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Geoff Shepherd, Jed Boardman and Maurice Burns POLICY Implementing Recovery A methodology for organisational change

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Page 1: A methodology for organisational change...framework for organisational change, Sainsbury Centre, 2009). “If adopted successfully and comprehensively, the concept of recovery could

Geoff Shepherd, Jed Boardman and Maurice Burns

POLICY

Implementing Recovery

A methodology for organisational change

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Box 1: 10 Key organisational challenges

1) Changingthenatureofday-to-dayinteractionsandthequalityofexperience

2) Deliveringcomprehensive,user-lededucationandtrainingprogrammes

3) Establishinga‘RecoveryEducationUnit’todrivetheprogrammesforward

4) Ensuringorganisationalcommitment,creatingthe‘culture’.Theimportanceofleadership

5) Increasing‘personalisation’andchoice

6) Changingthewayweapproachriskassessmentandmanagement

7) Redefininguserinvolvement

8) Transformingtheworkforce

9) Supportingstaffintheirrecoveryjourney

10) Increasingopportunitiesforbuildingalife ‘beyondillness’

(fromImplementing Recovery: A new framework for organisational change,

SainsburyCentre,2009).

“If adopted successfully and comprehensively, the concept of recovery could transform mental health services and unlock the potential of thousands of people experiencing mental distress. Services should be designed to support this directly and professionals should be trained to help people to reach a better quality of life. This will mean substantial change for many organisations and individuals.”

FutureVisionCoalition(July2009)

Introduction

‘Recovery’isawordcommonlyusedbypeoplewithmentalhealthproblemstodescribetheirstrugglestolivemeaningfulandsatisfyinglives.Theprinciplesofrecoverynowprovideaconceptualframeworktounderpindevelopmentsinmentalhealthservicesinanumberofcountries(Australia,NewZealand,IrelandandUSA).InEngland,theyfigureprominentlyintherecentpolicydocumentNew Horizons(DepartmentofHealth,2009)andhavereceivedwidespreadsupportfromthemajorprofessionalbodies.Althoughtheseprinciplesdonotconstituteanewformoftreatment thatcanbeappliedtopeopletomakethem‘recover’,webelievethatmentalhealthserviceswillcontinuetoplayacentralroleinsupporting–orimpeding–peopleintheirpersonalrecoveryjourneys.Thispaperpresentsapracticalmethodologytohelpmentalhealthservicesandtheirlocalpartnersbecomemore‘recovery-oriented’intheirorganisationandpractices,andtherebytosupporttheseprocessesmoreeffectively.

ItisthethirdinaseriesarisingfromtheSainsburyCentreforMentalHealthrecoveryproject.Thefirstpaper,Making Recovery a Reality(Shepherdet al.,2008)providedasummaryofthekeyprinciplesandtheirimplicationsforpractitioners.Thesubsequentposition paper,Implementing Recovery: A new framework for organisational change (SainsburyCentre,2009)presentedaframeworkfororganisationalchangeconsistingof10keychallengesthatneedtobeaddressedbymentalhealthservicesiftheyaretomovetowardsbecomingmorerecovery-oriented(seeBox1).Itwasdevelopedfromaseriesofworkshopsheldinfivementalhealthtrustswhichidentifiedthewaysinwhichrecoveryprinciplescould

bestbeincorporatedintoroutinepractice.Theworkshopswereattendedbymorethan300healthandsocialcareprofessionals,managersandrepresentativesfromlocalindependentorganisations.Theyalsohadextensiveinputfromserviceusersandcarers.

AlltheNHStrustsinvolvedintheworkshopshadmadeseriouseffortstodevelopmorerecovery-orientedservicesandhadcommitmentfromtheirseniormanagement,uptoBoardlevel,todoso.However,itwasclearthattherewasnosingleoverallapproachandnoone,uniquemodelofacomprehensiverecovery-orientedservice.Thekeyorganisationalchallengesidentifiedintheworkshopsthusprovideastartingpointtoassistinthedevelopmentofcomprehensiveandconsistentservices:theyarenota‘blueprint’forachievement.Thetaskisnowtoexploreexactlyhowthisorganisationalchangeagendacanbestbeaddressed.

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Thispaperpresentsamethodologicalapproachtoaddressthesechallenges.Itcanbeappliedbothbylocalmentalhealthproviders(statutoryandnon-statutory)andbyhealthandsocialcarecommissioners.Mentalhealthtrusts(andotherproviders)mayuseitaspartofafocused,self-assessmentprocess;alternatively,itcanbeusedtofacilitatediscussionsbetweenlocalserviceprovidersandcommissionersintheirjointattemptstomakeprogresstowardsmorerecovery-orientedservices.Webelievethatitprovidesaninnovativestartingpointforatruly‘person-centred’approachtoservicedelivery.

Whilerecognisingthatwhatweareaddressingherearecomplexmattersoforganisationalchange,weaimtodescribethechallengesandtheprocessesinvolvedinaclear,user-friendlyform.Indoingso,wealsohopetoprovideacommonlanguagewhichwillhelpproviderstoassesstheirprogresstowardsmorerecovery-orientedservicesandhelpcommissionersandproviderstoworktogetherto‘co-produce’systemchange.ThisisattheheartofthecommissioningguidancerecentlyissuedbytheNationalMentalHealthDevelopmentUnit,(NMHDU/NHSCommissioningSupportforLondon,2009).

Developing the methodology

Themethodologywasdevelopedbyagroupofcommissionersandserviceproviders,includingrepresentativesfromstatutoryandnon-statutoryorganisationsandwithcontributionsfromtheRecoveryCentreattheUniversityofHertfordshire.TheinitialworkwasalsodiscussedwithawidergroupofregionalcommissionersintheEastofEngland.Theprojectgroupfocusedon‘servicelevel’outcomes,differentiatingthesefrom‘individuallevel’outcomeswhichmaybeusedforassessingpersonalrecovery,suchastheRecoveryStar(MentalHealthProvidersForum,2008).

Atanorganisationalleveltherearealreadyanumberofinstrumentsandapproachesavailablewhichattempttomeasure‘recovery-orientation’.TheseincludetheDevelopingRecoveryEnhancingEnvironmentsMeasure(DREEM)(Ridgeway&Press,2004);theRecoverySelfAssessment(RSA)tool(O’Connellet al.,2005);theScottishRecoveryIndicator

(ScottishRecoveryNetwork,2009);andtheRecoveryPromotionFidelityScale(RPFS)(Armstrong&Steffen,2009).Theseinstrumentsareallusefulintheirownways,buttheyareoftenverylaboriousandtimeconsumingtouse(Dinnisset al.,2007).Somealsosimplydescribegeneralgoodpractice,ratherthanbeingspecifically relatedtorecoveryprinciples;othershaveproblemswithcross-culturalgeneralisationofitems.NonehavebeenspecificallydesignedanddevelopedforuseinanEnglishcontext(theScottishRecoveryNetworkcomesclosest).Hence,thereisaneedforanewinstrumentwhichcanbeusedeitherasaself-assessmenttool,oraspartofacommissioner/providerdialogue.

Views of commissioners

Inourdiscussionswithcommissionersitwasclearthatmanywereinterestedinsimplemetricsthatcouldbeusedto‘score’therecoveryorientationofalocalserviceand‘benchmark’itagainstcomparators.Whilethisisunderstandable,itposesconsiderableproblemsforasetofprincipleswhicharedifficulttodefineunambiguouslyandhavecomplicatedimplicationsforprocessesandpractice.Overlysimplifieddescriptionsarethereforenotjustdifficult,theymayalsobemisleadingandmayevenhamperinnovationanddevelopment.

Somecommissionersviewedthesheervolumeofinternationalliteratureandthebewilderingvarietyofexistinginstrumentstoassessorganisationalandindividualprogresstowardsrecoveryasbarrierstoorganisationalchange.Otherswantedtoadopta‘pickandmix’approach,selectingoutcomeindicatorsandmeasuresthatseemedtofitwithlocalcircumstancesandpracticability.Again,thisunderlinedtheneedtodevelopanapproachwhichwascomprehensive,butstillassimpleaspossible,andrelevanttolocalservices.

Inthecurrentclimateofeconomicandfiscaluncertainty,commissioners(andproviders)werealsounderstandablypreoccupiedwiththeprospectsoffacingafuturereductionofbudgetsandtheneedtoimproveeffectivenesswithoutincreasingcost(RoyalCollegeofPsychiatrists,NHSConfederationMentalHealthNetwork&LondonSchoolofEconomicsandPoliticalScience,2009).Wethereforewantedtoensurethatrecovery-orientedserviceswerenotseenasrelevantonlyinthe‘goodtimes’

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andsothemajorityoftheimplicationsforservicechangeimpliedbytheframeworkarecostneutral.Theydependonchangingthewaysinwhichthingsaredone,ratherthanonaninjectionofnewresources.Someevenhavethepotentialtoresultincostsavingsinthelonger-term;forexample,throughreducedserviceuseconsequentuponhigherratesofemployment,orreducedstaffingbudgetsresultingfromthesuggestedchangestotheprofessionalskill-mixoftheworkforce.

Manycommissionersalsoexpressedaninterestinusingsomeoftheleversofrecenthealthsystemreformtodrivetheperformanceofproviderstowardsmorerecovery-orienteddelivery.Theseincluded:

Thenew,standard,nationalMentalHealthContract(DepartmentofHealth,2010);

Consideringhowrecovery-orientedpracticecanbecostedandincentivisedwithinthedevelopmentofanationalsystemformentalhealthservicePaymentbyResults(PbR);

Combiningindividuallevelrecoveryoutcomeswithservicelevelchangeinanewkindofcommissioningcycle(asinNMHDU/NHSCommissioningSupportforLondon,2009);

Incorporatingacoresetofindicatorsfromothertools/measuressuchastheNationalSocialInclusionProgrammeindicatorset(NationalSocialInclusionProgramme,2009);

UsingCommissioning for Quality and Innovation(CQUIN)todeliverrecovery-orientedqualityimprovements(DepartmentofHealth,2008).

Manyoftheseinitiativesmayproveusefulinthelongterm,althoughitwilltakesometimebeforemostofthemareestablishedandbeddedin(forexample,thenewtariffformentalhealthservicesisnotnowexpecteduntil2013/14).Inthemeantime,therangeofissueshighlightedhereclearlydemonstratethatcommissioningmentalhealthservicesinthiscountryiscurrentlyinacomplexandrapidlychangingstate.Wethereforewantedtodevelopatoolwhichwasofimmediatepracticalvaluetoprovidersandcommissionersandtootherlocalstakeholders–includingserviceusersandtheirfamilies–andcouldhelpthemintermsofdeliveringmorerecovery-orientedservicesnow.

Aftertheframeworkhasbeenmodifiedandrevisedthroughfield-testing,wehopethatitmayinformthedevelopmentofasetof

standardsforregulatorssuchastheCareQualityCommissiontoclarifytheirexpectationsregardingthedevelopmentofrecovery-orientedservices.Thiswouldgivethenecessary‘top-down’incentivesfororganisationalchange,inadditiontotheessentially‘bottom-up’approachdescribedhere.Botharenecessaryforwidespreadandconsistenteffects.

How to use the methodology

ThemethodologyisspecificallyrelevanttoanEnglishmentalhealthservicecontext,althoughwebelieveitwillalsobeofinteresttoplannersandservicedevelopersinothercountries.Ourintentionisthatitshouldbeclear,systematicandnotunnecessarilybureaucraticortime-consuming.Wehavetakena‘systemsapproach’toservicechangewhichaimsexplicitlytoincludeallthelocalstakeholdersinthementalhealth‘system’–themainNHSprovider,localindependentsectorproviders,commissioners,serviceusersandcarers.Theeventualvalueoflocalsystemsinsupportingpeoplewithmentalhealthproblemsto‘recover’andlivetheirlivesastheywishwillultimatelydependonthequalityofpartnershipworkingbetweenthesedifferentagencies.

Themethodologyhelpsthoseusingittodevelopanunderstandingofthekeyideas(the‘vision’)behindwhatconstitutesrecovery-orientedservicesforthelocalarea,beforemovingontodevelopastrategyforcreatingthenecessarychangetoimplementtheseservicesandagreeingspecifictargetsandprecisemeasurements.Progressisthenmonitoredandreviewed,plansarerevised,newplansformulated,implemented,furthermonitored,reviewedandrevised.Thisformofinternalauditloop(or‘Plan-Do-Study-Act’cycle)isrecommendedasthemosteffectiveprocessforproducingsustainedorganisationalchange(Iles&Sutherland,2001).

Assessing services at the outset

Wesuggestthatthemethodologyisusedinatwophaseprocesscarriedoutjointlybetweenproviders(orprovidersandcommissioners)andtheirlocalstakeholders.Inthefirstpartoftheprocessthestakeholderstrytogettogripswiththecomplexitiesoftheideasunderlyingeachchallenge.Theythenassessthelevelof

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Box 2: Definitions for the three stage classification

Stage 1: Engagement

Theorganisationisclearlyengagedinitsintenttodeliverrecovery-orientedservices.AtaBoardlevelthereisanacknowledgementandownershipthattheorganisationneedstochangetowardsmorerecovery-orientedservices.Thereisanawarenessofexistinggoodareasofpracticeandthecommitmenttobuildonthese.Planstodeliverrecovery-orientedserviceshavebeenagreedandatimetableforimplementationisinplace,buttherehasbeenlittleprogressasyet.Weenvisagethatmosttrustswillstartatthislevelonmostdimensions.

Stage 2: Development

Actionisbeingtakenwithsomeevidenceofsignificantdevelopmentsinpractice,policyandculture.Goodprogressisbeingmadeindeliveringrecovery-orientedservicesinsomeareas,butthisisnotconsistentthroughouttheorganisation.Weenvisagethatsomeofthemoreadvancedtrustswillberatedatthislevelforatleastsomeofthedimensions.

Stage 3: Transformation

Thevisionforachievingsignificantchangehasbeenfullyrealised.Thenecessarypolicy,processesandpracticetodeliverarecovery-orientedserviceareembeddedateveryleveloftheorganisation–fromBoardstoteamsandfrontlineworkers.Thereareprocessesinplacetoachievecontinuousimprovementsbasedonlearningfromongoingreview.Theorganisationworksproactivelywitharangeofotherpartnersinsupportingpositivementalhealthandwellbeing.Weenvisagethatthislevelwillbeaspirationalformosttrustsonmostdimensions.

progressionofthemainmentalhealthproviderusingasimple,threepointclassification:‘Stage1=Engagement’,‘Stage2=Development’and‘Stage3=Transformation’(seeBox2andtheFrameworkonpages8-19).Thisassessmentprovidesasummaryofthecurrentsituationandcouldbeusedfor‘benchmarking’purposes,althoughitsprimarypurposeistodevelopajointunderstandingoftheconceptsandtheirimplicationsfororganisationalchange.Providersandotherlocalstakeholdersshoulddrawontheirdifferentperspectivestocometoasharedconsensusregardingthestageofdevelopmenttheyhaveachieved.ThiscanthenberecordedinTemplateA(seepage18).

Havingcompletedthisgeneralassessment,stakeholdersthenmovetothesecondpartoftheprocess.Inthistheyjointlyagreetheprioritiesfororganisationalchange.TheywillneedtoprioritiseactioninasmallnumberofareasandagreeasmallnumberofSMART(Specific,Measurable,Agreed-upon,Realistic,Time-based)goalstodefinethetargetsandmonitorprogress.Oncethegoalsareset,theywillbeimplemented,progresswillbemonitoredandthegoalswillberesetandthenfurthermonitoredinaniterativecycle.

Agreeing priorities for action

Itisclearthateachofthe10keyorganisationalchallengespresentsapotentiallysubstantialagendaforchange.Togethertheyopenupopportunitiestotransformservicesinwaysthataremuchmoreconsistentwiththeprioritiesofserviceusersandtheirfamilies,buttheyimplyalotofwork.Weacceptthatitisunlikely(andunrealistic)thatallthe10challengescanbeaddressedimmediately.Anorganisationalchangestrategywillneedtobeimplementedoveranumberofyearsandthenumberofprioritiesagreedatanyonetimeshouldbelimitedtoarealisticnumber(saynotmorethanfiveatanyonetime).The10keychallengesarenotlistedinpriorityorderandwehavenospecificviewsaboutthechoiceofwheretostart.Clearlyalllocalservicesaredifferentandallwillstartfromadifferentpoint.Nevertheless,itwouldseemsensibletoacknowledgeexistingstrengthsandtobuildonareasofrelativeweakness.

Basedonourexperienceinworkingwithtrustsandotheragenciesthatarecommittedtodevelopingrecovery-orientedservices,our

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impressionisthattwoparticularlyimportantchallengesshouldbeconsideredearlyon.TheseareChallenges‘3’and‘4’.WithoutaddressingOrganisationalChallenge3(Establishing a Recovery Education Centre) therewillbenofocusfordeliveringthetrainingprogrammesforstaffanduserswhicharenecessarytodrivetheorganisationforwards.WithoutaddressingOrganisationalChallenge4(Ensuring organisational commitment)thetraininginitiativesarelikelytohaveonlylimitedimpact.Leadershipandorganisationalcommitmentarealwaysimportantinanykindoforganisationalchangeprocessandmovingtowardsmorerecovery-orientedservicesisnoexception(Whitleyet al.,2009).

Tracking progress

Oncethereisagreementabouttheservicelevelgoalstobeachievedandacleardescriptionoftheactions,timescalesandresponsibilitiesforachievingthem,progresscanbetrackedusingasimpleformsuchasthatsuggestedinTemplateB(seepage19).

Toassistwithsettingandmonitoringspecifictargets,wehaveshownexamplesofservicelevelindicatorsandpotentialdatasourcesforeachoftheorganisationalchallenges.Theseexamplesareintendedtobeillustrativeratherthanprescriptiveandalternativeindicatorsmaybesubstitutedoraddediftheyreflectbetterthechosentargets.Providersandcommissionersshoulddeterminelocallywhichindicatorstheyaregoingtouseandhowambitiousthetargetswillbe.Thisgivesthemmaximumflexibility,withinaclearandcomprehensiveframework.OtherrecentpublicationssuchastheNationalSocialInclusionProgrammeserviceoutcomesandindicatorsmayalsobehelpful(NationalSocialInclusionProgramme,2009).

Future developments

Theprofileofrecoveryanddiscussionsabouthowtoimplementrecoveryideaswithinmentalhealthserviceshavegatheredconsiderablemomentuminrecentyears.Positivechangesaretakingplaceinmanyareasoforganisationalpracticeandservicedelivery.Inthiscontextofemergingdevelopments,wewouldnotexpectany‘goldstandards’ofbestpracticeidentifiedearlyin2010necessarilystilltoberelevantin

fiveyears’time.Indeed,ifthisworkcontributestoagenuinetransformationagenda,itwouldbeapositiveoutcomeifmuchofitappeareddistinctlydatedby2015.

Indevelopingthemethodology,somepeoplehavesuggestedthatweshouldspecifyminimumstandardsinmuchgreaterdetailanddevelopatoolmorelikeanInternationalOrganisationforStandardisation(ISO)accreditationscheme(seewww.iso.org)wherebystandardscanbeexternallyvalidatedandbenchmarkedacrossorganisations.Whilethisremainsanoptionforthefuture,webelievethatitisnotthebestwaytoproceedatthistimeasthedevelopmentofthesetypesofstandardsmaybetoolimitedandformulaic.Italsorunstheriskoflockinglocalprovidersandcommissionersintoarigidviewofwhatmustbeessentiallyinnovativedevelopments.

Themethodologyattemptstodescribeaconstructiveprocessof‘co-production’betweenlocalprovidersandcommissioners,inpartnershipwithserviceusersandcarers,whichaimstotransformservicesthroughthedevelopmentofthejointlyagreed,keyareasofrecovery-orientedpractice.Thekeyelementdrivingthistransformationwillthereforebethejointworkoflocalsystems,settingpriorities,agreeinggoalsandcontractsandthenmovingtheprocessforward.ThisiswhatwemustmaintainifWorld Class Commissioninginmentalhealthistobeachieved.

SainsburyCentre,theNMHDUandtheNHSConfederationwillnow‘fieldtest’themethodologywithanumberofcommissionersandprovidersaspartoftheactionscontainedintheNew Horizonsprogramme(DepartmentofHealth,2009,p.56,Action79).Wewillreviseandmodifythemethodologyinthelightofthatexperience.FuturedevelopmentsandupdateswillbepostedontheSainsburyCentrewebsitewww.scmh.org.uk.

Framework and templates

ThefollowingpagespresenttheFrameworkforeachofthe10keyorganisationalchallenges.Thisisfollowedbytemplatestohelporganisationstoidentifytheirpriorities.

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Acknowledgements

ThispaperwascommissionedbySainsburyCentreanddraftedbyGeoffShepherd,JedBoardmanandMauriceBurns(NationalMentalHealthDevelopmentUnit).Wewouldliketoacknowledgeandthankthefollowingcontributors:

DrGlennRoberts,DevonPartnershipNHSTrust

TonyPethick,HomeGroup

JessLievesley,NHSEastofEngland

MarkJordan,HertfordshirePCT/CountyCouncil

LindaSeymour,SainsburyCentreforMentalHealth

JanWoodward,HertfordshirePartnershipNHSFoundationTrust

ChristopherMunt,RecoveryCentreUniversityofHertfordshire

AnneMarkwick,HertfordshirePartnershipNHSFoundationTrust

JimSymington,NationalMentalHealthDevelopmentUnit

References

Armstrong,N.P.&Steffen,J.J.(2009)TheRecoveryPromotionFidelityScale:Assessingtheorganisationalpromotionofrecovery.Community Mental Health Journal,45,163-170.

DepartmentofHealth(2008)Using the Commissioning for Quality and Innovation (CQUIN) Payment Framework: For the NHS in England 2009/10.London:DepartmentofHealth.

DepartmentofHealth(2009)New Horizons: A shared vision for mental health.London:MentalHealthDivision,DepartmentofHealth.

DepartmentofHealth(2010)Guidance on the NHS Standard Contract for Mental Health and Learning Disability Services 2010/2011.GatewayReference13323.London:DepartmentofHealth.

Dinnis,S.,Roberts,G.,Hubbard,C.,Hounsell,J.&Webb,R.(2007)User-ledassessmentofarecoveryserviceusingDREEM.Psychiatric Bulletin,31,124-127.

FutureVisionCoalition(2009)A Future Vision for Mental Health.London:NHSConfederation.

Iles,V.&Sutherland,K.(2001)Organisational Change: A review for health care managers, professionals and researchers.London:NationalCo-ordinatingCentreforNHSServiceDeliveryandOrganisation(NCCSDO),LondonSchoolofHygieneandTropicalMedicine.

MentalHealthProvidersForum(2008)The Mental Health Recovery Star Tool.(http://www.mhpf.org.uk/recoveryStar.asp)

NationalMentalHealthDevelopmentUnit/NHSCommissioningSupportforLondon(2009)Mental Health World Class Commissioning.London:CommissioningSupportforLondon.(http://www.csl.nhs.uk)

NationalSocialInclusionProgramme(2009)AppendixC.ServiceOutcomeIndicators,inOutcomes Framework for Mental Health Services.London:NationalSocialInclusionProgramme.(http://www.socialinclusion.org.uk/publications)

O’Connell,M.,Tondora,J.,Croog,G.,Evans,A.&Davidson,L.(2005)Fromrhetorictoroutine:assessingperceptionsofrecovery-orientedpracticesinastatementalhealthandaddictionsystem.Psychiatric Rehabilitation Journal, 28,378-386.

Ridgeway,P.A.&Press,A.(2004)Assessing the Recovery Commitment of your Mental Health Services: A user’s guide for the Developing Recovery Enhancing Environments Measure (DREEM) – UK version 1 December, 2004.Allott,P.&Higginson,P.(eds.)([email protected])

RoyalCollegeofPsychiatrists,NHSConfederationMentalHealthNetwork&LondonSchoolofEconomicsandPoliticalScience(2009)Mental Health and the Economic Downturn: National priorities and NHS solutions.OccasionalPaperOP70.London:RoyalCollegeofPsychiatrists.

SainsburyCentre(2009)Implementing Recovery: A new framework for organisational change. Positionpaper. London:SainsburyCentreforMentalHealth.

ScottishRecoveryNetwork(2009)Scottish Recovery Indicator.http://www.scottishrecoveryindicator.net

Shepherd,G.,Boardman,J.&Slade,M.(2008)Making Recovery a Reality.London:SainsburyCentreforMentalHealth.

Whitley,R.,Gingerich,S.,Lutz,W.J.&Mueser,K.T.(2009)Implementingtheillnessmanagementandrecoveryprogramincommunitymentalhealthsettings:facilitatorsandbarriers.Psychiatric Services,60,202-209.

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ORGANISATIONAL CHALLENGE 1: Changing the nature of day-to-day interactions and the quality of experience“We are not cases and you are not our managers!” Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Thereisarecognitionthatrecoveryprinciplesandvaluesareimportant,butfewsystematicattemptshavebeenmadetoimplementthembychangingstaffbehaviour.Staff(andserviceusersandcarers)arefamiliarwiththegeneralprinciples,butunclearabouttheirimplicationsforpractice.Usersarenotgenerallyconsultedregardingthequalityofservicesdeliveredandstaffperformance.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Thereisclearevidenceofarecognitionthateverysignificantencounterbyeverymemberofstaffshouldreflectrecoveryprinciplesandpromoterecoveryvalues–aimingtoincreaseself-control(‘agency’),increaseopportunitiesforlife‘beyondillness’,andvalidatehope.Someattemptshavebeenmadetoensurethattheseprinciplesarereflectedinpractice,(e.g.pilotstoinvolveserviceusersandstaffselectionand/orevaluation)butthesearenotreflectedinroutinestaffsupervision.Someuserinvolvementinstaffselection,butnotroutine.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Everysignificantencounterbyeverymemberofstaffaimstoreflectrecoveryprinciplesandpromotesrecoveryvalues–increasingself-control(‘agency’),increasingopportunitiesforlife‘beyondillness’,andvalidatinghope.Eachinteractionacknowledgesnon-professionalexpertiseandattemptstominimisepowerdifferentials.Therehavebeensystematicattemptstoensurethattheseprinciplesarereflectedinday-to-daypractice(e.g.localaudits,useofNationalPatientSurveydata,etc.).Theimportanceofthequalityofstaff/userinteractionshasbeenincorporatedintostaffsupervisionandperformanceratings.Usersareroutinelyinvolvedinstaffselection.Humanresource(HR)policiesvalidaterecoverytrainingandlinkthistoopportunitiesforstaffprogression.

Examples of (service level) outcome indicators Proportionofstafftrainedinbasicrecovery-orientedpractice; AdoptionofSainsburyCentre’s‘TenTopTipsforRecovery-OrientedPractice’intooperationalpolicyand

practice; Systematicsurveysofuser(andcarer)perceptionsofstaffbehaviourinrelationtorecoveryprinciples(e.g.

usingmodifiedquestionsfromtheNationalPatientSurvey); Supervisionandappraisalsystemsarerevisedtopromotestaffinteractionsthatdemonstratepartnership

workingwithserviceusers; Proportionofinstancesofserviceusersbeinginvolvedinstaffselection.

Possible data sources NationalPatientSurveydata,orsimilarlocalprojects; Systematicsurveyofuser(andcarer)viewsregardingthequalityofday-to-dayinteractionswithstaffand

theextenttowhichthesereflectrecoveryprinciplesandvalues; Recordsofcompositionofinterviewpanels; Auditofstaffappraisals/supervision.

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ORGANISATIONAL CHALLENGE 2: Delivering comprehensive user-led education and training programmes “I’ve got into various groups, as an advocate and a representative for service users, and I found that extremely beneficial … made you feel less isolated and that you can help others. The most help I got was from the other people in the ward who had gone through similar experiences.”Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Thereisacommitmenttoincreasingthecoverageofuser-ledteachingandtrainingonrecovery,butitremainspatchy.Sometraininghastakenplace,butlessthan25%ofstaffhavebeeninvolved.Therehavebeenfewattemptstoembedlearningfromrecoverystoriesintopractice.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Arangeofevidenceconfirmstheincreasedprofileofuser-andcarer-ledtrainingonrecovery,supportedbyanagreedstrategyandpolicy.Approximately50%ofstaffhavereceivedtraininginrecoveryprinciplesformulatedandledbyserviceusers(andcarers).Thereissomeevaluationoftheeffectsoftraining,butthisisnotdonesystematically.Thefurtherdevelopmentofuser(andcarer)ledtraininghasBoardapprovalandfundingisbeingsought.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Acohortoftrainedserviceusersareinplaceactingas‘championsofchange’forrecoverywithintheorganisation.Serviceusersareacknowledgedasequalpartnerswithinacomprehensiverangeofrecoveryeducationandtrainingprogrammesandaprogrammeofuser-ledtraininginrecoveryhassecurefunding.Usersandcarersarecontractuallyengagedintheorganisationtodelivertrainingtostaffonrecoveryprinciples.Morethan75%ofstaffhavereceivedtraining.Thereisacontinuousprogrammeofevaluationandaudittomeasuretheimpactofthistrainingandteachingstandards.Positivepracticechangesareroutinelyimplementedasaresultofthetraining.

Examples of (service level) outcome indicators Acohortofuserandcarertrainershasbeenestablishedandusersandcarersarebothformulatingand

deliveringprogrammes; Adirectoryofaccrediteduserandcarertrainersisinplace; Ongoingfundingidentifiedforrollingprogrammesofuser-ledtrainingandeducation; Modulartrainingbeingplannedtoensuresustainability.

Possible data sources Systematicauditandevaluationtoestablishtheimpactofuserandcarerteachingandtraining; Evaluationroutinelygatheredattrainingandteachingevents,ananalysisofwhichisavailableinreport

form; Adirectoryofaccrediteduserandcarertrainers; Protocolstodemonstrateinvolvementatallphasesoftrainingandteaching.

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ORGANISATIONAL CHALLENGE 3: Establishing a ‘Recovery Education Centre’ to drive the programmes forward “The coaching programme has helped me to identify my aspirations, prioritise my goals and realise what I can realistically achieve. Before this I had never been so enthusiastic and optimistic about the future.”Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Thereisarecognitionthatcurrentattemptstoinvolveandsupportserviceuserstodelivertrainingonrecoveryhavebeenconductedonanad hocbasis.Itisagreedthatthereneedstobeamorestrategicapproach,butlittleprogresshasbeenmadeindevelopingthis,orconsideringhowitwillbedelivered‘ontheground’.Therehavebeendiscussionsaboutcentralisingtrainingandworkinginpartnershipwithuser-ledtraininggroups,butthesehavenotbeenfinalised.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Thereareplanstotakeamoresystematicapproachtosupportserviceusersinthedeliveryofrecoverytrainingtostaff.Formalcontractsarebeingconsidered(e.g.withalocalindependentsectorprovider)toprovidethisfunctionandthereareplanstobuildonthismodel.Areviewofexistingserviceuser-ledprogrammeshasbeenundertakenwithaviewtorefocusingtheseintoahubforpromotingrecovery-orientedpracticeacrosstheorganisation.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

A‘RecoveryEducationCentre’hasbeenestablishedwithintheorganisation.Thisisstaffedandrunby‘usertrainers’anddeliverssupportandtrainingforserviceuserstotrainstaffinrecoveryprinciplesforteamsandonwards.(Itmayormaynotbedeliveredbyanexternal,independentsectoruser/trainerorganisation.)TheCentrealsorunsprogrammestotrainserviceusersas‘peerprofessionals’toworkalongsidetraditionalmentalhealthprofessionalsasdirectcarestaff.Arrangementsforthemanagement,supervisionandsupportofthesestaffareco-ordinatedbytheCentrestaff.TheCentreofferscoursestoserviceusers,theirfamiliesandcarersonrecoveryandthepossibilitiesofself-management.Therearearangeoflinkstogeneraleducationalclassesinthecommunityandpathwaystocoursesandotherlearningopportunities.

Examples of (service level) outcome indicators Establishmentof‘RecoveryEducationCentre’,withstablefunding,employingatleast3-4usertrainers; Competencies,standardsandsupportidentifiedforpeersupportworkers; ‘RecoveryEducationCentre’activeintrainingandsupporting50serviceuserseachyearaspeer

professionalswithintheservice(andotherlocalservices,statutoryandindependent); Employmentofmultiplepeerprofessionalswithinexistingteams(includinginpatientwards).

Possible data sources Recordsof‘RecoveryEducationCentre’trainingprogrammesdelivered,curriculum,numbersofstaff/service

userstrainedorsupported; Auditofstaffandserviceusersonsatisfactionofprogrammesdeliveredbythecentre; Evidenceofpartnershipagreementswithexternalbodiessuchasuniversitydepartments,collegesetc.; Numbersofpeer-ledtrainingcoursesrun; Numberofpeerspecialiststrainedtoagreedstandardsandcompetencies.

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ORGANISATIONAL CHALLENGE 4: Ensuring organisational commitment, creating the ‘culture’. The importance of leadership“We are committed to services that build on the individual’s inner resilience and coping strategies and not on interventions that undermine or stifle these innate qualities of hope and potential.” TrustMissionstatement

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Thereisrecognitionthroughouttheorganisationthatthecultureneedstochangefroma‘problem-based’approach(focusonillnessandsymptoms)toa‘strengths-based’approach.Plansareinplacetoreviewinternal‘pathways’(referralsystems,assessments,careprogrammeapproach(CPA),dischargeplanning,etc.)tomakethemmorerecovery-oriented,butlittleprogresshasbeenmade.Therearecommittedindividualsleadingtheimplementationofrecoveryprinciples,buttheyareisolatedandonlyoperatingatateamlevel,oratseniorlevel,notboth.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

TheBoardhasendorsedaRecoveryStrategy,includingcoreunderpinningprinciplesandvalues.Thisisreflectedinthewordingofexternalandinternalpublications.Theorganisationisactiveatalllevelscommunicatingitsrecoveryapproach.ThereisevidenceofBoardworkshops,staffpresentationsandtrainingprogrammes.Recoveryforumshavebeenestablishedinpartnershipwithserviceusers.Someinternal‘pathways’(referralsystems,assessments,CPA,dischargeplanning,etc.)havebeenreorganised,withuserinvolvement,soastosupportrecoveryprocesses.Whilstthereareanumberofrecoveryinitiatives,itisrecognisedthatculturalchangehasnotyetoccurredatalllevelsandinallpartsoftheorganisation.Monitoringrecoverypracticedoesnotappearinstaffsupervision.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Recoveryconceptsareevidentatalllevelsoftheorganisation.ThereisstrongleadershipandactionatBoardleveltoensurethatthisisreflectedthroughalllevelsofmanagementandbyfrontlinestaff.Thereisrecognitionoftheneedtodeveloppartnershipworkingwithserviceuserssothatprofessionalexpertisedoesnotdominateoverthewisdomof‘livedexperience’.Theservicepromotesanenvironmentofhopeandoptimismthatrecognisestheuniquenessandstrengthsofeachindividual.Recoveryvaluesareembeddedineveryoperationalpolicy,managementprocessincludingrecruitment,supervision,appraisalandaudit.Allkeyinternal‘pathways’(referralsystems,assessments,CPA,dischargeplanning,etc.)havebeenreorganised,withusercollaboration,soastobettersupportrecoveryprocesses.

Examples of (service level) outcome indicators Policiesandproceduresdemonstrateorganisationalcommitment; Evidencethatinternal‘pathways’havebeenreviewed,incollaborationwithserviceusers,andredesigned

soastobettersupportrecoveryprocesses; Recordingofcareprocessesreflectshiftinculturalapproachtowardsstrengths-basedapproach; Theorganisationhasestablishedroutineauditofserviceuserexperienceandsatisfactionandfollows

throughonfeedbackreceived; Routineuseofindividualrecoveryoutcomemeasures.

Possible data sources Nationalandlocalsurveysofserviceusers; Auditoflocallyagreedstaffperformanceindicatorswithdesiredoutcomesidentifiedbyserviceusersand

carers; Recruitmentpracticesreflectwillingnesstoappointstaffwithahistoryof‘livedexperience’(see

OrganisationalChallenge8); Revisedpoliciesforriskassessmentandmanagement; Internalandexternalcommunicationsandpublicationsreflectrecoveryvalues; Caserecords(forrecoveryoutcomemeasures).

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ORGANISATIONAL CHALLENGE 5: Increasing personalisation and choice “I now feel in the driving seat for my life and wellbeing.” Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Thereisrecognitionthattraditionalcareplanningmustbechangedtogiveamuchgreateremphasistousers’prioritiesandtheachievementof‘lifegoals’,butthisisnotactivelymonitored.Thereissomeuseofinstruments,suchastheWellnessRecoveryActionPlan(WRAP),butthesearenotgenerallyused.Therehavebeensomeattemptstoincreasetheuseof‘personalbudgets’,butthisisnotwidespread.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Thereisagrowingmovetowardsgreaterpersonalisationandchoiceintermsoftreatmentandmanagementoptions.Newpoliciesreflectarevisedapproachtoshareddecisionmakingandjointplanning.Thereisevidencethatmorethan50%ofusersfeelactivelyinvolvedindirectingtheirCPAprocessanddeterminingthecontentoftheircareplan.Theorganisationhasproducedarangeofinformationandinterventionstosupportself-managementapproaches.Therehasbeenasubstantialincreaseintheuptakeofdirectpaymentsandtheuseofpersonalbudgets.Therehasalsobeenasignificantexpansionintheuseofjointlyagreed‘advancedirectives’(e.g.jointcrisisplans).AttemptsarebeingmadetoincorporateWRAPobjectivesintocareplans.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Theplanninganddeliveryofallservicesisdesignedtoaddresstheuniquecircumstances,history,needs,expressedpreferencesandcapabilitiesofeachserviceuser.Thereisaclearemphasison‘lifegoals’asopposedtosymptomtreatmentgoals.Usersareroutinelysupportedtocontrolanddirecttheirowncareplans,ataleveltheyarecomfortablewith.Morethan75%feelconsultedandinvolved.Organisationalpoliciesaffirmthatserviceusersshoulddirecttheirowncareprocess.Ifnecessarytheyaregivensupporttodoso(e.g.advocacy).WRAPandjointcrisisplansareinroutineuse.Thereiscontinuousevaluationtomeasureorganisationalcommitmenttopersonalisationandchoice.

Examples of (service level) outcome indicators Evidencethatallcarepathwayshavebeenreviewedtoidentifypointsforchoicestobeexercisedandfor

shareddecisionmakinge.g.treatmentoptions,medication,choiceofclinician; Availabilityofadvocacyservices; Progresstowardsagreedtargetsforpersonalbudgets; Dedicatedpostsareestablishedtoassistwiththe‘personalisationagenda’,e.g.‘brokers’(forindividual

budgets),advocates,etc.; Publishedinformationisavailabletoassistserviceuserstomakeinformedchoicesabouttreatmentoptions

(medical,psychologicalandsocial); Policiesarerevisedtostresspersonalisationincareplanningandtheencouragementofself-management; Clinicalgovernancestructuresincludepromotionofpersonalisationandchoiceasstandingitems.

Possible data sources Dataregardingtheuptakeof‘individualbudgets’(numbersandamountofvariation); Numbersreceivingadvocacyservices; Organisationalpoliciesandproceduresrelevanttochoiceandpersonalisation; Serviceusersurveys(e.g.NationalPatientSurvey)focusingontheextenttowhichchoice,agencyand

controlareexperienced; Informationleaflets; Contentoftrainingcourseswhichdemonstratesafocusonpersonalisation.

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ORGANISATIONAL CHALLENGE 6: Changing the way we approach risk assessment and management“The possibility of risk is an inevitable consequence of empowered people taking decisions about their own lives.”DepartmentofHealth

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Theorganisationisawareofthevalueofsystemsandproceduresthatsupportopen,transparentriskassessmentandmanagementpolicieswithinarecoveryframework.Somestaffareconversantwiththisapproachandsomeattemptsaremadetoinvolveserviceusersintheprocess,butitis‘patchy’(lessthan25%ofstaffinvolved).Thereisambivalenceaboutthevalueof‘positive’risktakingandthishasnotbeenaddressedataBoard/generalpolicylevel.Staffremainpreoccupiedwithriskasastaffissuealone.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Thereisarecognitionoftheneedforsafetywhileactivelypromoting‘positive’risktaking.Theorganisationhasintroducedformalproceduresthatsupportopen,transparentriskassessmentandmanagementpolicieswithinarecoveryframework,butthesehavenotbeenimplementedthroughouttheorganisation.TheseissueshavebeendiscussedatBoardlevel,butnoclearpolicieshaveresulted.Somestafftraininghasbeenundertakenandaround50%ofstaffareimplementingpoliciestoinvolveserviceusersintheirownriskassessment.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Theorganisationhasinplacesystemsandproceduresthatsupportopen,transparentriskassessmentsandmanagementpolicieswithinarecoveryframework.Theprocessroutinelyinvolvesserviceusersandtheirknowledgeofthemselvestoformulatesafeandeffectivemanagementplans.Allstaffarefullyconversantwiththisapproachtoriskassessmentandmanagementandarecomfortablewithit.Thereisaclearcommitmentonthepartoftheorganisationasawholetovalue‘positive’risktakingandawillingnesstoexamineandlearnfromincidentsandsupportstaff,ratherthan‘blame’themifuntowardincidentsdooccur.ThishasbeenmadeexplicittostaffbytheBoardandhasbeenreflectedinaction.Theorganisationhassuccessfullyreconciledtheneedtobalanceitsdutyofcaretoprovidesafeserviceswhilepromotingapositiveapproachtoriskassessmentandmanagement.

Examples of (service level) outcome indicators Staffhavereceivedtrainingintheapplicationofrecoveryprinciplestoriskassessmentandmanagement

andthisisbuiltintoallinductions; Riskassessmentandmanagementprocedures(e.g.CPA)containaclearexpectationthatserviceuserswill

beroutinelyinvolvedintheseprocessesandthisissystematicallyaudited; Trainingintheuseof‘JointWellbeingPlans’hasbeendeliveredandthesehavebeenincorporatedinto

routinepractice; Theorganisationroutinelyexaminesseriousanduntowardincidentreportswithaviewto‘learningthe

lessons’ratherthanapportioningblame; Riskmanagementpoliciesreflectashifttowardssupportingpositiverisktaking,whileensuringappropriate

corporategovernanceandadherencetosafepracticeandregulatoryrequirements.

Possible data sources Stafftrainingrecords; CPAauditresults; Clinicalgovernancerecords; Boardpolicies.

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ORGANISATIONAL CHALLENGE 7: Redefining service user involvement “Nothing about us without us” Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Theorganisationhasacceptedthatserviceusers(andcarers)shouldplayanimportantpartintheplanninganddeliveryofcare,butitisstillapparentthatthefinaldecisionsremainwiththe‘professionals’.Thereissomeevidenceofsystematicchangestoenhancetheroleofusersandcarersaspartnersincare,buttheirknowledgeandexpertiseisstillseenassecondary,ratherthanprimary.Theprinciplesof‘userinvolvement’areaccepted,butthisisnotreflectedintrue‘partnershipworking’.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Theorganisationhasacceptedtheroleofserviceusers(andcarers)asequalpartnersincare.ABoard-levelpolicyonuserinvolvementatalllevelsintheorganisationfromclinicalcaretostrategicplanninghasbeenagreedandisbeingimplemented.Thisacknowledgementofthecentralcontributionofusersandcarersisreflectedinpoliciesandproceduresgoverningthedeliveryofindividualcareandtheworkofteams.Approx.50%ofstaffunderstandhowtoadapttheirroletobe‘educators’(‘coaches’)and‘mentors’,ratherthantraditional‘therapists’.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Theorganisationhasclearlyacceptedtheroleofserviceusers(andcarers)asequalpartnersincare.Itrecognisesthattheirknowledgeandexperienceisvital(‘expertsbyexperience’)andthatthey–andtheirnetworks–mayhavesolutionstomanyoftheproblemsthatstafffindmostdifficult.Thisacknowledgementoftheneedforpartnershipisclearlyreflectedinpolicyandpracticeatalllevels–individualpractitioners,teamsandmanagers.Allstaffunderstandhowtodelivertheirexpertiseinthecontextofmoreequal‘partnershipsincare’andtheyarecomfortablewiththeirnewposition(‘on tap, not on top’).Theorganisationiscontinuallyreviewingitsprocessesforpartnershipworkingwithserviceusersandcontinually‘raisingthebar’intermsofextendingtheroleofserviceusersincontrollingthecareprocess.Thisnotseenasanabnegationofprofessionalresponsibilities,noradowngradingofprofessionalexpertise,insteaditisseenasahigherformofprofessionalpractice.

Examples of (service level) outcome indicators Serviceusers(andcarers)reportthattheyfeelconsultedasfull‘partnersincare’. Theyreportastyleof

workingwherestaffsharetheirexpertiseandexperience,ratherthancommandingattention; Thelanguageof‘partnership’isusedconsistentlyinwrittenmaterialsproducedbytheorganisationto

describetheprocessesofcareandservicedelivery; Serviceusersandcarershavesignedcareplanstoconfirmthattheyhavebeeninvolvedintheprocessof

careplanningatanindividuallevel; Robustplansareinplacetoensurethatserviceusersandcarersarefullyinvolvedinserviceplanningand

governancestructures.

Possible data sources Stafftrainingrecords; NationalPatientSurveydata,orsimilarlocalsurveys; Informalfeedbackfromindividuals(e.g.PatientGovernors); Boardpoliciesandminutes,newsletters,pressreleases,etc.; Auditofcareplans; PatientCouncilreports,Boardreports,notesofLocalInvolvementNetworks(LINks)meetings.

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ORGANISATIONAL CHALLENGE 8: Transforming the workforce “When my last worker met with me I was left with a feeling of hopelessness, it was all about my symptoms. When I see you we talk together about what I want for my future and I am full of optimism.” Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

TheBoardandseniormanagershaverecognisedthattransformingtheworkforcemayrequireachangeintheskillmixandbalancebetweentraditionalmentalhealthprofessionalsandpeoplewhoseexpertisecomesfrom‘livedexperience’.Thereareexamplesofstaffwith‘livedexperience’beingemployedincare-givingroles,e.g.SupportTimeandRecovery(STR)workers,buttheseareisolated,withlittlemanagerialsupportandsupervision.Humanresource(HR)andoccupationalhealthserviceshavenotbeenreformedandnothoughthasbeengiventoissuesof‘careerprogression’forpeerstaff.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Thetrusthasclearplansinplacethatwillleadtothecreationof‘peerspecialist’rolesacrosstheorganisation.Theseplansincludeclearjobdescriptions,identificationoftrainingresources,supervisionandmanagementresponsibilities,strategiesforplacementinteams,timescalesforcompletion,etc.Asmallnumberofserviceusershavebeenappointedintopaidpositionsintheworkforce,butonalimitedscale(e.g.5-10postsscatteredthroughtheorganisation).Plansareinplaceforpilotswhichwillprovidemoreintensiveinput(e.g.atleasttwoserviceusersperteam)withappropriatemanagerialsupport.Issuesregardingcareerprogressionforpeerspecialistshavebeendiscussed.ThetrusthasbeguntoaddressthespecificHRandoccupationalhealthproblemsassociatedwiththerecruitmentofgreaternumbersofpeoplewithdirectexperienceofmentalhealthproblemsintotheworkforce.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Theorganisationhasfullyacceptedthatpeoplewhohavedirectexperienceoflivingwithmentalillnesscan,withappropriatetrainingandsupport,makeasignificantcontributiontotheworkforce.Mostteamshaveanequalnumberofpeerprofessionalsworkingalongsideotherprofessionals.Peerspecialistsareseenashavinguniquequalificationsandexperiencewhichisdifferentfrom,butequalto,thoseoftraditionalmentalhealthprofessionals.Theyarethereforepaidandgivenstatusaccordingtotheirexperienceandexpertiseindeliveringthisrole.HRprocessesandoccupationalhealthassessmentshavebeenadjustedsoasnottoprovideobstaclestotheemploymentofpeoplewithmentalhealthproblems(asrequiredbytheDisabilityDiscriminationAct[DDA]andthetargetsunderPublicServiceAgreement[PSA]16).Cleararrangementsforsupervisionandcareerprogressionareinplace.

Examples of (service level) outcome indicators Clearidentificationofresponsibilityfordeliveringtrainingandsupportforpeerprofessionals(e.g.

partnershipagreementwithexternalspecialistprovider); Clearjobdescriptionsandpersonspecificationsagreedforpeerprofessionals; Peerspecialiststobethefirstpointofcontactwhereverpossibleateachstageofcarepathway; Numberofstaffemployedas‘peerspecialists’; Numbersofpeoplewithmentalhealthproblemsemployedinthecurrentworkforce(PSA16targets)

regularlymonitored.

Possible data sources RevisedHR,occupationalhealthandCriminalRecordsBoard(CRB)policieseliminatingbarriersto

employment; Staffingrecords; HRdataonskillmixandtrends; RecruitmentdatarecordedforDDA.

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ORGANISATIONAL CHALLENGE 9: Supporting staff in their recovery journey“Hear what I have to say and support me to do it” Staffmember

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Thereisawarenessthatmanystaffhavetheirownexperiencesoflivingwithmentalillnessandofrecovery,butthisremainslargelyunacknowledgedandtheyarenotencouragedtousetheseexperiencestoinformtheirworkpractice.Thereisstillconsiderablestigmaamongstaffregardingrevealingmentalhealthproblemsandthishasnotbeenaddressedprivately,orinthecontextofrecoverytraining.Staffhavebeengivenlittlehelpinthinkingabouthowtodevelopdifferentwaysofdeliveringtheirexpertise.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Theorganisationrecognisestheneedtosupportstaffinthedisclosureoftheirownlivedexperienceofmentalhealthproblemsandthisisincludedasanoptionalpartofrecoverytraining.Theorganisationrecognisestheneedtoensurethatthereareopportunitieswithinindividualsupervisiontoaddresstheseissues.Theorganisationisdevelopingasharedapproachwithstafftodeliveritsvisionregardingrecovery.Staffgenerallyreportfeelingincludedinthisprocessandcanseeaclearwayforward.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Staffdonotfearstigmaorprejudicefromcolleaguesintheworkplaceiftheyrevealtheirpersonalexperienceoflivingwithmentalillnessinanappropriatesetting.Allstaffhavereceivedappropriateinductionandtrainingandhavebeensupportedtohelpthemusetheirpersonalknowledgeandexperiencetohelpothersandtooptimisetheirownwellbeing.Theorganisationhasinplacecomprehensiveprovisionstooptimisestaffhealthandtoconstructivelyaddressstaffhealthproblems(e.g.augmentedoccupationalhealthservices).Thepersonalqualitiesandpriorexperienceofstaffarevaluedandincludedasselectioncriteria.Theorganisationformallyrecognisesthecommitmentandcreativityofstaffandfullyinvolvesthemintheimplementationoftherecoveryvision.

Examples of (service level) outcome indicators Comprehensivepolicyandpracticedevelopmentsreflectingtheneedtooptimisestaffmentalhealth,e.g.

programmestosupportstaffinpersonalself-careandself-management; Anonymousstaffsatisfactionsurveys,withevidencethatresultsareactedupon; Recruitmentpracticeshavebeenamendedsoastopositivelyreflectthevalueoflivedexperienceamong

staff,aswellasformalqualifications; ThereisBoard-levelcommitmenttotheprinciplesofMindfulEmployer(www.mindfulemployer.net).

Possible data sources Boardstrategypapers,evidenceofroutinereportsonstaffwellbeing; HRandoccupationalhealthpolicies; Staffsicknesslevelreturns; Staffmoralesurveys; Staffsickness/turnoverrates; Staffsurveyreturns.

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ORGANISATIONAL CHALLENGE 10: Increasing opportunities for building a life ‘beyond illness’ “I am no longer my illness.”Serviceuser

Stage 1: EngagementA commitment to implement recovery is in place, with some plans agreed on how to do so

Theorganisationhasaninter-agencystrategytopromotesocialinclusion,butlittleconcreteprogresshasbeenmade.Theorganisationisreviewing(orhasreviewed)withserviceusersandcarerswhatneedstobeinplaceinthecommunitytosupportrecovery.Someeffectivepartnershipsdoexistwithindependentsectorproviders(housing,employment,education,etc.)butthisispatchy.Similarly,someworkhasbeendonetoreducestigmainthecommunity,butthisisrelativelyunfocusedandtoogeneraltohavespecificimpact.Evidence-based,supportedemployment(IndividualPlacementandSupport,IPS)isnotwidelyavailable.

Stage 2: DevelopmentAction is being taken, with some evidence of significant changes in practice, policy and culture

Theorganisationhasinplaceastrategyforthedevelopmentof‘mainstream’communitysupport(includinghousing,employment,leisureandmentalhealthpromotion)andgoodprogresshasbeenmaderegardingimplementation.Theorganisationhaseffectivepartnershipsinplacetoprovideimprovedaccesstopaidemployment.IthasbeguntoappointIPS-trainedemploymentspecialiststosometeams.Operationalpolicieshavebeenrevisedtopromotecommunityintegrationondischargefrominpatientcare.Allserviceusershaveanagreedplanthattheyandtheircarersfeelissafeandwillsustaintheirrecovery.Workhasbeendonetoreducestigmaanddiscriminationamongcertainkeyagencies(e.g.housing,employers,policeandneighbourhoods).Theseprojectshavebeenledbysuitablytrainedserviceusers.

Stage 3: TransformationSignificant change is fully achieved; major service redesign; radically different

Theorganisationrecognisesthatfullcitizenshipandcommunityintegrationisessentialinpromotingindividualrecovery.Ithasdevelopedarangeofeffectivepartnershipswithexternalorganisationstosupportindividualsinbuildingalifeforthemselvesindependentofformalmentalhealthservices.Thereisafocusonpromotingsettledaccommodation;maintaininganddevelopingrelationships;paidemploymentandtraining;andfullinclusioninordinarycommunityactivities.Peersupportnetworkshavebeendevelopedtosustaincommunityinclusion.ThereisaparticularemphasisontheimportanceofpaidemploymentandIPSworkershavebeenestablishedinallteams.Issuesforpromotionofhealthandwellbeingacrossdiversecultureshavealsobeenaddressed.Theorganisationsupportssocialinclusionthroughacomprehensiverangeoftargetedanti-stigmaworkinthecommunitiesthatitserves.Theseprojectshavebeenledbysuitablytrainedserviceusersandthereisactivefollow-up.

Examples of (service level) outcome indicators Partnershipswithemploymentandtrainingspecialistsareinplace; Ratesofserviceusersattainingandsustainingpaidemploymentareregularlymonitored(PSA16); NumberofemploymentspecialiststrainedtodeliverIndividualPlacementandSupport(IPS)ineachteam; Numberofcareplanswithadequateassessmentsofemploymentneedsandappropriateactionplans; OtherPublicServiceAgreement(PSA)Indicators(e.g.8,15and21)arealsoregularlymonitoredandthe

resultsfedintoactionplans; Theorganisationroutinelyauditstheeffectivenessofdischargeplanstosustainrecovery; UseofNationalSocialInclusionProgrammeIndicatorset(2009).

Possible data sources KeyPerformanceIndicatorinformationonPSA16Targetsfornumbersofpeopleinemploymentandsettled

accommodation; Servicelevelagreementswithemploymentprovidersandotherpartners; Dischargeratesfromservices; Serviceuserandcarerquestionnairesregardingsatisfactionwithdischargearrangementsfrominpatient

care; NationalSocialInclusionProgrammeServiceOutcomeIndicatorsdataset(NSIP,2009).

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Organisational Challenge

Stage 1

Stage 2

Stage 3

Priority for action

(1-10)Comments

(tick one)

1. Changingday-to-dayinteractions

2. Comprehensiveuser-lededucationandtraining

3. EstablishingaRecoveryEducationUnit

4. Ensuringorganisationalcommitment

5. Increasingchoiceand‘personalisation’

6. Changingapproachestoriskassessmentandmanagement

7. Redefininguserinvolvement

8. Transformingtheworkforce

9. Supportingstaffintheirrecoveryjourney

10.Buildingalife‘beyondillness’

TEMPLATE AThisformshouldbecompletedbytheproviderorganisation’sleadforrecovery,incollaborationwithlocalstakeholders(serviceusercarergroups,independentsectorprovidersandcommissioners)followingdiscussionsabouttheOrganisationalChallenges(1-10).Thesediscussionsshouldbeopenandhonestandaconsensusreachedregardingappropriateassignmenttoeachbroadlevelofprogress.EachChallengecanbe‘scored’,buttheprimaryaimistoagreeprioritiesandthestartingpointforfurther,moredetailedactionplanning(seeTemplateB).

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TEMPLATE B ThisformshouldbeusedonceTemplateAhasbeencompletedtodevelopspecificactionplansinrelationtoparticularOrganisationalChallenges.Localtargets,timescalesandevidencesourcesshouldbeagreedjointly.

ORGANISATIONAL CHALLENGE:

CURRENTSTANDARD Stage1[] Stage2[] Stage3[] (Pleasetickone)

Describe:

Localgoals(agreedbycommissionersandproviders)

1.

2.

3.

Date:

Specificactionsrequiredtomakeprogressongoalsbeforenextreview

1.

2.

3.

Evidencesources:

Commissionername: signature:

Providerleadname: signature:

NextReviewDate:

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Sainsbury Centre for Mental Health

134–138 Borough High Street, London SE1 1LB

T 020 7827 8300

F 020 7827 8369

www.scmh.org.uk

Charity registration no. 1091156. A Company limited by guarantee registered in England and Wales no. 4373019.

About the authors

Professor Geoff Shepherd is Senior Policy Adviser to the Sainsbury Centre. He is a clinical psychologist by background and is also visiting professor in the Health Service and Population Research Department at the Institute of Psychiatry.

Dr Jed Boardman is Senior Policy Adviser to the Sainsbury Centre. He works as a Consultant Psychiatrist and Senior Lecturer in Social Psychiatry at South London and Maudsley NHS Foundation Trust and the Institute of Psychiatry. He is Lead for Social Inclusion at the Royal College of Psychiatrists.

Maurice Burns is Programme Manager for the World Class Mental Health Commissioning Programme at the National Mental Health Development Unit. He is a social worker by background and has held the post of Director of Mental Health in two NHS Trusts.

© Sainsbury Centre for Mental Health, 2010. Recipients (journals excepted) are free to copy or use the material from this paper, provided that the source is appropriately acknowledged.

Cover photograph: F.R.A. Taylor

Copies of the following can be downloaded from www.scmh.org.uk

Making Recovery a Reality (2008); Ten Top Tips for Recovery-Oriented Practice (2008); Implementing Recovery: A new framework for organisational change. Position Paper (2009).