Early on in the implementation of personalisation reforms in social care, mental health stood out as a tricky customer, but with potential to benefit enormously from person-centred practice, recovery and personal budgets.
The evidence points to particular trickiness with:
- Organisational cultures that encourage risk averse and defensive practice;
- Excessive bureaucratisation of personal budgets that compromises relationship-based working;
- The “clinicalisation” of recovery that compromises the individual’s freedom to determine personal recovery;
- The marginalisation of service users in making decisions and choices about their care and support; and
- The inherent tensions between individual choice and control and the practice of compulsion in mental health services.
It’s a complex situation where ostensibly progressive approaches are being implemented in NHS Mental Health Trusts via sometimes conflicting policy demands. And despite reconfiguration and reform, the Trusts retain largely unreformed cultures and maintain infrastructures and practice that rely heavily on bureaucracy and hierarchy.
Added to this is the evidence that relationships, trust and communication make all the difference in care and support and that, if done properly, personal budgets and personal recovery approaches can result in positive outcomes for service users and, to some extent, carers.
So far, most research studies on personalisation and recovery have looked at one or two specific issues, but have rarely attempted to understand whole relationships between policy, interventions, organisations and people. In elfin words, seeing the wood, not just the trees. This is what this study attempts to do.
A complex situation needs to be examined using a suitable study design, which the authors describe as:
a cross-national comparative study of care planning and co-ordination in community mental health care settings, employing a concurrent transformative mixed-methods approach with embedded case studies.
If anyone has ever seen the ‘7-pound monster breakfast burrito’ challenge episode of ‘Man v Food’, this study could well be the research equivalent of the said burrito.
The authors aimed to identify and describe the factors that ensure Care Programme Approach (CPA) in England and Care and Treatment Planning (CTP) in Wales are made up of care planning and co-ordination that ‘is personalised, recovery-focused and conducted collaboratively’.
In order to address the ambitious research aim, the authors designed the mixed-methods study to have several work streams:
- A literature review of international peer-reviewed research on recovery-oriented and personalised mental health care and of relevant national policy and guidance
- A series of detailed case studies on care and support assessment, planning and co-ordination
- An investigation into service user, carer, practitioner and manager views of the processes in the context of personalisation and recovery-orientation
- A measure of service user and staff perceptions of recovery-oriented practice
- A measure of service user views on the quality of therapeutic relationships and empowerment
- An assessment of the best methods, measures and processes for the successful evaluation of a complex intervention with specific aims regarding personalisation, recovery and improved patient outcomes
The research used mixed-methods and aimed to encompass the macro, meso and micro levels (see Blackstone, 2016) of implementation and assess the connections between the meso and micro levels; that is the relationship of policy and planning to frontline practice.
There were six contrasting NHS Trust or Board study sites, with four being in England and two being in Wales.
The authors describe their research activity at macro level as:
Meta-narrative mapping of peer-reviewed literature on recovery-oriented, personalised care planning and co-ordination in community mental health care. Comparative analysis of overarching English and Welsh policy and service contexts.
The literature and policy review used the Meta-Narrative Mapping method, which provides a review of the most relevant and rigorous evidence for practice that integrates a wide range of evidence.
The authors describe their research activity at meso level as being:
In six contrasting trust/board case-study sites: context, care planning policy, orientation to recovery, empowerment and personalisation.
Local guidance documents and policies for all six sites were identified and analysed for contextual information.
A purposive sample of senior managers (n=12), senior practitioners (n=27) (including mental health nurses and social workers) and care co-ordinators (n=28) from across the six sites were interviewed using a schedule of 15 questions about care planning and care co-ordination processes, recovery orientation, safety and risk management and personalisation.
The interviews were analysed using a framework method to explore the relational aspects of care planning and co-ordination, the extent to which service users and carers are involved in the CPA/CTP process and decision-making and the degree to which practice was oriented towards recovery and personalisation.
A total sample of 448 service users and 201 care co-ordinators were recruited across the six sites, with an overall total of 20 participating community mental health teams (CMHTs).
Via a postal survey, a total of 448 service users completed the following self-administered measures:
- 12-item Scale to Assess the Therapeutic Relationship (STAR-P)
- 28-item Empowerment Scale
A total of 201 care co-ordinators and 448 service users completed the following self-administered measure:
- 36-item Recovery Self-assessment Scale (RSA)
The survey data was subject to statistical analysis.
The authors describe their research activity at micro level as being:
In each site, six embedded case studies, triangulating experiences of care planning.
For gathering data on micro-level, face-to-face care a total of 33 randomly sampled service users from target CMHTs in each of the six sites were interviewed using a semi-structured schedule. The service user participants were asked to nominate an informal carer for interview and 17 carers were interviewed.
As with staff, service user and carer interviews focused on care planning and care co-ordination processes, recovery orientation, safety and risk management and personalisation and were also analysed using the framework.
With permission, the care plans of each service user were analysed using a template agreed with the project lived experience advisory group.
While the study showed no major differences between sites for service user scores on recovery or empowerment, it did show:
some significant differences for scores on therapeutic relationships related to positive collaboration and clinician input [and] significant differences between sites on some recovery scores for the care co-ordinators related to diversity of treatment options and life goals.
The qualitative data yielded a large number of findings from staff, service users and carers, as follows:
- Staff saw care plans as useful for record-keeping, but inflexible and burdensome, reporting that the administration time kept them from working directly with service users
- Staff were concerned about risk, but did not seem to discuss risk and safety with service users
- Service users and carers saw care plans as largely irrelevant to them and rarely used them
- Service users were often unaware of the content of risk assessments that seemed to limit the potential for exploring taking positive risks as part of recovery
- Service users valued and saw their relationships with care co-ordinators as being central to their recovery
- Carers valued the relationships they and service users had with care co-ordinators, but reported varying levels of involvement in care planning
- Lack of IT system integration across organisations and inflexible electronic record formats hampered recovery-focused work.
The authors conclude that:
Administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There are few common understandings of recovery which may limit shared goals. Conversations about risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work.
They note that:
Training in recovery-focused care planning and co-ordination also may be insufficient to bring about the necessary change as wider contextual factors need to be addressed.
They also express concern that:
There exists a gap between the macro-level policy aspirations for recovery focused, personalised care planning and coordination and the mess/micro ‘street-level’ practices and everyday experiences of service users, carers and care coordinators.
Strengths and limitations
The authors note limitations in the research including issues with potential bias and self-selection plus issues with weighting towards longer-term users of services. The journal article includes a helpful chart summarising the characteristics and population of the different sites, for easy comparison. It was useful to know the extent of involvement of the lived experience advisory group, who contributed to analysis, and that some of the user interviews were conducted by service user researchers.
Because of the limitations for full methodological reporting of a complex study in a brief journal paper, I was left wanting to know more about how all the participants were recruited, more about their demographic profile and what the interview schedules covered. These are available, but interested readers need to refer to the full research report.
Perhaps these limitations on methodological reporting highlight one of the challenges of this type of complex, mixed-methods research; you have a lot of methodology to report, potentially more methodology than findings!
Overall, the study is impressive in its ambition and scope, and yielded findings that not only confirm what other studies have been suggesting, but reveal the wider contextual and policy problems, as the authors note
After 25 years of the CPA and repeated accounts of bureaucratic over-load, it is time for innovative, flexible and person-centred solutions to this dilemma.
The study also shows that to understand something as complex as the topic under investigation, you need to have both quantitative and qualitative approaches. Having both in one study demonstrates how a complementary qualitative investigation can add multiple dimensions to the quantitative data, thus revealing a fuller picture.
If I’m honest, when I read this study I despaired for evidence-based practice and policy in mental health, particularly for qualitative evidence-based practice. It reminded me of one of the first user-led research studies into care management, conducted over 20 years ago (Beeforth, Conlan & Graley, 1994). The authors found that:
The case manager also makes all the other service arrangements, but the reason case management is successful is because it is in the context of a meaningful relationship – one which allows potential for development.
So, as well as confirming existing findings and explaining more about recovery and personalisation in care planning and co-ordination in community mental health care settings, the study also acts as an assessment of how little has been learned from or changed as a result of years of research on empowerment, personalisation and recovery. The authors conclude with a plea not to silt up the system with more procedures as this is likely to ‘create greater stress and resentment, rather than solutions’.
It’s certainly a ‘7-pound monster breakfast burrito’ of a study, but are mental health policy and practice decision makers hungry enough for it? It’d do them good after being asleep in bed for so long – wakey, wakey, breakfast time!
Simpson, A. et al. (2016) Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study. BMC Psychiatry 16:147 DOI 10.1186/s12888-016-0858-x [Full text]
Simpson A, Hannigan B, Coffey M, Jones A, Barlow S, Cohen R, et al. (2016) Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP). Health Serv Deliv Res 2016;4(5) [Full report]
Beeforth M, Conlan E, Graley R. (1994) Have we got views for you: User evaluation of case management London: Sainsbury Centre for Mental Health [Full report]
Blackstone A. (2016) Micro, Meso, and Macro Approaches. Chapter in Principles of Sociological Inquiry: Qualitative and Quantitative Methods, v. 1.0.