Working with Strengths

At a strategic level we are continually expanding the language, but essentially using new words and phrases to say the same thing... recovery, personalisation, self-directed support, person-centred planning, re-ablement/re-enablement. Nobody can seriously disagree with the premise that service users should be given a voice in order to say what they need and want, to reflect on how best to meet their wishes and aspirations, to exercise choice and feel supported in their decision-making. However, there is often a gap between what we are saying we are doing as services, and what service users are experiencing on the receiving end.

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Conference Presentations

The following files are presentations Steve has made regarding the implementation of personalisation.

Powerpoint: Personalisation and the art of coordinating care (147kb)

Powerpoint: Personalisation Opportunities and Risks (113kb)

‘Personalisation revisited’

The article linked within was first published in Openmind 159, Sept/Oct 2009) and is made available as a PDF with their kind permission.

Excerpt: The conundrum

The current driver for the transformation of all UK public services is the concept of personalisation.

But haven’t we been here before, and if so what have we failed to learn? Case management, the National Service Frameworks, Valuing People in learning disability services, and recovery are but a few of the recent designs on service delivery sharing some common characteristics. They all lay claim to service user-focused or person-centred ways of working, and all are intended to transform the way services are delivered. Personalisation may just be he latest catchphrase for the same messages. If so, is it the aims or the message that we are getting wrong?

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Getting Personal

As the National Service Framework (Department of Health, 1999) completes its 10 year plan there is cause for cautious optimism that the path has been set for a national standard in delivering responsive mental health services through functional teams. However, this is tinged with concerns when we scratch the glossy surface and examine the depth of quality and consistency. The focus of attention has been about getting structures and systems consistent, but at the ground level it is arguable just how much attention is being paid to nurturing and developing the complex arrangements we call multidisciplinary teams.

The framework, and accompanying NHS Plan (Department of Health, 2000) set the scene for establishing a national network of assertive outreach teams, crisis resolution & home treatment teams, and early intervention teams to complement the existing network of in-patient psychiatric units and community mental health teams that constituted the statutory sector service provision. These are now largely in place, and underpinned by the overarching mantra of ‘working to principles of recovery’ and ‘promoting social inclusion’.

This latter statement can be used to illustrate the gap between the rhetoric of policy and the reality of practice, as many practitioners and service users express anything from confusion to concern about what these statements mean; particularly where teams are re-branded as ‘support and recovery teams’ with little to illustrate what the change actually means. For some service user activists this has come to represent yet another usurping of their good ideas, as the service providers find another change of language to liberally sprinkle over their latest policy initiatives.

Pockets of good practice have undoubtedly flourished, providing a genuine service user-focused approach to delivery, and this has to be a tribute to determined practitioners and team managers who have finely tuned their values and attitudes to shape the way they provide a service, even while being bombarded with an avalanche of initiatives, targets and measures. We need to hear more of the voice of the service users experiencing these types of services, so that the new policy agenda can be driven by good experiences rather than the more usual need for change predicated on failures in services.

The next step in UK policy seems to raise the profile of what I would consider to be good practice in isolated initiatives, seeking to set a service user-focused agenda for all public services (not just social care and health, but housing, leisure and welfare benefits, etc) under the banner of personalisation. It is an agenda supported by all major political parties, and is already being seen as the picture of what the 21st century service imprint will look like. However, it is worryingly caged in grand gestures about ‘radical reform’ and ‘workforce transformation’; not particularly motivating mantras to people on the ground already giddy from the constant process of change proffered by the policy makers. The following sets out ideas and challenges underpinning this concept of personalistion.

What is personalisation? (1)

• A shift of emphasis from the service at the centre with the person fitting in, to the person at the centre with flexible services adjusting to the needs of the individual
• An over-arching philosophy of seeing the individual as a person with strengths and preferences, and networks of personal support [something I have long seen as being the ‘strengths approach’]
• Recognising the person as an ‘expert of their own experience’, who knows their own needs and the best ways to meet them
• Seeing people as being able to exercise choices, take responsibility for decisions, taking more control through expressing their needs, wishes and aspirations, but needing information and support in order to do so effectively
• Early intervention and prevention as priorities
• Developing individual budgets to provide genuine purchasing power
• Finding new collaborative ways of working and developing local partnerships
• Transformation of the whole system and culture of thinking, so that it becomes the outcome of a reformed service, not the process of reform itself

What are the potential barriers to implementation? (2)

• Fear of the volume of change represented by phrases such as radical reform and workforce transformation
• Is the current workforce sufficiently geared towards delivering services in these ways (professionals trained to manage will often struggle with the role of enabling)?
• Is there really a full menu of options to choose from? Where is the investment in a wider range of alternative services and treatments?
• Eligibility criteria for many services are being progressively tightened!
• Service users and/or carers taking on employer status, and all the legal and financial implications associated with this development
• Shared responsibility is not about leaving people to decide then blaming them if it goes wrong
• Adequate funding, more so at a time of economic recession
• Is the political will for the outcomes matched by the political will for the process? Is it all about destinations with little or no thought for the actual details of the journeys?

1. Carr, S. and Dittrich, R. (2008) Personalisation: a rough guide. Adult Services Report 20. London: Social Care Institute for Excellence.
2. Bird, A. and Wooster, E. (2008) Personalise this! Openmind, 153: 6-9.

What is 'Practice Based Evidence'?

As I start this new chapter in the 'Practice Based Evidence' website, I thought it worth revisiting a basic principle...

What is 'Practice Based Evidence'?

Established in October 2001 by Steve Morgan, 'Practice Based Evidence' presents a challenge for us all to think more carefully about the ways we can support the development of good practice in mental health services. If 'mental health research' is as informative as its authors believe, why is it inaccessible to the average practitioner and service user? If 'mental health training' is as effective as its facilitators believe, why is it having so little impact on practice?
The confines of the orthodox...

Good quality 'mental health research' should present challenges to routine ways of doing things. It should illuminate new as well as existing ways of working; and it should be able to excite people into thinking of ways they can change what it is they are doing.

Steve was ready for anything the critics were going to throw at him.

The amount of attention drawn to the concept of 'Evidence Based Practice' has conveniently supported the development of a citadel populated exclusively by academics, policy-makers and managers. A shared language helps to define a sense of self-importance, by presenting significant barriers to accessibility by others. Protocols, targets and audits present impenetrable walls, and the gold standard 'randomised control trial' is the heavy-duty portcullis barring the entrance to any external influences. Nowhere in this picture of fortification do we get a sense of the realities and details of everyday practical experience. Those who research and develop policy are largely exonerated from venturing out into the gritty and murky depths of poorly resourced services, mired in the local politics and personality battles.

Good quality 'mental health training' should engage the minds of participants, promote a sharing of experiences and ideas, and focus on specific needs for practice. The majority of the time it re-hashes the same old messages in uninspiring ways, unconnected with practitioner priorities.

When linked to research, training becomes little more than the mechanism for delivering the message'. As a resource training becomes a product, an end in itself, rather than a means to developing and refining the process of good practice. Translating the important messages from the workshop to the workplace is left entirely to the participants. Training can become a wasteful resource, through its failure to address the essential element of impact on changes in practice.

The logic of the unorthodox...

Where 'Evidence Based Practice' operates at a level of generality, 'Practice Based Evidence' acts at a deeper connection with real practice. The approach requires a direct acknowledgement of the context in which individuals and teams work. It gives a voice to practitioners and service users, recognising that they have first hand knowledge and experience of what works, what needs to change, and how it may change. Ordinary people have the ability to do the most extraordinary things, and these messages deserve to inform the concept of good practice every bit as much as the messages from research.

'Practice Based Evidence' is a concept that has a specific approach (practice development in mental health), is based on solid principles (a strengths approach), and works in important areas of practice (e.g. positive risk-taking). When linked to training, it has the potential to make more effective use of limited resources, and to create the impact that 'Evidence Based Practice' should be making.