Systems Change

Creating lasting systems change – at a local and national level.

About Systems Change

Systems are the people, organisations, policies, processes, cultures, beliefs and environment that surround us, and system change is a change to any of these elements that is:

  • Beneficial to people experiencing multiple disadvantage, sustainable in the long term and
  • Transformational

We want to ensure that it is not:

  • Tokenistic or minor tweaks to how things work
  • Doing the same thing as before but under a different name
  • Reliant on a few individuals

Defining Systems Change

The 12 Fulfilling Lives partnerships, alongside the MEAM coalition, coproduced the following definition of systems change:

“Changes to the people, organisations, policies, processes, culture, beliefs and environment that make up the system. Systems change is beneficial, sustainable in the long term and transformational. It is not tokenistic, doing the same thing under a different name, or overly reliant on key individuals.”

Dual Diagnosis

“The co-existence of mental health and substance misuse problems”

Substance use and mental health needs are two of the primary concerns for many people experiencing multiple disadvantage. We know that people who experience both issues at the same time (also known as “co-occurring conditions” or “dual diagnosis”) find it difficult or impossible to access the right support for their needs.

Dual diagnosis is not a new issue. The relationship between mental health and problematic substance misuse has a long and complex history. However, it is only comparatively recently that practitioners and policy makers have acknowledged the huge scale of the problem and begun to tackle the complex task of delivering appropriate care.

The core challenge is to co-ordinate disparate services to provide holistic care. There is usually little point in providing treatment unless we also recognise that people need homes, meaningful activity, adequate income, social networks and access to jobs and/or training.

Whilst everybody accepts the principle of holistic care, in practice there are real barriers between services. That is why this toolkit is a deliberate attempt to build bridges and promote mutual learning. Only by working together can we provide care that is realistic and pragmatic and that genuinely enables people to move forward.

There is no common understanding about what is meant by “dual diagnosis”. For services, diagnostic labels have value in defining a client group and enabling the commissioning and delivery of care. However, practitioners should be aware that both service users and staff often see the label “dual diagnosis” as problematic. “Dual” diagnosis can suggest that there are only two problems. In fact many people have multiple needs. These might include one or more medical problems and a range of social issues such as housing, income, employment and social isolation.

In practice, people are usually only given a formal diagnosis of dual diagnosis if they have severe mental health problems (generally psychotic disorders) and severe substance misuse problems that meet the criteria for specialist services.

The issue then arises of how to access appropriate care for people whose problems, whilst distressing, are not considered “serious” enough to meet the threshold for specialist care. For example someone who has serious substance misuse problems but “moderate” mental health problems (such as anxiety or depression) or vice versa.

The term “dual diagnosis” does not specify the disorders and so could potentially apply to a person with any two conditions eg a learning disability and a mental health problem.

A label of dual diagnosis can lead to stigma and barriers in accessing services. Paradoxically, it can also be a passport to services, especially when specialist care is in short supply.

It is important to note that the label “dual diagnosis” does not indicate a specifically new condition but rather identifies that the person has concurrent issues.

Developing Trauma-Informed Systems

“To achieve systemic change, a trauma-informed approach must be embedded strategically and operationally”

There is a growing understanding of the impact of trauma, particularly when experienced in childhood, and how these experiences can shape behaviours and emotional responses later in life. It is becoming more widely accepted that services and systems are often designed in a way that exclude people who have experienced trauma, and furthermore, that contact with services can be the very cause of the trauma or re-traumatisation.

To achieve systemic change a trauma-informed approach must be embedded strategically as well as operationally. This includes system-wide workforce development (including senior strategic stakeholders) to allow the system’s practices, policies, strategies, cultures and values to be viewed through a trauma-informed lens.

Local areas which understand trauma-informed approaches find that there are close links between trauma, strengths-based practice and coproduction. Imbalances of power between people and systems can be a cause of trauma, therefore sharing and re-distributing power can be key in restoring trust and healing.

Similarly, valuing a person for their strengths and co-creating opportunities for them to thrive is central to moving towards a more effective and truly trauma-informed system.

Key elements to success:

  • Developing an area-wide group of people and services committed to trauma-informed practice, alongside strategic support and resource for the work is a powerful combination for driving change.
  • A trauma-informed approach requires workforce development at all levels of the system. As well as formal training, this involves modelling trauma-informed practices and speaking out about problematic practices or language.
  • The work succeeds when strategic leaders invest time in understanding how trauma-informed approaches, strengths-based practice and coproduction can inform the whole system, not just the work of frontline colleagues.
  • Frontline workers have benefitted from recognising vicarious trauma experienced in their own work, which is a common cause of burnout in teams.

Traditional approaches to policymaking and commissioning hamper efforts to embed trauma-informed systems. There is more work to be done to achieve the structural conditions required for truly trauma-informed systems to be developed. Birmingham needs to commit to becoming a “trauma-informed city/place,” with significant investment in workforce development and a commitment to reviewing and transforming cultures, policies and practices that exclude people.

Modelling trauma-informed practice day-to-day is vital to leading change. Peer support across the network will allow this learning to be easily shared.

Working Definition of Trauma Informed Approach –

Embedding A Strength Based Approach

Most people know the basics of a strengths-based or asset-based approach; instead of looking at someone’s deficits (such as their ‘problems’ and what is ‘wrong’ in their lives) we focus on their strengths (what they are good at, their positive social networks and what they would like to achieve). While that is definitely at the core of the approach, there is a lot more to becoming strengths-based than just asking about strengths and goals.

As a starting point, being strengths-based involves building an equal and trusting relationship. It requires you to listen more deeply and take longer to understand one another in order to develop the trust needed for someone to share their most deeply held hopes and dreams. It involves helping someone to unlock their own self-esteem so that they believe in themselves enough to step forwards.

It is about having the freedom to break away from the narrow confines of referring people to the usual agencies for support and moving towards brokering new opportunities that neither of you have explored before. This is about being an equal partner in a process without knowing exactly where it will lead. It is truly person-led work and it cannot look the same for two different people.

There are many excellent services in our sector but the underlying ethos is often one of ‘fixing’ people and the issues that we (and wider society) have identified as problematic.

Being strengths-based turns that on its head. Strengths-based services work alongside people; finding out what they want and how they want to live. Being strengths-based is a sea change in our approach. For some it will be intuitive but for others it may require a significant shift in mind-set and practice.

Strengths-based approaches have become a popular concept within the homelessness sector; many people and services are attracted to the idea of working in a positive way. However, there can be a lack of clarity about what exactly is involved and how this way of working can be practically implemented.

At the most basic level, it makes sense to listen to the people that we are working with. We have a tendency to view the challenges people are facing from the outside looking inwards. We identify a problem, design a solution (sometimes grounded in solid research) and then apply it. But what if we’re solving the wrong ‘problem’ and what if what is actually needed is different to the solution on offer? There are numerous examples of services designing complex solutions to simple issues because they didn’t listen to the people involved. At every level, from service design to individual interactions, we need to listen to the people we are working with and change how we respond accordingly.

NICE Guidance Co-existing Severe Mental Health and Substance Misuse

Get in touch

If you would like to know more about our work,
please contact Harpal Bath, Head of Multiple Disadvantage.


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