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What’s important (and what isn’t) in a community mental health service when working towards an outcome based contract?

Time – missed calls and late calls

The current SIS contract pivots around commissioning of time and monitoring of time. So, it pays to examine the implications of this primary service structure.

Time is a crucial element which affects the quality of the service that the service user experiences especially when personal care is being offered; medication and food are time sensitive. It can’t be good practice to be running late on calls when such things are needed. Time, however, does not have the same importance within mental health, why not?

It is firstly important to note that:

  • We currently can provide the entire community mental health service in the most part without providing care (as it is defined by CQC). It has been previously mooted by commissioners that a mental health service may not even need to be registered with CQC at all in the future because care, in many instances, is not what is being provided. *
  • However, time does sometimes play an important factor when a NHS or other appointment is being supported by staff.

It is important to note the second point, because the support work we undertake in some instances is providing a link between the individual and the wider community, both socially and medically. When appointments are made we can invariably find ourselves being the driving force in getting the service user to the appointment on time. The idea of a service user waiting outside their accommodation tapping their watch is not one that happens very often if at all. If a service user possesses such good skill as ‘being on time’, they may very also have the skills of using public transport in which case we would meet them there deliberately to avoid creating dependence.  

There are some individuals who benefit from time being an important factor in the way their support is delivered. This is not out of any practical need but more out of a dichromatic world view and this too requires both our support and challenge in order to support the individual to better interact with the world in which they live in. Is it ok to be 10 minutes late when going for a chat over coffee with a friend compared with being 10 minutes late to going to the dentist/doctor? Time plays more of an important role in some interactions than it does in others.

To many of our clients, time has been relegated in their mind as an issue (for some it is non-existent), either out of perceived competing priorities or through general impaired cognition. Indeed, some seem not know what day it is. Some people’s sleep pattern can be affected, and so they are out shopping at 2am, and sleeping at 2pm. Many do not possess a watch. There are a proportion who are impacted by drug and alcohol issues. Sometimes our support visits are the first structured experience for a long period of time. A great deal of flexibility is required on our behalf to successfully build rapport and engage with such an individual. As individuals start to build a trusting relationship they start to understand the importance of better time keeping and the predictable nature of support visits at set times becomes easier for them to tolerate.

What is valuable in an effective service?

When we accept that care as CQC defined is not required then it is easier to see why ‘time and task’ in mental health services becomes increasingly irrelevant. Time is just one of many ingredients that leads to an outcome, but on its own is useless in predicting a good service. Other quality elements in addition to time are required for a good outcomes. Quality elements such as:

  • A trusting relationship.
  •  An experienced ‘recovery coordinator’** who can help navigate the mental health system.
  • A well supported, supervised and trained ‘recovery coordinator’.
  •  Safe and suitable housing.
  •  Experienced managers to deal with and support crisis.

Time is like the fuel that gets the car to its destination. Quality is the car. Poor quality in many instances leads to the breakdown of relationship and the support relationship. All the quality elements require servicing to keep the car on the road heading towards better outcomes.

‘Face to face’ understandably is an important issue in a care and time driven paradigm. A person physically needs to be there to achieve the desired outcome. This is not the case in mental health, and although it does most definitely require ‘face to face’ contact, outcomes can be achieved in other ways. In fact sometimes ‘face to face’ is not at all what is needed when we are attempting to promote independence. What kind of support requires non ‘face to face’ contact?

  • Negotiating medical appointments for people, which can include stopping service user from being struck off doctor’s and dentist’s lists.
  • Supporting financial issues:
    • Benefits applications
    • Negotiating with the bank about lost cards and pin number replacements
    • Dealing with debt
    • Support with budgeting
    • Researching where to find affordable household items
    • Researching changes to benefits and application process.
    • Ensuring the heating does not get cut off due to non-payment of bills or other plumbing and gas issues.
    • Ensuring they have budgeted enough money to buy food and if not liaise with food banks (including one we have to run ourselves)
  • Liaising with colleagues and statutory services about progress and risk changes. (This is much more time consuming than domiciliary care because the cases are many times more complicated).
  • Liaising with family and other carers about intensely complex issues to which they are extremely and rightly concerned about. This is all the more necessary when we are requiring to work alongside such individuals. This is exacerbated by lack of care manager time to help support these issues.
  • Liaising with others over housing issues.
    • General public, co-residents/neighbours who may have been affected by poor service user behaviour and strongly wants the service user to be evicted.
    • Liaising with landlords and agents who are fielding complaints about anti-social behaviour.
    • Liaising with landlords to ensure that the property is safe.
      • Fire safety
      • Gas and boiler safety
      • Lock and Access
      • Electrical
      • Window and stair
    • Liaising with the council to ensure that housing benefit is paid on time.
    • Liaising with landlords and agents regarding damage that is done by service users
      • Helping to organise tradesmen to competitively quote
      • Helping to organise tradesmen to repair damage
      • Helping tradesmen to safely get access to repair the damage.
    • Supporting and organising service users to move home.
    • Researching/ offering advice/ signposting for housing related issues.
  • Staff along and senior management involvement in complex crisis cases involving multi-disciplinary interventions from, Police, Crisis team and Ward managers, Psychiatrists, CMHT Nurses and Social Workers, Paramedics and A&E doctors, safeguarding team, Fire Service, Southern Rail, Courts and solicitors regarding incidents like:
    • Adult protections issues to vulnerable service users from family/carers/public
    • Self-harm and suicide
      • Cliff jumping
      • Hazardous behaviour on the railway and other transport
      • Deliberate drug/medication misuse or overdose
      • Knives and razor blades (including their insertion in the body)
      • Hanging
      • Body dysmorphia leading to unnecessary medical interventions like knee replacements.
    • Fire setting
    • Physical and verbal assault on staff and members of the public.
    • Theft
    • ‘Cuckooing’ - drug dealing and service user involvement with local armed gangs who target service user homes to temporarily ‘deal’ from.
  • The support of staff after dealing with serious untoward incidents
    • Organising Time off and cover for staff after traumatic serious untoward incidents
    • The organising and paying for counselling (which is routinely offered when service users die, whether it was a completed suicide or not or even serious attempt.)

Although this is by no means an exhaustive list, it does help paint a picture as to the complexity of support required.

It is often very unhelpful to have service users and sometimes inexperienced care managers to talk about hours being ‘face to face’, because not only does it disregard the importance of the work above in developing outcomes, it leads to misunderstanding of the relationship. Service user with support from their care manager can ask that ‘face to face’ time is ‘spent’ (because it has been purchased) to support things that they can do themselves, thereby creating dependence. Staff have been asked to cook meals for people who were previously cooking themselves, doing cleaning for service users who don’t want to, and driving service users to appointments when previously they were using public transport successfully. Care managers whether through misunderstanding of how recovery is developed, or though wanting to get their money’s worth can accidently promote poor practice by talking inputs (hours) rather than outcomes (independence).

Consideration should be given to developing a different contract or a different approach which reflects the complexity and risk contained in the issues above. It is certainly our feeling that costs for mental health service users could possibly be enveloped into packages which reflect their Mental Health Cluster which will already have been set by secondary mental health. Maybe a housing related support element which sits on top of their support costs. Contracts could continue therefore to be individualised.

What outcome/output measures could be used?

Commissioners are very much more experienced in determining how to measure success in contractual terms than service providers and have a duty to ensure that ratepayers’ money is effectively spent. Our novice exploration of the field leaves us wondering whether outputs should be measured as drivers of outcomes and, of course, outputs are easier to measure.

Obviously, because the area of mental health is so complex there is going to need to be some contextualisation of measures for commissioners. The table below outlines some possibilities.

Commissioners will be familiar with these. So, please skip this list if you feel the need to.

General Outcome Measures

Type of Measure

Pro

Cons

HoNOS – Health of Nation Outcome Scale. 12 Areas, graded from 0 to 4 depending on severity of presentation.

Developed by Royal College of Psychiatrists as a measure of health and social function for people with SMI.

  • It is widely used within Mental Health Services in England.
  • It has been used since the 1990’s
  • It is short to complete
  • It gives a quantitative output.
  • Is free to use in NHS funded services.
  • Requires training to assess properly
  • Is a deficits analysis
  • Requires time to assess.
  • A reduction in scoring can be both a reflection of poor performance as well as complex need.


Patient Related Outcome Measures (PROMS)

Type of measure

Pro

Con

WEMWBS

Warwick & Edinburgh Mental Wellbeing Scale. Is a 14 question scaled questionnaire. Scored 1-5

There is a shortened 7 question brief questionnaire

 

  • Captures Softer Outcome data
  • Recognised within Mental Health Field.
  • Is patient opinion centred rather than assessor
  • Requires Service User not to be suffering from Mental Ill Health induced cognitive impairment
  • Service users can be impacted by mood, over or underestimating their true feelings. Robustness could be questioned.
  • Not all service users want to participate.
  • Time and cost to gather and analyse this data.
  • Service users can suffer from paranoia, over estimating score in order not to upset their support service.

 

Other Quality Assurance survey

  • Service user satisfaction is a great indicator of good outcome and could be considered.
  • Is patient opinion centred rather than assessor
  • Not all service users want to participate.
  • Service users can be impacted by mood, over or underestimating their true feelings. Robustness could be questioned.
  • Service users can suffer from paranoia, over estimating in order not to upset their support service (because it has become a lifeline).
  • Time and cost to gather and analyse this data.
  • Sometimes service user dissatisfaction is due to poor service, but sometimes it is through challenging habits which foster dependence.
  • Questionnaires are not researched for their effectiveness.

Recovery Outcome Star for Mental Health

 

Improvement in an individual’s recovery star outcome measure.

 

  • This is more robust as it can more objectively be applied without the service user mood impacting the scoring.
  • It is recognised across the country as a mental health measure.
  • It introduces the theoretical recovery process to service users and staff.
  • We have been using this for 2 years.
  • Not all services use this
  • It takes time to train
  • Objectivity/robustness can be questioned. A support worker may over estimate their impact on the recovery.
  • It is time consuming to use and requires recording and data collection and data analysis systems to work properly.
  • Not all service users want to participate in the dialogue, although this doesn’t stop a score being developed independently by the assessor.
  • Requires a licence to use.

% of service user with their own Crisis Plan.

 

WRAP- Wellness Recovery Action Plan is a well-used type of comprehensive plan.

  • Service Users who engage with their own crisis planning reduce their risk of crisis and are less likely to use or misuse services.
  • Introducing it promotes crisis planning across entire sector.
  • Promotes service user and service provider communication on key issues.
  • Promotes service user responsibility and is person centred.
  • Is empowering for service user to plan what will happen during a crisis, who is to be contacted, what will happen to their belongings etc.
  • No licence required, free for service user to use.
  • Recording this data is less onerous as its either done or not.
  • This is not a performance indicator as a % of service user crisis planning is just as much a reflection of service user disengagement from services because of mental ill health as it is poor service performance.
  • The more ill the cohort of service users, the less they engage with crisis planning.
  • Takes time to put together

 

INSPIRE is an outcomes measure designed to assess a service user’s experiences of the support they receive from a mental health worker.

  • Developed as part of Kings College Institute of Psychiatry’s REFOCUS programme.
  • There is a 5 item (BRIEF INSPIRE)
  • Recovery orientated questions.
  • Could be deployed by SMS text base system

 

  1. Long version is 27 questions.
  2. Can be impacted by mood
  3. Not all service user will want to participate.


Service Output measures

Type of measure

Pro

Con

Staff supervision rate

  • The better a worker is supported the more likely a good outcome might be generated for the service users they work with.
  • A difficult balance is required when defining what should be in a supervision. The more prescriptive this is, the burdensome it may become. How is staff supervision quality measured?
  • Just because a staff supervision box has been ticked does not mean outcomes will automatically be better, but their ought to be a correlation.

Staff turnover rate

  • This is a good indicator of staff stability. The longer staff stay, the more experience they will have and the better the service user relationships will be.
  • The Market is heavily impacted by wage issues and stressful working conditions (especially in mental health with the lack of support from the CMHT). Staff turnover rate maybe in some respects outside of a provider’s control.

Staff Training

  • This is a good indicator of staff experience and competence.
  • Well trained staff does not necessarily impact service user outcome or experience.


Service Health Output measures

Type of measure

Pro

Con

% of Service users offered support to GP Wellman Wellwoman check

  • Supporting early intervention of physical health issues for a cohort of individuals who historically have suffered extremely poor physical health leading to early death.
  • We currently measure this.
  • The success of this marker is as much as reflection of service engagement as it is service performance.

% of service users who smoke or who are offered smoking cessation

  • Supporting reduction in smoking leads to better physical health outcomes.
  • We currently measure this.
  • The success of this marker is as much as reflection of service engagement as it is service performance.

% of service users who are offered support with drug and alcohol dependency

  • Supporting reduction in alcohol and drugs leads to better physical health outcomes.
  • We currently measure this.
  • The success of this marker is as much as reflection of service engagement as it is service performance.


References Links

HoNOS

http://www.rcpsych.ac.uk/traininpsychiatry/eventsandcourses/courses/honos/workingageadults.aspx

WEMWBS

http://www.healthscotland.com/scotlands-health/population/Measuring-positive-mental-health.aspx

INSPIRE

http://www.researchintorecovery.com/INSPIRE

WRAP

http://mentalhealthrecovery.com/wp-content/uploads/2015/07/CrisisPlan2012Manual.pdf

RECOVERY OUTCOME STAR

http://www.outcomesstar.org.uk/using-the-star/see-the-stars/recovery-star/


Commissioners may note that the 2014 ImROC paper (Implementing Recovery in mental health services: Quality and Outcomes) reported that ImROC themselves have had to be selective in assessing useful measurement tools and they concede they have made ‘subjective judgements’. In the end they chose 4 primary metric systems for 4 domains viz. INSPIRE, Goal Attainment Scaling, Questionnaire on the Process of Recovery and the Social Inclusion Web. These tend to measure softer qualities of service defined by service user personal responses. Alternatively, there are ‘hard’ factors reflected in attainment of outputs (results achieved after having completed an activity) like tenancy training and support, attendance at Wellman clinic for B.P. checks, sugar testing etc., training and preparation for meaningful occupation like employment, volunteering or education.

We understand the outcomes then to be stability of housing, improved health and securing of employment, volunteer post or education course participation.

Illustrating successful attainment of an output is relatively clear and represents hard data; illustrating the outcomes over time is more challenging and a community provider has no control over influential factors like, for example, the availability of housing via the statutory bodies, RSLs or through the private market – all of the effective preparation in the world cannot produce stability of accommodation if there is no housing available.

Selecting what reflects a good service and is not administratively burdensome is also an issue for both support teams and for service users too as they may not wish to participate in surveys, despite explanation, which they may not consider are of benefit to themselves.

A Comment of the effectiveness of measuring response time to newly offered packages

The more complex the needs of a group of service user, the more likely managers will be coordinating crisis response. By way of example, last week we had a service user who was upset at not been offered a lift (she was more than capable) home after a group activity, decided she would walk home via the train track where the high-speed train from London operates in order to get a response from staff. Staff were undecided whether to try and talk her off the tracks, whether the call rail track or the police. A manager invariably finds themselves dealing with situations like this (maybe not always so dramatic). In an instance like this, would one want a manager dealing with this situation or taking a referral? It might also be pointed out the being quick to respond to a referral within mental health does not have any impact on service quality as perceived by the service user. In fact, it might it be suggested that it is better that a little more time is spent considering which service provider might be best. Being responsive to referral is important but it needs to be balanced with other needs. This measure although understandable for a domiciliary care referral doesn’t mean quite the same thing within a mental health context. The council is not buying something off the shelf when commissioning complex support.

Value and values

A final note about value and values-based commissioning. The Joint Commissioning Panel for Mental Health state something about cost and value. What our clients want is values in mental health commissioning.

The committee conclude that ‘value-based commissioning, maximising outcomes relative to cost and relative to harm, is desirable; a return on commissioning investment is a good thing’.

However, they point out that 'this value for money approach goes hand-in-hand with values-based commissioning - commissioning what service users, patients and families think is important - courtesy, company, compassion, information, empowerment and employment - less so than what service providers consider important - equipment, buildings, technology, medication' (p10).

The importance of everyday support, peer support and perceived support

Related to the wide ranging, trustworthy relationships provided by family friends and also, of necessity when relationships have been disrupted, by Avondale staff and peer workers this sort of support is often unplanned, ad hoc when needed, but crucial to stability.

Avondale staff and peer workers, responsively and reliably available seven days a week, offer what is described by Milne as 'not only companionship, but also fulfilling or psychological needs for attachment, validation and social integration. In other words, every day support can we go need to be recognised, valued and have a sense of belonging to something outside of ourselves'.

The Royal College of Psychiatry report trials 'which indicate that appropriately trained and supported peers can increase service users' satisfaction; their self-control ..., empowerment and movement towards recovery'. (Recovery is for All p.16)

Finally, it may pay to note that the very existence of an identifiable local community organisation, a group of people, reliably available and often present in a fixed geographical spot also provides what has been researched by (Turner and Brown, 2010). They note that 'perceived support (knowing that support is available should it be required) can help protect an individual from the negative effects of stress in their lives and can benefit their personal and social development'. This is especially the case given the difficulties service users have in regularly or predictably accessing hard pressed care managers.

Other issues to be considered collaboratively before new mental health commissioning in Kent

The conditions attached to the improved better care fund impress upon local authorities that their plans, to be submitted this September, should reveal how health and social care integration will be promoted. Notably, delayed transfers of care are an integral part of any expected planning and subsequent action and collaboration with social care providers.

The Kent and Medway STP conveys that out of area mental health placements whether for acute treatment or specialist care are financially problematic for CCGs and, in our view, provision of appropriately effective social care community placements and support to facilitate 'reduction' should be part of any planning and reporting. Of course, effective social care community placements, when allied with other psychosocial interventions, also crucially 'prevent' the need for inpatient treatment. Successful community placements, therefore, offer what the Care Act requires, that is to 'prevent, reduce or delay' the need for inpatient treatment. This appears to be a priority for local authorities responding to the improved Better Care Fund planning conditions.

This future requirement also brings into play other socially purposeful supports such as the fundamental importance of suitable accommodation, participating in psychosocial and/or adult education, having meaningful activity, comorbidities and more; there is much to be considered if mental health in Kent is to be considered on parity and to support the aims of the DOH and NHS.

Where to go from here?

There is a reluctance amongst providers to use measures of service which either do not promote good practice or frustratingly reflect a fundamental misunderstanding of the work that is required within mental health community support. Developing a KICA authorised, commissioner/provider working group to research and develop proposals as part of engagement with the market might be helpful in constructing a contractual framework which reflects effective practice and allows the County Council to assess this effectiveness and jettison the counter-productive ‘time and task’ model; perhaps the use of a specialist facilitator from UKC could pave the way. Additionally, such a person centred and outcome focused framework could reflect the evidence needed for the iBCF planning and evaluation process.

 

Thomas Jeffs (Director @ Avondalecare) Sept 2017

 

References:

Implementing recovery in mental health services: Quality and Outcomes 2014.

Recovery is for All, Royal College of Psychiatrists 2010.

Turner and Brown, Social support and Mental health cited in A handbook for the study of mental health; Social Contexts 2010.

Joint Commissioning Panel for Mental Health. Financially, environmentally, and socially sustainable mental health services, 2014.

 

*Where care is needed there has either been a transfer of the individual into our residential care home (with care manager support) or a package of care is offered by the residential care team as a temporary outreach project or a permanent package is offered by another care agency.

** Last year we renamed support worker to recovery coordinator as part of a training drive in our staff group to promote recovery. Support workers can unfortunately ‘support’ the status quo rather than promote recovery. Recovery coordinators are sometimes required to challenge service users when it comes to their expectations of service, especially when it comes to service user wanting us to support their dependence on services.

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