Personalised care in mental health

Personalisation has become a defining feature of adult social care services. Direct payments and personal budgets are set to become default methods of funding local authority care as they are believed to provide service users with enhanced choice and control over the services they use. This agenda has widespread support from organisations commissioning or providing social care services in the UK.

So far, the personalisation agenda has had minimal impact on mental health services. However, the Department of Health is committed to providing people living with enduring mental health problems increased choice and control over their health and social care services. For example, it is currently piloting personal health budgets for people with long-term health conditions. The pilot includes sites within mental health services and the final report of its evaluation will be published in October 2012.

A number of barriers exist to the full implementation of personalisation in mental health services including organisational cultures being unable to respond to new ways of working; concern about the management of risk which may constrain risk-taking in the context of increased choice and control over care; difficulties in disentangling ‘social care’ and ‘health’ needs to justify funding; or bureaucratic obstacles to setting up personal budgets or direct payments. Although all local authorities have met the performance target of having 30% of social care service users in receipt of a personal budget by April 2011, notional personal budgets have been used in some cases (particularly for mental health service users). This raises questions about the extent to which meaningful choice and control is being provided within the nomenclature of a personalised service. 

In 2010 we set up a research group which brought together leading researchers, service users and carers to develop research proposals to investigate some of these issues. Facilitated by seedcorn funding by the NIHR Mental Health Research Network, this group has met on several occasions and has held two larger meetings with a range of stakeholders to develop a list of research priorities. These include personalised care in early intervention in psychosis; organisational culture change; brokerage; and the effect of personalised care on personal and social outcomes. Funding has just been confirmed for the first research proposal from the group and will commence in January 2012.

The group was successful with a bid for an NIHR Programme Development Grant on personalised care in mental health. This grant provides funding for a one-year project to investigate the feasibility of conducting a programme of studies to evaluate the effectiveness and cost-effectiveness of personalised care in mental health services. The work we will undertake in 2012 will have two components:

1) Practice survey and systematic reviews: Working in partnership with the Social Care Institute for Excellence and the Think Local Act Personal Partnership we will conduct a practice survey of mental health services to identify best practice in personalised care. We will also conduct systematic reviews of research on the outcomes of both the mechanisms (e.g. personal budgets and direct payments) and practice (e.g. self-directed support and empowering people to have more control over their care) of personalised care in mental health services.

2) Feasibility study for a randomised controlled trial: We will conduct semi-structured interviews with key informants to explore the feasibility of conducting one or more randomised controlled trials of aspects of personalised care to evaluate its effectiveness and cost-effectiveness.

On completion of this work, we aim to submit an application for an NIHR Programme Grant in 2013 which would provide funding for a five-year programme of studies. This programme would aim to produce high quality evidence to inform the implementation of personalised care in mental health services, including evidence about its effectiveness and cost-effectiveness.

This research project is a collaboration involving the following organisations:

South London & Maudsley NHS Foundation Trust

Institute of Psychiatry

University of Birmingham

Social Care Institute for Excellence

University of York

NIHR School for Social Care Research

We will be setting up a website shortly and will use this to engage practitioners, service users and carers in this research project as it develops. In the meantime, please do not hesitate to comment on this blog or contact me to exchange your views about personalised care in mental health.

Connecting People receives funding boost

The Connecting People Intervention will be piloted in 2012, thanks to success with a bid to the third wave of NIHR School for Social Care Research funding.

The grant provides funding for a multi-site pilot to evaluate the effectiveness and cost-effectiveness of the Connecting People Intervention in comparison with other interventions aimed to promote well-being and social participation. We will be drawing on the expertise of our collaborators to ensure its success: Professor David Morris (Inclusion Institute, University of Central Lancashire),  Professor Paul McCrone (Centre for the Economics of Mental Health, IoP), Dr Martin Stevens (Social Care Workforce Research Unit, King’s College London), Peter Bates (National Development Team for Inclusion) and Polly Kaiser (Pennine Care NHS Foundation Trust).

About the pilot study

It is increasingly important for social care service users in England to develop social relationships and engage in their local communities as care provision diversifies. Social care workers have some skills in supporting people with this, but there is little evidence about which approaches are the most effective or best value for money. This study will provide evidence about ways of working which produce the best outcomes at the lowest cost.

The study will have four components:

1) We will begin with a systematic review of research conducted on this topic across the world to identify examples of effective social care practice. We will also look for examples of good social care practice in England in helping people to participate in their communities and enhance their individual well-being.

2) Building on the work of the Connecting People study with people experiencing psychosis, which is developing a new way for workers to help people with their social relationships (the ‘Connecting People Intervention’), we will develop equivalent guidance for workers supporting people with a learning disability or older adults with a mental health problem. We will consult experts, including users of social care services and their carers, about this guidance to help ensure it is fit for purpose.

3) We will develop a questionnaire to be used in our research that will measure the extent to which workers are following the intervention guidance.

4) We will invite six social care agencies across England to test the Connecting People Intervention and an additional six, identified in the first part of the project, to continue to use their existing ways of working. We will invite 240 people with mental health problems, a learning disability or older adults with a mental health problem receiving services from these agencies for the first time to take part in the study. Participants will be interviewed when they start receiving services, and again twelve months later. They will all be asked the same questions to help us to evaluate the extent to which the Connecting People Intervention is effective and represents good value for money in helping people to improve their social participation and well being.

We aim to ensure that the project will have a significant impact on social care in England by sharing findings about effective and cost-effective ways of improving social participation and well-being widely throughout the sector.

Updates about the Connecting People study and the pilot of the intervention will be posted on the study blog.

Approved Mental Health Professional National Survey 2012

In 2002 I was a member of a research team headed by Professor Peter Huxley which conducted a national survey of stress and burnout in mental health social workers. Our findings were quite disturbing.

We found that almost half of respondents met the threshold for a common mental disorder such as anxiety and depression. Mental health social workers were more emotionally exhausted than psychiatrists in a parallel study. The findings for Approved Social Workers were even more worrying. They took more sick leave than mental health social workers who were not approved and were less satisfied with their employment. We suggested that extending the statutory role to other mental health professionals would increase levels of stress, burnout and dissatisfaction in these groups also.

In comparison with a previous survey, we also found that the rate of Approved Social Workers per 100,000 population in 2002 had decreased by over 50% since 1992. (This was likely to have been used as ammunition by the Department of Health for the widening of the statutory role to other mental health professionals.)

Finally, in spite of suffering high levels of stress and burnout, mental health social workers told us that they valued their face to face contact with service users. Their commitment to service users was an important factor in job retention.

Ten years on, we are now conducting a follow-up national study of Approved Mental Health Professionals (AMHPs). We are using some of the same measures as in the survey conducted in 2002 to evaluate changes in stress and burnout amongst mental health social workers over the last decade. However, as this is the first national survey since the widening of the statutory role to other mental health professionals, it will allow us to compare levels of stress and burnout in social work and non-social work AMHPs for the first time. The survey will provide important data to inform AMHP policy and practice nationally.

The other novel element to this national survey is that it is being conducted online and we will be using social media to promote it. This allows us to potentially invite all AMHPs working in England to participate in the survey – but only if they get to hear about it. This is where you come in. There are three ways in which you can help to promote the survey:

1) If you are an Approved Mental Health Professional working in England, please take the survey if you have not done so already. The link is below.

2) If you know an Approved Mental Health Professional working in England, please email them the link to the survey.

3) If you don’t know any Approved Mental Health Professionals working in England but want to help distribute the survey, please use social media tools such as twitter, facebook, linkedIn, or whatever you use to connect with other people, to send the link around.

Let’s test the six degrees of separation hypothesis and see if we can contact all the AMHPs working in England to invite them to participate in the survey. It is important that AMHPs from all professional backgrounds participate in the study. However, we would particularly like to encourage those from a non-social work background to take part as they are still relatively small in number.

The online survey takes only 10-15 minutes to complete and an information sheet containing further details about the study is displayed on the first page. If you would like to read more about and/or complete the survey please click on the link below:

This study is being led by Janine Hudson, an experienced AMHP studying the MSc Mental Health Social Work with Children & Adults programme at the Institute of Psychiatry. The survey questionnaire has been pre-tested by AMHPs and other social workers. The survey will remain open until March 2012.

Thank you in advance for your time and support.

Connecting People intervention model

The Connecting People study is in the midst of its final phase of data collection and is on schedule to complete later in 2012.

The outcome of the Connecting People study will be an intervention model and manual to support health and social care workers in their practice. Developed from observations of good practice in six different agencies, and informed by social capital theory, it will provide workers with an intervention framework to help people to connect with others.

Just before Christmas we published a draft of the intervention model on the study’s blog. We would like to engage people providing or receiving social care in discussion about the model. Please see below for a static view of the model, or click here to view an animated version.

The model assumes a worker-individual partnership dyad. This is not a rigid prescription, merely a way of representing how the model may function. It is conceivable that the model may encompass peer-support models of practice, for example, with peer supporters undertaking both functions simultaneously. It also permits a ‘service user’ (denoted as ‘individual’ in our model) to become a ‘worker’ as roles evolve over time, possibly bringing the green and blue circles into alignment with one another.

The model is based upon the principles of co-production. Rather than a traditional model of workers ‘doing’ and individuals ‘receiving’, workers and individuals co-create the objectives and actions within the model together. The model represents a shared journey of discovery with inputs being invested and outcomes being produced for both the worker and the individual. The New Economics Foundation manifesto for co-production provides an excellent and accessible introduction to the concept and what it means for public services.

At the top of the model are some pre-requisites which need to be in place before the wheels of the intervention cycle can begin to spin. The worker needs to have empathy, a ‘can do’ attitude and be a natural networker, while the individual they are working with needs to have some enthusiasm for engaging in this process and ownership over it. Together, the worker and individual work in partnership which includes the shared attributes of confidence, flexibility, lived experience (ideally), openness and trust. These individual and shared attributes are based on our observations of practice and are certainly not exhaustive. We are interested in your thoughts about whether or not you think they are necessary. Will the model work without them? If they are necessary, what might be missing from these suggestions?

The intervention model is not a traditional linear process of a worker doing something for or with the individual and an outcome occurring as a result of this. We have used two interlocking circles to represent the fluidity of the process and the uncertainty about when, or if, social network development will occur. The components of the model are as follows:

Shared development of objectives and activities (represented by the square in the middle). This is the heart of the model because it represents the co-produced activities. When the worker and individual meet for the first time in the context of this model, they discuss the life goals of the individual and they develop a realistic strategy together to help him or her achieve this. The activities may be in the context of what the agency provides or it may be additional to that. Some underpinning elements of these activities may include network (and asset) assessment; objective development; inspiration; facilitation; meeting expectations; orientation; sign-posting; skill recognition and feedback.

An individual’s journey (represented by the blue circle on the right). This is the focus of the intervention process as it is where the social network development is expected to occur. Although we are in the processing of finessing the process, we expect it to involve the individual being exposed to new ideas; being introduced to new people and activities; the development of skills and interests; development of social confidence; and building currency (both personal and social). We have deliberately omitted any details about what the individual and worker might do within this process as it is up to them to co-produce the activities. However, we hypothesise that social network development may occur at any point in this process. If you click here for the animated version, and click on the graphic, the circles will rotate and illustrate that social network development may occur at any point as a bi-product of the process.

Barriers to social network development (represented by the circle within the blue circle) work in the opposite direction to the intervention cycle and can pose considerable challenges for some individuals. These may include stigma; physical health problems; complicated external lives; countervailing attitudes of self and the organisation providing the context for the intervention; ‘bad’ social capital (I’ll write more on this in another post another day…); lack of information; or poor access to services. These barriers will present the worker with a number of challenges, and are likely to be the most time-consuming element of their work.

The worker’s journey (represented by the green circle on the left) is equally as important in the intervention process as the individual’s. This assumes that the worker will need to develop their own social network knowledge in order to support the individual on their journey. Workers will need to build relationships;  foster trust; identify opportunities; engage with the local community of the individual; develop their own networks and resources; adapt to new ideas; and utlise their contacts in the process of supporting the individual they are working with. At any point, they may need to provide extra support or reassess their involvement, while the individual they are working with may need to seek advice from them and develop their own self-awareness of their journey.

The agency context (represented by the orange square in the top left hand corner) is also fundamental as without a supportive organisation the process is unlikely to occur. There are a number of features of a supportive agency context including modelling of good practice; skill sharing; community engagement and good local knowledge. The agency can provide a physical environment which facilitates social connections and can provide useful connections with community resources which individual workers may not have. Shared knowledge of the local community and the intervention model held by the agency can prevent interventions failing when workers leave. This can also help to reduce reliance on individual workers who may be the only ones to hold connections within the local community.

As I said at the start of this post, this model is very much a work in progress. It is being refined as new observations are made in the course of the field work and as people comment on it. It will be further refined in a Delphi consultation involving numerous stakeholders next year. However, we are keen to receive comments on it now to move our thinking forward and help us to ensure that this will be feasible in practice. Please use the comment facility on this blog or email me your thoughts.

Practitioners on protocols

Social workers are familiar with protocols outlining eligibility criteria, referral pathways and inter-agency working. But what do they think of them? We conducted a study in a London Borough to investigate this and the findings were published online yesterday in the Child and Family Social Work journal.

Joint protocols between social services, health and other agencies have been established to ensure that practitioners working with adults are aware of their responsibility to safeguard children. However, there is limited evidence of the effectiveness of these inter-agency joint protocols.

We conducted a cross-sectional survey of practitioner self-reported experiences of joint protocols in an inner London borough, to evaluate their impact on professional practice. A self-complete questionnaire was administered to all professionals in adult mental-health and children’s social care services in the borough and yielded a response from 119 practitioners.

The survey found that the protocols had been widely disseminated and provided clear guidance to practitioners. Practitioners perceived that they had increased awareness of the risk factors for safeguarding children and some had used the protocols to help them gain access to services for their clients. Practitioners also perceived that they had improved inter-agency working between children’s social care and adult mental-health services. However, respondents indicated that positive interpersonal contact with practitioners from other agencies was equally important in promoting joint working and inter-agency collaboration. It appears that protocols can help to shape and define good practice, but words alone cannot change it!

If you would like a PDF version of the paper, please contact me by email.

What are your experiences of joint protocols? Do you think they help to change practitioners’ behaviour? Do you think they help to safeguard vulnerable children and adults? Please comment and add your perspective.

Recruiting now – research tutor required!

I am in the process of recruiting a new part-time course tutor for the MSc Mental Health Social Work with Children & Adults programe at the Institute of Psychiatry.

The tutor will lead on the teaching of research methods, basic statistics, critical appraisal skills and research protocol writing on the classroom programme and associated e-learning courses. The tutor will teach on three modules of this programme, e-tutor students on their e-learning equivalents and supervise some MSc student research projects. It’s an exciting opportunity for an ambitious post-doctoral researcher to join a leading advanced post-qualifying social work programme and help to shape its future.

We are looking for someone with an in-depth knowledge of qualitative and quantitative research methods and an ability to effectively teach research methods and basic statistics to postgraduate students with little prior knowledge of the subject. The tutor will need to be able to respond flexibly to student’s learning needs, whether they are classroom-based or distance learning students. The ideal candidate will have a PhD in social work, social care or a closely related discipline and have an interest in empirical research in this field. The post holder will work with department staff to develop research proposals in the field of social work and social care for external funding. Therefore, in addition to an interest in teaching, it is expected that the course tutor will be interested in developing as a post-doctoral researcher.

If you are interested in applying, or finding out more about the position, please visit the King’s College London vacancies page.