This post was written by Dr Olive Moloney, Clinical Director at MAC-UK.
Are service users the key to systems change?
Services are set up in ways that work for the majority of people most of the time. They do their utmost to reach excluded groups but these groups continue to find it challenging to reach them. We know that young people who do not show up at clinics are often the ones with the most complex needs and most entrenched in youth crime, the ones who will access services when in a crisis or when mandated to do so.
Violence is a major cause of ill health and poor wellbeing, and a drain on health services and the wider economy. It costs the NHS an estimated 2.9 billion every year, and the wider, total costs of violence to society are estimated at £29.9 billion per year (Department of Health, 2012).
Young people in custody are some of the most vulnerable in society and good access to health and mental health services is key to breaking the cycle of offending.
This is not just an issue for justice; it’s a problem for public mental health and a problem for us all.
MAC-UK is a registered charity (no. 1126144), which was founded in 2008 to radically change the way in which mental health and wellbeing services are delivered to our most excluded young people. MAC-UK’s Founding Director, Dr Charlie Howard (formerly Alcock), is a Clinical Psychologist who has local and international experience of working with young people in or at risk of gang membership. Whilst working in a community mental health service in Camden, Charlie was struck by the statistic that one in three young people who offend have a mental health problem, and that mainstream mental health services were not reaching this group. Having a diary filled with appointments for which no-one turned up, Charlie went out into the community and spent time on an Estate in Kilburn, hoping to engage with a group of extremely challenging young people, who were well known to the local police and youth services. The young people accused her of being an undercover police officer, spat at her and threw stones. One day one young man asked her: “What the **** are you doing here?” “I’m Charlie and I need your help,” she replied. “Why do you need my help?” “Because it seems to me nothing’s working for you and I think you know what works. How about we create what works together?” They founded Music and Change, the genesis for MAC-UK.
MAC-UK spent the next five years developing a unique, innovative and ground-breaking model which effectively bridges health and justice using a community youth-led model, we called it Integrate. We take mental health to the streets, where young people want it, where they need it. Streetherapy, as this approach is now known by, melds together the finest aspects of detached youth work, public health promotion, community development and the best practice from clinical interventions. It requires highly competent clinicians and non-clinicians who can work incredibly flexibly and can hold their nerve; it also needs a full team approach which wraps around each young person
Early research findings suggest it works – we are working with high levels of complex needs and distress, which reduce over the course of young people’ journeys with the project teams. We have invested in an external evaluation led by the Centre for Mental Health to further understand our model, how it works and why; results will be published in 2015.
Our model has been featured in several government reports as model of good practice. We also sit on an expert advisory panel to the Home Office. The police initially mistook us for engaging in joint enterprise with young people but now even they’re saying that it has a positive effect on offending rates.
Systems aren’t working
It seems that right now our systems are not working as well as they could; for many young people chaos and fear is the norm! There is no silver bullet answer to service transformation but we seem to have stumbled across something at MAC-UK, which is working:
- Serious youth violence and gangs are now recognized as a public mental health issue by the government
- NHS clinical staff are starting to work at street level
- Health and the police are better integrated around risk management
These have all been joint successes, we are working together with various agencies at different levels to tackle the whole system, not just the symptoms.
Starting with Young People
We quickly realized at MAC-UK that starting with young people was not an accident, it was the whole point – we started with the service users and developed a service to meet their needs – now we apply that same principle for every new project, in every new area. Donald Berwick, Leader in American Medicine, said that if we keep using healthcare to get to health then we are missing the point. 40% of health variance is due to things relating to where we live. It’s hard to get out and exercise if your neighbourhood is scattered with people who are after you.. Our young people were on the same page as Berwick; they led us to create a model that addressed all of these issues in one and took us to the services we needed on board to it – at the micro level, Integrate bridges health and social care
Culture and Capacity
We also noticed something about culture and capacity at MAC-UK, it was hugely understaffed in the early days and this meant we all had to do everything. Staff were operating at the frontline as well as the strategic level – going from a fight over food in KFC to a roundtable with the Home Secretary felt normal. It wasn’t until later that we realized that in most organisations people work at one level or the other. We had stumbled across something really important – staff crossing these more traditional boundaries meant that young people’ ideas could be implemented quickly fostering trust and empowerment. We also had real life examples at our fingertips at policy meetings. People liked stories – they listened.
As we’ve grown, finding all these skills and motivations in one person has proven challenging so now we are trying to pair people who complement each other. It’s a recruitment challenge but one that we are keen to solve as there seems to be something about it, which works!
Leadership has, of course, been critical! We’ve had to be disruptors of systems but we haven’t achieved this by taking a stance. It’s been about adapting our messaging to the system and adapting our language. We have deliberately invited people for a different reason to the same meeting: the police think they are coming to talk about crime, the health managers think it’s about reducing DNA rates, the housing people about better supporting their staff – it’s of course about all of these things but to get people into the room we have to speak their language. Again, having young people alongside either literally or by proxy has made others receptive to the disruption
Failing has been really important, it gives us clues as to what needs to change. One day MAC-UK will write a book on what hasn’t worked but these failures have been the key to our innovation and constant willingness to change. Young people tell us – tell people to just start things without being too concerned about the theory and not practically doing it! The world-changers are people who have a blessed naivety to do the things that everyone else knows too much about to tackle. The challenge is creating cultures where it’s OK to try new things and where we are more risk aware instead of risk averse.
One thing that seems certain is that nobody can do this alone; we need to work together across our sectors and in partnership with the communities we serve. The AMBIT model created by the Anna Freud Centre has helped us with this. Partnership is a non negotiable! It means that governance is a headache as you can imagine the chaos of working across 4 agencies, which have their own ways of managing risk and their own service-specific insurance policies. But actually it’s the governance, which becomes the key to get us all working together and to rewrite the system. If approaches like Integrate are to be mainstreamed, the systems have to be ready.
How does it work in practice?
About a year into MAC-UK’s existence, some young people wanted to set up their own business. With guidance from the staff team and with huge support from local agencies such as the Integrated Youth Support Services, local schools, HMPS, and the Met they have developed MiniMAC. A 50:50 ideology benefiting (1) young boys and girls in school who were on the verge of exclusion, had been excluded or were in youth offending institutes and (2) the founders – young people from disadvantaged backgrounds who were aided in the reintegration process and given employment, a stable source of finance, an opportunity to target any unmet mental health or stability needs they may have, and a variety of outlets for their professional development.
Lamont is one of the MiniMAC founders: “I feel the model works so effectively for so many reasons. For one, apart from the initial introduction when we explain to the students who Mini-Mac are, the term “Mental Health” rarely features again in the sessions, if at all. As I’m sure you’re aware, the term Mental Health comes with vast stigma and can act as a deterrent to student participation, engagement and willingness to contribute whole heartedly to sessions.
The Mini-Mac tutors are all in their 20’s and stem from similar backgrounds to the troubled students we encounter, and have therefore shared very similar experiences. This also means the tutors are often better equipped to communicate with students in a relatable manner. These are very powerful and important factors. When the students are made aware of these various factors, they immediately seem to feel more at ease and more comfortable to open up about their own experiences and personal issues. If mental health help was employed in the more standardised methods, it’s extremely unlikely we would achieve the same results.
The reality is that psychology as a profession is a scary unknown to these students. They do not understand it and are therefore hostile to this foreign field. At Mini-Mac, the theme of mental health is employed in a more subtle way. The psychologists do not facilitate or play a major role in the sessions. They observe and engage with students who may seem isolated or individuals who may be excluding themselves from their fellow students. They also write student reports and correspond with students’ teachers, parents, social workers and any other relevant parties who play a significant role in the well being of the students.
The Tutors however engage students in various mental health themes such as anger, pain, sadness, violence, bad behaviour through group discussions and lyric writing. The process is never formal, which in turn naturalises it and makes the students feel at ease, as they aren’t so conscious of the mental health aspect. “
MAC-UK’s hope is that the learning from our approach is used everywhere and that these new ways of working become the status quo. We’re now exploring how to do the next bit of the journey. What’s clear is that service users have been absolutely central to our innovation and that they will be core to the future of what we do. We are looking at how we might best position ourselves to transform mental health services for young people.
We are proud of what we have achieved in 5 years but also acutely aware that it’s easier to disrupt when and because we are small. So many innovative approaches that have gone before us have failed when they have gone to scale. Our latest thinking is that it is by building the evidence base from our practice and sharing the learning from our approach with others, we do not scale through delivery but scale by increasing capacity to work this way.
We invite you all to stay tuned, work with us or just root for us in our ambition to embed youth-led solutions to mental health service provision on a bigger scale.
About the authors
Lamont Emisebe is a youth mentor/tutor/session worker at Mini-Mac, which is a project branch under the umbrella of MAC-UK. He works within a multi-disciplinary team that consists of several tutors like himself, a clinical psychologist, a mental health practitioner, a youth support worker and various volunteers with a psychology background.
Dr Olive Moloney is a clinical psychologist and the Clinical Director at MAC-UK.
This blog relates to the recent Psychology Cultures lecture – Taking Mental Health to the Streets.
MAC-UK would like to thank the Psychology Department at Leicester University for making the team feel welcome; we’d also like to extend a special thank you to Stephen, who made the whole event possible; and to the audience members who bravely volunteered to take part in the “Look down and up” game – you were magnificent and very attentive, engaging and interactive throughout.
If you want to know more about MAC-UK and service users being key to systems change, please visit www.mac-uk.org or contact us info at mac-uk.org