Embedding cultural change in mental
health services in Bristol: Views from the
voluntary and community sector
Report for Bristol NHS
December 2012
1
Contents
Page
1.0
Foreword
3
2.0
Introduction
4
3.0
The culture required to deliver new mental health services in Bristol:
Overarching themes
5
4.0
Recommendations for action: How to embed cultural change in Bristol’s
new mental health services
12
5.0
Acknowledgements
15
6.0
About The Care Forum
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2
1.0
Foreword: Rachel Robinson, Chief Executive The Care Forum
The engagement and consultation
phases of modernising adult mental
health services in Bristol have offered
voluntary and community sector (VCS)
organisations the opportunity to share
their views and shape services.
The challenge ahead will be to sustain
the diversity, vibrancy and
responsiveness of the sector as new
mental health services in Bristol take
shape.
Many organisations have embraced
this opportunity. Their commitment to
this process does not demonstrate the
fact they have time on their hands.
Indeed most VCS organisations have
faced an unprecedented and less well
resourced demand for their services in
recent times. Instead, by engaging in
this process the VCS in Bristol have
shown their commitment to the
individuals and communities they
serve and their desire to help shape
truly responsive services.
This report builds on the initial work
The Care Forum undertook with VCS
organisations in the summer of 2011.
The findings were drawn together in
the report “Improving and modernising
mental health services in Bristol: Views
from the voluntary and community
sector” and were reflected during the
subsequently drafted model and
pathways for mental health services
which were subject to consultation in
the summer of 2012.
The next steps will be towards
implementation of new services. I
welcome the opportunity this event
and report gave to gather together the
views of the VCS on embedding
cultural change in mental health
services.
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2.0
Introduction: Louise Hudson
The event hosted by The Care Forum
on Tuesday, 20 November aimed to
facilitate voluntary and community
sector organisations to share their
views on embedding cultural change in
Bristol’s new mental health services.
The intention was to inform the next
phase of modernising mental health
services in Bristol and the
commissioning of new services. The
event was delivered in partnership with
NHS Bristol.
Andrew Keefe, Associate Director for
Mental Health in Bristol set the scene
while independent facilitator Amy
Shortridge chaired discussions and
challenged the audience to consider
the concept of culture.
Three discussions groups were
facilitated by Ruth Hallett, David Harris
and Andrew Keefe from NHS Bristol.
Participants were asked to consider
three key questions:
were coded and analysed. Alongside
those themes, the voices of the
voluntary and community sector
participants remain prominent
throughout this report, as their insights
on cultural change deserved
highlighting. The recommendations in
this report arise from the themes
emerging from the discussions with
and between VCS providers and are
wholly based upon the views of the
participants.
The recommendations are designed to
inform the work of commissioners as
modernising mental health in Bristol
moves towards its implementation
phase.
Lastly, I would like to thank the
voluntary and community sector
organisations who took part in the
meeting and gave their time to share
their views.
1. What is the culture required to
deliver the newly commissioned
mental health services for
Bristol?
2. How would you notice cultural
change in practice?
3. Using your own experience,
what do you consider works to
positively influence cultural
change? Please share
examples from your own
organisation or other places you
have worked.
Verbatim notes were taken and key
themes emerging from the discussions
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3.0
The culture required to deliver new mental health services in Bristol:
Overarching themes
Demonstrates strong leadership
Cultural change requires leadership.
“What I have seen in
Modernising Mental Health are senior
commissioners in meetings. That is
positive.”
Participants want commissioners to
continue to communicate with
providers during the implementation
phase of new mental health services.
“A lot of VCS groups feel that
the culture has been dominated by
NHS providers and not
commissioners.”
Strong leadership from commissioners
with a focus on outcomes will enable
providers to be clear about what is
expected from their services. Shared
expectations among providers and
commissioners will enable cultural
change to happen.
“Compared to drug services it
feels like providers are not so
responsive to commissioners.”
Providers must be accountable to
commissioners. Bold leadership from
commissioners should be followed by
bold leadership within organisations
themselves with a shared vision for
change and for what good services
should look like. Participants described
this as “leadership with vision for
change.”
Supports staff
Better staff morale will lead to staff
retention. There was a desire amongst
participants to see people enjoying
their jobs and feeling positive about
where they work. The view was that a
positive culture will come from staff
who are not overwhelmed and who are
supported and resourced to do their
jobs.
“Consistency of care and staff
retention will lead to better services
and will avoid people being continually
asked the same questions about their
needs.”
Internal and external communications
should celebrate success stories.
“Organisations must truly want
to bring out the best in people.”
Innovates and embraces change
“Recognise that there will be
other ways of doing things. Keep an
open mind and be innovative.”
Organisations must be open to new
approaches and embrace change.
“Have a can do attitude and
support new ideas even when it’s
different from what you have done
before.”
“Where there is a need create a
project to meet it.”
Organisations should be open to
receiving assistance from the outside
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to enable them to change and to
deliver new projects. An example was
given of a statutory service working
with the National Autistic Society
(NAS) and using NAS to monitor how
staff changed their practice following
training in autism awareness.
“When staff understand why the
previous way is not always right they
will find change easier to accept.”
Staff can be encouraged to recognise
that small steps towards change are of
value and are important.
“Change takes time and small
ideas can make a difference.”
A desire for change should filter
through an organisation.
“Staff from all levels in an
organisation should be involved in
cultural change. That way they can all
feel part of a solution.”
Demonstrates a commitment to
community engagement
“Listen to people and
communities, this will result in plans
which have needs, strengths and goals
included – currently it feels like only
needs are included.”
Services should work in partnership
with the community and value what
they have to offer. The knowledge held
by communities, individuals and carers
is a positive resource that can be used
to shape responsive services.
of service users and carers to have a
say. They should be encouraged to try
innovative approaches to giving people
a voice.
“A theatre company launched a
poetry session with mental health
service users. This gave a sense of
someone as a whole person.”
Community engagement must reflect
the community and not a narrow
section of the community. Services
should communicate how they are
involving the community. They must
also demonstrate what happens as a
result of community engagement.
“You need people that have
used the service to come forward and
say that things have changed.”
Outward-looking
Providers and commissioners must
look outward. Collaborative working
between service providers from the
statutory and voluntary sector services
will lead to seamless and less costly
services.
“We have recently taken a
referral from a social worker who
wanted to try a different approach. The
carer is now getting more support and
the client is feeling better and has not
been readmitted to hospital since we
have been working with them.”
Outward-looking organisations can
foster a shared understanding and
vision and work in partnership
effectively.
Services and organisations should
encourage and support a wide range
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“I think so far the AQP bit is
good. People were working with us.
We are now finding groups of
organisations contacting us, coming
together and having a dialogue. Before
it felt like working in isolation.”
Relationships between organisations
matter and will enable services to
become person-centred. Different
providers need to be clear about
different services and different skill
sets.
“We are a preventative service.
We complement each other. It is about
knowledge and shared understanding.
It is about clarity.”
Positive examples were given of multiagency meetings taking place in the
substance misuse and homelessness
sectors.
“Invest in monthly multi-agency
meetings.”
Knowledge of services beyond an
organisation’s own boundaries will
enable providers to refer onto
appropriate services. Organisations
should support each other, promote
each other’s services and be confident
about referrals and sharing
information.
“There should be more
information sharing amongst
professionals so that service users do
not need to keep repeating their
stories. Confidentiality can be used
negatively.”
Organisations that are outward-looking
will be able to take an asset-based
approach and use the resources that
already exist. Pooling budgets to jointly
commission services and to invest in
multi-agency training was
recommended.
“In the Vale of Glamorgan, a
range of health professionals from
different departments and different
roles joined budgets together for joint
training. This encouraged ward nurses,
occupational therapists and other staff
to think very differently. The training
was carried out in libraries and
included role play and positive mental
health service role models. Pooling
budgets for training works.”
The statutory sector must improve
their understanding of the value of
VCS agencies. The use of less costly
resources will lead to savings up the
line. There must be a broader view of
resources and solutions. Solutions do
not lie in services alone. They exist in
individuals, carers and communities.
“Potentially all the resources
that exist can be part of someone’s
recovery. Consider all the options for
someone. A broader view of solutions
is needed.”
Recovery-focussed
“The person themselves needs
to be seen as a potential resource in
their recovery. It needs to be a wholeperson assessment. You would know
when someone has been listened to
because the services they receive start
to match not just their needs, but also
their goals and strengths.”
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The relationship between client and
provider should be one of partnership.
A belief that change is possible should
cut across services, organisations and
staff/client relationships. Plans should
not be “care” plans but instead should
be “recovery/outcome” plans. They
should be personal and strengthbased. Outcomes should measure
achievements and not just stability.
“Hope and enthusiasm should
replace despair.”
“Aspirations need to be raised
on both sides (service users and
workers).
Participants want a culture in mental
health services that raises aspirations
and demonstrates an enthusiasm
about the potential for an individual to
positively change their life.
Reduces and challenges stigma
Mental health services must
demonstrate their commitment to
reducing and challenging the stigma
associated with mental health.
“The concept of mental health
and what good mental health means
should be grounded in all services. At
the moment we have a culture where
mental health means mental illness.
We need a sea-change where mental
health can be talked about. It is down
to the skills of those working in support
organisations and at the moment they
are not good enough. Any worker
should know about mental health not
just mental illness.”
Participants articulated a desire to see
professionals reducing stigma by not
just seeing symptoms and actively
promoting inclusion.
“Reduce stigma. One way to do
this would be for professionals not to
reflect people as a bundle of
symptoms and problems, as this leads
people to label them-selves as
mentally ill.”
It was suggested that services could
be promoted in a way that destigmatises.
“There is a danger that we
therapise everything. E.g. eco-therapy.
We should normalise everything that
nourishes us all.”
Participants wanted a culture overall
where mental health is easier to talk
about and this could be enabled
through facilitative skills held by more
people.
“There is a lot that could be
done in terms of de-stigmatisation.
You need to respond to mental health
and not just a diagnosis to be
managed medically.”
Promoting services commissioned via
GPs could help to challenge the
stigma associated with mental health
and ill-health. Promotion of newly
commissioned services means
visibility and can promote better quality
and better care.
Transparent
An understanding about statutory
sector mental health services – what
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exists and what people can expect –
will encourage people to feel confident
about using and referring onto
services.
Transparency will enable carers and
other organisations to understand how
people can access help. Transparency
about services will enable people to
regain trust in mental health services.
“People going into mental
health services face a dark corridor
compared to people accessing other
clinical services. People needing
mental health services should
understand a possible pathway.”
swifter access to all services when
needed.
“Avoid phone lines where
people get passed from person to
person.”
Proactively communicate and engage
with stakeholders.
“Support people in the
community to have the skills to say
when people need intervention and
provide a fast route when needed.”
Community services should have
access to mental health services and
access should be fast when needed.
Provides accessible information
and accessible services
Linked to transparency, mental health
services must be accessible in the
widest sense.
“We know when we pick up the
phone the person at the other end
doesn’t always want to pick up the
referral. Now we feel we can signpost
to other AQP providers.”
“Provide meaningful, appropriate
accessible information in all formats.”
Carers, service users and professional
– both experienced and novices –
should expect and receive a
meaningful response about what they
can expect from services in a short
timeframe.
Information about services and what to
expect should be available through a
variety of formats and outlets. External
and internal communications should
reflect an organisation’s values and
foster a shared understanding
amongst staff and outside
stakeholders.
“These things [values] need to
be visible in literature, the website etc.”
A provider’s communications should
demonstrate their values and their
values should be reflected in
accessible services. People want
“You want an organisation to
respond to emotional/mental distress.
You need to get a reliable response
about what you can expect from
services. Anyone should be able to
access professional advice about
clients and get a response.
Inexperienced colleagues without selfconfidence around mental health don’t
get the same response as me.”
“Access should not depend on a
diagnosis.”
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Investment in language and
communication support will foster
accessible services.
the service is of value. You need peersupport and you need evidence from
survivors.”
“We feel we get exploited. For
example, they may not have the right
worker and they turn to our
organisation and ask if we can be
there to give language support.”
There is a strong culture of userinvolvement in drug services.
Examples were given of approaches
that were self-directed and mutually
supportive.
Provides choice
Choice matters to service users and
carers.
“It is very powerful when people
can share life experiences. We take a
SMART approach – where ex-users
run these groups.”
“Young people and adults
should be able to go to any type of
organisation they are comfortable in.
Someone with an understanding and a
basic level of training should be there
to give them advice and direct them.
People need a place that is
independent, friendly and staffed by a
wide group of knowledgeable
practitioners that can signpost.”
As far as possible organisations
delivering mental health services
should offer choices and different
options to service-users. Non-clinical
approaches should be offered when
appropriate.
“User-involvement is within our
culture [drugs services]. It is the
engine of our provision. Specialist
groups are populated by peer support
workers and other people using
services.”
Participants described how user-led
involvement encouraged individuals to
feel valued. User organisations can
also shape and influence
commissioning.
“Medication needs to be used
as one approach and used
appropriately.”
“In drug services
commissioners funded a user
organisation which influences
commissioning. It is a vehicle for
service users to influence. It was
commissioned by the drug action team
and not the provider.”
Involves service users
Participants shared many positive
examples of peer-led service user
involvement.
Responsive to carers
Mental health services need to adopt a
culture that recognises carers as
central to delivery.
“In our fathers’ group there is
mistrust of statutory services. What is
powerful is having the group say that
“Understand that carers are an
essential part of it all. If carers are not
supported, the repercussions will affect
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service users. Carers need to be
central. However, remember that
service users’ aspirations are not
always the same as those of carers.”
Working proactively with carers and
carers organisations will help support
carers as a resource in an individual’s
care and recovery. Carers should be
informed of services that exist outside
mental health services to support them
and to enable them to support those
they care for.
“Understand cultural
differences, in particular around the
needs of carers.”
Respecting culture and at the same
time being proactive, in order to meet
needs, will require new approaches.
“One size does not fit all. There
are big challenges.
Understands cultural diversity
Voluntary and community sector
organisations want mental health
services that care about people and
understand cultural diversity.
“Cultural awareness and being
open to other approaches is
important.”
Organisations must connect with the
voluntary and community sector and
the grass-roots of a community to
understand cultural diversity in all its
guises.
“Places like the church are
important to people that are facing
mental health issues. Many people
would not go to the doctors to get help.
People from my culture [AfroCaribbean] need to see evidence of
things changing.”
In many communities [Afro-Caribbean
and South Asian were given as
examples] families will gather round
and hide the fact that someone has a
mental health need.
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4.0
Recommendations for action: How to embed cultural change in Bristol’s
new mental health services
3.
1.
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2.
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Map services
Organisations want a transparent
culture that communicates the
services available.
People and professionals want to
direct people to the right services.
They want to know how services
fit together, who is delivering the
different services and what to
expect from services.
Demonstrate how care pathways
will work in practice and how
pathways will link to other
services.
Communicate your values
Commissioners must explain and
repeat the mantra of cultural
change.
Organisations must demonstrate
their values via internal
communications that foster a
shared culture amongst staff.
External communications provide
an opportunity to foster a shared
culture with partners.
Communications must be
accessible for all stakeholders
including service users and
carers.
Communications must be
relevant and up-to-date.
Demonstrate how you value
those with expertise at all levels
from service users to family
members to psychiatrists.
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Invest in robust
commissioning and monitoring
procedures
Commissioning must seek to
maintain a diversity of provision
so that services are responsive
and offer choice.
Commissioners should lead the
way in fostering collaboration and
actively seek to avoid
organisations competing,
duplicating or dominating.
Pool resources and commission
jointly between statutory
agencies to foster the
development of creative and less
boundaried services.
During the implementation phase
of modernising mental health
senior commissioners need to
remain in dialogue with providers
across the board.
New GP commissioners need to
be visible and actively listening
and demonstrating their shared
understanding of the values
underpinning modernising mental
health in Bristol.
Commissioners must have an
open-door so that problems can
be aired and resolved.
Adopt outcomes-focussed
monitoring and robust servicelevel agreements which include
goals and outcomes.
Measure qualitative and
quantitative data. Measure shortterm and long-term outcomes
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4.
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5.
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Invest time in monitoring to
ensure that organisations are
accountable.
Monitor and audit the diversity of
providers.
Monitor and audit the quality of
recovery and care plans.
Monitor and audit multistakeholder customer
satisfaction, and user and carer
involvement.
Monitor the accessibility and
quality of culturally appropriate
services.
Use existing resources
Pool budgets and share
responsibility amongst
commissioners.
Actively promote the resources
that exist within individuals,
families and communities to
promote recovery and maintain
mental health.
Look outwards and use
community resources.
Actively seek non-clinical
solutions and work in partnership
with community organisations to
deliver innovative approaches.
Use signposting and information
services to identify community
resources. E.g. Well Aware,
Happy City and Mind databases.
Use care pathways to show the
links to and means of accessing
community resources.
Involve service users and
carers
Learn from approaches adopted
within drug treatment services
that have a strong-culture of user
involvement and peer support.
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6.
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7.
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Fund a user organisation that
influences commissioning and is
independent from NHS providers.
Invest in training
Invest in multi-agency training to
provide an opportunity for
organisations to come together,
share approaches and foster
shared values and
understanding.
Ensure multi-agency training
takes place in a variety of
community settings.
Invest in training to upskill
organisations to sign-post to
appropriate services and
community resources.
Invest in staff training to
engender confidence and to
demonstrate to staff they are
valued.
Monitor changes in practice that
come about as a result of
training.
Pool budgets for training.
Involve service users and carers
in multi-agency training.
Share information
Agree a multi-agency protocol for
confidentiality and information
sharing.
Agree a multi-agency protocol for
sharing and managing risk.
Invest in network meetings to
give professionals time-out to
meet each other and
commissioners.
Hold regular, face-to-face multiagency meetings.
Make the best use of existing
technology to information share
e.g. teleconferencing, video-
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conferencing, web-based
communication tools.
Share maps of services and
named contacts.
Agree who is responsible for and
paying for access needs to be
met.
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5.0
Acknowledgements
Thanks go to the following VCS
organisations that took part and
shared their views:
Alzheimers Society
Battle Against Tranquilisers (BAT)
Bristol Drugs Project
Bristol Mind
Dhek Bhal
Hartcliffe and Withywood Kick Start
(HAWKS)
Knightstone Housing Association
Life Cycle UK
Milestones Trust
Nilaari
National Autistic Society (NAS)
Off the Record
Positive Minds
Rethink Mental Health
Second Step
The Carer’s Support Centre
Windmill Hill City Farm
Womankind
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6.0
About The Care Forum
The Care Forum is a charitable
organisation that promotes health and
wellbeing and challenges inequalities
in heath and social care policy. We
have more than 20 years experience
of partnership work with statutory,
voluntary, community and social
enterprise sectors across the west of
England sub-region and beyond.
Our networks of voluntary and
community sector agencies inform and
support organisations and their service
users to express their views, make
their needs understood, participate in
decision-making and improve access
to health and social care services. The
Care Forum researches, evaluates
and promotes best practice in health,
wellbeing and social care policy and
services.
We host two Local Involvement
Network (LINks) and provide
advocacy, social prescribing and
information services to help improve
individuals’ access to and involvement
in health and social care services.
To find out more about our services
visit www.thecareforum.org.uk or
contact The Care Forum  0117 965
4444.
For further information about the
content of this report email
louisehudson@thecareforum.org.uk or
 0117 958 9337.
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