Sharing power in the planning and reviewing of services

Last Thursday I attended this training event at our Llandrindod office run by two Participation Officer colleagues – Carla Rosenthal and Carol Hay. As one of the attendees reported later it was “interactive, engaging and full of useful content”.

The session was arranged specifically for people who want to become citizen representatives (and a couple who already are). It is key to our work in the mental health team, and specifically for our Comic Relief funded project Stand up! for emotional health and wellbeing, that reps are recruited and well trained. Citizen reps volunteer their time, energy and passion to make a difference for others and to the services we receive, and are helping influence change at local, regional and national levels. We wrote about the achievements of mental health reps Rhydian Parry and Jan Rogers on this blog in Powys voices count at the top a couple of years ago.

This training session brought together two groups of individuals – those interested in sitting on the Powys Mental Health Planning & Development Partnership and a second cohort who recently started sitting round the table of the Health & Social Care Regional Partnership Board. Their ages and backgrounds were quite varied, with experience of mental health nursing, the Royal Air Force, specific health diagnoses and carers’ views all brought to the session. The module was based on a training package that was co-produced by mental health team volunteers and Participation Cymru, reflecting on the experiences of people who were interacting and engaging with organisations to shape mental health services.

It isn’t possible to cover the entire session in one blog post, so I’ll highlight a couple of areas and also focus on the points made by the two guest speakers, Sue Hughes – Coordinator Regional Partnership Board at Powys County Council, and Louisa Kerr – Mental Health Partnership Manager at Powys Teaching Health Board.

It was fascinating to hear at the start of the day what people thought about the title of the training, and in particular what “sharing power” meant to them. One of the reps’ responsibilities is to attend meetings with service providers, either locally or nationally (or both) and feedback grassroots opinions about current services. Comments included:

• You will be listened to.
• To be working alongside people as equal partners.
• To be part of the process.
• Using personal knowledge and experience to shape services.
• Sharing with other people what I have learnt.
• Being a team player.

Carla and Carol spoke about the importance of first impressions, being prepared and planning well, and emphasised that reps are representing other people – not just themselves and their own views – when sitting on the boards. “It is key to know who you represent, what is important to that group, and the key messages you want partner organisations to hear”. 

There was an interesting discussion about how it felt to sit around the table as a 'service user'. Whilst acknowledging that they brought a valid experience and were viewed as an equal some felt it put them on the back foot. Language, it was agreed, is extremely important. Some people felt comfortable being described as ‘experts’, whilst others said it was difficult being called ‘a carer’: “I’m a Mum. You’re given a label and boxed somehow. I find that really hard. People have masses more to bring other than being a service user.”

Sue and Louisa both emphasised that when individuals express their views passionately they are as important as anyone around the table. Sometimes we can box things in our own minds when actually we are being valued by everyone else there. “Everybody’s the same. There is no distinction between workers, volunteers and individuals. It’s about people coming together to talk informally. Collectively we are experts."

Carla and Carol went on to highlight the importance of researching partner organisations before attending meetings, and then we looked at “facts and assumptions”. “If I see a policewoman I might feel anxious. Guilty. Worried that she might arrest me. But that is an assumption. The only fact is that she is a policewoman, and I have to leave behind all the assumptions or I’ll be a nervous wreck.”

Sue then gave us a brief background to the Social Services & Wellbeing (Wales) Act which sets out the requirements for the Health & Social Care Regional Partnership Boards. Legally it is a requirement for citizens to sit on the boards. There is a need for people to work differently – for culture change – as the Act is all about the citizen’s voice. "We all need to challenge officers working in services to make sure they have involved citizens, but also to give praise where it is warranted".

Sue also spoke about how to use effective questioning at meetings. “Officers don’t encourage passivity as we won’t then have the opportunity to improve things. If you don’t understand a presentation as it’s not in lay language then it doesn’t comply with the Act. It has to be easily understandable language. You can raise this nicely – but the officers need to know.”

Louisa then provided us with an introduction to the Powys Mental Health Planning and Development Partnership Board which has been meeting for 2 years now. Mental health is governed by different legislation to Health & Social Care, so we look to the Mental Health Measure (Wales) for guidance, but there is much crossover. We learnt more about the various subgroups of the PMHPDP, including Engage to Change (looking at issues raised at the Stand up! for emotional health & wellbeing meetings), Performance, a Mental Health Officers’ Group and S136 Criminal Justice. Louisa recalled the first meeting of the board she attended where citizen reps Kate, Meriel and Rhydian spoke. “It was profound, and changed the dynamic of the meeting. Everyone was listening. That is the most important thing.”

By the afternoon we moved on to sessions on assertiveness, getting the most out of a meeting, and the support that Powys Association of Voluntary Organisations can provide to people. There were some intriguing slides on the nature of power, and specifically the 3 Faces of Power as described by Steven Lukes. And finally there were a few tips on building self-confidence – which can help us all in all areas of our lives. 

All in all a thoroughly interesting day, and we managed to have a fair few laughs too as we introduced ourselves early on in fictional roles as “superheroes, tooth fairies, aliens, scarecrows and witches”! 

Would you be interested in joining these citizen reps to take grass-root views and opinions to local board meetings where service providers can find out what is working and what needs to change? For further information about becoming a citizen rep in Powys, in the field of mental health or health and social care, just get in touch with us by emailing mentalhealth@pavo.org.uk or ringing 01597 822191.

No such thing as a free lunch? A review of a Review Check

 

by Carla Rosenthal, Participation Officer
and the PAVO Mental Health team

“No thank you, I do not want to spend six days doing a ‘Vanguard Method System Review Check’ that I know nothing about,” was the common response when I was tasked with the job of organising this event back in March 2016.

“But the results could be used to directly influence housing and mental health services in Powys!” I would counteract when confronted with such replies.

“Great! Tell me what I have to do and I’ll give up six days in my extremely busy working life to come along.”

“Uuuummmm, I’m not quite sure what happens but you have to turn up in Llandrindod, then go to either Welshpool or Brecon, do something there, then come back to Lland’od and it will all make sense.”

“No.”
“Expenses paid.”
“No.”
“Lunch provided - every day.”
“Maybe.”

Eventually, in November last year, individuals working in Third Sector mental health organisations came along to participate in the now legendary, Vanguard Method System Review Check. All I can say is, if you missed it, you missed a goody and despite no-one really knowing what it was all about to start with, by the end of the process, thinking had changed, systems had been unpicked, harrowing tales re-told and sceptical participants left feeling enlightened and in some cases, enriched.

In a nutshell, two teams of 4 - 6 individuals spoke to people we knew in and around Welshpool and Brecon about their experiences of emotional ill health. We examined their contacts with both statutory and voluntary services and found out what had been beneficial and empowering and what had been a waste of time or caused additional distress. The ongoing work was collected on lots and lots of large pieces of paper and got stuck on every available wall in the PAVO offices (white tack only!) then the findings from both teams were collated and clear and simple messages were pulled out.

It came as no surprise to discover that (amongst other things) people across Powys were frustrated by long waiting lists for psychological therapies and fed up with re-telling their story numerous times to a variety of professionals. However, it also became clear that the help, support and advice offered by the likes of MIND and Ponthafren was invaluable and in some cases, life saving.

The six day exercise meant that assumptions weren’t simply what we had heard over the years but provided definitive hard evidence to show service providers who may wish to look at where improvements could be made. The learning that Third Sector providers took away should ensure continuation of people-centred services and a commitment to delivering what matters to those who need it, being at the heart of their service provision - all done without having to spend any extra money.

Following on from the Review Check experience, I tend to question things more and find myself asking, “Why am I doing this? What is the point? Where is the benefit? Could this be done differently or more efficiently?” It’s not a bad way to approach things but sometimes, change needs to come about slowly and not everyone will query things in the same way. Maybe they need the opportunity to go on a Vanguard Method System Review Check . . . ? They might even get a free lunch.

 

NB: After submitting this blog post, Jackie pointed out that she still didn’t know exactly what the Review Check was all about, so in answer to her questions, please see below:

Why was the Review Check done in the first place?

Information given by Adrian Jones, Supported Housing Manager at Powys County Council:

“At its meeting on 6 January 2016, the Supporting People* Management Board decided to fund an intervention into the housing related support needed for people with mental health issues to live independently in the community with as high a quality of life as possible. The scope of the project was to cover North Powys and South Powys for any person of adult age with mental health issues. The costs of the project would cover the engagement of an external facilitator to use the Vanguard Method of Check and to cover the costs of involvement of staff and volunteers of third sector agencies specialising in mental health, none of whom are (currently) funded by Supporting People.”

* The Supporting People Programme provides the framework by which housing related support services are commissioned and funded within Wales.

Where did Housing fit into all this?

“Housing Related Support plays a key role in the system of early intervention and prevention, which is now being developed through locality-based response by the Council as part of its implementation of the terms of the Social Services and Well-being Act (Wales) 2014. From the point of view of Supporting People, the project was one of co-production to learn about the end-to-end experience of people with mental health issues when they ask for help and to establish a way of working to promote well-being in the lives of people and do the things that matter to people, as is now the requirement by law under the terms of the Act.”

What exactly is the Vanguard Method System Review Check?

Taken from Vanguard Consulting website:

In order to move organisations from a command and control to a systems thinking logic, Vanguard developed a version of Deming/Shewhart’s ‘Plan-Do-Check-Act’ cycle (Deming 1982 p88), with the emphasis on confronting managers starkly with the failings of the current system by starting at ‘Check’.

The first part of check provides a sound understanding of a system as it is and identifies waste and the causes of waste.

‘Check’ asks:

• What, in reality, is the purpose of this system?
• What is the nature of customer demand?
• What is the system achieving?
• How does the work flow?
• What is value work and what is waste?
• Why does the system behave like this?

Can you give some examples of some of the exercises you carried out.

Most of the time was spent talking to people who have had experience of the mental health system and use the services provided by statutory bodies and those provided by organisations such as Gwalia Housing Support, MIND groups or Ponthafren. We would ask them questions such as, “What matters to you? What does a good day look like? What would make your life better?” We then went on to map their flow through the system.

Give an example of something that was unpicked in a system currently used.

An example would be looking at someone’s journey from when they had first gone to see a GP about a mental health issue, to being referred to a psychiatrist for an assessment. Usually, drugs are prescribed and appropriate therapy might be offered. However, the waiting list for psychological therapies is unacceptably long.

What were some of the simple and clear messages that were revealed that we didn't know before?

Most things are common knowledge, but the evidence collected showed that people do not want to be passed from pillar to post, telling their story time and time again to others who take little or no notice. Waiting lists for talking therapies are off-putting, medication is often prescribed with no alternative offered and people want to be able to live their lives in the way they want to without being forced to conform to an unattainable ideal of ‘normal’.

What could change as a result of the Review Check?

One of the great things about this review check was the way that the third sector organisations got to grips with the process. We know that at least some of the groups involved are keen to have their own ‘check’ to make sure that they are really meeting people’s needs in the way that is best for those people.

It showed us how inter-linked everything is and how we can all support each other to make changes. It is certainly a challenge, but we know that at PAVO and in the wider third sector there is a lot of interest in working with statutory bodies to see how our learning can support this kind of thinking at a wider level in the mental health system. We are confident that there would be interest in this from the statutory services too, especially with the developing emphasis on prevention and early intervention. Everyone wants the system to work for people, the Vanguard Review Check process can show how very established systems can sometimes just keep doing what they just keep doing and that a fresh look can show where there are blockages and how to meet people’s needs more effectively, so that more people can be helped, often at lower cost too. 

What will happen now?

We will continue to support this process as an effective way of making changes that start with the people who use (or avoid) the services. Implementing change to deliver the right thing at the right time does need some careful consideration before real benefits can been made. It also needs everyone involved to be united towards the same goals and be willing to look at things with a fresh perspective.

You don't have to be mad to work here, but...

Carla Rosenthal recently joined the mental health team at PAVO to provide maternity cover for Angharad Griffiths. Some readers may know her from her previous role as editor of Headspace magazine for Powys Mental Health Alliance. During that time she organised some very interesting Open Days throughout the county.

Carla has thrown herself with great enthusiasm into her new role at PAVO; you can watch a video of her first Coffee Moaning, which took place in Knighton in May. She works very closely with Anne Woods, a participation colleague focusing on the Stand up! for emotional health & wellbeing project funded by Comic Relief.

With one of her many other hats on Carla is also a Mental Health Act Manager in North Powys. We spoke to Carla at her Llandrindod base to find out more.

Tell us more about your new role in the PAVO mental health team

The job title is Participation Officer and essentially it’s all about community engagement. I spend a lot of time meeting people and talking about Mental Health Services in Powys. All views, opinions and issues are collated and then given to Individual Representatives who take the grassroots voices to Board Level. I grab every opportunity to talk to service users, carers and third sector organisations to discover what is working well and what needs bringing to the attention of the health board and other mental health service providers. And I’m busy organising Coffee Moanings around Powys. (The next one is in Ystradgynlais Library on Friday 7th October 10.30 - 12.30 in the Wedding Room).

How is the new job going so far?

Four months in and I’m busier than ever! Along with supporting Individual Reps, attending Patients' Council at Bronllys Hospital, talking to people at events, and writing emails, there are lots of meetings to attend and new contacts to follow up. When I’m not travelling around Powys, I’m getting used to working in an office (a new experience for me) and I really enjoy the work I do - there’s never a dull moment.

Why should people who have been in contact with services come along to a Coffee Moaning, or a Stand Up! for emotional health & wellbeing session?

The aim of these events is for ANYONE who has interest and experience in mental health services to come along and get their voice heard. The evidence that’s gathered from these events is gold dust to the Individual Representatives who work closely with service providers such as Powys Teaching Health Board and partners on the board like the Police and the Council. It is imperative for those who plan services to hear what is needed from the people who actually use the services.

I believe you are currently looking for people to become new Individual Representatives for the Powys and National Boards. Can you tell us more?

Individual Reps are the voice of the people - it is thanks to them that service users and carers are represented. It’s an opportunity for anyone passionate about planning and developing mental health services to get involved and feel that they are helping to make a difference. Although it is a volunteer role, travel expenses are paid and there’s a fantastic training package being put together which equips Individual Reps to feel confident at strategic board level meetings. 

The partnership meetings are held every two months and there are opportunities to sit on sub-groups which are instrumental in delivering the Mental Health Strategy for Wales. Should an Individual Rep wish to attend the National Partnership Board, I assist in liaising with the Mental Health Foundation who appoint the National Reps and there are National Forums where all the Reps from across Wales get together to share information and good practice.

PAVO's mental health team with Seat 35, L:R - Jane, Anne, Jackie and Carla

What about your other role as a Mental Health Act Manager for Phoenix House Hospital in Welshpool? Tell us about that.

Mental Health Act Managers meet when an in-patient has requested an appeal hearing against their section. The title ‘Manager’ is somewhat misleading as we are all lay-people and come from a variety of backgrounds. My interest is this role came about due to having been a patient under section at a hospital in Surrey several years ago along with a brief spell in Bronllys. I can see things from the perspective of the patient as well as from a professional viewpoint.

As Managers, three of us meet before the hearing and read through the reports compiled by psychiatrists, doctors, lawyers, social workers, nurses etc. We then make a particular point of having an informal chat with the patient first, to help put them at ease and give them the opportunity to put their side across before everyone comes in. The hearing itself can be rather daunting as all professionals involved come together to give their opinion of the future care of the patient. When we have heard everything from everybody and the room has been emptied, we make a decision based on all the evidence presented.

To be held under the Mental Health Act, an individual is deemed to be at harm to self or others and needing treatment in a place of safety to prevent harm happening. If, as managers, we feel that the patient has received appropriate care and treatment and has recovered fully to become a ‘voluntary’ patient and/or even leave hospital straight away, we can lift the section. However, some people need to continue their treatment before they can be released and we then look at how they can work towards becoming a voluntary in-patient. We talk to the outside agencies such as community psychiatric nurses and social workers about what care will be put in place for when the patient leaves hospital. It’s an extremely important and responsible decision which cannot be taken lightly. Having been a patient, I understand how difficult a hospital stay can be but I’m also aware of what it’s like to be ill and needing care. Ultimately, the patient’s welfare is at the heart of our decision.

How did you get involved at Phoenix House?

When I was magazine editor of HeadSpace, I wrote a feature article on Phoenix House and one of my contacts there told me about the Managers' Panel and suggested I applied for the role. I had to complete an application form and have a formal interview before being given the position. In nearly two years, I think I’ve attended 6 hearings.

What qualities should a good MH Act Manager have and why?

As I mentioned earlier, the decisions we make have a direct and immediate impact on a patient and that responsibility is not to be taken lightly. Compassion, understanding and the ability to listen and read through a variety of evidence is essential along with a sound knowledge of the Mental Health Act and maintaining confidentiality. Along with these professional skills, a good Manager is one who genuinely listens to the patient and those working with them because whilst reports have their place, the conversations that happen during the hearing are the key to making the final decision. The Managers are aware that it is quite an emotional and stressful event for the patient and our behaviour and communication needs to reflect this during the hearing. A smile goes a long way :-)

Have you sat on an appeal panel which has discharged a patient from a section? What did it feel like?

Yes, I have and the emotions are mixed. Although seemingly a positive outcome, sometimes you get the feeling that this person is going to need support for while and although not needing a hospital setting, the willingness to engage with outside services has to be there in order for that person to thrive. I’ve worked with people who when they are in hospital they’re aiming for release, but when they’re back at home there’s nothing to aim for and they find themselves relapsing.

If during an appeal panel a patient is discharged from a section, what support has to be in place for the person?

From the moment of discharge, a patient’s status becomes ‘voluntary’ and they are free to leave. Sometimes, the section will be lifted on the proviso (agreed with patient and staff) that they stay for maybe an extra week in order for housing or a support service to be sorted out. In reality, lifting a section is only dependent on a person’s likelihood of harm to self or others so housing, support networks etc, are not part of that decision. However, our duty of care is such that we try to ensure that everyone involved is ready to provide the support as soon as possible.

What are the main challenges of the role?

This directly links with the previous question as there was a situation when if the patient was discharged, they would immediately leave the hospital into unsuitable accommodation and continue a lifestyle which had contributed to their initial ill health; however, there was no legal case to maintain the section. It’s times like this that the panel needs to consider very carefully the future of the individual. It’s all too easy to see a yo-yo effect of the same faces re-appearing in hospital but at the same time, we can’t keep someone detained in hospital just because on their release they want to go down the pub and have a beer and a fag!

Tell us about some of the most rewarding work you have done in the mental health field

On a personal level, I really enjoy going to Felindre Ward at Bronllys Hospital because some of the staff remember me from when I stayed there in 2011. It’s an amazing feeling when I can sit with patients in a Patients' Council meeting and say, I understand, I’ve been here too.

Recently I met some people at the PAVO offices who wanted to discuss a family member’s mental health. I sat across a desk telling them, “It’s ok, I’ve been in the same head-space that your family member is in and my mum has been in a similar situation to the one you’ve found yourselves in.” We all shed some tears. I signposted them to a variety of organisations, offered personal support and generally empathized. They were so reassured that just because someone is experiencing mental ill health, options don’t close down (as some people still think), instead options will open up.

And I still joke about my job: “You don’t have to be mad to work here - but if you put it on your CV, it’s a bonus”.

When you’re not working how do you enjoy spending your time?

I adore reading and devour books from the library - a day without my book time is not good! I’m also studying a Royal Horticultural Society course in horticulture and really enjoy gardening but a recent house move means most spare time is spent unpacking boxes I haven’t quite got round to yet . . . and I’ve got kids and dogs and horrible housework!

Many thanks to Carla for telling us about her various roles. If you would like to find out more about Coffee Moanings, or becoming an Individual Rep, just contact Carla by ringing 01597 822191 or emailing carla.rosenthal@pavo.org.uk