Case Study

DISCOVER! is an engagement tool designed by the PCU to support the commissioning of mental health services in North Yorkshire and York. DISCOVER! asks a critical question of anyone who has an interest in the provision of mental health services (service users/carers, NHS/local government organisations, voluntary partners, and local communities)  ‘What is your best experience of mental health services and how can we do more of that?’

DISCOVER! was developed in response to two important aspects of our commissioning responsibility; to find out what really matters to service users/carers about their mental health support, and to build the practice (ways of thinking/being/doing) of commissioning teams across our four North Yorkshire and York CCGs to engage with service users and communities in a meaningful way.

DISCOVER! is based on the principles of Appreciative Inquiry (AI)[1] a highly engaging, sense-making tool which inquires into what works well in any given situation and uses that as evidence to build strategies for change. DISCOVER! is based on the first stage of AI, which uses stories from people’s personal experience to draw out good practice that can be used for future planning.

Vale of York CCG was re-tendering its mental health contract and all four CCGs were keen to find new ways of engaging with service user/partners. The PCU made a decision to connect with service users who do not usually have a voice by adopting an inclusive approach which purposefully started from their perspective. The view from many service users is that they are often asked to consider an answer rather than being asked an open question about what matters to them. Staff similarly had developed ways of working which started from organisational perspectives. We wanted to create new ways of relating and to develop thinking about co-design and shared-ownership of commissioning services. Our aspiration is a sustainable environment for engagement based on appreciative and collaborative relationships, rather than asking specific questions about individual consultations. This initiative is lead by the PCU’s Director and senior managers with support from senior staff in the CCGs.

An outcome involved the Vale of York CCG’s re-tendering of its mental health contract; this provided a great opportunity to build comments/feedback from service users into the specification.

The key elements of the DISCOVER! process are:

• A launch event and development day to introduce DISCOVER! to anyone who has an interest in the commissioning of mental health services including service users/carers. The aim is to make clear ‘the offer and the ask’ of DISCOVER! and to generate energy/commitment across a shared group of stakeholders. The ‘offer’ is an AI training day to develop understanding of the tool, whilst the ‘ask’ is for participants to use the AI approach to host conversations about the DISCOVER! question in their own sphere of influence  –  e.g. GP surgery, family home, community group, local shops.
• DISCOVER! Conversations  – participants from the launch took the process into their communities/organisations and asked the DISCOVER! question to everyone they met; sometimes through AI events. The intelligence from the question was fed back to the PCU.
• World Cafe Conversations[2] – these PCU-facilitated events were held in a range of settings and focused on different aspects of mental health commissioning, e.g. adult mental health, dementia, learning disabilities, children’s and adolescent mental health services. The World Cafe conversations attempted to create an informal cafe environment, rather than a formal meeting and encouraged the kind of conversation where friends might gather to have coffee to talk about whatever mattered to them about mental health. The intelligence from the cafes was fed into the knowledge capture process.
• Knowledge Capture  –  a range of vehicles were utilised for feeding back and distilling peoples’ experience of mental health services, including the @PCUDiscover Twitter account and a dedicated email address. A particular innovation which exemplified the participatory and purposeful nature of programme was the DISCOVER! postcard designed by Laurie, a mental health service user, as his response to the AI ‘ask’. Laurie’s contribution was to design a communication tool which would allow anyone to write their response to the DISCOVER! question to be included in the feedback.
• Open Space and Feedback – the information was analysed, gathered into themes and then fed back to all stakeholders at an Open Space event[3]. The aim was to refine themes/principles which would be used to underpin the commissioning of services. This allows for an iterative on-going process of engagement.

Impact on commissioning of mental health services – in the Vale of York CCG the DISCOVER! themes/principles had a direct relationship to the development of new service specifications for the re-procurement of the main mental health contract. In the three North Yorkshire CCGs this will be used to inform ongoing conversations with providers about the kind of services required. A repeated theme was the role of service users/families in decision-making, which has led to a request from the CCG/PCU for HealthWatch to recruit two service users to be part of the interview/decision-making panel for the mental health provider for the Vale of York. Similarly, a powerful message from service users was that mental health services are the smallest part of what works well about living with mental health, and that families/communities/community-based organisations are the most important enablers of living well with mental illness. There is now a clear steer in the commissioning specification about how providers will work with families/community-based organisations to support people with mental illness.

A significant impact of DISCOVER! was the development of the thinking and practice of staff about how to work with service users/communities. The process consciously set out to challenge assumptions about engagement as a consultation tick-box exercise in which staff have no views and simply listen to service users without disclosing the givens and realities of the issue being discussed (and then often ignore what is said!). Instead, DISCOVER! encouraged staff to share their views about what was important in a more collaborative dialogue with service users. This enabled the dilemmas of how to provide high quality services against the backdrop of financial constraints to become a shared challenge for dialogue between commissioners/providers/service users. This approach contrasts with many NHS consultations in which the challenges or knowledge about what is possible are not openly discussed. DISCOVER! encouraged and set the conditions for an open conversation about these issues and enabled a genuinely collaborative approach to emerge based on mutual interests and a shared vision for what ‘good’ might realistically look like.

This was underpinned by a development process to embed a more collaborative, sense making mindset amongst staff, which will continue beyond the current dialogue about mental health services, and has been incorporated into our ongoing engagement strategy. The AI training and review of experience was particularly useful in supporting behaviour change. Staff were encouraged to base their relationships with service users on the principle of asking questions which seek to understand what is important from the perspective of the other and to keep reviewing their learning. This approach marks a significant culture change for NHS staff and builds on the current post-Francis policy directives (reinforced in Simon Stephens’ 5 year Plan for the NHS Chapter 2) to develop a new kind of relationship with service users/communities which puts their needs, rather than organisational needs, at the heart of decision-making.

•  – Shared ownership between commissioners/stakeholders of the principles for future commissioning of mental health in North Yorkshire.
•  – An appreciative and inclusive engagement approach starting from the perspective/needs of service users.
•  – Recognition of the need to enable staff to develop new ways of working and thinking rather than assuming building a new kind of relationship is easy.
•  – Dedicated capacity to lead the programme.
•  – Feedback given to everyone who attended the events and we were clear about what we would do with the data gathered e.g. procurement process for Vale of York CCG.
•  – Learning about what works well explicitly shaped commissioning decisions
•  – Opportunity for intelligence to form part of JNSA in City of York Council.
•  – Service users have been part of the delivery team (co-production model), providers/commissioners/service users have all learnt from each other.
•  – Participants were equipped with AI skills to facilitate conversations within their local

DISCOVER! is an evolving process. We have learnt from the highlights and challenges we have encountered:

• The flexibility of the process and clarity of our critical question enables people to join the process at different stages, in ways that suit them. Its design is inclusive.
• The focus on mental health services was appreciated by everyone involved and asking our critical question from an AI perspective generated positive and genuine conversations/debates across and between local communities.
• Initially we struggled to reach beyond organisational agendas as AI proved to be a challenge in terms of organisational cultures. However, DISCOVER! focuses on the positive experiences of a diverse range of service users. Therefore it is a valuable mechanism in creating a vision for mental health services.
• Being part of the DISCOVER! process can be personally challenging for service users/their families/carers. This can raise immediate and live issues that need to be addressed.
• The DISCOVER! postcard was a fantastic symbol of what we wanted to achieve.
• We have been asked to share this model across the other NHS/local government organisations. The approach has been included in the National Systems Leadership Forum’s forthcoming Total Place 2 guide on how to lead system change. This will enable our experience to be disseminated across communities, and NHS and local government partnerships in the UK.

[1] The Appreciative Inquiry Handbook, 2008 by David Cooperrider, Diana Whitney, Jaqueline Stavros

[2] The World cafe � drawn from the world caf� tool kit – Juanita Brown

[3] Open Space Technology � Harrison Owen