CHANGING SYSTEMS FOR PEOPLE WITH …...EXECUTIVE SUMMARY INTRODUCTION Fulfilling Lives1 is an eight-year programme funded by the Big Lottery aimed at people with multiple and complex

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

Writtenby:JulietteHough

[email protected]+44(0)2078206300@NEFRegisteredcharitynumber1055254©2017TheNewEconomicsFoundation

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

too

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.

Documents

CHANGING SYSTEMS FOR PEOPLE WITH …...EXECUTIVE SUMMARY INTRODUCTION Fulfilling Lives1 is an eight-year programme funded by the Big Lottery aimed at people with multiple and complex