Thriving not Surviving! How a town in NW England cut child mental health referrals by 50% in just one year.

On the face of it, what Fleetwood, a small town with very high levels of poverty on the Lancashire coast, does is simple. Instead of referring every child with poor mental health to GPs, those seeking help are put in touch with a mental health lead for the town - otherwise known as Liz Loftus. Liz then takes her time to get to know the human in front of her - treating them not as a medical case but as a whole person with a complex life, multiple strengths and possibly multiple challenges well beyond the bounds of their ‘condition’.?

Based on that knowledge, Liz then works with the child and their family to identify how best to address their needs. And the solution very commonly involves alternatives to medical treatment: enabling physical or other activity outside the home, finding a place to develop human connection and access peer support, adapting the school environment, offering support to change diet and lifestyle - the options are varied, plural and always bespoke. But one thing is very clear: many of the children who are automatically referred by a GP to the local CAMHS team simply do not require clinical help.

The results have been stunning. Not only are children getting much speedier, local support (the nearest CAMHS team is in Blackpool and the waiting time for an initial consultation is seventy weeks), they are getting more personalised care. And most strikingly, given the vast and growing demand for mental health services, referrals to CAMHS from Fleetwood were cut by half between January 2023 and January 2024.

Underlying Principles

What Liz and her colleagues in Fleetwood have done bears close similarities to other frontline innovations that are reducing demand by providing better, more holistic care not just in mental health but in a range of other areas. Three common principles stand out:

1. Deep understanding: taking the time to really listen and understand what is going on in a person’s life beyond the immediate issue of concern to the public sector professional.

2. Versatile response: based on that understanding, developing a bespoke response that meets needs or preferences that may go well beyond a narrowly framed ‘problem’ such as poor mental health, addiction, homelessness and so on.

3. Collaborative delivery: working closely with the person, their network and the wider assets that exist within a community to improve that person’s health and well-being.

However, the simplicity of the process and these principles belies the considerable effort and change required to deliver them as effectively as they are being delivered in Fleetwood.

First, and most obviously, it requires someone like Liz! A person who is not only trained in holding strengths-based conversations but who is plainly fired-up by a passion to do whatever it takes to make the lives of the people of Fleetwood better. Liz grew up and lives in the town and her work is as much about a vision for the healthier, happier place she loves as it is for a clinical concern for the children sat in front of her. In that way, Liz is always thinking about the children she helps in the context of their community and what Fleetwood can do as a place to support them.

But that rootedness and understanding of place goes well beyond one individual. An absolutely key part of the success is the close working that has developed between public sector bodies and between the public sector, the voluntary sector, and the community.?

Thriving in Fleetwood

This is where Thrive comes in. Thrive is a joint effort across the town to improve the lives of young people. It brings public, voluntary and community sectors together with this one goal and the focus on mental health is just its starting point.?

Thrive’s regular meetings attract around forty people and the sense of a collective with a shared purpose is strong. But, most importantly, this is a group who know in detail what each other is up to and what assets and expertise they have to offer. That means that when Liz, or any other Thrive member, is working with a child and their family they just know implicitly where to find help and support that can meet particular needs and preferences.?

And none of that is really about organisations working together at all. It's about the people who work in those organisations building personal relationships with each other built on understanding, compassion and, most of all, trust. That requires a leadership style and focus from Liz, and indeed from everyone involved in Thrive, that is as much about creating those trusting relationships as it is about anything else.

In short, Thrive is integration for real: public sector, voluntary sector and community working together with a shared sense of strategic purpose that feeds through into joint operational effort.?

The Community is the Key

The importance of that link with the community alongside the public and voluntary sectors in Thrive cannot be overstated. Thrive’s focus on young people and mental health and its way of working was not the brainchild of a senior NHS leader but emerged from a dialogue with children, parents and public sector professionals. This not only ensured Thrive was focusing on the things that really mattered to the community but also started creating the energy and connections that are so key to Thrive’s success.?

In this, Thrive was following in the footsteps of Healthier Fleetwood - an equally successful initiative to move to community-led primary care for adults in the town which itself began with a big conversation launched by a local GP, Mark Spencer. Since its start, ten years ago, Healthier Fleetwood has seen the launch of around 130 community-led groups addressing isolation, inactivity and poor mental and physical health. It has massively expanded the range of community assets that can be drawn upon to support someone beyond the normal medicalised or institutionalised route. This is something Thrive is actively replicating.

The whole approach is undoubtedly also helped by working at the right scale. Fleetwood has a population of around 30,000. For Mark and Liz this is ideal. As they put it: that size is small and simple enough to allow personal relationships and shared knowledge to flourish both inside and outside the public sector, but big enough to ensure there are enough energetic people and community assets to make the approach work.

A New Way of Being: doing with not to

So, there are clearly a lot of factors playing into the success of an initiative that appears quite simple at first glance: adherence to core principles, genuine frontline integration built on personal relationships, letting the community lead, operating at the right scale.?

That may sound intimidating to those working in the current, failing conventional model and desperate for change. However, speak at any length to Liz and Mark and they will tell you that it all begins with a simple change of mindset, or as Liz puts it a “different way of being”.?

I’d summarise that as a shift from a ‘do to’ to a ‘do with’ approach. Basically ditching the idea that the role of the public sector professional is to use their personal expertise and institutional resource to hand down care from on high and instead shifting focus to always finding ways to work in the closest and most humble collaboration with everyone outside your institution: patients, residents, communities, other public sector professionals, volunteers. In short, whoever can help.?

The implications for the NHS and the wider public sector of the success of Fleetwood and other similar innovations is great. They show a way forward out of the crisis currently roiling public services but they also throw down a daunting challenge.

So much of what occurs across the public sector is the very opposite of what happens in Fleetwood. Integration is weak and the solutions are often sought in high level governance committees rather than on the operational frontline. Communities are widely treated as passive recipients of care and policies rather than the lead decision-maker. And the biggest decisions are taking at scales far, far bigger than the 30,000 or so where real change is possible. But of greatest concern is the way a do to rather than a do with mentality has embedded itself so deeply into the culture of public services.

Thus, if we are to learn from innovations like Fleetwood, change will need to be as radical as it is urgent.