Equally Well
framework for
collaborative action
How we work and what actions we
can take to improve the physical
health of people who experience
mental health and addiction
problems
Phase 3: 2015
Contents
Contents................................................................................................................................................................................ 2
Introduction ........................................................................................................................................................................ 3
Phase One: Evidence review ................................................................................................................................... 3
Phase Two: Stakeholder engagement and consensus .................................................................................. 3
Phase Three: Proposed framework for collaborative action ..................................................................... 4
The five conditions of collective impact ........................................................................................................ 6
Underpinning principles of the collaborative .................................................................................................. 7
Equally Well Collaborative Action Framework .................................................................................................... 8
Programme of collaborative action........................................................................................................................... 9
1. Improve the quality of physical health care ............................................................................................ 9
2. Reduce exposure to risk factors ................................................................................................................ 12
3. Promote prevention and early intervention ........................................................................................ 13
Appendix one: Organisations who endorse the consensus statement (as at January 2015) ......... 14
2
Introduction
The associations between mental health and/or addiction problems and relatively poor physical
health outcomes have been well-established over many decades. Equally Well attempts to
address this longstanding and unacceptable inequity through a programme of collaborative
action, involving a wide range of individuals and organisations willing to work together for
change.
Phase One: Evidence review
Platform1 and Te Pou2 initiated the response during 2013, and began by defining the extent of
the problem. International and New Zealand literature was analysed3, and information about
New Zealand health sector initiatives were brought together through a ‘call for evidence’. This
material was used to inform discussions with health sector leaders and gain support for action.
Equally Well aims to draw on expertise and knowledge across the health and related sectors to
translate the available evidence and sector knowledge into individual and collective action.
Phase Two: Stakeholder engagement and consensus
A consensus position paper calling for a concerted and sustained effort by all those who can
effect change was developed in consultation with a range of interested stakeholders during
2014. This paper has now been signed by a wide range of professional peak bodies and health
and health related agencies. Leaders in health policy and professional development, funding and
planning, universities, primary care and mental health and addiction treatment services have
agreed to work in partnership with people with lived experience4 of these challenges to effect
change. Changes are needed at both policy and service delivery levels.
The signatories to the consensus statement recognise the urgent need for coordinated action
that will contribute to improved physical health and increased life expectancy. Equally Well
collaboration members have agreed that people who experience mental illness and/or
addiction need:
 to be identified as a priority group at a national policy level based on significant health risks
and relatively poor physical health outcomes
 to have access to the same quality of care and treatment for physical illnesses as everybody
else, and in particular to have a right to assessment, screening and monitoring for physical
illnesses
 to be offered support and guidance on personal goals and changes to enhance their physical
wellbeing.
(www.platform.org.nz) The peak body for mental health and addictions non-government organisations
(www.tepou.co.nz) A national mental health workforce development centre which incorporates Matua Raki, national addictions
workforce development centre
3 Te Pou o Te Whakaaro Nui. 2014. The physical health of people with a serious mental illness and/or addiction: An evidence review.
Auckland: Te Pou.
4 The definition used in the evidence review of ‘people who experience serious mental illness and/or addiction’ includes those who
have been diagnosed with schizophrenia, major depressive disorder, bipolar disorder, schizoaffective disorder and/or addiction
with the primary focus on alcohol, cannabis and methamphetamine addiction. However, it is likely that many people with other
mental health conditions and/or addiction face similar challenges. Equally Well will also benefit this wider group of people who are
affected.
1
2
3
More than 100 Equally Well stakeholders met in Wellington on 10 November 2014 to take the
first step in planning collaborative action. The summit provided an opportunity for a wide range
of people who had been engaged with the project for the previous six months or more to come
together and share experience and ideas. Prior to the meeting itself, an online conversation
between stakeholders was generated using Loomio, open access software developed in New
Zealand, to facilitate collaborative activities. This process generated a number of proposals for
collaborative action, in addition to those that had emerged through the evidence review
process.
The evidence review, online conversations, meetings with stakeholders and the summit itself
resulted in a whole range of possible activities. More than 40 proposals were generated and
these have been brought together in the following draft framework which takes into account the
multi-dimensional nature of the problem.
Phase Three: Proposed framework for collaborative action
A number of models of collaborative action were identified as possibilities for the next stage of
Equally Well. The one most closely fitting what we are trying to achieve appears to be the
“constellation model of collaborative social change” developed by the Centre for Social
Innovation5 in Toronto, Canada. It is proposed that this model (see below) is adapted as
outlined.
The constellation model was designed to serve a partnership of organisations wishing to
collaborate to achieve a desired outcome. It utilizes a lightweight governance framework, a
stewardship group, action-focused groups referred to as constellations, and a support team for
co-ordination.6 The model is held together by shared commitment to achieving the desired
outcome, and recognition that this will require working together. In adapting this model we
have changed some of the language and design features (see following illustrative model).
5
Retrieved from http://socialinnovation.ca/constellationmodel on 28 November 2014.
6
From material on the Centre for Social Innovation website, retrieved 28 November 2014.
4
Features of the adapted model are as follows:
1. Funding – adding value to existing services
The proposed model assumes minimal additional funding. Partner organisations will need to
utilise their existing resources for working together on Equally Well projects, and this may
require negotiating with their current funders on variations to existing contractual agreements,
or in some cases applying for additional funding from external sources. The intention of Equally
Well is to improve the quality of existing services and incorporate additional activities into
‘business as usual’ for all participating agencies, to provide for long-term, sustainable change.
For some people already working in this area it might just mean linking up to others doing
similar work, sharing experiences and building on what’s already in place.
2. Backbone team
Another model that has been drawn from for Equally Well is outlined in a Stanford Social
Innovation Review paper7 which identified five success factors (see Table One below) for
collaborative action, by looking at examples of such efforts which had been effective in
achieving substantial impact.
Backbone support is identified as one of the most important pre-requisites for successful
collaborative effort, and to date this function has been provided by Te Pou, in consultation with
a group of sector leaders who initiated the project. With agreement and support from the
Ministry of Health, Te Pou has funded part-time project management (Helen Lockett), analyst
Hanleybrown F., Kania J, & Kramer M. (2012) Channeling Change: Making Collective Impact Work.
Stanford Social Innovation Review.
7
5
input (Candace Bagnall), communications and administrative support, and input from Carolyn
Swanson, Te Pou’s service user lead.
For Phase Three, it is envisaged that the backbone group will:
 provide overall direction and maintain momentum
 facilitate dialogue between stakeholders
 manage online (Loomio) stakeholder engagement and decision-making processes
 monitor, analyse and incorporate online discussions into activities
 analyse and disseminate research data and support outcome measurement
 manage communications including web presence
 provide accountability back to organisations that have signed the consensus paper
 identify leads and ‘champions’ for areas of work, and encourage leadership
 identify and share models of good practice from across the country
 encourage more organisations to endorse the position paper and make commitment to
taking action.
The five conditions of collective impact
Common agenda
Shared
measurement
Mutually
reinforcing
activities
Continuous
communication
Backbone support
All participants have a shared vision for change including a
common understanding of the problem and a joint approach to
solving it through agreed upon actions.
Collecting data and measuring results consistently across all
participants ensure effects remain aligned and participants hold
each other accountable.
Participant activities must be differentiated while still being coordinated through a mutually reinforcing plan of action.
Consistent and open communication is needed across the many
players to build trust, assure mutual objectives, and create
common motivation.
Creating and managing collective impact requires a separate
organisation(s) staff and a specific set of skills to serve as the
backbone for the entire initiative and co-ordinate participating
organisations.
3. Stewardship group
Equally Well was initiated by a small group of individuals who have been guiding the project
now for more than a year. It is intended that this group will be expanded to include more people
with lived experience, and other people who agree to lead and champion Equally Well projects.
Membership of the stewardship group will be as flexible as possible. Organisations participating
in Equally Well will have their own governance arrangements and internal accountabilities and
therefore the backbone group does not envisage organising and servicing regular formal
meetings. Rather, the collaboration and the Stewardship group will function as a network, with
agreed communication mechanisms.
4. Projects and activities
The Equally Well projects and activities that have been identified (and more will evolve) are
described in the Canadian model as “self-organising action teams that operate in co-operation
6
with a broader strategic vision”. We acknowledge that a lot of work is already under way, and
many systems already in place are aligned with the purpose of Equally Well, which may or may
not come under the collaboration.
A lead partner, what we have termed ‘activity lead’ will be needed for each project/activity,
along with any person or organisation with an interest in the action area to form a team focused
on taking action on this issue.
The idea is that projects and activities teams are relatively loose arrangements relying on
success through influential and committed champions, whereas the co-ordination and
stewardship group functions are more formal and provide the accountability needed for
keeping the overall momentum going on this work.
In addition, we have added ‘action pushes’, and described these as ‘windows of opportunity for
action’ where there is a focused set of activities on a specific issue and the timing is right.
Examples might be the opportunity to influence the development of DHB’s district annual plans,
or a one-off consultation process on new clinical guidelines.
It is envisaged that many of the actions identified in the Equally Well framework will become
project teams. Through identifying the project teams’ activities as part of Equally Well, their
progress will continue to be visible and projects supported in various ways through the coordination function and wider network.
The model allows for a creative, flexible and dynamic set of relationships between agencies and
individuals committed to the common goal of improving physical health outcomes. It relies on
collaborative leadership based on mutual respect, organisational autonomy and a shared vision.
Underpinning principles of the collaborative
1. Partnership between health professionals, people with lived experience of mental illness
and addiction and their families and whānau.
2. Stigma and discrimination will be addressed wherever it occurs.
3. Where possible good quality research evidence will inform activities and improve services.
4. Sustainable changes will be made by incorporating new approaches into business as usual.
5. People who experience mental health and addiction problems have a right to be wellinformed about treatment options and wellness opportunities.
6. Different perspectives and world views are accepted and welcomed.
7. Quality of life is as important as extending lives.
On the following page is a conceptual framework for Equally Well, which attempts to give a
single page overview of the programme of collaborative action which is then outlined in more
detail in the table of priority areas of action that follows it.
7
Equally Well Collaborative Action Framework
All activities informed by
Treaty of
Waitangi
principles
Partnership with
Reducing
people with lived
inequities
experience
addiction
problems
VISION: Improving the physical health of people
who experience mental health and addiction problems
GOAL
GOAL
GOAL
Improve the quality of
physical health care
Reduce exposure to risk
factors
Promote prevention and
early intervention
Some specific actions
Some specific actions
Some specific actions







MH&A training for health
professionals - building
capability and confidence
Communicate side effects
of medication, and
different treatment and
recovery options to
service users
Promote routine
metabolic screening &
CVD risk assessment &
follow-up
Develop recoveryfocused guidelines for the
prescribing of
psychotropic medication
Develop ‘Recoveryoriented Systems of Care’
led by service users





Routinely offered effective
smoking cessation support
Address stigma and
discrimination in health
services
Support better access to
employment and suitable
housing
Improve access to dental
health services for mental
health and addiction
service users
Investigate including
psychotropic medication
as a risk factor for CVD and
type 2 diabetes in
PREDICT
Reduce access to alcohol in
communities



Promote self-control
skills training in early
childhood settings
Endorse the HeAL
Declaration for young
people with psychosis,
and put the goals into
practice in New Zealand
Adapt the HeAL
Declaration for people of
all ages using mental
health and addiction
services
Trial complementary
treatment options to
minimise the impact of
psychotropic
medications
Promote recognition as priority group in national and regional policies
Support ‘communities of practice’ with good quality research, evaluation and
monitoring
8
Programme of collaborative action
The following themes and possible actions have emerged through the Equally Well process so
far. The lead agencies and partners column has deliberately been left blank so that people
volunteer for areas they’d like to get involved in and/or take a lead on. We would like your input
to this process, so please feel free to make a copy of this template, add any other possible
projects we have missed, and nominate yourself or other agencies as leads or partners for any
particular action. Some examples of measure of success have been identified, but we’d expect
the groups themselves to develop and agree these for each project. Please email your feedback
to us directly, via Chelvica.Ariyanayagam@tepou.co.nz as soon as possible, preferably by 16
March 2015. We’ll then update the template and re-circulate it in the next email update.
1. Improve the quality of physical health care
Themes
Actions
Possible measures of
success
Increase
visibility as a
priority group in
policies
impacting on
physical health
outcomes
Strengthen mental health and addiction
service requirements of DHBs to improve
their response to physical health in
District Annual Plans (DAPs)
Changes to Service
Coverage Schedule for
2015/16 and out-years
Lead agency
and partners
Strengthen requirements for all health
services to respond to the physical health
of people who experience mental health or
addiction problems
Work with DHB funders and planners to
prioritise funding for services likely to
impact on better health outcomes for this
group, and include in DAP and PHO
alliance contracts
Changes to DAPs for
2015/16 and out-years
Consider review of the use of the Mental
Health (Compulsory Assessment and
Treatment) Act 1992, to take into account
concerns raised by people with lived
experience and their families
Identify, develop
and share
examples of
good practice
Identify models of good practice and share
stories. E.g. Bay of Plenty model using
physical health check KPIs in contracts
and establishing free nurse-led clinics
An increase in local
initiatves which build on
others’ success stories
Encourage evaluation of models for
effectiveness and share results
Number of SPARK8
projects
MH&A provider contracts
all have KPIs around
physical health
8
SPARK stands for Supporting the Promotion of Activated Research and Knowledge – NZ training based on a
Canadian model.
9
Themes
Actions
Possible measures of
success
Lead agency
and partners
Evaluation reports
disseminated
Models of good practice
initiated as a result
Promote metabolic screening guidelines
and improved routine screening practice
in mental health and addiction services
Numbers of people
screened?
Improve consistency in routine
monitoring of the physical health of people
using MH&A services & physical health
screening
Numbers of people
screened?
Adapt International models on pathways
and algorithms for physical health
screening and action
Evidence of use of
algorithm and increased
percentage of health
checks completed
Promote routine checks in primary care
for CVD and diabetes risk for any person
on psychotropic medication
PHOs reporting
percentage of people
checked
Formal recognition in the
IPIF9 as an eligible
population
Ensure access to routine breast and
cervical cancer screening for mental
health service users
Formal recognition in the
IPIF as an eligible
population
Promote shared care models of
strengthening links between mental health
and primary care to support physical and
mental health
Evaluate effectiveness of
current shared care
initiatives and
disseminate learnings
Investigate linkage of PREDICT across
both mental health and primary care
services
Communicate effects and potential
impacts of medication on physical health
to service users, as well as the different
treatment and recovery options
Recovery-focused
prescribing guidelines
developed10?
IPIF stands for the Integrated Performance and Incentive Framework. More details on the IPIF can be found
on the Ministry of Health’s website
10
This action area is strongly linked to the action area in the quality improvement section below
10
Themes
Actions
Possible measures of
success
Lead agency
and partners
Promote effective psychological therapies
and family interventions as alternatives to
and/or alongside medication
Reduce stigma
and
discrimination
MH&A training and supervision for health
professionals in primary care - building
capability and confidence in working with
mental health and addiction issues
Physical health assessment training and
supervision for health professionals
working in mental health and addiction
services
Promote the use of peer support
workers11 and educators across the health
sector, particularly primary care
Research and
evaluation
Support research that leads to better
understanding of how to manage the side
effects of psychotropic medication
Undertake qualitative research to include
the perspectives of people with lived
experience in finding solutions
Quality
improvement
Develop recovery-focused guidelines for
the prescribing of psychotropic
medication
Develop ‘Recovery-oriented Systems of
Care’ led by service users
Encourage open dialogue, transparency,
and reflective practice, with a view of
recovery and treatment choice across
MH&A services
Increase access to funded extended
primary care consultations
Increased numbers of
extended consults
Increase use of patient-held records across
all health services including MH&A
services
11
Peer support workers work alongside people who experience addiction or mental distress to inspire them to
move forward with their lives. Other peer roles include peer educators, peer advocates, peer researchers, peer
supervisors, peer consultants and consumer auditors.
11
2. Reduce exposure to risk factors
Themes
Actions
Increase visibility
as a priority
group in policies
impacting on
physical health
Ensure that smoke-free policies are in
place in all mental health and addiction
services and that personalised support is
provided to heavy smokers who want to
quit (while ensuring this doesn’t create
more stigma/discrimination)
Possible measures of
success
Lead agency
and partners
Support public health advocacy to reduce
access to alcohol, including supporting all
the 2013 recommendations of the Law
Commission.
Develop and
share examples
of good practice
Identify good models of wellbeing
programmes through ‘call for evidence’
network, promote through newsletters
and online networks
Reduce stigma
and
discrimination
Ensure that people who experience
mental health and addiction problems are
provided appropriate access to screening
for CVD and cancers
Reduce the impact of lowered
socioeconomic status through supporting
better access to employment support and
suitable housing
Develop awareness in the health
workforce of how to address the stigma,
especially self-stigma, that can prevent
people from engaging in wellness
programmes
Research and
evaluation
Analyse NZ data to inform the possible
inclusion of additional risk factors related
to mental health in the PREDICT CVD
assessment tool widely used in primary
care
Review smoke-free practices in inpatient
units around the country and how to
provide more effective support for people
who want to quit smoking, with a
particular focus on Māori
Trial alternative and complementary
treatment options to minimise the side
effects and provide viable alternatives to
psychotropic medication
12
Quality
improvement
Improve access to oral health services for
mental health and addiction service users
Advocate for monitoring, screening and
management of physical health problems
in quality frameworks for MH&A services
(and a physical health KPI)
Ensure people have access to good
information and support on the
importance of nutrition to physical and
mental health
3. Promote prevention and early intervention
Themes
Actions
Increase visibility
as a priority
group in policies
impacting on
physical health
Strengthen requirements of DHBs to
prioritise early intervention services
through DAP processes
Endorse the HeAL Declaration for young
people with psychosis, and put the goals
into practice in NZ
Possible measures of
success
Lead agency
and partners
Adapt the HeAL Declaration for people of
all ages using mental health and addiction
services
Develop and
share examples
of good practice
Promote self-control skills training in
early childhood and health curriculum in
schools
Addiction performance target – screening
and brief intervention in primary care for
alcohol
Comprehensive annual wellness check
and screening for everyone in contact
with secondary and primary MH services
Reduce stigma
and
discrimination
Support ongoing funding and delivery of
Like Minds Like Mine programme to
address stigma and discrimination at a
population level
Research and
evaluation
Trial complementary treatment options
to minimise impact of psychotropic
medications
Quality
improvement
Training all health professionals (comorbidity, reduce stigma and
discrimination)
13
Appendix one: Organisations who endorse the
consensus statement (as at January 2015)
14