South London Partnership: Change Without Change
South London Partnership is a collaboration of three NHS Trusts, Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, and South West London and St George’s Mental Health NHS Trust. Between them they provide mental health services to a population of 3.6 million people and employing over 8000 staff.
In October 2017 three NHS Mental Health Trusts formed a partnership to become a New Models of Care pilot for Child and Adolescent Mental Health services – specifically inpatient care. This NHSE policy gives provider Trusts responsibility for specialist commissioning budgets at population level.
The challenges to improve patient care and outcomes were clear. 65% of local children and young people (CYP) needing admission to a CAMHS ward were placed outside the area, an average 73 miles from home. This has detrimental impacts for their care and recovery, and their families/carers. A second challenge was the national growth trend in these specialised services of 8% - which wasn’t reflected in available commissioning budgets.
Another major change challenge for the Trusts CAMHS services was they hadn’t worked in true partnership before. Indeed, for the past decade, they had often competed for service contracts.
In the early development stages it became clear that new services, as well as new approaches, were needed, and these would take time to develop.
Approach – building appetite for change
We took a people-centred approach – the changes had to be identified, developed and made by those providing and using the services.
A key starting point was bringing people together for the first time. Clinicians, operational and corporate staff at all levels and from inpatient, community and highly specialist services for complex mental health conditions across three Trusts tackling common challenges; All in the same room.
An early workshop focused on bed management and was structured for introductions and a ‘show and tell’ session, where different organisations outlined their own ways of working. The group met regularly and although progress felt slow, it was a really important period. The atmosphere became more collegiate and as new relationships were forged a vision of what could be achieved began to emerge, hurdles were raised and solutions developed.
Workshops were challenging, with some unhelpful behaviours inside and outside the events. Ongoing, purposeful engagement at all levels was vital.
At an early stage the aim of developing a single bed management function was developed, it was seen as the best approach to reducing out of area placements.
Approach – a shared desirable vision to drive change
Focussing on the impact of out of area placements, and the opportunities to change this by combining resources and efforts for patients’ benefit, improved team working. Together, the group developed a shared, vision and clear goals.
It became clear that improved bed management was a key lever to bringing care closer to home and optimising bed usage. This became a focus for action – with the goal of a shared function across all three Trusts.
Sharing and surfacing their own data, experiences and sometimes frustrations helped inform more innovative service development ambitions. Colleagues all wanted to do more to help localise services, keeping families closer together and aiding the recovery of young people –providing the right care when and where it was most needed.
Building capacity and capability to lead change
The group grew its understanding and confidence to successfully present a coherent approach to colleagues across services and senior managers This was by no means straightforward. Negative comments in the background, and passive and active challenges within the group could have derailed progress. However, our independent coordination helped maintain the groups focus and resilience, and these often typical wider responses to change slowly dissipated.
New processes had to be developed for this unique centralised function. The group grappled with the design of new processes; What are the activities? Why is it needed? Who is responsible, accountable, to be consulted and informed? Although challenging and answers didn’t come easily, this approach led to highly valuable discussions and processes that everyone owned agreed and formed the basis for operationalising the new service.
Outcome - What happened?
Joint working started developing results. Before the new centralised function could even be put in place, something had changed significantly. The relationships between people improved, culture and behaviours changed, and people were being creative to prevent local young people being admitted many miles away. After 9 months:
• Out of area placements dropped by 75% against the baseline.
• Use of local units for local young people increased from 52% to 90%.
• Overall demand reduced by around 12%.
Although not the only factor, these changes were recognised as a direct result of a new collaborative culture which emerged from the strong shared vision to make a difference to the lives of young people and their families.
Transformation programmes are often challenging in NHS Trusts and working at scale across three very different organisation cultures required even more flexibility. We were able to create an effective environment and culture for change through, working at all levels simultaneously, building a strong desirable vision, independent coordination, improved relationships, commitment to true co-production and more empowered people.
Two Years On – sustainable change
Those involved, having built on the relationship and knowledge of how to work together to achieve changes, have been able to sustain the progress made in the first few months for the following two years. The single bed management function is now fully in place, and a range of additional community services are now providing more care upstream.
Overall demand for inpatient beds has fallen by 32%, and the percentage of young people now placed out of area is just 5%.