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The transformation of community mental health services relies on a healthy, motivated workforce. Systemic change depends on the capacity of the workforce to take on new roles or adapt the ways that staff from different teams and sectors work together to deliver services with better experiences and outcomes. Our focus here is on what we have learnt from the sites we have studied:
New roles – provide a broad range of new interventions and liaison or linking functions.
Cross-team work for dissolving boundaries - working with and understanding other practitioners in the system is a key function that the whole workforce needs to understand.
Building and Sustaining VCSE workforce – requires attention to ensure support for managing complexity and recognition of the value base underpinning delivery.
Supervision and training – both to bring in new skills and take a new approach to clinical care (e.g. risk and trans-diagnostic working) and cross-team working. Recognition of the approaches needed to support staff working in systems are in flux.
Staff outcomes - wellbeing, retention and motivation as key part of a whole system approach.
Summary of our findings
Summary of our findings
On the whole, the principles of the CMHF have been welcomed by practitioners involved in the delivery of mental health services across all parts of the community, i.e. primary and secondary (specialist) health or voluntary, community or social enterprise (VCSE), especially the ambitions to promote integration and remove gaps in care.
Working in the community transformation has given permission to some local systems to deliver the services that many practitioners wish they could, instead of having to say no to people in distress who might otherwise fall into gaps in care provision. We also heard that some local managers thrived with being given authority and freedom to innovate: “It’s very good actually. I love it. I struggle when I have to wait for someone to tell me what to do”.
The large-scale change promoted by the CMHF requires practitioners to work in new ways and learn new skills, sometimes working alongside new colleagues coming in from different working cultures. Enabling differing working cultures to come together as a system is a challenge that requires strong collaborative leadership – it appears this is required from both system / organisation leaders and from team leaders. We have seen in some sites that bringing together workforces with different cultures means everyone can learn together about what is available in services and local communities. We have also seen how staff coming together can help develop a shared culture as advocated in the CMHF - trauma-informed, person-centred, and not overcome by the risk-averse culture so common in mental health and community health services. These changes need to be underpinned by support and supervision for those making these changes and learning new ways of working.
We have, however, seen tensions play out when staff start to become overwhelmed by large numbers of referrals. In only limited areas have we seen sustained support for staff to work flexibly and in a ‘good enough’ way - that is, supporting people to manage with personal and community assets so that others with high need and complexity can be brought into the system. More often, we have noted a reversion towards use of tighter eligibility criteria and potentially burdensome assessments, triaging most people away from support.
Richard Byng discusses how practitioners can be afraid of acting because of possible risk.
New Roles
New Roles
While the CMHF has provided opportunities and given permission to service providers to work differently, some existing practitioners are struggling to understand their role within the transformation. Completely new roles have been developed, such as peer support workers, associate psychologists and community connectors / navigators, which are populated by new, often inexperienced staff. Their roles within community services are developing as organisations understand more about their offer and the contribution they can make to service users.
In the systems, many people valued the addition of community connectors / navigators and associate psychologists, and some saw the former as particularly key signifiers of the CMHF being successfully implemented. Community connectors / navigators were seen to have the potential to add something to the community support offer for service users: they acted as a social connection with community resources, reaching across boundaries of health, social care and community. Assistant Psychologists were seen to have the potential to offer something to people on waiting lists for psychological therapies, thereby taking some of the pressure off the specialist psychological therapies.
The range of functions the new roles take on include:
Primary care based – as first main mental health contact (referred on to by GPs or during initial access to general practice); some taking a more triage role signposting or referring on, others carrying out assessment and brief treatment (A&BT) to a wide range of complexity; specialising in supporting physical health checks.
Located in Single Point of Access (SPA) - taking on triage and initial assessment for secondary care.
Multi role linking workers – experienced mental health workers with strong links across the system – SPA, primary care, talking therapies – providing brief interventions, liaison and advice etc, making the system run smoothly.
Therapy roles with a range of grades from experienced psychologists to Associate Psychology posts: providing various types of therapy, group and individual.
Supervision and support for voluntary sector providers – experienced mental health workers supporting VCSE deliver peer support for individuals who often have significant complexity.
Social connection (community connectors) – helping individuals decide what social support might be needed (like social prescribers) and / or helping link people to agreed community asset support.
Peer support – individuals with lived experience trained to provide support including running groups.
Medication management – often Pharmacists helping with medication issues, reviewing medication, deprescribing.
New roles are more than additional staff capacity – they can bring with them a different ethos which adds value to the mental health system. For staff on lower NHS banding or lower grades in VCSE (e.g. social support and supporting therapy, but not accredited therapists, peer workers) there is a need for good supervision and support. The potential for these new workers to become overwhelmed was evident. Sometimes workers were expected to fulfil difficult roles even for experienced workers such as engaging with service users who may have complex stories to tell and untangle. Those taking on important new roles need supervision and support – emotional as well as routine case management and for further development of skills.
This quote gives a good understanding of what it might be like starting in a new role:
“I’m quite nervous about it, I won't lie to you. I don't really know, I think I would just have to see with time. I guess having an idea of it and people being quite transparent about it has helped a lot”.
Existing staff taking on new or adapted roles experienced this uncertainty too. It is important to include good practice from previous services:
“What went on in primary care previously, should not be thrown away. We should keep those and actually build on those strengths, rather than throwing it away”.
Some professional groups, i.e. nurses, were concerned that key skills and roles that worked well in primary care could be forgotten or lost with the change in emphasis under the CMHF.
Change requires a familiarity with and acceptance of flexible working against a culture of uncertainty as new services become established. This can be supported by offering opportunities for learning and skill enhancement, which can be a core part of integrated teams.
Alex Stirzaker talks about the benefits that new roles can bring, as well as the opportunities for staff in existing roles.
Cross team working to dissolve boundaries
Cross team working to dissolve boundaries
Joint working across teams and sectors is likely to foster closer working relationships between the transforming teams within the system. There are a number of ways in which we have seen this work well:
Promotion of flexible cross-team working by system leaders can contribute to dissolving professional and organisational boundaries - for example, through supervision across teams, joint training and mutual support. This enables the workforce to learn new skills together rather than wait for external opportunities for learning, thereby speeding up the process of upskilling the workforce.
At a system level, providing an “umbrella of services” under which stakeholders from NHS and VCSEs sit allows for collaborative working to develop across teams. This creates opportunities for collaborative decision making and learning to take place.
Understanding and learning about how different staff work and the services which they offer is enabled through a range of mechanisms:
Shared premises - when services are integrated into one place face-to-face meetings involving mental health stakeholders plays a crucial role in developing this understanding. Sharing premises also creates more opportunities for learning and for developing trust in one another and the decisions that are being made with, or on behalf of, the service user.
Practitioners being part of more than one team - integrated working was described by one system in some detail where practitioners have feet in different teams, bringing together opportunities for joint working. They had aligned their primary care delivery alongside PCNs.
“So, working very much, having core teams around PCNs with the integrated mental health practitioners really working within that integrated space. But also, then having one foot across into the locality teams. So, there's no, or try to, to make sure that streamline across the piece. And also, making sure – I mean, we collaboratively deliver the transformation with MIND anyway. So, they're in the picture, and then we also make sure that IAPT are invited to all of our meetings as well. So, we've got that piece there. So, that's where we started, and that's how we've rolled out. "
We have seen examples of a change in delivery where the idea of there being ‘no wrong door’ has been put into practice: one assessing practitioner was able to immediately have a discussion and arrange for a person to be seen by the most appropriate part of the system, wherever that might be - either in statutory services or VCSEs. The result is that the right person with the right skill base will be sought to offer the best intervention for the individual.
This is based upon a set of mutually reinforcing mechanisms:
The development of a trusting relationship, informed by knowledge of how colleagues work and an increase in understanding of the system as a whole.
Beginning to trust each other in the decision-making process allows for service user journeys to become more seamless – service users are less likely to be ‘bounced around’ the system and are more likely to get the services they need, without telling their stories multiple times.
Having a mixture of people present as part of that decision making process adds to the richness of decision making which in turn is likely to have an impact upon the confidence of practitioners to make decisions.
Alex Stirzaker talks about the importance of dissolving boundaries between teams and making sure that all staff involved are included and supported.
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Building and sustaining the VCSE workforce
Building and sustaining the VCSE workforce
Particular attention needs to be given to the role of VCSEs. Most VCSE providers felt valued, but there was evidence that working practices could be improved.
"I hear from the team that they find our role within it is valued. But I still kind of feel maybe they don't fully understand what exactly, so these questions do time to time arise. Based on that training I've been through, I'm going to be doing a presentation next month, to the team, to kind of go through what peer support is and how we are going about it, and what are the principles and kind of obvious support?”
But sometimes VCSE providers were being asked to undertake work which they did not feel competent to take on, i.e. as a counsellor rather than as a supporter. Role confusion adds to the potential worries that VCSE providers have. All new systems are developing their understanding of the role of the VCSEs and, inevitably, roles will change as services develop. Acknowledgement of this would be helpful, so that all delivery partners are clear on their roles and whether they have the skills and competences to fulfil them - and what support and supervision they might need to fulfil a potentially expanding role. There needs to be a specific focus on what VCSE partners realistically feel competent to offer, so that expectations are not too high.
“... it’s about the expectation, and the expectation is that we are on the same level as the mental health practitioners, but we’re not. We’re not because our training isn’t the same as the mental health practitioners. They are a lot more trained up and qualified as we are, also our band is completely different. However, some of the expectations are down to us. [laughter] I think they’re Band 7, there’s a Band 7 level, we’re not Band 7, like I said, we’re not therapists, we’re not counselling. There’s the disparity there, that’s the disparity. I think if they recognised, it’s not to say they don’t recognise the importance of our role, because they do, and they make that known in meetings, which is nice to know that we are contributing and making a difference and appreciated. However, I think sometimes it’s like: “Okay, the coaches can take that on,” and it’s like, well, our level is so much different to the mental health practitioners, it doesn’t add up [laughter]."
True service integration can respond to the need for support and supervise the VCSEs if they become more equal partners in delivery.
Nicola Hall talks about the unique contributions VCSEs can make to the CMHF.
Louise Knox talks about the role of VCSE in the CMHF transformation.
Supervision and training
Supervision and training
Supervision can enhance the skills and competences of practitioners old and new, and it is crucial in developing relationships. It creates opportunities for joint working, which increases the understanding of how individual practitioners work, and enables knowledge to be shared.
"Second Step invited me [Trust member of staff], so I started clinically supervising some of the voluntary sector partners [...] When, when this [VCSE staff member] left her position, [VCSE staff] asked if I would like to co-interview with her, so it was me and [VCSE staff] interviewing together, which was lovely, and that was like proper joint working."
We found evidence that training staff helped considerably to increase the knowledge of the workforce and increase their confidence. Some systems had invested in training the newly appointed staff, recognising that they may have limited knowledge of mental health.
“Oh, yes, definitely. So, we have an initial training programme that we started up with. Because it's technically an unqualified role to be a mental health coach, we had an initial training programme of what we do, the sort of things that we do for the majority of our staff, with certain things that we do for everyone who works with us, mental health first aid and different courses like that. But then we picked up a few things that we wanted to start them on initially, that we did on our end. But as time has gone on, we've identified certain categories that we're seeing a lot more of in patients. In which case, we've gone back to xxxx and said, "We're seeing a lot of this type of patient. We feel like the coaches could use some more training in this area." And then they've helped us to source that. A lot of it we're sourcing ourselves, but we are also able to go back to xxxx and say, "Do you have any training in this?" And if they do, they'll let us have it. They just did training last week in personality disorder and complex needs.”
Staff outcomes
Staff outcomes
Staff outcomes - wellbeing, retention, motivation - are a key part of a whole system approach.
The whole system approach we advocate proposes that key workforce outcomes are part of the overall goal of a balanced system. Staff need to be well-motivated and have an achievable workload – and this needs to be achieved while optimising service user outcomes.
A whole system understanding of staff outcomes
This figure brings together the key issues we have discussed into an overarching programme theory in relation to workforce. Supporting the workforce to be able to practice a set of CMHF practices appears to be key to achieving staff and service user outcomes. This requires training, support and supervision, decisions about system working that optimise flow, and support for staff to be less risk averse.
Subodh Dave reflects on the exposure to risk inherent for people working in healthcare and the importance of effective support structures in response to those risks.
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