Richard Smith: Tales of sustainability I—transforming mental health services in Lambeth

richard_smith_2014In 2010 adult mental health services in Lambeth in South London were at breaking point, with most acute wards running at over 100% capacity (possible because of overspill into the expensive private sector). There was a collective view amongst partners that resources were not being spent effectively, going on small numbers of people, often with little benefit. Something had to change.

I was told the story of how services in Lambeth are being transformed by Denis O’Rourke, who is assistant director for integrated commissioning in mental health for NHS Lambeth Clinical Commissioning Group. He’s the opposite of the stereotyped bureaucrat; a Celtic supporter, he’s both passionate and pragmatic about working with everybody and anybody to improve the lives of people who use mental health services.

I went to visit as a member of a team advising the NHS Sustainability Unit on the role of research in sustainability. I was interested in how research might have helped a group within the NHS build services that promise to be sustainable and affordable when so much in the NHS looks neither sustainable nor affordable.

Changing the relationship with people who use services

Recognising the need for change and feeling that they wanted to “change the nature of the relationship” between people who use the system and providers, the Lambeth commissioners brought together a collaborative of all those who were part of the system: people who use services, carers, social care, voluntary sector providers, primary care, clinicians, public health, and the mental health trust, South London and Maudsley Foundation NHS Trust (SLaM). The collaborative began by creating a shared vision of how it would do things:

“We will ‘work to’ provide the context within which every citizen whatever their abilities or disabilities, can flourish, contribute to society, and lead the life they want to lead.”

These words are all important: there are not patients but citizens; there is not treatment or services but rather “‘work to’ provide the context”; and the aims are not to achieve a healthy mental state but to allow citizens to “flourish [a bold word], contribute to society and lead the life they want to lead [not that professionals or the health service thinks they ought to lead.]”

To go with the vision there were principles of “co-production” of the desired outcomes. These included:

  • Building on people’s existing capabilities
  • Recognising people as assets [not liabilities]
  • Mutuality and reciprocity
  • Facilitating rather than delivering
  • Peer support networks
  • Blurring boundaries [between citizens and clinicians, different parts of the system, and the public, voluntary, and private sectors]

In other words the Lambeth collaborative is promoting an asset based approach, the opposite to the prevailing deficit model which dominates health and social care. Too many people in contact with mental health services have never had a conversation about the broader issues affecting their life such as housing, income, and relationships. All too often the focus is on people’s diagnosis and what they can’t do at the expense of focusing on how people can regain control over their lives.

It didn’t seem that much of this thinking was based explicitly on traditional research, but there is a body of evidence that supports asset based working and “co-production” rather than health and social care workers doing things to and for patients, the traditional way.

Three big aims

The collaborative had three big aims for people who engaged with the services: to recover and stay well; to be able make their own choices and achieve personal goals; and to be able to participate on an equal footing in daily life. Another way to express the aim is that the collaborative wanted to, as O’Rourke put it, “turn the adult mental health system on its head,” from a low volume, high cost service to a high volume, low cost service, helping people avoid crises by focusing on their strengths and ambitions.

The system is being transformed with three key components: a living well network front end; an integrated personalised support alliance; and the traditional adult mental health secondary care services. SLAM provides the secondary care services but continuing with the aim of reducing reliance on inpatient beds and transferring patients to primary care.

The integrated personalised support alliance is concerned with the roughly 200 patients with the most complex needs and is comprised of the clinical commissioning group, SLAM, the council, and two voluntary sector organisations. It uses an outcomes-led contract and works with open financial books, transparent reporting of outcomes and performance, and unanimous decision making. This sounds managerial and bureaucratic but provides the framework for encouraging integration among providers organised around the delivery of outcomes for people. It has a proved track record in the construction and engineering industry, which is notoriously competitive—but the companies have realised cooperation is better for the bottom line. It’s ironic that those in the care world claim to be motivated by common purpose and values and yet continually fail to integrate for the benefit of patients. The alliance in Lambeth has produced better outcomes for those who use the service at lower cost.

The living well network

The living well network is made up of a wide range of services in the community offering support not only with health but also with housing, employment, relationships, benefits, and all that is necessary to “flourish, contribute to society and lead the life they [people who use the services] want to lead.” Much of the support is provided by voluntary organisations (in collaboration with statutory sector), which often, said O’Rourke, have a stronger track record of focusing on people’s holistic needs and including people whom the statutory sector often “unhelpfully” describe as “challenging or complex.” Support can be accessed by people introducing themselves to the service or via GPs or other agencies.

Lambeth spends about £66m on adult mental health services. In 2016/17 about £37m of the investment went to secondary care and £29m to the living well network, including £4m to primary care, £3m to social care, and £8m to voluntary organisations.

Since the living well network was launched in the north of the borough in November 2013 and the rest of the borough in July 2015 about 400 people a month have been supported and referrals for secondary care have fallen by 43%. There has also been a reduction in the number of people entering residential care. It seems too that black and minority ethnic people have benefited the most, reflecting perhaps a more sympathetic system.

The collaborative has made progress with its aim of moving from a low volume, high cost service to a high volume, low cost service, helping people avoid crises. More people are seen, fewer people need secondary care services, and costs have fallen. The programme, said O’Rourke, is challenging the previous narrow focus on people’s medical needs.

Pressures continue

But the pressures continue: demand is increasing; further savings are required; inequalities persist; services are still fragmented; and there is still insufficient focus on outcomes among providers. So the only option is for reform to continue, with the ambition of placing the total mental health budget into a single whole system living well network alliance. This will require a shift of resources from “secondary care” into the multiagency living well network. It will be necessary, says O’Rourke, to further reduce demand on beds and improve the community services so they work 24 hours a day, seven days a week. The old demarcations of primary and secondary care are unhelpful and are getting in the way of supporting people on terms helpful to them.

Spreading innovation

One of the great problems of the NHS—and other health systems—is that beneficial innovations don’t spread. I asked O’Rourke whether he knew of other places that were making the changes being made in Lambeth. He was aware of some other projects and programmes elsewhere trying to take a more holistic asset based approach—for example in North East London and the North West of England—but not many at a whole system level. The other boroughs served by SLaM are looking on with interest as to how this work develops.

Research in the traditional sense does not seem to have been important in the developments in Lambeth: there have been no randomised trials or publications. But data on outcomes, activity, attendances, and finances have been central to the programme, and the whole transformation might be described as action research focused on creating value by co-producing better outcomes between people seeking and needing support and front line staff. Others can certainly learn from what has happened and is continuing to happen in Lambeth.

Richard Smith was the editor of The BMJ until 2004.

  • There are many issues in this piece which provide tangible evidence that. despite all the bewailing that the NHS can’t be nimble, can’t innovate, can’t modernise, can’t respond to patient needs and preferences – here are some folk who are doing exactly that.

    What’s interesting is, that although as Richard Smith notes, doing research before any changes happen didn’t appear to happen, the group does seem committed to using data in the broadest sense – and two of those important pieces of data seem to be: resources better used (financial and other), and outcomes for those who matter.

    Secondly, it provides real evidence that that refutes the claim that you can’t improve quality and reduce cost. Similarly, it also suggests that you can combine sustainability with affordability. Perhaps sustainability (financial, environmental and social) should be much more a dimension of quality in the NHS as it is in other sectors.

    Do others agree that some of how Richard Smith describes this is very similar to Amartya Sen’s approach in “Health as Development”: which goes something like “…to create the conditions that help people live lives they have reason to value”? This fits well with asset based approaches, letting go, trusting users, genuine collaboration, de-institutionalising, de-professionalising… (all of which the NHS claims is tricky…).

    It’s good to raise awareness of this sort of progress and acknowledge the progress that Denis O’Rourke and others have clearly made: vision into action, getting people to do things together, properly listening to the people we purport to serve. However, perhaps the main issue is: if THEY can do it, why is it so difficult to normalise this approach wherever else there is the vision, commitment and opportunity. Surely we are all interested in improving outcomes, reducing waste, and providing services that people actually want, need and value. Is this not what people mean when they say we have “a duty of care”?

    (Declaration: I work in the Sustainable Development Unit for the NHS and PHE that Richard Smith refers to)

  • This is a very encouraging example – and heartening to read.
    I would like to draw attention to a very closely related issue – which I believe may be ‘tripping up’ many good intentions. My observation was published recently in GP View :
    http://gpview.co.uk/an-outsiders-observation/