Are Service Users the Key to Systems Change?

05.11.2013 Blog

Last month I attended an event at The RSA: “Are Service Users The Key To Systems Change?” This featured Dr. Charlie Alcock of MAC-UK in conversation with Chris Wright of Catch-22 and Clare Tickell of Action For Children, chaired by Matthew Taylor of The RSA. The purpose of the event was to provide an opportunity for Charlie to have an open discussion about the ability of MAC-UK to scale up while maintaining its innovative approach, and to seek guidance informed by Chris and Clare's experience.

Charlie Alcock on the story behind MAC-UK

Charlie Alcock set up MAC-UK five years ago while working as a clinical psychologist in an NHS Community Outreach team. She realised that young people who were at risk of offending rarely attended scheduled appointments, and that it was precisely these people who were most in need of professional help. Mindful of the fact that youth crime costs billions of pounds every year, and knowing that a third of youth offenders have an undiagnosed mental health problem, she began to think about what she could do to make it easier for vulnerable young people to access care.

Around this time she undertook a placement in New York, working with two rival gangs. One day, she was walking through The Bronx and a young person confided in her: “My cousin used to talk to somebody like you – now he’s dead. The gang thought he was snitching.” This casual conversation made her realise that security was crucially important when working with young people in gangs, and she knew then that any successful intervention had to begin with the insights and needs of the group, rather than established systems.

Charlie developed the Integrate model, whereby psychologists and counsellors spend time with young people and conduct therapy wherever feels most comfortable for clients – whether that is in Nando’s, on the bus or on the estate. She commented, “When people asked me how I started MAC-UK I used to say that it was all by accident. That is what it felt like. Then I realised that was the whole point: we had started with the service users and developed a service to meet their needs.” Or, as one young person said to her recently: “It’s easy, tell people to just start things – people are too preoccupied with the theory – they need to get out there and do it!” Although Charlie was doing a brilliant job of connecting with the young people whom she wanted to reach, she found that she had an equally hard task ahead of her in explaining her model to established professionals. At the beginning, the police assumed that she must be dealing crack – how else could she be capturing the attention of the young men she was working with?

Charlie commented that she has had to become skilled in an art which she calls ‘the opposite of campaigning’ – adapting her messaging to the existing system and working within it for the benefit of the young people she supports. She gave an example: “Recently, I set up a meeting, and everyone in the meeting thought they were in the wrong place.  The police thought they were there to talk about reducing crime, the health people thought they were there to talk about reducing DNA (Did Not Attend) rates, and the housing people thought they were to better support their staff. Of course, they were all there for the same reason – to better support young people – but I had to play to their agendas to get them all in the same room. It was after this meeting that they all signed up to be a borough that would be the next pilot of our model.”

An additional factor which has assisted MAC-UK in being taken seriously at a policy level has been the organisation’s flat structure. Charlie commented: “we were hugely understaffed in the early days, which meant we all had to do everything. Staff members were operating at the frontline as well as the strategic levels… Staff crossing these more traditional boundaries meant that young people’s ideas could be implemented really quickly, and this fostered trust and empowerment. We also had real life examples at our fingertips at policy meetings. People like stories. They listened.”  As the organisation has grown, it has been hard to preserve this model, however MAC-UK are now trying to pair people who complement each other in order to prevent knowledge being lost. ” Charlie also stresses the need to find a way to learn from mistakes. She says: “the challenge is creating the culture where it’s okay to try new things and where we become far more risk aware, rather than risk averse.”

As MAC-UK celebrates its fifth birthday, Charlie is looking to the future. The organisation already has over eighteen staff members, and a turnover of more than £1 million, however it has so far not invested many resources in securing public sector contracts. Charlie says she is “acutely aware that it is much easier to disrupt when small”, and she knows that too many innovative approaches have failed when they have tried to scale up. Just as she sought the help of young people when she was first establishing MAC-UK, she is now looking for advice from people who have experience of delivering successful and non-traditional interventions at a national level, such as Clare Tickell and Chris Wright, from Action for Children and Catch-22.

Chris Wright and Clare Tickell Respond

Clare Tickell responded to Charlie by commenting that she was sure there was a lot Action for Children could learn from MAC-UK, particularly around connecting with service users. She noted however that sometimes founders find that different skills are needed to stay with and manage an organisation as it grows. In particular, Clare suggested that as the organisation gets bigger, Charlie may find that she needs to disrupt and agitate less, and if that is the case she may need to think about whether this is something that she wants to do. Matthew Taylor agreed that when you run a large and well-established organisation, compromises sometimes have to be made for the sake of the organisation continuing.

Charlie acknowledged these concerns but stated her view that success for her was not about MAC-UK continuing, but rather was about others taking her model forward. She said “For me, the biggest failure of all would be if in three years people say: Integrate works because MAC-UK did it. I want people to say, it works because the NHS did it and the council did it, and I want them to take it forward.” Unfortunately, Chris and Clare were very critical of the current commissioning structure, which at the moment is the most obvious way that organisations like MAC-UK might seek to scale up. Chris commented that: “In many markets, if you have a good product, people will buy it. In this world, if you have a good product, people won’t buy it. Commissioners look from the perspective of the commissioner, [and] look through a lens that says this is what we want. They are risk averse, and reluctant to engage with innovation – they look for things that they can measure easily. This means we end up bidding for work that looks exactly like the local government service.”

Charlie agreed with Chris' assessment, and commented that the one thing which she has found to be the biggest barrier to her quest to put users at the centre of services was “commissioning that commissions outputs rather than outcomes”. For example, she has come across commissioning that placed a large number of requirements on the organisation which delivered the contract in terms of how many people they should get through the door, but few requirements in terms of which outcomes they should achieve. She said, “I’m pushing back all the time, and I say to commissioners, if you want to commission a service that works with lots of people and does it quickly, don’t commission us.” She finds that her preferred approach of speaking frankly to commissioners about what MAC-UK can and can’t do works well when she has established relationships with commissioners and the diversity of public service managers within a particular area, but is more difficult when working in new boroughs. However, she has had one experience of working with commissioners in a particular borough and helping with the design process, and they are now working together to implement a whole new service for 16-25 year olds based on the Integrate model. This is encouraging, as it is hoped that her work in this borough will lead the way for the model to be extended to other areas of the country, and provide an example of creative commissioning that takes the needs of service users seriously.

I really enjoyed this event, as it linked in with work that we have been doing as part of the TEPSIE Project, particularly around barriers that social enterprises face while navigating the world of public sector commissioning (Work Package 3) and ways that social innovations scale and grow (Work Package 7). Much of what Charlie had to say about the problems she has faced resonated with me, yet I was encouraged by her experience in bringing representatives from the NHS, the Police and Housing Associations together and using the insights of service users to deliver outcomes valued by all these organisations. I will be interested to follow the progress of MAC-UK as it attempts to scale up, over the next five years, and beyond.

Photo credit: zoetnet on flickr