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- Introduction
- Critical Success Factors for Good Practice in Community Mental Health Services
- Conclusion
Introduction
For the past five years David King’s work has enabled him to examine a large number of mental health services at grass roots level. As Leader of the Mental Health Task Force at the Department of Health in London, he had the opportunity to see mental health services across the whole of Britain. Since then he has worked for purchasers both in the United Kingdom (UK) and in New Zealand. The work has also brought him into contact with services in the United States and Europe. All of this experience has given David more of a chance than most people to collect evidence to address the question, ‘What constitutes good practice in community mental health services and how is it achieved?’
"There was a time when I thought that only a few places in the world could justifiably claim that they were providing effective community mental health services; one or two places in Italy, Sydney and a few locations in the USA. They seemed to be the ‘models’ to follow. Now that I have had the chance to see a host of local services, I am convinced that there are examples of the work being done well everywhere. But the ground cover is patchy. Small scale good examples are frequently surrounded by examples of less than good practice. Most areas are like the proverbial curate’s egg: good in parts.
"The more I got to see services and agencies which appeared to be making their customers better and helping them to manage their own lives again, the less concerned I was with the ‘model’ and the more interested I became in trying to distil what features or qualities successful services had in common. I have identified 10 which are briefly described below."
For the purposes of this article, David has concentrated on services for people with severe and enduring mental illness but the principles apply to other areas and sectors of the mental health market.
Critical Success Factors for Good Practice in Community Mental Health Services
Clear Work Priorities
In the adult field, there is increasing recognition that addressing the needs of people with severe and enduring mental illness is the first priority. Being clear about which segment of the market is being targeted is very important if staff are to work effectively as a team and the impact of resources (staff and other investments) is to be measured.
There are places where individual members of staff seem free to choose the work that interests them and the only requirement is to fill in the forms which say how many contacts they have. In these circumstances the term ‘team’ is as meaningless as a game in which some are playing hockey, others rugby or soccer. It is impossible to know the score or to assess the contribution of existing or additional resources.
An Expectation of Recovery
Successful services operate with the conviction that people with severe mental illness can do better (significantly improve their health and social functioning, to use the jargon) and that the consumers themselves must be part of the solution. They are not daunted by slow progress (or setbacks) and their respect for and faith in their customers is natural, not just a paper policy.
Where this expectation of improvement does not exist, there is, at best, an attitude that little can be done for consumers, except to give them some kind of daily routine. David says, "I have encountered situations where, because a clinician has no expectation of improvement at all, it is still possible for a consumer to be discharged because they are not making progress. Yet these are the people in greatest need of help. So they sink down until, once more, they are admitted to the acute mental health unit, victims of the ‘revolving door’".
An Effective Key Worker (Support, Service Integration or Case Management) System
When it works well, this is the element of community services which ensures access, integration and, above all, continuity.
The key worker is a case manager or broker who is acceptable to and gets things done for the consumer principally by arranging realistic assessment of need and the delivery of the health and social support which the need prescribes. The consumer and key worker need to be able to find each other easily and stay in touch in the community, in hospital, in the care of social support agencies, indeed, wherever the consumer happens to be. Even when a consumer is in an intensive social support service, eg, supported housing, work programmes, etc, the link continues. Consumers will have significant relationships with other people, staff or family members who may be in close personal and day-to-day contact with the consumer. They are part of the chain of support of which the key worker is a crucial and integrating element.
Key workers should not be just anybody who happens to be working in a community team but people selected for their ability to do the work. A ratio of 25 consumers to 1 key worker is a reasonable level. The key workers cannot discharge consumers and are accountable to a manager for the conduct of the relationship.
Knowing the People
Severe mental illness affects small numbers of people and the population changes slowly; the same people are around for a long time. There is increasing evidence to suggest around 0.6% of the adult population (aged 15–54 years) are in this category and have health and social needs for which services should be designed to reach out to and support.
Good Integration
The key worker provides for an integrated programme of health and social support which may be provided by specialist mental health agencies, or by general health and social programmes available to everyone. This can mean an ordinary rented flat or job instead of one which is provided by a specific mental health social support agency. "With the assistance of an effective key worker, the consumer can shop around to get what suits him or her and gradually achieve the normality we all appreciate."
Continuity
Good key worker systems do not give up on the consumer. They stay in touch and go out to find people who fail to attend appointments or support programmes, for it is at just these times that people are at their most vulnerable. It may be that the day-to-day contact is conducted by a support agency. For example, it is a feature of the USA-based day support programme Club Houses that the members themselves keep in touch with each other and seek out non-attenders. The key worker needs to be aware, and the provider must be able to look to the key worker, if any situation is more than they can handle.
Moving home or going into hospital are times when a consumer most needs to be in touch with someone they know, yet this is often the signal for their current key worker arrangements to terminate and their case to be transferred. In addition, this can sometimes take some while to occur during which time the consumer is in an unsupported organisational limbo when things can go wrong.
For example, it is still the practice in some places that admission for acute inpatient care is an event which disrupts previous community arrangements, interrupting continuity. The admission might be handled by an emergency team whose personnel may not be known to the consumer. As soon as the consumer is hospitalised, they cease to have a community-based key worker.
Discontinuity also arises when consumers move home. It becomes the hospital’s responsibility to discharge the person and a new key worker is appointed by the community team, often a long time after discharge.
The key worker is most valuable in assisting admission when it is needed, staying in touch, and making arrangements to ensure that discharge is well planned. Key workers should really stay in touch with their consumers until satisfied that their consumers are in contact with their successor, ie, the case is handed on rather than leaving the consumer waiting until something or someone turns up.
Access
This is usually shorthand for ‘assistance in crisis’ or ‘impending crisis’. Crisis may be occasioned by recurrence of an illness or some social event producing unmanageable stress, eg, the telephone being cut off, etc Good key workers help consumers to prepare their personal ‘crisis drills’ for such occasions and to anticipate problems whenever possible. When there is no such system and there is pressure on hospital beds, the crisis really has to deepen before anyone will take notice.
Key Worker Accountability and Support
Key workers need to be accountable to a manager responsible for ensuring their effective performance and to whose assistance they can turn for help or advice. Good key workers may perform miracles, but they do need support from their superiors to ensure that when no clear solution can be identified they have someone to turn to who can help. Managers of key workers should be experienced at dealing with the exceptional problems which may be beyond a key worker. And, when the managers hit a brick wall, they will need to be effective at activating higher levels of management to do what is needed.
Measuring Outcomes
Good key worker systems look at whether they are improving the lives of the people in their care by posing simple questions such as:
- Do consumers know their key worker?
- Have consumers received the programme of health and social support that their assessment prescribed?
- Have targets been met? For example, it may have been a local intention to help a number of consumers to move from staffed accommodation to their own residence with home-based support; what happened?
- Are more consumers in purposeful jobs than when last reviewed?
- Are hospitalisation and the number of occupied bed days increasing or decreasing?
- How is this local service performing in comparison with the measured performance of other local services?
Community teams which look at their performance in this way, changing the selection of factors that they use for comparison, are in a good position to give account of themselves and what they achieve for their customers.
Annual Service Review
The information described above can be used for service planning so that providers and purchasers reviewing performance on an annual basis can add and recycle resources to better use. If, as a result of a community team’s efforts, the use of hospital beds has been reduced, the money should be available for some other local priority – a bonus for good practice. Consumer views should be canvassed and their opinion sought on what is needed. Making improvement becomes a step-by-step process informed by local experience. Some places will be farther ahead than others, but by this method they should all be moving forward.
Conclusion
None of the foregoing 10 points are novel in themselves. It is in combination that they make the difference, in the same way that a good dish is more than the ingredients of the recipe. In its briefest expression, the system must see the consumer as its responsibility, keeping in contact with him or her and assisting in improving his or her life.
