What makes up a Systems Model?
Each system we have worked in had a different model for their delivery of the community mental health framework, including roles, teamsand underpinning philosophy. A system model is a description of what leaders intend their system to look like. We have created a description of the part of the model which system leaders may want to consider and use to describe their system.
The CMHF does not describe how its vision should be put into practice, allowing room for innovation. There is no prescribed model, as provided for the Improving Access to Psychological Therapies (IAPT) roll out, or even a ‘taxonomy’ of possible parts to be used across systems, for describing different approaches with a common language.
We have found that staff or teams with similar roles have different names, e.g. the role linking to community resources or assets might be referred to as 'community connector' or 'community link worker'. We have also found that teams or roles with similar names can provide very different functions. So, we provide a method (or taxonomy) for describing the System Model in different sites.
Our description incorporates:
Organisational principles – influencing how teams and practitioners work together.
Clinical culture – how staff are encouraged to think about and handle risk and use diagnostic or needs based models for understanding distress.
Interventions – range of psychological and social support.
Roles - types of new and adapted roles.
Teams and relations between teams – types of new teams and links between teams.
Flow rules – those formal and informal rules (including pathways, protocols and eligibility criteria) which guide what happens to individuals on their journey into, around and out of services.
The System Model
Generic components in each system's model of care
The above diagram depicts the generic components in each system’s model of care. We describe them below. Other pages on this website describe which different aspects of the models seem likely to be helpful, the underpinning mechanisms of actions, and, evidence permitting, the circumstances in which different configurations or principles of working might be more or less effective.
We found that the initial focus of each system’s transformation was around new roles (to recruit to) and specific interventions. Varied attention was paid to clearly articulating the principles for the organisation of care (such as ‘no wrong door’) and even less to the principles of clinical care – for example, related to managing risk of whether to use diagnosis. Additionally, we developed the concept of ‘flow rules’, formal and informal rules which are designed to create some level of consistency about what happens to whom – and when. These appear to have a fundamental impact on an individual’s flow through a complex system.
Organisational principles
Each system interpreted the aims and principles of the CMHF in different ways, combining new ideas with previous initiatives and existing practices. Some system models have more clarity than others: some make a considerable effort to publicise their principles; some allow individual teams the flexibility to adopt different practices for each locality – sometimes managing to achieve the same aims in different contexts.
No wrong door
One of the key principles we saw was the idea of ‘no wrong door’ – meaning that wherever in the system someone arrived, their journey to the right place, person and support would be easy. This ideal can be seen as a response to the bad experiences of being rejected, of needing an additional referral to somewhere else, or of being discharged without an ongoing plan. Some systems incorporated a range of principles into 'no wrong door':
That people could be referred (or self-refer) directly to a range of teams/support (this contrasts, as we will see, with the single point of access).
That, if it was not the right team, they would be passed seamlessly, and kindly, elsewhere (so-called ‘warm transfers’).
That assessments, or shared understandings, would be built on, or ‘trusted’, rather than started again (to respect expertise and avoid both having to repeat narratives and wasteful duplication), often called ‘trusted assessments’.
That endings did not constitute ‘discharges’, requiring another referral and assessment if the service user wanted more support – and incorporated a plan for next steps including self-care, community support and how to re-access specialist support).
Beccy Wardle reflects on the challenges of achieving a 'no wrong door' approach.
Single Point of Access
A very different organisational principle, mainly reflecting past iterations of redesign and a desire from referrers for simplicity, was that of the Single Point of Access (SPA). A SPA aims to make referrals easier for the referrer by providing a single number or email address to which all referrals for mental health problems can go. We saw how SPAs had been expanded to cover populations of over a million people.
See access to support for more in-depth discussion of different models and how this SPA principle can come in conflict with the ‘no wrong door’ approach.
Whole population, whole system
Another organisational principle, reflecting the essence of the CMHF, was that ‘the system’ should be seen as a whole. For some, this means bringing together primary care networks (PCNs), voluntary sector organisations and the new mental health teams funded by CMHF transformation monies. For others this goes further so that systems are seen to incorporate the work of IAPT (Talking Therapies) services, community mental health teams and other specialist teams and pathways.
Some systems went further and recognised the importance of an individual’s own role through self-care, as well as the role of family and friends and voluntary sector organisations that, though not specialising in mental health, make important contributions (e.g. debt relief, green space exercise, etc.). Here wellbeing promotion and prevention can into the picture. While the CMHF advocated an integration of public mental health, the targets relating to people seen by services for support and treatment were at odds with this wider approach.
Clinical care principles
A set of clinical issues have been significant tensions in community and inpatient care for the last twenty years: assessment and diagnosis, the recovery movement, and risk. Much has been written about these and here we indicate their relevance to system ‘transformation’ and the CMHF.
Assessment or shared understanding
Assessment or shared understanding
Assessment is often understood and promoted as an important clinical function that needs completing before a plan of treatment is made. We saw that the assumption often remained that assessments need be carried out by specialist expert professionals who have a particular knowledge and ability to decide ‘what is going on’ and ‘what is best for the individual’.
But we also saw indications (from interactions observed in team meetings) of some ways in which this way of working was starting to be modified:
By building on previous work (for example around person-centred care and recovery) that the individual themselves has a key role in understanding what is happening to them and being part of the assessment process.
That ‘shared understanding’ may be more user-friendly than the words ‘assessment’ and ‘formulation’ – it indicates less passivity on behalf of the individuals; that the outcome is something ‘held in mind’ (and/or writing) by the individual as well as a professional.
That gaining an understanding and providing support or treatment can go hand in hand; that this can incorporate efficiencies; and that a generalist approach can allow brief assessment and treatment to be carried out together (this builds on long standing practices in therapy, and on the formalised ‘Assessment and Brief Treatment’ models).
Diagnosis and person-centred or diagnostic models
Related to assessment, the tension between diagnostic and person-centred or bio-psycho-social approaches was noted as a frequent source of tension across the systems we worked in. The CMHF proposed less emphasis on diagnosis, and we did witness some systems explicitly reducing emphasis on diagnosis. This was done by encouraging assessments or development of shared understandings that emphasised social stressors, which in turn led logically to shared plans that included support to link to social interventions, for example by ‘community connectors’.
For the most part, however, diagnostic language remained, with talk of personality disorder sometimes replaced by ‘complex emotional needs’, and surprisingly little discussion of specific psychological problems (e.g. rumination, emotional reactivity) that might be addressed by specific therapeutic approaches. Instead, the main points of discussion were around which team was best suited to an individual's needs, based on a broad interpretation of individual complexity and risk.
There was also limited explicit discussion, given their importance over the last 20 years, of recovery models. Although the key underpinning components, such as connectedness, hope, identity, meaning and empowerment (CHIME model), as well as strengths-based approaches, were inferred and appeared consistent with the stated ambitions of most systems. Newer ideas such as trauma-informed care were more explicitly part of the talk in many systems.
Risk
Risk is a serious issue in the NHS, with ways of thinking and acting around risk related both to objective safety and to perceptions of safety and organisational reputation. In mental health much of the focus has been on prevention of harms, such as suicide and homicide. In contrast, a positive risk management approach focuses on making considered judgements about where the risks of harm are low and on the delivery of positive interventions to improve wellbeing (and therefore reduce risks of harm).
We have seen different organisational culture around risk, as well as a variation in specific approaches to limit risk. Risk was sometimes discussed explicitly as a major problem, and we saw evidence of what might be considered risk-averse culture with layers of assessment to ensure that ‘risky’ people were not taken on by some teams. We consider that a system’s approach to risk needs assertive repeated attention form leaders across teams.
Subodh Dave reflects on the need for structural change to enable continuity of care.
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Interventions
The range of interventions seen across the sites demonstrated the creativity of local communities and services, a response to permission from the framework to broaden the range of types of support, intervention and therapy:
Social interventions and support are recognised by most systems as important contributors to mental health. Some have teams of ‘connectors’ who do intensive work to support people to housing, debt advice or legal advice agencies. Others provide support to reduce loneliness or links to social activities such as groupwork, volunteering and outside-based green space activities. Some others rely on existing PCN-based Social Prescribing Link Workers with variable levels of integration (those link workers may or may not be trained and supervised to support people with significant mental health problems).
Psychological support was seen as key in all systems we have work with. Variation in provision was great and generally the need for a range of approaches to fill the gap between NHS Talking Therapies (IAPT) and secondary carewas recognised. The value of generic skills of listening and showing care, or being alongside someone, was not always explicit. Sometimes the focus was mainly on matching people to the ‘right’ therapy. New types of therapies not usually included in IAPT, such as Dialectical Behaviour Therapy (DBT), Compassion Focused Therapy (CFT) and Acceptance and Commitment Therapy (ACT) are included in some systems, as are individual and group-based derivatives of CBT. A range of other support that was found includes development of Wellness Recovery Action Plans (WRAPs), groups addressing a range of issues such as bereavement and loss, as well as one-to-one work for trauma, such as current domestic violence or past sexual violence, or strong links to specialist trauma services.
Peer support was evident in diverse ways. Some system ran groups led by individuals with lived experience for relatively low level needs, some had peer support workers in teams, while others had commissioned VCSE peer led support for people with a wide range of needs including some deemed high risk (interestingly in this service they never claimed to be ‘holding’ the risk, generating an interesting tension with NHS services worried about ‘holding’ the risks which could be considered lower).
Medication support forms part of some systems and is rarely a key focus except in relation to recruiting new roles such as pharmacists and non-medical prescribers. Support includes initial prescribing (as an alternative to GPs), reviewing medication or, in some systems, deprescribing.
Physical health care has been emphasised in only a few sites, with provision for proactive support to those with psychosis only occasionally put in place. See our PARTNERS webinars for discussion about how proactive care for the most vulnerable can be achieved.
New roles
The range of new roles included those focused on functions such as assessment, treatment or connecting individuals, as well as other roles based around a specific type of support (e.g. medication management, specific group or individual therapy).
The extent to which roles were about assessment, connection or therapy - or managed all three - is an important theme. For example, community connectors appear to be working well, using their ability to engage and transfer trust to interventions beyond the core mental health system, such as debt advice agencies or outside activities. However, separating assessment and treatment could lead to problems when waits between assessment and treatment are too long or when the trust is not transferred.
The names of different roles were also very varied, and the bottom-up nature of development has led to a range of roles with different names, but effectively doing the same work. For example, there is a big overlap between community connectors and social prescribing link workers in primary care networks. The challenge of creating names that ‘say what it does on the tin’ was a problem and practitioners across the system often didn’t understand what certain people in certain roles were doing.
See our workforce page for detail about different roles and how they can be supported.
New teams and links between teams
As with new roles, the proliferation of new teams with different names and changing names was obvious across the sites. Some teams started with names that were interesting but did not indicate their function, and moved to more traditional names such as 'psychological therapies'. There are also teams within teams, and teams operating across geographical areas whose members became part of teams within particular geographical areas. This was not just at a primary care network level, but also at the level of populations of one hundred thousand. Sometimes these teams at a neighbourhood or one hundred thousand population level or smaller were composed effectively as multi-disciplinary meetings without any administrative or management function, while others were highly managed.
Supervision across teams was also inconsistent, and, while there was an obvious need for support for individuals taking on new roles and working with people with significantly complex mental health needs, getting the supervision from expert mental health practitioners was one thing, and making it work out well was quite another.
See our neighbourhood working page for more details.
Flow rules
We coined the term ‘flow rules’ as a means of describing the formal and informal rules operating through the system, which, together with other factors, influence how people navigate the system, from initial access, to moving around the system and stepping down to less care (or discharge).
Flow rules can be formal, for example written down with clear inclusion and exclusion criteria for teams to navigate, as both referees and teams receiving referrals. There might be detailed instructions about, for example, whether an assessment should be done before or after an individual is seen by particular people, or inclusion criteria based on complexity, risk, diagnosis or other criteria. Alternatively, there might be clarity that flexibility is required and that practitioners should decide on an individual basis or according to team capacity.
We have seen how for some this creates clarity and may allow people to be referred to the right team, but also how it can create resistance and resentment (e.g. where teams appeared too bounded if there were no alternative options, referrers and individuals were found to provide negative remarks about these teams). We have seen tensions around uniformity versus flexibility across services, particularly at the primary care network level. We have also seen how organisational cultures can encourage or discourage flexibility both within and across teams.
These flow rules (written and/or held in mind) relate to and influence a variety of actual things that happen: decisions taken as a result of, against or working around the rules; the individual’s mental health ‘journey’, including the sequence of practitioners that they might then see; data flowing (or not) around the system; and the financial resourcing of different teams.
While we see these rules as important for systems ‘to pay attention to’, we do not have enough data from individuals to know what kind of flow rules are likely to work well to generate better outcomes for whole systems and individuals.
This topic is discussed at greater length in the first of our series of webinars.
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