The big hours debate: how to deliver up to date person centred support within a ‘time and task’ based contract. Let’s have a conversation.
Non statutory community support teams have increasingly taken centre stage as the primary contact and source of support for people with severe mental illness living in the community. This is related over the last decade to the increasingly challenging resource environment within which CMHTs and CHRTs operate where poor staffing and retention levels, low morale and sickness have all taken a toll (Helen Gilbert comments upon this in her Kings Fund Briefing). So, now non statutory community teams of less qualified professionals, often only to NVQ levels, are now being asked to accept responsibilities which would have been the daily activity of qualified nurses or social workers ten years or more ago. It has become a very significant alteration within our social support landscape.
Community support organisations working under the auspices of the Local Authority therefore have a level of responsibility they could not have imagined at the beginning of the century. Commendably, NVQ qualified personnel wish to achieve highly for their clients and ought to do what they can to offer the most effective and most relevant service supporting their statutory colleagues. Perceptions of effectiveness and relevance, as may have informed contract stipulations before 2012, appear quite different today in 2018.
Recent theory and practice essays, research documents, governmental advisories and more have contributed to this increasingly amended view of community mental health support. To achieve well for community mental health service users, rarely visited in some areas by CMHTs and often rationed for use of in patient placements, community support practitioners would, arguably, be negligent if they failed to pay heed to research which helps us all understand what works best.
Now, this is not the time and place to rehearse every single line of argument produced by reliable ‘governmental’ bodies, academic institutions or consumer/user rights organisations. This is not an academic paper.
But picking a few random arguments gives us all a start.
Firstly, The Care Act references matters related to independent living in the community as part of the wellbeing principle. ‘Section 1 of the Care Act includes such matters as control over day to day life, suitability of accommodation, contribution to society and crucially requires local authorities to consider each person’s view, wishes, feelings and beliefs’ Care Act Statutory Guidance 2018 p7.
‘Promoting wellbeing as the general principle obliges Local Authorities ‘to have regard to the importance of preventing or delaying the development of needs for care and support and the importance of reducing needs that exist’ ibid p6.
So, from this random search of the legal and academic backdrop, social care and support organisations, faced with the reality of clients with significant mental health challenges, low economic status, compromised physical health, social isolation and poor or no accommodation are beset with requests for help by clients and their families which are not currently and reliably met by the statutory services in the way this might have been 10-15 years ago. What is to be done?
Would it be best to ignore these factors and provide only the services detailed in current contracting, predicated on active Care Manager involvement and governance through LA Care Plans and Risk Assessments with access to a well-resourced Homelessness unit within the District Council, LA or NHS provided social inclusion activities, more liberal Income support and Disability payments, in patient bed occupancy levels back down to mid 80% etc etc. This is not now the landscape and much of the housing and social need so pertinent to wellbeing is inaccessible to vulnerable people. So, they loudly ask social support organisations to do what they can.
Of course, this pertinence can be ignored. LAs have budgets always on the decrease and provision of service to prevent reduce or delay greater needs, as described in The Care Act, can always look unaffordable to responsible budget holders. But innovative thinking and use of community resources can help them and relieve the statutory service of greater problems later.
Tragic outcomes stay with us all. Suicide within this group of fellow citizens is notable. From a swift random search of relevant documents, I note the relevance of Local Suicide Planning and its reflection within Kent recommendations for suicide prevention. The focus being on men, people who self-harm, people who misuse drugs, people in the care of the mental health services and more. So, when community support teams come across people inadequately accommodated (7% mental health service users who died by suicide 2008-12 were in ‘unstable housing’ p57 Local Suicide Prevention Planning, Public Health England 2016), who have self-harmed (a risk factor for subsequent death by suicide including ideation ibid p49) or people who are vulnerable due to economic circumstances (18% of service users’ who died by suicide between 2012-13 had experienced serious financial difficulties in the three months before death) ibid p57, then we should ask the question – what would you do to discharge your duty of care to fellow citizens? Ignore these factors which might comprehensively have been dealt with in the year 2000 or try to work in partnership with colleagues to reduce such social inequalities (referenced in The Health and Social Care Act 2012). Lots of people can survive such inequalities ‘after a fashion’ but some, when they experience a constellation of such negative issues, kill themselves.
That is the consequence of outdated social provision for some and we should do what we can avoid this by working flexibly and innovatively with an eye to the research and guidance.
Let’s have that conversation.
The difference between care and support.
There is a fundamental difference between the care needs of an elderly person and the support needs of a recovering mental health service user. Resources can be allocated more easily in a conventional care situation, needs can be identified and estimated. It is often also very important that they happen when they are supposed to happen because people need to have medication, be clean, and eat at the right time. Failure to be time sensitive can quickly become catastrophic. Mental health support can be very different.
|Is time sensitive most of the time.||Is time sensitive only some of the time. In some instances, not at all.|
|Is related to easily specified tasks which can be timed i.e. feeding, shopping, showering - which impact physical health. Care planning is relatively more simple because of this.||Tasks vary depending upon fluctuating mental health and can change quickly. Rarely are there tasks that relate to physical need, so care planning is almost always more complex.|
|Missing a care visit may lead to a health crisis.||Missing a support visit may be considered a deficit but may also offer opportunity to develop some independence.|
|An assessment of need more likely to remain reliable for the medium term.||An assessment of need can change within time scales of 24 hours or less|
|People with physical health needs may not be especially mobile and are likely to be good at keeping appointments. Indeed, they may have restricted mobility and be more home focused.||People with mental health support needs are not always the best time keepers. Their time keeping ability often decreases as their support need increases.|
|Time is allocated to meet the clear task assessed need.||It is impossible to accurately estimate the time required to meet a need.|
|Care managers can suggest when visits ought to take place and how long they should be.||Experienced care managers do not suggest when visits ought to take place or how long they should take.|
|Outcomes usually improve the more time is spent.||There is not a strong link between time spent and outcomes achieved. Other contingent factors are crucial. Sometimes spending more time can lead to ‘institutionalisation’.|
One experienced recovery coordinator once remarked “People don’t have a mental health crisis to fit in with a care plan”. It is obvious to those who work in community mental health that needs are usually more psychosocial than biological and so the way support is delivered needs to respond to that fundamental difference. Over the last 15 years we have listened to professionals and service users and have developed a model which reflects the best practice of person centred support in order to develop outcomes. We call this model the “Proactive/Reactive Model” as opposed to a “Fixed Hours Model” which is widely used.
Under a proactive/reactive model a proportion of the support hours is allocated to doing proactive work. Proactive work is work that may be defined by a care manager or by the service user in their support plan. The proportion of hours that is assigned is secondary to the chance of developing an outcome, but it is usually 60-100% of the hours. It therefore flexes day by day and may even sometimes be more than the allocated hours if a good outcome looks likely to be achieved.
|Total Allocated hours|
Support planned work developing a personal recovery. Scheduled work happening by appointment.
|Reactive Work (Flex)
Unplanned work that happens at a time and place at the service users request.
|Reactive Work (Crisis)
Work that is crisis driven which is used to reduce risk and prevent harm.
|Reactive Work (Background)
Work that is undertaken on behalf of a service user but is not face to face.
Fig1. Proactive/Reactive Model showing how total allocated hours can be allocated. Although we have included percentages this is only indicative and, in reality, real world circumstances dictate the allocation of resources.
This is work which is agreed in advance and reflects matters set out in the care plan. This can include anything from accompanying service users to appointments through to doing ‘one to one’ work on meeting their needs as defined in their KCC care plan and their personal support plan.
Reactive work (Flex)
Reactive work (flex) is proactive work that happens at a time the service user chooses rather than a time we had previously planned. It is not uncommon that individuals with poor mental health and thought/cognitive disorder to have relegated the importance of time in their mind. One of the reasons they are offered support in the first place is because of their inability to engage with the world at the right time (e.g. being at appointments on time, paying their bills on time). It is not unusual for service users to miss appointments or to want to change their support appointments to a later time. This work is about engaging with service users to develop outcomes whenever it is suitable for them.
They may wish for several reasons not to want to engage with the full, planned support (proactive work):
- The medication makes them tired and so they don’t want their support visit at all.
- They are not in a ‘good mood’ and so they don’t want their support visit at all.
- They have forgotten their support visit and are out, and they can’t be found.
- They are spending time with other people (friends/family) and so they don’t want their support visit at that moment in time.
- They have paranoid thoughts and so they don’t want their support visit at all or in full. If initiated it may curtailed by the client.
- The support visit has ‘surprisingly’ achieved its ‘goal’ before the planned time is discharged.
In these instances, we will not have delivered ‘face to face’ time but we will have planned to do so. Depending on the need and the opportunity we may be able to engage with this person later in the day. This is risk assessed, considering their recent mood, the unusual nature of their absence or even a reflection of how much support time they have already missed. The more visits that are missed the more concerning it is. If we return later, the time spent is ‘fresh time’ and unplanned for, but it still needs to be accounted and invoiced for. We therefore try to build this into how we spend the originally defined resources/hours, rather than invoicing for more hours. We may attempt contact later and have blocked out time for an unscheduled visit, but the person may still not be engaging or can’t be found. We still need to account for this time also even though it has not been used at all. This is where a ‘time and task’ contract is functionally incompatible with reality in the community setting.
The solution of a proactive/reactive model is also a reflection of the system and its needs and the lack of time that care managers have to approve ‘extra hours’. We would be contacting CMHT’s multiple times per week per client to approve extra flexible hours. This is unworkable for both CMHTs and us. When care managers are dealing with crisis issues or are on sick leave we could spend 2 hours of calling and negotiating trying to approve 1 extra hour of support; we therefore, instead, accept this issue and try to build this work into the pre-existing resourcing.
Reactive work (Crisis)
“People don’t have a mental health crisis to fit in with a care plan”. This work is arguably some of the most important work we can do and it has saved many lives. Sometimes ‘Reactive work (flex)’ becomes ‘Reactive work (crisis)’ when the client becomes unwell. In this instance, we may have to involve multi-agency teams and attempt to coordinate a response. We attempt to reduce the impact of their poor mental health whilst attempting to pull in extra resources for a person from CMHTs, Crisis team, Hospital, GP, A&E and the Police. Crisis interventions can be extremely time consuming. With limited resources this is often very challenging.
Hours being spent can be used very quickly. As risk increases during a crisis period we are more likely to involve more staff to do dual visits, we also require our management team to become involved to help coordinate the response.
No one would want a support provider to delay their crisis response whilst they are awaiting approval for extra hours. We attempt to build such response into the person’s original resources so that we are not chasing a care manager when we should be protecting a service user. In the vast majority of cases we do not invoice for all this work. We could find that we get into a debate every time there is a crisis on how much time we have actually spent or should have spent if we were to invoice post crisis. The problem with this approach is that it may appear that the person is ‘not getting their hours’. Being in crisis is relatively common, but it obviously doesn’t happen all of the time for all people, so it is difficult to establish how much resource should be assigned to this. We could roughly assign an hour or two per week to this bit of work, almost like an insurance policy. As we develop the evidence to show that it is not needed, then we can reduce it to zero.
Reactive work (background)
‘Reactive work (background)’ is work which develops outcomes for an individual without them being present. This is not planned work that is contained within a care plan because these issues raise themselves in the course of offering support. These issues are much more likely to be required for a person in a community setting contending with poor mental health compared to a person with good capacity and mood who is receiving care orientated visits. These are also issues, which if not dealt with, have the potential to trigger a relapse. There is a range of activity this might involve, and the list below is not an exhaustive one, but it does paint a picture. Reactive work for example can include:
- 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).
- Extra complex report writing
- Negotiating medical appointments for people, which can include stopping service users from being struck off GP and dentist’s lists
- Liaising with family and other carers about intensely complex issues about which they are extremely and rightly concerned. 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 desire 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 issues
- Window and stair safety.
- 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
- Liaising with Housing Associations in order to develop housing options for individuals
What if a person doesn’t need or make use of reactive work?
We think it is sensible to make some allocation to reactive work. We have developed a relationship-based service where outcomes are primary over ‘time and task’. The amount of time allocated is not formally decided but is impacted by:
- History and risk assessment (Previous history of relapse)
- Need as it arises on the day (service users don’t always want to see someone)
- Care manager direction. (a care manager who wants a responsive service for their client rather than ‘time and task’)
- Service user direction (a service user forgets a support visit and requests contact later after their friends/family have left)
Offering this person-centred service means that sometimes it appears that a person is ‘not getting their hours’. However, this can become an extremely challenging thing to establish given the importance of the reactive work, where resources are available but not always used. We may have instances where:
- A person misses planned support visits
- A person reorganises their support visit last minute and accepts it may be less time later on
- A person may decide to stop the support visit early
- All that can be achieved is achieved and there is no point continuing with just ‘spending time’ with a person without achieving an outcome (which arguably would be a form of community-based institutionalisation)
- We are undertaking important ‘reactive work (background)’ on their behalf
In all of these instances, we would need to continue to invoice for the planned hours rather than the delivered hours, as the delivery of hours can be altered by service user and circumstance. We still have the expense of having a trained person ready to deliver such support.
If a person is regularly failing to make use of the reactive work on offer than it may be an opportunity to reassess the resource as the person has developed more stability, resilience and independence from services. However, this needs to be an evidenced based decision rather than based on hope of stability. This happens too frequently within our service and building flexibility into the support package develops a culture of self-reliance for the service user making it more likely that they can successfully cope with a reduction in planned support at a future time. We are more than happy to have a conversation about this.
A comment on the challenges of Personality Disorder.
We would also like to point out that ‘allocating hours’ to people with a personality disorder sometimes encourages competition between some service users to display behaviour in order to gain more support. Some service users with PD mistakenly believe their inherent value is reflected in the hours they are assigned. It is good practice to concentrate on outcomes rather than inputs with this particular cohort of individuals and care managers can sometimes accidently undermine the promotion of independence by talking about inputs (hours) in front of service users.
It is plain to see that providing mental health support in the community does not fit in with traditionally prescribed methods of working and that we have to be flexible to develop the outcomes we as a society wish to see. Working in this fashion is demonstratively better when looking at the benefits and outcomes people have achieved. It does leave the door open on a difficult question, ‘Has someone had all their hours’?
The answer is sometimes:
- Yes, but some of it has not been ‘face to face’ but been ‘Reactive work (background)’.
- Yes, but the person had chosen not to engage with planned or unplanned support visits by accident or deliberately.
- Yes, but some of it was ‘duelled’ by 2 workers or more.
- No, because we have done well in reducing the service user’s reliance on support, we will need to review the case with care management to review the allocation of hours.
T Jeffs / L Jeffs