motivation.
What people say about her? Sara is worried that Magda is using work to block out how she is really feeling. Magda’s GP thinks she is depressed and has prescribed her anti-depressants. She does not really know her GP. She is reluctant to take it and doesn’t take it. She is drinking wine heavily in the evening to cope. The GP has also offered her a leaflet to access IAPT, but she does not know what to do. She has looked on the website to try to find out some self help leaflets.
How can we help Magda in her recovery?
- Help Sara in her feelings to help Magda. Help her to have something to look forward to i.e. tickets to the O2 to see Gareth Malone.
- GP to listen: to support her to self refer to IAPT and explain more about what the service can do for her ie they can engage with Status Employment at the same time as therapy so that if she wants they can speak to her employer and help her employer support her.
- Talk to her about her motivation to rejoin the choir and engage back in life so that reduces her drinking.
- Go at her pace: talk to her about her alcohol and give her information but revisit when she wants to.
- Give information to Sara about depression to explain as to why she is feeling neglected and help give her coping strategies, signs and symptoms etc. Perhaps give details of a support group for her.
Local resources to help
- Her friends at school and friends at the choir
- Gay/lesbian support groups
- Local church/choir
- IAPT service together with Status
- Independent bereavement counselling
- Carers groups
- Information resource centre for information on self help and depression, wellbeing.
- Exercise on prescription
What does this mean we need to stop doing?
- pushing professional agenda, and begin listening, moving at Magda’s pace
- stop prescribing medication as a solution if she wishes to explore alternatives
- make sure people, including GPs have access to information
What does it mean we need to start doing?
- A greater role in motivating Magda
- Recognising that she is missing something
- Identifying who is the best person to work with her and her support network
- Asking her what she wants and what she has to offer rather than what she needs.
- Discussing realistic aspirations
- Remember Status Employment and relationship with keeping in her employment.
What does this mean we need to do more of?
- emphasising working with carers, and support networks
- knowing where to go for resource provision, knowing who to contact who can help, rather than knowing all resources yourself
- exploring her loneliness more, focusing on her targets.
- publicise the resources we have at the moment more i.e. MIND information website. No-one on the table was actively using this resource.
What ideas could we prototype to help us think more about how this could work?
- Community freephones i.e. like the community toilet idea whereby key shops in the area have access to a free information line so that if people do not have credit on their phones they can still access information and help
- Peer support for people with common mental illness i.e. via IAPT, local peer support group.
- Recall system for GPs so GPs can ring people to find out how they are doing for people they are worried about.
My name is Bill Tidnam and I work for Thames Reach. On our table we were thinking about George:
We came up with thoughts around a sports centre and specifically the Herne Hill velodrome, also First Step Trust. The group was a bit divided on how or whether we should be helping him rebuild his relationship with Abdul, or with his daughter who lives in Southampton, and who he hasn’t seen for a while. A Timebanking offer around bicycle repair was also a possibility.
Some sort of peer support was an agreed need, but we weren’t sure about what form this might take – a sense that this was likely to be some sort of befriending, and that it might need to focused around an activity to be palatable to George – this might take us back to First Step Trust or cycling.
We discussed the lack of time and the GP workload for the kind of pastoral care that George would benefit from and thought about how GP practice space could be used as amenity space for local groups that weren’t specifically health related.
Some interesting comments from some people, which I’d summarise along the lines of, ‘Why are we discussing George? His needs are no way high enough to justify getting a service’, also a sense that this approach ran the risk of broadening the criteria for services so that many thousands of people who don’t access services would be eligible. The same people felt that meddling in George’s relationships with others was too risky, and would require significant skilled clinical input.
Hi my name is Karen Hooper and I am a carer. On our table we were thinking about George
Discussion to get less prescriptive options for George was really interesting… to see him as a citizen in a community as opposed to a problem that needed to be fixed highlighting the need to listen and treat people holistically… Also to see beyond professional roles at the table/and or how can we think differently about that or bring otheroptions as humans..
Poor George was challenged further by the death of his mum… but this challenge probably made us think about human relationships (the group also decided to give George two estranged children and wife). With more time the funeral may have reconnected some of these relationships or put him back in touch with Abdul.
We also had on the table a health trainer (a resource open by GP referral) and there was much discussion about the greater role of the GP surgery – or how if we want to move away from medical options to link up people like George with resources which he might choose to take up. We found it hard to move away from the ‘got to fix him’ model!
Time banking was a popular option and we were really lucky that an entrepreneur gave us his bicycle-building option, which sort of saved the day for George. Ronnie’s garage was also an option.
How peer support might work in the GP surgery was really interesting. So for example, rather than follow-up call from the GP or nurse about him not turning up for discussion on drinking, he could have someone who been in the same boat (this would need referral permission from George). Also more work with employers on retirement/grievance issues. Make sure we don’t buy into the nanny state though!
If it goes downhill for George what do we do (promotion of Solidarity in Crisis with the police, so that George gets a crisis card when he’s next in the cell… promotion to landlords .. Empower people to recognize triggers (mum’s death could easily send him to the brink).
Accessing people from local pubs, betting shops and general meeting places (take note this weekend’s Lambeth country show) and transforming the way people spend their time and offer alternatives – setting up clubs, fishing cycling, music… Reading out Loud groups in pubs (I have sent an email regarding this option already).
PS – I just asked my nephew what he thought we could do and apart from suggesting “leave him alone’, his prescription for George was to get him into something he like’s doing… like cycling!
My name is David Singer and I am the Transformation Projects Lead for Lambeth Council. On our table we were thinking about Magda
First session was centred on thinking about finding ‘that thing’ that might tip the balance and help lift her spirits and see more hope. We connected to her enjoyment of singing – churches and the local Red Cross centres were considered to be great assets for her to use.
Close to her home in Streatham, Tooting Bec Common was another great asset where she walked her dog ‘Porridge’ each day. There was consideration of how she might use time-banking as a way to share her love of dogs, support others (who might be a little time poor) to do some more dog walking, which might not be as stressful an environment as her school as a place to take her mind off things.
Whilst not something known to be provided at her local GP surgery, Ed Davie spoke about a GP collaborative initiative in Devon that have set up a Patient’s café run by people have/experience depression where they can come to support others and support one another. This was relevant to Magda as something we added to her personality was her love of cooking. She might find this type of food-centred initiative something easier to hook into. Also related to food was the possibility of her heading down to the People’s Kitchen as an activity to do with Sara – food & cooking something they both find a lot of enjoyment in. Their relationship needs a bit of support as Sara is struggling to deal with Magda’s depression and isn’t sure that she can live as they are together much longer.
Finally a Personal Health Budget referral through her GP practice was suggested – again focussed on improving her relationship with Sara by spending some of it on a weekend break. The rest of it was to be spent on a home grooming kit for her dog and possibly the scope of a social enterprise using these tools a little further down the line if things are on the up for her.
The second session started with a question as to why IAPT hadn’t been suggested so far. More background to Magda was created and suggested that Magda had not wanted to go to see a counsellor, possibly owing to the stigma.
So this took us to what should we stop doing? Irrespective of her not wanting IAPT, GPs should not be prescribing anti-depressants without some sort of more social connection – so if not IAPT, what else?
I then threw in an individual challenge that Magda was feeling lonely as Sara wasn’t coping and decided she had to take some time out. Magda now being without someone at home to connect to, circumstances were getting worse and she was spending time off work and isolating from her good friend at work Bill.
What we should start doing? Connecting GPs to peer support opportunities and support workers who could guide Magda to become less isolated and link into the community stuff first discussed and/or IAPT again, perhaps initially with a bit of support. Conversation moved on to the sense that all parts of the system are disconnected from the more social aspects of support, both informal and formal.
What do we need to do more of? People are generally not aware of the richness of Lambeth’s assets (public and professionals) and that ‘Community needs to be more visible’ and that people need to take responsibility to know Lambeth better
Is there a way that peers with certain specific experiences like sex working, sub misuse or bereavement could be identified to make more meaningful matches for those feeling like more formal peer support could work for them? One place, rather than having to go to lots of sep agencies
- There is a co-produced food strategy sitting with the Cooperative Council that Ed Davie mentioned we should get closer to as there are strong links. There was also conversation about hubs of activity that are centring on Libraries which are not about mental health (such as Clapham Family Practice and the plans for the reopening of West Norwood Library). So there is definitely a need to link more closely (Ed Davie suggested this specifically) with the progress of the Coop Council.
- Is there scope for mini GP practice Collaborative efforts to set up initiatives that are centred on support requirements like the one in Devon?
- Stories are really powerful things. There was some scepticism about how the idea of the Network could work for people who have long term complex care needs. I went over the stories from the prototyping, which dealt with the level of need in questions and the table were glad to hear that we’re not just working with ‘simple’ cases.
- There was a sense that we need to support people to start asking questions that they wouldn’t normally ask the people they support. Eg. One of the table said, I know that my clients won’t receive this approach with open arms, so a possible suggestion that there’s no point trying. We need to ask the whole system and the people it supports to ask new questions and remember that the first new question we ask, might be turned down, but that’s not the only new question we can ask to encourage new thinking, new responses and new glimmers of hope to turn things around.
My name is Stephanie Correia and I work at SRA. On our table we were thinking about Magda:
Our character was Magda. We thought that her GP should have been more proactive when he first saw her for depression – perhaps asked different questions, refer her to IAPT/self help programs and the local leisure centre/walking group rather than give her antidepressants. The GP could signpost her to where she could get more information about activities, which might help her to recover. Also thought some peer support might be useful and some support for her partner to prevent breakdown in relationship. There is a choir at the local church. Perhaps getting back into the choir, which was one of her interests, might be both therapeutic and supportive.
Providing more information and publishing how to access this information is crucial. If you are local and can’t access a computer how do you know where you can find information? We need to use Google, etc. to advertise the number to ring/website where you can get information.
The challenge we looked at was to do with not enough time/feeling under pressure. The remedies we discussed included: using the Users’ assets/peer support/other services to share the load, as part of intervention. An individual provider does not have to do everything for everyone!!
My name is Brent Withers and I work in Mental Health COmmissioning at NHS Lambeth CCG. On our table we were thinking about Magda
It was felt that Magna would benefit from gentle, reliable, ongoing, non-pressured weekly support via a peer/buddy system in the workplace or via her GP surgery. It was felt she needed low intensive support and would not be ready for ‘formal’ services so low key peer support, time banking to utilise her skills, or a self help tool kit would be most suitable to address her needs.
What does this mean we need to stop doing?
- Magic Pill: Stop feeling lonely
- Where medication is prescribed it must be prescribed along with a social intervention/activity – in other words not just medication
- Less labelling
What does this mean we need to start doing?
- Peer support for lonely/bereaved
- Be alert but not pathological – “keep and eye out” to try and intervene at the right time when the person is ready
- Be more creative – aware of other options based on the individual person
What does this mean we need to do more of?
- Level 2 – talking therapies availability
- Holistic lifestyle healthy living advisor in GP surgeries
What ideas could we prototype to help us think more about how it could work?
- Early first steps – social approach – connecting people to peers in social setting e.g. activity groups and out of hours
- Co-production approach to diagnosis
Summing up from David Monk:
- Be more Creative
- Base everything on real equal, human relationships
- Mesh the physical with psychological
- Take responsibility for deficits in knowledge
- Create an inquisitive system
- Stop being prescriptive start being facilitative
- Stop talking start listening
- Search for enablers in every conversation
- Information is the most important game changer