Tag: community mental health

Care coordination as imagined, care coordination as done

IJIC aIn July 2018, in the context of writing about the COCAPP team’s newly published meta-narrative review of care planning and coordination in community mental health, I mentioned a further article which had just been accepted for publication. Today this paper has appeared online in the International Journal of Integrated Care. As with all outputs from the COCAPP study this new article is available in gold open access form, meaning that copies can be read and downloaded by anyone with an internet connection.

The paper is titled Care coordination as imagined, care coordination as done: findings from a cross-national mental health systems study. For a taster, here’s the abstract:

Introduction: Care coordination is intended to ensure needs are met and integrated services are provided. Formalised processes for the coordination of mental health care arrived in the UK with the introduction of the care programme approach in the early 1990s. Since then the care coordinator role has become a central one within mental health systems.
Theory and methods: This paper contrasts care coordination as work that is imagined with care coordination as work that is done. This is achieved via a critical review of policy followed by a qualitative analysis of interviews, focusing on day-to-day work, conducted with 28 care coordinators employed in four NHS organisations in England and two in Wales.
Findings: Care coordination is imagined as a vehicle for the provision of collaborative, recovery-focused, care. Those who practise care coordination are concerned with the quality of their relationships with service users and the tailoring of services, but limits exist to collaboration and open discussion. Care coordinators describe doing necessary work connecting people and the system of care. However, this work also brings significant administrative demands, is subject to performance management which distorts its primary purpose, and in a context of scarce resources promotes generic professional roles.
Conclusion: Care coordination must be done. However, it is not consistently being done in the way policymakers imagine, and in the real world of work can be done differently.

 

Public Uni

After finishing work next Thursday (October 15th 2015) I’ll be heading off to Chapter to take part in the 7th Public Uni. At Public Uni, which is organised by Marco Hauptmeier in the Cardiff Business School, academics get a ten minute opportunity to present their research to an assembled audience. I gather there is some retiring to the bar at some point in the evening, which seems very sensible.

Here’s the flyer for next week’s event: and what an eclectic bunch us five speakers are! In my slot the aim is to compress a history of mental health care, and a summary of where we are now, into 600 seconds of talking. What fun! For a taster of what I’m planning to say, here’s my summary:

Changing landscapeUntil the middle of the last century most formal mental health care was provided in hospitals. This changed with the emergence of community care. Dr Ben Hannigan, Reader in Mental Health Nursing in the School of Healthcare Sciences, explains how this change came about and discusses the people, policies and practices found within the system now.

Prospects and challenges: revisited

In 1999 I wrote a paper for the journal Health and Social Care in the Community titled Joint working in community mental health: prospects and challenges. The back story is that the work for this article was mostly done during my first year of part-time study for an MA in Health and Social Policy, during my time working as a community mental health nurse in East London.

Frustratingly, I can’t find my original wordprocessed copy of this paper from which to create a green open access version for uploading to the Orca repository and for embedding a link to here. But not to worry. The abstract, at least, is a freebie:

This paper reviews the opportunities for, and the challenges facing, joint working in the provision of community mental health care. At a strategic level the organization of contemporary mental health services is marked by fragmentation, competing priorities, arbitrary divisions of responsibility, inconsistent policy, unpooled resources and unshared boundaries. At the level of localities and teams, these barriers to effective and efficient joint working reverberate within multi-disciplinary and multi-agency community mental health teams (CMHTs). To meet this challenge, CMHT operational policies need to include multiagency agreement on: professional roles and responsibilities; target client groups; eligibility criteria for access to services; client pathways to and from care; unified systems of case management; documentation and use of information technology; and management and accountability arrangements. At the level of practitioners, community mental health care is provided by professional groups who may have limited mutual understanding of differing values, education, roles and responsibilities. The prospect of overcoming these barriers in multidisciplinary CMHTs is afforded by increased opportunities for interprofessional ‘seepage’ and a sharing of complementary perspectives, and for joint education and training. This review suggests that policy-driven solutions to the challenges facing integrated community mental health care may be needed and concludes with an overview of the prospects for change contained in the previous UK government’s Green Paper, ‘Developing Partnerships in Mental Health’.

Fifteen years on the structural divisions remain. As with other areas, community mental health care continues to be funded and provided by a multiplicity of agencies, with ‘health care’ and ‘social care’ distinctions still very much in place. This year’s Report of the Independent Commission on Whole Person Care for the Labour Party and the King’s Fund’s work on integrated care are examples of recent initiatives aimed at closing these gaps. Labour’s Independent Commission recommends the creation of a new national body, Care England, bringing together NHS and local authority representatives at the highest level. Note, of course, that these proposals are for England only: these are ideas for health and social care in one part of a devolved UK.

In my article I drew attention to the problem of competing policies and priorities for NHS and local authority organisations, the lack of shared organisational boundaries, non-integrated information technology systems and separate pathways bringing service users into, through and out of the system. An illustrative example I gave was the parallel introduction, in the early 1990s, of the care programme approach (CPA) and care management. Here in Wales, with the introduction of the Mental Health (Wales) Measure there is now, at least, a single care and treatment plan (CTP) to be used with all people using secondary mental health services. But how many health and social care organisations in Wales and beyond have managed to integrate their information systems? This, I suspect, remains an idea for the future.

And then there are the distinctions, and the relationships, between the various occupational groups involved in community mental health care. In my Joint working paper I emphasised the differences in values, education and practice between (for example) nurses and social workers, and (perhaps rather glibly) suggested that the route to better interprofessional practice lay through clearer operational policies at team level. Getting mental health professionals to work differently together became, for a time at least, something of a policymakers’ priority in the years following my article’s appearance. Here I’m thinking of the idea of distributed responsibility, and ‘new ways of working’ more generally, of which more can be found in this post and in this analysis of recent mental health policy trends (for green open access papers associated with both these earlier posts, follow this link and this link).

Two other things strike me when I look back on this 1999 article and reflect on events in the time elapsing. First is how much I underemphasised, then, the importance and influence of the service user movement. Over 15 years much looks to have been gained on this front, and I detect improved opportunities now for people using services to be involved in decisions about their care. Services have oriented to the idea of promoting recovery, as opposed to responding solely to people’s difficulties and deficits. This all takes me neatly to COCAPP and Plan4Recovery, two current studies in which I am involved which are investigating these very things in everyday practice. Second, I realise how little I foresaw in the late 1990s the changes then about to happen in the organisation of community mental health teams. Not long after my paper appeared crisis resolution, early intervention, assertive outreach and primary care mental health teams sprung into being across large parts of the country. More recent evidence suggests a rolling back of some of these developments in a new era of austerity.

And what of the community mental health system’s opportunities and challenges for the fifteen years which lie ahead? Perhaps there’s space here for an informed, speculative, paper picking up on some of the threads identified in my Joint working piece and in this revisiting blog. But that’s for another day.

More on mental health services at a time of austerity

For the second time in two months the BBC and Community Care have collaborated to establish the extent of funding cuts to mental health services in England. Freedom of Information requests were sent to 51 NHS trusts, of whom 43 responded. Summaries of this investigation, and headline findings, can be found on the BBC website here and on the Community Care website here. Community Care says:

Data returned by over two-thirds of the mental health trusts, obtained in two separate Freedom of Information requests, showed that:

  • Overall trust budgets for 2013/14 had shrunk by 2.3% in real terms from 2011/12. Ten out of 13 trusts that provided forecast budgets for 2014/15 are projecting further cuts next year.
  • Budgets for ‘crisis resolution teams’ fell 1.7% in real terms compared to 2011/12 while the average monthly referrals to these teams rose 16%. The teams provide intensive home treatment in a bid to prevent acutely unwell people being hospitalised.
  • Budgets for community mental health teams flatlined in real terms but referrals rose 13.3%. These services provide ongoing support in a bid to prevent people’s mental health deteriorating to crisis point.

Community Care also lists 10 ways this underfunding is damaging care.

This is also the month that a special, free-to-download, ‘impact of austerity’ edition of Mental Health Nursing journal has appeared. In an email forwarded to all members of Mental Health Nurse Academics UK by Steve Hemingway (who is both an MHNA member and a member of the MHN editorial board), Dave Munday at Unite the Union (which publishes the journal) says:

This month the Mental Health Nursing journal is focused on austerity and mental health. I hope you’ll agree with me that this is a vitally important topic that not only every mental health nurse should know about, but every citizen. We hope that the journal will help to trigger some thoughts and debates that you can have locally in your workplaces but also outside of work. To this end we’re making the journal free to access even if you’re not a MHNA member or MHN subscriber.

Mental health services at a time of austerity

Last week I drafted a short, commentary-type, paper for a special edition of Mental Health Nursing which will be focusing on practice and services during a time of austerity. Some years ago I was on the editorial board of MHN. I’m pleased to learn that having disappeared from the library shelves in favour of becoming an online journal (available only to members of Unite the Union) it has made a return in traditional paper form. I’ve been sent a stack of copies, which I’ll be distributing to students.

Anyway: no sooner had I completed my draft and sent it onwards than yesterday’s big health and social care story broke. Under the banner England’s mental health services ‘in crisis’ the BBC ran a report drawing on a joint investigation conducted with Community Care magazine. The headlines were sobering, suggesting over 1,500 mental health hospital beds being lost since April 2011. These bald figures were illustrated with personal stories, revealing people needing crisis admission being transferred to wherever beds could be found around the country, and wards running at over 100% occupancy.

This is very bad news, and suggests a shrinkage back to the way things last were in the early to mid 1990s. In writing my paper for MHN I fished out my copy of this article by David McDaid and Martin Knapp, in which the point is made that at times of economic hardship demand for mental health care increases. And yet, as we are finding, services are actually retracting as austerity bites.

Divergence and difference in mental health policy

Yesterday’s main business was a there-and-back trip to the University of Nottingham to act as a PhD external examiner. Reading this (very interesting) thesis in advance, discussing with the candidate at viva and talking with supervisory and examiner colleagues over lunch has reminded me (again) how mental health policy and services in Wales and England are diverging.

As an example, there really is no equivalent to the Mental Health (Wales) Measure on the English side of the Severn Bridge. For those not in the know here, ‘measure’ in this context means ‘law’. The Welsh Government’s brief public summary of this piece of legislation says:

The Mental Health (Wales) Measure 2010 is a new law made by the Welsh Government which will help people with mental health problems in four different ways.
Local Primary Mental Health Support Services
The Measure will make sure that more services are available for your GP to refer you to if you have mental health problems such as anxiety or depression. These services, which may include for example counselling, stress and anxiety management, will either be at your GP practice or nearby so it will be easier to get to them.
You will also be told about other services which might help you, such as those provided by groups such as local voluntary groups or advice about money or housing.
Care Coordination and Care and Treatment Planning
Some people have mental health problems which require more specialised care and support, (sometimes provided in hospital). If you are receiving these services then your care and treatment will be overseen by a professional such as a psychiatrist, psychologist, nurse or social worker. These people will be called Care Coordinators and will write you a care and treatment plan – working with you as much as possible. This plan will set out the goals you are working towards and the services that will be provided by the NHS and the local authority and other agencies to help you reach them. This plan must be reviewed with you at least once a year.
Assessment of people who have used specialist mental health services before
If you have received specialised treatment in the past and were discharged because your condition improved, but now you feel that your mental health is becoming worse, then you can go straight back to the mental health service which was looking after you before and ask them to check whether you need any further help or treatment. You don’t need to go to your GP first, although you may wish to talk it through. You can ask for this up to three years after you are discharged from the specialist team.
Independent Mental Health Advocacy
If you are in hospital and you have mental health problems you can ask for help from an Independent Mental Health Advocate (IMHA). An IMHA is an expert in mental health who will help you to make your views known and take decisions in relation to your care and treatment (but will not take decisions on your behalf!)

COCAPP, as some readers of this blog will already know, is investigating care planning and care coordination in community mental health: so the Care Coordination and Care and Treatment Planning component of the Measure is a really important part of the study’s context. It will be interesting to see how far national-level legal and policy differences are ‘felt’ at the level of everyday practice.

There are other important differences in emphasis across the two countries, too. I hear anecdotally that to save money some of the work done by England’s assertive outreach and early intervention teams is being called back into comprehensive, locality-based, community mental health teams (CMHTs). Assertive outreach and early intervention teams, alongside crisis resolution and home treatment services, sprung up in England in the first decade of this century following the publication of the National Service Framework for Mental Health, the Policy Implementation Guide and the NHS Plan. Here the strategy document Adult Mental Health Services for Wales, which appeared in 2001, was strong in its commitment to CMHTs and as a result (I have always thought) we never had quite the range of differentiated services which England had. We have, of course, got crisis services in Wales, as I have previously written about here, here and here.

And it’s not only in the mental health field that policy and services are diverging. We have no clinical commissioning groups in Wales, for the obvious reason that the Health and Social Care Act 2012 applies to England only (for more on this, check out this post dating back to the time I heard Raymond Tallis speak at the Hay Festival).