Implementation of Care Programme Approach for people with learning disabilities and mental health issues very limited in London NHS Trust

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The Care Programme Approach (CPA) was introduced in the early 1990s as a response to a number of high profile situations involving significant lack of coordination of care. The CPA meant that anyone with experiencing severe mental health problems and who meets one or more criteria, should have their care co-ordinated under the Care Programme Approach which covers assessment, planning and reviewing mental health care needs.

One of the criteria set out in the original guidance which should lead to getting care coordinated in this way was if the person had a learning disability. At the time of its introduction, the health and social care system was undergoing strategic and organisational change as a result of the introduction of the ‘purchaser/provider’ split and the introduction within adult social services departments of the role of the care manager.

The researchers in this study were interested in looking at what was currently happening for people with learning disabilities who also had mental health issues. They were interested in looking at what factors at the strategic level might be helping or hindering progress in the use of the CPA currently.


What they did was to look at the experiences in one a mental health National Health Service Foundation Trust in a large English city. This Trust was in the process of implementing a joint mental health and learning disability CPA policy across five of its constituent boroughs.

The researchers developed a semi-structured interview schedule, and administered this to a number of key informant. The questions looked at the approach to the overall strategy for implementing CPA as well as the experience of putting this into practice operationally.

They also looked at the administration of the ‘Partnership Assessment Tool’ through documentary analysis.


What they found was although there was some variation across the five boroughs of the Trust, the progress in implementing the CPA was extremely limited.

They identified six key contextual challenges that they argue significantly hindered the implementation progress.

  • organisational complexity
  • arrangements for governance and accountability
  • competing priorities
  • financial constraints
  • high staff turnover
  • complex information and IT systems

Interestingly, they found one element of the policy linked to CPA that had been systematically, which was the Green Light Framework and Audit Toolkit  and the researchers point out that the toolkit has targets with penalties associated with these not being met, and that this was behind why its implementation had been given priority.

Conclusion and comment

The researchers point out that the contextual challenges they identified in the study were not unique to the introduction of the CPA policy. However, this did not mean that they were not real or impactful on the introduction and implementation of the approach. It is interesting to note that many of the challenges identified would feel very familiar to those who were responsible for the introduction of the CPA in the early 90’s.

The research uses an informant based approach which enables the gathering of rich qualitative data from key informants, but the downside to this is that it is not possible to get a good sense of the impact of the policy’s implementation of outcomes for people with learning disabilities and mental health issues.

The authors suggest that there is a need to more clearly acknowledge these generic factors in order that they might be addressed when introducing organisation change policies and implementing co-ordination approaches such as the CPA, or they suggest “the chances of effective implementation will inevitably be compromised.”


Implementation of the care programme approach across health and social services for dual diagnosis clients, Kelly M & Humphrey C, in Journal of Intellectual Disabilities, 17, 4, 314-328

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John Northfield

After qualifying as a social worker, John worked in community learning disability teams before getting involved in a number of long-stay hospital closure programmes, working to develop individual plans for people moving into their own homes. He worked for BILD, helping to develop the Quality Network and was editorial lead for the NHS electronic library learning disabilities specialist collection. This led him to found the Learning Disabilities Elf site with Andre Tomlin as a way of making the evidence accessible to practitioners in health and social care. Most recently he has worked as part of Mencap's national quality team and also been involved in a number of national website developments, including the General Medical Council's learning disabilities site.

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