Overview of the Work
The York Pathways Partnership was instigated in 2015 in response to a sharp rise in the amount of repeat police and ambulance incidents in the city arising from a relatively small number of people experiencing mental distress. Most of these incidents involved last resort cries for help by those feeling let down by other services, or because they had ended up in some kind of trouble, rather than because they were experiencing a genuine one-off emergency situation.
This is not an uncommon situation, but North Yorkshire Police brought other partners across York together and pressed for action, not just because of the acute pressure this was bringing on their budgets, but because they recognised that they weren’t best placed to help and that people were being badly let down by the whole “system”.
Since 2015 a small project team, employed by national mental health charity Together UK, has been working to take referrals from a range of other public and voluntary sector services wherever those services identified a person with complex needs who was in imminent danger of presenting demands on emergency services. The team uses methods developed by Together and applies them using a patient, whole-person, and person-centred approach. The main aim of the intervention is to re-engage individuals with those public services which have largely turned their back on them.
The project has been very successful in turning many lives around, as demonstrated by an evaluation which has also found early evidence of significant financial savings to a whole range of agencies. The costs of its continuation are being picked up by local agencies in the short term (until 2019), although its longer term future is more uncertain.
But attention is now turning to the extent to which the pre-conditions which led to the project being created in the first place have started to change. Has the existence and approach of the Pathways project influenced the ways in which mainstream services operate? Have people started to get the help they need earlier in order to prevent the escalation to emergency service provision previously seen?
The flow of referrals into Pathways has not really slowed, which suggests that the answer to these questions is probably ‘no’. In the ‘early intervention’ analogy which asks whether we are building fences at the top of the cliff or funding an ambulance at the bottom, we might describe the Pathways partnership as a safety net half way down (with a ladder and a guide to help you back to the top, if we really want to stretch the analogy to its limit).
The question now is whether there is more that can be done to prevent people falling from the cliff in the first place, or whether the erosion of our public services has become such that safety nets should be there indefinitely. After all, this would be better (and cheaper) than funding the ambulance. This may yet be the conclusion, but until a consensus is reached on that, the work of Lankelly Chase will continue to be to ask difficult questions about whether that should really be the limit of our ambition.
Methodologies being used
• Leading not with actual money, but with support and capacity
Lankelly Chase has supported some of the costs of the project itself, but has also ensured that some of its resource is exclusively being used to provide support and challenge.
• Holding people to a collaborative and collective approach to change
There is widespread interest in York in new ways of doing things, and particularly in whole-system approaches, but there is still sometimes the danger that change projects are pursued in narrow and introspective ways. Our work is trying to encourage broader and more shared perspectives wherever we can.
• Galvanising people, networks and ideas
Through our various learning workshops we are trying to encourage curiosity and the generation of new ideas and new conversations which wouldn’t otherwise have happened.
Convening a regular Strategic Board comprised of service users and key agencies
Having multiple conversations with stakeholders at all levels of the system – service users, service managers, senior managers and commissioners – using the experience and evaluation findings of the project to challenge current thinking and consider what the learning from the project is saying about what needs to change
Running a series of “system change” workshops for frontline practitioners working in a range of agencies
Running a “co-inquiry” learning project to identify the changes that service users, service managers, commissioners and partners want to see, and providing the space for those involved to themselves research and investigate how these changes might be implemented
Identifying the various initiatives across York which are independently pursuing person-centred service change and trying to improve the links between them
Providing a feedback loop back to the Pathways project itself to identify potential changes and service improvements
• Resources. York has one of the worst per capita mental health budget settlements from central government in the country. Room for manoeuvre feels limited to people, and the focus within individual agencies is largely on internal service efficiencies to resolve short term deficits rather than exploring the system-wide efficiencies and improvements that might be possible
• Flow of demand. The need for an intervention to deal with the consequences of system failure was acute, and remains so. The project has largely been focused on addressing presenting demand, and partners have struggled to find the space to consider and address the causes of that continuing demand
• Flow of information. The process of putting together Information Sharing Protocols with each agency involved has been painstaking and these are still not all in place in the most helpful way. Trying to effectively join up services when those services are prevented from sharing personal information with each other is nigh-on impossible
• Insider-Outsider. The Pathways project is positioned on the periphery of mainstream services and this has served it well in many ways, as it has been able to take a flexible and service-challenging approach, being linked to the public sector but ultimately not bound to it. However this position has made it more difficult to influence or challenge the deeper workings and more strategic developments of those partners
• Whose project is it anyway? In theory this is a multi-agency project, and it can only succeed if it is. But it originated from the insights and enthusiasm of individuals from North Yorkshire Police, and is still convened and chaired by them, and the engagement of other agencies can sometimes feel patchy and limited, perhaps because of this origination.
Which System Behaviours are you focussing on?
People see themselves as part of an interconnected whole
This has been the main focus of the work to date. It has been assumed that the main system failure originally stemmed from specialised and siloed services focussing on their own narrow interests and capacity/demand problems, and being only intermittently aware of system-wide flow and demand pressures. Pathways as a project acts to try to reconnect services for individuals on a case by case basis. The system change work is in part aiming to ensure that these connections become established more generally.
Feedback and collective learning drive adaptation
By stimulating conversations between silos that typically have very little interaction, connections and sharing of perspectives will hopefully begin to happen more naturally. There is frustration with the lack of join up and consequently a real appetite for collective learning
All people are viewed as resourceful and bringing strengths
The emphasis on frontline workers is encouraging individuals who might normally feel powerless and just a cog in a machine to realise that they have insights and abilities which have the potential to start to drive change. Links are being made to the Local Area Co-ordination pilot of the council, which itself takes an asset-based approach with individual service users and their local communities