Navigating the System
Access to support and navigating the system
All sites have had a focus on achieving access to support. Operational work to do this included recruiting for new roles and developing system ‘flow rules’ (protocols, pathways) and setting up regular meetings to make decisions about how to get people to the right support. However, there has been less focus on establishing or explicitly discussing the principles underpinning both the organisation of care and clinical practice.
Our key conclusions:
Innovations in some sites have supported individuals to rapidly access care in proportion to their need.
Protocols (flow rules) designed to limit access to those meeting certain criteria, to ensure full assessments are completed and to standardise care all have the potential to worsen inequalities and create disjointed and disappointing experiences.
Putting in place No Wrong Door and related principles are likely to help to prevent experiences of being rejected, repeatedly assessed or ‘passed around’ between teams.
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Jamie Stafford reflects on variation in practice within a system.
Individual pathways to access
The direct relationship between system practices and an individual's journey of support.
System practices, or ‘care as it happens’, together with input from individuals and their supporters or carers, determine how the journey to access support plays out and is experienced.
Our evaluations are starting to explore how the experiences (e.g. empowered or bewildered) and behavioural outcomes (e.g. attending or not attending an appointment) of individuals arise as understandable responses to the actions of practitioners and experiences with digital technology (e.g. text messages about appointments or links to resources) and paper-based communication (letters of appointment or ‘discharge’).
The key intermediate outcomes required could be considered to be:
Engagement
Developing a shared understanding about the issue (diagnostic or formulation)
Making decisions that match need to available support (social, psychological, medication, etc)
Passing on to further teams or practitioners or ongoing treatment with initial practitioner (e.g. where assessment and brief treatment combined)
Endings or next steps (which do not need to be full ‘discharges’)
Service user feedback about the experience of these steps in the journey can be elicited by survey (email or text linked) or telephone call (including by peer evaluators).
The practices which generate these outcomes occur through a combination of:
Individual practitioners and service user/patient encounters (face-to-face, video or phone based 1:1 encounters),
Group encounters (formal group therapy, peer support, information/education),
Team meetings with the individual absent, and
Engagement with digital support, such as text messages or websites, and paper-based objects, such as questionnaires and letters.
This set of system ‘resource offers’ results in very varied responses from individual service users and in dramatically different access journeys, often taking patients across systems and between teams. It appears that individuals with quite similar needs can have very different journeys, these being influenced by this combination of system flow rules and the different people in roles, each of whom has varied experience/skills/capability, capacity (time/workload) and supervision.
Richard Byng discusses the importance avoiding highly standardised assessments.
Service user journeys
Scenario 1: Social anxiety, arguments with school, debt and trauma:
In Journey A, an individual with social anxiety, ongoing arguments with her child’s school and a past history of adolescent sexual violence, meets with a GP, who makes a referral. The referral is triaged by the locality team. The individual attends an encounter by telephone with a primary care network-based worker who has significant previous experience of mental health care. Because the situation is complex, the network-based worker makes an assessment and takes it back to a team meeting, where it is decided that they need to wait for psychological therapy. Unfortunately, the individual only receives a letter some weeks later, and, because she's worried about debt, she doesn't open the letter, fails to attend and is discharged. Weeks later she attends the emergency department in desperation and is signposted back to the GP.
Alternative Journey:
In an alternative pathway, in scenario B, the person gets help from a friend to complete an online GP appointment request and, because the information is clear and the GP can see that she has significant past problems, she is triaged by the GP to go directly to the mental health worker. She is seen by a practice-based worker face to face, who quite quickly develops trust with the individual - due both to the known setting and because the individual senses that the practice-based worker has read and had access to the past records. The worker also shows that they care and says that they will provide some help, rather than focusing on assessment. The individual is seen for several sessions, providing a combination of a shared understanding and brief treatment. She makes a decision to attend DBT training.
Scenario 2: Long term difficulties
A second example shows how an individual with complex but well-known problems can be treated very differently by different systems. This individual has good literacy skills and a good understanding of their problems: ongoing suicidal ideation, but no intent, having obsessional tendencies, attachment-related emotional reactivity.
This individual was referred by the GP to the Single Point of Access (SPA) for the whole county, and because of the suicidal thoughts was given a full mental health assessment by a nurse, who then discussed the case with an experienced psychiatrist. It was agreed that the individual did not meet the criteria for any of the specialist mental health teams and was signposted back to the GP and to the local MIND group. These options were not taken up.
In this situation, significant resources had been used, but little opportunity had been taken to listen to the ideas of the individual, as the focus had been on risk minimisation. A set of negative outcomes had been created by the system, including waste of resources, further anger and resentment, and frustration for the general practitioner. These negative outcomes are what we refer to as system harms.
Alternative Journey:
In a different system, the journey begins with an initial phone consultation with someone who has access to their records and who was able to appreciate that the individual had a good understanding of their situation. The assessment was brief because the individual was clear about not wanting therapy or medication, and had coherent ideas about what they wanted: time away from the house, somewhere not too crowded. They accessed a helpful local website and made contact with two nature-based programmes, one of which was able to provide support and transport.
Mechanisms underpinning Access
Mechanism supporting CMHF aligned practices and support needed from the system
Resources and key mechanisms needed for access
This figure depicts the key steps and underpinning mechanisms which are needed for accessing care. Systems may want to pay attention to each of these in order to deploy resources which achieve key overarching outcomes: matching individuals to the best resource for them available, supporting those most in need with the most resources, creating a sense of positivity and hope and reducing negative experiences (caused by system harms).
The follow key steps (or processes of care) for achieving access are underpinned by ‘resource offers’ from staff (and digital support) in systems.
Initial engagement and trust can be generated by helping people believe they are right for and will be welcomed by the service:
Clear information about what the support is and why it might be helpful for different people.
Words and pictures indicating that a diverse range of people will be supported.
Staff showing that every individual matters, e.g. by showing a common humanity and / or being culturally competent.
Providing early brief treatment or signposting to social intervention to achieve quick wins and trust.
A mutual shared understanding of the needs and issues can be generated by:
Listening to people's most pressing concerns.
Eliciting strengths which have helped them cope, survive and flourish.
Explaining the practitioner / health care perspective in understandable language.
Working with the individual to bring these together as one ‘shared understanding’ – this would use a bio-psycho-social approach and be needs- and strengths-based.
Matching individual need to available resource through:
Finding out what has worked before and what people's preferences are.
Explaining what resources are available (including self care, digital and community support) that might match needs described in the shared understanding.
Shared decision making about what is likely to work.
A coherent plan might require:
Bringing together the agreed immediate future actions into one plan
Being explicit about how these actions link together.
Sharing this in a suitable written (or diagrammatic or digital) form.
Engagement with ongoing resources can be assisted by:
Coaching to support attendance (some people may need to be taken along on a first visit).
More detailed information to reduce anxiety.
Information sharing with those in new service (with permission if outside of NHS) to help staff their understand how to respond to particular needs (e.g. anxiety, voice hearing or emotional volatility).
The resources required to put the above steps in place include both individuals and practitioners, with their shared skills and experience, as well as technology with prompts or websites with local resources, and written information. Each of the steps may not happen in the sequence above. All of these steps may involve the same practitioner, a different practitioner, or take place in another setting.
Richard Byng discusses what needs to take place for a system to be effective.
Contributing to an efficient, balanced system
Because an individual’s needs are complex, and system resources are limited, the deployment of resources needs to be both personalised and efficient if we are to achieve the overarching aims of a balanced system - better health for the population, reduced inequalities, balanced budgets and a motivated workforce.
There are a number of issues that make creating beneficial community mental health systems a challenge:
Because we lack precision diagnostics in mental health (compared to many areas of physical medicine where diagnosis based on tests is accurate) it is hard to predict, even after a full assessment, whether the support (of any type) provided will make a difference.
This is made more problematic because in mental health care the effects or benefits of treatments are relatively small (numbers needed to treat are high), unlike, for example, treatment of cataracts or HIV where definitive ‘cure’ is common. Put another way, in mental health care any one intervention will help only a small number of people of those who are treated.
Further, system harms (rejections, long uncertain waits, re-traumatisation) appear common and are important to individuals with lived experience, and efforts to reduce them would likely improve the balance of benefit and harm.
Together these difficult, contested issues suggest that we support practice which acknowledges uncertainty – both about what is going on and what support might be helpful. So, rather than protocolising each of the steps from engagement to endings, we propose that the system encourages flexibility. This could mean we get more positive examples like the alternative journeys above.
For practitioners, personalisation may therefore be the key to achieving efficiency and addressing inequality. Practices will likely involve:
Paying attention to micro-practices, such as non-verbal cues, to ensure engagement.
Making judgements collaboratively about matching needs to available resources – with an appreciation that decisions may need revisiting.
With experience, gaining confidence to omit unnecessary steps.
Being aware of the potential for system harms and avoiding these when possible.
Considering the whole system when making decisions – in order to play a part in creating a balanced system that addresses inequalities.
Reducing time spent with people who are easiest to engage, and more time with those who are marginalised, who need time to build trust or who have complex problems.
Bringing in increasingly AI-based digital aids, especially for those with lower needs.
For some individuals, the key steps for access might be carried out between two people in a single room over a series of meetings, or even within one. For those with more complex needs, a team approach with several individuals and a set of support activities may be required to meet those needs. How these resources are deployed will determine whether the positive outcomes of a balanced system are achieved or not; whether motivated staff and individuals efficiently get to what they need, or significant waste and negative harms are created by individuals feeling resentful or frustrated.
See Webinar 3 to hear more about Balanced Systems.
Alison Brabban reflects on the importance of talking to people using services to understand how to get the best outcomes.
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