Personalisation for community mental health services
SCIE At a glance 18
Published: November 2009
Written by SCIE in collaboration with the AMHP National Leads Network and the Social Care Strategic Network for mental health.
Personalisation for community mental health services means:
- making sure people with mental health problems can take as much control as possible over their support arrangements, to pursue their recovery and social inclusion on their own terms
- committing to developing a more equal and creative relationship between people using services and practitioners
- closing any gaps of understanding and procedure between local authorities and provider NHS Trusts to make sure self-directed social support can benefit people with mental health problems
- having relationship-based rather than process driven ways of working, changing your own personal practice as a community mental health worker or manager
- dealing effectively with the specific challenges of risk management, fluctuating conditions and public stigma to make sure people with mental health problems benefit equally from more choice and control
- adapting job roles, the organisation of teams and the allocation of resources over time to make sure services can meet people’s needs and aspirations in more personalised ways.
This briefing examines the implications of the personalisation agenda for practitioners and managers in community mental health services.
Personalisation means thinking about care and support services in an entirely different way. This means starting with the person as an individual with strengths, preferences and aspirations and putting them at the centre of the process of identifying their needs and making choices about how and when they are supported to live their lives. It requires a significant transformation of all adult social care services including mental health, so that all systems, processes, staff and services are geared up to put people first.
The traditional service-led approach has often meant that people have not received the right help at the right time and have been unable to shape the kind of support they need. Personalisation is about giving people much more choice and control over their lives and goes well beyond simply giving personal budgets to people eligible for council funding. Personalisation means addressing the needs and aspirations of whole communities to ensure everyone has access to the right information, advice and advocacy to make informed choices about the support they need. It means ensuring that people have services such as transport, leisure and education, housing, health and opportunities for employment regardless of age or disability.
What are the implications for community mental health services?
Personal budgets and self directed-support
There is emerging evidence, for instance from the IBSEN evaluation of the then individual budget pilots, that people with mental health problems may have the most to gain from increased choice and control over their support arrangements. Support available to date has often been inadequate, unsuitable or unacceptable. The benefits of choice will be most effectively realised through greater integration of health and social care resources (Glendinning et al 2008). However, perceptions about risk have sometimes compromised access to and uptake of, options like direct payments for people with mental health problems (Carr & Robbins 2009).
Personal health budgets are also being piloted for England. These will build on the experience of personal budgets in social care and test out ways of giving people with long term conditions, like mental health problems, greater control over the health services they use.
A direct payment is only one way to receive a personal budget. The following points are crucial for understanding how personal budgets work:
- personal budgets should be focused primarily on funding ongoing support and care needs, and normally only considered after looking at relevant preventative and enabling options
- personal budgets can be offered as a direct payment, or as an ‘account’ managed by the council or a third party
- personal budgets should be implemented within the framework of self-directed support – this involves self-directed assessment, ‘up-front’ allocation and support planning, to ensure maximum choice and control.
Self-directed support involves finding out what is important to people with social care needs and their families, and helping them to plan how to use the available funds to achieve these aims. Implementing self-directed support in social care means ensuring the following elements are in place:
- Self-directed assessment: simplified assessment that is led as far as possible by the person in partnership with the practitoner and focuses on the outcomes that they and their family want to achieve in meeting their eligible needs. Assessment looks at the situation as a whole and takes account of the situation and needs of family members and others who provide informal support. The council’s duty to assess needs can be met through proportionate self-directed assessment and support planning processes.
- Up-front (indicative) allocation: The person has a strong indication at an early stage of the amount of council money (if any) that is likely to be available to achieve these outcomes before support planning takes place. This amount may be adjusted following the development of the support plan.
- Support planning: There is advice and support available to help people (irrespective of their means) to develop plans that will achieve a desired set of outcomes. Arrangements should make the most use of natural support and mainstream services. For those people who will be receiving a personal budget to meet their care and support costs, the council should have a process for signing off support plans to ensure that eligible needs will be met and any risks managed.
- Choice and control: the person should (as far as capacity allows) decide how any council funding should be managed and decide how best to spend it to meet their needs to achieve their agreed outcomes. Decisions should not be constrained by the menu of services currently offered. Councils should not require personal budgets and support plans to be expressed in terms of ‘hours of support’. This could reduce flexibility and result in service-led solutions.
- Review: The council should have a process for checking whether the outcomes agreed in the support plan are being achieved.
We stopped talking about my ‘needs’ and started talking about how I wanted to live my life.Person with a progressive neurological condition using direct payments
Challenges for mental health
While there are common principles for implementing personalisation for everyone requiring social care resources, there are some particular challenges in mental health.
- People using mental health services should be supported to maintain maximum choice and control throughout fluctuations in their mental health, wherever possible. This may involve mechanisms such as use of advance statements about how personal budgets are to be used at different times as well as the adoption of a flexible general approach by staff.
- Under the management of integrated NHS Trusts, mental health may not feature as strongly in local authority/Northern Ireland health and social care trust implementation of personalised social care support. Extra effort may be needed to ensure staff are part of the local authority/Northern Ireland health and social care trust’s training and workforce development initiatives on personalisation and that systems are made to work together.
- Staff need to support positive risk taking and equality of access to social care resources for people with mental health problems – but they have to do this often in the context of public fear and risk-averse organisational cultures. Managers and leaders must offer excellent guidance and support in these circumstances, showing their commitment to personalisation and risk enablement and ensuring practitioners have confidence in organisational risk management systems. Practitioners should be supported to define risks and negotiate risk management strategies with individuals.
Personalising the journey through mental health community services
Personalisation encourages you to think about what it is like for someone trying to navigate the system – to walk in their shoes. Your role is to empower them to find the sort of support most appropriate for them as an individual. This may mean facilitating access to services, resources and opportunities for meaningful occupation, leisure and education. In some cases it may mean helping people to make choices and identifying who else in their social circle of support might be helpfully involved in that. It is also important to discuss specialist support options if the person is, for example, from a black or minority ethnic group, or identifies as lesbian, gay or transgender.
In order to do this, you will need to have:
- relationships with people that are about respecting each other’s expertise, experience and assets and working together, sharing knowledge and ideas
- conversations with the people using services that are more open, exploratory and creative, looking at their life goals and the things that really matter to them
- an understanding of people’s rights and entitlements – and the discrimination and stigma they may face – and the ability to share this understanding with them.
Personalisation challenges the traditional notion that staff and managers know what is best and determine what someone should have. While professional expertise is important, our challenge now is to improve how we share our expertise and respect the experience and expertise of people using services, their families and friends who are often in the best position to identify both problems and solutions.
Stages in a person’s journey
The following section offers an overview of some main stages in the journey through services that a person might experience – and how as a practitioner or manager you can work differently to personalise each stage. The stages are not exhaustive and do not necessarily happen in this order. Different stages may also be revisited or happen in tandem. The suggestion here is intended to get you thinking and to recognise that personalisation has relevance to all aspects of your work.
- How personalised is my practice?
- How personalised is my team?
- How personalised is the system?
... when a person with mental health problems:
… is in touch with primary care services:
- Is there anything I can do to give earlier, more preventive responses to people in touch with primary care?
- Can I facilitate better access to primary physical health care for the people I work with?
- How can we work with partner organisations to develop better universal access to information and advice about mental health issues and provider services?
… needs crisis and home treatment services:
- Is the service ‘holistic’, offering psycho-social intervention at an early stage?
- Does it provide enough advice and information to carers, or family members or friends involved?
- Does this service link well with services providing ongoing support?
- How easy is it to access?
… experiences a Mental Health Act assessment:
- Are Approved Mental Health Practitioner (AMHP) assessments in my team organised and carried out in order to maximise the control a person can retain over the situation?
- Are suitable advocates (both formal and informal) routinely involved in assessments?
- Are resources and personalised plans available to provide alternatives to admission where it is safe and appropriate?
- Are AMHPs able to appropriately influence the ongoing support plans of people they assess?
- Have we discussed with the local authority/Northern Ireland health and social care trust how new alternatives to admission might be created?
Example: AMHP, Hertfordshire
This time, when Jenny was assessed under the Mental Health Act, I talked to her about what was most important to her at this point. It was the safety of her children. She was able to spend time with her children before leaving the house, reassuring herself the arrangements for them were OK. I then made enough time to talk about whether she could leave the house without further restraint. She had been held by several police officers on all previous occasions and this time she could walk to the ambulance unrestrained. This Mental Health Act assessment was a very different experience for her. She retained more control and she remembered this when she felt more well – it gave her hope of change.
… needs to access an ongoing community mental health service:
- Can I offer more choice of appointment time and places, and/or choice of who the person sees?
- Are my letters easy to understand and free of jargon and is the team’s telephone manner always helpful and courteous?
- Can I offer good access to specialist support, translation and interpretation?
- Do I routinely suggest to people that they might create their own agenda in advance of their first and subsequent appointments?
- Do I invite them to bring someone with them?
- Do we have quality standards in our team for information provision at different stages of contact with the service?
- Can I let them know how to complain and signpost access to independent advice?
… experiences assessment, review and care coordination:
- Is self-directed support and self-assessment for social care resources the standard approach for initial or subsequent assessments and is risk management part of the discussion with the individual?
- Do I and all colleagues understand personal budgets?
- Is there a clear, accessible assessment document produced with the person that they can take away with them and refer back to?
- Do I and colleagues understand Fair Access to Care Services eligibility criteria and financial assessments?
- Do I and colleagues understand how support planning is changing and can we ensure people using our services benefit from this?
- Have we received training on how the CPA and care coordination role will evolve in response to personalisation?
- Am I routinely considering direct payments for all eligible and willing people with capacity to use them?
- Do I routinely review that a self-directed support self-assessment has been offered and undertaken as appropriate over time?
- Are all CPA meetings organised such that the person using services and their circles of support from families and friends take optimal control over how, where and when it happens and what is on the agenda?
- Is there a coherent approach to risk management and safeguarding that focuses on the individual?
Example: Person with a progressive neurological condition using direct payments, Oldham
The thing that has really changed was the types of conversations I had with my social worker. We stopped talking about my ‘needs’ and started talking about how I wanted to live my life which made much more sense and opened up new opportunities. It was so different for me – and for her!
… is part of a family or other important social network:
- Do I talk routinely with people about their social circle of support or the one they would like to create?
- Do I routinely try and involve families, friends and carers in support planning, (with the person’s consent) to make mental health support more effective and to promote the individual’s mental health management and help prevent relapse?
- Do I pay enough attention to sharing my knowledge and skills with families and friends, to help them in their supporting roles?
- Do I make sure I know who the substantial carers are and whether they might benefit from a personalised carer’s assessment in their own right?
Example: Father of man using long term mental health services, South London
The psychiatrist had been telling me for months that he couldn’t tell me about my son John’s treatment, including his medication – he said John doesn’t want me to know. John has been quite unwell and it has been difficult to talk much with him recently even though he is back living with us. When I finally did raise this issue with John and asked when he had told his psychiatrist that he couldn’t tell us about his treatment regime, John was adamant he had never told him that and that he certainly hadn’t asked him recently. John then got a new care coordinator who was really comfortable talking with me and my wife. She told us about advance statements – that John could say what he wanted to happen in the event that he became ill again, including what information he wanted shared with us. No one had told us about that before. It was a revelation. The care coordinator came to the house, offered practical advice to us as a family and made all of us including John feel we had an active, adult part to play in moving on.
… wants to feel a fuller part of society:
- How well informed am I and my colleagues about the opportunities that people might access from local community, education, leisure and employment resources?
- Do we monitor and review the social inclusion progress of the people we work with?
- How do we address equality and diversity issues, such as those for people from black and minority ethnic communities or for people who identify as lesbian, gay or transgender?
- What are we doing enable people to stay in work if they have a job?
- How can I and my team help people with housing difficulties?
- What are we doing to challenge stigma and discrimination against people with mental health services and to promote positive attitudes in other public services and in the local community?
- How am I working to enable this person to discover and build on their strengths, social networks, interests and activities to improve self-confidence, independence and self-determination?
There are many sources of further information on personalisation. Here is a short selection of helpful resources:
- Brewis, R.K. (2007) A voice and choice. Self-directed support by people with mental health problems, London: In Control.
- Carr, S & Robbins D. (2009) Research briefing 20: The implementation of individual budget schemes in adult social care, London: SCIE.
- CSIP/RCPsych/SCIE (2007) A common purpose: Recovery in future mental health services, Joint position paper, London: SCIE.
- Glendinning, C. et al (2008) The national evaluation of the individual budget pilot programme: experiences and implications for care coordinators and managers , York: Social Policy Research Unit, University of York.
- MIND (2009) Personalisation in mental health. Breaking down the barriers: A guide for care coordinators. London: MIND.
- NSIP (National Social Inclusion Programme) (2009) Vision and progress, London: NSIP.
- Department of Health/ADASS (2009) Making progress with Putting People First: self directed support London: Department of Health/ADASS/IDeA/LGA.
- Allen, R, Gilbert, P, & Onyett, S. (2009) Report 27: Leadership for personalisation and social inclusion in mental health, London: SCIE.