Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP)

Abstract

BackgroundConcerns about fragmented community mental health care have led to the development of the care programme approach in England and care and treatment planning in Wales. These systems require those people receiving mental health services to have a care co-ordinator, a written care plan and regular reviews of their care. Care planning and co-ordination should be recovery-focused and personalised, with people taking more control over their own support and treatment.Objective(s)We aimed to obtain the views and experiences of various stakeholders involved in community mental health care; to identify factors that facilitated, or acted as barriers to, personalised, collaborative and recovery-focused care planning and co-ordination; and to make suggestions for future research.DesignA cross-national comparative mixed-methods study involving six NHS sites in England and Wales, including a meta-narrative synthesis of relevant policies and literature; a survey of recovery, empowerment and therapeutic relationships in service users (n = 449) and recovery in care co-ordinators (n = 201); embedded case studies involving interviews with service providers, service users and carers (n = 117); and a review of care plans (n = 33).Review methodsA meta-narrative mapping method.ResultsQuantitative and qualitative data were analysed within and across sites using inferential statistics, correlations and the framework method. Our study found significant differences for scores on therapeutic relationships related to positive collaboration and clinician input. We also found significant differences between sites on recovery scores for care co-ordinators related to diversity of treatment options and life goals. This suggests that perceptions relating to how recovery-focused care planning works in practice are variable across sites. Interviews found great variance in the experiences of care planning and the understanding of recovery and personalisation within and across sites, with some differences between England and Wales. Care plans were seen as largely irrelevant by service users, who rarely consulted them. Care co-ordinators saw them as both useful records and also an inflexible administrative burden that restricted time with service users. Service users valued their relationships with care co-ordinators and saw this as being central to their recovery. Carers reported varying levels of involvement in care planning. Risk was a significant concern for workers but this appeared to be rarely discussed with service users, who were often unaware of the content of risk assessments.LimitationsLimitations include a relatively low response rate of between 9% and 19% for the survey and a moderate level of missing data on one measure. For the interviews, there may have been an element of self-selection or inherent biases that were not immediately apparent to the researchers.ConclusionsThe administrative elements of care co-ordination reduce opportunities for recovery-focused and personalised work. There were few shared understandings of recovery, which may limit shared goals. Conversations on risk appeared to be neglected and assessments kept from service users. A reluctance to engage in dialogue about risk management may work against opportunities for positive risk-taking as part of recovery-focused work.Future workResearch should be commissioned to investigate innovative approaches to maximising staff contact time with service users and carers; enabling shared decision-making in risk assessments; and promoting training designed to enable personalised, recovery-focused care co-ordination.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Talking about mental health nursing: a qualitative analysis of nurses’ and service users’ accounts

“…The only challenge came from Abby who reported she had seen patients asked about their feelings in a ward round. However, recent research indicates that there is insufficient service user involvement occurring in care planning (Grundy et al, 2016;Simpson et al, 2016b). Findings from my study suggest student participants' views are clear that elements of service user involvement in care planning are not widely evident.…”

“…However, users have reported that limited collaboration has been the reality (Newman et al, 2015). Interestingly, research in the area of personalised, recovery focused care planning in mental health is under-developed (Simpson et al, 2016b), with limited peerreviewed articles in the mental health nursing literature in this area. The participants referred to in this section provided accounts that suggest the activity of involving users in care planning occurs seldom, and that nurses have limited skill and confidence regarding how to accomplish such activity.…”

“…However, despite increased guidance and legislation promoting user involvement, it is reported that user involvement levels in mental healthcare could be significantly improved (Grundy et al, 2016;Simpson et al, 2016b). Bee et al (2015a) highlight that policy imperatives about involvement remain inconsistently implemented, and can be contested or diluted by more procedural or traditional practices.…”

“…Whilst there would be occasions when service users may be deemed too unwell to engage in meaningful discussions about their care, there are also too many examples of services users being excluded from these conversations Grundy et al, 2016;Simpson et al, 2016b). I also note Mary's continued use of 'they' which implies othering, a 'them and us' mentality, which perhaps reinforces the sense of a lack of partnership working.…”

“…There have been moves to increase such service user involvement in healthcare (Department of Health, 1991. This type of involvement has now been firmly established in legislation (National Assembly for Wales, 2010), yet a lack of service user involvement in care has been reported (Coffey, 2006;Simpson et al, 2016b). Whilst mental health nurses have often described their role and purpose under the banner of the therapeutic relationship (Browne et al, 2012), it does not transpire that they have necessarily taken on the principles and practice of collaborative working and a true sense of service user involvement.…”