How To Answer What Is Your Idea Of Service Delivery In Communtiy Mental Health

Globe Psychiatry. 2008 Jun; 7(2): 87–92.

Steps, challenges and lessons in developing community mental health care

GRAHAM THORNICROFT

^aneWellness Service and Population Enquiry Department, Institute of Psychiatry, Rex's College London, De Crespigny Park, London SE5 8AF, UK

MICHELE TANSELLA

²Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology, University of Verona, Italy

ANN Police

^aneHealth Service and Population Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK

Abstract

This paper summarises our own accumulated experience from developing community-orientated mental health services in England and Italy over the last 20-30 years. From this we have provisionally concluded that the following problems are central to the development of balanced mental health services: a) services need to reflect the priorities of service users and carers; b) evidence supports the need for both hospital and community services; c) services need to be provided close to home; d) some services need to be mobile rather than static; e) interventions need to address both symptoms and disabilities; and f) treatment has to be specific to private needs. In this paper nosotros consider x key challenges that often confront those trying to develop community-based mental wellness services: a) dealing with anxiety and uncertainty; b) compensating for a possible lack of structure in community services; c) learning how to initiate new developments; d) managing opposition to change within the mental health arrangement; eastward) responding to opposition from neighbours; f) negotiating financial obstacles; g) avoiding system rigidities; h) bridging boundaries and barriers; i) maintaining staff morale; and j) creating locally relevant ser- vices rather than seeking "the right answer" from elsewhere.

Keywords: Customs intendance, community mental health services, psychiatric services

Iii elements tin serve equally a guide in improving mental health services: ethics, testify and feel one. In our view, when planning community-based mental health services, it is preferable to starting time with a argument of the principles intended to guide new service developments. Such principles tin be used in a course of triangulation, so that this ethical base is combined directly with the relevant prove base and with the feel base to produce the strongest possible case for change.

In this paper we shall present key bug which arise in everyday clinical practice, and so that these can be helpful as y'all implement meliorate mental health care. We shall therefore discuss here only 1 of the above iii key elements, the experience base, which is relatively rarely covered in the literature. We shall organise our main findings in relation to 10 key challenges which are often faced by those attempting to better customs mental health services. Our starting point for this paper is our own accumulated experience from developing community-orientated mental health services in England and Italy over the terminal 20-30 years.

A FRAMEWORK FROM Experience

From our own experience, we accept provisionally concluded that the post-obit issues are central to the development of balanced mental wellness ser- vices 2: a) services need to reflect the priorities of service users and carers; b) testify supports the need for both infirmary and community services; c) services need to be provided close to domicile; d) some services need to be mobile rather than static; e) interventions demand to address both symptoms and disabilities; f) treatment has to be specific to individual needs.

DEVELOPING COMPREHENSIVE GENERAL ADULT MENTAL Wellness Care

Within the wider context of these guidelines, we shall discuss next the primary categories of service which are necessary for comprehensive intendance. We take proposed that there are v central categories of service, all of which are necessary to provide a comprehensive range of local services 2: a) out-patient/ambulatory clinics; b) community mental health teams; c) astute in-patient care; d) long-term residential care in the customs; e) rehabilitation, work, and occupation.

In improver to these main categories, it may be important to develop variations, or even separate forms of support, which are directly service user-led, such as peer support workers, peer advocacy workers, or self-help groups 3. Pragmatically this means that, for a service in transition 4, information technology is non necessary to delay reducing the size of a long-stay psychiatric hospital until all these components exist in the community. That would often be incommunicable because the chief or the only source of funds for community services is from savings fabricated at the big hospital as it reduces in size five.

In fact, there is frequently a dilemma about whether to spend money on increasing the quality of intendance inside large and usually neglected psychiatric hospitals, or rather on developing services exterior hospital. In our experience the reply to this dilemma will need to exist resolved according to local circumstances, just in general information technology is important to progressively motion an increasing proportion of the whole mental health budget, and in many cases somewhen the bulk of the budget, to community based services while simultaneously bringing the quality of care in the (shrinking) institutions to an acceptable level. Here over again in that location is a balance: likewise rapid a shift of resources can produce unstable and confused new clinical ser- vices that are unable to offer integrated care, especially to people with long-term mental disorders; also deadening a process may non let any momentum for change to be created.

Investment during the transition from a more hospital to a more community oriented organization often needs a focus upon training to accomplish individually-orientated staff attitudes and practices (invisible inputs), for staff in hospital and customs settings, rather than upon investment in the physical environment. The advantage of this way of setting priorities is that staff in the future, wherever they work, will accept a more therapeutic approach.

STAKEHOLDERS

In our view, mental wellness services are best planned by bringing together the whole range of stakeholders who have an active interest in improving mental health intendance vi-8, including: a) service users; b) family members/carers; c) professionals (mental health and primary care); d) other service provider groups (eastward.g., non-governmental organisations); east) policy makers; f) advocacy groups; g) planners.

There is also a need to ensure that groups which are not powerful advocates for their ain interests are also given equitable consideration in planning services, such as recently established service user groups ix. What can exist done where some key stakeholder groups do not be? In this case it may be necessary to take a long-term view and for those decision-making mental health financial resource to invest to initiate and back up the growth of, for example, ser- vice user and family member groups.

TEN KEY CHALLENGES

From our experience in developing and working in community mental health services, we have identified x cardinal challenges facing people committed to improving mental health care. We nowadays each cardinal challenge in the grade of a statement (in italics) followed past a cursory discussion on each claiming.

Claiming 1. Anxiety and dubiety

Creating new services necessarily produces dubiety about the future. Information technology is ordinarily helpful if clear undertakings tin be given, for example, guarantees to staff to avert redundancies. It is an advantage to have some staff who prefer to work in hospital every bit such services volition continue to be needed in future. Service leaders tin help staff by openly supporting shared gamble taking, and by assuasive mistakes equally long as there is a learning/adaptation process at the same fourth dimension.

Although guarantees of no redundancies, if possible, tin be very helpful, for instance through effective discussions with merchandise unions, in depression resource countries there may be loftier staff vacancy rates and the question of redundancy does not arise. Similarly, if the service provider organisation tin can brand a articulate statement of back up to staff, such as that below on risk-taking, and so this can provide a clear framework for staff to work with conviction (Table 1).

Table 1

Tabular array 1 S London and Maudsley NHS Foundation Trust policy on responsible risk-taking

The Board accepts that staff, users and carers will all make decisions which are risky in that they may non have predictable or definitely successful outcomes. Taking these oft difficult decisions are a part of everyday practise. The Board fully supports staff in takign these decisions provided they are made responsibly by reference to the principles of good professional practice.

Examples of ensuring responsible run a risk taking include:

- Making use of the care plan approach (case direction and care planning) policy; crunch and contingency planning can help in arriving at a high take chances decision and ensuring expert communication

- Risky decisions are discussed fully with primal members of the team

- Testing decisions with colleagues

- Seeking advice from professional bodies

- Seeking communication from Trust lawyers

- Clear entries in the healthcare record should outline how the decision was made and alternatives considered

- Good annotation-keeping enalbes i to justify decisions

Claiming ii. Lack of construction in customs services

The alter of service structure, and in particular developing more and smaller services away from the primary hospital site, tin can run the chance of destroying established routines and structures. One of the positive functions of these routines is to reduce anxiety, and recognising this it may exist important to develop, particularly for a transitional period, even more structure and routine than is strictly necessary. This may include, for case, staff support groups, regular data sharing meetings between managers and staff, and clear timetable of regular clinical meetings, as well as written operational policies and referral procedures.

In the first stages of working in ser- vices which operate exterior hospital sites, staff often feel an increased level of anxiety as the structures and routines they were familiar with do not operate in the aforementioned way in community services. At least in the transitional period until community services become consolidated, information technology may be useful to deliberately introduce arrangements which give many levels of structure to reduce such staff anxiety. Examples include regular staff group and individual supervision meetings, regular clinical instance review meetings, and periodic forms of audit or cocky-appraisal on the performance of the clinical team.

Claiming three. How to initiate new developments?

Often the biggest challenge facing stakeholders in beginning a procedure of reform is that information technology is difficult to imagine how the mental health system could perchance exist unlike. An invaluable way to brainstorm is past visiting other places which have started or completed the development of community-based care. Information technology is oft helpful to borrow a copy of some of their basic tools such as timetables, cess forms, job descriptions, or operational policies. As a local service development plan develops, it is often of import to allocate each job to a person or group and to set a deadline for its completion, along with a mechanism, such as the next meeting of the planning group, to run into whether tasks have been completed or non. It may need to become clear to staff that it does matter, for case to their bacon or to their promotion, whether they fulfil the agreed tasks or not.

1 of the first difficulties for staff with long experience of institutional exercise is that they cannot imagine working in any other way. A remedy that is often used is to visit services in otherwise comparable sites, perchance in the same region, that have recently initiated customs-based care. Such visits provide the opportunity to see ideas in practice and from one's own direct experience what information technology is possible to practise, and to learn from specific aspects of do elsewhere, and then to adjust this for local benefit. For example staffing rotas, operational policy documents, and job descriptions can exist taken away and adjusted for local utilize.

Challenge 4. How to manage opposition inside the mental health system

Usually there volition be a range of staff views on proposals to alter the care system. Many opportunities may be necessary to involve the range of staff, including a widespread process of consultation, with planning groups including diverse opinions. Linking local specific proposals to generally agreed plans, such as the Globe Health Arrangement declarations, tin put your services in a wider context, and help to create a sense of the inevitability of alter.

Many staff members volition exist rightly cautious near large scale service changes. They may fear that changes are motivated by price-cutting reasons, or that any such changes will leave people with mental illness liable to neglect. Such reasonable concerns demand to be addressed straight, explaining in good faith why the new model of care is expected to provide better services. If budget changes are planned, they need to be made explicit. Often, after lengthy discussion, a number of staff will brand it clear that, despite all the arguments for developing community services, they wish to remain working on in-patient units. In the balanced intendance model that we have described ii,10, at that place is a clear need for some (limited) acute in-patient facilities (unremarkably in general hospitals) and there is a continuing demand for specialists in astute in-patient treatment and care.

Challenge 5. Opposition from neighbours

Neighbours volition frequently have reservations, or may protest against plans for new mental health facilities in their locality. There is a dilemma here between maintaining the confidentiality of patients, and so not telling neighbours in advance about the new residents, or trying to engage support of neighbours through information-sharing and consultation. Our view is that involving neighbours throughout the procedure of developing of services is usually the better long-term option.

It is ofttimes the case that when new projects are proposed within local communities, neighbours are opposed to such developments. Often this is considering their limited noesis about people with mental affliction leads them to believe (wrongly) that any new mental health facility volition bring with it a loftier level of risk, peculiarly to their children eleven. Despite this, many staff feel strongly that it is unhelpful to inform neighbours almost the nature of a new community mental health facility in advance. Indeed, a decision not to requite advance observe to neighbours can be seen as a way to avert marginalising people with mental illness and related disabilities. There is no research base to aid make up one's mind what to do in these situations, and in England, for example, it is common to inform neighbours in advance of the planned new service 12, often with many detailed meetings to address the concerns of neighbours. In our view, whatever the stage at which neighbours are informed, or go aware of the nature of the new facility, information technology is very important to take seriously their views. The ultimate aim will be to foster expert neighbourly relations betwixt people in the community care dwelling and local residents.

Claiming half-dozen. Fiscal obstacles

Although some policymakers, politicians or managers may run into a motion from hospital towards community care every bit a cost saving procedure, the feel of many countries is that money can only be saved by reducing the quality of intendance. It is therefore essential to monitor very closely the resources available to mental services, and to ensure that no monies mysteriously become lost in the process. One very valuable asset that tin can exist released in changing the system of care is the value of state and buildings occupied by the large psychiatric hospitals. It is important to establish whether y'all can retain the money realised past their rental or sale to use for new staff and facilities. Wherever possible keep maximum flexibility in your mental health service budgets, and share these budgets with other agencies if this is an advantage to you.

Money is critical for mental wellness care. The purpose of the balancing hospital and community care is non to reduce the mental health budget. Rather it is to provide the all-time possible services with the resource available. In relation to moving long-stay patients from large psychiatric institutions to customs facilities, the evidence from evaluations carried out in high resource countries shows that, where this is done reasonably well, it is overall cost-neutral 5. Indeed, in that location is no evidence that comprehensive mental health care costs less than long-stay psychiatric hospitals. On the other paw, in that location is no support from research for the common idea that cake handling in hospital is more than cost-effective (unless information technology is lower quality care). At the same time, such service changes can be used every bit the occasions to make budget cuts.

I important fiscal issue is whether the total resources bachelor for mental wellness care, for example for a local area, can be identified and protected (sometimes called "ring-fenced"). This is a very important issue, considering where such budgetary protection is not maintained, then it is very common to come across mental health budgets lost to other medical or surgical departments. More positively, the resale value of the country and buildings occupied by long-stay hospitals depends upon its location, condition and reputation, and frequently the value cannot exist realised to use for other mental health services locally.

Challenge seven. System rigidity

One of the organisational features of large institutions is their hierarchical nature and the rigidity of their procedures. In customs systems it is possible to prefer a more flexible approach to how staff are used. For example, secondments to other services, or periods of shadowing key members of staff can be useful to develop new skills and roles. Sometimes it is helpful to brand articulation appointments, where 1 mail is shared between two organisations.

A oftentimes occurring trouble when initiating community-based services is that the financial system underpinning clinical care is hospital based. For example, reimbursement to the mental health intendance provider may be on the basis of the number of beds occupied. In this example establishing a new community mental health team may be difficult, as there is no tariff or currency that volition allow for the costs to be paid. In such cases it is necessary to create new categories of payment, but equally these financial changes are usually very tiresome to take place, in the interim considerable flexibility is needed on all sides to permit new services to start up using the old financial rules. For example, a 24-hour interval infirmary may be paid for the number of people attending each mean solar day, rather than for the number sleeping on the unit each dark. While this flexible approach tin help new teams or services to get-go up, they rely on good volition and are vulnerable to changes in staff or political volition. So, it is vital to institutionalise new financial rules as soon as possible to explicitly pay for the new categories of community care services.

Challenge 8. Boundaries and barriers

As community mental health systems tend to be more complex than their hospital predecessors, it is vital that senior staff can maintain an overall view of the system as a whole. Individual components of service, for instance clinical teams, must not be immune to ascertain their roles in isolation. They must be required to negotiate with other clinical teams to hold how they volition put into practise a joint responsibility for all those patients who need to care. Ane way to manage inevitable ongoing boundary discussions about who does what is to take regular and frequent meetings between the leaders of all the clinical teams which serve a particular expanse.

It is common to hear those who wish to develop "seamless" care. In fact any local service volition necessarily include many different teams or services. Every boundary betwixt unlike teams is a potential point for boundary disputes or service dysfunction, for case communication problems between an in-patient ward and a community mental health team. Information technology is therefore necessary to create methods to minimise the confusing effect of friction at such boundaries. Ways to do this include arranging for staff from ane squad to "shadow" their equivalent person in the other squad, for instance for a 24-hour interval or for a week. Some other mechanism is to arrange staff rotation schemes, so that for example doctors or nurses piece of work for one or two years in a hospital team, and so for a period in a community mental health squad. The fundamental effect is to promote means for staff in each part of the organisation every bit a whole to understand the perspective of their colleagues in other teams, and to want to work together to solve issues which backbite from the quality of clinical care.

Challenge ix. Maintain morale

The morale of mental wellness staff is usually found to exist depression wherever the study takes identify. In add-on, morale may be particularly low during times of arrangement modify. Managers may therefore need to brand special arrangements, during these transitional periods, to boost morale, for example by paying attending to social events, past communicating successes, and by taking any alibi to throw a party.

Creating and maintaining high staff morale is universally recognised equally vital to an constructive mental health service, both the morale of individual staff members, and developing a stiff reputation as a modern and professional team. 1 fashion to enhance team morale is to visit other centres, for example away. This can take several advantages: to realise that one's own issues occur besides elsewhere, to promote meliorate social contact between staff squad members, to learn direct from the practical experiences of others, and for the staff to be given some valuable reward for their commitment to the ser- vice, often over years or decades. There are considerable cultural differences in what activities raise staff morale: in some settings it may be frequent staff parties, in others it may exist close attention to authentic job descriptions, aiming to reduce role blurring. In each case the starting point is for team leaders to be able to assess the morale of their team, and to understand what is necessary to keep this reasonably high almost of the time.

Challenge 10. What is the right answer?

There is no correct answer! Although there are a big number of mental health service models and theories, these are best seen as suggestions for what might help y'all in your particular situation. Maintain every bit much flexibility as you can in the new system, because you volition brand mistakes and need to change the service every bit information technology develops. The best guide about whether your mental wellness services are going in the correct direction is the feedback you receive from service users and family members about how far their preferences and needs are being responded to.

It is common for those starting a process of mental health service alter to believe that someone else, in some other identify, knows exactly what should be done. In our view each local setting needs to find its own specific fashion to amend mental health intendance. A vital guide to doing this will stalk from supporting, seeking and using feedback from ser- vice users and family members. Feedback can be based on comments or complaints received, or it can be formally invited, for instance with service user satisfaction surveys. It is oft the case that, before feedback can be received, statutory services need to invest time and money to support the creation and initial survival of service user groups. In this way, over fourth dimension, advocacy groups can join forces with staff to lobby for more resource allocation to mental health care, and often politicians are more moved and persuaded by individuals who have personal experience of mental illness than by staff, whom they may suspect of being motivated for reasons of self-interest.

LESSONS LEARNED

What are the overall lessons that we feel we have learned that others may be able to acquire from? Beginning, robust service changes, improvements that volition last, take time. Part of the reason for this is that staff will need to be persuaded that change is probable to bring improvements for patients, and indeed their scepticism is a positive nugget, to act as a buffer confronting changes that are too rapid or too frequent. Another reason for non rushing change is that in guild to succeed one is likely to need the support of many organisations and agencies, and they need to be identified and included gradually, at the start of each cycle of service changes. Those which are, or which feel, excluded are probable to oppose modify, sometimes successfully. Further, in situations where health service changes may be a topic for political debate, then it is normally necessary to build a cross-party consensus on the mental wellness strategy, so that information technology will continue intact if the government changes. Once again this will often take fourth dimension to achieve.

Fourth dimension is also needed to progress from the initiation stage of a modify to the consolidation stage. Typically at the early on stages of service reform a charismatic individual or small group volition champion the chief proposals, and recruit support from stakeholder groups and from others with influence within the health care system. In Eastern European countries, for example, the medical director/superintendents of the psychiatric hospital volition in practice hold a veto for or against change 4. But, later on a series of initiatives, such as creating mental health day centres in the larger cities of a country, the mental wellness organisation needs to systematise these changes and then that they can keep over many years. In this subsequent phase, it is often true that charismatic leaders go on to new challenges, and the people who are most useful are those who are able to patiently consolidate the new arrangement, and to plant consortia that are viable in the long term. For example, these less visible individuals will prepare proper supervision for staff, ensure the regular maintenance of buildings, arrange for personnel to undergo regular grooming, gear up up multi-agency working groups to identify and fix day-to-day issues in the running of the services, establish and take part in consultation or partnership meetings with service users/consumers and with family members, and monitor that the services run properly within their allocated budgets.

While maintenance activities of a newly established organization may be less attractive to innovators, in fact this consolidation is vital to make services robust and able to survive and thrive in the long term. This will not normally crave a single loftier-profile leader, but rather a consortium made upwards of a wider group of stakeholders who need to cooperate in providing all the service components within the wider organization of intendance. The successful completion of these policy decisions, and their implementation on the footing, will often also need organised and repeated lobbying by a coalition of stakeholder groups, to build sufficient political pressure, for example for modernised mental health laws. An example of the timescale required is the blueprint of service changes in Verona, Italy over the last 30 years, derived from the local instance register, founded in 1979 13 (Figure ane). Equally the number of psychiatric beds has progressively declined, and so the provision of twenty-four hours care, residential care, and out-patient and community contacts has steadily increased over many years.

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Patterns of mental wellness service provision in Verona, 1979-2006

The 2nd overall lesson is that information technology is essential to heed to users and families' experiences and perspectives. Anybody involved needs to keep a clear focus on the fact that the primary purpose of mental wellness services is to improve outcomes for people with mental disease. The intended beneficiaries of intendance therefore demand to exist, in some sense, in the driving seat when planning and delivering handling and intendance. This is a profound transformation, changing from a traditional and paternalistic perspective, in which staff were expected to take all important decisions in the "all-time interests" of patients, to an arroyo in which people with mental illness work, to a far greater extent, in partnership with care providers. This requires a fundamental re-orientation for staff, for instance to be and to feel less responsible for deciding all aspects of a patient'south life. It also requires that people with mental disease become able to express their views and expectations of care. At the outset this may exist very hard, for case for people who have lived for many years in psychiatric institutions, where their views and preferences were rarely sought or valued. This volition often require a stage of back up, for example from advocacy workers, and so that such individuals tin can in a sense be re-activated to recognise and limited their own points of view. One consequence is that while service quality may improve during a period of developing community mental health services, ordinarily the expectations of the people being treated rising even faster, leading to a paradoxical decrease in satisfaction. While staff may interpret this equally a criticism of the care they provide, another style of looking at this is that such dissatisfaction or complaints are in fact very clear signals of which parts of the service need to exist improved next. In other words service users are the best experts.

The third lesson that emerges from this overview is that the team managing such a process needs clear expertise to manage the whole budget and that the risks are loftier that services changes volition be used as an occasion for budget cuts. Having a protected budget is necessary but not sufficient, as it is as well vital to be able to exercise flexibility within the overall budget, typically to re-utilize money saved by reducing the use of in-patient beds for community mental health teams, or occupational or residential services. When such a fiscal boundary (sometimes chosen a "ring argue") for mental health funds is non established and fiercely maintained, then money tin can easily exist diverted to other areas of wellness care. In other words, fiscal mechanisms demand to be created which ensure that coin follows service users into the customs.

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