A Summary of 'Practice Development' initiatives and protocols

The following lists outline the areas in which 'practice development' initiatives have had a positive impact on team working. Whilst these initiatives and protocols have been largely developed within CMHT's and Assertive Outreach services so far, they have also been adapted to other parts of the system. Practice Based Evidence as a practice development initiative could offer consultancy work around these areas with teams in statutory and voluntary sector agencies across the spectrum of mental health services...

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NFAO Assertive Outreach book published in March 2011

The National Forum for Assertive Outreach has published a textbook entitled ‘Assertive Outreach in Mental Healthcare: Current Perspectives’. I was engaged to contribute a chapter in collaboration with Sue Jugon, the Team Manager of the AO North based in Kettering, Northamptonshire. This presented me with a wonderful dual opportunity… to write a creative piece with enormous respect to the work Sue has done with her team over the last 11 years, but also to respond to the review in 2004 of my previous publication with Peter Ryan which referred to the work as ‘the funky business of mental health care’. I have long since wanted to expand on the theme of funky mental health, so here it is.

FUNKY MENTAL HEALTH

Steve Morgan & Sue Jugon

Warning: the following chapter should only be read by those with an open mind, and a challenging disposition!

Introduction

If you spend so many of your waking hours, and some anxious restless nights, devoted to working in mental health, are you right to expect at least some joy, fun, excitement, productive challenge, and even intrinsic reward from your complex interactions with service users and colleagues? Our managed, regulated, monitored and audited system is intended to ensure consistent good practice, but it is arguable whether it contributes anything towards producing a motivated workforce through its relentless pursuit of numbers and targets. A sea of fidelity scales, outcome measures, policy initiatives, service protocols and templates, research based models, and increasing mountains of paperwork may be a satisfying representation of service delivery for the academics and managers, but largely feels unconnected to the pursuit of genuine creative person-centred practice for practitioners, or service users for that matter.

The strengths approach to assertive outreach was fully articulated by Ryan and Morgan (2004), and in a review of their book (replicated in Practice Based Evidence, 2009) the approach was likened to ‘the Funky Business of mental health care’; providing practitioners with a different perspective from the mire of mechanistic, risk averse, box-ticking required by most organisations. The book places a strong emphasis on creative collaboration, true team-working and the need to be anchored by the well-being of the people we serve.

Continuing the theme of this book review, funky mental health should be seen primarily as working with and around the rules. It is about how different people may look at the same thing but see something different. A small proportion of all practitioners are exceptional in their ability to reflect on situations, think creatively about complex interactions, and manage the demands placed on them organisationally without losing their vision of person-centred practice as the most important goal. A small proportion of all practitioners are exceptionally poor, shouldn’t by rights be inflicted upon service users, but organisational systems and teams can be cursed by an inability to offload them. The large majority of practitioners are good people wanting to do good work, but become easily paralysed by their narrow interpretation of policies and outcome measures within the wider perceived context of a blame culture. They unintentionally prioritise a focus on what might go wrong before considering the challenges and often risk-taking demands of a genuine person-centred approach. The ultimate losers will always be the service users, though you wouldn’t necessarily believe this from the incredible spin the management machine can often place on its own contradictory demands of services.

Funky mental health is not about ignoring the rules or breaking the rules in any illegal way. Buckingham and Coffman (2005) talk about ‘First, break all the rules’, but only as a challenge to see and do things differently in order to gain the most positive and successful outcomes from identifying and working with anyone’s individual talents. Rules are generally guidelines, not usually immovable impositions or rigid barriers. Assertive outreach has been established specifically to find ways of working with people for whom the traditional rules of community mental health have proved less workable. So, by definition these rules, or norms, have failed to bring about anyone’s desired outcomes (neither service user nor service provider). In this instance do we give practitioners more time to do more of the same thing, in the hope of re-shaping the service user to better fit the pattern of service delivery? This undeniably represents a ‘service-centred’ approach to practice, and often includes punitive responses towards the service users and their needs. Or, do we give practitioners the permission to create new ways of engaging and working alongside the service users in creative and flexible ways (i.e. a more person-centred approach)?

Funky working needs a vision

In some instances funky mental health should produce the ‘I can’t believe you do that’ response from the majority of the good practitioners. It starts with a clear underpinning vision that can be returned to and checked against at any stage of a team’s development or experience of significant challenges. The vision should be about how we develop and sustain a ‘team’ that can incorporate the maximum range of qualities in a small group of practitioners so they may be made available to the diverse range of people who naturally make up the client group. It is about a clear underpinning philosophy, and an eagerness to reflect, individually and collectively, on the personal values that influence our every decision; including the big questions of why we do this type of work, what we feel about the people who need services, and how we intend to best work with them. It is about people who have a healthy respect for how work and personal lives inter-relate, not about rigid 9-5 demarcations. It is about genuine flexible responses to needs, rather than the rigidity of extended shift patterns. It is about being challenged to think, and being aware of the rewards of the intrinsic value of thinking through a challenge. In the world of funky mental health there is a more healthy developed appreciation of how much we become a part of service users lives; but also going one step further, seeing how service users become an important part of our lives if we have a belief in the value of the work we are doing.

Remaining contents:

 What do the exceptional few do?

 It is also about the environment

 Underpinned by a ‘team’

 Can local effectiveness be centrally legislated?

 A Day in the Life

 8.56a.m. … Morning Handover…

 White Lightening…

 9.49a.m. … Doing the work…

 1.14p.m. … Team Reflection & Practice Development…

 4.01p.m. … Administration Hour…

 6.29p.m. … Real flexibility and response to needs…

 7.00p.m. … A daily phone conversation…

 7.11 p.m. … A call to the ‘buddy’

 Conclusions

 The practice of a funky mental health approach is not without its challenges and difficulties; not the least of which will be some staff members within any team who just don’t get it. There is no accounting for the lack of reflection and fixed mindsets that will regularly be encountered, and even denied or defended by those practicing them. For some, the opportunity to reflect on, think about, and creatively develop their practice is nothing more than a hindrance to just getting on with all the pressures they experience in a busy and demanding job. There is also no substitute for a good consistent moan to some people. This is not to say they do not do good work; but the amount of energy expended on negative feeling and expressions of emotion takes away from time that could be devoted to more constructive management of the challenges, but also serves to demotivate others subject to the whining and claims to have done it all before. 

The individuals who practice funky mental health are a lucky few… predominantly reflective and ethical people, they understand how to achieve a level of enjoyment out of their work, it being an intrinsic part of their life interwoven with other elements of who they are. They encounter a majority of people who are eternally trying to find reasons to separate what they do at work from who they are as people outside of demarcated work hours. They understand that the less you integrate the more you fragment, and a fragmented life is the basis for further dissonance. However, these practitioners or team managers are not naïve enough to allow themselves to be exploited by the considerable demands of a system more equipped to grind down excellence for the sake of uniform bureaucratic mediocrity. They understand the system better than most, because they reflect on and analyse what is going on around them, and think about the sometimes hidden motives and connections in the games people play.

In the real world of person-centred practice funky mental health is about ‘permission’ to think and do things differently, rather than a ‘prescription’ of how things are expected to be done. Traditional expected ways can be fine, in some circumstances, but don’t have to be the usual way in all circumstances. Can funky mental health apply outside of AO? Yes, in the funky world of trying to recapture all that is interesting, motivating and exciting about working in mental health… assertive outreach could be seen as providing a guiding light for other areas of practice to adapt into their functions and responsibilities. Whether that will be understood from a higher level policy and management perspective is another question altogether.

To order the book click here.

Creating Capable Assertive Outreach Teams - slide presentation

The following Powerpoint presentation, 'Creating Capable Teams: AO (North) Northamptonshire A Case Study', was written by Steve Morgan (Practice Based Evidence) and Sue Jugon (AO North Team Leader)

Powerpoint: Creating Capable Teams: AO (North) Northamptonshire A Case Study (119kb)

'Strengths' Assertive Outreach: A Review of Seven Practice Development Programmes

The following article was first published in the Mental Health Review Journal (June 2008) and is reproduced with their kind permission.

Abstract

Assertive outreach is based on extensive international research and has been promoted in the UK in 1999 as a key area of the National Service Framework for Mental Health. Its primary aim is to provide a specialist service for people disengaged from traditional approaches of mental health services, but very little attention has been paid to how such services can be developed. Practice Based Evidence, a practice development consultancy, has engaged seven assertive outreach teams to focus on development first, and follow-up evaluation of the impact of reflective practice on team functioning. This has prompted a number of strengths-based recommendations for changing the way we think about developing services before we engage in research and evaluation.

PDF: 'Strengths' Assertive Outreach: A Review of Seven Practice Development Programmes

Excerpt from Part 3: Evaluating a Strengths Approach to Practice Development

Developing a tool to guide and capture the strengths messages

The rationale underpinning a strengths approach led to the development of a 13- item tool to help capture some measurement of how practice development and team functioning can influence positive changes in team practice. The tool should also act as a prompt to areas of good practice, so the items are designed to be a sufficiently comprehensive reflection of ethical issues, care process, team functioning, and an underpinning knowledge base. Yet, this also needs to be a manageable tool (i.e. fitting one side of paper) if it is to engage practitioners interests and be used.

Ethical practice
1. Service users are fully involved in determining the ‘priorities’ for the working relationship.
2. As a team, we regularly examine and review the impact of ‘values and principles’ on our practice.
Care process
3. Time for creative approaches to ‘engagement’ is a priority.
4. Our assessment of needs includes the identification of service user ‘strengths’.
5. We identify and manage the appropriate opportunities for ‘positive risk-taking’ in practice.
6. Our working practice draws on a broad range of ‘practical and research based’ approaches.
Team working
7. We are clear about our ‘purpose’ as an assertive outreach team.
8. We have a clearly agreed model of ‘team-working’ (within team).
9. We have effective systems of ‘support and supervision’.
10. We have clear processes of ‘decision-making’ in the team.
11. We ‘link’ effectively with other parts of the mental health system (including primary care).
Knowledge in practice
12. We make full use of the ‘diverse’ knowledge, skill and experience within the team.
13. We access appropriate expertise from outside of the team.

Developing the method of evaluation

The method focuses on evaluation of changes in practice that gives useful feedback to the teams about their global functioning, as well as indicators to priorities they may choose to focus specific attention on. This is not the same as the approach established in many of the well known research projects examining the effectiveness of assertive outreach. The research approach has been one of top-down influences, whereby external sources examine questions relating to their desire to compare outcomes to other known and established research. The evaluation approach is a bottom-up influence, whereby the practitioners are engaged in reflecting on how their team is performing in relation to practice-based outcomes.

A review of the Assertive Outreach Strengths Approach textbook

February 2004 saw the publication of a textbook written by myself and Peter Ryan, with a foreword by Professor Charlie Rapp. It is primarily aimed at developing assertive outreach, but its focus on a strengths approach is applicable to all parts of the mental health system.

Why not check it out at Amazon (or read an excellent user review from Amazon below) and Elsevier Health or click on the image for more information.

4.0 out of 5 stars 'A funky approach to mental health care' by "beauchampbooks"

"In 2000, two Swedish business gurus wrote a book called Funky Business. The concept was that the corporate world had become a more interesting place in which people could be creative, risk-taking entrepreneurs. Assertive Outreach (subtitled A strengths approach to policy and practice) could be the Funky Business of mental health care; it could almost have been called Funky Mental Health Care! This is not to suggest that it lacks seriousness or depth. The design of the book does suggest a... funkier approach, but the book is a sincere and important contribution to changing policy and practice."

"Paradoxically, in some ways, it is not particularly about assertive outreach. It is really about a strengths approach which could (and arguably should) influence mental health care generally. The Strengths Model of Case Management (developed in the USA by Charles Rapp since the early 1980s) is the organising principle of the book and, indeed, Rapp contributes a foreword which describes it as "a clarion call for policy and practice to be intelligent and coherent, and anchored by the well-being of the people we serve."

"Assertive Outreach is a breath of fresh air for nurses bogged down in the mire of risk-averse, box-ticking, mechanistic organisations. It provides a perfectly clear and comprehensive account of the history, the evidence base and the present day practice of what, in the UK, is called assertive outreach and what the differences are between this and the related concept of case management. It was a delight to see a whole chapter devoted to risk-taking (instead of risk management). Throughout, the reductionism of care coordination is put in its place with the emphasis being on creative collaboration, with excellent sections on true team-working and an argument for, not just evidence-based practice, but practice-based evidence - all necessarily funky."