Are service users the key to systems change?

‘Going from a food fight in KFC to a round table with the Home Secretary felt normal’

We’re delighted to welcome our first guest blogger, Dr Olive Moloney of MAC-UK, a service that’s revolutionising the way mental health services are delivered to young people who offend. Here she shares reflections on her learning journey with MAC-UK, including the challenges, mistakes and successes…

I’m Olive, a clinical psychologist and the Clinical Lead at MAC-UK. I’ve been invited to write a blog related to what I spoke about at the recent CYCJ conference in Dundee – Taking Mental Health to the Streets. I thoroughly enjoyed the conference, and was inspired by the speakers.

I’d like to share some reflections from our work at MAC-UK, a charity set up to radically transform how mental health services are delivered to excluded young people aged 16-25 who offend. We develop projects in the community with young offenders, and shaped by them, for them and their peer groups, over the course of three years. We aim to bridge them into services such as mental and physical health, housing and banking, into employment, education, training, and to reduce reoffending rates. We also focus on changing systems to recognize the social inequalities aspect of serious youth violence, and to join us in creating new ways of working for excluded young people involved in this world.

We have had some success, and made a lot of mistakes, as we expected we would. I’d like to share some of our learning with you, and I hope that you can connect to this learning journey. I invite you to share your ideas with us about systems change or any of our work in response.

The Founding Director at MAC-UK, Charlie, is also a clinical psychologist. Five years ago she founded MAC-UK with a group of young people. They set it up to change the way that mental health is delivered to young offenders.

Services are set up in ways that work for the majority of people most of the time. They do their utmost to reach excluded groups, but these groups continue to find it challenging to reach these services. Something doesn’t work in the services we are working in. I joined MAC-UK after working in medium secure hospitals where I saw a need for early intervention and preventative work to divert people from offending lifestyles.

We know that young people who do not show up at clinics are often the ones with the most complex needs and most entrenched in youth crime, the ones who will access services when in a crisis or when mandated to do so.

Charlie wanted to find out how we could reach this group. She didn’t know the answers but she did know that by working alongside young people we would find them together.

Young people told Charlie that safety is one reason why young offenders don’t want to go to clinics – but that there are many others. Charlie had to get her head around a whole load of structures and processes to make it happen, and she needed just about everything that she had ever learned how to do it! Things like finding a supervisor; funding; leasing a building; employment law; HMRC; employer’s national insurance; dangerous dogs; learning how to deal with weapons; how to speak with police and working all hours. She also surrounded herself with people who knew what to do – young people and professionals with years more experience.

Charlie describes this as one of the most challenging times of her life – the pressure she felt was enormous because suddenly she had a group of young people who were working with her and she didn’t want to let them down

What she saw matched what we know about mental health needs amongst young offenders…

The Problem

• 1 in 3 young people who offend have an unmet mental health need
• Youth crime costs the UK 4 billion a year
• Young people in custody are some of the most vulnerable in society and good access to health and mental health services is key to breaking the cycle of offending
• This is not just an issue for justice, it’s a problem for public mental health and a problem for us all

The Solution

• MAC-UK created a new grassroots model for mental health service delivery
• We take mental health to the streets, where young people want it, where they need it – Streetherapy
• Streetherapy melds together the best aspects of detached youth work, public health promotion, community development and the best practice from clinical interventions
• It requires highly competent clinicians who can work incredibly flexibly and can hold their nerve
• And a full team approach which wraps around each young person
• It’s at the heart of our Integrate model

It works

• Early research findings suggest it works – we are working with high levels of complex needs and distress, which reduce over the course of young people’s journey’s with the project teams
• We won the Kings Fund & GSK Health Impact Award earlier last year
• And our model has been featured in several government reports as model of good practice
• We also sit on an expert advisory panel to the Home Office
• The police initially mistook us for engaging in joint enterprise with young people but now even they’re saying that it has a positive effect on offending rates
• We have invested in an external evaluation led by the Centre for Mental Health to further understand our model, how it works and why – results will be published in 2015

2.  Systems Change

• Integrate, MAC-UK’s model of work, is much more than streetherapy
• We quickly realized that other things needed to change too…

o   Like not being able to open a bank account because you have no ID

o   Having to quit work experience because it clashes with signing on

o   Needing a diagnosis to get supported accommodation

• Sometimes as professionals it can feel like we are hitting our heads against a brick wall

3. Systems aren’t working

• It seems that right now our systems are not working as well as they could
• For many young people chaos and fear is the norm
• And there are a number of intractable problems which continue to challenge us – there must be some creative solutions out there
• MAC-UK are trying to work together with various agencies at different levels to tackle the whole system, not just the symptoms
• There is no silver bullet answer to service transformation but we seem to have stumbled across something at MAC-UK which is working

o   Serious youth violence and gangs are now recognized as a public mental health issue by government

o   NHS clinical staff are starting to work at street level

o   Health and the police are better integrated around risk management

• These have all been joint successes
• What’s perhaps more interesting is how they happened

4. Starting with Young People

• We quickly realized at MAC-UK that starting with young people was not an accident, it was the whole point – we started with the service users and developed a service to meet their needs – now we apply that same principle for every new project, in every new area
• Donald Berwick, Leader in American Medicine, said that if we keep using healthcare to get to health then we are missing the point
• 40% of health variance is due to things relating to where we live
• It’s hard to get out and exercise if your neighbourhood is scattered with people who are after you
• Our young people were on the same page as Berwick
• They led us to create a model that addressed all of these issues in one
• And took us to the services we needed on board to it – at the micro level, Integrate bridges health and social care

5. Culture and Capacity

• We also noticed something about culture and capacity at MAC-UK
• MAC-UK was hugely understaffed in the early days and this meant we all had to do everything
• Staff were operating at the frontline as well as the strategic levels
• This was just what we had to do. There wasn’t anyone else!
• Going from a fight over food in KFC to a round table with the Home Secretary felt normal
• It wasn’t until later that we realized that in most organisations people work at one level or the other
• We had stumbled across something really important
• Staff crossing these more traditional boundaries meant that young people’s ideas could be implemented quickly
• Fostering trust and empowerment
• We also had real life examples at our fingertips at policy meetings
• People liked stories
• They listened
• As we’ve grown, finding all these skills and motivations in one person has proven challenging
• So now we are trying to pair people who complement each other
• It’s a recruitment challenge but one that we are keen to solve as there seems to be something about it which works

6. Leadership

• Leadership has of course been critical
• We’ve had to be disruptors of systems but we haven’t achieved this by taking a stance. It’s been about adapting our messaging to the system and adapting our language – this is a skill which we actively develop in our clinicians
• Charlie has deliberately invited people for a different reason to the same meeting: the police think they are coming to talk about crime, the health managers think it’s about reducing DNA rates, the housing people about better supporting their staff – it’s of course about all of these things but to get people into the room we have to speak their language
• Again, having young people alongside either literally or by proxy has made others receptive to the disruption

7. Failing

• Failing has been really important
• It gives us clues as to what needs to change
• One day MAC-UK will write a book on what hasn’t worked
• But these failures have been the key to our innovation and constant willingness to change
• Young people tell us – tell people to just start things. They are too concerned about the theory and not practically doing it!
• Isn’t this true?
• This made me think of something someone said to me recently – that world changers are people who have a blessed naivity to do the things that everyone else knows too much about to tackle
• It really resonates with us because if Charlie had known what lay ahead when she started MAC-UK she would probably never have started it
• The challenge is creating the cultures where it’s OK to try new things and where we are more risk aware instead of risk averse
• Ben & Jerry’s, who are one of our sponsors, are good at this.  At their offices in Vermont they have a flavour graveyard for all of their ice-cream flavours which they have tried on the market which haven’t worked
• We know that young people’s lives are more precious than Ben & Jerrys ice-cream but perhaps there is something to be learnt here about how we celebrate and share things that go wrong in a non-threatening way

8. Working Together

• One thing that seems certain is that nobody can do this alone
• We need to work together across our sectors
• The AMBIT model created by the Anna Freud Centre has helped us with this
• The AMBIT approach focusses on helping front line workers to understand the distrust that young people have of services, and to work with the inevitable anxiety that comes up
• It helps create positive relationships which help to fix this mistrust
• It then works across all agencies to embed this process
• In a dynamic and innovative way – http://ambit-mac.tiddlyspace.com/
• When we run Integrate sites we insist that we do so in partnership with others – across all sectors
• It’s a non negotiable
• It means that governance is a headache
• You can imagine the chaos of working across four agencies which all have their own way of managing risk and their own service-specific insurance policies
• But actually it’s the governance which becomes the key to get us all working together
• And to rewrite the system
• If approaches like Integrate are to be mainstreamed then the system has to be ready

9. Is this stuff easy?

• Of course it’s not!
• But we are all doing the very best we can already so that has to be a good starting point
• Our pilots would be so much easier if we ran them on our own
• But that wouldn’t be changing systems

In summary

MAC-UK’s hope is that the learning from our Integrate model is used everywhere and that these new ways of working become the status quo.

We’re now exploring how to do the next bit of the journey. What’s clear is that service users have been absolutely central to our innovation because they’ve been there alongside us, and that they will be central to the future of what we do. This makes things like financial stability really matter to us – we see the impact of things like this letting them down. So we are looking at how we might best position ourselves to transform mental health services for young people.

We are proud of what we have achieved in five years but also acutely aware that it’s easier to disrupt when and because we are small. So many innovative approaches that have gone before us have failed when they have gone to scale. Our latest thinking is that it is by building the evidence base from our practice and sharing the learning from our approach with others, we do not scale through delivery but scale by increasing capacity to work this way.

My job at MAC-UK is to help us work towards that goal. I’d invite you all to stay tuned, work with us or just root for us in our ambition to embed youth led solutions to mental health service provision on a bigger scale.

The featured photo shows Norman Baker MP visiting MAC-UK’s music project aimed at helping gang members turn away from crime. View the full story.

About our blogger

Dr Olive Moloney is responsible for all aspects of clinical service delivery at MAC-UK. She has been the Project Lead at the founding Music & Change project, and in 2012 set up the most recent Integrate multiagency partnership project in Southwark. She is a UEL graduate who previously worked in forensic mental health services, and is a member of the Community Psychology Network. Read more.