Transforming TogetherWritten by Lisa Williams and Laurie Oliva

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Contents

Summary

What is Transforming Together?

Introduction to Systems Thinking and Participation

Transforming Together Principles

Transforming Together Steps

Acknowledgements

References

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Lisa Williams specialises in transformation and service improvement for children’s emotional and mental health systems. She has over 25 years of experience working from grass roots up in mental and public health, education and children’s services. As a Community Fellow at the University of Brighton, Lisa has collaborated with academics and practitioners for nearly 20 years to strengthen the links between research and practice in the fi eld of children’s resilience.

Lisa was regional lead for teenage pregnancy and vulnerable groups at DfE in the nineties, before returning to Local Authority as a joint children’s commissioner, leading on mental health, and then Assistant Director at East Sussex County Council. Lisa went on to lead the Department of Health’s National Support Team for children and young people’s mental health before joining YoungMinds as Head of Commissioning Support in 2014.

Laurie Oliva is Head of Participation and Consultancy at YoungMinds. She provides strategic leadership to the participation element of our extensive range of programmes, projects and policy infl uencing work at national, regional and local levels. This has included leading the engagement of children and families in the development of Future in Mind and reviewing the participation of children and families in inpatient CAMHS. Laurie and the participation team work with hundreds of young people and parents every year using a wide variety of engagement approaches including arts, social media and participatory research methodology.

They also work with commissioners and providers across the country to support service improvement and systems transformation. Laurie specialises in work with marginalised communities and applies her experience from across the social sector including in social housing, the justice system and working with LGBT+ groups to bring a social focus to mental health.

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What is Transforming Together?

Transforming Together is a process led by YoungMinds, designed to deliver change in children and young people’s mental health settings and local systems. It combines systems thinking and participation to put the experience of children, young people and families at the centre of transformation.

All systems are made up of inter-connected parts. Systems thinking builds an understanding of how

these parts interrelate.

People who will be impacted by change are involved in generating an understanding of the system and the design and implementation of

interventions.

Systems Thinking Participation

The Transforming Together process is designed to embed these three principles into the children’s mental health system because we believe they are essential if we are to change the culture of the system.

Transforming Together: Principles

Ensuring the system is designed to meet the needs of the most vulnerable

children and young people, can help improve it for everyone.

Improving outcomes for children and young people, helping them to manage

and bounce back from challenging times.

Understanding how all the resources and settings within the local system can work together to support young

people’s mental health.

Transforming Together: Steps

The Transforming Together process involves three steps. These steps combine quick cycles of innovation with a longer term change process and ensures all stakeholders are engaged throughout.

Principle 1 Principle 2 Principle 3

Vulnerable Groups Building resilience Think whole-systems

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• Embed co-ownership of change and vision for future across all stakeholders

• Build accountability to children, young people and families into the change process

• Analysis of step one insights• Co-production of system goals• Co-production of design criteria

to defi ne how goals should be met

A robust framework for change including:

• Clarity of the role of different parts of the system in achieving change• Alignment between purpose of different groups and individuals within

the system• Increased infl uence of children, young people and families within the

system

• Deliver change through: - Introducing evidence-based

interventions - Iterative cycles of action:

development, testing, evaluation and delivery

• Embed systemised communication and engagement across the system

• Cycles of development, delivery, testing and evaluation

• Peer evaluation• Repetition of the Step 1 insights

and engagement process• Communication processes

• Increased trust between different groups and individuals in the system• Improved:

- Experience and outcomes for children, young people and families - Service quality

• Transformed culture across the system

Purpose: What is involved? What is produced?

Transformation goals

Design Criteria

Indicators for measuring change

What are the outcomes?

Purpose: What is involved? What is produced?

What are the outcomes?

Purpose: What is involved?

• Creation of core group of stakeholders to lead change including CYP

• Involvement of all stakeholders in participatory activities to understand current system

• Analysis of system data

• Develop a picture of how the system works now - and why it works that way

• Identify change leaders• Identify what needs to change

and the assets that can support change

• Commitment to the change process amongst all stakeholders• Increased understanding between different stakeholders• Increased workforce understanding of experiences and needs of

children, young people and families

What is produced?

What are the outcomes? Core group to drive change

Step 1: Engagement and Insights

Step 2: Design

Step 3: Delivery

Business case for change

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Map of assets and partners to support change

Co-design of new interventions

Changes to practice

Evidence of impact of change process

What is Transforming Together?Transforming Together is a change process for service improvement and local transformation in children and young people’s mental health.

It combines systems thinking and participation to put the experiences of children, young people and families at the centre of transformation, producing change that is collaborative, person-centred, and sustainable and which makes use of evidence-based interventions.

This document is relevant to commissioners, school leaders, public health teams, mental health services and other organisations within the children and young people’s mental health system who want to design services and local systems around the experiences of children, young people and families.

How and why has Transforming Together been developed?

The development of Transforming Together has been led by YoungMinds, a national charity that champions the wellbeing and mental health of children and young people.

In 2015, the publication of Future in Mind (Department of Health, 2015)i set out a national vision for transformation across the children and young people’s mental health system. The changes it called for were ambitious, and refl ect the change that the families, commissioners and services that YoungMinds works with have long been calling for. YoungMinds supported over 1,000 children, young people and parents to contribute to its development (YoungMinds, 2014)ii. YoungMinds also worked specifi cally with the task group looking at the needs of the most vulnerable children and young people.

Following the publication of Future in Mind, YoungMinds has been commissioned to work with a range of commissioners and services across the country to support the implementation of their local visions for transformation. Each piece of work occurs in a different context with varying ambitions for change. What has emerged over time is that the processes needed to ensure change was truly transformative, sustainable and centred on the experience of children, young people and families have been consistent. These key processes build upon the approaches that have always been at the heart of YoungMinds work with services and local systems: participation and systems thinking.

Transforming Together draws together these approaches into a comprehensive change process which has been supported by the bold thinking commissioners who have worked with us over the last two years, as well as other experts in systems thinking.

Transforming Together is designed to deliver change within any children and young people’s mental health setting or local system. In this document we set out the case for taking this approach to change and introduce the steps for doing so. Whatever the ambition sought for children, young people and family, and whatever the intervention chosen to deliver that change, it has to be owned by everyone and centred on the experiences of children, young people and families if it is going to be truly sustainable and transformative. This can be achieved through Transforming Together.

In 2015, the publication of Future in Mind set out a national vision for transformation across the children and young people’s mental health system

Transforming Together is designed to deliver change within any children and young people’s mental health setting or local system

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Terminology

In this document, the children and young people’s mental health system is defi ned as meaning all the settings (organisations) and resources which can contribute to promoting, restoring and maintaining emotional and mental health.

The whole local system is referring to all of the organisational settings and individuals in the system and the dynamic relationships between them. Each single setting such as a mental health service or school is also a system in itself made up of individuals, teams and departments which all relate to each other.

Introduction to systems-thinking and participation and their role in Transforming Together

Systems thinking

Systems thinking is based on the idea that all systems are made up of inter-connected parts – and it’s the way that those parts link together that determines how the system behaves. So, taking a systems thinking approach means building an understanding of a system based on how the different parts of that system interrelate (Senge, 1990)iii.

This approach leads to change that is ‘adaptive’ rather than simply ‘technical’. Instead of moving parts of a system around, or solving individual problems one at a time, systems thinking leads to a deeper cultural shift based on building a community of shared purpose and values through challenging the behaviours in a system and the beliefs they are based on. This drives change that is collaboratively owned and sustainable (Heifetz, 2009)iv.

Taking a systems thinking approach means building an understanding of a system based on how the different parts of that system interrelate

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Participation

Participation means that the people who will be impacted by change are involved in it. In children and young people’s mental health, this means involving children, young people and families, as well as the professionals working in any of the settings impacted by the change. Participation in change means these groups are involved in every project phase including:

The typical power dynamics that exist in many systems can make bringing these groups together complex. For example the relationships between settings in the system and between professionals and the children, young people and families that use their services are often laden with values and assumptions formed from past experiences. In addition, change itself provokes uncertainty. It can feel risky and it is not unusual for stakeholders to be concerned about whether their voice is being genuinely heard. However, it is exactly this different experience and expertise that leads to fi nding the most effi cient and sustainable solutions. What’s more, some research has found that participation can contribute to improved trust between decision-makers and patients, therefore transforming the power relations (EMA, 2011)viii.

Why systems thinking and participation crucial to improvement and transformation

Systems thinking and participation are closely related and we have found both to be critical in the change process. Systems thinking can ensure participation has clear purpose and focus and that it isn’t approached as something that happens alongside the change process, but is understood as a tool for change itself.

The relationships between different parts of the system is usually a big part of the challenge

It is not unusual for stakeholders to be concerned about whether their voice is being genuinely heard

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Diagram adapted from New Trends in Management, Change Management pagevi

To effectively understand a system’s behaviour, we have to go beyond evaluating the success of specifi c interventions. Rather than just asking “was that intervention effective?” we must also ask “was that the right intervention in the fi rst place?” Challenging the assumptions that underpin the interventions we choose, sense-checking them against the overarching goals of the system, is what leads to real, transformational change. This ‘double-loop learning’, shown in the diagram below, is an integral part of systems thinking (Argyris and Schon, 1996)v.

Rather than just asking “was that intervention effective?” we must also ask “was that the right intervention in the first place?”

Systems thinking is especially “useful for tackling issues that are embedded in complexity, particularly where that includes human activity”vii (Chapman, 2004, p35) and where “there is rarely agreement about where the problem actually lies or where improvements can best be made, and they are subject to high levels of uncertainty” (Chapman, p36). The problems in the children and young people’s mental health system almost invariably fall into this category and cannot be solved by an approach which tries to deal with parts of the system in isolation. The relationships between different parts of the system is usually a big part of the challenge. It is these kind of messy systems and messy problems that systems-thinking is most useful in addressing.

For those leading systems improvement and transformation, a systems thinking approach includes:

• Focussing on how the elements of the system relate to one another, rather than trying to improve elements of the system independently.

• Integrating improvement as an on-going part of delivery through sustained collaboration between partners and continual review and adaptation of change.

• Active participation of all stakeholders in sustained change so the whole system is co-creating the future.

Many local areas tell us that while they have great ambitions for transforming their systems or organisations, they find it really hard to deliver these

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Systems thinking and participation matter in children and young people’s mental health because of the complexity of many of the challenges faced in the system. If we think of common types of query that commissioners present YoungMinds with – things like inappropriate referrals, long waiting times or the need for improved access for specifi c vulnerable groups – we can see that none of these problems can be solved by changes in one setting alone. They will involve the effective collaboration of multiple settings, and the children, young people and families who engage with those settings.

Like any busy system with multiple drivers, high levels of need and a wide diversity of expertise, children and young people’s mental health systems are messy. And fragmented relationships within local systems, often caused by unaligned purposes and different cultures within different types of setting (for example, between schools and mental health services) are the norm in many areas. Systems thinking is an approach that accepts that messiness. An approach to change that works with the reality of local systems is vital, which is why systems thinking, aligned with participation, is crucial in the transformation of children and young people’s mental health.

Change in the children and young people’s mental health system

Anyone working in the children and young people’s mental health system is likely to have experienced the feeling that change is a continual state in this system. Whether prompted by external factors like changes in policy or by our own improvement processes, change is part of the culture of this system. It is unrealistic then to think about change as a series of distinct problems that can each be solved to eventually create the perfect system. Improving a service, or transforming a system, are processes that never really end, even if frameworks are put around periods of that change.

The specifi c changes that are needed in a given setting or across a local system will vary. However, there are common goals that systems focussed on children and young people’s mental health will want to achieve. These are likely to include things like:

1. Improved outcomes for children, young people and families.2. Improved services/interventions that better meet the needs of individuals

and provide them with a positive experience.3. Improved use of resources and cost effectiveness.

Locally owned change and partnerships

Future in Mind set out a new forward-looking vision for children and young people’s mental health to be delivered through fi ve priority areas:

1. Promoting resilience, prevention and early intervention.2. Improving access to effective support – a system without tiers.3. Care for the most vulnerable.4. Accountability and transparency.5. Developing the workforce.

Research has found that participation can contribute to improved trust between decision-makers and patients

An approach to change that works with the reality of local systems is vital

The Government also set out the requirement for implementing the changes called for in Future in Mind accountably and transparently within local systems. CCGs are required to work with local partners – including schools, Health and Wellbeing Boards, mental health services and the voluntary and community sector – to create shared Local Transformation Plans (LTPs) (NHS England, 2015)ix. LTPs set out how the national vision will be delivered locally, and how resources will be managed to enable this.

Driving at similar change, Sustainability and Transformation Partnerships have also been introduced. Set across 44 areas (so incorporating multiple CCGs in each) these partnerships are tasked with creating Sustainability and Transformation Plans (STPs) (NHS England, 2017)x which set out proposals to improve health and care. These, of course, will need to incorporate the priorities and plans set out in LTPs. As with LTPs, communities and a whole range of system partners are required to be involved in the development of STPs.

The requirement in both LTPs and STPs for change to be delivered collaboratively is a useful foundation for change. This whole-system involvement generates the chance to look at the relationships between settings, and not just the process and functions of individual settings themselves. Transforming Together builds on this policy requirement for collaborative approaches by enabling those involved in the change process to collectively defi ne their own localised purpose for change. This is important for ensuring that change develops a locally owned momentum which drives towards a shared local purpose and therefore strengthens and sustains the partnerships required by policy.

Many of the local areas YoungMinds has worked with tell us that while they have great ambitions for transforming their systems or organisations, they fi nd it really hard to deliver these in reality. They also tell us that often it can be hard to bring the different partners on board, especially where cynicism and scepticism may have set in about ‘another round of change’. This isn’t surprising or wrong. Change is diffi cult, especially in such complex contexts. Transforming Together is about addressing this complexity and through it creating a shared commitment and vision for change across all those whose involvement is essential for transformation to happen.

Transforming Together: Principles Earlier, we mentioned some of the goals that all organisations and local systems within children and young people’s mental health are likely to want to achieve. These were:

• Improved outcomes for children, young people and families.• Improved services/interventions, and• Improved use of resources.

The three Transforming Together principles set out in this section will support systems to move towards these goals as part of an effective change process.

Principle 1: Meeting the needs of children, young people and families who experience extra vulnerability

By ‘children, young people and families who experience extra vulnerability’ we mean those individuals who are:

• More vulnerable to experiencing mental illness.• More vulnerable to experiencing poor access to interventions and support

with their mental health, as well as poor experiences when they do access these.

This vulnerability is caused by a range of social and interpersonal factors, including experiences of childhood trauma, poverty, displacement, social exclusion. This includes those who face systemic discrimination and marginalisation within society and social institutions. As such, groups of children and young people we might speak about as experiencing extra vulnerability include:

• Children with experience of the care and justice system.• Victims of child sexual exploitation.• Children with special educational needs.• Children with neuro-diverse conditions like autism or attention defi cit

disorder.• Children with refugee or asylum seeker status. (Bush, 2016)xi.

While these individuals will have different day-to-day experiences based on their own circumstances, there are many commonalities in how they interact with children and young people’s mental health systems. Individuals within these groups all have potential to:

• Be users of multiple services.• Require levels of intervention that are more specialist and therefore costly.• Find mainstream services do not meet their needs, for example because

they may communicate in different ways to their peers or may feel safe and supported in different environments to their peers. (Department of Health, 2015)xii .

All of these commonalities have both access implications for the individuals and resource implications for the systems.

Vulnerability is caused by a range of social and interpersonal factors, including experiences of childhood trauma, poverty, displacement, social exclusion

Improvements within these areas result in services centred around the needs of individuals, leading to better use of resources

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For these children and young people we might therefore specifi cally aim to deliver improved access to support; deliver support in ways that are relevant to the specifi c experiences and needs of these groups; and develop stronger collaboration across the settings they engage with. Improvements within these areas result in services centred around the needs of individuals, leading to better use of resources, improved experience and quality of intervention, and improved outcomes for those individuals. Furthermore, these changes will benefi t all children, young people and families in the system, not just those who experience extra vulnerability.

Principle 2: Building resilience

In Transforming Together, when we talk about building resilience we are describing an asset-based approach that focusses on identifying and strengthening the assets within a system, including community, family and individual assets. This process is undertaken from the perspective of children, young people and families.

In Transforming Together, building resilience includes both improving outcomes for the most vulnerable young people and helping all children to manage and bounce back from challenging times. It is therefore an important part of both specialist support and community mental health prevention and promotion strategies.

Systems organise themselves around shared values that inform and shape the culture or ‘how we do things round here’. The traditional mental health system values identifi cation and treatment of mental disorders and access to specialists. This infl uences the responses and the behaviour of those in the broader system as well as the specialists, the commissioners, and the policy makers. Young people and parents consistently tell us that whilst they value specialist help they equally value help to be resilient because everyone has tough times and, for some, adversity can be both chronic and at times acute. Transforming Together recognises this request, and the link between resilience and better outcomes in every area of life.

Building resilience is a task that can be taken on by anyone in any setting across the system (Hart, 2007)xiii. In a defi cit focused system which is busy identifying and responding to problems it is not always easy to fi nd ‘one thing everyone can do’ whatever their role or position. Building resilience answers this challenge. In fact, it elevates the non-specialist and recognises the contribution everyone can make including children and young people themselves, to strengthening individuals, families, and communities (Zautra, 2010)xiv. It cuts across the different cultures of diverse settings and isn’t ‘owned’ more by one than by any other. Resilience is not only associated with good mental health, it is linked to better outcomes across all areas of life. It has the potential to contribute to the outcomes required of just about every setting in the children’s system.

For this reason, developing interventions and outcomes based on building the resilience of children, young people and families can help level traditional hierarchies and power dynamics between different settings and generate a level playing fi eld in which a range of professionals can make an important contribution.

In Transforming Together, building resilience includes both improving outcomes for the most vulnerable young people and helping all children to manage and bounce back from challenging times

Young people and parents consistently tell us that while they value specialist help, they value help to build resilience equally

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Creating this map collaboratively with individuals and groups across a system can help everyone see the role that a range of settings play in meeting the needs of the child in the centre, and the different assets that each bring. For example, some bring specialist knowledge, and others access and virtual understanding. These are all critical contributions to transformation and mapping the system in this way can be a powerful starting place for designing change.

Thinking ‘whole-system’ is about considering all the elements and relationships which constitute the children and young people’s mental health system

Creating this map collaboratively with individuals and groups across a system can help everyone see the role that a range of settings play in meeting the needs of the child in the centre

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Principle 3: Think whole-systems

Thinking ‘whole-system’ is about considering all the elements and relationships which constitute the children and young people’s mental health system. In Transforming Together how the system is visualised is based on ecological systems theory developed by the developmental psychologist, Bronfenbrenner. Bronfenbrenner’s model for child developmentxv (Bronfenbrenner, 1979) places the child at the centre and maps outwards from them the infl uences within the system that impact them.

We use this model as it presents two perspectives on systems that are key to the Transforming Together process: fi rst, that systems need to be organised around the needs and demands of individuals, and second that systems need to be viewed as a whole, with the relationships between different settings as important as each individual setting itself.

This approach also makes visible the relationships that need to be addressed within the change process. This will include relationships between the child and the different elements in the system, and relationships between settings across the system. Plus, the culture of the system, its attitudes and purpose.

How the principles are embedded in Transforming Together

The activities across the three steps in Transforming Together use these three principles as tools to deliver the change process, including through:

• Identifying stakeholders in change.• Developing an understanding of the perspectives of the different

stakeholders.• Promoting an asset-based approach that makes the most effi cient use of

the resources within the system, and• Creating a shared language and purpose across different system elements.

Transforming Together: Steps This section outlines the three steps within the Transforming Together process:

1. Engagement and Insights2. Design3. Delivery

Step 1: Engagement and Insights

The purpose of the Engagement and Insights phase is to build the foundations for change by:

1. Identifying and engaging the individuals and groups who will champion change in the system.

2. Creating a comprehensive picture of how the system currently works from the perspective of all stakeholders.

3. Identifying existing strengths and assets in the system that can be built on to deliver change.

This involves:

1. Participatory engagementStakeholders across the system - including children, young people and families and professionals from different settings and roles, as wells as systems leaders - are engaged in participatory activities to share their perspective on how the system works now and what should change. The activities are co-designed and delivered with peers, and use a range of methods like system mapping, journey mapping and dialogue to enable each group to express their perspectives.

2. Establishing a core steering groupIndividuals are identified from every stakeholder group who are willing to join a core steering group which holds accountability for the whole project. This core group comprises young people, parents and carers, and other stakeholders. A facilitator supports effective dialogue and decision-making within the group to ensure that the varying needs of all groups are met. The core group is provided with relevant training and support to enable them to effectively perform their role.

3. Analysis of system data Data, including data about the local population, waiting times, service experience and more, is brought together and analysed with the insights to generate a comprehensive community profile that illustrates what’s happening in the system and why.

This stage produces:

1. Business case for change.2. Comprehensive map of assets and partners that impact and support children

and young people’s mental health and audit of their contributions and values.3. Community profile, detailing specific groups of children, young people and

families impacted by change and the values, experiences and priorities of these groups.

4. Recommendations about key areas for change.5. Core committed group ready to drive change.

Activities are delivered with children and young people, parents and carers and with different parts of the workforce

The core group is provided with relevant training and support to enable them to effectively perform their role

Outcomes achieved through this stage are:

1. Increased understanding of, and language for, mental health and resilience across all individuals and groups involved in the process.

2. Increased understanding between different partners in the community about one another’s purpose and value.

3. Increased understanding of the experiences of children, young people and families within the workforce.

4. Commitment to the change process within all key stakeholder groups.

Engagement

It is important that the core transformation process is ‘held’ by a consistent group which is representative of all groups impacted by change. This includes young people, parents and carers, as well as professionals, system leaders and commissioners where relevant.

This group holds the lead accountability for transformation and is responsible for ensuring the effective participation of wider groups in the process. It is important to have a facilitator within this group who is able to be neutral. They could be an external facilitator, a local participation worker or similar. Their tasks will be engaging the various individuals and groups, facilitating activities and ensuring an effective flow of information across everyone involved.

The wider groups collectively form a ‘transformation network’ and include the different teams, settings, groups and individuals who have a stake in the change process.

The diagram below sets out these two groups:

Core group

• Consistent membership to build ownership

• Accountability for transformation

• Equal influence and expertise across all members

• Provided with training and support

Transformation Network

• Consistent communication between network and core group

• Effective feedback loops between network and core group

• Easily accessible information about change process

• Range of mechanisms to share experiences and influence change

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Everyone who is implicated in the change process must be represented in this step

Particularly important is the participation of those groups who experience extra vulnerability, because their perspectives are likely to vary from others

Insights

In Transforming Together, key questions about the focus of change are used to build a comprehensive picture of the system, shown from multiple perspectives. These key questions are defined by the core group and then insights about different stakeholder groups’ views on each question are gathered.

Everyone who is implicated in the change process must be represented in this step. It is important to look beyond those who will be immediately impacted and consider who else might have valuable perspectives. Particularly important is the participation of those groups who experience extra vulnerability, because their perspectives are likely to vary from others and, if not included, the system design won’t fulfil their needs.

Gathering insights from across the system serves three purposes:

1. Capacity buildingEngaging with groups on topics such as mental health, service design and commissioning builds knowledge within these groups. In the development of Transforming Together, YoungMinds found that young people who participated in workshops to share their views on mental health and factors impacting it within their local community experienced a positive increase in their understanding of mental health as a result of the workshop.

2. Partnership buildingWhen activities brought different groups together to share their own experiences and perspectives, it led to an increased understanding between those different groups. For example, service providers who participated in a workshop with colleagues from across the local system to share their views on local challenges reported an increase in understanding of the value and purpose of their partners in the system.

3. Establishing accountabilityThe process of gathering insights establishes direct relationships between the groups implicated in change and those leading the change process. It also ensures that the experience of children, young people and families form the foundation of the change process, so that transformation is designed with this as the guiding focus.

Step 2: Design

The purpose of this phase is to:

• Define a clear direction and framework for change which is centred on the experiences of children, young people and families and makes use of assets across the system (as identified in Step 1).

• Sustain and develop engagement across all individuals and groups involved, building ownership of the change process amongst all stakeholder groups.

This involves:

1. Co-produce system goalsGoals are co-produced within the core group to reflect the experiences of children, young people and families as expressed in Step 1. This involves participatory analysis of the insights from Step 1 by the core group and then cycles of review and feedback with the transformation network.

2. Co-production of design criteriaDesign criteria are produced for each goal to define in clear terms how each goal will translate into practice to improve the experience and meet the needs of children, young people and families.

3. Identification of indicatorsIndicators are identified, to align with the goals and set out how progress and impact on children, young people and families, services, and the system as a whole (including economic and cultural impact) will be measured.

This stage produces:

A robust framework for change, including:

1. Transformation goals in the form of outcomes and/or values which reflect the priorities of children, young people and families and build on existing system strengths.

2. Design criteria for the successful implementation of goals, setting out how the priorities of children, young people and families can be delivered in practice.

3. Indicators for measuring change that can be used to ensure delivery and contracting are accountable to children, young people and families.

Outcomes achieved by this stage are:

1. Increased clarity of the role of different parts of the system in achieving change.

2. Increased alignment between purpose of different groups and individuals within the system.

3. Increased influence of children, young people and families within the system.

System Goals

The system goals state the outcomes and changes in values and culture that are sought through the transformation process. Goals should bring together national policy with the local systems insights generated in step one to create a locally owned expression of the national vision.

The goals provide an accessible way for everyone to understand and co-own the system’s aspirations. They can also be used in measuring change if top level indicators are aligned against the goals. This can be an effective way of accessibly communicating information about the progress of change to children, young people and families.

The system goals are developed through analysis of the insights from step one by the core group and identifying where the perspectives of different groups on what the system is like now and should be like in future converge – these points of overlap form spaces in which goals can be developed. Careful attention must be paid to minority perspectives, ensuring these are not lost.

The goals are important as they express what matters to everyone collectively and as the change process moves forward they provide a focal point to continually return back to. They function as a safe-guard against ‘coming off track’.

YoungMinds found that young people who participated in workshops to share their views on mental health experienced a positive increase in their understanding of mental health and resilience

The process of gathering insights establishes direct relationships between the groups implicated in change and those leading the change process

Goals are developed from the insights so they incorporate the experience of the children, young people and families implicated in the change

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Criteria Design

In Transforming Together, a set of design criteria is co-produced for each goal. The criteria express both the priorities of children, young people and families, and the requirements of the system in terms of safety, quality, resourcing, feasibility - and other structural factors.

The development of the design criteria builds accountability into the delivery of transformation by defi ning clear measures that the appropriateness of different interventions can be tested against. The criteria can be weighted to refl ect the extent to which each matters in decision-making. Some criteria are likely to be set as absolute requirements that an intervention has to meet to be considered.

This stage is vital between insights and decision-making about what interventions to test. Without defi ning criteria, different perspectives, often of children, young people and families are often lost in the decision-making process. What’s more, setting the criteria within the core group can help identify any potential confl icts that may arise later on when it comes to deciding how to implement change by making people commit to what’s important at this stage.

There are different ways to generate design criteria with young people. The example below shows user stories generated by children and young people involved in the design of a new transitions policy:

Each goal requires a set of design criteria that express how the goal would look and feel in practice from the perspective of the children, young people and families

The most important aspect of the delivery phase is systemised feedback from children, young people and families implicated by the change

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As a service user I want to be taught coping skills so I can maintain the management of my own mental health:of my own mental health:of my own mental health:

“It should be with my peers so I can develop my social skills”

“I should be able to practice the skills in the session as I learn them”

“I should be supported to practice the skills at home”

As a service user I want to be informed about adult services so I can feel prepared:

“The differences between child and adult services should be introduced so I understand them in advance of change”

“I should be informed of any waiting times for adult services”

As a service user I want to be aware of transition processes from the start so I know what to expect:

“Transitions should be spoken about in a way that feels planned and supported”

“I should be able to ask questions about transitions at any point”

Step 3: Delivery

The purpose of this phase is to:

• Deliver change through: - Identifi cation and implementation of evidence-based interventions to

deliver the transformation goals. - Iterative cycles of action with three phases: development, testing and

evaluation and delivery.• Embed systemised communication and engagement across the system.

This involves:

1. Cycles of development, delivery, testing and evaluationThe most important aspect of the delivery phase is systemised feedback from children, young people and families implicated by the change. As new interventions are introduced, feedback is continually sought about the impact on experience. This contributes to further iteration of the delivery plan and interventions to work towards the goals.

2. Peer evaluationPeer evaluation by the core group feeds back into the insights process.

3. Repetition of the Step 1 insights and engagement processStep 1 needs to be repeated routinely (proportional to the scope of the change process) to identify new issues and resources within the system that can be enlisted in achieving the transformation goals.

4. Communication processesAccountable and strategic communication processes are necessary between system leaders, the core group and the wider system. This means all groups and individuals are able to understand the priorities within the system and progress made towards them. It also ensures that there are regular opportunities for groups and individuals outside of the core group and transformation network to share feedback.

This stage produces:

• Successful introduction of change in the form of system re-design or new interventions being introduced to the system.

• Clear evidence on the impact of changes on the experience of children, young people and families.

Outcomes achieved by this stage will depend on the goals set and they will vary within different systems. However, they are likely to fall within outcomes that improve the experience of children, young people and families within the system, and which improve the personal outcomes for these groups. This outcomes may also lead to a greater return on investment.

Alongside these, through using the Transforming Together process, outcomes around the three principles will be achieved including: better support for the most vulnerable children and young people, increased trust and improved working between different partners in the system, as well as outcomes linked to young people’s resilience.

All groups and individuals are able to understand the priorities within the system and progress made towards them

Longer term outcomes can include a greater return on investment in terms of improved experience

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Further development of Transforming TogetherIn line with our commitment to an iterative approach, YoungMinds is continuing the development of Transforming Together in collaboration with partners from the first phase and of course, children, young people and parents and carers.

This will include evaluation of the impact of Transforming Together on children, young people and families, services, workforce and local systems, including both their culture and efficiency.

Additionally, we are looking for new partners who are embarking on, or have started, change journeys in their organisations or local systems and who want to apply the Transforming Together approach.

To find out more about joining phase two of Transforming Together, please contact Laurie Oliva, Head of Participation and Consultancy at YoungMinds: laurie.oliva@youngminds.org.uk

AcknowledgementsWe would like to sincerely thank the commissioners who we initially worked with to support their local transformation work and who then shared their advice and input on the Transforming Together model as part of our Expert Reference Group. Their expertise and commitment to a participatory approach has been hugely valuable. Commissioner members of the Expert Reference Group were:

• Lee Golze - role at the time of membership: Head of Strategy & Delivery, Children & Maternity, Doncaster Clinical Commissioning Group.

• Andrew Sjurseth - CAMHS Commissioner, Warwickshire County Council• Duduzile Sher Arami - Consultant in Public Health, London Borough of

Redbridge.• Martin Bould - role at the time of membership: Senior Joint Mental Health

Commissioner, Tower Hamlets CCG.

In addition, other individuals gave their time and expertise in specialist areas as part of the ERG and informed the development of the model:

• Karl Royle - University of Wolverhampton, Faculty of Education Health and Wellbeing.

• Rob Mack - Children, Families & Young People Service Manager, Norfolk & Suffolk NHS Foundation Trust.

• Louise Bauer - Resilience Training Lead, London Borough of Newham.

We also thank the many schools, services and professionals and of course the young people and parents within these areas who were or are engaged in our work there and whose input to their local transformation programme has greatly shaped the model.

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i. Department of Health and NHS England (2015) Future in Mind- Promoting, protecting and improving our children and young people’s mental health and wellbeing: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf

ii. Oliva. L., (2014) Report on Children, Young People and Family Engagement for the Children and Young People’s Mental Health Taskforce. YoungMinds

iii. Senge, P (1990) The Fifth Discipline: the Art and Practice of the Learning Organization. New York

iv. Heifetz, R et al (2009) The Practice of Adaptive Leadership. Harvard Business Press, Boston

v. Argyris, C and Schön, D (1996) Organizational learning II: Theory, method and practice Reading, MA: Addison-Wesley

vi. New Trends in Management Wiki https://ntinm4.wikispaces.com/Change+Management Accessed: 21/11/17

vii. Chapman, J (2004) System failure. Demos: London

viii. The role of patients as members of the EMA Human Scientific Committees (2011) European Medicines Agency. http://www.ema.europa.eu/docs/en_GB/document_library/Other/2011/12/WC500119614.pdf Accessed: 21/11/17

ix. NHS England https://www.england.nhs.uk/mental-health/cyp/transformation/ Accessed: 30/10/17

x. NHS England https://www.england.nhs.uk/stps/ Accessed: 30/10/17

xi. Bush, M. (2016) Beyond Adversity: Addressing the mental health needs of young people who face complexity and adversity in their lives. YoungMinds: http://www.youngminds.org.uk/assets/0003/0188/Report_-_Beyond_Adversity.pdf

xii. Department of Health and NHS England (2015) ibid

xiii. Hart, A., & Blincow, D., with Thomas, H. (2007). Resilient Therapy: Working with children and families. London: Brunner Routledge

xiv. Zautra, A.J., Hall, J.S. & Murray, K.E. (2010). “Resilience: A new definition of health for people and communities”, pp. 3–34 in J.W. Reich, A.J. Zautra & J.S. Hall (eds.), Handbook of adult resilience. New York: Guilford

xv. Bronfenbrenner, U. (1979). The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press

References

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About YoungMindsYoungMinds is the UK’s leading charity championing the wellbeing and mental

health of young people. We exist so that young people have the strongestpossible voice in improving their mental health. We strive to make sure

everything from practice in schools and services to Government policy is drivenby young people’s experiences and aspirations.

We support parents to help their children through diffi cult times, we equipprofessionals to provide the best possible support to the young people that

they work with, and we empower young people to change their world.

Telephone 020 7089 5050Parents Helpline 0808 802 5544

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Crosby RowLondon SE1 1YW

ymenquiries@youngminds.org.uk

youngminds.org.uk