We outline the historical context and analysis of contextual factors influencing adoption and implementation, discuss assimilation by case, and then present a cross-case analysis. Table 3 captures the key features of each case, Figs. 1–3 summarize the adoption, implementation, and assimilation timelines, and Tables 4–6 summarize the cross-case analysis.
Table 3
Case features
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Case 1 ESTHER
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Case 2 Making Recovery Real
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Case 3 CMHA Learning Centre
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Structurally vulnerable group
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Initially older patients with complex care needs, then expanded to patients of any age with complex needs
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Initially, people with lived/living experience of serious mental illness
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Initially, people with lived/living experience of serious mental illness but expanded to whole community with interest in living well.
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Coproduction approach
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Initial focus on radical customization of an Esther’s journey through health, and evolved over time to become coproduction with patients through the involvement of Esthers in meetings and projects, to provide feedback based on their experiences
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Coproduction is at the heart of initiative from the start. The intention was to bring people with lived/living experience together with health and social service providers in community of Dundee to determine how to make recovery real in this community. Adopted an asset-based approach that discovers capacity within individuals.
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Coproduction, co-development, and co-learning are at the heart of the Recovery College model. The aim is to be peer-centric and peer-led and to foster collaborative and authentic relationships with students, so they have meaningful involvement. Social or co-learning is active and involves looking at topics from both the professional and experiential lenses, interaction with others, learning from their experiences, and contributing to the learning of others.
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Guiding question(s)
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• What is best for, or important to, Esther?
• Who needs to cooperate to fulfill this?
• What do we need to improve?
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What would make recovery real in Dundee?
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Provide educational programming to foster recovery and living well
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Inclusivity principles
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• Focus on care coordination in complex needs population
• Openness, transparency
• Joy, ‘serious fun’
• Driven by value (not money)
• Reconnection to original healthcare values
• Balancing power
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• Rooted in mental health recovery principles (connection, hope and optimism, identity, meaning, empowerment)
• Sharing lived experience through recovery stories
• Aim is transformational system change within and by communities
• Moving beyond the medical model of service delivery
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• Rooted in mental health recovery principles
• Living well for all
• Inclusive educational approach
• Courses are open to anyone interested in participating/learning
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Addressing structural vulnerability
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The objective of ESTHER is the coordination of those care needs identified as most important to patients themselves. Vulnerable populations, specifically those with chronic diseases, are those expected to benefit most from ESTHER as these groups are more likely to ‘fall through the cracks’ of the system, given their complex care needs across the health and social care systems.
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Collaborative conversation approach to create an environment through sharing recovery stories in which people with lived and professional experience can work together to identify what’s possible. Focus on encouraging involvement from underrepresented communities.
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The coproduction approach fosters a fundamental relationship shift between staff and students. The instructional climate creates a sense of community that is absent for many structurally vulnerable individuals. Service providers develop skills in coproduction, wellbeing, and recovery, and become more open to innovation.
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Table 4
Cross-case comparison: Adoption
CFIR/DOI element
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Case 1: ESTHER
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Case 2: Making Recovery Real
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Case 3: CMHA Learning Centres
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External context
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• Early ESTHER work normalized collaboration between health with social leaders
• National awards created enthusiasm to continue to build on work to date
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• Health and social care integration legislation fostering collaboration
• External change agent shifting toward local coalitions for change created opportunity for mentorship
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• Changing policy ideas at the national and regional levels provided philosophical support
• Conference promoted recovery, introduced English Recovery College knowledge purveyor
• Facilitated by change agent organization, and local and international networks
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Internal context
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• ESTHER had shifted medical relationships to co-leadership
• Internal management resistance to patients in decision-making remained
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• Tension for change within local mental health service provider collective
• Opportunity to influence the new mental health strategy
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• Model values well-aligned with organizational culture
• Evaluation showed gaps
• Culture of innovation and solidarity in the region
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Individual characteristics
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• System leaders realized a focus on value and what is best for the patient leads to the best outcomes
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• SRN leader with a vision for change and community development approaches
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• Visionary branch leaders also regional leaders in recovery, mental health promotion, and community development
• Existing peer staff to support
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Innovation features
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• Flexible philosophy enabled participation of patients (Esthers) in co-producing ongoing innovations
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• Opportunity for local network to receive support to centre lived experience in the identification of local needs and solutions
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• Recovery college model evolved existing philosophy, aligned with CMHA values, and was adaptable to local context
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Process
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• Initial evaluation showed a 20% reduction in hospital beds
• Incremental approach to introducing Esthers to venues of greater strategic importance
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• TSI facilitated proposal development, and building trust between partner organizations
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• Coproduction processes aligned with aim to be community-led
• Agreement between two branches and National Office to move forward in Manitoba
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Table 5
Cross-case comparison: Implementation
CFIR/DOI element
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Case 1: ESTHER
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Case 2: Making Recovery Real
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Case 3: CMHA Learning Centres
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External context
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• Development of Esther network and national recognition helped maintain momentum despite other system priorities
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• Received local political support, including representation at events
• External change agent supported implementation
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• Strong community partnerships with other local agencies to promote and co-deliver courses
• Peer organization supported with funding
• External change agents supported conceptualization, implementation, and evaluation
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Internal context
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• Structures to support Esther input developed
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• Led by TSI which held a strong commitment to coproduction approach
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• Philosophical alignment with organizational values and culture facilitated implementation
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Individual characteristics
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• ESTHER leaders committed to the philosophy
• Bottom-up nature and growth was threatening to senior leadership
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• Support available to build local capacity and confidence
• Leads motivated by personal or professional experiences
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• Passionate staff with lived experiences supported establishing and managing Learning Centres
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Innovation features
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• Philosophy aligned with reason people entered healthcare
• Coaches became grassroots change facilitators
• Incorporated “serious fun”
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• Coproduction via recovery-focused events key to meaningful involvement
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• Adaptability to become “something for everyone”
• Lived experiences is valued as expertise
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Process
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• Adopted incremental, quality improvement approach to integrating coproduction
• ESTHER Cafés attract a broad range of listeners to hear lived experiences and identify improvements
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• Worked with the willing, starting with the local integration bodies
• Recovery story film became an important tool for documenting and spreading the message
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• Shared vision and philosophy to overcome challenges, evolved from consultation with people with lived experience that transformed previous approaches
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Table 6
Cross-case comparison: Assimilation
Assimilation Scenarios
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Case 1: ESTHER
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Case 2: Making Recovery Real
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Case 3: CMHA Learning Centres
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Co-optation
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• Co-optation resisted at a number of points (e.g., not participating in national project that required a name change, changing name of Strategy Days to Innovation Days rather than not hold them)
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• Resisted co-optation of the approach by the health care sector by intentionally avoiding the term ‘coproduction’, and by not agreeing to proceeding in conditions that didn’t align with the philosophy
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• Manitoba Justice ministry has co-opted the Anger Management course, making it mandatory for some criminal offenders, which is contrary to the Recovery College philosophy
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Loose coupling
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• Without dedicated funding and leadership questions about sustainability remain
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• NA
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• Due to lack of resources, CMHA Central Manitoba branch has been unable to continue coproduction processes during the COVID-19 pandemic, yet still offering pre-existing courses
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Customization
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• NA
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• NA
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• Name change and expansion of target group, no longer tailored to mental health recovery but to living well for everyone
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Transformation
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• ESTHER mindset considered fully assimilated as a mindset in Jönköping
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• Building infrastructure for transformation through i) establishment of a local partnership approach and commitments to priority areas, and ii) continuing to build peer-led services into the system (co-designed and -delivered)
• Locally, has influenced the mental health strategy, however political support and/or government direction unknown with upcoming leadership change
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• Co-design, -delivery, and co-learning seen as “transformational” by students and staff
• Introduction and expansion of coproduction approaches incorporating lived experiences into broader programming design
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Case 1
Historical Context. ESTHER is a complex system of public health and social care services run by 13 municipal councils in Region Jönköping County, Sweden that has brought intersectoral health and social care providers together since the 1990s to increase coordination and to redefine service experiences around the needs of the person receiving the services. In a context of restricted public sector funding, ESTHER began in 1997, initially for two years, with the aim of finding ways to meet population health needs using approaches other than increased hospital bed capacity. Hospital leaders in Region Jönköping County aimed to transform ways of working and to prevent hospital admissions through what informants called ‘radical customization’, which considered the needs of individual patients using a bottom-up change process referred to as health process re-engineering. This approach ‘shadowed’ a patient with complex needs through their health service experience journey and included interviews and surveys with patients, staff, and government officials and observations of care encounters and processes to gain new insights into what was needed to improve the system from the patient perspectives. Storytelling of the experience of ‘Esther’, a persona of an elderly person with complex health needs, actualized this process, pointing out what needed to be done differently by demonstrating the importance of focusing on the experience of the person receiving care. The lessons learned from ESTHER fueled health and social service-wide change, including coproduction with patients beginning in 2006 through patient roles on advisory committees and councils, and has expanded to include initiatives such as ESTHER Cafés, ESTHER Coach training, and ESTHER Family Meetings, among others.
Adoption. In the internal context, healthcare process re-engineering efforts since the 1990s centered on the question of “What is best for Esther?” and demonstrated the importance of person-centred care and emphasizing the experiences of the person in need of complex care, laying the foundation for a coproduction approach to emerge. In the external context, system-wide efforts by health and social leaders to create a system map led to ESTHER becoming more than a health quality improvement project but rather a health and social systems-wide movement. From a process perspective, the initial project’s evaluation results indicated a 20% reduction in hospital beds, an achievement that earned recognition in the external context through two national awards. As project funding ended, the benefits of the ESTHER philosophy were recognized, and ESTHER transitioned from a project to a ‘network’ without funding. Over the next few years, the ESTHER Network further developed as ‘cousins’ emerged across Sweden, and the approach was adopted in other countries, including Italy, England, Scotland, and France.
By 2006, ESTHER in Sweden transitioned toward adopting coproduction approaches that actively invited participation of people with lived experience expertise (Esthers) in coproducing ongoing innovations. The flexibility of a guiding philosophy was a key feature that enabled this emergence of innovation in the coproduction approach. By this time, individual system leaders had come to recognize that keeping the focus on value and what is best for the person being treated in their daily lives would lead to better results than a preoccupation with resources and cost-cutting. ESTHER had transformed relationships internally in hospitals to team-based (doctor‒nurse) co-leadership, and externally across the region via interorganisational collaboration between hospitals, primary care, community care, and social care to improve Esthers’ care journeys. These collaborative ways of working were preparation for collaboration with Esthers, helping to create receptivity among senior leaders to coproduction. Nonetheless, there was still some internal resistance, particularly at management levels, as Esthers began attending and sharing stories about their experiences at leadership meetings.
“I think one of the most important decisions was to take patient in the room. In addition, there was a lot of resistance.” [JKG-01]
Implementation. Around this time, factors in the outer context shaped ESTHER’s continued development, as Esthers became increasingly present in local patient committees and began to participate in and influence the ESTHER Steering Committee. While ongoing primary care reform was a distraction for many health service managers, an external network of Esthers developed from different programs across municipalities, and annual Esther ‘family’ meetings were held, where Esthers could convene to share experiences and ideas, strengthening the grassroots support. ESTHER was again gaining international recognition, becoming the subject of a BBC documentary film, and being declared "One of the Coolest Innovations in the World” by CNN.
In the internal context, further developments included the creation of internal structures to support greater involvement of patients with multiple vulnerabilities in coproduction activities: The ESTHER Competence Center, training health care teams to follow the ESTHER philosophy, and ESTHER Coach quality improvement training programmes for approximately 30 health and social service providers to become new ESTHER Coaches each year, and with growing numbers of Esthers as faculty. Key features of the approach were supportive of grassroots growth. Coaches developed innovations on an ongoing basis with input from Esthers, and health and social service providers remarked that the ESTHER philosophy takes them back to the reasons they entered their professions. At the same time, the bottom-up nature driving innovation continued to be threatening to individuals in senior leadership positions who were more distanced from observing the benefits.
“Esther is very much bottom-up. So, you are very close to Esther … you see what's going on and what you can do better. The steering is from the bottom, and then the managers got a bit threatened. I think there was suddenly too much; the movement was suddenly too big. So, people were reacting to that. …That still is a challenge.” [JKG-01]
Creative approaches have been used to foster growth despite this resistance. Small changes such as renaming committees have enabled participation by Esthers.
“We had our ESTHER strategy days. It was once a year that we had a really big gathering about what we are going to focus on. And we invited managers, we invited the coaches, we invited Esthers. So one-third of the group [30] were Esthers and the other were working in health and social care. And, for me, that was a very big success, but it also became a threat. So, they took it away because they said you can't have strategy day because you are not a manager. So, we changed the name. Now we have the ESTHER Inspiration Day.” [JKG-01]
The implementation process has been incremental and iterative to balance the grassroots pressure for innovation with the internal resistance to patients as equal partners, while ensuring real change results. As an example, in 2007, ESTHER Cafés were introduced to connect Esthers and to identify the improvement possibilities most important to Esther. These cafés continue to be held four times per year and have attracted a wide audience, including clinicians and politicians. Esthers share their stories to help leaders and practitioners understand individual experiences, but the process also builds credibility: it requires a check-in with leaders and service providers about what they heard and whether that is consistent with what the storyteller feels is most important, and agreements are reached before the meeting ends about specific action(s) that will be taken to address what is important to Esthers.
“When we listen to a story, we ask the group, "What did you hear?" And we are trying to confirm whether we are hearing different things than [what] Esthers really mean. So, the staff sometimes think, "This is very important." But when we give that back to Esther, she says, "Well, that's not so important for me. For me, this is important." So, the ESTHER Café is an activity to identify improvement possibilities. That's one of the activities.” [JKG-02]
Assimilation. By 2016, ESTHER had evolved from being a network to becoming assimilated as a mindset – the central concept driving innovation in the system in the Jönköping region. By this time, there was no funding targeted to ESTHER other than to support coach education and no single person responsible as leader, as it is intended to be part of the normal way of working. At the same time, without dedicated funding and leadership, questions remain about sustainability.
“As I said, it is a mindset. Now it is implemented in these programs -- the question: “What's best for Esther?” --, you will find you can't find one person who is responsible for ESTHER in Sweden, but there is a program group and the program group is trying to find out ways how to spread it in the whole region, because we have some difficulties there. It's a mindset and it should be part of the daily work. And we are getting there. I think it's very much dependent who is leading all these kind of leadership programs, and do they really take the ESTHER philosophy to heart?” [JKG-02]
At this point, all steering groups were removed, being seen as no longer necessary. This removal of infrastructure (formal structures, funding) initially concerned committed leaders, with a risk of co-optation of the ESTHER concept without true adherence in practice. However, there was a widespread sense among interviewees that the ESTHER philosophy has been assimilated as a core value that continues to influence all activities, permeating the culture to become the routine practice in Jönköping.
“It's a very normal mindset in one of our hospitals to ask the question, "What's best for Esther?" That's just a normal way of working and people are just using that word and that question.” [JKG-FL-01]
Case 2
Historical Context. Making Recovery Real gives people with lived experience of mental health difficulties the opportunity to be at the centre of decision-making, service design, and practice development in the community of Dundee, Scotland by changing the terms of the dialogue about recovery, mental health, and wellbeing. It began in 2015 as a collaboration of 10 local public, voluntary, and community organisations who responded to a call from the Scottish Recovery Network (SRN) to work together to take a new approach to improve the experience and outcomes for people living with mental illness. The partner organisations endeavoured to develop and deliver more recovery-focused policies and practice by answering the question: “How can we make recovery real in Dundee?” They brought together interested people, including those with lived experience, at collaborative cafés; a series of events where priorities and accompanying actions were identified, and where participants were equal contributors to the process and its outcomes. The priorities identified were to i) collect and share recovery stories so that lived experience is at the core of service design, delivery, and practice; ii) develop peer support roles and training; and iii) celebrate recovery [31].
Adoption. In the external context, the mental health system remained dominated by the medical model, a lack of system innovation, and acute services prioritized over community services. Yet, recent Scottish health and social care system integration has supported partnership working. Simultaneously, SRN, a national voluntary organisation established in 2004 to promote recovery principles within the mental health system, was shifting from working with the National Health Service toward building coalitions of change within communities and a whole-systems approach to promoting recovery. SRN solicited proposals from local groups and organisations, offering their support for community-based collaborations that would involve people with lived experience in developing local initiatives to support mental health.
Factors in Dundee’s internal context also converged to support a proposal put forward to SRN for an innovative approach. First, the Dundee Third Sector Interface (TSI), which supports the representation of third sector organisations in local authority planning, had been working to better involve people with lived experience in mental health system planning, and meetings with their network members were becoming more recovery focused. A recent inquiry into mental health services and a fairness commission on poverty (a longstanding local issue) also motivated the local council and Health and Social Care Partnership (HSCP) to take innovative action focused on prevention versus mitigation.
“And I think the health and social care partnership realized that they needed to do more than mitigation … they have been really, really clear on the need for new ways of doing things for about the last 10, 15 years.” [DND-02]
Furthermore, Dundee City was preparing to develop a new mental health strategic plan, and so, the TSI brought partners from across community services, the local authority, and representative groups who had been attempting to make change in the system to submit a proposal for SRN’s support. Individual leaders from within the partner organisations, motivated by their own lived or professional experience, were drawn by the innovation’s features: to support any concerned citizen to contribute their inherent resources through meaningful involvement and an asset-based approach:
“ … So lived experience is essential, bringing people together, involving everybody who wants to be involved in each aspect of the process, so firstly in agreeing what it is they want to achieve, then in making sure that is carried out, also in having an actual role in actively carrying it out, so not just identifying things other people should do but having a vested interest and an active contribution to the activities that are going to be–whatever it is that’s going to be done differently, basically.” [DND-04]
The coalition was successful in its proposal bid and began their process by increasing local knowledge of recovery approaches and exploring what recovery meant to local citizens. SRN acted as a change agency in developing this new philosophy, helping to alleviate tensions among the coalition.
Implementation. First, SRN helped to bring the individuals involved together to first establish a shared vision for the process among the local integration bodies (TSI and HSCP) and a TSI-supported service user network, reducing competition among the service provider partners. Within the inner context of the partnership, there was a commitment to coproduction processes and peer support as a critical opportunity to incorporate more lived experience into the mental health system. Despite these efforts, some of the original partners could not align themselves with the experience-led approach and discontinued their involvement knowing they could return at any time. Undaunted, the remaining partners proceeded by working with the ‘willing’.
“… at the very start, it was a case of, “Right. We don’t really know where we want this to go. And actually, are we the ones to be dictating where this should go? No, we’re not. What’s most important is that we’re listening to people with lived experience, people on the ground, and they should be the ones that are telling us what needs to be changing.” So from the beginning, the sort of first step was looking at how we can engage with local people. And we were really keen to make sure that it was meaningful … And we thought this involvement can’t be tokenistic. People need to be on board, and it needs to be collaborative from the start.” [DND-05]
To build connection and trust between participants while shifting to a peer-led approach, the implementation process involved facilitating a series of coproduced, discussion-based events where people with lived experience were invited to be involved in all stages from planning and executing the events, to identifying and achieving priorities. The role of professionals shifted to “being on tap, not on top” [01-DND-ST-02-01]. SRN provided developmental support to the Dundee partners to deliver the events, whose features were welcoming and inclusive, avoiding formal presentations in favour of fun, health-promoting activities that allowed community members to feel heard, and demonstrated alignment with their own ideas and values.
“… what we did – and I would say I think that really set the tone – was rather than have lots of presentations, what we did was, at the event, we welcomed everybody, but we invited lots of the groups to run taster sessions of the things they did. So that actually brought a lot of people with lived experience because they were coming along to demonstrate their finger painting. There was hula-hooping. There was wellness action planning. There was how to sleep well powwows. And in every corner of this venue, there was little groups of people who were painting pebbles, things like that. And then in the afternoon, we had a big conversation happen world café style. And the sort of comments we got from people were, “I felt this was my event. This was for me. It wasn’t for them, the professionals.” ” [DND- 02]
From these discussions, it emerged that understanding local experiences of personal recovery was the most preferred and effective conveyor of local knowledge and motivator for change for the range of stakeholders. Storytelling became the primary vehicle for relationship-building. Peoples’ stories were compiled into a film that premiered at a well-attended prestigious, ‘red-carpet’ event at a local cinema house, and subsequently became a tool to foster collaborative conversations at engagement events.
“And the film galvanised things and I think because we’d moved beyond that individual telling their story to having a 20-minute film of people reflecting on recovery, which is quite different from telling a story, say, of illness.” [DND-02]
The film drew strategic attention to MRR. This culminated into a consensus to embed recovery, backing for continued peer support, and recovery work into the new Dundee Mental Health Strategy and accompanying action plan.
Assimilation. The MRR approach has been included in the Dundee mental health strategy, and the partner organisations have adopted it to move the strategy forward, granting the third sector more influence and collective power in local health and social care planning. The adoption of the MRR approach by the Dundee HSCP has strengthened the importance of mental health locally, dovetailing with the recommendations of the independent inquiry on poverty. At the national level, a Scottish government funding program to increase the number of mental health workers in community-based services provided an opportunity for the HSCP to fund additional peer support roles, a key initiative within MRR.
Overall, the MRR partnership can be said to have had a transformative effect. It has led to better working relationships between providers and continues to drive progress. Partners are now far more involved in collectively determining the distribution of funding through the HSCP and in designing new mental health services. Furthermore, lived experience is being built into the system infrastructure through support for the local peer recovery network, development of peer support roles, implementation of peer-led services, peer support training provision, and building recovery awareness. A key feature of ongoing progress has been that lived experience partners have been able to move in and out of active participation roles throughout the process, as their recovery journeys and contexts have allowed.
“There was that sense of collaboration that continued ... We kind of all came together to discuss how we felt our organisations could contribute to that bigger picture and the strategic objectives moving forward, and not just the strategic objectives in relation to Making Recovery Real but the wider kind of city and what they were looking for in relation to the local mental health strategy and the city plan.” [DND-05]
Participants describe the process as a difficult yet joyful and rewarding journey. For some organisations, the introduction of the MRR approach has motivated significant recovery-oriented change in their values and structure, further cementing system-level impact.
“Making Recovery Real has really been – I suppose we’ve adopted the principles and approaches … We try to adopt those as far as possible in all of our work. And we don’t badge it all Making Recovery Real, but we use the learning from it, I would say, in everything we do now, everything in the program.” [DND-04]
Case 3
Historical Context. CMHA Learning Centres began development in Manitoba in 2015 as a coproduced adaptation and renaming of Recovery Colleges, which originated in England in 2009 with a focus on people with lived/living experience of serious mental illness. The aim of Recovery Colleges is to bring the lived experience of people with mental illness and other community members together with professional expertise to locally plan, develop, and deliver educational courses about mental health and recovery, with the aim of empowering people to support their mental health and wellbeing. The concept of recovery education originated in the US [32, 33], and before adopting the Recovery College model, CMHA Winnipeg had offered psychosocial rehabilitation (PSR)-based recovery education since the early 1990s. In 2015, the CMHA Winnipeg branch leader conducted an internal evaluation of this programming, which suggested that improvement was needed to meet the psychosocial health and wellbeing needs of the community. Around the same time, the new leader of the CMHA Central branch in Portage la Prairie, Manitoba sought a fresh approach to its clubhouse program, a mutual support drop-in centre, in response to member feedback. Leaders and service users of both branches embraced the Recovery College and coproduction approach to better meet client needs. CMHA Learning Centres build on the Recovery College principles, with the programming and the target audience expanded to promote living well among the broader population, as well as recovery education for people with lived experience of mental illness. The CMHA Central branch’s Thrive Learning Centre and the CMHA Winnipeg and Manitoba branch’s Well-being Learning Centre opened in September 2017 and January 2018, respectively.
Adoption. In the external context, the national policy context was supportive of a recovery and well-being approach; it was the focus of consultations over the 2008 to 2012 period prior to the release of Canada’s mental health strategy [34]. This enabled Manitoba bureaucrats to pressure provincial government leaders to co-sponsor a ‘Recovery Days in Mental Health Conference’ held in Winnipeg in June 2015. An English Recovery College champion was a keynote speaker and sparked interest in the model among CMHA branches in Manitoba. The Winnipeg Regional Health Authority (RHA), the major funder of the Winnipeg CMHA branch, also supported recovery and mental health promotion approaches. Informants reported that Manitoba’s culture of innovation and solidarity, with its many small rural communities, also aligned with the coproduction philosophy of inclusive innovation.
In the internal context, the Recovery College model resonated with existing branch cultures of deep commitment to recovery-oriented work and strong peer support foundations. CMHA’s federated structure allowed each branch autonomy to develop its own programming, with support from a national office. Attractive innovation features were the existing evidence base, emphasis on lived experience through coproduction in course development and facilitation, opportunity for student skill-building, and flexibility to accommodate local needs and strengths. The instructional climate was also appealing, as it could offer people with lived experience a sense of community and could promote their self-efficacy and confidence while reducing the power imbalance and fostering relationships between staff and students. The Recovery College model could also offer a more immediate response in terms of educational support to people needing care and facing long wait times for traditional services.
“I would say there’s probably many other things besides instruction. I think there’s relationship-building that happens so there are connections between students and between the facilitators and the learners. It’s the development of a space that allows for people to develop skills that are unrelated to the content. So, people also learn skills like sharing in a group context, so confidence-building, self-efficacy. When you can cultivate a skill in one area, you build confidence, and you start to believe that you have the ability to learn and to develop new skills. So that sense of self-efficacy is very integral to the recovery and well-being journey.” [WPG-02]
The importance of individual characteristics was demonstrated as passionate leaders in the Winnipeg and Central branches who were committed to advancing upstream mental health promotion and PSR were impressed by the model and together, they researched it further to inform adoption decisions. The coproduction process aligned with CMHA’s ‘nothing about us without us' approach and could foster a sense of ownership. In both branches, the name Recovery College was changed to Learning Centre during the adoption process, which better resonated with community and agency participants.
Implementation. In the external context, in early 2017, CMHA Winnipeg and Central branches met with CMHA National to implement Learning Centres. Although no new funding was made available by the RHAs, philosophical support enabled the repurposing of existing funding for recovery education and peer support. In 2018, CMHA National and CMHA Winnipeg leadership visited England to meet recovery-focused mental health services experts and to see the model in action. This visit was crucial in fostering strong relationships between the model initiators and CMHA leaders who discovered common visions to widen the target audience to anyone in the community interested in mental health issues, thereby making mental health a universal concern, and promoting a living well approach. Collaboration with an Ontario-based psychiatric hospital, with similar values and interest in Recovery Colleges, supported program evaluation to produce evidence of effectiveness.
Internally, the Winnipeg and Central branches collaborated on initial model and course development, and took a staged approach to opening their Learning Centres. In the Central branch, where resources were tighter and there was a large geographic area to serve, creative approaches to leverage local support and assets were used. Health professional placement students supported the small branch to prepare for launch and in doing so, encouraged staff buy-in. Another peer service organisation provided funding support and this, along with community grants, covered staffing, technology, social marketing, and other costs that are traditionally not eligible for provincial funding.
“[A] critical moment would be the establishment of a partnership. I think that was a critical moment. I walked away and I know my staff did, too, with an immense sense of relief after I could tell them that [a peer Manitoban mental health community organisation] was on board to help make this a reality.” [PLP-22]
The Winnipeg branch also leveraged internal resources, including an existing peer support group whose members assisted in developing the first five courses.
“And so we actually relied on some communities that existed within our CMHA. So we had a group of individuals who are peer supporters to one another. They had taken our workshops in the past. And then they created, on their own, their own support group, and designed that support group based on their needs and on an educational focus. So we actually asked them if they would be our initial coproduction group.” [WPG-04]
The passion of individual CMHA staff and leaders, many with their own lived experience, made them champions who demonstrated their commitment to valuing expertise derived from lived experience. These individuals also helped build the external linkages with organisations and key people both nationally and internationally. Innovation features allowed for initial small-scale implementation, leveraging local assets and community strengths before expanding further. The flexibility to offer ‘something for everyone’ and promote ‘living well in your community’ garnered broad interest and unanimous buy-in from community members. The flexibility of the model also allowed the Winnipeg branch to retain PSR influences from their colleagues at Boston College.
The collaborative coproduction process fostered a sense of ownership, friendship-building, balance across perspectives, and acceptance within the classroom. This affirming process allowed room for creative input, and for trial and error, with the process itself evolving to become more effective over time. It also facilitated the expansion of course offerings, as students were encouraged to lead future course development. Accompanying changes to the physical space and staff roles helped in welcoming the whole community, meeting the needs of vulnerable groups in society and addressing access barriers.
Assimilation. The Central branch has been unable to coproduce new Learning Centre material during the COVID-19 pandemic, yet it continues to offer its existing content. The Winnipeg Learning Centre was able to shift to virtual and then hybrid online and in-person coproduction activities, while ensuring fidelity to the core Recovery College principles.
“And some of the other things that are in the fidelity assessment are: Are you recovery-focused? Are you community-focused? Are you collaborating with the people who are consuming your services? So, it’s a really easy fidelity to conform to but also have room to be kind of creative because they’re not dictating what courses you should have. The fidelity is that you provide courses.” [WPG-04]
In Winnipeg, the Learning Centre continues to expand and evolve, and is reported to have had a gradual, but transformative impact on organisational context and values within the branch, by providing a universally accessible platform that demonstrates the value of engaging people with lived experience in every step. Leaders’ commitment to the model and ongoing evaluation to ensure it is meeting local needs have supported wider assimilation of coproduction approaches. The coproduction approach to course development has ensured that content remains current and relevant through creativity, diversity, and responsiveness to people’s needs. New leadership in the Central branch has expressed the desire to revive the Learning Centre’s coproduction activities.
Cross-Case Comparison
Adoption. Shifting ideas in the public policy realm and supportive external change agents created a conducive external context. In Cases 1 and 2, shifting ideas pertained to interprofessional and intersectoral collaboration, and in Case 3, national and provincial discussions about a recovery and well-being orientation were important precursors to coproduction with people with lived experience. Internally, tension for change was evident in all cases; however, the process by which this unfolded differed, as a natural progression of ongoing improvement efforts in Cases 1 and 3 and as a deliberate response to an opportunity created by an external change agent for local system-wide transformative change in Case 2. In all cases, passionate individuals, many with their own lived experience, and a philosophical approach that resonated deeply and widely was a core feature leading to adoption.
Implementation. In all three cases, building local partnerships and/or networks in the external context was integral to implementation. These partnerships and networks helped to overcome internal resistance within existing power structures (Case 1), created a community coalition that could move forward in the face of resistance within traditional mental health services (Case 2), and offered material support and expertise to support implementation (Case 3). In Cases 1 and 2, there was no ‘programme’ per se, rather a philosophy steered by guiding questions, and in Case 3, the Recovery College model itself was designed to realize its embedded philosophy through coproduced educational programming. These features drove a micro-level movement for change (all cases) that was locally adapted, for example, to become ‘something for everyone’ (in Case 3). Philosophical alignment also helped in building trust across collaborating organisations to support implementation, and as a shared foundation for overcoming differences during implementation. Implementation proceeded incrementally at the grassroots level in all cases and by working with the willing.
Assimilation. There has been a high level of assimilation across all three cases, with transformative impacts not only on the organisations involved but with impacts extending to the broader organisational and political context. A widely embraced mindset, new structures, and a growing international network (Case 1), impact on the local mental health strategy and continuing transformative effects on partnerships among community agencies (Case 2), and assimilation to other programs and branches (Case 3) are some of the ongoing transformative impacts. In Case 3, assimilation was characterized by customization, as both branches have changed the name and broadened the reach of Recovery Colleges, while maintaining fidelity to core principles. At the same time, challenges to sustaining such transformative change going forward were a concern without targeted leadership and funding (see Table 6).