The benefits of community mental health standards

Community mental health standards: what will it mean for people who use services?

When a person comes out of hospital after they are treated for a mental health condition, the right care plan is a crucial part of their recovery. Dr Sarah Markham, patient representative for PRSB, speaks about her experiences and why she wants care plans to be standardised and made available to the people involved in a person’s care.

Please can you tell us a bit about you and your experiences using mental health services?

I have been a mental health patient in a range of inpatient and community settings following a serious suicide attempt which left me with multiple injuries in 2007. I had suffered from anxiety and depression since my late teens, but found it hard to access treatment and felt as though I was discounted by GPs and other health care professionals as I was articulate and academic. I experienced intense and chronic feelings of suicide over a period of 18 months, but it was not until the suicide attempt that I ended up as an inpatient in hospital. My experience of mental health services has been mixed. I, along with many of my peers, don’t always feel listened to by my mental health professionals, who don’t always understand the value of self-reporting. This has been reflected in a national survey conducted by the Department of Health and Social Care as part of the Independent Review of the Mental Health Act (MHA), which I supported in 2018. It’s very common for people to feel like support or treatment is something that is being done to them rather than with them.

What were the biggest challenges for you in terms of joined up services and information sharing?

Information that should be shared between different care teams and services is not always used and sometimes can’t be found. For instance, I have a relapse prevention care plan which I constructed two years ago with support from a psychologist. But my community mental health care team don’t adhere to the care plan.

When anyone is discharged from an inpatient setting, they can experience multiple anxieties. During an inpatient stay, people may be treated as though they are incapable of assuming adult responsibilities, only to be discharged right back into taking responsibility for their own well-being. An appropriate transition period is crucial to help them to rebuild their self-confidence and re-accustom themselves to the outside world, which is why a shared care plan is crucial.

What inspired you to support the community mental health project as a patient leader?

I got involved as patient leader on this project because I believe there is a real need within mental health services to respect the contribution patients can make to their own care planning and management. This also needs to be incorporated into care records in a way that means it can be used and shared within and between services.

If implemented, how do you feel a standardised community mental health care plan could support and benefit people with existing mental health problems?

It could encourage and support mental health professionals and services to respect and value patient self-knowledge and reporting, then record this appropriately in the records in a way which makes it accessible and usable by other care partners. Hence the value of having and promoting use of the ‘About Me’ section in the standardised community mental health care plan. If mental health staff and services were able to be more responsive to the preferences, needs and concerns expressed by patients themselves, this would improve accessibility, confidence in services and patient experience. Inevitably this will lead to better outcomes for patients and reduce hospital admissions.

How do you feel that services could be more personalised for individuals and how would this aid recovery?

The ‘About Me’ section, which records information that is meaningful and relevant to the individual, is ideal for this purpose. Patient access and transparency about what is recorded is essential, and will help people to build effective and therapeutic relationships with professionals. It is the perfect place for a person’s views, preferences and wishes concerning which types of care and treatment and mental health settings work best for them, including types of medication and psychological therapy. It might also be a place for people’s concerns about their treatment to be recorded and tracked, so they don’t get lost in the system.

 

For more information on the community mental health project please contact info@theprsb.org

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Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.