Unsurprisingly, the findings of our study included a strong call for more training in recovery-focused care planning and co-ordination. Our data would support the need for training to include exploration of the different understandings of recovery; coproduction and joint working, including around care planning, goal setting, risk assessment and management, and the choice and use of recovery tools. Similarly, training could include a greater focus on personalisation and in particular the use of personal budgets. This might include training in conducting assessments and developing a‘recovery support plan which identifies the goals a person has for his or her recovery and how those goals could be met’.143(p. 4)But it also needs to
explore some of the tensions identified in our study around negotiating with multiple providers on issues of risk, communication and confidentiality.
Unfortunately, training brings as many challenges as answers. First, there are great difficulties for health service managers to provide time and support for training alongside all the mandatory training required of staff and the ever-increasing demands placed on practitioners. Second, there is also little evidence that training alone leads to any significant change in practice.
The impressive THORN training programme156in psychosocial interventions for clinicians who work with
people with serious mental illness and their families included case management, cognitive–behavioural therapy and family therapy. Despite a lengthy training programme, back-filled posts and highly positive evaluations of the training, there is very little evidence of this leading to major changes in clinical
practice.156In particular, attempts to increase work with families was a dismal failure, with often as little as
one extra family receiving input within a year of training. Stanbridge and Burbach157suggest a strategic
and whole-team training approach shaped to the particular needs and interests of the team to maximise impact.
Just such a whole-team approach in relation to delivering recovery-focused working within CMHTs has been adopted in Slade et al.’s REFOCUS programme of research.158The aim of the intervention was to give
It comprised team training for 12 months to help professionals understand more about personal recovery and how they can better support people on their individual recovery journeys. The intervention encourages team members to focus more on service users’ values, strengths and personal goals, and helps professionals develop and practise coaching skills. It encourages mental health professionals to work more collaboratively with people who are unwell and to make sure that care plans emphasise personal goals and reflect a service user’s preferences for treatment.
The REFOCUS trial158was a cluster randomised controlled trial involving 29 community-based teams;
15 of the teams were trained in the REFOCUS intervention. The study compared the recovery journey of service users who have been supported by professionals working in these teams with the recovery journeys of service users supported by professionals working in the other 14 teams, who have not had the specialist REFOCUS training (the control arm). Unfortunately, despite great efforts, the results from this study have been disappointing (see Appendix 12):159
The REFOCUS Trial shows that implementation within mental health systems is more challenging than simply introducing a new intervention, and requires organisational commitment. However, we did show that where REFOCUS was fully implemented, a positive impact on recovery was found. So the major challenge is implementation, which starts but does not end with training.
Professor M. Slade, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 2014, personal communication
Another programme of research that holds out hope is Lovell et al.’s Enhancing the Quality of User Involved care Planning (EQUIP) in mental health services programme.160,161This programme is now
delivering user- and carer-led training to CMHTs in a cluster randomised controlled trial designed to bring about more user-focused care planning. We keenly await the results.
The Implementing Recovery through Organisational Change (ImRoc) programme led by the Centre for Mental Health162is also a major driver in trying to bring about recovery-focused organisations and practice
in mental health in England. A key part of their strategy sees the introduction of peer workers in the workplace as a key driver of recovery-focused work.163The lead author of this report is involved in a new
NIHR programme of research (RP-PG-1212–20019) aimed at evaluating the impact of mental health peer support workers. This 5-year programme of research began on 1 March 2015. Although not specifically focused on care planning, it will be interesting to see whether or not the presence of peer workers within teams influences work culture.
In Wales, the National Institute for Social Care and Health Research (NISCHR)-funded Plan4Recovery164
study is examining social approaches to promote recovery. In particular, it is asking how people share in decisions about their care and how they make links with others in their communities for support and friendship. The aim is to assess how these are related to recovery and quality of life. The study is measuring involvement in decision-making, social contacts, recovery and quality of life with a cohort of people using a range of statutory and non-statutory services. Again, we keenly await the results.
The challenge of bringing about and maintaining change in practice is well-recognised and has led to the growth of Improvement Science, with a focus on implementing and sustaining evidence-based change within organisations and practice.165,166Simply delivering more training, even if possible, is unlikely to be
enough and the challenge is to develop and evaluate innovative quality improvement approaches that also include a focus on the meso-level context of organisations, as they attempt to bring about a meaningful shift in mental health care culture.167Training and related interventions aimed at care co-ordinators and
bringing about change should draw on the best evidence available and be delivered as part of a high-quality programme of research.168
DISCUSSION
NIHR Journals Library www.journalslibrary.nihr.ac.uk 118
Public and patient involvement
This study was developed and conducted with a high level of service-user and carer involvement from the start, including an independent service-user researcher as co-investigator. Regular consultations throughout the study with both SUGAR, the in-house service user and care advisory group on research169and the
project’s specially convened LEAG ensured that the study was conducted with a clear focus on the views and experiences of service users and carers, and that the methods used reflected this.
Additionally, five service-user researchers were employed to work alongside the research team, helping with recruitment and interviewing service users and carers. Training and support was provided and structured reflection methods employed to help both the service users and academic researchers to learn from the joint experience and improve their ways of working. A blog post was published, and the service-user and academic researchers jointly produced and gave a presentation on their work at an international psychiatric nursing research conference. They will jointly produce a paper for publication exploring the benefits and some of the challenges for both parties in the near future.