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Locked Hexagon Model Implementation Toolkit HS Consultancy, 2012

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1 Locked Hexagon Model Implementation Toolkit HS Consultancy,

2 Contents About this toolkit: This is designed to be used on a computer with an internet connection. This documents should be launched as a PowerPoint presentation. Click ‘View’ on your toolbar at the top of your screen and find the ‘slide show’ button (or just press your F5 button). Press esc at the top left of your keypad and end the presentation at any time. PART I – Introduction to the Locked Hexagon model PART II - Implementation Toolkit PART III – Glossary, references and further reading © HS Consultancy

3 INTRODUCTION TO THE LOCKED HEXAGON MODEL This model has its origins in a project to reduce the proportion of African Caribbean people admitted to psychiatric hospitals. It recognises that despite the socioeconomic antecedents to over-representation, mental health services have some responsibility, and the ability to change outcome S PART 1 © HS Consultancy

4 What is the Locked Hexagon Model? See larger image on next slide  A model for identifying a baseline level of performance and implementing coordinated action that directly achieves demonstrable improvement in outcomes for people of Black and minority ethnic backgrounds in secondary mental health care.  Evolved from a Focused Implementation Site as part of the Delivering Race Equality in Mental Healthcare programme  Predicated on the idea that there are six key components required to create the conditions for demonstrable outcomes to be achieved.  The hexagon is locked because the model works only if all key components are present. There is a disproportionately negative impact if even just one component is missing.  Is best implemented in one small service delivery system i.e. a discrete system, e.g. with a single community mental health team at the hub.  Aim is to achieve proof of concept, e.g. to create a causal link between action and reduced admissions. © HS Consultancy

5 Targets for % improvement in key areas (e.g. admissions) Carer and Community Engagement Staff and Managers Knowledge and Skill Development Promotion of employment, training, volunteering, education Use of Narrative Approaches Service Users as experts in shaping services Locked Hexagon Model: Essential unified components required to achieve improved outcomes for BME Groups © HS Consultancy

6 Explanations of the key components  Targets for improvement in key areas: These are defined locally in the service, team or sector implementing the Locked Hexagon Model. The approach is the start with the end in mind then ask “what do we need to be doing differently in order to achieve this?”  Service users as experts in shaping services: Not traditional service user involvement but imagining a (soon to be realised) world where service users are real customers who chose whether or not to buy services.  Use of Narrative Approaches 1 : Along with explanatory models this draws professionals into a focus on the story behind the presentation, the person and not the symptoms. It is a redefining of a deficit model into a greater emphasis on the capacities of people. Adverse life events are not seen as triggers for illness but as having, to some extent, a causal relationship.  Promotion of employment, training, volunteering, education: The active support for BME service users to pursue structured activity is important as the case has been made that this is a critical factor in developing and maintaining good mental health.  Staff and Managers Knowledge and Skill Development: The focus is not just on training but any mechanism that enables staff to enhance their knowledge and skills to work creatively and in focused way with groups for whom variations in outcomes persist.  Carer and Community Engagement: This is engaging carers in joint problem solving about how to enhance the care and treatment provided and learning from communities why some groups remain hidden or delay using services until a major crisis occurs. © HS Consultancy

7 Rationale and Evidence  Research evidence shows that services are less effective at keeping BME people out of hospital than they are white people, once they are known to service. Discrimination in wider society and services, disadvantage and cultural factors will have a pernicious effect on BME people before they enter mental health services. However, services become culpable in being less effective in their interventions with BME people 2.  McKinsey 7S model 3 answered the question ‘why does change fail’ by identifying seven of an organisation that ALL need to be attended to. The Locked Hexagon Model adopts a similar approach  Change management theory suggests change should be piloted 4  Evidence of effective services does not necessarily equate to effectiveness of a system design – assertive outreach has a strong international evidence base for effectiveness in reducing beds but this was not demonstrated consistently in the English configuration of services under the National Service Framework for Mental Health 5  The LHM is consistent with Government policies such as No Health Without Mental Health 6, Joint Strategic Needs Assessments (JSNAs) 7, led by Health and Wellbeing Boards, commissioning for outcomes 8, which call for services to be shaped by evidence of inequalities, analysis and population input. Additionally, the Equality Delivery System (EDS) 9 calls for work to reduce inequality in the NHS.  The Five Year Review of the Delivering Race Equality in Healthcare programme 10 highlighted positive initiatives, with some success. There was little evidence of all the positive initiatives occurring in the same place at the same time.  The Centre for Social Justice recommended that the Locked Hexagon Model be rolled out nationally 11 © HS Consultancy

8 IMPLEMENTATION TOOLKIT PART II © HS Consultancy

9 Implementation stages Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy

10  A clear decision to give particular attention to improving specified outcomes in one or more clearly identified BME groups in a discrete geographical locality within an organisation will require a mandate to proceed to a scoping project. This mandate should identify and release resources (which may be across directorates or services) such as staff time to help with scoping and small financial investments, for example in running a stakeholder session. A framework for a report to be submitted to a senior management team requesting a mandate to proceed to evaluate various inequalities and scope a focused implementation project can be found here: Decision to Scope ReportDecision to Scope Report  A scoping project needs to be informed by good intelligence and should be led by a suitably qualified person (employee, secondee or consultant). A specification of the knowledge and skills required for the manager of the scoping project is found here: Scoping Project – Manager’s SpecificationScoping Project – Manager’s Specification  A decision to scope presupposes that following a robust scoping exercise the senior management team will be prepared to take a decision to embark on an implementation project based on the Locked Hexagon Model (LHM). Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy

11  Once a decision has been made to scope the potential improvement work, a scoping project group needs to be formed. Most organisations will be familiar with implementing projects, using a clear methodology. This scoping project will require a senior manager sponsor, a project lead, a project group and the engagement of support functions such as the information team. A guide to the composition of a LHM scoping project group is found here Project Group and Resource TeamsProject Group and Resource Teams DATA  Information and data to be considered in the scoping project includes:  Admissions (last 2 years annual figures) – by ethnicity, by section, post code cluster  Average length of stay & median length of stay by ethnicity  Admissions by the criminal justice system and under s4 by ethnicity  Analysis of the individuals who in the top quartile for having three or more admissions per year  BME as a % of the whole number who in employment or who are volunteering, in education or training Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy

12 INFORMATION In addition to the data the following information needs to be gleaned and analysed:-  Views of people from BME service user and community groups about their priorities for action  Staff perspectives on barriers and priorities  Up to date research findings about ethnic disparities, methods for achieving improvements in clinical practice  Feedback from frontline managers about patterns of need by service users from BME backgrounds and skill and knowledge deficit by staff A framework for presenting potential data and information can be found here: Data and Information ReportData and Information Report Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy

13  The decision to move from scoping to implementation needs to be made by the senior management team. In doing so services will be mandated to use resources that may be outside of their line management control. Here is an Outline ReportOutline Report  The LHM provides a framework for increasing the likelihood that effort is translated into improved outcomes. Some key principles need to be explicit:-  Implementing a LHM project is designed to initially test the proof of concept.  This may be in ‘lab conditions’, i.e. the investment of time, start up funds (small amounts) and availability of expertise may not be that which is sustainable but will prove that intractable problems can be overcome. This may have particular relevance for projects attempting to reduce higher than average rates of detention for people of African Caribbean backgrounds.  LHM is aimed at a defined geographical area, service or delivery system rather than across a large organisation. This should be identified clearly and will potentially require an invitation for a number of potential sites to express an interest in implementing the LHM and a decision made based on the usual operational considerations such as capacity and the cohesion of the team.  One or two BME groups may be targeted for some specific focus on improved outcomes. Keep it narrow to strengthen the ability to demonstrate cause and effect between actions taken and improved outcomes.  There will be costs associated with delivery but will need to be invested in the real expectation of cash releasing improvements.  Evaluation arrangements need to be in place from the start of the project. A budget for this should be approved. Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy

14 Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy  Project Management methodology needs to be applied  There should be a workstream for each of the six components of the LHM. These do not need to be major formalised working groups but rather a clear accountability back to a single person who is overseeing the programme. An individual may have responsibility for more than one component (e.g. For service users as experts shaping services and also for carer and community engagement). A Community Mental Health Team (CMHT) manager may be the lead on setting and monitoring local targets, as part of their routine management role. The main point is that accountabilities much be clear., leading back to an overall project manager with a senior sponsor.  From the outset, arrangements should be in place to evaluate the process and impact of any change. This should be a rigorous exercise so that learning from success and failures can be understood.  The programme structure and accountabilities can be found here. Locked Hexagon Model programme structure.

15 Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy Target setting  Metrics may be national but targets must be local. The lead for the target setting is likely to be a community based team manager, who will work with team members and partners to create a common mission to achieve an improvement that has been hitherto illusive.  The targets must be reflective of the views of front line staff about priorities and will be shaped by the inputs of service users, carers and stakeholders.  They must be generated by the team, service or system implementing the LHM  Avoid arbitrary target setting, such as a reduction in admissions by X% without first testing a hypothetical target then undertake simple modelling to establish what it means in practice. For targets involving small (

16 Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy Service users as experts shaping services  The lead for this work is likely to be the organisation’s service user engagement/ participation lead. This person will however work with a lead from within the team or service implementing the LHM.  The aim is to secure detailed and widespread feedback from BME service users about the experience of the treatment and care that they receive.  The LHM project should consider gathering local feedback, analysed by ethnicity, using mechanisms in each of the three groups below: Group A: Data and information collected corporately, reported only at the organisation-wide level  Complaints reports  PALs reports  Service user survey reports  Feedback from organisation-wide consultations Group B: Data and information collected corporately, reported at the level of the LHM project  These may include the reports above Group C: Data and information collected locally about practice of front line staff within the project scope  Brief feedback tools, for example, six point rating scale of the effectiveness of practice. These could be postcards or a simple web based questionnaire. This will need to be costed. See an example here. Six Point Questionnaire.Six Point Questionnaire.  Feedback from a local BME service user group. You may need to set this up  Engagement of BME service users in the project group

17 Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy Use of Narrative Approaches and Explanatory Models  The lead for this work is likely to be someone in the service or team within the scope of the LHM project who has knowledge and expertise in this area. If there is no local person who is equipped to lead, check with a senior operational manager or clinician if they are aware of someone who may guide a member of the team to lead.  As this is likely to signify practice change it will be important that whoever is leading develops the approach with the team manager.  Ensure that the needs of staff in relation to knowledge and development are included in the staff development workstream of the locked hexagon.  Make provision in practice or clinical discussions in the team for staff to share their experience of using narrative approaches and explanatory models.  Brief all practice supervisors within the scope of the project to incorporate narrative approaches and explanatory models within their work. 4. Promotion of employment, training, volunteering, education  Indentify local organisations that work within mental health service users to promote employment, training, volunteering, education and form a working partnership with them to improve performance.  Ensure that there is a mechanism, either through monitoring or audits to establish a baseline and track the rate of progress in improving performance in relation to BME service users.  Arrange a showcase event where BME service users can give their testimonies about the benefit they derived from employment, training, volunteering or education.

18 Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy Staff and Managers Knowledge and Skill Development  Identify a service-based Lead to partner the Learning and Development team  Based on the proposed changes (or enhancements to practice) carry out a knowledge and skills audit of the manager and any deputies. Establish:-  Confidence in arguing the rationale for prioritising attention on the groups that are the focus of the LHM project  Ability to detect weaknesses or gaps in practice in the team, in relation to working effectively with BME groups  Whether a manager network exists or needs to be set up to act as a learning set to share problem solving around working with ethnicity, race and culture in a safe context.  Based on the proposed changes (or enhancements to practice) carry out a knowledge and skills audit of the team. Establish:-  Knowledge of the factors that drive ethnic inequalities as detected in mental health and other metrics, including socioeconomic measures, education and the criminal justice system  Potential ambivalence about prioritising the groups being given focus  Knowledge of community and other resources locally that could enhance the delivery of the LHM project objectives Consider gaps in knowledge around narrative approaches and explanatory models. Work with the Learning and Development team to develop mechanisms for closing knowledge and skills gaps. Select the interventions from the list here. Interventions for closing knowledge and skills gaps.Interventions for closing knowledge and skills gaps

19 Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy Carer and Community Engagement  The lead for this workstream is most likely to be the same as the service user engagement lead but not necessarily the case.  The engagement of BME carers is to help clarify how their role may be maximised for the benefit of the service user. As such, the focus is not about a carer assessment and provision for the carer.  Such an approach will only work if there are appropriate resources and responses for carers that free the lead to refer issues of personal need to the relevant carers support service.  As with community engagement, Appreciative Inquiry methodology is well suited to shift dialogue away from discussions about deficits in the relationship with services or service users, to a hopeful focus on a more positive future. Appreciative Inquiry can be found here. Appreciative Inquiry Information sheetAppreciative Inquiry Information sheet  Establish a BME carers group to support the LHM project. Community Groups  Identify the BME community groups in the local area, making use of community development workers of similar roles (including those working towards similar aims in other local organisations)  Establish a regular feedback loop by holding regularly (monthly) meetings.  Regularly survey community groups to identify potential learning for the LHM project. Develop a simple survey, making use of online resources where possible (e.g. Survey monkey)

20  A clear specification for an evaluation partner must be drawn up. The LHM project lead may need to rely on expertise by an academic within the organisation.  An individual or team (whether internal or commissioned on contract against the specification) must have met with the LHM project team at inception and explored the information and data to be collected.  An evaluation may capture information on:-  Measures of effort (e.g. how much time is spent, whether agreed processes are followed). These are also known as inputs.  Output measures (e.g. Measures of the impact of effort. This may include an increase in the number of BME people in employment or training)  Outcome measures (these are challenging to collect over a large number of people and will relate to the extent to which people are ‘better’ – largely defined by themselves)  The progress from input to output to outcomes shows a gradual increase in the evidence that the actions being taken have an impact in the mental health of BME service users. This reflects a progression of time. The progression assumes some reliability to the expectation that certain inputs will deliver the outcomes being pursued, e.g. That the use of narrative models will improve engagement and thereby improve recovery. Decision to scope Analysis of data and information Decision to embark Project management Implementation of six components Reviews of inputs, outputs and outcomes © HS Consultancy Inputs outputs outcomes

21 GLOSSARY, REFERENCES AND FURTHER READING PART III © HS Consultancy

22 © HS Consultancy Glossary BME: Black and minority ethnic groups LHM: Locked Hexagon Model s4: Section 4 of the Mental Health Act 1983 (Revised 2007). S4 allows for an emergency admission bypassing the usual requirements of recommendations by two doctors. References 1-Epston D &White M, (1992) Experience, contradiction, narrative & imagination : selected papers of David Epston and Michael White, Adelide: Dulwich Centre Publications 2- Singh, S., Greenwood, N., White, S. Churchill, R. (2007) ‘Ethnicity and the Mental Health Act 1983.’ British Journal of Psychiatry 191, Waterman, R.H; Peters T.J, and Phillips,J.R. (1980) "Structure is not organisation", McKinsey Quarterly in-house journal, McKinsey & Co., New York, 4 – Newton, R (2007) Managing Change Step by Step: All you need to buold a plan and make it happen. Oxford: Peason 5 - Killaspy, H., Bebbington, P., Blizard, R.,Johnson, S. et al (2006) ‘The REACT study: randomised evaluation of assertive community treatment in north London.’ British Medical Journal 332, Crown (2011) No Health Without Mental Health: a cross-Government mental health outcomes strategy for people of all ages. London: Crown 7 - Local Government Improvement and Development (2011) Joint Strategic Needs Assessment: A Springboard for action. London: LGID 8 – See the NHS Commissioning Board 9 - Crown (2011a) The Equality Delivery System for the NHS (Amended January 2012). London: DH Delivering Race Equality in Mental Health Care: Five year review (2010)

23 Developed by: Hári Sewell HS Consultancy 2012 Contact


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