Geoff Shepherd, Jed Boardman and Maurice Burns POLICY Implementing Recovery A methodology for organisational change
Geoff Shepherd, Jed Boardman and Maurice Burns
POLICY
Implementing Recovery
A methodology for organisational change
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Box 1: 10 Key organisational challenges
1) Changingthenatureofday-to-dayinteractionsandthequalityofexperience
2) Deliveringcomprehensive,user-lededucationandtrainingprogrammes
3) Establishinga‘RecoveryEducationUnit’todrivetheprogrammesforward
4) Ensuringorganisationalcommitment,creatingthe‘culture’.Theimportanceofleadership
5) Increasing‘personalisation’andchoice
6) Changingthewayweapproachriskassessmentandmanagement
7) Redefininguserinvolvement
8) Transformingtheworkforce
9) Supportingstaffintheirrecoveryjourney
10) Increasingopportunitiesforbuildingalife ‘beyondillness’
(fromImplementing Recovery: A new framework for organisational change,
SainsburyCentre,2009).
“If adopted successfully and comprehensively, the concept of recovery could transform mental health services and unlock the potential of thousands of people experiencing mental distress. Services should be designed to support this directly and professionals should be trained to help people to reach a better quality of life. This will mean substantial change for many organisations and individuals.”
FutureVisionCoalition(July2009)
Introduction
‘Recovery’isawordcommonlyusedbypeoplewithmentalhealthproblemstodescribetheirstrugglestolivemeaningfulandsatisfyinglives.Theprinciplesofrecoverynowprovideaconceptualframeworktounderpindevelopmentsinmentalhealthservicesinanumberofcountries(Australia,NewZealand,IrelandandUSA).InEngland,theyfigureprominentlyintherecentpolicydocumentNew Horizons(DepartmentofHealth,2009)andhavereceivedwidespreadsupportfromthemajorprofessionalbodies.Althoughtheseprinciplesdonotconstituteanewformoftreatment thatcanbeappliedtopeopletomakethem‘recover’,webelievethatmentalhealthserviceswillcontinuetoplayacentralroleinsupporting–orimpeding–peopleintheirpersonalrecoveryjourneys.Thispaperpresentsapracticalmethodologytohelpmentalhealthservicesandtheirlocalpartnersbecomemore‘recovery-oriented’intheirorganisationandpractices,andtherebytosupporttheseprocessesmoreeffectively.
ItisthethirdinaseriesarisingfromtheSainsburyCentreforMentalHealthrecoveryproject.Thefirstpaper,Making Recovery a Reality(Shepherdet al.,2008)providedasummaryofthekeyprinciplesandtheirimplicationsforpractitioners.Thesubsequentposition paper,Implementing Recovery: A new framework for organisational change (SainsburyCentre,2009)presentedaframeworkfororganisationalchangeconsistingof10keychallengesthatneedtobeaddressedbymentalhealthservicesiftheyaretomovetowardsbecomingmorerecovery-oriented(seeBox1).Itwasdevelopedfromaseriesofworkshopsheldinfivementalhealthtrustswhichidentifiedthewaysinwhichrecoveryprinciplescould
bestbeincorporatedintoroutinepractice.Theworkshopswereattendedbymorethan300healthandsocialcareprofessionals,managersandrepresentativesfromlocalindependentorganisations.Theyalsohadextensiveinputfromserviceusersandcarers.
AlltheNHStrustsinvolvedintheworkshopshadmadeseriouseffortstodevelopmorerecovery-orientedservicesandhadcommitmentfromtheirseniormanagement,uptoBoardlevel,todoso.However,itwasclearthattherewasnosingleoverallapproachandnoone,uniquemodelofacomprehensiverecovery-orientedservice.Thekeyorganisationalchallengesidentifiedintheworkshopsthusprovideastartingpointtoassistinthedevelopmentofcomprehensiveandconsistentservices:theyarenota‘blueprint’forachievement.Thetaskisnowtoexploreexactlyhowthisorganisationalchangeagendacanbestbeaddressed.
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Thispaperpresentsamethodologicalapproachtoaddressthesechallenges.Itcanbeappliedbothbylocalmentalhealthproviders(statutoryandnon-statutory)andbyhealthandsocialcarecommissioners.Mentalhealthtrusts(andotherproviders)mayuseitaspartofafocused,self-assessmentprocess;alternatively,itcanbeusedtofacilitatediscussionsbetweenlocalserviceprovidersandcommissionersintheirjointattemptstomakeprogresstowardsmorerecovery-orientedservices.Webelievethatitprovidesaninnovativestartingpointforatruly‘person-centred’approachtoservicedelivery.
Whilerecognisingthatwhatweareaddressingherearecomplexmattersoforganisationalchange,weaimtodescribethechallengesandtheprocessesinvolvedinaclear,user-friendlyform.Indoingso,wealsohopetoprovideacommonlanguagewhichwillhelpproviderstoassesstheirprogresstowardsmorerecovery-orientedservicesandhelpcommissionersandproviderstoworktogetherto‘co-produce’systemchange.ThisisattheheartofthecommissioningguidancerecentlyissuedbytheNationalMentalHealthDevelopmentUnit,(NMHDU/NHSCommissioningSupportforLondon,2009).
Developing the methodology
Themethodologywasdevelopedbyagroupofcommissionersandserviceproviders,includingrepresentativesfromstatutoryandnon-statutoryorganisationsandwithcontributionsfromtheRecoveryCentreattheUniversityofHertfordshire.TheinitialworkwasalsodiscussedwithawidergroupofregionalcommissionersintheEastofEngland.Theprojectgroupfocusedon‘servicelevel’outcomes,differentiatingthesefrom‘individuallevel’outcomeswhichmaybeusedforassessingpersonalrecovery,suchastheRecoveryStar(MentalHealthProvidersForum,2008).
Atanorganisationalleveltherearealreadyanumberofinstrumentsandapproachesavailablewhichattempttomeasure‘recovery-orientation’.TheseincludetheDevelopingRecoveryEnhancingEnvironmentsMeasure(DREEM)(Ridgeway&Press,2004);theRecoverySelfAssessment(RSA)tool(O’Connellet al.,2005);theScottishRecoveryIndicator
(ScottishRecoveryNetwork,2009);andtheRecoveryPromotionFidelityScale(RPFS)(Armstrong&Steffen,2009).Theseinstrumentsareallusefulintheirownways,buttheyareoftenverylaboriousandtimeconsumingtouse(Dinnisset al.,2007).Somealsosimplydescribegeneralgoodpractice,ratherthanbeingspecifically relatedtorecoveryprinciples;othershaveproblemswithcross-culturalgeneralisationofitems.NonehavebeenspecificallydesignedanddevelopedforuseinanEnglishcontext(theScottishRecoveryNetworkcomesclosest).Hence,thereisaneedforanewinstrumentwhichcanbeusedeitherasaself-assessmenttool,oraspartofacommissioner/providerdialogue.
Views of commissioners
Inourdiscussionswithcommissionersitwasclearthatmanywereinterestedinsimplemetricsthatcouldbeusedto‘score’therecoveryorientationofalocalserviceand‘benchmark’itagainstcomparators.Whilethisisunderstandable,itposesconsiderableproblemsforasetofprincipleswhicharedifficulttodefineunambiguouslyandhavecomplicatedimplicationsforprocessesandpractice.Overlysimplifieddescriptionsarethereforenotjustdifficult,theymayalsobemisleadingandmayevenhamperinnovationanddevelopment.
Somecommissionersviewedthesheervolumeofinternationalliteratureandthebewilderingvarietyofexistinginstrumentstoassessorganisationalandindividualprogresstowardsrecoveryasbarrierstoorganisationalchange.Otherswantedtoadopta‘pickandmix’approach,selectingoutcomeindicatorsandmeasuresthatseemedtofitwithlocalcircumstancesandpracticability.Again,thisunderlinedtheneedtodevelopanapproachwhichwascomprehensive,butstillassimpleaspossible,andrelevanttolocalservices.
Inthecurrentclimateofeconomicandfiscaluncertainty,commissioners(andproviders)werealsounderstandablypreoccupiedwiththeprospectsoffacingafuturereductionofbudgetsandtheneedtoimproveeffectivenesswithoutincreasingcost(RoyalCollegeofPsychiatrists,NHSConfederationMentalHealthNetwork&LondonSchoolofEconomicsandPoliticalScience,2009).Wethereforewantedtoensurethatrecovery-orientedserviceswerenotseenasrelevantonlyinthe‘goodtimes’
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andsothemajorityoftheimplicationsforservicechangeimpliedbytheframeworkarecostneutral.Theydependonchangingthewaysinwhichthingsaredone,ratherthanonaninjectionofnewresources.Someevenhavethepotentialtoresultincostsavingsinthelonger-term;forexample,throughreducedserviceuseconsequentuponhigherratesofemployment,orreducedstaffingbudgetsresultingfromthesuggestedchangestotheprofessionalskill-mixoftheworkforce.
Manycommissionersalsoexpressedaninterestinusingsomeoftheleversofrecenthealthsystemreformtodrivetheperformanceofproviderstowardsmorerecovery-orienteddelivery.Theseincluded:
Thenew,standard,nationalMentalHealthContract(DepartmentofHealth,2010);
Consideringhowrecovery-orientedpracticecanbecostedandincentivisedwithinthedevelopmentofanationalsystemformentalhealthservicePaymentbyResults(PbR);
Combiningindividuallevelrecoveryoutcomeswithservicelevelchangeinanewkindofcommissioningcycle(asinNMHDU/NHSCommissioningSupportforLondon,2009);
Incorporatingacoresetofindicatorsfromothertools/measuressuchastheNationalSocialInclusionProgrammeindicatorset(NationalSocialInclusionProgramme,2009);
UsingCommissioning for Quality and Innovation(CQUIN)todeliverrecovery-orientedqualityimprovements(DepartmentofHealth,2008).
Manyoftheseinitiativesmayproveusefulinthelongterm,althoughitwilltakesometimebeforemostofthemareestablishedandbeddedin(forexample,thenewtariffformentalhealthservicesisnotnowexpecteduntil2013/14).Inthemeantime,therangeofissueshighlightedhereclearlydemonstratethatcommissioningmentalhealthservicesinthiscountryiscurrentlyinacomplexandrapidlychangingstate.Wethereforewantedtodevelopatoolwhichwasofimmediatepracticalvaluetoprovidersandcommissionersandtootherlocalstakeholders–includingserviceusersandtheirfamilies–andcouldhelpthemintermsofdeliveringmorerecovery-orientedservicesnow.
Aftertheframeworkhasbeenmodifiedandrevisedthroughfield-testing,wehopethatitmayinformthedevelopmentofasetof
standardsforregulatorssuchastheCareQualityCommissiontoclarifytheirexpectationsregardingthedevelopmentofrecovery-orientedservices.Thiswouldgivethenecessary‘top-down’incentivesfororganisationalchange,inadditiontotheessentially‘bottom-up’approachdescribedhere.Botharenecessaryforwidespreadandconsistenteffects.
How to use the methodology
ThemethodologyisspecificallyrelevanttoanEnglishmentalhealthservicecontext,althoughwebelieveitwillalsobeofinteresttoplannersandservicedevelopersinothercountries.Ourintentionisthatitshouldbeclear,systematicandnotunnecessarilybureaucraticortime-consuming.Wehavetakena‘systemsapproach’toservicechangewhichaimsexplicitlytoincludeallthelocalstakeholdersinthementalhealth‘system’–themainNHSprovider,localindependentsectorproviders,commissioners,serviceusersandcarers.Theeventualvalueoflocalsystemsinsupportingpeoplewithmentalhealthproblemsto‘recover’andlivetheirlivesastheywishwillultimatelydependonthequalityofpartnershipworkingbetweenthesedifferentagencies.
Themethodologyhelpsthoseusingittodevelopanunderstandingofthekeyideas(the‘vision’)behindwhatconstitutesrecovery-orientedservicesforthelocalarea,beforemovingontodevelopastrategyforcreatingthenecessarychangetoimplementtheseservicesandagreeingspecifictargetsandprecisemeasurements.Progressisthenmonitoredandreviewed,plansarerevised,newplansformulated,implemented,furthermonitored,reviewedandrevised.Thisformofinternalauditloop(or‘Plan-Do-Study-Act’cycle)isrecommendedasthemosteffectiveprocessforproducingsustainedorganisationalchange(Iles&Sutherland,2001).
Assessing services at the outset
Wesuggestthatthemethodologyisusedinatwophaseprocesscarriedoutjointlybetweenproviders(orprovidersandcommissioners)andtheirlocalstakeholders.Inthefirstpartoftheprocessthestakeholderstrytogettogripswiththecomplexitiesoftheideasunderlyingeachchallenge.Theythenassessthelevelof
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Box 2: Definitions for the three stage classification
Stage 1: Engagement
Theorganisationisclearlyengagedinitsintenttodeliverrecovery-orientedservices.AtaBoardlevelthereisanacknowledgementandownershipthattheorganisationneedstochangetowardsmorerecovery-orientedservices.Thereisanawarenessofexistinggoodareasofpracticeandthecommitmenttobuildonthese.Planstodeliverrecovery-orientedserviceshavebeenagreedandatimetableforimplementationisinplace,buttherehasbeenlittleprogressasyet.Weenvisagethatmosttrustswillstartatthislevelonmostdimensions.
Stage 2: Development
Actionisbeingtakenwithsomeevidenceofsignificantdevelopmentsinpractice,policyandculture.Goodprogressisbeingmadeindeliveringrecovery-orientedservicesinsomeareas,butthisisnotconsistentthroughouttheorganisation.Weenvisagethatsomeofthemoreadvancedtrustswillberatedatthislevelforatleastsomeofthedimensions.
Stage 3: Transformation
Thevisionforachievingsignificantchangehasbeenfullyrealised.Thenecessarypolicy,processesandpracticetodeliverarecovery-orientedserviceareembeddedateveryleveloftheorganisation–fromBoardstoteamsandfrontlineworkers.Thereareprocessesinplacetoachievecontinuousimprovementsbasedonlearningfromongoingreview.Theorganisationworksproactivelywitharangeofotherpartnersinsupportingpositivementalhealthandwellbeing.Weenvisagethatthislevelwillbeaspirationalformosttrustsonmostdimensions.
progressionofthemainmentalhealthproviderusingasimple,threepointclassification:‘Stage1=Engagement’,‘Stage2=Development’and‘Stage3=Transformation’(seeBox2andtheFrameworkonpages8-19).Thisassessmentprovidesasummaryofthecurrentsituationandcouldbeusedfor‘benchmarking’purposes,althoughitsprimarypurposeistodevelopajointunderstandingoftheconceptsandtheirimplicationsfororganisationalchange.Providersandotherlocalstakeholdersshoulddrawontheirdifferentperspectivestocometoasharedconsensusregardingthestageofdevelopmenttheyhaveachieved.ThiscanthenberecordedinTemplateA(seepage18).
Havingcompletedthisgeneralassessment,stakeholdersthenmovetothesecondpartoftheprocess.Inthistheyjointlyagreetheprioritiesfororganisationalchange.TheywillneedtoprioritiseactioninasmallnumberofareasandagreeasmallnumberofSMART(Specific,Measurable,Agreed-upon,Realistic,Time-based)goalstodefinethetargetsandmonitorprogress.Oncethegoalsareset,theywillbeimplemented,progresswillbemonitoredandthegoalswillberesetandthenfurthermonitoredinaniterativecycle.
Agreeing priorities for action
Itisclearthateachofthe10keyorganisationalchallengespresentsapotentiallysubstantialagendaforchange.Togethertheyopenupopportunitiestotransformservicesinwaysthataremuchmoreconsistentwiththeprioritiesofserviceusersandtheirfamilies,buttheyimplyalotofwork.Weacceptthatitisunlikely(andunrealistic)thatallthe10challengescanbeaddressedimmediately.Anorganisationalchangestrategywillneedtobeimplementedoveranumberofyearsandthenumberofprioritiesagreedatanyonetimeshouldbelimitedtoarealisticnumber(saynotmorethanfiveatanyonetime).The10keychallengesarenotlistedinpriorityorderandwehavenospecificviewsaboutthechoiceofwheretostart.Clearlyalllocalservicesaredifferentandallwillstartfromadifferentpoint.Nevertheless,itwouldseemsensibletoacknowledgeexistingstrengthsandtobuildonareasofrelativeweakness.
Basedonourexperienceinworkingwithtrustsandotheragenciesthatarecommittedtodevelopingrecovery-orientedservices,our
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impressionisthattwoparticularlyimportantchallengesshouldbeconsideredearlyon.TheseareChallenges‘3’and‘4’.WithoutaddressingOrganisationalChallenge3(Establishing a Recovery Education Centre) therewillbenofocusfordeliveringthetrainingprogrammesforstaffanduserswhicharenecessarytodrivetheorganisationforwards.WithoutaddressingOrganisationalChallenge4(Ensuring organisational commitment)thetraininginitiativesarelikelytohaveonlylimitedimpact.Leadershipandorganisationalcommitmentarealwaysimportantinanykindoforganisationalchangeprocessandmovingtowardsmorerecovery-orientedservicesisnoexception(Whitleyet al.,2009).
Tracking progress
Oncethereisagreementabouttheservicelevelgoalstobeachievedandacleardescriptionoftheactions,timescalesandresponsibilitiesforachievingthem,progresscanbetrackedusingasimpleformsuchasthatsuggestedinTemplateB(seepage19).
Toassistwithsettingandmonitoringspecifictargets,wehaveshownexamplesofservicelevelindicatorsandpotentialdatasourcesforeachoftheorganisationalchallenges.Theseexamplesareintendedtobeillustrativeratherthanprescriptiveandalternativeindicatorsmaybesubstitutedoraddediftheyreflectbetterthechosentargets.Providersandcommissionersshoulddeterminelocallywhichindicatorstheyaregoingtouseandhowambitiousthetargetswillbe.Thisgivesthemmaximumflexibility,withinaclearandcomprehensiveframework.OtherrecentpublicationssuchastheNationalSocialInclusionProgrammeserviceoutcomesandindicatorsmayalsobehelpful(NationalSocialInclusionProgramme,2009).
Future developments
Theprofileofrecoveryanddiscussionsabouthowtoimplementrecoveryideaswithinmentalhealthserviceshavegatheredconsiderablemomentuminrecentyears.Positivechangesaretakingplaceinmanyareasoforganisationalpracticeandservicedelivery.Inthiscontextofemergingdevelopments,wewouldnotexpectany‘goldstandards’ofbestpracticeidentifiedearlyin2010necessarilystilltoberelevantin
fiveyears’time.Indeed,ifthisworkcontributestoagenuinetransformationagenda,itwouldbeapositiveoutcomeifmuchofitappeareddistinctlydatedby2015.
Indevelopingthemethodology,somepeoplehavesuggestedthatweshouldspecifyminimumstandardsinmuchgreaterdetailanddevelopatoolmorelikeanInternationalOrganisationforStandardisation(ISO)accreditationscheme(seewww.iso.org)wherebystandardscanbeexternallyvalidatedandbenchmarkedacrossorganisations.Whilethisremainsanoptionforthefuture,webelievethatitisnotthebestwaytoproceedatthistimeasthedevelopmentofthesetypesofstandardsmaybetoolimitedandformulaic.Italsorunstheriskoflockinglocalprovidersandcommissionersintoarigidviewofwhatmustbeessentiallyinnovativedevelopments.
Themethodologyattemptstodescribeaconstructiveprocessof‘co-production’betweenlocalprovidersandcommissioners,inpartnershipwithserviceusersandcarers,whichaimstotransformservicesthroughthedevelopmentofthejointlyagreed,keyareasofrecovery-orientedpractice.Thekeyelementdrivingthistransformationwillthereforebethejointworkoflocalsystems,settingpriorities,agreeinggoalsandcontractsandthenmovingtheprocessforward.ThisiswhatwemustmaintainifWorld Class Commissioninginmentalhealthistobeachieved.
SainsburyCentre,theNMHDUandtheNHSConfederationwillnow‘fieldtest’themethodologywithanumberofcommissionersandprovidersaspartoftheactionscontainedintheNew Horizonsprogramme(DepartmentofHealth,2009,p.56,Action79).Wewillreviseandmodifythemethodologyinthelightofthatexperience.FuturedevelopmentsandupdateswillbepostedontheSainsburyCentrewebsitewww.scmh.org.uk.
Framework and templates
ThefollowingpagespresenttheFrameworkforeachofthe10keyorganisationalchallenges.Thisisfollowedbytemplatestohelporganisationstoidentifytheirpriorities.
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Acknowledgements
ThispaperwascommissionedbySainsburyCentreanddraftedbyGeoffShepherd,JedBoardmanandMauriceBurns(NationalMentalHealthDevelopmentUnit).Wewouldliketoacknowledgeandthankthefollowingcontributors:
DrGlennRoberts,DevonPartnershipNHSTrust
TonyPethick,HomeGroup
JessLievesley,NHSEastofEngland
MarkJordan,HertfordshirePCT/CountyCouncil
LindaSeymour,SainsburyCentreforMentalHealth
JanWoodward,HertfordshirePartnershipNHSFoundationTrust
ChristopherMunt,RecoveryCentreUniversityofHertfordshire
AnneMarkwick,HertfordshirePartnershipNHSFoundationTrust
JimSymington,NationalMentalHealthDevelopmentUnit
References
Armstrong,N.P.&Steffen,J.J.(2009)TheRecoveryPromotionFidelityScale:Assessingtheorganisationalpromotionofrecovery.Community Mental Health Journal,45,163-170.
DepartmentofHealth(2008)Using the Commissioning for Quality and Innovation (CQUIN) Payment Framework: For the NHS in England 2009/10.London:DepartmentofHealth.
DepartmentofHealth(2009)New Horizons: A shared vision for mental health.London:MentalHealthDivision,DepartmentofHealth.
DepartmentofHealth(2010)Guidance on the NHS Standard Contract for Mental Health and Learning Disability Services 2010/2011.GatewayReference13323.London:DepartmentofHealth.
Dinnis,S.,Roberts,G.,Hubbard,C.,Hounsell,J.&Webb,R.(2007)User-ledassessmentofarecoveryserviceusingDREEM.Psychiatric Bulletin,31,124-127.
FutureVisionCoalition(2009)A Future Vision for Mental Health.London:NHSConfederation.
Iles,V.&Sutherland,K.(2001)Organisational Change: A review for health care managers, professionals and researchers.London:NationalCo-ordinatingCentreforNHSServiceDeliveryandOrganisation(NCCSDO),LondonSchoolofHygieneandTropicalMedicine.
MentalHealthProvidersForum(2008)The Mental Health Recovery Star Tool.(http://www.mhpf.org.uk/recoveryStar.asp)
NationalMentalHealthDevelopmentUnit/NHSCommissioningSupportforLondon(2009)Mental Health World Class Commissioning.London:CommissioningSupportforLondon.(http://www.csl.nhs.uk)
NationalSocialInclusionProgramme(2009)AppendixC.ServiceOutcomeIndicators,inOutcomes Framework for Mental Health Services.London:NationalSocialInclusionProgramme.(http://www.socialinclusion.org.uk/publications)
O’Connell,M.,Tondora,J.,Croog,G.,Evans,A.&Davidson,L.(2005)Fromrhetorictoroutine:assessingperceptionsofrecovery-orientedpracticesinastatementalhealthandaddictionsystem.Psychiatric Rehabilitation Journal, 28,378-386.
Ridgeway,P.A.&Press,A.(2004)Assessing the Recovery Commitment of your Mental Health Services: A user’s guide for the Developing Recovery Enhancing Environments Measure (DREEM) – UK version 1 December, 2004.Allott,P.&Higginson,P.(eds.)([email protected])
RoyalCollegeofPsychiatrists,NHSConfederationMentalHealthNetwork&LondonSchoolofEconomicsandPoliticalScience(2009)Mental Health and the Economic Downturn: National priorities and NHS solutions.OccasionalPaperOP70.London:RoyalCollegeofPsychiatrists.
SainsburyCentre(2009)Implementing Recovery: A new framework for organisational change. Positionpaper. London:SainsburyCentreforMentalHealth.
ScottishRecoveryNetwork(2009)Scottish Recovery Indicator.http://www.scottishrecoveryindicator.net
Shepherd,G.,Boardman,J.&Slade,M.(2008)Making Recovery a Reality.London:SainsburyCentreforMentalHealth.
Whitley,R.,Gingerich,S.,Lutz,W.J.&Mueser,K.T.(2009)Implementingtheillnessmanagementandrecoveryprogramincommunitymentalhealthsettings:facilitatorsandbarriers.Psychiatric Services,60,202-209.
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ORGANISATIONAL CHALLENGE 1: Changing the nature of day-to-day interactions and the quality of experience“We are not cases and you are not our managers!” Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Thereisarecognitionthatrecoveryprinciplesandvaluesareimportant,butfewsystematicattemptshavebeenmadetoimplementthembychangingstaffbehaviour.Staff(andserviceusersandcarers)arefamiliarwiththegeneralprinciples,butunclearabouttheirimplicationsforpractice.Usersarenotgenerallyconsultedregardingthequalityofservicesdeliveredandstaffperformance.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Thereisclearevidenceofarecognitionthateverysignificantencounterbyeverymemberofstaffshouldreflectrecoveryprinciplesandpromoterecoveryvalues–aimingtoincreaseself-control(‘agency’),increaseopportunitiesforlife‘beyondillness’,andvalidatehope.Someattemptshavebeenmadetoensurethattheseprinciplesarereflectedinpractice,(e.g.pilotstoinvolveserviceusersandstaffselectionand/orevaluation)butthesearenotreflectedinroutinestaffsupervision.Someuserinvolvementinstaffselection,butnotroutine.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Everysignificantencounterbyeverymemberofstaffaimstoreflectrecoveryprinciplesandpromotesrecoveryvalues–increasingself-control(‘agency’),increasingopportunitiesforlife‘beyondillness’,andvalidatinghope.Eachinteractionacknowledgesnon-professionalexpertiseandattemptstominimisepowerdifferentials.Therehavebeensystematicattemptstoensurethattheseprinciplesarereflectedinday-to-daypractice(e.g.localaudits,useofNationalPatientSurveydata,etc.).Theimportanceofthequalityofstaff/userinteractionshasbeenincorporatedintostaffsupervisionandperformanceratings.Usersareroutinelyinvolvedinstaffselection.Humanresource(HR)policiesvalidaterecoverytrainingandlinkthistoopportunitiesforstaffprogression.
Examples of (service level) outcome indicators Proportionofstafftrainedinbasicrecovery-orientedpractice; AdoptionofSainsburyCentre’s‘TenTopTipsforRecovery-OrientedPractice’intooperationalpolicyand
practice; Systematicsurveysofuser(andcarer)perceptionsofstaffbehaviourinrelationtorecoveryprinciples(e.g.
usingmodifiedquestionsfromtheNationalPatientSurvey); Supervisionandappraisalsystemsarerevisedtopromotestaffinteractionsthatdemonstratepartnership
workingwithserviceusers; Proportionofinstancesofserviceusersbeinginvolvedinstaffselection.
Possible data sources NationalPatientSurveydata,orsimilarlocalprojects; Systematicsurveyofuser(andcarer)viewsregardingthequalityofday-to-dayinteractionswithstaffand
theextenttowhichthesereflectrecoveryprinciplesandvalues; Recordsofcompositionofinterviewpanels; Auditofstaffappraisals/supervision.
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ORGANISATIONAL CHALLENGE 2: Delivering comprehensive user-led education and training programmes “I’ve got into various groups, as an advocate and a representative for service users, and I found that extremely beneficial … made you feel less isolated and that you can help others. The most help I got was from the other people in the ward who had gone through similar experiences.”Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Thereisacommitmenttoincreasingthecoverageofuser-ledteachingandtrainingonrecovery,butitremainspatchy.Sometraininghastakenplace,butlessthan25%ofstaffhavebeeninvolved.Therehavebeenfewattemptstoembedlearningfromrecoverystoriesintopractice.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Arangeofevidenceconfirmstheincreasedprofileofuser-andcarer-ledtrainingonrecovery,supportedbyanagreedstrategyandpolicy.Approximately50%ofstaffhavereceivedtraininginrecoveryprinciplesformulatedandledbyserviceusers(andcarers).Thereissomeevaluationoftheeffectsoftraining,butthisisnotdonesystematically.Thefurtherdevelopmentofuser(andcarer)ledtraininghasBoardapprovalandfundingisbeingsought.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Acohortoftrainedserviceusersareinplaceactingas‘championsofchange’forrecoverywithintheorganisation.Serviceusersareacknowledgedasequalpartnerswithinacomprehensiverangeofrecoveryeducationandtrainingprogrammesandaprogrammeofuser-ledtraininginrecoveryhassecurefunding.Usersandcarersarecontractuallyengagedintheorganisationtodelivertrainingtostaffonrecoveryprinciples.Morethan75%ofstaffhavereceivedtraining.Thereisacontinuousprogrammeofevaluationandaudittomeasuretheimpactofthistrainingandteachingstandards.Positivepracticechangesareroutinelyimplementedasaresultofthetraining.
Examples of (service level) outcome indicators Acohortofuserandcarertrainershasbeenestablishedandusersandcarersarebothformulatingand
deliveringprogrammes; Adirectoryofaccrediteduserandcarertrainersisinplace; Ongoingfundingidentifiedforrollingprogrammesofuser-ledtrainingandeducation; Modulartrainingbeingplannedtoensuresustainability.
Possible data sources Systematicauditandevaluationtoestablishtheimpactofuserandcarerteachingandtraining; Evaluationroutinelygatheredattrainingandteachingevents,ananalysisofwhichisavailableinreport
form; Adirectoryofaccrediteduserandcarertrainers; Protocolstodemonstrateinvolvementatallphasesoftrainingandteaching.
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ORGANISATIONAL CHALLENGE 3: Establishing a ‘Recovery Education Centre’ to drive the programmes forward “The coaching programme has helped me to identify my aspirations, prioritise my goals and realise what I can realistically achieve. Before this I had never been so enthusiastic and optimistic about the future.”Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Thereisarecognitionthatcurrentattemptstoinvolveandsupportserviceuserstodelivertrainingonrecoveryhavebeenconductedonanad hocbasis.Itisagreedthatthereneedstobeamorestrategicapproach,butlittleprogresshasbeenmadeindevelopingthis,orconsideringhowitwillbedelivered‘ontheground’.Therehavebeendiscussionsaboutcentralisingtrainingandworkinginpartnershipwithuser-ledtraininggroups,butthesehavenotbeenfinalised.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Thereareplanstotakeamoresystematicapproachtosupportserviceusersinthedeliveryofrecoverytrainingtostaff.Formalcontractsarebeingconsidered(e.g.withalocalindependentsectorprovider)toprovidethisfunctionandthereareplanstobuildonthismodel.Areviewofexistingserviceuser-ledprogrammeshasbeenundertakenwithaviewtorefocusingtheseintoahubforpromotingrecovery-orientedpracticeacrosstheorganisation.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
A‘RecoveryEducationCentre’hasbeenestablishedwithintheorganisation.Thisisstaffedandrunby‘usertrainers’anddeliverssupportandtrainingforserviceuserstotrainstaffinrecoveryprinciplesforteamsandonwards.(Itmayormaynotbedeliveredbyanexternal,independentsectoruser/trainerorganisation.)TheCentrealsorunsprogrammestotrainserviceusersas‘peerprofessionals’toworkalongsidetraditionalmentalhealthprofessionalsasdirectcarestaff.Arrangementsforthemanagement,supervisionandsupportofthesestaffareco-ordinatedbytheCentrestaff.TheCentreofferscoursestoserviceusers,theirfamiliesandcarersonrecoveryandthepossibilitiesofself-management.Therearearangeoflinkstogeneraleducationalclassesinthecommunityandpathwaystocoursesandotherlearningopportunities.
Examples of (service level) outcome indicators Establishmentof‘RecoveryEducationCentre’,withstablefunding,employingatleast3-4usertrainers; Competencies,standardsandsupportidentifiedforpeersupportworkers; ‘RecoveryEducationCentre’activeintrainingandsupporting50serviceuserseachyearaspeer
professionalswithintheservice(andotherlocalservices,statutoryandindependent); Employmentofmultiplepeerprofessionalswithinexistingteams(includinginpatientwards).
Possible data sources Recordsof‘RecoveryEducationCentre’trainingprogrammesdelivered,curriculum,numbersofstaff/service
userstrainedorsupported; Auditofstaffandserviceusersonsatisfactionofprogrammesdeliveredbythecentre; Evidenceofpartnershipagreementswithexternalbodiessuchasuniversitydepartments,collegesetc.; Numbersofpeer-ledtrainingcoursesrun; Numberofpeerspecialiststrainedtoagreedstandardsandcompetencies.
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ORGANISATIONAL CHALLENGE 4: Ensuring organisational commitment, creating the ‘culture’. The importance of leadership“We are committed to services that build on the individual’s inner resilience and coping strategies and not on interventions that undermine or stifle these innate qualities of hope and potential.” TrustMissionstatement
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Thereisrecognitionthroughouttheorganisationthatthecultureneedstochangefroma‘problem-based’approach(focusonillnessandsymptoms)toa‘strengths-based’approach.Plansareinplacetoreviewinternal‘pathways’(referralsystems,assessments,careprogrammeapproach(CPA),dischargeplanning,etc.)tomakethemmorerecovery-oriented,butlittleprogresshasbeenmade.Therearecommittedindividualsleadingtheimplementationofrecoveryprinciples,buttheyareisolatedandonlyoperatingatateamlevel,oratseniorlevel,notboth.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
TheBoardhasendorsedaRecoveryStrategy,includingcoreunderpinningprinciplesandvalues.Thisisreflectedinthewordingofexternalandinternalpublications.Theorganisationisactiveatalllevelscommunicatingitsrecoveryapproach.ThereisevidenceofBoardworkshops,staffpresentationsandtrainingprogrammes.Recoveryforumshavebeenestablishedinpartnershipwithserviceusers.Someinternal‘pathways’(referralsystems,assessments,CPA,dischargeplanning,etc.)havebeenreorganised,withuserinvolvement,soastosupportrecoveryprocesses.Whilstthereareanumberofrecoveryinitiatives,itisrecognisedthatculturalchangehasnotyetoccurredatalllevelsandinallpartsoftheorganisation.Monitoringrecoverypracticedoesnotappearinstaffsupervision.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Recoveryconceptsareevidentatalllevelsoftheorganisation.ThereisstrongleadershipandactionatBoardleveltoensurethatthisisreflectedthroughalllevelsofmanagementandbyfrontlinestaff.Thereisrecognitionoftheneedtodeveloppartnershipworkingwithserviceuserssothatprofessionalexpertisedoesnotdominateoverthewisdomof‘livedexperience’.Theservicepromotesanenvironmentofhopeandoptimismthatrecognisestheuniquenessandstrengthsofeachindividual.Recoveryvaluesareembeddedineveryoperationalpolicy,managementprocessincludingrecruitment,supervision,appraisalandaudit.Allkeyinternal‘pathways’(referralsystems,assessments,CPA,dischargeplanning,etc.)havebeenreorganised,withusercollaboration,soastobettersupportrecoveryprocesses.
Examples of (service level) outcome indicators Policiesandproceduresdemonstrateorganisationalcommitment; Evidencethatinternal‘pathways’havebeenreviewed,incollaborationwithserviceusers,andredesigned
soastobettersupportrecoveryprocesses; Recordingofcareprocessesreflectshiftinculturalapproachtowardsstrengths-basedapproach; Theorganisationhasestablishedroutineauditofserviceuserexperienceandsatisfactionandfollows
throughonfeedbackreceived; Routineuseofindividualrecoveryoutcomemeasures.
Possible data sources Nationalandlocalsurveysofserviceusers; Auditoflocallyagreedstaffperformanceindicatorswithdesiredoutcomesidentifiedbyserviceusersand
carers; Recruitmentpracticesreflectwillingnesstoappointstaffwithahistoryof‘livedexperience’(see
OrganisationalChallenge8); Revisedpoliciesforriskassessmentandmanagement; Internalandexternalcommunicationsandpublicationsreflectrecoveryvalues; Caserecords(forrecoveryoutcomemeasures).
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ORGANISATIONAL CHALLENGE 5: Increasing personalisation and choice “I now feel in the driving seat for my life and wellbeing.” Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Thereisrecognitionthattraditionalcareplanningmustbechangedtogiveamuchgreateremphasistousers’prioritiesandtheachievementof‘lifegoals’,butthisisnotactivelymonitored.Thereissomeuseofinstruments,suchastheWellnessRecoveryActionPlan(WRAP),butthesearenotgenerallyused.Therehavebeensomeattemptstoincreasetheuseof‘personalbudgets’,butthisisnotwidespread.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Thereisagrowingmovetowardsgreaterpersonalisationandchoiceintermsoftreatmentandmanagementoptions.Newpoliciesreflectarevisedapproachtoshareddecisionmakingandjointplanning.Thereisevidencethatmorethan50%ofusersfeelactivelyinvolvedindirectingtheirCPAprocessanddeterminingthecontentoftheircareplan.Theorganisationhasproducedarangeofinformationandinterventionstosupportself-managementapproaches.Therehasbeenasubstantialincreaseintheuptakeofdirectpaymentsandtheuseofpersonalbudgets.Therehasalsobeenasignificantexpansionintheuseofjointlyagreed‘advancedirectives’(e.g.jointcrisisplans).AttemptsarebeingmadetoincorporateWRAPobjectivesintocareplans.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Theplanninganddeliveryofallservicesisdesignedtoaddresstheuniquecircumstances,history,needs,expressedpreferencesandcapabilitiesofeachserviceuser.Thereisaclearemphasison‘lifegoals’asopposedtosymptomtreatmentgoals.Usersareroutinelysupportedtocontrolanddirecttheirowncareplans,ataleveltheyarecomfortablewith.Morethan75%feelconsultedandinvolved.Organisationalpoliciesaffirmthatserviceusersshoulddirecttheirowncareprocess.Ifnecessarytheyaregivensupporttodoso(e.g.advocacy).WRAPandjointcrisisplansareinroutineuse.Thereiscontinuousevaluationtomeasureorganisationalcommitmenttopersonalisationandchoice.
Examples of (service level) outcome indicators Evidencethatallcarepathwayshavebeenreviewedtoidentifypointsforchoicestobeexercisedandfor
shareddecisionmakinge.g.treatmentoptions,medication,choiceofclinician; Availabilityofadvocacyservices; Progresstowardsagreedtargetsforpersonalbudgets; Dedicatedpostsareestablishedtoassistwiththe‘personalisationagenda’,e.g.‘brokers’(forindividual
budgets),advocates,etc.; Publishedinformationisavailabletoassistserviceuserstomakeinformedchoicesabouttreatmentoptions
(medical,psychologicalandsocial); Policiesarerevisedtostresspersonalisationincareplanningandtheencouragementofself-management; Clinicalgovernancestructuresincludepromotionofpersonalisationandchoiceasstandingitems.
Possible data sources Dataregardingtheuptakeof‘individualbudgets’(numbersandamountofvariation); Numbersreceivingadvocacyservices; Organisationalpoliciesandproceduresrelevanttochoiceandpersonalisation; Serviceusersurveys(e.g.NationalPatientSurvey)focusingontheextenttowhichchoice,agencyand
controlareexperienced; Informationleaflets; Contentoftrainingcourseswhichdemonstratesafocusonpersonalisation.
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ORGANISATIONAL CHALLENGE 6: Changing the way we approach risk assessment and management“The possibility of risk is an inevitable consequence of empowered people taking decisions about their own lives.”DepartmentofHealth
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Theorganisationisawareofthevalueofsystemsandproceduresthatsupportopen,transparentriskassessmentandmanagementpolicieswithinarecoveryframework.Somestaffareconversantwiththisapproachandsomeattemptsaremadetoinvolveserviceusersintheprocess,butitis‘patchy’(lessthan25%ofstaffinvolved).Thereisambivalenceaboutthevalueof‘positive’risktakingandthishasnotbeenaddressedataBoard/generalpolicylevel.Staffremainpreoccupiedwithriskasastaffissuealone.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Thereisarecognitionoftheneedforsafetywhileactivelypromoting‘positive’risktaking.Theorganisationhasintroducedformalproceduresthatsupportopen,transparentriskassessmentandmanagementpolicieswithinarecoveryframework,butthesehavenotbeenimplementedthroughouttheorganisation.TheseissueshavebeendiscussedatBoardlevel,butnoclearpolicieshaveresulted.Somestafftraininghasbeenundertakenandaround50%ofstaffareimplementingpoliciestoinvolveserviceusersintheirownriskassessment.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Theorganisationhasinplacesystemsandproceduresthatsupportopen,transparentriskassessmentsandmanagementpolicieswithinarecoveryframework.Theprocessroutinelyinvolvesserviceusersandtheirknowledgeofthemselvestoformulatesafeandeffectivemanagementplans.Allstaffarefullyconversantwiththisapproachtoriskassessmentandmanagementandarecomfortablewithit.Thereisaclearcommitmentonthepartoftheorganisationasawholetovalue‘positive’risktakingandawillingnesstoexamineandlearnfromincidentsandsupportstaff,ratherthan‘blame’themifuntowardincidentsdooccur.ThishasbeenmadeexplicittostaffbytheBoardandhasbeenreflectedinaction.Theorganisationhassuccessfullyreconciledtheneedtobalanceitsdutyofcaretoprovidesafeserviceswhilepromotingapositiveapproachtoriskassessmentandmanagement.
Examples of (service level) outcome indicators Staffhavereceivedtrainingintheapplicationofrecoveryprinciplestoriskassessmentandmanagement
andthisisbuiltintoallinductions; Riskassessmentandmanagementprocedures(e.g.CPA)containaclearexpectationthatserviceuserswill
beroutinelyinvolvedintheseprocessesandthisissystematicallyaudited; Trainingintheuseof‘JointWellbeingPlans’hasbeendeliveredandthesehavebeenincorporatedinto
routinepractice; Theorganisationroutinelyexaminesseriousanduntowardincidentreportswithaviewto‘learningthe
lessons’ratherthanapportioningblame; Riskmanagementpoliciesreflectashifttowardssupportingpositiverisktaking,whileensuringappropriate
corporategovernanceandadherencetosafepracticeandregulatoryrequirements.
Possible data sources Stafftrainingrecords; CPAauditresults; Clinicalgovernancerecords; Boardpolicies.
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ORGANISATIONAL CHALLENGE 7: Redefining service user involvement “Nothing about us without us” Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Theorganisationhasacceptedthatserviceusers(andcarers)shouldplayanimportantpartintheplanninganddeliveryofcare,butitisstillapparentthatthefinaldecisionsremainwiththe‘professionals’.Thereissomeevidenceofsystematicchangestoenhancetheroleofusersandcarersaspartnersincare,buttheirknowledgeandexpertiseisstillseenassecondary,ratherthanprimary.Theprinciplesof‘userinvolvement’areaccepted,butthisisnotreflectedintrue‘partnershipworking’.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Theorganisationhasacceptedtheroleofserviceusers(andcarers)asequalpartnersincare.ABoard-levelpolicyonuserinvolvementatalllevelsintheorganisationfromclinicalcaretostrategicplanninghasbeenagreedandisbeingimplemented.Thisacknowledgementofthecentralcontributionofusersandcarersisreflectedinpoliciesandproceduresgoverningthedeliveryofindividualcareandtheworkofteams.Approx.50%ofstaffunderstandhowtoadapttheirroletobe‘educators’(‘coaches’)and‘mentors’,ratherthantraditional‘therapists’.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Theorganisationhasclearlyacceptedtheroleofserviceusers(andcarers)asequalpartnersincare.Itrecognisesthattheirknowledgeandexperienceisvital(‘expertsbyexperience’)andthatthey–andtheirnetworks–mayhavesolutionstomanyoftheproblemsthatstafffindmostdifficult.Thisacknowledgementoftheneedforpartnershipisclearlyreflectedinpolicyandpracticeatalllevels–individualpractitioners,teamsandmanagers.Allstaffunderstandhowtodelivertheirexpertiseinthecontextofmoreequal‘partnershipsincare’andtheyarecomfortablewiththeirnewposition(‘on tap, not on top’).Theorganisationiscontinuallyreviewingitsprocessesforpartnershipworkingwithserviceusersandcontinually‘raisingthebar’intermsofextendingtheroleofserviceusersincontrollingthecareprocess.Thisnotseenasanabnegationofprofessionalresponsibilities,noradowngradingofprofessionalexpertise,insteaditisseenasahigherformofprofessionalpractice.
Examples of (service level) outcome indicators Serviceusers(andcarers)reportthattheyfeelconsultedasfull‘partnersincare’. Theyreportastyleof
workingwherestaffsharetheirexpertiseandexperience,ratherthancommandingattention; Thelanguageof‘partnership’isusedconsistentlyinwrittenmaterialsproducedbytheorganisationto
describetheprocessesofcareandservicedelivery; Serviceusersandcarershavesignedcareplanstoconfirmthattheyhavebeeninvolvedintheprocessof
careplanningatanindividuallevel; Robustplansareinplacetoensurethatserviceusersandcarersarefullyinvolvedinserviceplanningand
governancestructures.
Possible data sources Stafftrainingrecords; NationalPatientSurveydata,orsimilarlocalsurveys; Informalfeedbackfromindividuals(e.g.PatientGovernors); Boardpoliciesandminutes,newsletters,pressreleases,etc.; Auditofcareplans; PatientCouncilreports,Boardreports,notesofLocalInvolvementNetworks(LINks)meetings.
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ORGANISATIONAL CHALLENGE 8: Transforming the workforce “When my last worker met with me I was left with a feeling of hopelessness, it was all about my symptoms. When I see you we talk together about what I want for my future and I am full of optimism.” Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
TheBoardandseniormanagershaverecognisedthattransformingtheworkforcemayrequireachangeintheskillmixandbalancebetweentraditionalmentalhealthprofessionalsandpeoplewhoseexpertisecomesfrom‘livedexperience’.Thereareexamplesofstaffwith‘livedexperience’beingemployedincare-givingroles,e.g.SupportTimeandRecovery(STR)workers,buttheseareisolated,withlittlemanagerialsupportandsupervision.Humanresource(HR)andoccupationalhealthserviceshavenotbeenreformedandnothoughthasbeengiventoissuesof‘careerprogression’forpeerstaff.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Thetrusthasclearplansinplacethatwillleadtothecreationof‘peerspecialist’rolesacrosstheorganisation.Theseplansincludeclearjobdescriptions,identificationoftrainingresources,supervisionandmanagementresponsibilities,strategiesforplacementinteams,timescalesforcompletion,etc.Asmallnumberofserviceusershavebeenappointedintopaidpositionsintheworkforce,butonalimitedscale(e.g.5-10postsscatteredthroughtheorganisation).Plansareinplaceforpilotswhichwillprovidemoreintensiveinput(e.g.atleasttwoserviceusersperteam)withappropriatemanagerialsupport.Issuesregardingcareerprogressionforpeerspecialistshavebeendiscussed.ThetrusthasbeguntoaddressthespecificHRandoccupationalhealthproblemsassociatedwiththerecruitmentofgreaternumbersofpeoplewithdirectexperienceofmentalhealthproblemsintotheworkforce.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Theorganisationhasfullyacceptedthatpeoplewhohavedirectexperienceoflivingwithmentalillnesscan,withappropriatetrainingandsupport,makeasignificantcontributiontotheworkforce.Mostteamshaveanequalnumberofpeerprofessionalsworkingalongsideotherprofessionals.Peerspecialistsareseenashavinguniquequalificationsandexperiencewhichisdifferentfrom,butequalto,thoseoftraditionalmentalhealthprofessionals.Theyarethereforepaidandgivenstatusaccordingtotheirexperienceandexpertiseindeliveringthisrole.HRprocessesandoccupationalhealthassessmentshavebeenadjustedsoasnottoprovideobstaclestotheemploymentofpeoplewithmentalhealthproblems(asrequiredbytheDisabilityDiscriminationAct[DDA]andthetargetsunderPublicServiceAgreement[PSA]16).Cleararrangementsforsupervisionandcareerprogressionareinplace.
Examples of (service level) outcome indicators Clearidentificationofresponsibilityfordeliveringtrainingandsupportforpeerprofessionals(e.g.
partnershipagreementwithexternalspecialistprovider); Clearjobdescriptionsandpersonspecificationsagreedforpeerprofessionals; Peerspecialiststobethefirstpointofcontactwhereverpossibleateachstageofcarepathway; Numberofstaffemployedas‘peerspecialists’; Numbersofpeoplewithmentalhealthproblemsemployedinthecurrentworkforce(PSA16targets)
regularlymonitored.
Possible data sources RevisedHR,occupationalhealthandCriminalRecordsBoard(CRB)policieseliminatingbarriersto
employment; Staffingrecords; HRdataonskillmixandtrends; RecruitmentdatarecordedforDDA.
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ORGANISATIONAL CHALLENGE 9: Supporting staff in their recovery journey“Hear what I have to say and support me to do it” Staffmember
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Thereisawarenessthatmanystaffhavetheirownexperiencesoflivingwithmentalillnessandofrecovery,butthisremainslargelyunacknowledgedandtheyarenotencouragedtousetheseexperiencestoinformtheirworkpractice.Thereisstillconsiderablestigmaamongstaffregardingrevealingmentalhealthproblemsandthishasnotbeenaddressedprivately,orinthecontextofrecoverytraining.Staffhavebeengivenlittlehelpinthinkingabouthowtodevelopdifferentwaysofdeliveringtheirexpertise.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Theorganisationrecognisestheneedtosupportstaffinthedisclosureoftheirownlivedexperienceofmentalhealthproblemsandthisisincludedasanoptionalpartofrecoverytraining.Theorganisationrecognisestheneedtoensurethatthereareopportunitieswithinindividualsupervisiontoaddresstheseissues.Theorganisationisdevelopingasharedapproachwithstafftodeliveritsvisionregardingrecovery.Staffgenerallyreportfeelingincludedinthisprocessandcanseeaclearwayforward.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Staffdonotfearstigmaorprejudicefromcolleaguesintheworkplaceiftheyrevealtheirpersonalexperienceoflivingwithmentalillnessinanappropriatesetting.Allstaffhavereceivedappropriateinductionandtrainingandhavebeensupportedtohelpthemusetheirpersonalknowledgeandexperiencetohelpothersandtooptimisetheirownwellbeing.Theorganisationhasinplacecomprehensiveprovisionstooptimisestaffhealthandtoconstructivelyaddressstaffhealthproblems(e.g.augmentedoccupationalhealthservices).Thepersonalqualitiesandpriorexperienceofstaffarevaluedandincludedasselectioncriteria.Theorganisationformallyrecognisesthecommitmentandcreativityofstaffandfullyinvolvesthemintheimplementationoftherecoveryvision.
Examples of (service level) outcome indicators Comprehensivepolicyandpracticedevelopmentsreflectingtheneedtooptimisestaffmentalhealth,e.g.
programmestosupportstaffinpersonalself-careandself-management; Anonymousstaffsatisfactionsurveys,withevidencethatresultsareactedupon; Recruitmentpracticeshavebeenamendedsoastopositivelyreflectthevalueoflivedexperienceamong
staff,aswellasformalqualifications; ThereisBoard-levelcommitmenttotheprinciplesofMindfulEmployer(www.mindfulemployer.net).
Possible data sources Boardstrategypapers,evidenceofroutinereportsonstaffwellbeing; HRandoccupationalhealthpolicies; Staffsicknesslevelreturns; Staffmoralesurveys; Staffsickness/turnoverrates; Staffsurveyreturns.
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ORGANISATIONAL CHALLENGE 10: Increasing opportunities for building a life ‘beyond illness’ “I am no longer my illness.”Serviceuser
Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so
Theorganisationhasaninter-agencystrategytopromotesocialinclusion,butlittleconcreteprogresshasbeenmade.Theorganisationisreviewing(orhasreviewed)withserviceusersandcarerswhatneedstobeinplaceinthecommunitytosupportrecovery.Someeffectivepartnershipsdoexistwithindependentsectorproviders(housing,employment,education,etc.)butthisispatchy.Similarly,someworkhasbeendonetoreducestigmainthecommunity,butthisisrelativelyunfocusedandtoogeneraltohavespecificimpact.Evidence-based,supportedemployment(IndividualPlacementandSupport,IPS)isnotwidelyavailable.
Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture
Theorganisationhasinplaceastrategyforthedevelopmentof‘mainstream’communitysupport(includinghousing,employment,leisureandmentalhealthpromotion)andgoodprogresshasbeenmaderegardingimplementation.Theorganisationhaseffectivepartnershipsinplacetoprovideimprovedaccesstopaidemployment.IthasbeguntoappointIPS-trainedemploymentspecialiststosometeams.Operationalpolicieshavebeenrevisedtopromotecommunityintegrationondischargefrominpatientcare.Allserviceusershaveanagreedplanthattheyandtheircarersfeelissafeandwillsustaintheirrecovery.Workhasbeendonetoreducestigmaanddiscriminationamongcertainkeyagencies(e.g.housing,employers,policeandneighbourhoods).Theseprojectshavebeenledbysuitablytrainedserviceusers.
Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different
Theorganisationrecognisesthatfullcitizenshipandcommunityintegrationisessentialinpromotingindividualrecovery.Ithasdevelopedarangeofeffectivepartnershipswithexternalorganisationstosupportindividualsinbuildingalifeforthemselvesindependentofformalmentalhealthservices.Thereisafocusonpromotingsettledaccommodation;maintaininganddevelopingrelationships;paidemploymentandtraining;andfullinclusioninordinarycommunityactivities.Peersupportnetworkshavebeendevelopedtosustaincommunityinclusion.ThereisaparticularemphasisontheimportanceofpaidemploymentandIPSworkershavebeenestablishedinallteams.Issuesforpromotionofhealthandwellbeingacrossdiversecultureshavealsobeenaddressed.Theorganisationsupportssocialinclusionthroughacomprehensiverangeoftargetedanti-stigmaworkinthecommunitiesthatitserves.Theseprojectshavebeenledbysuitablytrainedserviceusersandthereisactivefollow-up.
Examples of (service level) outcome indicators Partnershipswithemploymentandtrainingspecialistsareinplace; Ratesofserviceusersattainingandsustainingpaidemploymentareregularlymonitored(PSA16); NumberofemploymentspecialiststrainedtodeliverIndividualPlacementandSupport(IPS)ineachteam; Numberofcareplanswithadequateassessmentsofemploymentneedsandappropriateactionplans; OtherPublicServiceAgreement(PSA)Indicators(e.g.8,15and21)arealsoregularlymonitoredandthe
resultsfedintoactionplans; Theorganisationroutinelyauditstheeffectivenessofdischargeplanstosustainrecovery; UseofNationalSocialInclusionProgrammeIndicatorset(2009).
Possible data sources KeyPerformanceIndicatorinformationonPSA16Targetsfornumbersofpeopleinemploymentandsettled
accommodation; Servicelevelagreementswithemploymentprovidersandotherpartners; Dischargeratesfromservices; Serviceuserandcarerquestionnairesregardingsatisfactionwithdischargearrangementsfrominpatient
care; NationalSocialInclusionProgrammeServiceOutcomeIndicatorsdataset(NSIP,2009).
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Organisational Challenge
Stage 1
Stage 2
Stage 3
Priority for action
(1-10)Comments
(tick one)
1. Changingday-to-dayinteractions
2. Comprehensiveuser-lededucationandtraining
3. EstablishingaRecoveryEducationUnit
4. Ensuringorganisationalcommitment
5. Increasingchoiceand‘personalisation’
6. Changingapproachestoriskassessmentandmanagement
7. Redefininguserinvolvement
8. Transformingtheworkforce
9. Supportingstaffintheirrecoveryjourney
10.Buildingalife‘beyondillness’
TEMPLATE AThisformshouldbecompletedbytheproviderorganisation’sleadforrecovery,incollaborationwithlocalstakeholders(serviceusercarergroups,independentsectorprovidersandcommissioners)followingdiscussionsabouttheOrganisationalChallenges(1-10).Thesediscussionsshouldbeopenandhonestandaconsensusreachedregardingappropriateassignmenttoeachbroadlevelofprogress.EachChallengecanbe‘scored’,buttheprimaryaimistoagreeprioritiesandthestartingpointforfurther,moredetailedactionplanning(seeTemplateB).
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TEMPLATE B ThisformshouldbeusedonceTemplateAhasbeencompletedtodevelopspecificactionplansinrelationtoparticularOrganisationalChallenges.Localtargets,timescalesandevidencesourcesshouldbeagreedjointly.
ORGANISATIONAL CHALLENGE:
CURRENTSTANDARD Stage1[] Stage2[] Stage3[] (Pleasetickone)
Describe:
Localgoals(agreedbycommissionersandproviders)
1.
2.
3.
Date:
Specificactionsrequiredtomakeprogressongoalsbeforenextreview
1.
2.
3.
Evidencesources:
Commissionername: signature:
Providerleadname: signature:
NextReviewDate:
Sainsbury Centre for Mental Health
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About the authors
Professor Geoff Shepherd is Senior Policy Adviser to the Sainsbury Centre. He is a clinical psychologist by background and is also visiting professor in the Health Service and Population Research Department at the Institute of Psychiatry.
Dr Jed Boardman is Senior Policy Adviser to the Sainsbury Centre. He works as a Consultant Psychiatrist and Senior Lecturer in Social Psychiatry at South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry. He is Lead for Social Inclusion at the Royal College of Psychiatrists.
Maurice Burns is Programme Manager for the World Class Mental Health Commissioning Programme at the National Mental Health Development Unit. He is a social worker by background and has held the post of Director of Mental Health in two NHS Trusts.
© Sainsbury Centre for Mental Health, 2010. Recipients (journals excepted) are free to copy or use the material from this paper, provided that the source is appropriately acknowledged.
Cover photograph: F.R.A. Taylor
Copies of the following can be downloaded from www.scmh.org.uk
Making Recovery a Reality (2008); Ten Top Tips for Recovery-Oriented Practice (2008); Implementing Recovery: A new framework for organisational change. Position Paper (2009).