What makes up a Systems Model? 

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. 

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 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.

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. 

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.