1. Together we are making a difference Lessons learnt from the Aotearoa New Zealand Equally Well collaborative
Caro and Helen have both been instrumental in the development and continued expansion of the Equally Well movement in Aotearoa/New Zealand. The Equally Well collaborative is underpinned by evidence, both in terms of understanding the issues and in designing the solutions. It is also underpinned by principles, most importantly the principle of co-design with people with lived experience. In this presentation, Caro and Helen will take us through how the Aotearoa New Zealand Equally Well collaborative began, and some of the highlights from their five year journey. They will also share some of their reflections on lessons learnt. As they share their experiences, they hope to inspire Equally Well Australian champions, outlining what make up the key ingredients of an ‘Equally Well action or set of actions’ and explaining the underpinning mechanisms and success factors which support the continued growth of this diverse and impactful collaborative.
Over the next 30 minutes we are going to share with you the journey we have taken over the past five years and some reflections on lessons learnt.
We are going to highlight what from our perspectives are some of the crucial ingredients of the Eq W collaborative and some of our key junctures on this journey
Helen & Caro’s main messages:
Equally well is underpinned by evidence both in terms of what we are addressing and how we are addressing it
Co-design is crucial and needs to be there from the start (talk about Caro’s reservations – scared of being further labelled, shame)
Need to mention also the shock value vs. recognising the information is really horrific for the people and families / whanau affected – so we needed to be careful and kind in our delivery
We were intentional and targeted with the stakeholder we contacted (e.g. primary care, heart foundation, diabetes NZ, … but we also went where the energy was (the willing)
Try to model strengths-based language whilst also recognising that different groups use different language
Model authenticity and non-blame approach in our leadership
Trust and mutual respect essential…
Caro Swanson and Helen Lockett
#EquallyWell

2. The Equally Well collaborative
Best research evidence
Evidence informs both What we do and How we do it
Equally Well is a collaborative of people and organisations, we are evidence-informed informed in terms of both ‘what we do’ (the issues and solutions to the identified ‘problem’ and ‘how’ we work together drawing on the emerging evidence-base around collective impact.
Evidence includes published evidence and people’s experiences and knowledge, especially people with lived experience
Lived experience
Practitioner
expertise
EBP

3. The beginnings
A meeting of leaders from the non-government mental health and addiction sector were discussing the number of untimely and unexpected deaths of people using their services This is not acceptable
It was definitely not acceptable and yet somehow it was accepted.
While the issue had been around and known about for some time, there had been a helplessness about what to do.
Yes things needed to change but there were a few things I was worried about
First and foremost after being a person accessing services for quite some time, initially it felt scarily like more people making decisions about us and for us, not with us. All with the purest and most caring of motives, but without our input how could it work?
There were assumptions made that bothered me. Like, how do you know we want longer lives for a start? By that I mean, the need to consider what a good life is for people. 25 extra years sounds good but only if those years contain the stuff that makes life worth living.
I worried that about the potential for extra stigma unless this was done right. We already have so much of our lives held up for inspection and judgement, would this add more? On top of the other beliefs many people hold around having a diagnosis, would we now also be seen as even more of a problem? In the early days I did hear from mental health professionals who were of the opinion that the physical health problems we might have were our problem, largely the result of our own poor health choices and lack of motivation. Yet truly, all most of us are doing is just trying to survive in really awful circumstances which we never asked for.
I talked to Helen. We talked a lot. She listened, really listened. There was a core group in the beginning. A whole mix of people. What was a fair, compassionate and respectful way to change what was becoming clearer was a huge gnarly problem?

4. Understand the issues Phase 1 (from mid 2013) Evidence collection
Listening to people’s experiences and concerns
Making some new friends
Firstly, we needed to understand what was happening for people in NZ living with mental health and addiction issues and most importantly we needed to understand what the solutions were
The first literature review asked:
What is the mortality and morbidity gap?
What’s contributing to it?
What can be done to improve physical health outcomes and reduce the disparity?
Here is a good time for Caro to talk about initial reservations, concerns… ?
But we also had to make some new friends….
… this because what we were reading was telling us that because this is complex its going to take a few of us…

5. It takes a system
“… because of the complex and interrelated factors contributing to this disparity, a systemic approach is needed”
Nease, 2014
March edition of the NZ Journal of Primary Health Care – there was a guest editorial on this very issue. Professor Nease is saying yes, this is complex and the contributing factors are interrelated, that is why we need a systemic response
Equally Well is about diversity, a range of players effecting change in their sphere of influence as well as working with others to find new solutions

6. Wicked problems
Wicked problems are difficult to define and they fight back when you try to solve them.
Chaos theory, complexity theory and ecological theories only begin to describe the ‘wicked problems’ that await those who attempt to change practices, organisations and systems (Fixen et al., 2013)
Rittel and Webber (1973) described wicked problems as those that are difficult to define and that fight bacl when you try to solve thme,
That is interest vested in the system-as-is suddently appear and typically deter atttenpts to change a system. In addition, attenpts to change a system expose faulty operating assumptions that stand in the way of systems accomplishing their stated / legislated goals.
(all from Fixen et al., 2013, Statewide implementation of EBPs)
Sources: Fixen et al., 2013; Rittel and Webber, 1973

7. September 2014 - an evidence-informed Call to Action
Be identified as a priority group at a national policy level based on significant health risks and relative poor physical health outcomes.
Have access to the same quality of care and treatment for physical illnesses as everybody else, and in particular to have a right to assessment, screening and monitoring for physical illnesses.
Be offered support and guidance on personal goals and changes to enhance their physical wellbeing.
In the November we held a hui / meeting … deliberately invited new friends

8. November 2014 – Equally Well summit Growing the crowd

9. Identified the drivers of inequalities
Health systems
Workforce issues
Exposure to known risk factors
Psychotropic Medication
Socio-economic status
Adverse childhood experiences
Helped people to see their part in affecting change
The message behind this slide is to remind people of all the contributing influences on this health inequity
Updated since Dec 2017, to add ACE
Many interventions focus on individual risk factors, I.e. smoking, obesity, but there is much more that can be done.
Remind group - if addressing individual risk factors, particularly important that interventions are peer led
We therefore need to focus on all 6

10. A fundamental shift in the way we ‘view’ the issues
Here is the what is probably a very familiar optical illusion (old and young woman)... Now you are familiar with it you can probably see both women interchangeably.... But when you first saw it, it is likely you could only see one of the women until someone pointed out the other image.
For far too long we’ve been viewing this as just an issue for mental health and addiction services and health professionals, but now we are looking at this from a ‘whole of health’ lens, this is a health equity issue and therefore a group who have ‘priority health needs because of their physical health’ ...
Becomes an important issue for all sectors of health and health professionals....

11. Equally Well: leveraging change across the health and social care system
Improving the physical health of people with mental health and addiction issues
Cardiology
Diabetes care
Primary care
Mental health and addiction services
A stronger focus on people with mental health and addiction needs
So this is what we are trying to do…
A stronger focus on physical health
Bringing together mental health, addiction and physical health

12. In under 4 years it has grown from 8 organisations to more than 120
Also now in Australia and the UK
September 2014, consensus paper launched
June 2016 – 69 endorsing organisations
Oct 2016 over 80
Dec 2016 over 100
15 out of 20 DHBs (75%)
Most of the large PHO organisations and peak bodies
A number of medical colleges, but also the Council of Medical Council (So all 14 of the medical colleges)
You may wish to point out that we have the Royal College of Psychiatrists, London (as well as the Australasian College) and the Australian MH Commission!
More than 250 on Loomio 

13. Equally Well underpinning principles
Partnership
Addressing stigma and discrimination
Co-design
This is what makes something an Equally Well initiative or action… worth highlighting its about co-design with people with lived experience and partnership with others…
We embrace diversity, in fact we actively and deliberately seek it out and we have challenging discourse
We use an online Platform Loomio
Evidence informed
Shared care
Sustainable

15. Collective impact Backbone Team: Increasing access to primary care
Conducting research and data analysis
Sharing good practice
Developing the workforce
Building a network of champions
Informing Policy
Backbone Team:

16. TheMHS award for innovation and excellence
“Equally Well demonstrates that a great deal of value can be added to the health sector through collaboration around a common goal.
…the number of organisations involved is impressive and there are excellent examples of organisations creating change.

17. Examples of impact
Worth highlighting we are seeing a major lot of action in primary care (and we’ve been targeting primary care too with our BBT support):
From left to right:
Equally Well Canterbury GP appointments – oversubscribed Equally well funded and extended consults (some 2000 taken up!)
Canterbury clinical network have put Equally Well measures in their reporting on the Systems Level Measures framework
3 How to Treat – NZ Doctor article on physical health comorbidities with mental health and addiction issues (article and e-learning module)
4. Dec 2017 – Te Pou evidence update
5. Feb New primary care CVD risk assessment and management guidance – risk assess people with major mental health and addiction issues from age 25, current tools will underestimate
6. Picture – new prescribing for wellbeing toolkit and video for GPs (ones for other prescribers are under development)
7. Analysis of the NZHS
8. RNZCGPs are about to release an updated Equally Well policy brief
Gave keynote presentations and ran prescribing workshops at the two major GP CME conference this year, as well as workshops and presentations at RNZCGPs and RANZCP conferences

18. Be intentional about building and sustaining a collaboration
Create a sense of urgency
Involve the people affected from the outset
Help individuals and organisations see how they can contribute
Build a virtual community
Develop distributed leadership
Work with diversity, respect difference
Build understanding and bridges across different sectors
If people can see their part of the picture / puzzle they are happy to be responsible for that bit
Having a wide conversation through multiple lens offers more solutions. Diversity matters!
Good ideas travel fast

19. Leading by example - trust and mutual respect
“Caro brings OODLES of wisdom, personal insights, experience, and knowledge along with creativity, aroha, kindness, compassion, and is prepared to challenge and question”.
“Helen brings a HUGE sense of justice, a soul deep caring for people that is resolute, immense drive and energy, tenacity that is legend, she listens, she explores, she confronts, she affirms”.

20. Helen.lockett@wisegroup.co.nz Caro.swanson@tepou.co.nz
Ngā mihi nui ki a koutou