Two Words That Power Change — Reflections on how we can best pursue system change
This piece is written by Matt, one of our Community Mental Health Development Leads in Exeter, East & Mid Devon.
“What if this is not the darkness of the tomb, but the darkness of the womb?”
My two favourite words in the English language, when placed beside one another, are “what” and “if”. What if? Those two words have the power to change moments and create movements when they are mindfully held and intentionally spoken.
Valarie Kaur had the bravery to stand up and utter those two words at a time when many Americans (myself included) were losing hope at ever being able to live in a nation no longer riddled with hatred and division. She dared to ask if the darkness we are facing right now might not be the end, but the beginning.
In ancient Jewish thought, a day begins when the last light from sunset flickers away beyond the horizon. For them, the day doesn’t finish with darkness — it begins in the darkness out of which light is birthed.
On my desk at home I have a wood carving with the image of a seed buried in the darkness of the ground, beginning to sprout and push towards the surface. If you were looking from above the ground, you would see no signs of life, but life is in fact blossoming and getting close to breaking through into the light.
For those of us involved in systems change work at this moment in time, it can often feel like our hopes and ambitions are being buried beneath the weight of financial mismanagement and budget cuts, staff burnout and recruitment woes, incredible organisations closing their doors and services, political corruption and incompetence, and a culture that is continuously eating vision for breakfast. But, what if?
What if there is change and transformation growing in this darkness?
What if it is nearly ready to break through into the light?
Over the last nine months, I have been privileged to be a part of a piece of work here in Devon being led by the Innovation Unit called the Healthy Devon Learning Lab (HDLL). This space has brought together clinicians, commissioners, and community champions to explore if there are ways we can bring change to the wider system of prevention and support given to those who are experiencing a negative impact related to their weight.
At a recent conference hosted by the HDLL, Harry Rutter (Professor of Global Public Health at the University of Bath, Founder Director of the English National Obesity Observatory) spoke to us about the difference between ‘complexity’ and ‘complicated’. Things that are complicated often have many parts that require great skill to assemble and use, but ultimately, they are predictable and controllable when assembled correctly. Think of a spaceship being built, launched into outer space, and returned to a relatively exact location on the ground. Things that are complex also often have many parts, but the way those parts interact and change is not always predictable or controllable.
Take the obesity system map below, for example. It highlights a portion of the factors that contribute to someone having weight that is negatively impacting their health. If it was just complicated, we could intervene in one of those factors and immediately see a reduction in the number of people impacted. But it doesn’t work like that — it is too complex.
Throughout the country, you will hear more and more people talk about “the gap” in relation to severe mental health issues. What they’re usually talking about is the increasing number of people who have a mental health need too severe to be properly supported by primary care (GPs, talking therapies, social prescribers, health and wellbeing coaches, etc.), but not severe enough to be able to get past the huge waiting lists for secondary care (community mental health teams, psychologists, etc.). In Devon, we estimate that there are somewhere between 25,000 and 40,000 people who meet these criteria.
How do we go about changing the system that is meant to support these individuals, on a statutory and community level, when it shares a similar degree of complexity to the obesity map above? How do we make meaningful changes when we don’t always know the impact those changes will have?
Despite the different crises facing the system in Devon at the moment, I choose to believe this darkness is a “womb” darkness instead of a “tomb” darkness. If that’s the case, what could we do to prepare ourselves and our communities for the birth that is coming? After reflecting on these last nine months with the Innovation Unit at the HDLL, and my own experience in system change work, here are five things that I believe could make a real difference if we understand and implement them:
Do more of what we do in a way that is “Helpful for all, but essential for some”
I first heard this phrase, “helpful for all, but essential for some” from Jenna Grace, one of the directors of Esteem Team, an incredible community interest company in Exmouth that supports neurodivergent young people and their families.
Jenna used the analogy of the automatic doors outside a supermarket to make her point. For most people, we don’t need automatic doors — we could still enter the store without them. At times, they are very helpful if our hands are full of bags, kids, and a trolley; but we could still manage if we had to. However, for a small number of people, the fact that there is an automatic door is the only reason the store is accessible to them — it is entirely essential.
What if we modelled our services on this motto? What if we focused not just on changes to how we support individuals, but also on community-wide changes that impact everyone?
Take our social health, for example. We know some people are surviving extreme loneliness and isolation, and that their mental health is massively impacted as a result. A person who survives a suicide attempt is much more likely to have another attempt in a relatively short period of time if they live on their own. We need to find ways to help those individuals access and have a healthy community, but this is also a need of our entire population — we all need better social infrastructure, particularly since Covid. What if we started to reshape our communities to have those healthy social opportunities for everyone?
2. Systems always adapt to protect themselves
Harry Rutter used the example of the sugar tax to make this point. The government brought in a tax on sugary drinks to reduce the amount consumed by our society. A number of drinks providers reduced their sugar levels to avoid the tax and we know an increase in price does directly impact sales. However, the system adapted, found loopholes, increased advertisement, lobbied other parts of the system, and made changes. These adaptations were not entirely predictable, but massively impacted the overall outcomes of the change.
What if, instead of just initiating change and evaluating its outcomes, we invested in developing tools to monitor the wider adaptations? What if we made real time research and evaluation teams a standardised portion of these projects?
Those of us who get involved in system change work are often solution-focused people; we like seeing a problem and finding a way to solve it. That approach doesn’t necessarily get us to where we want to be, though. If we really want to shift things, we need a more learning-focused approach. This approach is both about trying new things and taking risks, as well as it is about developing mechanisms to learn and adapt along the way.
3. The system will only change when what we measure changes
The experience of those working alongside people whose health is being impacted by their weight couldn’t be clearer: when we focus on how much a person weighs, it rarely leads to improved health, and often creates a system that discriminates against those struggling. Focusing on BMI has led to greater shame and stigma, people being blamed for their health problems, and a resistance of the system to understand and support the wider issues that have led to that health concern.
What if, instead of measuring a person’s weight to determine the outcomes, we measure the degree of compassion they have towards their body? What if, instead of counting the number of times someone self-harmed, we counted the number of times they used agency to protect themselves from, or de-escalate, a risky situation?
A large reason why our system looks the way it does right now is because of the things we started measuring a generation ago. If we want to be a part of preparing society for the level of changes it needs, we need to start measuring now the things that will lead to that change. What could you measure differently in your services?
4. Whenever a professional helps someone, they become a part of that person’s family system
Another inspiring speaker at the HDLL conference was Dr Yolanda Alins-Sahun, Consultant Paediatrician. Dr Yolanda powerfully shared about her journey developing as a clinician. A significant point in that journey was when she undertook training in systemic family therapy. This training taught her about the level of impact professionals have when working with someone, and the grief experienced when that support changes. She learned that putting a patient first doesn’t always look the same as delivering the outcomes related to our health service.
What if we genuinely considered the impact of the baggage we (and our organisation) each bring into a relationship with our patient before we started an intervention? What if we adjusted the length and type of intervention provided to a patient according to what they need instead of what we are commissioned to provide?
If we want to build sustainable and meaningful systems of support, we need to be more mindful of the impact we have on each other and the people we are trying to support. We need to see people as having a greater expertise when it comes to understanding themselves and their needs, than we do as professionals trying to meet those needs. Inviting people with lived experience to co-design and reshape the way we deliver services is essential to move things forward.
5. Stop working backwards
The final point is one particularly aimed towards mental health, and is another point made by Dr Yolanda at the conference. Often in healthcare, we begin with people’s physical symptoms and issues. The only solutions to physical problems we have in our services are often medical and clinical, and those solutions are applied first — pharmacology, therapy, and interventions by highly qualified clinicians. When we have done what we can, or the person fails to engage with our plans, we may then turn to their emotions and demanding the person controls them better. The final piece, only addressed when both of those areas are solved or have failed, is to try to help the person engage with their wider social sphere more actively.
What if this is backwards? What if it would be more effective to improve someone’s social health first? What if a person’s physical symptoms were addressed after their social and emotional needs were met?
Mental health needs urgently de-medicalising. A person struggling with their mental health is not diseased and they do not have an illness — the symptoms we see are the way they as a whole person are surviving and adapting to the stresses and dangers they are facing. We categorically know that healthy social networks enable people to survive, mitigate, and recover from trauma significantly better than those who don’t have such networks. We categorically know that the emotions created from not feeling safe have a significant impact on our physiological body. If we don’t start prioritising taking time to really listen and understand the whole of someone and their history at the beginning of them seeking support, we will continue to see people cycling in and out of services, and never really getting well.
I fully realise that these five brief priorities are not simple. They are also not achievable unless we move from our silos and find more collaborative ways to deliver, innovate, and change. But movements like these listed do spark hope that we can, and will, have a better system supporting those who are struggling most in our society.
I once heard someone say that “direction always determines destination”. No matter where you want to go, or where you are planning on going, the direction you head in always determines where you end up. In this present darkness, it is time to make sure we are finding ways to change our direction, so we stand a chance of being somewhere different, and better, a decade from now. Please, today, take a moment and give yourself permission to ask, “what if?”. Use those two little words to start to imagine a new direction for your services and the people they support.