Los cambios en la sacralidad de los seres del bosque por las religiones judeo-

Data were collected from a wide range of participants using a mix of methods from across a reasonable spread of teams and service providers in geographically varied locations in two countries. The interview data in particular are rich, and the framework method provided a time-consuming but structured and visible method of organising, analysing and comparing these data within and across sites. We believe that the framework method and detailed presentation of results supports the transferability of these findings to other similar services.

However, there remains the possibility that within each sub-group of service users, carers, practitioners and managers, there may have been an element of self-selection or inherent biases not immediately apparent to the researchers. There appears to be a wide selection of professions and viewpoints identified among the staff interviews but the service-user sample may be weighted more towards those with long-standing contact with services. This may have been reflected in more limited experiences of a more recovery-focused approach from clinicians who may feel longer-term service users are less likely to respond to a focus on recovery. Similarly, such a population may have different expectations of care co-ordinators and mental health services than a younger sample less habituated to the familiarities of mental health service delivery. Overall, the postal survey response rate of service users surveyed was low, ranging between 9% and 19%, which may introduce bias. Owing to the nature of the survey, it is not possible to make comparisons between responders and non-responders, as we had no access to data for non-participants. There was a moderate level of missing data for the RSA scale completed by service users, possibly owing to some of the difficult language used. As a consequence, more detailed analysis of covariance within these data was restricted by lack of power. The RSA scale was selected for use after consideration of several organisational-focused measures of recovery. Nonetheless, this was not a satisfactory measure as too many participants found some of the language and North American terminology unfamiliar and unclear. Adaptation and re-validation of this measure to a British population or the identification of a more suitable measure would be recommended for future studies. Mindful of not taking up too much of the time of busy health care staff, the care co-ordinators were asked to complete the RSA scale only. On reflection, this was perhaps a wasted opportunity, as once practitioners had consented to participate, it might have been beneficial to have requested their views on other aspects of services and their work with service users and carers, with minimal additional time burden. The involvement of service users and carers throughout the study as researchers and advisors has also provided added value to the study through additional viewpoints and interpretations. However, greater involvement of service users and carers in the analysis may have provided even greater insight and may be something that can be explored in a further analysis.

Conclusions

The results of this cross-national, multisite, mixed-methods study suggest that there is a gap between the macro-level national policy aspirations for recovery-focused, personalised care planning and co-ordination

and the meso-/micro-level‘street-level’ practices and everyday experiences of service users, carers and care

co-ordinators. Of particular concern was evidence of a perhaps widening discrepancy between policy and practice and the indications of an emergent cynicism among participants as recovery concepts and ideals are subverted by higher order organisational needs, directives and ends. There is a serious risk that the hope and optimism that recovery approaches can offer often much-maligned mental health services is

being dampened and perhaps snuffed out by the‘re-conceptualisation of recovery’ at a macro-level.

Clearly, among participants in this study within and across the six sites, there was a lack of consensus about what recovery means. This may be expected with such a relatively nascent and contested concept. But a loss of focus and legitimacy at a time when services are and will continue to be under enormous pressure to respond to the increasing demands placed upon them at a time of continued austerity is worrying and could have serious ramifications for the engagement, safety and well-being of local populations and communities and the retention of top-quality staff. Mental health service commissioners and providers need to ensure that there is clarity and consistency in establishing and communicating with partners and recipients of services what is meant by recovery and to ensure that the aims and operations of the organisation are designed to support staff and service users in realising that vision.

Care planning itself was seen by care co-ordinators and managers as a useful way of recording and evidencing plans and actions but were largely deemed irrelevant thereafter by most frontline staff and the majority of service users. However, the processing, completing, updating and uploading of care plan documentation is (again) reported to require considerable time and energy away from direct contact with services users, families and wider networks, while appearing to have a minimal role in aiding recovery. IT may provide some assistance in accessing and sharing information but paradoxically appears more often to require even yet more time away from the service user as care co-ordinators grapple with inflexible,

unwieldy systems and, from the service user’s viewpoint, depersonalised outputs. After 25 years of the

CPA and its more recent siblings and repeated accounts of bureaucratic overload, it really is time for innovative, more flexible, genuinely person-centred solutions to this dilemma. It is clear from service users and carers in this study that the key instrument in helping and enabling people towards recovery is the therapeutic relationship with empathic, respectful and skilful care co-ordinators and wider family and social support networks. The allocation or choice of care co-ordinator and care planning processes must be redesigned to support rather than hinder that. WRAPs and similar approaches, as often discussed in our data, may provide a more individualised and recovery-focused method that merits more detailed investigation, especially in light of recent evidence.170

Issues of safety and risk go hand-in-hand with mental health service delivery, perhaps more than in any other area of health care. Our data showed clearly that for managers, senior practitioners and front-line clinicians, risk assessment and management is central to their work and a key component in care planning and co-ordination. However, for the majority of service users and some carers, this was far less evident and there was a clear disjuncture between these experiences. Most service users did not feel that their safety had necessarily been considered, or that perceptions of their risk towards others had been discussed with them. In order to provide genuinely personalised, recovery-focused care planning and to ensure the safety and well-being of all, attention must be given to how greater openness, partnership working and shared decision-making can be developed in this important area.

The findings from this study will inform our sister project, commissioned by NIHR HS&DR (13/10/75), in which we undertake to employ a similar design and methodology to investigate recovery-focused care planning in acute inpatient mental health settings. It is anticipated that the combined outcomes will help us design and evaluate a whole-system intervention that helps bring about more personalised, collaborative care planning and co-ordination across settings. In the interim, the following recommendations are presented, including those for research.

DISCUSSION

NIHR Journals Library www.journalslibrary.nihr.ac.uk 120

Recommendations (by macro-, meso- and micro-level)

1. Commissioners and providers of mental health services should aim to ensure that there is clarity and consistency in establishing and communicating with partners and recipients of services what is meant by recovery and to ensure that the aims and operations of the organisation are designed to support staff and service users in realising that vision. These understandings need to be developed through the involvement of people using these services and frontline practitioners. They need to be shared with external organisations and appear in operational policies so that it is clear what is meant by recovery and how it will be achieved (macro-level).

2. Similarly, there is a need for a simple, accessible and universally understood definition of what

personalisation means in the context of mental health service delivery. There is also an urgent need for the methods and processes that support personalisation to be simplified and streamlined (macro-level). 3. Commissioners need to recognise that therapeutic relationships lie at the heart of effective care

planning, co-ordination and recovery-focused work and team and care co-ordinator allocation and workloads need to be adapted to support this (macro-level).

4. Care and treatment planning processes must be redesigned to enable care co-ordinators to better support recovery in service users. Serious consideration should be given to introducing and evaluating explicitly personalised, recovery-focused care planning tools and methods, such as WRAPs, instead of existing CPA/CTP documentation (macro- and meso-level).

5. High-quality research should be commissioned to investigate the clinical effectiveness and cost-effectiveness of the following:

(a) innovative organisational approaches to freeing up staff time to increase direct contact time with service users, carers and social networks with the aim of providing explicit recovery-focused interventions (macro-, meso- and micro-level)

(b) use of mobile IT aimed at increasing staff–service user contact time and delivering more flexible,

personalised recovery-focused care (macro-, meso- and micro-level)

(c) collaborative working and shared decision-making with mental health service users and carers in risk assessment and management (meso- and micro-level)

(d) innovative staff/team training interventions, drawing on best evidence available, designed to enable and support care co-ordinators and teams to provide personalised, recovery-focused care planning and co-ordination (meso-level).

Acknowledgements

M

Ms Jennifer Egbunike (Research Assistant in Health Research), who conducted data collection and contributed to the literature review.

Mr David Hindle (Service User Researcher in Mental Health), who conducted data collection. Ms Katherine Barrett (Service User Researcher in Mental Health), who conducted data collection. Mr John Tear (Service User Researcher in Mental Health), who conducted data collection.

Ms Bethan Mair Edwards (Service User Project Assistant in Mental Health), who conducted data collection. Mr Alan Meudell (Service User Project Assistant in Mental Health), who conducted data collection.

Ms Alex Thornton (Research Administrator), who conducted data collation and helped with analysis and collating the final report.

Ms Nafiso Ahmed (Research Assistant in Mental Health), who contributed to qualitative analysis and the final report.

Dr Mark Haddad (Senior Lecturer in Mental Health), who contributed advice on sampling. Mrs Barbara Keogh (Research Nurse and approved mental health professional).

Ms Tara Harvey (Clinical Studies Officer). Ms Neelam Laxhman (Research Assistant). Ms Rebecca Holland (Clinical Studies Officer). Ms Sue Thomson (Research Nurse).

Ms Bethan Rees (Clinical Studies Officer).

Ms Philippa Case (Senior Clinical Research Co-ordinator). Ms Serena Gregory (Senior Clinical Research Co-ordinator). Mr Adam Baxter (Clinical Research Co-ordinator).

Many thanks to all local principal investigators, service managers, staff, service users and carers who took part in or helped with the study.