CHANGING SYSTEMS FOR PEOPLE WITH …...EXECUTIVE SUMMARY INTRODUCTION Fulfilling Lives1 is an...

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CHANGING SYSTEMS FOR PEOPLE WITH MULTIPLE AND COMPLEX NEEDS EVALUATION OF FULFILLING LIVES NEWCASTLE AND GATESHEAD 2017

Writtenby:JulietteHough

2NewcastleandGatesheadFulfillingLivessystemschangeevaluation

CONTENTS ExecutiveSummary........................................................................................................................3

Introduction.....................................................................................................................................................3

Keyfindings.....................................................................................................................................................3

Conclusions......................................................................................................................................................6

Recommendationsforthefuturedevelopmentoftheprogramme........................................7

Introduction...................................................................................................................................10

AboutFulfillingLivesNewcastleandGateshead..........................................................................10

Aboutthisresearch...................................................................................................................................12

Systemschangetheory............................................................................................................................14

Systemschangeoutcomes.........................................................................................................18

OutcomesoftheSystemBroker-ledwork......................................................................................18

Changesexperienced/implementedbypartners.........................................................................21

Influencinglanguageandculture........................................................................................................24

Influencingthepre-conditionsofsystemschange......................................................................25

Achievingsystemschange:theprocess................................................................................30

Stagesinthesystemschangeprocess...............................................................................................30

Routestosystemschange.......................................................................................................................33

Rolesinthesystemschangeprocess.................................................................................................35

Learningabouttheprocess...................................................................................................................40

Scaleandsustainability..............................................................................................................43

Stepstoscaleandsustainability:theSixStepModel.................................................................43

Routestoscaleandsustainability.......................................................................................................43

Conclusionsandrecommendations.......................................................................................47

Conclusions...................................................................................................................................................47

Recommendationsforthefuturedevelopmentoftheprogramme.....................................47

Endnotes..........................................................................................................................................51

EXECUTIVE SUMMARY

INTRODUCTION FulfillingLives1isaneight-yearprogrammefundedbytheBigLotteryaimedatpeoplewithmultipleandcomplexneeds-individualswhoarelikelytoexperienceatleastthreeofthefollowing:homelessness,reoffending,problematicsubstancemisuseandmentalhealthproblems.Oneoftheintentionsoftheprogrammeistochangesystemsforpeoplewithmultipleandcomplexneeds.

FulfillingLivesNewcastleandGatesheadisdeliveredbyaCorePartnershipledbyChangingLivesinpartnershipwithMentalHealthConcernandOasisAquilaHousing.EmployingorganisationsAdvocacyCentreNorth,AgeUK,MentalHealthConcern,OasisAquilaHousing,NorthumbriaCommunityRehabilitationCompany,Tyneside&NorthumberlandMind,andTynesideWomen’sHealtharesupportedbyBlueStoneConsortium.TheyemployServiceNavigatorswhosupportindividualclientstonavigatesystems.ThreeSystemBrokersleadonpriorityareasofsystemschange:workforcedevelopment,transitionsandaccesstomentalhealthservices.TheprogrammeissupportedbyExpertsbyExperience,OperationalandStrategicReferenceGroups,andbyaResearchandEvaluationteam.Theprogrammecommencedin2014,andwillendin2022.

FulfillingLivesNewcastleandGateshead(‘theprogramme’)askedtheNewEconomicsFoundationtoconductresearchintotheeffectivenessoftheprogramme’soverallapproachtosystemschange.Groupdiscussionsandinterviewswereconductedwith48peopleinvolvedintheprogramme,includingstaff,corepartners,StrategicandOperationalGroupmembersandemployingorganisations.Thisresearchwillhelptoinformthefuturedirectionoftheprogrammeasitmovesintoitsfourthyear.

KEY FINDINGS Changeshavebeensuccessfullymadeinseveralpartsofthesystem,includinginidentifiedpriorityareas.Keychangesinclude:

• TheimplementationofPsychologicallyInformedEnvironment(PIE)andmultipleandcomplexneedstraininginkeyservicesworkingwithpeoplewithmultipleandcomplexneedsisbeginningtochangeworkingculturesandbenefitclients.

• PeerresearchconductedbytheprogrammewasembeddedintherecommendationsoftheGatesheadHomelessnessandMultipleandComplexNeeds:HealthNeedsAssessment.

• FulfillingLives’ExpertsbyExperienceNetworkhasbeenpartofco-producingfilms

andscenariosanddeliveringRESPONDTraining,amulti-agencysimulationtraining

packageformentalhealthcrisiscareprofessionals.18initialpilottrainingsessions

for“BlueLight”respondershavebeencompletedandthepackagehassincebeen

approvedforrollouttoCumbriaandNorthYorkshire.• ADualNeedsStrategyforGatesheadhasbeendevelopedwithPublicHealth

Gateshead,withtheintentionofovercomingalong-termsystembarrierofaccesstomentalhealthservicesforthosewithadualdiagnosis.

• TheDepartmentforWorkandPensionshasmadeasinglepointofcontactavailableforpeoplewithmultipleandcomplexneedswhoareclaimingUniversalCredit,onatrialbasis,andtheprogrammeisresearchingtheimpactofUniversalCreditonthisgroupofpeople.

• CorepartnerOasisAquilahaschangeditscriteriafordispersedsupportedhousing,with16unitsnowavailableforpeoplewithmultipleandcomplexneeds.

• Employingorganisationsarereportedtobeworkingmoreflexiblyandcollaboratively.

Theprogrammeissuccessfullycreatingsomeofthepre-conditionsofsystemschange(asidentifiedinresearchbyCollaborate).Forexample,ithasdevelopedtrustedpartnershipswithmanythroughoutthesystem;ispracticingdistributedleadership;andiscreatinganenvironmentinwhichitis‘safetofail’.Issuesareincreasinglyacknowledgedassystemicandrequiringcollaborationbypartnersinvolvedintheprogramme.

Theprogrammehasdevelopedaresearchandevaluationstrategythathasenabledittoidentifyfourkeyareasoffocusforitssystemschangework:Accesstomentalhealthservices,genderspecificservices,transitionalperiods(e.g.institutionaldischarge),andworkforcedevelopment.

Severalresearchparticipantsfeltthattheprogrammehassuccessfully‘diagnosedthesystem’,althoughothersfelttherewasmoreworktodoaroundthis.Mostparticipantsbelievedtheprogrammenowneedstofocusonmovingtowardsactionforchange.Ideasfortakingthisforwardincluded:establishingtaskandfinishgroups;adoptingsolutionsfocusedpracticethatenablesindividualstoidentifywhere

theyhavethepowertoinfluencethesystem,includingchangingtheirownpractice;andrefocusingtheServiceNavigatorrolesothatitincludesanelementofsystembrokerage.

Researchparticipantsbelievedthattheprogrammenowneedstoestablishitselfmorefullyasasystemschange(ratherthanservicedelivery)programme,andtocommunicatetobothprojectpartnersandbroaderexternalstakeholderswhatsystemschangemeans,andhowtheprogrammehopestoachievethis.

Thereareanumberofactualandpotentialroutestochangethroughtheprogramme.Keyroutesinclude:

• WorkledbytheSystemBrokers.• WorkledorinfluencedbytheServiceNavigators.• Workinggroups/taskandfinishgroups.• Individualsinitiatingchangeintheirownorganisation’spractice(forexample

supportedbypeerresearchorinfluencedbyothertypesofinvolvement).• TheExpertsbyExperienceNetwork.

ThededicatedSystemBrokerroleisvitalindrivingchange.Theycanworkonpriorityareasofchange,withpartnerswhomightnototherwisecomeintoclosecontactwiththeprogramme,buthaveawillingness/opennesstochangeandaremotivatedinpartbytheresourceandsupporttheSystemBrokersbring.

Theprogrammehasdevelopedandbenefitsfromstrongpartnershipsandcollaborativeworking,includingsupportiveStrategicandOperationalGroups,employingorganisationsandcorepartners,aswellasotherpartnersworkingonspecificareasofsystemschange.

Thereareseveralexamplesofindividualsbeinginfluencedbytheirinvolvementintheprogrammetochangetheirownorganisation’spractice.ThisismostcommonlyreportedbymembersoftheStrategicGroupandEmployingOrganisations.Notallofthoseinvolvedintheprogrammehaveconsideredhowtheymightchangetheirownpractice.

TheExpertsbyExperienceNetworkhasundertakenanumberofsuccessfulsystemschangeactivities,forexamplethroughitsinvolvementinRespondtraining,theGatesheadHealthNeedsAssessment,andinvolvementinagrouplookingatHumanResourcespracticearoundrecruiting,employingandprovidingasufficientsupporttoretainpeoplewithlivedexperienceinemployment.

However,thevoicesofthosewithlivedexperiencecouldbemorestronglyrepresentedintheprogramme.TheExpertsbyExperienceNetworkiscurrentlybeingreviewedbytheprogrammeinrecognitionofthis.Beneficiaryimpactover

systemschangeprogrammes/organisationshasbeenidentifiedbyCollaborateasapre-conditionofsystemchange,andthereisscopeforthenetworktoplayamorecentralroleinthesystemschangeprocess.

Evidenceisseentobeastrengthoftheprogramme,andakeyroutetodemonstratingtheneedforchangeaswellasevidencingtheeffectivenessofnewpractice.

Theprogrammeisbeginningtoachievechangeatscalethroughworkforcedevelopmenttraininginseveralpartsofthesystem;seeingPIEpilotsbeingadoptedintopracticebypartnerservices;andbyinfluencingchangesinlanguage,attitudesandworkingcultureinpartsofthesystem.

Sustainedsystemschangeislikelytobeachievedprimarilyby:

1. Creatingstructuresandprocessthatembedthechangesmadetosystemcomponentsasaresultoftheprogramme.Thismightincludeensuringthatpilotsareadoptedintopractice,newwaysofdoingthingsareformalisedinpolicyandservicespecifications,andnewservices/successfulapproachesarecommissioned/funded.

2. Creatingtheconditionswithinasystemthatmeanitcancontinuetochangeinresponsetoemergingsystemicissues,evenaftertheprogrammeisnolongerinplacetoleadchange.Thismightincludeembeddingreflectivepracticeandco-productionacrossthesystem;creatinglastingconnectionsbetweenpartsofthesystem;andinfluencinganunderstandingofthesystemschangeapproachwithinthesystem.

CONCLUSIONS FulfillingLivesNewcastleandGatesheadisutilisinganeffectiverangeofapproachestoachievingsystemschange:eachofthefourmainroutestochangeidentifiedisanimportantelementofitsapproach.Theprogrammeanditspartnershaveachievedsomesignificantearlysystemschanges.Itissuccessfullycultivatingmanyofthepre-conditionsofsystemschange,puttingitinastrongpositiontoinfluencefurtherchangesovertime.

Nowtheprogrammeshouldturnitsattentiontoestablishingitselfmorefullyasasystemschange(ratherthanservicedelivery)programmeandcommunicatingwhatthismeans;strengtheningtheexpertbyexperiencevoiceinitswork;andmovingfromtheidentificationofsystemicissuestowardsactionandthedevelopmentofnewwaysofdoingthings.

RECOMMENDATIONS FOR THE FUTURE DEVELOPMENT OF THE PROGRAMME Thefollowingrecommendationsarebasedontheviewspresentedbythoseinterviewed,andonananalysisoftheresearchevidencecollectedinthelightofselectedexistingsystemschangeliterature.Itisrecommendedthattheseareusedasastartingpointfordiscussionamongprogrammestakeholders,forgainingdeeperunderstandingoftheissues,andforestablishingagreedaction.

Astrong,clear,systemschangefocus

Morestronglyestablishtheprogrammeasasystemschangeprogrammeandspreadunderstandingofwhatsystemschangeis.Thisincludescommunicatingaboutwhatsystemschangeis,thedifferentlevelsofthesystem,andhowsystemschangecanbeachieved.Thismeansmovingawayfromunderstandingsoftheprogrammeasaservicedeliveryorganisation;andensuringthatallthoseinvolvedunderstandwhatsystemschangemeans.

Developacoherentdefinitionofsystemschangeandtheprogramme’sroleandaspirationsinrelationtothisthatcanbeusedbyallthoseinvolvedintheprogrammetocommunicatetoexternalstakeholders.Thiswasrequestedbyseveraldifferentgroupsintheresearch.

Celebrateandcommunicatethesystemschangesmade:Stakeholderswerenotalwaysawareofthesystemschangesthattheprojecthadinfluenced.Celebratingthechangesthathavebeenmadeislikelytomotivateandinspirefurtherchange,aidunderstandingofwhat‘systemschange’means,andmorestronglyestablishtheprogrammeasasystemschangeprogramme.

Clarifythedifferentlevelsofthesystematwhichsystemschangecantakeplace,andusethisasatooltoidentifywherechangeisneeded.Thishasbeendoneinsomeforums,butnotyetbeenspreadwidelyacrosstheprogramme.Thediagramonp.16ofthisreport(adaptedfromamodelbyMakingEveryAdultMatter(MEAM))describesonewayofunderstandinglevelsofchange.

Reviewtheextenttowhichtheprogrammeisinfluencingchangeatalllevelsfromindividualpractice,toservicedelivery,tocommissioning(asoutlinedintheabovediagram).Thisincludesclarifyingwithpartnerstheextenttowhichtheprogrammeintendstoinfluencethenationalsystem;partnerswerenotallclearaboutthis.

Moveawayfrom‘diagnosingthesystem’(withafocusonidentifyingsystembarriersandblockages)towardsactionforchange.Thiscouldincludeexistingpartners(suchastheStrategicandOperationalGroups)consideringhowtheycouldchangetheirownpracticeandinfluencebroaderchange,andtakingmoreactiveownershipof/playingmoreactiverolesinstrandsofwork.Ideasforthisincludedestablishingtargetedworkinggroupsortaskandfinishgroups,andintroducingsolutionsfocusedpractice.

Adoptamoreasset-basedapproachthatfocusesonidentifyinganddrawingonassetsatalllevelsofthesystem.Atpresenttheprogrammeprimarilyfocusesonidentifyingsystemsbarriersandblockagesandsolutionstothese(oratleastdescribesitsworkintheseterms).

Rolesandrelationships

EnsuretheExpertsbyExperienceNetworkismorecloselyinvolvedinthesystemschangeprocess,buildingonsuccessfulsystemschangeactivitiesalreadyundertakenbythegroup.Amorecentralrolecouldincludeadirectvoiceindiscussionsaroundunderstandingtheproblem,generatingideasforchange,anddesigningnewwaysofworking;andco-deliveringworksuchastrainingorresearch.

ReviewtheServiceNavigatorrole:SeveraldifferentgroupsofresearchparticipantssuggestedexploringpossibilitiesfortheNavigatorroletobecomemoresystems-changefocused,forexamplebyincludingbrokerageandsupportforservicestochangetheirownwaysofdoingthings.Thiscouldperhapsfocusonchangeattheindividualservicelevel,whilstSystemBrokerscontinuedwithabroaderfocusacrosstheservicedelivery,commissioningandpolicylevelsofsystemschange.

RetaintheSystemBrokerfunction:InitialprogrammeplanssawthenumberofSystemBrokersbeingreducedfromthreetooneinthefourthyearoftheprogramme.ThisresearchsuggeststhatthededicatedSystemBrokerrolefulfilsanimportantfunctionofsystemschangeleadership.ThecapacityoftheBrokerstoconvenepartnerships,andtosupportinnovativepractice,hasmotivatedpartnerstobecomeinvolvedwiththeprogrammeandbeenanimportantroutetochange.Itisrecommendedthatanychangestothemodelofsystemschangedeliveryensuresthatthesefunctionsareretained.

Strengthenlinksbetweendifferentstakeholdergroups:Severalparticipantgroupssaidthattheydidnotfullyunderstandtherolesofothergroupsinvolvedinthe

programme,andhowthisfitwiththeirownrole.IdeasraisedbyparticipantsincludedStrategicGrouprepresentationontheOperationalGroup,andviceversa.

Reflectonpowerdynamicsintheprogrammeandthesystem:Powerdynamicswerementionedbyveryfewresearchparticipantsdespitebeingcentraltosystemschangetheory.Theoreticalissuesincludetherebalancingofpowerbetweenprofessionalsandthosewithlivedexperience;theneedtogiveupsomedegreeofpowerinordertocollaborateforsystemschange;andtheuseofpowertosettheboundariesorlimitthescopeofsystemschangeactivities.Itcouldbehelpfulforprogrammestaffandpartnerstohavetheopportunitytolearnaboutandreflectonpowerdynamicsintheirwork,forexamplethroughtraining.

Learningandevidence

Determineanapproachtoevaluatingthesystemschangesinfluencedbytheprogrammeoveritsfinalfiveyears,buildingonthecurrentResearchandEvaluationStrategy:Theprogrammehasconductedsomeusefulandinfluentialevaluationsofsomeofitssystemschangeactivities(suchasthepilotofPIE).Thiscurrentresearchshowsthattheprocessofsystemschangeiscomplexandunpredictable,andthat,becausesystemschangecanonlyhappeninpartnership,attributingchangetotheprogrammeisnotstraightforward.Capturingthechangesinfluencedbytheprogrammeisimportantfortheprogrammetolearn,understandwhatworksinsystemschange,anddevelopitsapproach.Itisrecommendedthattheprogrammedevelopsaprimarilyqualitativeapproachtoevaluatingsystemschangeoveritsfinalfiveyears.Thisshouldincludeassessingthedifferenceanysystemschangeshavemadeforpeoplecurrentlyexperiencingmultipleandcomplexneeds.

INTRODUCTION FulfillingLivesNewcastleandGateshead(‘theprogramme’)askedtheNewEconomicsFoundationtoconductresearchintotheeffectivenessoftheprogramme’soverallapproachtosystemschange.Thisresearchwillhelptoinformthefuturedirectionoftheprogrammeasitmovesintoitsfourthyear.

Thisbuildsonpreviousresearchfortheprogrammeincluding:

• Aliteraturereviewconductedin2014thatsummarisedselectedliteraturerelatingtosystemschangeforpeoplewithmultipleandcomplexneeds.

• ResearchconductedinJune2016exploringthesystemschangesbeingmadebytheprogrammeinrelationtolocalconnection,accesstobenefits,andsupportingpeoplewithnorecoursetopublicfunds.

ABOUT FULFILLING LIVES NEWCASTLE AND GATESHEAD Background

FulfillingLives2isaneight-yearprogrammefundedbytheBigLotteryaimedatpeoplewithmultipleneeds-individualswhoarelikelytoexperienceatleastthreeofthefollowing:homelessness,reoffending,problematicsubstancemisuseandmentalillhealth.Theprogrammeaimstobringdifferentorganisationsandservicestogethertoofferpeopleoneco-ordinatedsupportservicethatmeetsalltheirneeds.Oneoftheintentionsoftheprogrammeistochangesystemsforpeoplewithmultipleneeds.

Theprogrammecommencedin2014,andwillendin2022.

TheNewcastleandGatesheadFulfillingLivesprogramme(hereafterreferredtoas‘theprogramme’)isbeingdeliveredbyaCorePartnershipledbyChangingLivesinpartnershipwithMentalHealthConcernandOasisAquilaHousing.

Awiderpartnershipoforganisationsemploytheprogramme’sServiceNavigators.EmployingOrganisationsareAdvocacyCentreNorth,AgeUK,MentalHealthConcern,OasisAquilaHousingTyneside&NorthumberlandMind,andTynesideWomen’sHealth.Aseparateshort-termpilotwithNorthumbriaCommunityRehabilitationCompany(CRC)asanemployingorganisationisduetoendon31August2017,andanevaluationwillassessthesuccessofthis.BlueStoneConsortiummanagesthedeliverycontractEmployingOrganisationshavewithFulfillingLives.

TheServiceNavigatorssupportindividualclientstonavigatesystems.Theprogramme’sinformationsystemenablesthemtolog system issues and barriers encountered by their clients, and link these to the programme’s priority systems change areas (see below), providing a source of evidence that the System Brokers and others can compile to illustrate and examine system problems.

The SystemBrokersidentifythemesandprioritiesinsystembarriersbasedonevidencefromboththeServiceNavigatorsandthewiderpolicypicture,andleadonindividualareasofsystemschange,collaborating,influencingandsupportinginnovativepracticeandchange.

TheprogrammehasestablishedExpertsbyExperience,andOperationalandStrategicReferenceGroups.Thepurposeofthesegroupsistounderstandandchangethewayservicesrespond,arecommissionedandaredelivered,basedonevidenceoftheissuesencounteredbypeoplewithmultipleandcomplexneeds.

TheprogrammeismanagedbytheProgrammeManager,andsupportedbyaResearchandEavluationTeamthatprovidesevidenceandevaluations,andaCommunicationsTeamwhosupportthecreationandcommunicationofkeymessages.

Systemschangepriorityareas

Attheendofitssecondyear,theprogrammeidentifiedfourareasonwhichtofocusitssystemchangeefforts,throughitsResearchandEvaluationStrategy:

• Workforcedevelopment,includingpsychologicallyinformedenvironments(PIE),multipleandcomplexneedstraining,andreflectivepractice.

• Accesstosecondarymentalhealthservicesforpeoplewithmultipleandcomplexneeds.

• Transitions,includingprisonrelease,hospitaldischarge,accesstowelfarebenefits,andmovingtowardsindependentliving.

• Genderspecificservices.

EachofthethreeSystemBrokersleadsononeofthefirstthreepriorityareas,whilstworkaroundgenderspecificservicesisstillindevelopmentsupportedpredomininentlybytheResearchandEvaluationteam.

Context

FulfillingLivesNewcastleandGatesheadistakingplaceatatimeofsignificantchangeswithinthesystem.Inparticular,participantsmentioned:

• Increasedfundingcutstolocalandnationalservices,bothstatutoryandvoluntary.Participantsinthisresearchbelievedthatthisbroughtbothchallengestotheprogramme,forexamplearoundstakeholders’capacitytoengage,andopportunitiesinthatstakeholderswerelookingfornewwaystoworkmoreeffectivelywithinsmallerbudgets.

• FulfillingLivesNewcastleandGatesheadisoneofseveralnationalprogrammesthatforegroundtheimportanceofsystemschange.ThisincludesworknationallybyMakingEveryAdultMatter(MEAM)andLankellyChase.

ABOUT THIS RESEARCH Researchquestions

Thisresearchaimedtoanswerthefollowingresearchquestions.

1. Howeffectiveistheprogramme’sapproachtoachievingsystemschange?• Whatevidenceisthereabouttheextentofsuccessoftheprogrammein

achievingsystemschange,andwhatdoesthisshow?• Wherechangestothesystemhaveoccurred,howhasthishappened?• Whathavethoseinvolvedlearnedsofaraboutwhatsystemschangemeansand

entails,andwhatitmightlooklikeinpractice?• Whataretheviewsofthoseinvolvedindeliveringtheprogrammeaboutthe

effectivenessoftheprogramme’sapproachtoachievingsystemschange?• Towhatextenthastheprogrammeinfluencedthepracticeofthoseinvolved(e.g.

employingorganisations,StrategicGroupandOperationalGroupmembers),andthepracticeandpolicyoftheirorganisations?

• Howeffectivelyistheprogrammeutilisingidentified‘enablers’ofsystemschange?(Issuestobeexploredincludecollaboration,modelling,andsharinglearningandgoodpractice).

• Whatbarrierstosystemschangeistheprogrammeexperiencing,andhowcanitovercomethese?(Issuestobeexploredincludepowerandvestedinterests).

2. Howshouldtheprogrammedevelopoveritsremainingyears,inordertobestachievesustainedsystemschange?• Whatarethekeyactualandpotentialroutestosystemschangeforthe

programme,andhowdothoseinvolvedintheprogrammethinkthatthesecanbestbeutilised?

• Whataretherolesofthoseinvolvedintheprogramme(e.g.StrategicGroup,OperationalGroup,ExpertsbyExperience,CorePartners,employingorganisations,SystemBrokers,ServiceNavigators,ResearchandEvaluationandCommunicationsteam)inachievingsystemschange,andhowcouldthesebedeveloped?

• Whatcanbelearntfromtheliteraturereviewpreviouslyconductedandtheviewsofthoseinvolvedindeliveringtheprogrammeabout(i)howtheprogrammecanmoreeffectivelyinfluencesystemschange;and(ii)howtheprogrammecanachieveasustainedimpactafteritcomestoanend?

• Howcantheprogrammebestensureitisinapositiontomakerecommendationsforaneffectivesystemforpeoplewithmultipleandcomplexneedswhenitcomestoanend?

Methodology

Arapidappraisalapproachwasundertaken,gatheringinformationfromarangeofpeopleinvolvedintheprogrammeandreportingtheirviews,inordertoquicklyprovideinformationthatcanbeusedfordecision-makingaboutthefuturedevleopmentoftheprogramme.

Thefollowingmethodswereused:

1. Areviewofselectedprogrammedocumentsrelatingtosystemschange.2. Groupdiscussionsandinterviewswereconductedwith48people1involvedin

theprogramme.

Groupsdiscussionswereconductedwiththe:

• ServiceNavigators(8people)• SystemBrokers(3people)• EmployingOrganisationsForum(4people)• OperationalGroup(24people)• StrategicGroup(12people)• CorePartnership(3people)

OnetooneinterviewswereconductedwiththeExpertsbyExperienceCo-ordinator,twoSystemBrokers,the(nowformer)ResearchandEvaluationLeadandtheProgrammeManager. 1Somepeopleattendedmorethanonediscussion.

SYSTEMS CHANGE THEORY Systemsthinkingisawayofunderstandingproblemsandhowtheycanbesolved.Systemsthinkingsaysthat:

• Thesystemsthatpeopleinteractwithcancauseproblems,evenwhentheyaredesignedtohelppeople.

• Wecansolveproblemsbyseekingtochangethesesystems.

Thisresearchdrawsonseveralconceptualframeworksfromthesystemschangeliteratureinitsanalysis.TheseframeworkshavebeenhelpfulinidentifyingthestrengthsofFulfillingLivesNewcastleandGateshead,andidentifyingareaswherethereispotentialforFulfillingLivesNewcastleandGatesheadtofurtherdevelop.Theseareoutlinedinthissection.

Componentsofthesystem

InThinkinginSystems,herclassicworkonsystemschange,Meadowsidentifiesthreesystemattributes:elements,interconnections,andpurpose.3

• Elements:bothtangible(people,physicalresources,buildingsetc.)andintangible(cultures,valuesetc.).

• Interconnections:therelationshipsthatholdtheelementstogether,suchasacceptancecriteria,referrals,budgetsandmoneyflows,knowledgeandinformationetc.

• Purpose:thepurposeofthesystemratherthanthestatedpurposeofpeoplewithinthesystem.Thiscanbe‘deducedfrom[system]behaviour,notfromrhetoricorstatedgoals’.Thisalmostalwaysincludesthepurposeofperpetuatingitselfasasystem,whichcanmakechangedifficult.

Burns4describestwosubsequentwavesofsystemstheorythatplaceanadditionalemphasison:

• Meanings: the ideas, concepts and values ascribed to the world by different actors in the system.

• Power: including the way in which we construct boundaries around issues.

Levelsofsystemschangeforthosewhowishtochangethesystem

Thefollowingdiagram,adaptedfromamodelbyMakingEveryAdultMatter(MEAM),capturessomeofthedifferentlevelsofsystemschangethatwerediscussedbyparticipantsinthisresearch.

Levelsofsystemschangeforthosewhowishtochangethesystem

ChangingmyownpracMce

Changewithinthesystem(services)

Changetothelocalsystem(commissioning,policy)

ChangetothenaMonalsystem(naMonalpolicy)

Theprocessofachievingsystemschange:SixStepstoSignificantChange

ForumfortheFuture’ssixstepsmodelsetsoutaprocessforachievingsignificantchange.

ImagefromForumfortheFuture5

Ninepreconditionsforsystemschange

Collaborate’s nine preconditions for systems change identify the necessary vision and behaviours to begin to achieve systems change.

ImagefromCollaborate6

SYSTEMS CHANGE OUTCOMES ThissectionoutlinessomeofthesystemschangeoutcomesFulfillingLivesNewcastleandGatesheadhasinfluenced.Thisisnotanexhaustiverecordofsystemschangeachievedbytheprogramme,butgivesexamplesthatparticipantsintheresearchdescribed.

OUTCOMES OF THE SYSTEM BROKER-LED WORK Workforcedevelopmentandpsychologicallyinformedenvironments(PIE)

Thisareaofworkcoverspsychologicallyinformedenvironments(PIE),reflectivepracticeandcomplexneedstraining.Guidanceexplainsthatapsychologicallyinformedenvironment‘takesintoaccountthepsychologicalmakeup–thethinking,emotions,personalitiesandpastexperience-ofitsparticipantsinthewaythatitoperates.’7Itcan‘helpstaffworkmoreeffectivelywithpeoplewhohavecomplexandmultipleneeds.’8

FulfillingLivesNewcastleandGatesheadhas:

• PilotedaPIEapproachinthreeservicesrunbycorepartnerorganisations,andconductedandpublishedanevaluationevidencingitseffectiveness.

• Delivered‘trainthetrainer’sessionsonPIEfor10frontlineorganisationswhichisduetobeevaluated.

• Partneredwiththecorepartnerorganisationstodelivercomplexneedstrainingbothinternallyandtoexternalpartners.

• ProducedaseriesoffilmsmadewithExpertsbyExperienceMembersusingboth1-2-1interviewsandgroupdiscussions:allarefreelyavailableonyoutube.

Systemschangeoutcomesinclude:

• Allcorepartnerorganisationssaidthattheyhadbeguntoimplementapsychologicallyinformedapproachinsomeoralloftheirservices.TheyreportthatthePIEtraininghasincreasedcapacityandresilienceinstaff,andbenefitedclientsasaresult.

• TheSystemBrokerleadingonWorkforceDevelopmentandPIEhasbeensecondedtoChangingLives(theleadFulfillingLivesNewcastleandGatesheadpartner)parttimetohelpitembedreflectivepracticeinitsservices.

• AGeneralPracticehasagreedtotrainallsurgerystaffinPIEandunderstandingpeoplewithcomplexneeds.FulfillingLivesNewcastleandGatesheadhopesthat,ifsuccessful,thiscanberolledouttoGPsurgeriesacrossNewcastleandGateshead.

• ItisreportedthatLocalAuthoritycommissionersareconsideringmakingPIEakeyrequirementofservices.Forexample,SheffieldsetoutacitywidetenderforPIEdeliveryandGatesheadareconsideringitsusewithintheirsoontobere-commissionedsupportedhousingcontracts.

‘Weidentified[throughadoptingaPIEapproach]thatwedidn’thaveacalmquietspacetohaveconversations.Weputafewwallsupandnowwehavearoomfortheseconversations.’–CorePartner

‘[PIE]createscapacityandresilienceinstaff.It’shelpedtohavereflectivepractice,theycanoffload[whentheyexperiencedifficulties].Staffreportedfeelingresilience–notreachingtheendoftheweekatsnappingpoint.Thisisbenefitingclientsbecausestaffarelookingforwardtoconversations[…]Andthismeanshavingthecapacitytoholdclientsabitlonger.Yourealisetheyoftenwantsomeonetolisten,andstaffcandothis.’–CorePartner

Accesstosecondarymentalhealthservices

Peoplewithmultipleandcomplexneedsoftenstruggletoaccesssupportfromsecondarymentalhealthservices.

NewNationalInstituteforHealthandCareExcellence(NICE)guidelineswerepublishedinautumn2016recommendingthatsecondarymentalhealthservicesshould‘notexcludepeoplewithseverementalillnessbecauseoftheirsubstancemisuse’,andshould‘ensure[a]carecoordinatorworkswithotherservicestoaddresstheperson'ssocialcare,housing,physicalandmentalhealthneeds,aswellastheirsubstancemisuseproblems,andprovideanyothersupporttheymayneed.’ 9FulfillingLivesNewcastleandGatesheadworkedwithMEAMtosubmitevidencetoinformtheseguidelines.Theprogrammeisnowfocusingonensuringtheseguidelinesareimplementedlocally.Keysystemschangeoutcomesinclude:

• TheSystemBrokerleadingonthisareaofworkworkedwithPublicHealthGatesheadtodraftaDualNeedsStrategyforGatesheadreflectingthenewNICEguidelines,whichiscurrentlybeingfinalised.

• ThestructureandformatofGateshead’sDrugRelatedDeathsPanelhaschanged,toincludeanevidence-basedexplorationofsystemicissues.FulfillingLivesissupportinganappreciativeenquiryintothedeathsofGatesheadclientsexperiencedatFulfillingLivesandisworkingwiththeLocalAuthoritytoexplorefuturepreventativesolutions.

• Gateshead’sDualDiagnosisteamhasstartedtoholdmonthlydualdiagnosisforums,whichprovideaforumforfrontlinestafftotalkaboutclientswithdualdiagnosisissues.

• FulfilingLivesisworkingwithNorthumberlandTyneandWearNHSFoundationTrust,whichoperatesacrossNewcastleandGateshead,toexploreapotentialPilot.FulfillingLivescirculatedasurveyofprofessionalsworkingacrosstheNewcastleandGatesheadsystem,scopingtheirconcernsandexperiencesinaccessingsecondarymentalhealthservices19Surveyshavebeenreceivedatthetimeofwritingthisreport,whichincludesomerobustsuggestionsandfindings.FollowingdiscussionattheFulfillingLivesStrategicGroup,theProgrammeManager’spresentationtotheMentalHealthProgrammeBoard,andsubsequentmeetingwiththeChiefMedicalOfficerforNorthumberlandTyneandWearNHSFoundationTrustthenextOperationalGroupwillfocusondevelopingthescopeofapilotandsharetheexpectedre-structureofservicesatthebeginningofOctober.

• FulfillingLiveshasbeeninvolvedintheTogetherinaCrisisproofofconceptproject,whichwillinformthedevelopmentofanurgentcaremodel.TheprojectisbeingledbyleadagencyMentalHealthConcernandpartnerorganisationsHomeGroup,CitizensAdviceNewcastleandChangingLives.FulfillingLivesprovided£15k

toensurethatpeerevaluationwaspartoftheoverallevaluationfortheprojectand

aresupportingtheexternalevaluatorbytrainingPeerResearcherswhowillspecificallyaskrecipientsoftheserviceabouttheirexperienceofthenewconcept

whichwillbeincludedinthewiderevaluation.

UniversalCreditandothertransitions

NewcastleisaDepartmentforWorkandPensions(DWP)testandlearnsiteforUniversalCredit.FullserviceUniversalCreditwasintroducedinNewcastleinMay2016.

TheSystemBrokerleadingontheprogramme’sprioritysystemschangeareaoftransitionsidentifiedUniversalCreditasapriorityissue.Manyinthesystemwere

concernedabouthowelementsofUniversalCreditdeliverywouldaffectpeoplewithmultipleandcomplexneeds.

TheprogrammeisworkingwiththeDWPlocallytocollectevidenceofhowwelltheintroductionofUniversalCreditisworkingforthisclientgroup.TheSystemBrokerfoundthatapre-existingtrustedpartnership(whichexistedasaresultofpreviousworktheprogrammehadconductedwiththeDWParoundaccesstobenefits)helpedfacilitatethisjointworking,asdidNewcastle’spositionasatestandlearnsite.

Keysystemschangeoutcomesare:

• AsinglepointofcontacthasbeenassignedtemporarilyineachofthethreeJobCentresinNewcastle(andsoontobeinGateshead)tosupportpeoplewithmultipleandcomplexneedswithUniversalCredit.TheseprovidesupportforNewcastleWelfareRightsTeamclientsaswellasFulfillingLivesclients.

• ResearchevidenceisbeingcollectedbytheprogrammeinpartnershipwiththeDepartmentforWorkandPensionsandNewcastleWelfareRightsTeamontheeffectivenessofthisapproach.

• FulfillingLiveswillbeprovidingreflectivepracticesessionsandmultipleandcomplexneedstrainingwith16frontlineDWPstaff.

Workisalsounderwayinrelationtootherpointsoftransition.Areportevidencingtheexperiencesofpeoplewithmultipleandcomplexneedsonreleasefromprisonissoontobepublished.TheSystemBrokerisalsoworkingwithlocalpartnerstodevelopatenancysustainmentprogrammetailoredtopeoplewithmultipleandcomplexneeds.

CHANGES EXPERIENCED/IMPLEMENTED BY PARTNERS Thissectionconsiderstheextenttowhichsystemschangeshavebeenexperiencedorimplementedbycorepartners,employingorganisations,andOperationalandStrategicGroupmembers.

Corepartnerandemployingorganisationsspokentodescribed:

• PilotingandsubsequentlymorefullyimplementingaPIEapproachintheirservices.

• Deliveringmultipleandcomplexneedstrainingbothinternallyandwithintheexternalsystemastrainingpartnerstotheprogramme.

• Reflectingonandchangingtheirownpractice(seeboxedexamplebelow).

• Takingpartinmoremulti-disciplinarymeetings,whichhadbeenencouragedandconvenedbytheServiceNavigator.

• Improvedinformationsharing.• IncreasedserviceuserinvolvementthroughtheExpertsbyExperienceGroup.

Ofthethreeemployingorganisationsspokento,twoweremembersofcorepartnerorganisations,somightbeexpectedtobemoreinvolvedinchangethannon-partnerorganisations.However,theirexperiencessuggestthatemployingNavigatorswithinorganisationshasbeenaneffectiveroutetochange,byinfluencingservices’thinkingandgentlychallengingtheirpractice.

Wedelayedsteppingbackfrompeopleafterweidentifiedweweren’tthebestorganisationtoworkwiththemandneededtoreferthemon.Thiscamefromrealisingthosepeopledidn’tgetthereovernight;theyhadahistoryofbeingpassedaroundorganisations[andbyreferringthemonweweredoingthesamething].Wethought:‘istheresomethingwecandotomakesurethesepeopledon’tthink“what’sthepointoftrying,theyjustpalmyouoffelsewhere”?’–EmployingOrganisation

OperationalGroupmembers(whoincludedsomecorepartners)described:

• Strongerrelationshipswithothergroupmembers.• Increasedopportunityforreflection,includingtheopportunitytotakepartin

‘excellentconversations’and‘reflectonsystems’.• Increasedknowledge,forexampleaboutotherpartsofthesystem.• Somepeopledescribedcollaborationandpartnershipwork.• Somepeopledescribedsomechangesintheirpractice,forexamplepracticing

PIE,introducingmultipleandcomplexneedstrainingtotheirorganisation,‘lookingatnewwaysofworking’,andonepersonsaidtheirinvolvementinFulfillingLivesNewcastleandGatesheadhad‘influencedthedirectionofworktomeetingtheneedsof[this]clientgroup’inrelationto‘strategydevelopment’.

OasisAquilaHousing:changingcriteriafordispersedsupportedaccommodation

Onecorepartnerandemployingorganisation,OasisAquila,describedthechangesithasmadetoitsaccommodationserviceasaresultofFulfillingLives.

‘Weradicallyadaptedouraccommodationservice.Previouslywerarelyaccommodatedpeoplewithmultipleandcomplexneeds,butnowtheyareournewtargetgroup.ThiscameaboutduringadiscussionwithourServiceNavigator:Iwasencouraginghertobecreativeinsourcinganaccommodationoptionforaclientwithmultipleevictionsandnoapparentoptions,whilstwehadanemptyproperty.Ifeltahypocritenotacceptingtheclient.Wehousedtheclientandayearonhewalkedintoourcentreinasuitonhiswaybackfromajobinterview.

Myrolewastochallenge[thewayweworked]–canwesayasanorganisationwe’rehousingthemostvulnerablepeople?

Wehadsixdispersedhousingproperties.That’sextendedto16now–wegotadditionalpropertiesfromthehousingcompany[thatmanageshousingforthelocalauthority].Itworksbecausepeoplearen’tlivingtogether–alothadmultipleevictionsbecauseoftheirbehaviourwithotherpeople.It’saHousingFirststyleapproachwithintensivesupport.

Wegotinvolvedascorepartnersbecausewesawtheneedforchange.FulfillingLiveshasfacilitatedthat,givenustheopportunitytoexploreandtestnewwaysofdoingthings.’

StrategicGroupmembersdescribed:

• Thegenerationofasystem-wideperspectiveinthegroupandthewidersystem,andadeeperunderstandingofcomplexneedsandsystemicissues.

• Implementingpilots(suchasPIE)andstafftrainingonmultipleandcomplexneedsintheirorganisations.

• Theircommissioningpracticebeinginfluencedbyprogrammeprinciples.• Strongercollaborationincluding(i)experiencingcloserworkingrelationships

withothersinthesystem,and(ii)brokeringrelationshipsfortheprogrammewithothersinthesystem.

Theysaidthattheprogrammehadinformed:

• NewcastleGatesheadClinicalCommissioningGroup(CCG)andMentalHealthConcern’sTogetherinaCrisisproject(whichaimstoprovideasupportivementalhealthrecoveryprocessforpeoplewithanurgentbutnon-clinicalmentalhealthneed,incorporatingPeerResearchandPeerEvaluation).

• AGateshead-widehomelesshealthneedsassessment.• AGatesheadhousingreport.• Arenewedfocusonthevalueoflivedexperience,withtheExpertsbyExperience

GroupworkingwithGatesheadCouncilandformingakeypartofRespondtraining.

INFLUENCING LANGUAGE AND CULTURE Arangeofparticipantssaidthattheyhadnoticedthelanguagebeingusedbythoseinthesystemchangingtoreflectthelanguagebeingusedbytheprogramme,andbelievedthatFulfillingLivesNewcastleandGatesheadhasplayedasignificantpartinthis.2Theygaveexamplesoftermslike‘PIE’,‘systemschange’and‘transitions’:

‘It’spoppingup,inameetingwithsomeoneunrelatedtoFulfillingLives.Andyouthink:that’sourlanguage,ourinfluence.Isuspectalotofitiswordofmouthandthededicatedworkbuildinglinksinkeyservices,andpeoplegooutfromthose.Andtherehasbeensomeconsciousefforttosharethemessage.’–FulfillingLivesstaffmember

‘Ican’temphasiseenoughhowmuchthedialoguewithinthesystemhaschangedsinceFulfillingLives.[…]Idon’tknowifit’sjustcoincidencethatthingswe’veled

2Participantswereawarethatothernationalprogrammes,forexamplethoseledbyMEAMandLankellyChase,werealsousingsomeoftheseterms.

onisstartingtopopupinpolicy.It’shardtotakecreditforthingswhenit’sotherswhoarechanging,butit’scertainlydialogueandthoughtprocessesIthinkwe’veinfluenced.’–SystemBroker

SystemBrokersalsobelievedtheyhadhelpedinfluencetheculturewithinsomeorganisationsinvolved.Thisincludedhavingamoresystemicperspective,andbeingmorewillingtodiscussflawsintheirownpractice:

‘Ithoughtitwasreallyhealthytohearpeoplelike[name]besochallengingaboutsystemchange[intheOperationalGroup],andbeingsoopenandhonestandsaying,“I[conductwork]knowingthatit’snotgoingtowork,becausewhatelseisthere?Thesystemneedstochange.”[…]Wedon’twanttotakeownershipofthat[…but]we’vechangedthatculture.’–SystemBroker

INFLUENCING THE PRE-CONDITIONS OF SYSTEMS CHANGE Aswellasidentifyingthemoretangibleoutcomesoftheprogramme,itisimportanttoconsidertheextenttowhichtheprogrammehascultivatedtheconditionsthatfacilitatesystemschange,whichcanbeexpectedtohelpleadtosystemschangeovertime.Themodelofpre-conditionstosystemschangedevelopedbyCollaborateprovidesausefulguidetothese(seep.17).Thissectionconsiderstheextenttowhichtheprogrammeisdemonstratingthebehavioursandvisionsetoutbythismodel,andtouchesonhowsometheseconditionshavebeencreatedandhavehelpedtocreatesystemschange.

Behaviours

Thefirstsetofpre-conditionsreferstothebehavioursofactorsinthesystem,or‘howyouplantodosystemschange’.

Trustedpartners:understandandadapttoeachother’svaluesFulfillingLiveshashadahighdegreeofsuccessincreatingtrustedpartnerships.Ithaswell-attendedStrategicandOperationalGroups,andSystemBrokershavebuiltstrongpartnershipswithseveralsystemactors.TheSystemBrokersbelievethattrustedpartnershipsarecentraltothesystemschangeoutcomestheyhaveachieved.

‘[Theimportanceof]relationshipshasbeenmassive.Andbeingabletobeindependent,sayingthisnotapersonalthing,we’rejustholdingamirror,whyis

thedatashowingthisandthat?Thereisalotoftrustthere,the[partnerorganisation]trustusasaprogramme.’–SystemBroker

TheProgrammeManagerhasfoundthatadeepdegreeoftrustisrequiredinorderforpartnerstoopenlyreflectonflawsintheirownwayofworking.Shehasfoundthatbeingopenabouttheprogramme’sownfailingshashelpedothersinthesystemtofeellessexposed:

‘Inthesetimeswhicharedifficultandaustere,howcanpeoplehavethefreedomtobeupfrontandopenabouttheirfailingsinfrontofcompetitors?[…]Thewaywe’reasaprogrammebeingmoreopenaboutourlearningandfailing,Ithinkthat’sreallyimportant’–ProgrammeManager

TheSystemBrokersreportthatpeoplearemorelikelytotalkopenlyaboutelementsoftheirpracticethatarenotworkingwellinonetoonediscussionsratherthaninpublicmeetings.Theyhavefoundthatasupportiveratherthancriticalapproachisessential:

Iwentinwithacollaborativeheadon,thinkingthisnotaboutbashing[thissystemproblem]andsayingwhatisreallybadaboutit,it’saboutlearningandunderstandingwhatourclients’journeyisandunderstanding,wherethingsdon’tworksowell,whatcanbedone.Thisapproachworkedwellandkeptthemengaged.Theyfeelwe’reanally.’–SystemBroker

Distributedleadership:enabling,noegos,fluid,conveningTheprogrammehasfoundthatpracticingdistributedleadershiphashelpedtobuildtrustedpartnerships.Severalstakeholdersdescribedtheimportanceoftheproject‘workingalongside’organisationsratherthanseekingtobeexpertssolvingsystemsproblemsfortheorganisations.EmployingOrganisationscitedthemodelofemployingServiceNavigatorswithinservicesasanimportantexampleofthis;theNavigatorswereseenasanextraresourceandsupportbyfrontlinestaff.LikewiseSystemBrokersdescribedthemselvesassupportingandconveningconversationswithstakeholders.

TheProgrammeManagerdescribedlearningbytheprogrammearoundhowtoperformtheroleofsystemschangeleadership,givingtheexampleofhowtheprogrammerelatestotheStrategicGroup:

‘We’vehistoricallyhad[theStrategicGroup]asreceiverofallourwonderfulstuff,anotherreport,moreinformation,‘cleverus’,insteadof:let’stakesomethingabitunfinished,anduseallthebrainsaroundthetabletohelpus.It’smuchhealthiernow.’–ProgrammeManager

TheResearchandEvaluationLeaddescribedthisasstopping‘tryingtoproblemsolveourselves.’ThisnewapproachhasreportedlyledtomoreofasenseofownershipovertheprogrammebytheStrategicGroup,andhelpedthemtounderstandhowtheycouldusefullyinfluencethesystem.

‘You’vegottosometimesstopandthinkwhatdoyou[asstakeholders]thinkweshouldbelookingat?Aretheserightthings?Askingnottelling,approachingwhatisimportanttothem.’–ProgrammeManager

Resilientandriskembracing:safetofail,abletoquicklybouncebackStakeholdersdescribedtheriskembracingapproachoftheprogramme:

‘FulfillingLivesgivestheopportunitytotryandlearn,thisisreallypositive.It’snotafailurethat[oneprogrammeactivity]didn’twork.’–Corepartner

BeingsafetofailandabletoquicklybouncebackisimportanttotheSystemBrokerwork.Someelementsoftheirworkhavebeenmoresuccessfulthanothers,forexamplewhenstakeholdershavenotwishedtopursueanareaofsystemschange,orwhenexternalpolicychangesaffectthesystemonwhichsystemschangeworkisfocusing.3SystemBrokersdescribedtheimportanceofbeingabletorecogniseandmoveonfromunsuccessfulareasofwork.TheResearchandEvaluationLeaddescribedthis,inparticularinrelationhowtheprogrammeprioritiseswheretofocusstaff’slimitedcapacity:

‘There’ssomethingaroundbeingincrediblyflexible.Everyoneintheprogrammehastohavethesamefocusbuthastohaveawillingnesstodropsomethingifit’snotworkingbecauseyoucouldwastehugeamountsoftimeandenergyandnotgetanywhere[…]Ourworkaroundpeoplewithnorecoursetopublicfundswasagoodexampleofthis–weweretryingtodosomethingwherewedidn’teverhavethepowertochangeitbecauseit’ssonationalpolicybased.’–ResearchandEvaluationLead

Thisdecisionrelatestopersonalisationandanongoinguseoffunds.Theworkstreamhascontinuedwithmoreimpactbyidentifyingthekeystrategicleadstotakethisworkforwardandcontributetotheirworkratherthanleadit.

3AnexampleiswhentheearlierthanexpectedintroductionofUniversalCreditlocallyrenderedworkaroundaccesstotheexistingbenefitssystemlessimportant.

Strengthsbased:utilisingtheassetsofpeopleandplaceTheprogramme’sapproachtoworkingwithpartnersisastrengthsbasedapproach;thedistributedleadershipdescribedaboverequiresthis.Theprogrammerecognisesanddrawsonthestrengthsofpartnersinitscollaborativework.

Therearesomeexamplesofwheretheprogrammecouldmakemoreuseoftheassetsavailabletoit:

• TheExpertsbyExperienceNetworkdoesnothaveastronglyembeddedroleinthesystemschangeprocess,sotheassetsofpeoplewithlivedexperienceofmultipleandcomplexneedsarenotbeingmadefulluseof.

• ThemodeloffocusingonsystembarriersexperiencedbycasestudiesintheOperationalGroupusefullyhighlightssystemicissues,butfocusesonsystemdeficitsratherthanassets.Theassetsofgroupmembers,andtheareasinwhichtheycouldinfluencesystemschange,couldbeusefullyexploredfurther.

• Therolesinthesystemchangeprocess(seep.34)focusstronglyontheidentificationofsystembarriersandblockages,andonidenitifyingsolutionstothese.Amoreasset-basedapproachwouldalsoidentifytheassetsavailableateachstageoftheprocess.

AbletoletgoandactasaplatformforinnovationTheSystemBrokershavedescribed‘lettinggo’ofanumberofareasofwork.AnexampleistheworkonLocalConnection4thatisnowbeingledbyHomelessLink.Theyreportthatitcansometimesbedifficulttojudgewhentoletgoandwhentocontinuetosupportareasofwork,andthiswouldbeausefulareafortheSystemBrokerstoreflectonastheprogrammeprogresses.

Vision

Thesecondsetofpre-conditionsreferstotheambitionofthesystem.

IssuesareacknowledgedassystemicandrequiringcollaborationProjectpartnersdescribeanincreasingunderstandingofthesystemicnatureofmanyissuesencounteredbypeoplewithmultipleandcomplexneeds,andtheneedforasystemicresponsetothese.Thisisdemonstratedbyexamplesintheabovesections

4Thisworkexplores the possibility of agreements between local authorities to house people in areas with which they have no ‘local connection’ (forexample,havinglivedthereforsixmonthsoutofthelast12,orhavingclosefamilywhohavelivedintheareaforatleastfiveyears), which is usually a stipulation for help with housing.

‘Changesexperienced/implementedbypartners’(p.21)and‘Influencinglanguageandculture’(p.24).Programmestaffandpartnerssaidthatthiswasnotyetfullythecaseacrossthesystem:

‘Therewasastrongresponsefrom[specific]servicesabout[onesystemicbarrieridentified]–theydidn’tagreethiswasanissue.’–corepartner

However,theysaidthatpartnersincreasinglyacknowledgedissuesassystemic,anddescribedbuildingpositiverelationshipswithnewpartnersastheprogrammeprogressed.

Citizencentred:fromconcepttodelivery,andbeneficiaryimpactoverorganisationfocusTheprogrammeiscentredontheneedsandexperiencesofpeoplewithmultipleandcomplexneeds,withitssystemschangeworkbasedonevidenceoftheexperiencesofclientsbeingsupportedbytheServiceNavigators.Thereisscopefortheprogrammetoensuremoredirectinfluenceofbeneficiariesoveritswork,forexamplebystrengtheningtheroleoftheExpertsbyExperienceNetworkinthesystemschangeprocess.

GroundedintheplacebutopentonewapproachesTheprogrammeisstronglygroundedinthelocalcontext,respondingtolocalissuesandopportunities(suchitsestablishmentasatestandlearnsiteforUniversalCredit).Ithasalsodrawnonnewapproachesfromotherareas,forexampledrawingonnationallearningaboutPIE,andlearningfromotherlocalitiesaboutdifferentLocalConnectionpractices.

ACHIEVING SYSTEMS CHANGE: THE PROCESS Thissectionexploresthesystemchangeprocess,including:stagesintheprocess;routestosystemschange;rolesinchangingsystems;andtheprogramme’slearningabouttheprocess.

STAGES IN THE SYSTEMS CHANGE PROCESS ForumfortheFuture’sSixStepsModeloutlinesthestepsinaprocesstoachievingsystemschange.ThisisavaluabletoolforunderstandingwhereFulfillingLivesNewcastleandGatesheadisintheprocess;eachstepisconsideredbelow.

Step1:Experiencingtheneedforchange

FulfillingLivesNewcastleandGatesheadplacesastrongemphasisonprovidingcasestudiesandotherevidenceoftheneedforchange,basedonthedirectexperiencesoftheServiceNavigators’clients,andthishasplayedanimportantpartinconvincingstakeholdersoftheneedforchange.Theword‘experience’highlightstheimportanceofgoingbeyondtheprovisionof/passivereceiptofevidence.Thesystemschangeliterature10suggeststhattoexperiencetheneedforchange,peopleneedtogobeyondbeingpresentedwithevidenceandparticipateindiscussionsandreflection;hearingthetestimoniesandexperiencesofpeoplewithmultipleandcomplexneedscanplayausefulpartinthis.Theprogrammeprovidesmanyopportunitiesforsuchdiscussions,

forexampleviatheOperationalandStrategicGroups,workinggroups,anddiscussionsconvenedbytheSystemBrokers.However,opportunitiestohearthevoicesofthosewithlivedexperiencefirsthandarelimited.

Asdescribedinprevioussections,thisresearchshowsthatmanystakeholdersknowthereneedstobechange,althoughnotallkeystakeholdersareyetfullyinvolvedwiththeprogramme:

‘It’screatedanappetiteandplatformforpeopletochange[…]forpeopletolistenandworktogether’–FulfillingLivesstaffmember

However,notallstakeholdersinvolvedwiththeprogrammerecognisetheneedforchangeintheirownpractice.Thismayinpartstemfromalackoffullunderstandingofthenatureofthesystemschangeapproach,whichinvolvesexamininghowone’sownpracticeformspartofthesystemandcouldhelpfullychange,asthisquotationfromthesystemschangeliteraturedescribes:

‘Ihavetostartbyreflectingonandchangingmyself.Ihavetounderstandmyself,becausethepersonwhowillbethehardestformetoleadthroughchangeisme.’11–HelenBevan(systemschangepractitionerandtheorist)

Step2:Diagnosingthesystem

Therewasgeneralagreementbytheresearchparticipantsthatthestageof‘diagnosingthesystem’hasbeencompleted,ornearlycompleted.Thesystemicproblemsthatpeoplewithmultipleandcomplexneedsencounterarefelttobewell-knownandunderstood,anditisgenerallyfeltthattheprogrammehascollected(ifnotyetfullyanalysed)sufficientevidenceaboutthese.

‘We’vemappedthesystem–we’venotyetgonetothenextlevel.’–CorePartner

Someprogrammeactivitiesstillfocusondiagnosingsystemproblems.Examplesincludediscussionsofsystemicbarriersrevealedbycasestudies,andelementsoftheServiceNavigatorrole.Theremaystillbeavaluablerolefortheseactivities:forexample,theycanbeausefulstartingpointforgeneratingideasformoreeffectivepractice,andcancreatemoreengagementandownershipovermakingchanges.Theyalsoenabletheprogrammetocontinuouslydiagnosechangingissuesinachangingsystem.However,itisrecommendedthatanysuchactivitiesshouldhaveaclearpurposewhichenablesmovingbeyonddiagnosistowardsactionforsystemschange.

Whathasnotyetbeenfullydiagnosediswhereaboutsinthesystemtheproblems,andpotentialsolutions,sit.Theprogrammehasbeguntodistinguishbetweenstrategicand

operationallevelsystemicbarriers,andthisisvaluedbytheStrategicGroup,enablingthemtoseeksolutionstostrategiclevelbarriers.ItwouldbehelpfulfortheOperationalGrouptoexploremorefullywherechangesmightusefullybemadeatanoperationallevel.

Step3:Creatingpioneeringpractices

Asoutlinedinprevioussections,anumberofinnovativepracticeshavebeenimplementedasaresultoftheprogramme.Examplesinclude:embeddingPIEapproachesincorepartnerservices;triallingasinglepointofcontactmodelforUniversalCreditforpeoplewithmultipleandcomplexneeds;andtheHousingFirst-stylemodelofdispersedsupportedhousingadoptedbyOasisAquila.

Steps4to6:Enablethetipping,andbeyond

Thesestepsrelatetoscaleandsustainability.Someareasoftheprogramme’sworkmaybemovingtowardsa‘tippingpoint’toscale.Workforcedevelopmenttraining(includingPIE,complexneedsandreflectivepractice)istakingplaceonagrowingscale,includingtrainthetrainercourses.PIEisbeingimplementedincorepartnerservices,andmultipleandcomplexneedstrainingistakingplaceinseveralpartsofthesystem(forexamplewithDWPandGPstaff).

Stakeholdersalsoreportsomechangesinlanguageandculturethatmayindicateatippingpointinunderstandingofissuesassystemic.

Anumberofpilotsofinnovativepracticehavetakenplace,andakeychallengefortheprogrammenowwillbetofindawaytoembedthesuccessfulpracticesfromthepilotsinpracticeandpolicy.

Steps4to6areconsideredfurtherinthesection‘ScaleandSustainability’.

ROUTES TO SYSTEMS CHANGE

Theprogrammemakesuseofseveralmainroutestosystemschange.Eachoperatesacrossboththeservicelevelandthelocalpolicy/commissioninglevelofthesystem.TheResearchandEvaluationteamsupportsmanyoftheseroutes,forexamplebyconductingActionLearningSetsandco-ordinatingtheevidenceinordertoidentifybarriersandblockagesrequiringchange.

Route1:WorkledbytheSystemBrokers

TheSystemBrokershavethecapacitytoproactivelyworkwithpartnerstosupport,influenceandencouragechangeintheprogramme’spriorityareas.ExamplesofSystemBrokeractivityincludesupportingpilots,conductingtrainingandresearch,anddraftingstrategy.Theycanworkwithstakeholderswhomightnototherwisecomeintoclosecontactwiththeprogramme,buthaveawillingness/opennesstochangeandaremotivatedinpartbytheresourceandsupporttheSystemBrokersbring.TheSystemBrokersworkatdifferentlevelsofthesystemdependingonthelevelandtypeofthesystemsbarrier(e.g.withservicesorcommissioners,andwiththestatutoryorvoluntarysectors).Thesededicatedrolesarecrucialindrivingchangeintheseareas.

Route2:WorkconductedbytheServiceNavigators

TheServiceNavigatorsprovideadirectlinktothecurrentexperiencesofpeoplewithmultipleandcomplexneedsandproblemstheyencounterinthesystem,ensuringtheprogrammeisgroundedinthese.Theroleprovidesevidenceofsystemsissuesfaced,apotentialpathforpeopleintotheExpertsbyExperienceNetwork,buildsrelationshipswithorganisationswithinthesystem,andcaninfluencesmallsystemsflexes.Therolehasalsosuccessfullyencouragedemployingorganisationstoreflectonandchange(todifferentdegrees)theirpractice.

Route3:Workinggroups/taskandfinishgroups

Theprogrammehaspreviouslyestablishedsomeworkinggroups;littleevidenceabouttheextentofthesegroups’effectivenessemergedinthisevaluation.However,researchparticipantswantedtoseemoreworkinggroupsortaskandfinishgroupsaswaysofmovingtowardsactionforsystemschange.Theysuggestedthesegroupscouldusefully

spinofffromtheStrategicorOperationalGroups,andincludepeoplewithparticularinterestsinthegivenareaofthesystem.

Route4:Individualsinitiatingchangeintheirownorganisation’spractice

Thisareaofchangeisledbyindividualswhoarepartoftheprogramme,whoimplementchangewithintheirownorganisations.Theyareopentomakingchange,andtheprogrammeprovidesthechallenge,opportunity,knowledgeandideastohelpthemdoso.TheseindividualsmayincludeCorePartners,EmployingOrganisations,servicescomingintocontactwiththeServiceNavigators,andmembersoftheStrategicorOperationalGroups.Theyalsoincludeotherstakeholderswhocomeintocontactwiththeprogrammebyothermeans.Thistypeofchangeemergesfromindividuals’contactwiththeprogramme.Itcanbeencouraged(forexamplebycultivatingthepre-conditionsofsystemschangeorestablishingworkinggroups),butitislessstructuredandcannotbeplannedforinanydetail.

Sometimesyoudon’tknowyou’redoingit[systemschange],andthat’sprobablythebestthing,whenothershavetakenaleadonthings,andyoudon’tknowwhatyou’redirectlyimpacting.’–SystemBroker

Route5:TheExpertsbyExperienceNetwork

TheExpertsbyExperiencenetworkhasprovidedexpertisetosystemactorssuchascommissionersandthepolice.Thereisscopeforthenetworktoestablishitselfasasourceofexpertadviceinservicedesignandcommissioningdecisions.Assuch,thenetworkisavaluablepotentialroutetoembeddedsystemschangeinpolicyandcommissioningaswellasatservicelevel.

ROLES IN THE SYSTEMS CHANGE PROCESS Thediagrambelowshowstherolesthatitisintendedthatkeystaffmembers,partnersandstakeholdersplayinachievingsystemschange.Thisisanevolvingmodel,andparticipantssaidthatsomepartsoftheprocessworkedmoreeffectivelythanothers.

Rolesinthesystemschangeprocess

Partners

Programmestaff

ServiceNavigatorsdirectlysupportpeopleexperiencing

multipleandcomplexneedsandidentifysystemsbarriers

encountered

SystemBrokersworkwithstaffacrosstheprogrammetoidentifythemesinsystembarriers,supportcollaboration,andhelp

initiate,pilotandsupportinnovativepractice.

TheResearch&Evaluationteamhelpsprovideevidenceofsystemsbarriers,andevidenceoftheeffectivenessofinnovativepractice–clientjourney

Referencegroups

TheOperationalGroupbringstogetherserviceprovidersfromacrossthesystem

toaddressoperationalbarriers.

TheStrategicGroupbringstogetherseniormanagersandcommissionersfromacrossthesystemtoaddressstrategic

barriers.

TheExpertsbyExperienceNetworkprovideanexpertviewonsystembarriersandhowthesystemcouldworkbetter,andhelpshapethedevelopmentofthe

system.

Corepartners,employingorganisations,andother

partnersembedchangewithintheirownorganisationsand

influencewiderchangeinotherstheyworkwith.

Stakeholdersfromacrossthesystemchangetheirownpractice

andpolicy

TheProgrammeManagerandExpertsbyExperienceCo-

ordinatorprovidemanagementandco-ordination.

Theeffectivenessofthismodel,andopportunitiesfordevelopingtheseroles,areconsideredbelow.

TheServiceNavigatorrole

TheNavigatorroleisimportantforanumberofreasons.First,itprovidesadirectlinktothecurrentexperiencesofpeoplewithmultipleandcomplexneedsandproblemstheyencounterinthesystem,ensuringtheprogrammeisgroundedinthese.Throughthis,theroleenhancestheprogramme’scredibility(accordingtopartnerorganisations),andisavaluablesourceofuptodateevidenceinaconstantlychangingsystem.Andsecond,ithassuccessfullyencouragedemployingorganisationstoreflectonandchange(todifferentdegrees)theirpractice.

Astheprogrammemovesawayfromdirectserviceprovisiontoastrongerfocusonsystemschange,peoplefromacrossdifferentpartsoftheprogrammesuggestedthattheNavigatorrolecouldusefullybecomemoresystems-changefocused.MembersoftheStrategicGroupandtheEmployingOrganisationsgroupsuggestedtherewasscopeforarolethatspentmoretimebrokeringsystemschange,supportingservicestochangetheirpractice(inresponsetoblockagesexperienced)ratherthansupportingindividualstonavigateservicesonamoreadhocbasis.Itwasfelttobeimportantthatpeopleinthisrole‘workedalongside’servicesratherthanbeingseentobebroughtintosortoutproblemsintheservice.ThefeelingthatServiceNavigatorsare‘workingalongside’servicesisisseentobeoneoftheadvantagesofthecurrentmodelofemploymentwithinservices.

TheServiceNavigatorsthemselvessaidtheywouldliketobemoreinvolvedinchangingsystemsthroughtheirrole.TheygavetheexampleofaNavigatorwhohadbeencloselyinvolvedinthepilotwithDWParoundaccesstobenefitsasanexampleofthis.ExpandingtheNavigatorrolewouldenabletheprojecttobroadenitssystemschangereach;theSystemBrokersreportedlargeworkloadsandsaidthattheirlimitedcapacitylimitstheprogramme’sreachintermsofsystemschange;theysaidtheyhaveusefullydrawnonsomeNavigatorstohelpwithsomeareasofwork.

TheSystemBrokerrole

Theexperiencesoftheprogrammesofarsuggeststhatthisdedicatedrolefocusingonsystemschangeisvitalindrivingchangeforward.TheroleprovidesthelinkbetweentheNavigators’roleofcollectingon-the-groundevidenceandundertakingsysteminfluencingandflex,andotherpartsofthesystem.TheBrokershaveagreatdealof

experienceanddemonstrateasophisticated,evolvingunderstandingofhowtocreatesystemschange.TheexpertresourcethattheBrokerscanprovidehasbeenimportantinbuildingtrustedpartnershipsandmotivatingstakeholderstoworkwiththeprogramme.TheBrokershavehadthecapacity,forexample,todelivertrainingonPIEtoservices,tosupportthedevelopmentofadraftDualNeedsStrategyforPublicHealthGateshead,andtoconvenepartnershipmeetings.Theimportanceoftherolemayreduceovertime,asthosewithinthesystemtakeonamoreleadingroleinmakingsystemschange,butatpresenttheroleiscentraltoachievingsystemschange.

Theevaluationteam

ExternalpartnersandstakeholderssaidthatstrongevidencewasoneofthestrengthsoftheFulfillingLivesprogramme.Adedicatedinternalevaluationrole(alongsidegoodinformationsystemsanddatacollectionbytheServiceNavigators)iscentraltothis.Theprogrammehascollectedagreatdealofevidence,firstlyaboutthecharacteristicsandexperiencesofpeoplewithmultipleandcomplexneeds,andsecondlyabouttheeffectivenessofinnovativepracticebeingtestedinpilots.Thishasbeenvitalinconvincingsomestakeholdersoftheneedforchange;somestakeholderswerenotwillingtoworkcloselywiththeprogrammewithoutthisevidence.Evaluationsevidencingeffectivenesshaveenhancedthecredibilityoftheprogramme’spilots,aswellasusefullyindicatingareasforimprovementinthese.Theinternalevaluationteamhasprovedausefulresourceforexternalpartnersinpilots(suchastheDWP)thathasmotivatedpartnershipworking.Theteamalsodevelopedacostcalculator,whichprogrammestaffreportedtobepositive.

TheExpertsbyExperienceNetwork

TheroleoftheExpertsbyExperienceNetworkiscurrentlybeingreviewed.TheNetworkhasconductedvaluableworkwithinthesystem(forexamplebringingtheexpertvoicetoRespondtraining).ThereissignificantscopefortheNetworktobemorecloselyinvolvedinthesystemschangeprocess,andtheExpertsbyExperienceCo-ordinatorisintendingtoworkwiththeNetworktoidentifyhowthiscouldbestwork,indiscussionwithprogrammestaff.ThesystemschangeworkisgroundedintheNavigators’clients’experiences(whoarenotcurrentlymembersoftheNetwork),butthereiscurrentlylessopportunityforthevoicesofexpertsbyexperiencetodirectlyinformthesystemschangeworkbeyondthis.Amorecentralrolecouldincludeadirectvoiceindiscussionsaroundunderstandingtheproblem,generatingideasforchange,

anddesigningnewwaysofworking;andco-deliveringworksuchastrainingorresearch.

TheOperationalGroup

TheOperationalGrouphasagoodattendanceofengagedstakeholdersfromacrossthesystem.Itisworkingwellasaforumfordiscussion,formingnewrelationships,increasingknowledgeandawareness,andgeneratingnewideas.Forexample,atleasttwopeopleapproachedtheSystemBrokersattheendofthemostrecentOperationalGroupmeetingwithideasofsystemchangestheywantedtohelpimplement.

AmeetingformatthatenablestheGrouptomovebeyonddiscussiontowardsactionwouldhelptobuildonthestrengthsoftheGroupandmaintainmotivation.OneSystemBrokersaidtheywouldliketoadoptasolutions-focusedpracticeapproachtotheGroupthatencouragedpeopletoidentifywhattheywereabletocontrolandchange.Anotherstaffmembersuggestedthatactionlearningsetsorcommunitiesofpracticecouldbeusefullyestablished.

ThediscussionsofcasestudiesofServiceNavigators’clientsexperiencesduringOperationalGroupmeetingsarehelpfulingroundingdiscussionsinlivedexperience,evidencingsystemicproblemsandtheneedforchange,andgeneratingdiscussionsandideas.However,thesepotentiallyleavepeopleexposedtodefendingtheirownprocessesandpracticeinapublicmeeting,andotherapproachesmaybemorehelpfulinencouragingpeopletotakeownershipofmakingchange.Oneofthenine‘pre-conditionsforsystemschange’identifiedbyCollaborateisanapproachthatis‘strengthsbased:utilisingtheassetsofpeopleandplace’.Itcouldbeusefultoconsideradoptingmorestrengths-basedapproachestomeetings,suchasappreciativeenquiry.

TheStrategicGroup

TheprogrammereportsrecentlearningaroundtheroleoftheStrategicGroup.ThisincludesmovingawayfromthemodeloftheGroupasoversighttotheproject,andtowardstheGroupasactiveparticipantsinsystemschange.Groupmembersrequestedthatprogrammestaffclearlydistinguishbetweenstrategicandoperationalsystemsbarrierssothattheycouldexplorehowtheycouldhelpresolvethestrategicbarriers.StrategicGroupmembersreportbrokeringconnectionsfortheprogramme,andimplementingsomechangewithintheirownorganisations.

Partnerorganisationsandemployingorganisations

Havingorganisationsinvolvedaspartnerstotheprogrammeand/oremployersoftheServiceNavigatorshasbeenanimportantroutetosystemschange.Thepartnerandemployingorganisationsspokentoforthisevaluationareclearthatakeyroleoftheirsistoimplementchangewithintheirownorganisation(itshouldbenotedthatonlyoneemployingorganisationthatwasnotaCorePartnertookpartintheevaluation).

Somesystemschangesthatpartner/employingorganisationsreportedimplementingincluded:implementingPIEinservices;openingaccesstodispersedhousingtopeoplewithmultipleandcomplexneeds;andworkingmoreflexiblyandcollaboratively.OrganisationscreditedtheiremploymentofNavigators(aswellas,forpartners,theirstrategic-levelinvolvementintheprogramme)withthesechanges,sayingthatthisencouragedthemtochallengeandchangetheirownwayofworking.Navigatorsreportedtheiremployingorganisationsbeingmorewillingtoworkwithpeoplewithmultipleandcomplexneeds,workingmoreflexibly,andexpandingtheirrolestoincludesupporttheywouldnotnormallyhaveprovided.OneexamplegivenwasofAgeUKsupportingpeoplewithbenefitsandhelpingwithfamilyreconnection.

Themodelofemployingnavigatorsinservicesasaroutetosystemschangehasnotprovedeffectiveineverycasehowever.Itwasfeltthatthemodelprovidedanopportunityfororganisationswishingtomakechangetodoso,butthatwheretherewaslessmotivationfor(orotherbarriersto)change,themodelmightnotbeaseffective.

StrengtheninglinksbetweendifferentGroups

TheExpertsbyExperienceNetwork,OperationalGroupandStrategicGroupcurrentlyworkquiteseparately.OperationalGroupmemberssaidtheywouldvalueastrongerlinkwiththeStrategicGroup,includingmorefeedbackaboutwhathashappenedtostrategicissuestheyhaveraisedthathavebeentakentotheStrategicGroup.TheysaiditwouldbevaluableforaStrategicGroupmembertoattendOperationalGroupmeetings,perhapsonrotation,andpotentiallyforanOperationalGroupmembertoattendtheStrategicGroupmeetings.Likewise,representationacrossmeetingscouldbeconsideredfortheExpertsbyExperienceNetwork.StaffmembersalsosaidtheywouldlikestrongerlinkswiththeReferenceGroups.

Noteveryonehadaclearunderstandingoftheirownroleinthesystemschangeprocessandhowthiscouldfitinwithotherrolesinthewiderprogramme;itwouldbehelpfultoclarifythisforallGroups.

LEARNING ABOUT THE PROCESS Researchparticipantsdescribedthefollowinglearningabouttheprocessofsystemschange.

Usingevidenceeffectively

Evidencewasseenbystakeholderstobeoneofthestrengthsoftheprogramme,whichcollectsawealthofevidenceaboutclients’experiences.Programmestaffdescribedlearningabouthowtouseevidenceeffectively:

‘[We’vebeen]thinkingmoreaboutintention,targeting,whoisitfor,whatisitspurpose.’–ResearchandEvaluationLead

Evidencehashelpedtoconvincestakeholdersthatasystemicissueexists,todemonstratethescaleoftheissue,andtoprovide‘directlearningfromourclients’stories[whichcanbe]categorisedandanalysed’.

Piloting

TheSystemBrokershavefoundthatpilotsareameansoftestinginnovativepracticeandinitiatingsystemschangethat‘thesystemcantolerate’.

‘Workingalongside’partners,asaresourcetobedrawnon

Thecapacityoftheprogrammetosupportorganisationshasbeenhelpfulinencouragingpartnerships.Forexample,theSystemBrokerworkingwiththeDWParoundUniversalCreditwasabletooffersupportwithresearchingclients’experiences:

‘There’sakeymotivationinNewcastle,becausewe’reclassedasatestandlearnsite,toworkwitharesearchprogramme[FulfillingLives]thathasgottheinfrastructureandthefocustoreallyapproachitfromacollaborativeresearchperspective.’–SystemBroker

Likewise,theServiceNavigatorswereseenasadditionalresourcesbythoseontheground:

‘Ithink[thefactweemployNavigators]helpedstafftoacceptthem,sothey’reanextraresource.’–EmployingOrganisation

Findingtherightlevelatwhichtoinfluence

Akeylearningpointfortheprogrammehasbeenaboutthevalueofidentifyingtherightlevelatwhichtoinfluence:

‘Ifirstthoughtitwasaserviceissue,thenIfoundoutstaffwereonlydoingwhatmanagersweretellingthem,managersweredoingwhatcommissionerstoldthem,andcommissionersweredoingwhatpolicytoldthem.’–SystemBroker

Thisincludesidentifying‘howIcanchangemyownpractice’.

Behavingdifferentlyfromtheexistingsystem

Beingbothrelativelyindependentfromthecurrentsystem,andabletobehavedifferentlyfromthesystem,wasseentobeimportant:

Wehavetheluxuryofbeingabletobedifferent,sowecangoinandtalktoanagencyseparatelyratherthanbeinganotherpartofthesystem.It’sallaboutmodelling[adifferentbehaviour].–ProgrammeManager

Overcomingbarrierstochange

Eachoftheroutestosystemchangedescribedinthesection‘Routestosystemschange’(p.32)workswiththosewithsomewillingnesstoworkwiththeprogrammeandconsidermakingchangestotheirownpractice.Theprogrammehasencounteredthefollowingbarrierstochangeamongsomesystemactors:

• Fearofexposingflawsinmypracticeandadmittingvulnerability• Abeliefthatmyownpracticedoesnotneedtochange• Anxietyaboutanewapproachandbeingoutofmycomfortzone• Lackoftime/capacity/resources• Policydoesnotsupportanewkindofpractice

Thoseinvolvedhavefoundthatthefollowinghaveworkedwellinconvincinglesswillingpartnerstotakepartintheprogramme’ssystemschangeactivity:

• Listeningtolesswillingpartners,understandingtheirvaluesandpriorities,andattemptingtomeettheirneeds.

• Providingrobustquantitativeandqualitativeevidenceoftheneedforchange.• ‘Workingalongside’partnersratherthanbeingseenascomingintosortout

problems.

• Awillingnesstodropissueswhenthediscussiongetsstuck,andmovetowardsbuildingaconstructivepartnershiparoundotherissueswherechangeismorepossible.

SCALE AND SUSTAINABILITY FulfillingLivesNewcastleandGatesheadisduetoendin2022.Thissectionconsiderswaysinwhichtheprogrammemightensuresystemschangetakesplaceatscaleandissustainedaftertheprogrammeends.

STEPS TO SCALE AND SUSTAINABILITY: THE SIX STEP MODEL ThefinalthreestepsofForumfortheFuture’sSixStepstoSignificantChangemodelfocusonscaleandsustainability.Theseare:

• Step4:Enablethetippingpoint.Thisinvolvesachievingscalethroughthreeroutes-growing,replicating,anddiffusingandinfluencing.

• Step5:Sustainthetransition.Thisincludesaddressingresistancethatcanariseatthisstage.

• Set6:Setnewrulesofthemainstream.Thisentailscementingchange,forexamplethroughpolicychange,whichisoftenprecededbyshiftsinattitudesandevidencethattheywillwork.

ROUTES TO SCALE AND SUSTAINABILITY Scalingchange

Asdiscussedinthesection‘Stagesinthesystemschangeprocess’(p.29),theprogrammehasbeguntoreachscalethrough:

• WorkforcedevelopmentandPIEtraininginseveralpartsofthesystem.ThishasresultedintheimplementationofPIEandreflectivepracticeinsomeservices,andisintendedtoresultinagreaterunderstandingofthemultipleandcomplexneedsamongsystemactors.

• Influencingchangesinlanguage,attitudesandworkingculture,forexampleanunderstandingofsystemschangeandrecognitionthatissuesaresystemic,amongactorsinseveralpartsofthesystem.

PathwaystoscaleidentifiedbyForumfortheFutureare:

• Inspireandenableinfluencers.• Networksandcollaboration.• Barrierremovalandlock-in,includingpolicyandadvocacy.

• Communicationandbehaviourchange.• Newfinancialmodels,measuresandstandards.• Incubateandaccelerateentrepreneursandtechnologies.

Sustainingsystemschange

ThissectionpresentsananalysisbytheNewEconomicsFoundationbasedonlearningfromtheliteratureandtheideasofparticipantsinthisresearch.

Therearetwo(inter-related)issuesinrelationtosustainabilityofsystemschange,whichareconsideredbelow.

1. Creatingstructuresandprocessthatembedthechangesmadetosystemcomponentsasaresultoftheprogramme–sothat,forexample,pilotsareadoptedintopractice,differentapproachesareintegratedintocommissioning,andstrategiesareadheredto.Thismayinclude:• Ensuringthatsuccessfulprogrammepilotsareadoptedintopractice(with

separatesourcesoffundingsecuredifnecessary).• Ensuringthatsuccessfulelementsoftheprogramme(examplesgivenby

participantsincludethefunctionofnavigationforpeoplewithmultipleandcomplexneeds,andtheExpertsbyExperienceNetwork)securetheirownsourcesoffundingand/orareadoptedintootherorganisations’deliverymodels,socancontinueaftertheprogrammeends.

• Ensuringthatnewwaysofdoingthingsareformalisedinpolicyandservicespecifications.

• Achievingchangesinthecomponentsofthesystem:forexample,thecommissioningofnewservicesordevelopmentofnewpathways.

• Influencingchangesinattitudeandunderstandingofpeopleacrossthesystem,forexampleadeeperunderstandingoftheneeds,experiences,andassetsofpeoplewithmultipleandcomplexneeds,howtheycanbestbesupported,andindividualsystemactors’ownrolesinthis.

• Ensuringthatsustainedchangeisnotdependentononeindividualinanorganisation,butisembeddedinprocesses,policies,andattitudesacrossawiderteam.

2. Creatingtheconditionswithinasystemthatmeanitcancontinuetochangeinresponsetoemergingsystemicissues,evenaftertheprogrammeisnolongerinplacetoleadchange.TheliteraturereviewconductedbytheNewEconomicsFoundationforFulfillingLivesNewcastleandGatesheadin2014foundthat:‘Systemschangeisneverfinished;instead,aprocessthatenablessystemicproblemstobeidentifiedandrespondedtoisinplace.’12Thismayinclude:• Creatingstrongconnectionsbetweendifferentpartsofthesystemthat

continueaftertheprogrammeends,includingforumsfordiscussionandaction.

• Buildinganunderstandingacrossthesystemofsystemschange,thesystemicnatureofmanydifficultiesencounteredbypeoplewithmultipleandcomplexneeds,andtheroleofreflectivepractice,collaboration,learningandopennesstochangeinresponsetothis.

• Creatinglastingprocesses,forumsandothersmeanswhichfacilitateareflective,open,flexibleandcollaborativeapproachwithinorganisationsacrossthesystem.

• Ensuringthatreflectivepracticeisembeddedacrossthesystem(forexample,inservices,throughtheimplementationofPIE).

• Ensuringthatco-production,meaningfulserviceuserinvolvement,andtheexpertbyexperiencevoiceisstronglyembeddedwithinthesystem(forexampleinservicedesign,commissioningdecisions,andservicedelivery).

• Supportingsystemsleadershipbyindividualsoutsidetheprogramme,sothattheycancontinuetotakeonsystemsleadershiproleswithindifferentpartsofthesystemaftertheprogrammeends.

‘Ifyoucanhavemoregenuineco-productionandserviceuserinvolvement,thatwouldhelpthesystemtochangewithoutusbeinginvolved.That’sthewaytoinfluencethesystemwhenwe’renotaround.’–SystemBroker

‘I’dliketoseethatservicesareinreflectivemode,areopen.It’saboutreachinganendwheremoreservicesareabletocollaborativelylookandkeepchanging–soit’sworkforcedevelopment.’–ProgrammeManager

Developingevidenceandrecommendationsforthesystem

Oneofthequestionsthisresearchsetouttoanswerwas:Howcantheprogrammebestensureitisinapositiontomakerecommendationsforaneffectivesystemforpeoplewithmultipleandcomplexneedswhenitcomestoanend?

Thesystemschangeliteraturesuggeststhatsustainedsystemschangeislikelytobeachievedprimarilyasaresultofhavinginfluencedcollaborativechangeintheareasoutlinedabove(forexampleinpolicy/commissioningandinattitudes/workingcultures),ratherthanthroughleavingrecommendationsforaneffectivesystem.

However,itwillbeofvaluefortheprogrammetocaptureandshareitslearningaroundtheprocessofsystemschange,andtheoutcomesofitssystemschangeapproach(includingeffectiveelementsofthesystemandremainingsystembarriersandblockages).Tothisend,itwouldbeofbenefitfortheprogrammetoconductanevaluationofthesystemschangeelementoftheprogrammeoveritsremainingyears.

Theprogrammeisalsobuildingabodyofevidenceofeffectivenessofinnovativeapproaches,inparticularthroughitsevaluationsofpilots,whichwillformavaluablepartofitslegacy.

CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS FulfillingLivesNewcastleandGatesheadisutilisinganeffectiverangeofapproachestoachievingsystemschange:eachofthefourmainroutestochangeidentifiedisanimportantelementofitsapproach.Theprogrammeanditspartnershaveachievedsomesignificantearlysystemschanges.Itissuccessfullycultivatingmanyofthepre-conditionsofsystemschange,puttingitinastrongpositiontoinfluencefurtherchangesovertime.

Nowtheprogrammeshouldturnitsattentiontoestablishingitselfmorefullyasasystemschange(ratherthanservicedelivery)programmeandcommunicatingwhatthismeans;strengtheningtheexpertbyexperiencevoiceinitswork;andmovingfromtheidentificationofsystemicissuestowardsactionandthedevelopmentofnewwaysofdoingthings.

RECOMMENDATIONS FOR THE FUTURE DEVELOPMENT OF THE PROGRAMME Thefollowingrecommendationsarebasedontheviewspresentedbythoseinterviewed,andonananalysisoftheresearchevidencecollectedinthelightofselectedexistingsystemschangeliterature.Itisrecommendedthattheseareusedasastartingpointfordiscussionamongprogrammestakeholders,forgainingdeeperunderstandingoftheissues,andforestablishingagreedaction.

Astrong,clear,systemschangefocus

Morestronglyestablishtheprogrammeasasystemschangeprogrammeandspreadunderstandingofwhatsystemschangeis.Thisincludescommunicatingaboutwhatsystemschangeis,thedifferentlevelsofthesystem,andhowsystemschangecanbeachieved.Thismeansmovingawayfromunderstandingsoftheprogrammeasaservicedeliveryorganisation;andensuringthatallthoseinvolvedunderstandwhatsystemschangemeans.

Developacoherentdefinitionofsystemschangeandtheprogramme’sroleandaspirationsinrelationtothisthatcanbeusedbyallthoseinvolvedintheprogrammetocommunicatetoexternalstakeholders.Thiswasrequestedbyseveraldifferentgroupsintheresearch.

Celebrateandcommunicatethesystemschangesmade:Stakeholderswerenotalwaysawareofthesystemschangesthattheprojecthadinfluenced.Celebratingthechangesthathavebeenmadeislikelytomotivateandinspirefurtherchange,aidunderstandingofwhat‘systemschange’means,andmorestronglyestablishtheprogrammeasasystemschangeprogramme.

Clarifythedifferentlevelsofthesystematwhichsystemschangecantakeplace,andusethisasatooltoidentifywherechangeisneeded.Thishasbeendoneinsomeforums,butnotyetbeenspreadwidelyacrosstheprogramme.Thediagramonp.16ofthisreport(adaptedfromamodelbyMakingEveryAdultMatter(MEAM))describesonewayofunderstandinglevelsofchange.

Reviewtheextenttowhichtheprogrammeisinfluencingchangeatalllevelsfromindividualpractice,toservicedelivery,tocommissioning(asoutlinedintheabovediagram).Thisincludesclarifyingwithpartnerstheextenttowhichtheprogrammeintendstoinfluencethenationalsystem;partnerswerenotallclearaboutthis.

Moveawayfrom‘diagnosingthesystem’(withafocusonidentifyingsystembarriersandblockages)towardsactionforchange.Thiscouldincludeexistingpartners(suchastheStrategicandOperationalGroups)consideringhowtheycouldchangetheirownpracticeandinfluencebroaderchange,andtakingmoreactiveownershipof/playingmoreactiverolesinstrandsofwork.Ideasforthisincludedestablishingtargetedworkinggroupsortaskandfinishgroups,andintroducingsolutionsfocusedpractice.

Adoptamoreasset-basedapproachthatfocusesonidentifyinganddrawingonassetsatalllevelsofthesystem.Atpresenttheprogrammeprimarilyfocusesonidentifyingsystemsbarriersandblockagesandsolutionstothese(oratleastdescribesitsworkintheseterms).

Rolesandrelationships

EnsuretheExpertsbyExperienceNetworkismorecloselyinvolvedinthesystemschangeprocess,buildingonsuccessfulsystemschangeactivitiesalreadyundertakenbythegroup.Amorecentralrolecouldincludeadirectvoiceindiscussions

aroundunderstandingtheproblem,generatingideasforchange,anddesigningnewwaysofworking;andco-deliveringworksuchastrainingorresearch.

ReviewtheServiceNavigatorrole:SeveraldifferentgroupsofresearchparticipantssuggestedexploringpossibilitiesfortheNavigatorroletobecomemoresystems-changefocused,forexamplebyincludingbrokerageandsupportforservicestochangetheirownwaysofdoingthings.Thiscouldperhapsfocusonchangeattheindividualservicelevel,whilstSystemBrokerscontinuedwithabroaderfocusacrosstheservicedelivery,commissioningandpolicylevelsofsystemschange.

RetaintheSystemBrokerfunction:InitialprogrammeplanssawthenumberofSystemBrokersbeingreducedfromthreetooneinthefourthyearoftheprogramme.ThisresearchsuggeststhatthededicatedSystemBrokerrolefulfilsanimportantfunctionofsystemschangeleadership.ThecapacityoftheBrokerstoconvenepartnerships,andtosupportinnovativepractice,hasmotivatedpartnerstobecomeinvolvedwiththeprogrammeandbeenanimportantroutetochange.Itisrecommendedthatanychangestothemodelofsystemschangedeliveryensuresthatthesefunctionsareretained.

Strengthenlinksbetweendifferentstakeholdergroups:Severalparticipantgroupssaidthattheydidnotfullyunderstandtherolesofothergroupsinvolvedintheprogramme,andhowthisfitwiththeirownrole.IdeasraisedbyparticipantsincludedStrategicGrouprepresentationontheOperationalGroup,andviceversa.

Reflectonpowerdynamicsintheprogrammeandthesystem:Powerdynamicswerementionedbyveryfewresearchparticipantsdespitebeingcentraltosystemschangetheory.Theoreticalissuesincludetherebalancingofpowerbetweenprofessionalsandthosewithlivedexperience;theneedtogiveupsomedegreeofpowerinordertocollaborateforsystemschange;andtheuseofpowertosettheboundariesorlimitthescopeofsystemschangeactivities.Itcouldbehelpfulforprogrammestaffandpartnerstohavetheopportunitytolearnaboutandreflectonpowerdynamicsintheirwork,forexamplethroughtraining.

Learningandevidence

Determineanapproachtoevaluatingthesystemschangesinfluencedbytheprogrammeoveritsfinalfiveyears,buildingonthecurrentResearchandEvaluationStrategy:Theprogrammehasconductedsomeusefulandinfluentialevaluationsofsomeofitssystemschangeactivities(suchasthepilotofPIE).Thiscurrentresearchshowsthattheprocessofsystemschangeiscomplexand

unpredictable,andthat,becausesystemschangecanonlyhappeninpartnership,attributingchangetotheprogrammeisnotstraightforward.Capturingthechangesinfluencedbytheprogrammeisimportantfortheprogrammetolearn,understandwhatworksinsystemschange,anddevelopitsapproach.Itisrecommendedthattheprogrammedevelopsaprimarilyqualitativeapproachtoevaluatingsystemschangeoveritsfinalfiveyears.Thisshouldincludeassessingthedifferenceanysystemschangeshavemadeforpeoplecurrentlyexperiencingmultipleandcomplexneeds.

ENDNOTES

1BigLotteryFund(n.d.)FulfillingLives:Supportingpeoplewithmultipleneeds.http://www.biglotteryfund.org.uk/prog_complex_needsAccessedon01.09.20142BigLotteryFund(n.d.)FulfillingLives:Supportingpeoplewithmultipleneeds.http://www.biglotteryfund.org.uk/prog_complex_needsAccessedon01.09.20143Meadows,D.(2008)Thinkinginsystems:aprimer.(edbyWright,D.).SustainabilityInstitute.4Burns,D.(2007)Systemicactionresearch:astrategyforwholesystemchange.PolicyPress.5Draper,S.(n.d)Creatingthebigshift:Systeminnovationforsustainability.ForumfortheFuture.Imagefrom:https://www.forumforthefuture.org/blog/introducing-forum’s-six-steps-significant-change6Billiald,SandMcAllisterJones,L.(2015)Behavinglikeasystem?CollaborateandLankellyChase.https://collaboratecic.com/behaving-like-a-system-184e70563822 7RobinJohnson,co-authorof“PsychologicallyInformedServicesforHomelessPeople–Goodpracticeguide”2012DepartmentofCommunitiesandLocalGovernment,anddeveloperofhttp://pielink.net/,citedinRichie,C.(2015)CreatingaPsychologicallyInformedEnvironment:ImplementationandAssessment. NoOneLeftOut:SolutionsLtdforWestminsterCityCouncil.8Richie,C.(2015)CreatingaPsychologicallyInformedEnvironmentImplementationandAssessment. NoOneLeftOut:SolutionsLtdforWestminsterCityCouncil.9NationalInstituteforHealthandCareExcellence,Coexistingseverementalillnessandsubstancemisuse:communityhealthandsocialcareservices.NICEguideline[NG58]Publisheddate:November2016https://www.nice.org.uk/guidance/ng58/chapter/Recommendations#first-contact-with-services10SeeforexampleChapman,J.(2004)Systemfailure:whygovernmentsmustlearntothinkdifferently(2nded.).11Bevan,H.(n.d.)HelenBevanontheChallengeofSystemReform.NHSInstituteforInnovationandImprovement.http://www.institute.nhs.uk/quality_and_value/introduction/article_13.html.Accessedon01.09.2014.12Hough,J.(2014),Changingsystemsforpeoplewithmultipleneeds:Learningfromtheliterature.NewEconomicsFoundation.

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