Community Mental Health Knowledge Exchange

A Whole Systems Approach

A whole systems approach to the Community Mental Health Transformation

Our work in six systems, an understanding of wider literature and our personal experiences have all contributed to the development of our thinking about a whole systems approach to the Community Mental Health Framework (CMHF) and developing community mental health systems. Our whole systems approach aims to bring to life the most important connections to assist the people who are actively developing services and systems. The following are key and described in more detail below:

How individual journeys through the mental health system are influenced by system practices and care culture.

The system model – how it is made up of practitioners with roles, and team, as well as organisational principles and ‘flow rules’ which influence practices and individual journeys.

How actual system practices (care as it happens provided by staff) may not match what was intended in the model and are influenced by many factors in the system.

How key supporting functions such as supervision and training, collaborative leadership and evaluation activities work to support change and sustain improvements.

How a range of system outcomes are important and are critical when considering whether there is system balance.

On this page ...

Overarching themes

A map of the community mental health system

System outcomes and system balance

Conclusions about system transformation

Richard Byng discusses how the transformation process can be seen as a whole system.

See also: our approach for details of our methods, who we are to learn about our team members, evaluation and research partners for the sites we work with, as well as our ambitions for an ongoing knowledge exchange.

Overarching themes

A set of overarching themes have emerged that guide our approach. These are highlighted here. In part, this is in order to emphasise just how difficult CMHF transformation work is, but it is also to emphasise its potential to really make a difference:

The need to consider and bring together all relevant resources for mental health support - newly funded roles, existing practitioners and teams, community partnerships, and individuals, their carers and their families.

Mental health system ‘transformation’ does not start from scratch - the existing context and history of each system is important, alongside new additions and innovative efforts.

The systems of care created were variably influenced by changing national NHSE and ICB leadership and directives.

Each system (primary care, secondary care, voluntary sector and social care) has its own principles, values and ethos that shape strategy and practice – these included official aims and underlying culture.

It requires sustained cross-system collaborative leadership for significant change to be achieved; without a bold strategy the status quo is too easily left in place.

Co-production (deciding together what to change) is challenging and the extent to which individuals with lived experience (especially from low income or marginalised communities) and point of care staff were involved varied.

The system is complex and unpredictable, and only partly knowable, but decision makers do have significant influence on how it operates - through how staff are deployed, the support that staff are given, the way people collaborate, and how a system operates and encourages new ways of working including flexibility.

CMHF ‘transformation’ requires persistence and courage over time – every step can involve changing someone’s way of thinking or mindset.

Richard Byng discusses the need for a greater emphasis on a whole system approach to care, bringing in self-care and community.

A map of the community mental health system

The word system can have lots of meanings. We use it in two ways. Firstly we are thinking about the different teams which make up the system. The two figures below depict the mental health system before the CMHF, with significant gaps in care, and following investment, with new teams aiming to bridge gaps in care.

The main teams and services involved in the mental health system before the CMHF

The main teams and services involved in the mental health system after the CMHF

Secondly, we are using the word system to describe causal links between more abstract ideas such as individual journeys, collaborative leadership and flow rules. This approach is based on ‘systems theory’ and ‘complexity theory’. Things are connected, but unlike in many areas of physical science, causal links are not only complex but it is not possible to understand the whole system or to predict how changes to the system will affect care as provided. For those with responsibility for transforming system we have created a map, showing how we see the main links and influences operating across the whole system. It demonstrates how changes at an organisational level should be able to influence the balance of the whole system, in terms of outcomes for individuals, populations with inequalities and staff.

Our map, showing how we see the main links and influences operating across the whole system

Individual Journeys

Key in the model is the individual and their journey through support. People can be engaged in self-care and getting support from communities, and/or gaining support from services. Journeys can be experienced as timely and helpful or disjointed and difficult.

We have seen that system practices (care as it happens) are key to determining an individual’s journey through support. Additionally the system model (what has been agreed should happen), training, support and supervision and collaborative leadership activities each influence individual journeys. Service users will also influence these journeys – both through their varied responses to service offers and also based on their psychological state or social situation.

Naheen Ali reflects on the importance on focussing on the overall wellness of a person in the healthcare system, and how it feels to face fragmented care.

Arun was referred quickly by his GP and was called by the practice based mental health worker. He felt reassured and noticed the kindness in her voice. He was referred onto a team for people with ‘complex emotional needs’. He did not hear and wondered what this team might do. He missed their call and was away for a couple of weeks and then received a letter saying he had been discharged. This left him confused.

System Model

In each transforming system, different parts of the locality community mental health service offer come together in a more or less integrated way. And how these parts of different sectors – primary care or secondary care or voluntary community - are designed to come together makes up the system model. This system model is the model as set up (and sometimes) described by local services and commissioners.

It incorporates adapted or new teams and roles as well as previously available and new interventions. It also includes what we call flow rules. Flow rules are the formal protocols for how individuals with mental health needs should move around the system to different practitioners and getting different interventions. These include what might be called pathways, eligibility criteria, etc, that define which team or practitioner should see which type of service user; also whether practitioners from one team are encouraged to liaise with practitioners from another and trust previous assessments - or start assessments again. Some are deliberately flexible, others designed to be much tighter. Flow rules can also be informal, developed within teams without approval or endorsement from the leadership.

Clinical culture as found to be sometimes, but not always, formally part of the system model, agreed and promoted by system leaders. We use this term to include how risk for individuals is thought about, whether flexible decision making is endorsed (rather than prioritising protocolisation) and whether they promote diagnostic-based care or prefer person-centred or strengths-based approaches. Like flow rules, cultures of care can also be informal, emerging from past practices and current practice.

Additionally, there are organisational principles which may or may not be described explicitly. These include whether referral into mental health support is via a Single Point of Access (SPA) or whether practitioners are expected to refer to the team they think is most appropriate, and can be passed on seamlessly if needed (the no wrong door model). They also incldude whether proactive, as well as reactive care, is encouraged (e.g. for those with psychosis but not under specialist teams).

What we found is that most systems could describe the new teams, the practitioners, and key additional interventions, but many were less clear about the care culture and organisational principles that they had set up. Some systems did not have clear descriptions of what they wanted their system model to be – either for teams within the system or for the public.

See our Systems Model page for more details on these areas.

Neighbourhood teams have been a key part of some transforming systems. We might see that a system has been clear in their system model: that they want to receive all referrals (except to Talking Therapies/IAPT); that a ‘core team’ includes certain practitioners; and that the weekly Neighbourhood Multi Disciplinary Team meetings also welcome GPs and VCSE staff. They might not however have specified that a social, as well as psychological model of care is being promoted.

System Practices

What we see when observing or being part of the system is a set of system practices. This is ‘care as it happens’ (in reality, rather than a model of what is wanted) and is what makes a difference to individual journeys. It may or may not correspond to the system model and, while influenced by the model, is very much affected by collaborative leadership and training, support and supervision.

In a system with a SPA, in order to carry out triage and initial assessment we might see the formal and detailed protocolised flow rules enacted ‘correctly’, but resulting in a series of procedures such as emails back and forth, internal waiting lists, initial telephone assessments, etc. This system practice might not lead to the care the system model had intended, with people dropping out along the way, waiting a significant time before being signposted out to community voluntary sector care or being passed on to specialist teams to carry out their own assessment.

In each system, we have seen how sets of meetings are developed for practitioners to make decisions both about care flow, and, to a lesser extent, to reflect on how the system model should be adapted.

Different balances of 1:1 encounters and group work have been put in place, with variable lengths of encounter, different roles, and different functions. Differences also exist in terms of mode of contact (telephone, video or face to face) and in the extent to which clinical contacts are about flow decisions, understanding an individual (doing an assessment) or providing support, care or therapy – or all of this together.

Together these practices shape individuals’ experiences of gaining access, being passed around the system and being supported (or not) in their next steps.

Supporting functions

How the system model and the system practices develop are also seen to depend upon three key supporting functions across the system:

The support, supervision and training that practitioners are given, as well as their own previous experience. You can look at our workforce page for more on this isssue.

The type of collaborative leadership work that goes on in a system - how practitioners work together across teams, how team leaders make decisions about the way their teams will work together, and how organisational leaders of the voluntary sector, primary care and mental health teams work together - or not. Especially important is whether they help to build the capacity of lived experience leadership and what approach they take to voluntary sector involvement in leadership.

The learning, analysis and redesign that occurs, including monitoring spending and patient activity by team, or even the flow of individuals through teams, and the evaluation of individuals’ and staff experience to inform further changes to the system model. See Webinar 3 for more detail.

We found that these functions were very varied across systems and that, while all our sites were making brave attempts to improve, this is an enormous endeavour and no one site had put everything in place. The CMHF transformation has a strong rationale as to how it will help individual service users and improve the work of staff, but it requires persistence and sharing of knowledge.

System outcomes and system balance

The way in which individuals access services, get ongoing support or are supported back into self-care makes a difference not just to experiences, but to health and quality of life outcomes. Added together, these experiences and outcomes determine whole population outcomes, including mental health and wellbeing, and whether equality or inequality has been generated. Other system outcomes, including staff wellbeing and retention and whether or not there is a balanced budget, are also important.

Some of these system outcomes can be monitored (budget, staff retention most easily), but measuring health outcomes is not straightforward.

Webinar 3 focuses on system balance and on how to evaluate and monitor to achieve an often-elusive system balance.

Conclusions about system transformation

Systems are complex, with multiple factors interacting. Community mental health transformation is not a process that happens quickly – we believe it is likely to need 10 years of sustained effort. We observed evolving new practices being introduced alongside established structures and processes that are not necessarily disappearing.

Some of the key ingredients appear to be:

Collaborative leadership – both top down and collective leadership with focused commitment to the system level and in localities involving all key sectors (secondary, primary, voluntary and social care). Leadership styles are important being both flexible and responsive.

Culture change – this appears to be needed in relation to risk, flexible more than protocol driven working and needs led as much as diagnostic thinking. Changes in use of language promoted by leaders also appears to be important. Shifts in hierarchy might need to be more openly discussed – involving lived experience leaders, clinical professional leadership and bringing in VCSE leadership.

Investment in new posts - Resources are invested in new front line staffing groups. This is not back filling previous staffing positions but creating new capacity through new roles.

System support for staff – supervision is an essential part of the programme, including different partners sharing their support systems – cross organization learning and collaboration.

Learning system – regular review and feedback needs to be built into ways of working. Understanding and acknowledging complexity, uncertainty, system stress (and distress) in a continually evolving system is critical. Reflective practice can be built into staff development, team ethos and quality improvement processes.

Communication – many people remain unclear about ‘transformation in practice’, but alongside these gaps are investments in events (learning sets, open days), videos and local newsletters to tell the story of all the efforts to integrate provision through the transformation investment. It is an important area and needs sustained prioritisation.

Visible change programmes – within the layers of transformation key task and finish groups can address local or national priorities such as work on inequalities, or around carer needs, culture change related to risk, the phasing out of CPA. These can become mechanisms for openly addressing vital and complex areas of work where disagreements often surface on both philosophical and practical grounds.