London mental health models of care competency framework

Transcription

1 London mental health models of care competency framework

2 Foreword It is important that non-specialist mental health services and professionals do not exclude people with mental health needs. 2 London Health Programmes

3 Foreword Foreword The London mental health models of care seek to improve the quality and outcomes of services for those experiencing a mental health crisis, and to support those with a long term mental health condition to better manage their own mental and physical health in line with a recovery approach. Both models concentrate on refocusing existing services and those who work in them rather than creating additional services and interfaces between services. The nature of support and services for people with mental health problems in London has evolved rapidly in recent times, and is likely to change even more in the coming years. In future, a wider range of organisations and staff are likely to become further involved, to varying degrees, in providing such support for people with mental health problems. Many will not work in the health sector, nor will they be specialists in mental health. Successful implementation of the models of care will require staff from an increasingly wide and diverse range of backgrounds, sectors and services to have the right knowledge, skills and behaviours to work positively and effectively with people with mental health problems. The framework aims to indentify the key competencies which will increase the expertise and confidence of the full range of staff that support people with a long term mental health condition or in a crisis, thereby improving patient experience and the quality, effectiveness, productivity and sustainability of services. This new competency framework does not seek to replicate or replace the range of welldeveloped frameworks providing detailed coverage of the competence and capability requirements of different professional groups, but to reflect the knowledge and skills which will support successful implementation of the mental health models of care. David Jobbins Associate Director, Mental Health This competency framework is not aimed exclusively at specialist mental health staff, but at everyone who comes into contact with people with mental health problems and those who are responsible for commissioning and developing services. A competency framework for all those working with people with mental health problems in London 3

4 Executive summary Executive Summary This competency framework has been developed to support the implementation of the two mental health models of care; for people with long term mental health conditions and people experiencing a crisis. The models of care require development of the skills and practices of the workforce, identifying best practice in London and building upon it. This competency framework will help to identify training needs within and across the health and social care workforce enable organisations to design and provide training to a consistent model help employers to draw up job descriptions support in group training Part two: setting out further competencies for staff who are not mental health specialists, but who work with a wider client group including people who may have a mental health problem, and/or people who may be experiencing a mental health crisis. Part three: setting out additional competencies for staff working with people with mental health problems either as a main client group, or as a significant part of a wider client group, for example mental health clinicians and GPs. Clinicians, managers and commissioners should aspire to see all individuals within their organisations gaining part one competencies. For part two and part three competencies however, the requirements will differ according to factors such as the nature of the team, service or organisation, its functions, ways of working and overall skill-mix. support individuals self-assessment of their own development needs function as a guide for designing local care pathways and commissioning services. The competencies are organised into three parts, with each part of the framework building upon the preceding parts. Part one: setting out universal competencies relevant to everyone who may, as part of their day-to-day work, come into contact with people with mental health problems; 4 London Health Programmes

5 To assist workforce leads, commissioners and training managers the competency framework is designed to be used on a number of levels - at an individual level, at a team level or at an organisational level. Executive summary At an individual level, the competencies can be used by individuals across a very wide range of services, professions and roles for self-development, to reflect on work and practice, and to identify development and training needs in discussion with their managers. At a team or organisational level, the competencies can be used by providers, clinicians, managers and commissioners to consider requirements within a given team, service or organisation, and identify collective development and training needs. The competency framework is designed to help clinicians, commissioners, employers and managers when designing local care pathways and commissioning services, to identify training needs within and across workforces; to inform the development of job descriptions and training and development plans and to support individual self assessment and development. A competency framework for all those working with people with mental health problems in London 5

6 Introduction and background Introduction and background The London mental health models of care are concerned with better supporting those with a long term mental health condition in managing their own mental and physical health more effectively in line with a recovery approach and raising the quality and outcomes of services for those experiencing a mental health crisis. Both models were driven by the case for change which highlighted the challenges for mental health services in London and seek to refocus existing services and those who work in them rather than creating additional services and interfaces. This framework uses the same terminology as used in the models of care. For more detail see Appendix 1. The model of care for long term mental health conditions seeks to strengthen the quality and capacity of provision in primary care, and how primary and secondary care work together, to enable more people with a long term mental health condition to receive their healthcare support through professionals in a primary care setting, working in partnership with user self management groups, informed carers and families and third sector organisations offering home based personalised care support. Key to this is improving the ability of individuals and services to prevent crisis occurring, improving the availability of specialist advice, highly skilled expert assessment, and interventions available in primary care. Particularly for people with long term mental health conditions, attention is given to recovery, appropriate care settings, partnership working and shared care. For people experiencing a mental health crisis, the emphasis is on appropriate and timely responses and recognition of the wide range of professionals and others who may be a first point of contact - people should receive a response based on the principles of right place, right time, right person, right assessment, first time. Rather than redesigning services, the models of care focus on improvements to four key elements of typical care pathways: How people access help when they or someone they care for needs it. What happens when people ask for help. How the response from the NHS and partners can be improved. The model of care for people experiencing a mental health crisis describes a care pathway that should be in place consistently and systematically across London, offering consistent, appropriate and timely responses. The availability of alternative services and information about them. 6 London Health Programmes

7 A key objective of the models of care is to enable more people with mental health problems to be supported appropriately within primary care and community settings, thereby reduce unnecessary secondary care admissions. Such an approach should lead to better, more person-centred care, while at the same time enabling secondary care services to provide better quality care for those who need that level of support. The models are intended to contribute to the delivery of the government s mental health strategy, suicide reduction strategy and quality, innovation, productivity and prevention (QIPP) plans for mental health. Several national policies and programmes are aimed at reducing variation and ensuring continuous improvement in quality, productivity and innovation within health services, including mental health. These create the operational context in which large numbers of staff - within and outside the NHS - will support people with mental health problems, and will impact on the way many services are commissioned and run. The key policies and developments that are driving these changes are summarised in Appendix 2. Staff across a range of health and public and voluntary sector services need to develop the skills, knowledge and confidence to work in different ways if QIPP benefits are to be realised and this framework defines what individuals and teams need to do in order to support service users more effectively. The mental health models of care can be downloaded at tinyurl.com/d7vs967 The London population and the mental health of Londoners London is home to some 8.17m people 1 with an extremely diverse and transient population. It is the UK s most culturally diverse city; more than 300 languages are spoken in London and over 40% of the UK s Black and Minority Ethnic population live in the capital. London has high levels of deprivation, with significant variation across the city: more than half of London s boroughs are within the 30% most deprived areas in England, and ten boroughs are amongst the most deprived 10% 2. Significant numbers of people come to London and leave London each year, with many inner London boroughs having particularly transient populations. An estimated one in four of the UK population will experience a diagnosable mental health problem at some point in their lives 3. At any given time, around one in six adults are experiencing a mental health problem, and for half of these people the problem will last for over a year 4. Within London the levels of mental health need and demands on mental health services are greater than the UK average 5. Prevalence is greatest in the most deprived parts of London, with social and economic factors affecting the incidence and duration of 1 GLA Intelligence Update demography team, 2010 mid-year population estimates, estimates for June 2010, based on data issued by the Office for National Statistics, and published June Mental health services case for change for London, London Mental Health Models of Care project, London Health Programmes, June mental_health_ pdf 4 New Horizons: a shared vision for mental health, Department of Health, Mental health services case for change for London, London Mental Health Models of Care project, London Health Programmes, June 2011 Introduction and background A competency framework for all those working with people with mental health problems in London 7

8 Introduction and background mental health problems, and worsening health inequalities 6. Dementia is more common in outer London due to its older population. London has higher than average numbers of people with complex needs including refugees, asylum seekers, homeless people and people with a dual diagnosis of mental illness and drug or alcohol problems 7,8. The nature of the London population, and the needs of this population is dynamic and will continue to change in future years. 6 ibid 7 ibid 8 In March 2011 London had 35,920 statutory homeless households in temporary accommodation, out of a total of 48,920 in England, Live Tables on Homelessness, Department for Communities and Local Government, last updated March 2012 The London mental health models of care core pathway To support the models of care, the project team at London Health Programmes, supporting the project clinical leads, has, with a range of other stakeholders, developed a core pathway, setting out the five essential functions that staff working with people with mental health problems need to carry out: l Assessment l Effective referral to appropriate services l Planning l Implementation (intervention and treatment) l Evaluation 8 London Health Programmes

9 Training needs pathway flowchart Planning Implementation Evaluation (Intervention & Treatment) Function The effectiveness of all interventions /periods of care and support should be evaluated from the service and the service user s perspective People should access and use evidence based interventions, which are built around them and their needs, and the needs of family members, in the context of their lives. Person, family, friends and workers agree needs to be addressed, goals to achieve them, and ways of achieving those goals in the context of a person s life Introduction and background People access the most effective source(s) of help/ support Evaluation of individual outcomes Holistic person centred assessment of health and social care needs in the context of their lives Support implementation of wellbeing and crisis plans Agree personal goals and monitor progress towards achievement Make/ accept referrals according to locally agreed protocols (seeking specialist advice as needed) Provide specialist advice to those health workers who might require it Make appropriate onward referrals to specialist mental health services, local authority services & other community agencies Maintain local directory of services to meet mental health need, including those for wider determinants of health (including how to access them) Evaluation of quality of services Work in partnership with users, carers, other services Provide personalised care, taking account of diverse needs (including ethnicity, gender, sexual orientation etc) Support access to and effective use of personal health budgets Deliver evidence-based physical & mental health interventions (including medical and psychosocial interventions) and interventions with families Enable self management of physical and mental health Support the use of health promotion information/ advice and services Monitor & review progress, and act when setbacks occur Discharge safety/risk and statutory duties/ responsibilities effectively Assessment of mental health, physical health, risk, functioning (including work, social life, relationships, self care, spirituality etc) Ensure that carer s assessments are carried out and implemented Evaluation of cost benefit and service efficiency Collaboratively develop living well/wellbeing and crisis plans Agree risks with individuals and family members/friends etc and how they will be managed Description Assessment Complete care plans which meet relevant statutory requirements as needed (including Care Programme Approach) Effective referral to appropriate services A competency framework for all those working with people with mental health problems in London 9

10 The London MHCF The London mental health competency framework How the competency framework was developed The process of developing the competency framework was very inclusive, as was the process for developing the models of care. Significant input was harnessed from mental health specialists in the field including the core professional groups of nursing, occupational therapy, psychiatry, psychology, and social work and in addition a wide range of other stakeholders were engaged including people using mental health services, their families, friends and carers, GPs, pharmacists, mental health charities and voluntary and community sector providers, employer and workforce organisations, and non-mental health staff. Through a series of focus groups and interviews, over 100 people were involved. This wide-level engagement has made a substantial contribution to the rigour and relevance of the framework. In developing this competency framework, it has been important to be mindful of the potential linkages with existing frameworks, but also of the complexity of trying to map a large number of links to many different documents. The aim of such mapping should always be to assist those using the frameworks, not to confuse them. Appendix 3 (Related competency frameworks) summarises the competency frameworks (in chronological order) that are relevant to the broadest range of staff working with people with mental health problems in London 9. This competency framework is not aimed exclusively at specialist mental health staff, but at everyone who comes into contact with people with mental health problems. Thus, it has been explicitly linked most closely with those existing frameworks that have the widest reach and application the Ten Essential Shared Capabilities 10, and the NHS Knowledge and Skills Framework (KSF) 11. However, there is, quite rightly, a great deal of consistency and congruence with the other competency frameworks mentioned in Appendix 3. An accompanying document is available which maps the London mental health competencies and NHS Knowledge and Skills Framework (KSF), linking the competencies in the framework to the dimensions in the KSF. This document is available at tinyurl.com/cn4azcm 9 It is also worth noting that the Social Care Institute for Excellence (SCIE) has produced a suite of briefings, guides and other materials that are useful to those working with people with mental health problems. See 10 The Ten Essential Shared Capabilities A Framework for the Whole of the Mental Health Workforce, National Institute for Mental Health England, Sainsbury Centre for Mental Health, NHS University, Department of Health, August The NHS Knowledge and Skills Framework (NHS KSF), Department of Health, Oct London Health Programmes

11 Rationale for the competency framework The models of care promote a refocusing of existing services and the roles of those who work in them. They introduce new roles and ways of working. Implementing the models will require people to do things differently in different settings; this competency framework identifies the knowledge and skills required to support them. The competencies identified in each of the parts of the framework will support and bring about some of the changes proposed within the models of care: Refocusing existing services to do things differently so as to promote recovery and enable people who no longer need specialist services to control the planning and delivery of their own care. Introducing shared care approaches for many people with long term mental health conditions: this means a transfer of clinical responsibility from secondary to primary care, with the active support and collaboration of secondary care, and enhanced information exchange. Creating navigator roles to help people access services that can support them with a range of issues, such as employment and housing, which may be integral to their recovery. Enabling better partnership working and drawing on the expertise of individuals, family members, friends and carers, and a range of relevant professionals, especially in developing the most appropriate plan for an individual s care. Sharing of expertise by specialists to help build capacity in non-specialist services, and to ensure the holistic needs of individuals can be met without the need for them to be managed in secondary care. Reforming secondary care services to provide swifter access to people who need their input, and improve their capacity to develop the specialised mental health services that only they can provide. The competency framework also articulates the means by which the aspirations of the models of care can be achieved - improving communication between primary and secondary care, the voluntary and community sector, clinical commissioning groups and local authorities; ensuring that physical health needs are properly assessed and addressed by all services and the physical health inequalities suffered by people with mental health problems are minimised; promoting a personalised recovery approach, involving people s family, friends and carers where appropriate; reducing the stigma associated with mental health problems, as more people receive support in non-stigmatising settings; promoting the routine use of outcome measures in relation to mental health; and contributing to the delivery of the government s mental health strategy, suicide reduction strategy The London MHCF A competency framework for all those working with people with mental health problems in London 11

12 The London MHCF and quality, innovation, productivity and prevention (QIPP) plans for mental health. Changes across health and social care organisations and systems are such that commissioning, partnership and governance arrangements are still developing. However, clinical commissioning groups (CCGs), local education and training boards (LETBs) and health wellbeing boards will provide opportunities to lead service and professional improvement. Further considerations include an increasingly mixed provider market supplying health services to NHS patients and potentially greater choice for patients. There will be on-going challenges in ensuring sufficient integration of services and continuity of care for people with long term mental health conditions. The competency framework is designed to: framework was that it is also important to consider the competencies required to support and work with people outside of the core pathway for example, people who may not have had any formal assessment or diagnosis, or those who have had a diagnosis but seek most or all of their support independently, and not through formal referral and care planning processes. The focus groups and interviews identified a need for specific competencies required to effectively support people experiencing a mental health crisis. Such competencies are important in supporting people in crisis irrespective of whether they have had a formal assessment and diagnosis, have been referred to other services, or have a care plan. help to identify training needs within and across the health and social care workforce enable organisations to design and provide training to a consistent model help employers to draw up job descriptions be useable in group training support individuals self-assessment of their own development needs function as a guide for designing local care pathways and commissioning services. One aim of this competency framework is to identify the competencies needed to deliver the five functions in the core pathway effectively. In addition, the clear feedback from the focus groups and interviews held in developing this 12 London Health Programmes

13 How the framework is structured The competency framework is presented in three parts: Part one sets out universal competencies relevant to everyone who may, as part of their day-to-day work, come into contact with people with mental health problems. Part two sets out further competencies for staff who are not mental health specialists, but who work with a wider client group which may include people with a mental health problem, and/ or people who may be experiencing a mental health crisis. Part three sets out additional competencies for staff working with people with mental health problems either as a main client group, or as a significant part of a wider client group for example mental health clinicians and GPs. This new competency framework does not seek to replicate or replace the range of well-developed frameworks providing detailed coverage of the competence and capability requirements of different professional groups. Rather the intention is to articulate a set of knowledge, skills, attitudes and behaviours that are desirable and appropriate for everyone who comes into contact with people with mental health problems. Very specific or technical frameworks for certain mental health professionals are placed at the top of the diagram below. These are not examined in detail here, as they have their own rigour and legitimacy. Nothing within this London mental health competency framework is intended to contradict or replace these existing frameworks. Competencies for specific professional groups The London MHCF Structure of the competency framework Part three competencies Part two competencies Part one competencies A competency framework for all those working with people with mental health problems in London 13

14 The London MHCF How to use this competency framework The competencies in this framework are necessarily generic enough to apply across a wide and diverse range of people. Each part of the framework is additional and complementary to the previous parts: people with part two competencies should also have part one competencies; they are further competencies, not alternative ones. The competencies in this framework are intended to be developmental: it would not be realistic to expect all staff, across such a wide range of services and organisations, to have all these competencies as a minimum requirement. Rather, they are intended as competencies that clinicians, commissioners, managers and staff will aspire to, and will support staff to work towards through training and development. In considering these competencies, it will also be necessary to think about an individual s scope of practice the areas where a person has the knowledge, skills and experience to work safely and effectively. An individual s scope of practice is likely to change over the course of their working life, and may expand as they develop new skills, for example through training or education. When using this framework, individuals and their managers should pay attention to their existing scope of practice, what an individual is currently feeling confident and competent to do, and what impact it would have were they to gain some of the other competencies in this framework. organisational level to assist workforce leads, commissioners and training managers. At an individual level, the competencies can be used by individuals across a very wide range of services, professions and roles for selfdevelopment, to reflect on work and practice, and to identify development and training needs in discussion with their managers. At a team or organisational level, the competencies can be used by managers and commissioners to consider what competencies are required within a given team, service or organisation, and identify collective development and training needs. The competencies in part one should apply to everyone who may come into contact with people with a mental health problem as part of their day to day work, and therefore managers and commissioners should aspire to see all individuals within their organisations having part one competencies. For part two and part three competencies however, the requirements will differ according to factors such as, for example, the nature of the team, service or organisation, its functions, ways of working and overall skill-mix. The competency framework is designed to be used on a number of levels - at an individual level, at a team level or at an 14 London Health Programmes

15 How might evidence of the competencies be provided? There is no single right way to use these competencies as part of an assessment or appraisal process. As they apply across such a broad range of staff and professional groups, they will be assessed in different ways in different organisations and situations. It will be up to individuals, line managers, senior managers and commissioners to determine, in any given situation or service, which specific competencies are required, and what evidence they draw on to determine whether a competency is being met, however the following may provide useful examples of ways in which evidence might be gathered: Learning and reflections from: informal or formal study and reading; training courses (including accredited courses); attending events or conferences; watching programmes, videos or DVDs; shadowing other staff or visits to other services; conversations with people with mental health problems and/ or relatives and carers; networking and conversations with colleagues and others, membership of groups or forums; use of directories, toolkits and other resources. Using the competency framework Reflections on one s own work and practice and on interactions with others. Feedback from line managers, informally and/or more formally e.g. through one-to-one meetings, supervisions, appraisals and performance reviews. Feedback from colleagues, informally through discussions and/or more formally, including through reviews if these are available. Feedback received formally or informally from people who use the services or the public, about individuals or the service/place of work. A competency framework for all those working with people with mental health problems in London 15

16 Using the competency framework Using the competency framework The competency framework is designed to be used on a number of levels and settings; at an individual, team or organisational level. It will be for local consideration as to how the framework could be most usefully applied in different settings The table below provides an overview of a range of possible roles and how they might apply the framework. It is not intended that either the list of possible roles nor the potential applications should be considered exhaustive; they are included to provide guidance. Group definition Possible roles Part Part Part Application People who may come into contact with people with mental health problems as part of their day to day work Staff who are not mental health specialists, but who work with people who may have a mental health problem, and/or people who may be experiencing a mental health crisis, as part of a wider client group Primary care receptionist A&E receptionists Housing department staff Employment staff Voluntary sector staff Practice /district nurses Health visitors /health trainers A&E staff /general hospital staff Police London Ambulance Service staff Housing support workers Advice services Pharmacists Substance misuse workers Social care staff 4 Identifying areas for personal development Increasing mental health awareness Identifying individual training needs Preparing for appraisal 4 4 Personal development Increasing mental health awareness Indentifying individual training needs Preparing for and providing staff appraisal Informing policy development Service development Developing training programmes 16 London Health Programmes

17 Group definition Possible roles Part Staff working with people with mental health problems either as a main client group or as a significant part of a wider client group Mental health clinicians Police officers with particular mental health responsibilities GPs Voluntary sector mental health workers Mental health advocacy workers London Ambulance Service Navigators/peer support workers 1 Part 2 Part 3 Application Indentifying areas for personal development Identifying individual training needs Team training needs analysis Developing training programmes Informing and developing job descriptions and person specifications Service design and redesign Mental health strategy and policy development Using the competency framework Developing outcomes frameworks Local education and training boards (LETBs) Clinical commissioning groups (CCGs) Local HR, workforce and training leads Healthcare providers, education and training providers, and professional advisory bodies. Collectively commissioning education and training according to locally determined need. Healthcare providers, clinicians and professional advisory bodies. Collectively commissioning clinical services according to locally determined need. Individually or collectively designing policies and tools for organisations and health communities, to support recruitment, training, professional and team development and appraisal processes. A competency framework for all those working with people with mental health problems in London 17

18 Part one universal competencies Part One: Universal competencies One in four people experience mental health problems; it is likely that we will all encounter people with mental health problems at some point as family, friends, neighbours, work colleagues, and in our professional roles. Mental illness can affect all aspects of a person s life, including employment, family life, and friendships. There is a recognised need to improve basic understanding of mental health (also known as mental health literacy ). This can make a significant difference to how well people are supported formally and informally, and by many different staff and professional groups. Staff in first point of contact roles, such as reception staff in GP surgeries and accident and emergency departments, are key. valuable within organisations and agencies such as housing departments, education and advice centres. The competencies in part one are about having a basic awareness and understanding of mental health. They are not about diagnosis or treatment but will support staff to feel more confident in supporting those with mental health problems to manage their own lives and to access appropriate and effective help and support. Some staff need awareness; some staff need expertise. The competencies in part one also underpin the development of part two and part three competencies. The part one competencies are universal, and apply to all people who may come into contact with someone experiencing a mental health problem as part of their day to day work. They are fundamental to promoting positive mental health and have a significant impact on an individual s wellbeing. In particular, a focus on part one competencies may be particularly valuable for individuals and organisations with little experience or knowledge of mental health problems. They provide a framework to identify the knowledge and skills needed to respond appropriately to someone with a mental health problem and may be particularly 18 London Health Programmes

19 1. Personal orientation and interpersonal skills Domain and Competency heading Empathy Being able to understand the thoughts and feelings of other people, to see things from their perspectives, and to give sensitive and appropriate responses to other people's emotional states. Respect Interacting with other people with courtesy and respect, irrespective of their status (e.g. health, social, professional status). Not acting in ways which are rude, belittling, patronising, dismissive, or consciously hurtful. Nonjudgemental them. Accepting and valuing other people as they are, without judging attitude Evidence could include being able to Demonstrate an ability to reflect on own work and practice, including interactions with others (and possibly be able to describe changes in own behaviour or ways of working as a result). Part one universal competencies Holistic approach Self awareness Communication Being able to see the 'whole person' rather than seeing someone just in terms of 'a problem' or 'a diagnosis'. Self awareness of the impact of one's own behaviour, language, and body language on others, including people with mental health problems. Being able to communicate clearly, sensitively and effectively; this includes communicating both verbally and in writing, and sharing relevant information appropriately. A competency framework for all those working with people with mental health problems in London 19

20 Part one universal competencies 2. Awareness and knowledge Domain and Competency heading Awareness of Awareness of the prevalence of mental prevalence of health problems, and the likelihood that mental health many people may have experience of mental problems health problems. Awareness of Awareness of the main kinds of mental mental health health condition and symptoms (e.g. conditions and depression, anxiety disorders, bipolar symptoms disorder, schizophrenia). Evidence could include being able to Demonstrate an awareness of the range and prevalence of mental health problems. Demonstrate an understanding of the potential impact for people experiencing a mental health crisis. Awareness of concept of mental health crisis Awareness of concept of long term mental health condition Understanding of mental health stigma and discrimination Awareness of the concept and possibility of mental health crisis, and the potential impact on people's behaviour, feelings and perceptions when experiencing such a crisis. Awareness of the concept and possibility of long term mental health conditions, and the potential impact on people's behaviour, feelings and perceptions of living with a long term mental health condition. Understanding of the stigma and discrimination faced by people with mental health problems. Demonstrate an ability to reflect on whether there are gaps in own awareness and knowledge of mental health problems and how these might be addressed. Demonstrate an ability to apply own mental health awareness and knowledge in real-life situations, and to identify whether this knowledge was adequate for the situation(s). 20 London Health Programmes

21 3. System knowledge Domain and Competency heading Signposting people Knowledge of appropriate with a range of sources of help and mental health support for people with problems a range of mental health problems. Ability to signpost people to appropriate support. Evidence could include being able to Demonstrate knowledge of mental health resources including sources of information used to support people experiencing a mental health crisis (local resources and services). Demonstrate an ability to identify what additional resources could be drawn on. Part one universal competencies Seeking support to ensure the immediate safety of someone in mental health crisis Signposting people in mental health crisis Knowledge and ability to seek necessary help and support to ensure the immediate safety of someone experiencing a mental health crisis. Knowledge and ability to signpost people experiencing a mental health crisis to appropriate sources of help and support. Identify any gaps in knowledge of mental health system and resources, include: non-statutory as well as statutory services, specialist mental health services and non- mental health services. Demonstrate an ability to reflect how own mental health knowledge has been applied either formally or informally, whether that knowledge was adequate for the situation and what further knowledge would be useful. A competency framework for all those working with people with mental health problems in London 21

22 Part one universal competencies 4. Proactive behaviour Domain and Competency heading Non-discriminatory Non-discriminatory behaviour towards behaviour people with mental health problems. Evidence could include being able to Demonstrate ability to reflect on individual work and practice, including any situations where this competency has been demonstrated. Understand the nature of discrimination in mental health. Demonstrate the ability to challenge inequality and discrimination in own role. Taking responsibility Willingness to take responsibility for positively addressing a situation where somebody with mental health problems needs support. Demonstrate ability to reflect on individual work and practice, including any situations where this competency has or has not been demonstrated. 22 London Health Programmes

23 Applying part one competencies in practice How do these competencies support implementation of the core pathway and London mental health models of care? These competencies should support staff to recognise that a person may be experiencing a mental health problem, to offer an empathetic and sensitive approach, and to signpost them to appropriate support. The competencies in part one will support staff to have the self-awareness to understand the impact of their own behaviour, language and body language, provide a good understanding of the stigma and discrimination faced by people with mental health problems, and to demonstrate non-discriminatory behaviour themselves. They should help staff in developing a good knowledge of local resources both to refer people formally, and also to signpost people to other sources of support, including nonstatutory services. This should help people access support beyond statutory health and social care services, for example housing or employment advice, education or training, self-help groups, support from mental health charities, or volunteering opportunities. Stigma and fear of discrimination can lead to reluctance to engage with mental health services. It is important that people involved in any part of the pathway understand this as it can fundamentally shape the quality of people s experience of mental health care, treatment and support, and willingness to seek appropriate ongoing help. If staff demonstrate self awareness and an understanding of the stigma and discrimination faced by people with mental health problems, they are more likely to build relationships of trust and engage in ways that enable people to play a full and active role in determining and achieving their own care goals. Whilst support and signposting are not identified as a part of the core pathway, they are key to reducing stigma and helping people to access the right support. For some this will mean entering the care pathway through an assessment, and for others getting support through wider community resources. Without empathy I don t believe there can be a change in attitude and behaviour. Highly developed empathy, a respectful and non-judgemental attitude, and a holistic approach are all important competencies for anyone carrying out any function on the pathway: the pathway makes clear that assessments should be done in a holistic, person-centred way, and include a person s physical health as well as mental health These same competencies remain core for all the other functions in the pathway: effective referral to appropriate services; planning and Part one universal competencies A competency framework for all those working with people with mental health problems in London 23

24 Part one universal competencies It makes such a difference when someone treats you as a normal human being. development of care plans (and living well, wellbeing and crisis plans, as appropriate); intervention and treatment, and evaluation. They are fundamental to building strong, positive and trusting relationships with people with mental health problems, and with their families, friends and carers. of mental health crisis and of long term mental health conditions will enable staff to feel more confident to support people experiencing mental health problems more effectively, in a range of different settings. In some cases, these will be covered by people s professional training and the clinical and profession-specific competencies required to perform these functions. An appropriate awareness of the prevalence of mental health problems, of conditions and symptoms, and of the concept and nature The best doctors are nonjudgemental, compassionate, kind and take you seriously. 24 London Health Programmes

25 Part two competencies These are competencies for staff who are not mental health specialists, but who work with people who may have a mental health problem, or who may be experiencing a mental health crisis, as part of a wider client group. There are a large number of roles whose main focus is not on mental health, but where staff need a good knowledge of mental health issues and to be able to engage supportively and effectively with people with a range of mental health problems. It is likely that increasing numbers of staff who are not mental health specialists, or who work outside traditional mental health services, will become more involved in providing support, care, treatment and services to people with mental health problems. Some non-mental health staff work with people with mental health problems and require the skills and knowledge to respond and provide appropriate support. In addition, staff in certain roles are likely to encounter people experiencing a mental health crisis and need to have the knowledge or training to know how best to respond as safely, effectively and supportively as possible. They need to recognise when people may be experiencing a crisis and have the confidence and competence to help respond appropriately to that crisis and enable the person to get the care and support they need. It may not necessarily be their role to provide these themselves. The focus of part two competencies is on building skills and knowledge of mental health issues, to increase the confidence of staff in a variety of settings and to improve the support provided to people with mental health problems. Competencies in this part of the framework may be particularly valuable in relation to services/organisations in which there is a need to have a good level of mental health knowledge to be able to recognise and respond to people with mental health needs and be able to recognise and respond to people experiencing a crisis. This may include primary care staff, police, ambulance and A&E staff as well as staff in a range of other settings including some housing support and employment staff. It will be for commissioners and managers to decide what proportion of staff, and which posts or roles, should have these competencies within a given team, service or organisation. It is important to note that people with part two competencies should also have part one competencies - these are additional competencies, not alternative ones. Part two competencies A competency framework for all those working with people with mental health problems in London 25

26 Part two competencies Part two For staff who are not mental health specialists, but who work with people who may have a mental health problem, and/or who may be experiencing a mental health crisis, as part of a wider client group 1. Personal orientation and interpersonal skills Domain and heading Working sensitively with people in distress Working collaboratively, including in a crisis situation Competency Ability to work empathetically and sensitively with people in distress, in a way which is calming and reassuring, and seeks to reduce their distress. Interacting with other people with courtesy and respect, irrespective of their status (e.g. health, social, professional status). Not acting in ways which are rude, belittling, patronising, dismissive, or consciously hurtful. Evidence could include being able to Demonstrate an ability to reflect on own work and practice, including interactions with others (and be able to describe changes in behaviour or ways of working, as a result). Demonstrate understanding and appreciation of the role of others involved in providing support, care, treatment and services to people with mental health problems. 26 London Health Programmes

27 2. Awareness and knowledge Domain and Competency heading Awareness of Ability to recognise that someone the signs that may be experiencing a mental someone may health problem and to respond be experiencing appropriately a mental health problem Awareness of Awareness of the concept and possibility of possibility of mental health crisis, mental health and the potential impact on people's crisis, and behaviour, feelings and perceptions potential impact when experiencing such a crisis. on people's (This requires a more detailed level behaviour, of awareness than in part one, and feelings and is linked to the ability to identify perceptions immediate symptoms of possible mental health crisis, below.) Identifying Ability to identify the immediate immediate symptoms and behaviours symptoms of that indicate a person may be possible mental experiencing a mental health crisis, health crisis and to respond appropriately Evidence could include being able to Demonstrate an ability to recognise the signs that a person may be experiencing a mental health problem Demonstrate an ability to respond sensitively, safely and appropriately to a person with a mental health problem Demonstrate understanding of the potential impact of a mental health crisis on people s behaviour, feeling and perceptions. Demonstrate an ability to identify immediate symptoms and behaviours that indicate that a person may be experiencing a mental health crisis. Demonstrate an ability to respond sensitively, safely and appropriately to a person experiencing a mental health crisis. Part two competencies Understanding concepts of risk, risk assessment, and risk management Understanding of concepts of risk, risk assessment and risk management in relation to mental health crisis and in relation to long term mental health conditions. Ability to apply these concepts by making judgements about risk in the immediate situation when dealing with and supporting a person experiencing a mental health crisis, and/or when dealing with and supporting a person with mental health problems who is not in crisis. Continued u A competency framework for all those working with people with mental health problems in London 27

28 Part two competencies Knowledge and ability to provide support to ensure immediate safety of someone experiencing Knowledge and ability to provide necessary help and support to ensure the immediate safety of someone experiencing a mental health crisis. Demonstrate understanding of the concepts of risk, risk assessment and risk management in relation to mental health problems and mental health crisis, and ability to apply these concepts in own judgements and actions. mental health crisis Demonstrate the ability to apply a range of De-escalation skills Ability to apply a range of skills and learnt techniques including both verbal and non-verbal communication skills with the aim of reducing a person's anger, aggression, agitation, hostility or skills and learnt techniques including both verbal and non-verbal communication skills with the aim of reducing a person s anger, aggression, agitation, hostility or distress and preventing disturbed, unsafe or violent behaviour. Suicide intervention skills distress and preventing disturbed, unsafe or violent behaviour. Ability to recognise the signs of distress, including suicidal thoughts and intentions, and to provide an appropriate response to support a person at risk of suicide to remain safe. Ability to recognise the need Demonstrate the ability to recognise signs of distress, including suicidal thoughts and intentions, and to provide an appropriate response to support a person at risk of suicide to remain safe; and the ability to recognise the need to seek further advice/ support as required. to seek further advice/support as required. Understanding Understanding that people can Demonstrate understanding of the different different kinds experience many kinds of crisis that kinds of non-medical and non-health crises of crisis that can are not health or medical crisis, that people can experience, and of the ways affect mental but that can affect people s mental in which these can affect people s mental health health (e.g. social crisis, housing health. crisis, financial crisis, etc). Demonstrate ability to respond to people experiencing such crises in ways that are sensitive to the potential impact on mental health. Understanding Understanding the relationship Demonstrate an understanding of the need to the relationship between mental health and physical exclude physical causes for mental health. between physical crisis and the need to exclude and mental health physical health problems (for crisis example impact of infection and pain in the elderly). Continued u 28 London Health Programmes

29 Understanding recovery in mental health Understanding person-centred Understanding of the concept of recovery and recovery-based approaches in mental health care, treatment and services. Understanding the importance of having care and services that are Demonstrate understanding of the concept of recovery and recovery-based approaches in mental health care, treatment and services. Demonstrate understanding of the concept of person-centred care and services, and the Part two competencies care and services person-centred and based around ability to apply this in one's own practice each individual's needs, preferences when working with people with mental health and choices. problems. Understanding Ability to understand and respect Demonstrate understanding of, and and respecting diversity relating to: age; race; respect for, diversity relating to: age; race; diversity culture; disability; sex, gender culture; disability; sex, gender and gender and gender reassignment; reassignment; spirituality, religion or belief; spirituality, religion or belief; sexual sexual orientation; pregnancy, maternity orientation; pregnancy, maternity and parenthood; marriage, marital status, and parenthood; marriage, marital civil partnership and civil partnership status. status, civil partnership and civil partnership status. Understand the impact of discrimination and prejudice on people s mental health and wellbeing. Demonstrate a commitment to equal opportunities for all people, and to challenging discrimination and prejudice. Demonstrate an ability to promote people s rights and responsibilities and recognise people s rights to privacy, dignity, respect and confidentiality. A competency framework for all those working with people with mental health problems in London 29

30 Part two competencies 3. System knowledge Domain and Competency heading Directing people Knowledge and ability with mental health to ensure people with problems to care, mental health problems treatment and are directed or signposted support to places, services or resources where they may receive appropriate care, treatment and support, including knowledge of what service options are available locally and how they can be accessed. Evidence could include being able to Demonstrate knowledge of appropriate available resources including local service options for people with mental health problems and how they can be accessed. Demonstrate understanding of own role in supporting people with mental health problems and/or experiencing mental health crisis to access appropriate services. Demonstrate an ability to identify what additional resources could be drawn on. Identify any gaps in knowledge of mental health system and resources, including non-statutory as well as statutory services, specialist mental health services and non-mental health services. Demonstrate an ability to reflect how own system knowledge has been applied formally or informally to support people with mental health problems, whether that knowledge was adequate for the situation and what further system knowledge would be useful. 30 London Health Programmes

31 4. Proactive behaviour Domain and Competency heading Understanding, Understanding and accepting responsibilities accepting that accompany own professional role, and and acting on demonstrating ability and willingness to take responsibilities responsibility for positively addressing a situation of role where somebody with a mental health problem needs help, including to ensure their immediate safety or support Recognising and acting within the parameters of individual/role responsibility (This is a greater level of responsibility than in part one: it involves recognising that taking such responsibility is part of one s role.) Evidence could include being able to Demonstrate understanding of own role, and the expectations and responsibilities that accompany the role, in relation to working with people with mental health problems Demonstrate ability to reflect on individual work and practice, and to give examples of situations where this competency has been demonstrated. Part two competencies A competency framework for all those working with people with mental health problems in London 31

32 Part two competencies Applying part two competencies in practice How do these competencies support implementation of the core pathway and London mental health models of care? The competencies in this part are designed to equip professionals to support people, at whatever part of their mental health journey, whether they are experiencing mental health problems for the first time or whether they have been, or are currently, engaged with mental health services. It outlines the competencies which support different ways of working with people with mental health problems, where the focus is toward more people being supported in primary care or with greater shared care between primary and secondary care settings. The competencies in part two identify the skills and knowledge required to enable people in different settings to work with people with mental health problems in a different way. They may also be useful for those who commission services to identify the competencies required to support changes in service design and configuration and for workforce development. These competencies should enable a variety of professionals to support people appropriately through all parts of the care pathway by providing a holistic, personcentred assessment in the context of their lives. This should result in people being offered the care, treatment and support they need to progress along the next steps of the pathway and towards recovery. The competencies identify the need for good system knowledge so that people can be supported to access the most appropriate services. The sheer number and complexity of available services in London is vast and ever-changing so good, up-to-date knowledge of local resources is extremely important. Crucially, professionals system knowledge should include non-medical services and support options, as well as mainstream health services. Professionals, such as police officers, paramedics, primary care and accident & emergency staff, may have a particular focus on supporting people experiencing a crisis and the competencies that relate to the skills and knowledge needed to respond appropriately and to provide effective support, including care and treatment, while also ensuring immediate safety and minimising distress. Drawing on the competencies in both part one and part two will support a good understanding of these different circumstances and the skills and knowledge needed to respond in a way which is tailored to the particular situation and the needs and best interests of the individual. 32 London Health Programmes

33 Part three Part three Competencies for staff working with people with mental health problems either as a main client group, or as a significant part of a wider client group, for example mental health clinicians and GPs For staff whose role involves providing information, advice, support, care or treatment to people with mental health problems, either as their main client group, or as a significant part of a wider client group. This might be within the NHS, other public services, in a charity or voluntary sector organisation, or in the private sector (e.g. independent organisations providing health and/or social care services). This part addresses the competencies needed to tackle the challenges identified in the models of care and may be particularly relevant for staff supporting and implementing the system and role changes proposed. As with part one and part two, the competencies in part three are based on findings from the focus groups and interviews held to develop the competency framework and there was great consistency There is a lack of understanding from staff of what holistic means. It is not just listing all the areas that you are having difficulty with. It is about working with the person, seeing them as a whole person, not a long list of conditions. with the Ten Essential Shared Capabilities 12. Like this competency framework, the Ten Essential Shared Capabilities were developed to be applied very broadly and are aimed at the whole mental health workforce; that is everyone working with people with mental health problems, irrespective of sector or profession. The Ten Essential Shared Capabilities continue to provide a strong, relevant framework that can support the implementation of the mental health models of care for London. Accordingly, they have been used as the basis for part three, but have been adapted to apply in the context of the mental health models of care for London. As with part two competencies it will need 12 The Ten Essential Shared Capabilities A Framework for the Whole of the Mental Health Workforce, National Institute for Mental Health England, Sainsbury Centre for Mental Health, NHS University, Department of Health, August 2004 A competency framework for all those working with people with mental health problems in London 33

34 Part three to be decided what proportion of staff, and which staff, should have these competencies within a given team, service or organisation. The competencies in part three are generic competencies, to be applied in addition to any clinical/role-specific competencies for people s professional roles 13. The examples of evidence given here are indicative, and are suggestions for the kinds of evidence that might be sought to demonstrate whether an individual or team has a particular competency. The examples of evidence draw heavily on the examples given in Appendix D of the Ten Essential Shared Capabilities, but have been amended and developed to ensure they fit with the models of care and the direction of travel of care, treatment and support for people with mental health problems in London. [We need] up-to-date knowledge and understanding of other available services and sources of support, information and advice for service users: including mental health services, but also employment welfare, benefits, housing, and relevant voluntary and community sector organisations and services. An ability to signpost/formally refer people on to these services and organisations, as appropriate to their needs. 13 For example, a suite of competence frameworks for psychological therapists have been developed by a team at University College, London (UCL). These are designed to promote therapists capacity to deliver psychological therapies both for adults, and for children and adolescents. Currently there are nine separate frameworks (including frameworks for CBT, psychodynamic, systemic and humanistic therapies); these underpin the curriculum for the national IAPT programme, and have been adopted by many of the major psychotherapy organisations in the UK. They can be downloaded at 34 London Health Programmes

35 Heading Competency Evidence could include being able to Working in partnership (ESC 1) Developing and maintaining constructive working relationships with service users, carers, families, colleagues, lay people and wider community networks. Working positively with any tensions created by conflicts of interest or aspiration between partners in care. Ability to explain own role and working parameters, in a way which is understandable to people using services, their family and carers, and others working in different organisations, disciplines and sectors. Ability to engage people with mental health problems constructively and effectively, with a clear focus on the individual s needs and choices, including (where applicable) engaging individuals in a collaborative assessment process. Understanding and appreciation of the role of others involved in providing support, care and treatment to people with mental health problems, including appreciation of others roles, expertise, and differing perspectives (including professionals, advocates, volunteers, relatives, carers and friends). Part three Knowledge of available local organisations, services and resources (within and outside the NHS) that can provide support, care and treatment to people with mental health problems, and ability to refer/signpost effectively, and in line with individuals specific needs and preferences. This includes ability to use relevant local directories (e.g. covering a local authority or CCG area), Ability to communicate with all stakeholders involved in an individual s care. Understanding the role that families and carers can play in supporting individuals with mental health problems, and ability to engage them as active partners in care and support. Understanding the specific needs of carers and families of people with mental health problems. Ability to provide support to carers and families and help address their needs, including supporting people to receive a carer s assessment if appropriate Ability to communicate effectively across disciplinary, professional and organisational boundaries. Continued u A competency framework for all those working with people with mental health problems in London 35

36 Part three Understanding of the wider determinants of health (i.e. the social, economic and environmental factors that influence the health of individuals and populations) and ability to work collaboratively with partners to address these factors and improve the health of individuals and populations. Respecting diversity (ESC2) Working in partnership with service users, carers, families and colleagues to provide care and interventions that make a positive difference in ways that respect and value diversity including: age; race; culture; disability; sex, gender and gender reassignment; spirituality, religion or belief; sexual orientation; pregnancy, maternity and parenthood; marriage, marital status, civil partnership and civil partnership status. Provide care, treatment and support that recognises the importance of housing, employment, occupational opportunities, recreational activities, social networks and welfare benefits. Understanding and acknowledging diversity relating to: age; race; culture; disability; sex, gender and gender reassignment; spirituality, religion or belief; sexual orientation; pregnancy, maternity and parenthood; marriage, marital status, civil partnership and civil partnership status. Understanding the impact of discrimination and prejudice on mental health and mental health services. Demonstrating a commitment to equal opportunities for all people and encouraging their active participation in every aspect of care, treatment and support. Ability to promote people s rights and responsibilities and recognise service users rights to privacy, dignity, respect and confidentiality. Ability to contribute to evidence-based programmes of care and treatment that are sensitive to, and responsive to, diversity. Ability to identify, communicate with, and refer appropriately to other (statutory and non-statutory) services designed to address people s specific needs relating to their identities and cultures 36 London Health Programmes

37 Practising ethically and legally (ESC 3) Recognising the rights and aspirations of service users and their families, acknowledging power differentials and minimising them whenever possible. Providing treatment and care that is accountable Understanding of, and commitment to, the legal and human rights of all people using services, and of their carers and family. Understanding of the legal context and framework within which care, treatment and support are given to people with mental health problems, including legislation relevant to own practice and services (this will depend on own specific role and service, but might include e.g. Mental Health Act 1983, Disability Discrimination Act 1995, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, Mental Health Act 2007, Equality Act 2010). Part three to service users and carers within the boundaries prescribed by legislation and by national (professional), legal Knowledge of, and ability to, apply policies, practices and procedures concerning the local implementation of mental health and related legislation, including working with concepts of appropriate services and least restrictive options for those detained under the mental health or mental capacity legislation. and local codes of ethical practice. Understanding of principles and practice of debriefing those who have been detained under mental health legislation, their families, carers and staff. Understanding of, and adherence to, local and professional prescribed codes of ethical conduct and practice. Understanding of own and others responsibilities in relation to safeguarding children and vulnerable adults. Ability to conduct a legal, ethical and accountable practice that remains open to the scrutiny of peers, colleagues and appropriate others (e.g. regulators, HealthWatch, patient bodies, complaint investigators). Ability to respond to people s needs in an ethical, honest, nonjudgemental manner. Continued u A competency framework for all those working with people with mental health problems in London 37

38 Part three Ability to promote service users (and carers ) rights and responsibilities and recognise and maintain their rights to privacy, dignity, safety, effective treatment and care based on the principle of informed consent. Ability to work as a member of the therapeutic team in making a safe and effective contribution to the de-escalation and management of anger and violence, including through the use of control and restraint techniques where these are appropriate to own professional role. Challenging inequality (ESC 4) Addressing the causes and consequences of stigma, discrimination, social inequality and exclusion on service users, carers and mental health services. Creating, developing or maintaining valued social roles for people in the communities they come from. Ability to work within local complaints management systems, to address complaints positively and constructively, including being willing and able to adapt and improve own practice, services and way of working in response to complaints. Understanding the nature of stigma, and the effects of discrimination and exclusion. Understanding the role that mental health services play in creating and maintaining inequality and discrimination. Understanding the role that services play in fighting inequality and discrimination. Ability to challenge inequality and discrimination within own role. Ability to communicate own concerns to others within the care system. 38 London Health Programmes

39 Promoting recovery (ESC 5) Working in partnership to provide care and treatment Understanding the concept of recovery and recovery-based models and approaches in mental health care, treatment and services, including understanding that recovery is a process unique to each Part three that enables service individual users and carers to tackle mental health Understanding of the evidence-base for recovery-based models problems with hope and approaches in mental health care, treatment and services and optimism and to work towards a valued lifestyle within Understanding of core and evidence-based models of relapse prevention and beyond the limits of any mental health problem. Ability to explain concept of recovery and recovery-based approaches to people who use mental health services, and their family and carers Application of recovery-based approaches in own practice Understanding of the individual s wider social and support networks and the contribution made by carers, family and friends to the recovery process. A competency framework for all those working with people with mental health problems in London 39

40 Part three Identifying people s needs and Working in partnership to gather information Ability to work in a way that acknowledges and values the personal, social, cultural and spiritual strengths and needs of each individual. strengths (ESC 6) to agree health and social care needs in the context of the preferred lifestyle and aspirations of service Understanding how the physical and mental health of an individual can be promoted or demoted, and the impact that an individual s mental and physical health needs may have on other parts of the system. users, their families, carers and friends. Ability to acknowledge and work with a person s physical and mental health needs in a way that demonstrates understanding of the connections between the two, including the vulnerabilities of people with physical long-term conditions. Ability to support people to self-manage physical long-term conditions using psychological methods and interventions, possibly including principles of cognitive behavioural therapy (CBT). Understanding of the impact that other parts of the system may have on an individual s physical and mental health. Ability to work in partnership with individuals support networks to collect information to assist understanding of the person and their strengths and needs. Carrying out (or contributing to) a systematic whole systems assessment that has, as its focus, the strengths and needs of the individual using services and those family and friends who support them. 40 London Health Programmes

41 Providing service user centred Negotiating achievable and meaningful Ensuring that all care, treatment and support for people with mental health problems is focused on understanding and addressing the individual s specific needs, in ways Part three care (ESC 7) goals, primarily that take account of individuals preferences, choices, from the lifestyles, identities, culture, and support networks. perspective of service users and Ability to encourage individuals active choices and participation in their own care and treatment. their families. Influencing and seeking the means to achieve these goals and clarifying the responsibilities Ability to support individuals with mental health problems in accessing and using existing and emerging mechanisms to support and promote personalised approaches to their own care, treatment and support (e.g. personal budgets; personal health budgets; social prescribing; access to navigators, peer supporters, and self management programmes; choice through any qualified provider; advance directives and advance statements of wishes and feelings, etc.) of the people who will provide any help needed, including systematically evaluating outcomes and achievements. Ability to provide people with mental health problems and relatives and carers with information on their conditions and the services and standards they can expect, including treatment outcomes, in the format they find most accessible including multi-media approaches that accommodate varying language and cultural needs. This includes providing information that supports effective and empowered decision-making by people with mental health problems about their care and treatment options. Ensuring that any goal-setting is driven by the needs of the individual using services. Working with individuals using services to help them to describe their own goals as precisely as possible in ways that are meaningful to them. Helping individuals using services to identify and use their strengths to achieve their goals and aspirations. Working with individuals using services to identify the strengths and resources within each service user s wider network which have a role to play in supporting goal achievement. Supporting individuals using services to ensure that goals are achievable and measurable. Understanding the difference between broader long term and short term, more specific goals A competency framework for all those working with people with mental health problems in London 41

42 Part three Making a difference (ESC 8) Facilitating access to, and delivering, the best quality, evidencebased, valuesbased health and social care interventions to meet the needs and aspirations of service users and their families and carers. Understanding the concept of evidence-based and values-based best practice as enshrined in NICE guidance and psychosocial interventions training, etc. and understanding and applying specific NICE guidance relevant to own role and practice Awareness of and ability to apply other best practice guidance from a range of bodies, as appropriate to own role and client group (e.g. from SCIE, Royal Colleges, mental health charities etc.) Ability to design, or contribute to the design of, (as appropriate to role) a programme of care based on best practice or the best available evidence. Appreciation of the value of qualitative evidence, including surveys and other feedback from people who use services, and ability to apply learning from such evidence in own practice and services. Understanding own role in delivery and implementation of such a programme of care, and the role that others (in statutory services and outside of statutory services) can plan in such a programme of care. Knowledge and appreciation of the diversity of organisations and services that can contribute to a programme of care, depending on the specific needs and preferences of the individual. Ability to communicate clearly and effectively with all, including individuals using services and carers, who have a part to play in a programme of care. Understanding the impact of any particular problem on the life of the person using services and their carers, family and friends. Ability to identify physical health needs, and to identify care pathways that will deliver an effective response including, for example, outreach and home based care and treatment. Understanding of the range of medical and non-medical approaches to care and treatment available for people with mental health problems, and ability to discuss these various approaches, and their merits and drawbacks, with individuals to support them in achieving the care, treatment and support that best meets their individual needs. Understanding the importance of good and ongoing medicines management in the care and treatment of people with mental health problems, and the potential for polypharmacy (use of multiple medications) and associated risks (e.g. potential for: drug interactions; side-effects and adverse drug reactions; non-compliance; patient confusion over medication regime). Where appropriate to own role, ability to support people with mental health problems in reviewing, rationalising or reconciling their medication. 42 London Health Programmes

43 Promoting safety and positive Empowering the person to decide the level Understanding the value and importance of involving people using mental health services in assessments of the risks relevant to them, and in agreeing and implementing plans and strategies for managing Part three risk taking of risk they those risks. In addition, demonstrate understanding of the value and (ESC 9) are prepared importance of involving people s family and carers in assessment and to take with management of relevant risks. their health and safety. Understanding when it is essential for a physical cause of crisis to be This includes assessed, discounted or treated. working with the tension between promoting Promoting understanding of the factors associated with risk of harm from others, and risk of harm to self or others through violence, selfneglect, substance misuse, self-harm or suicide. safety and positive risk taking, Promoting an understanding of the commonest social causes of crisis and how to deal with them. including assessing and dealing with possible risks Applying a range of skills and techniques with the aim of supporting a person at immediate risk of suicide to remain safe; seeking or providing further support as appropriate to own role. for service users, carers, family members and the wider public. Contributing to accurate effective risk assessments using agreed tools and protocols, identifying specific risk factors relevant to the individual, their family and carers and the wider community. Contributing to development of risk management strategies and plans that are developed with involvement of the person they concern, name all the relevant people involved in their care and treatment (including family, carers and other non-clinical and/or non-statutory sources of support), and clearly identify the agreed actions to be taken and by whom, and the goals to be achieved. Continued u A competency framework for all those working with people with mental health problems in London 43

44 Part three Contributing, as a member of the therapeutic team, to the safe and effective management and reduction of any identified risks. Knowledge and understanding of national and local policies and procedures for minimising risk and managing harm to self and others. Knowledge and understanding of the Care Programme Approach and its role in ensuring safe and effective care and treatment for service users and carers, particularly those with a history of risks to self or others. Understanding the importance of multi-agency, multi-disciplinary working in promoting safety and positive risk taking, and actively contributing to a constructive, multi-agency approach. Awareness of the available spectrum of individual and service responses to help manage crises and minimise risks as they are happening e.g. diffusion strategies, crisis response services. Contributing to use of medical and psychosocial interventions with the expressed goal of managing a person s risk behaviours in the long term (e.g. through use of medication, anger management, supportive counselling, etc.) Educating users and carers about the role, function and limitations of mental health services in relation to promoting safety and managing risk of harm. 44 London Health Programmes

45 Personal development and learning Keeping upto-date with changes in Active participation in personal and professional development and life-long learning, and commitment to applying new learning in practice. Part three (ESC 10) practice and participating in lifelong learning, personal and Ability to set personal/professional goals that are realistic and achievable, including through personal/professional development plans where this is appropriate to own role. professional development for oneself and colleagues through Understanding personal responsibility to achieve goals set in own development plan, and understanding responsibilities of employer/service to provide support in meeting the goals set in the development plan. supervision, appraisal and reflective Recognition of importance of supervision and reflective practice and ability to integrate both into everyday practice. practice. Ability to be proactive in seeking opportunities for personal supervision, personal development and learning. Ability to identify and reflect on areas of practice where things have gone well, and where things have not gone well, to articulate the reasons why, and to identify and apply learning from these experiences in future working practice Understanding responsibility for continuous learning to reflect development and innovations in practice. A competency framework for all those working with people with mental health problems in London 45

46 Part three Applying part three competencies in practice How do part three competencies support implementation of the core pathway and London mental health models of care? Fundamentally, the competencies, pathway and models of care are all based on approaches that are about promoting recovery, seeing individuals holistically, and engaging people as active partners and participants in their own support, care and treatment. In addition the importance of families, friends and carers, and of their involvement in people s recovery, is recognised in these approaches, as well as the specific needs of carers themselves. All ten of the part three competencies underpin the effective implementation of the pathway. The competencies do not map directly onto one or more specific functions in the pathway, rather they are all essential to the provision of high quality support, care and treatment across the entire pathway. The examples of evidence show some of the specific ways in which the competencies are likely to support effective, high quality implementation of the models of care and core pathway. 46 London Health Programmes

47 References References Acknowledgements and thanks Thanks are due to The Office for Public Management (OPM) who produced this competency framework on behalf of London Health Programmes and NHS London. Thanks go to everyone who helped to develop this competency framework through taking part in interviews, focus groups and workshops, and contributing comments on various drafts. Particular thanks are due to the relatives, carers and people with direct experience of using mental health services, many of whom shared very moving and personal information about their experiences. Their insights and firsthand accounts were invaluable in shaping this framework. We greatly appreciate the support of the charities Mind, Bipolar UK, and Rethink Mental Illness in helping to recruit participants to the focus groups and interviews. We are also grateful to the many professionals who generously gave their time and expertise to support the framework s development. Views and experiences Throughout the process of developing this competency framework people with direct experience of using mental health services and those involved in delivering services generously shared their thoughts and experiences. A selection of these have been included throughout the document. It was not possible to include all the contributions in the body of the document. We felt the comments raised important issues and have therefore included them in Appendix 4. A competency framework for all those working with people with mental health problems in London 47

48 Appendix 1 Appendix1: Terminology used in this competency framework Throughout this competency framework, we use the same terminology as that used in developing the London mental health models of care: Mental health problem - in line with the government mental health strategy, in most circumstances, this document uses the phrase mental health problem as an umbrella term to describe the full range of mental illnesses and disorders, including personality disorder. When quoting other documents or when other terminology is in common use, the document will reflect those differences. Mental health problems may be more or less common, may be acute or longer lasting and may vary in severity. They manifest themselves in different ways at different ages. Some people object to the use of terms such as mental health problems on the grounds that they medicalise ways of thinking and feeling and do not acknowledge the many factors which can prevent people reaching their potential. We recognise those concerns and the stigma attached to mental ill health, however there is no universally acceptable terminology that we can use as an alternative. Mental health crisis - a broad definition of crisis has been adopted: adults who are experiencing a period of acute psychological distress or disturbance, associated with a mental health problem (which may or may not have been given a formal diagnosis). The crisis may be a sudden deterioration of an existing mental health problem or they may be experiencing mental health problems for the first time. They need immediate treatment and/or care and/or support to prevent further damage to their mental wellbeing. Long term mental health conditions - encompasses the likely diagnoses of schizophrenia, bipolar disorder, schizoaffective disorder, recurrent depression, and chronic neurotic, stress related and somatoform disorders. It was decided to name this group long term mental health conditions as there are important parallels to the group with long term physical conditions and it should help to resonate with primary care teams and to integrate it into more business as usual for primary care. 48 London Health Programmes

49 Appendix 2: Related competency frameworks Appendix 2 The Capable Practitioner Framework (CPF) This was published in 2001 by the Sainsbury Centre for Mental Health. It describes the inputs, knowledge, skills and attitudes considered necessary to become a capable practitioner working within mental health. It sets out five domains: ethical practice; knowledge; process of care; interventions, and applications to specific service settings. All staff are expected to follow ethical practice, but there is increasing specialisation as one progresses through the domains. It was originally published to support the National Service Framework (NSF) for Mental Health. NHS Knowledge and Skills Framework (NHS KSF) The NHS Knowledge and Skills Framework (KSF) was published in 2004 by the Department of Health, and sets out the knowledge and skills required to perform job roles within the NHS. It is intended to apply to everyone working in the NHS. It is divided into 30 dimensions: six core dimensions that apply to everyone in the NHS, and 24 specific dimensions that each apply to some jobs and not others. specific dimensions are grouped under four themes: health and well being; estates and facilities; information and knowledge, and general. Each dimension has four levels, with level descriptors for each competency to describe how knowledge, skills and behaviour should be applied at that level. The NHS KSF is specific to the NHS, but it is not mental health specific. It is widely used in the NHS, especially in developing job descriptions. The National Occupational Standards for Mental Health (MH NOS) These were developed in 2004 and set out detailed competencies required in providing mental health services. They were largely intended to support the use of the NHS KSF i.e. by providing the detail and evidence that a practitioner is demonstrating and achieving a particular NHS KSF dimension. They are aimed at all staff working in mental health services. However, as they are also intended to support the NHS KSF, they are more likely to be used within NHS services, than in social care or the voluntary sector. The core dimensions are: communication; personal and people development; health, safety and security; service improvement; quality, and equality and diversity. The A competency framework for all those working with people with mental health problems in London 49

50 Appendix 2 The MH NOS are grouped into three key areas: Operating within an ethical framework (Standard A) Working with and supporting individuals, carers and families (Standards B to J) Influencing and supporting communities, organisations, agencies and services (Standards K to O) Closing the Gap This is a capability framework for working effectively with people with combined mental health and substance use problems (dual diagnosis). It is intended for all staff who come into contact with this service user group in a range of settings. It was published in 2006, with funding from the Department of Health and other partners. Capabilities for Inclusive Practice Standard A is expected to apply to all staff, with the other standards applying to specific staff and/or teams, depending on their roles and functions. The MH NOS are intended to provide a measurement of performance. It is expected that the knowledge, skills and behaviours set out in the MH NOS should be developed as part of pre-qualification training, post-qualification training, and continuing professional development (CPD). This was published in 2007 by the Department of Health in collaboration with a wide range of partners. It is a capability framework for socially inclusive good practice for those working with mental health service users, and is structured around the ten Essential Shared Capabilities. The Ten Essential Shared Capabilities (ESC) These were developed jointly in 2004 by the Sainsbury Centre for Mental Health, the National Institute for Mental Health in England, and the NHS University (NHSU). They provide a framework for the whole mental health workforce, and therefore apply to everyone working with people with mental health problems, and not just to the NHS or statutory services. They specifically aim to set out shared capabilities that all staff working in mental health should achieve, irrespective of whether they hold a professional qualification, and of the sector in which they work. 50 London Health Programmes

51 Appendix 3: Policy context and drivers of change Appendix 3 The key policies and developments that are driving changes in services and support for people with mental health problems are summarised here. Government mental health strategy The 2011 mental health strategy No health without mental health highlights the importance of mental wellbeing that is holistic and outcomes focussed as opposed to solely medical. Priorities include increasing the availability of psychological therapies for people with severe mental illness, and a focus on high quality mental health services accompanied by national indicators to judge progress. Personalisation and person-centred care There is growing recognition that people with mental health problems should have greater choice and control in the support they receive, and should be centrally involved in identifying their own needs, and in planning care, treatment and support that meets their specific needs and preferences. Policies to support personalisation mean that an increasingly wide range of organisations will become involved in providing tailored support and services to people with mental health problems. However, some studies suggest that staff attitudes can still be a hindrance to achievement of personalisation for people with mental health problems. Recovery There are many definitions of recovery in mental health, but in essence it is about taking a holistic approach that focuses on recovering a meaningful life rather than on cure or elimination of symptoms. Hope and optimism are central guiding principles. Recovery is seen as a process, not an end point, and is about building resilience. Strong systems of support from family, friends and professionals are important elements, and people from a very wide range of groups and services may be involved in supporting a person s recovery. Recoverybased approaches are becoming increasingly central to the way mental health services are commissioned, designed and operate. Inclusion Many people with mental health problems lack equal access to opportunities including paid employment, volunteering, housing, education, financial services, and social participation; such exclusion can lower self esteem. Improving opportunities can enhance recovery, bring hope, and reduce dependence as people are able to contribute to society. Understanding and promoting inclusive practice is important for everyone working with people with mental health problems: Capabilities for Inclusive Practice points out that practicing inclusivity is everyone s job and some staff may have a particularly strong focus on particular inclusive goals. A competency framework for all those working with people with mental health problems in London 51

52 Appendix 3 Self management and self care The principles of self management and self care are about supporting and encouraging people with long term conditions to take greater control, and also greater responsibility, for their own care. Again, the ethos is holistic, and includes supporting people to learn about techniques and approaches for managing specific conditions, and the potential impact of lifestyle choices and changes. Accredited self management courses are usually run by specialist charities or the NHS, for example Bipolar UK runs self management courses based on evidence of what works, and delivered by accredited trainers with personal experience of the condition. Self management can help people gain the skills, understanding and confidence to better manage their own condition. For people with mental health problems, this includes learning to recognise the early signs of a potential decline or crisis, and developing strategies to minimise the impact. In addition to courses, self management can also be promoted through other mechanisms such as support groups, peer support, workbooks, etc. skills and practices to people with specific long term conditions (the self management programme, SMP) and to clinicians (the advanced development programme, ADP). Both programmes are co-facilitated by someone who is successfully managing their long term condition and a clinician, and focus on three enablers: goal setting, shared agenda setting and goal follow up. Sites are supported to improve the way their services are designed and operated to better support self management. The evaluation found that for people with long term conditions there were statistically significant changes in positive engagement in life, adopting a more constructive attitude and approach to their condition, having more positive emotional well being and using self management skills and techniques. In addition clinicians completing the ADP commonly report an increased motivation to improve their practice and greater belief that improvement is possible, increased job satisfaction, and a greater sense that they are now helping people in a way that reflects why they came into healthcare. Social prescribing or community referral Co-creating health This is a self management demonstration programme, funded by the Health Foundation. It aims at enabling people with various long term conditions, including depression, to improve their health and have a better quality of life through taking a more active role in their own care. In phase one ( ) eight sites received 150k and a package of integrated support; following evaluation phase two ( ) focuses on sustaining and spreading the approach. Based on evidence of what works in enabling self management, the programme teaches This is a mechanism for health professionals to link people with mental health problems with non-medical sources of support within the community, with the aim of improving their mental health and wellbeing. Social prescribing is usually delivered through primary care, e.g. through exercise on prescription, prescription for learning, or art on prescription schemes, although there are a range of models and schemes in different areas. Social prescribing can enable people to access opportunities for arts and crafts, physical exercise, learning new skills, volunteering, and to access support in relation to employment, benefits, 52 London Health Programmes

53 debt, housing, education, legal issues or parenting problems. Social prescribing for mental health provides a framework for developing alternative responses to mental distress, while recognising the impact of social, economic, environmental and cultural factors on mental health and wellbeing. It can also be a mechanism to improve access to mainstream services and opportunities for people with long term mental health conditions. Social prescribing can be used in addition to, or as an alternative to, medication and psychological approaches to care, treatment and support for people with mental health problems. In addition, social prescribing can be used to prescribe respite breaks or other support for carers. The Care Programme Approach (CPA) This is intended to provide a high degree of support to people diagnosed with a severe mental health problem, or who are at risk of suicide, harm to self to others, or have a wide range of needs or are vulnerable. It is also available to people who have recently been detained under the Mental Health Act, or have parenting responsibilities, or a history of violence or self harm. Under the CPA, a person with mental health problems is given a named care co-ordinator. The person should be involved in the assessment of their own needs, and the development of a written care plan, including outlines of any risks and what should be done in a crisis or emergency. They should be informed about choices available, and treated with dignity and respect. The care co-ordinator should co-ordinate the assessment and planning process, ensuring the care plan is reviewed regularly, at least once a year. CPA is supposed to be an example of personalisation in care of people with mental health problems, but in practice there is still variation in the quality of implementation. Navigators and Peer Supporters Navigators help people navigate their way through the complex myriad of health, social care, welfare and voluntary sector systems and services available, so that people can access the kinds of advice and support that best meet their needs. Navigators need some understanding of mental health conditions and services, and to be familiar with what is available locally to reflect the diversity of the local population. Crucially, they work across sector boundaries to identify and harness the best support for any individual. Thus they may be involved in helping people find accommodation, employment, education or training, access benefits, or identify social and leisure opportunities. Peer supporters are people with direct experience of using mental health services who are recruited and trained as paid staff or volunteers to provide some or all of these kinds of support. There is increasing interest in the potential of navigators and peer supporters to support people with mental health problems, and these roles are seen as crucial to the successful implementation of the models of care. Experts by Experience This refers to people who have insight and understanding of services gained from their experiences as patients or service users. Experts by experience are recruited and deployed in a number of ways, such as being involved in service design, development, evaluation or inspection, or participating in oversight or advisory bodies. The Care Quality Commission (CQC) is increasingly including experts by experience in service inspections, as part of a team alongside professional inspectors. Within CQC inspections, experts by experience pay Appendix 3 A competency framework for all those working with people with mental health problems in London 53

54 Appendix 3 particular attention to hearing the views of current service users. Experts by experience are likely to play an increasing role in the development and evaluation of services for people with mental health problems in London, thus increasingly staff will need to understand how best to work with, deploy and support mental health experts by experience. Personal Health Budgets (PHBs) These are another initiative aimed at giving people more control over their services, care and support, as part of a personalised approach to public services. Between 2009 and 2012 PHBs are being piloted in around 70 areas across England, with an independent evaluation due in October Around a third of pilots - including some in London - are testing PHBs to meet needs of people with mental health problems. PHBs can be used in flexible, innovative ways to meet agreed health outcomes, including for care and services not provided by the NHS. Each person must have a written care plan (sometimes called a support plan), stating their health and wellbeing needs, intended health and wellbeing outcomes, the amount of money in their PHB and how it will be spent. This must be agreed by the lead clinician and lead commissioner, or a panel which includes these two people and others on the basis of being financially and clinically appropriate. The aim is to involve people as equal partners in planning and choosing their own care and treatment. Some people are using PHBs to meet needs traditionally classed by the NHS and local authorities as social needs e.g. to undertake classes, go swimming, or enable social interactions. People can use PHBs to shop around and choose their own provider (e.g. a counsellor) rather than just taking one allocated by the NHS. PHBs do not cover core GP services or emergency care. Subject to successful evaluation, PHBs will be rolled out across England by April 2014 for everyone eligible for NHS continuing healthcare (i.e. care provided outside hospital for people with complex medical conditions, or requiring highly specialist nursing care). Any Qualified Provider (AQP) This government policy is designed to give people a choice of providers and services to meet their health needs, rather than simply having one NHS service available in their area. The AQP scheme started in April 2012, but is initially limited to specific conditions in specific PCT areas. For example, people are offered a range of approved psychological therapy providers in some parts of the country, but not yet in London. Services remain free with access based on clinical need, just as they are when provided directly by the NHS. As this policy is extended, a wider range of approved providers including NHS, independent sector, charities and social enterprises will be involved in delivering NHS services. Local commissioners will control contracts and prices, and providers will need to go through a qualification process and be approved. The government wants people using secondary mental health services to have more choice. It has proposed that by April 2013 all service users should be able to choose any named consultant-led team within their secondary mental health provider, as well as any mental health services within their secondary mental health provider run by other professionals such as mental health nurses, occupational therapists or clinical psychologists. 54 London Health Programmes

55 Quality and Outcomes Framework (QOF) This is an annual incentive programme for GP surgeries in England, to resource and reward good practice. The QOF consists of four domains: clinical, organisational, patient experience, and additional services. Each domain contains a set of indicators; GP practices score points based on their achievement against each indicator. Higher scores result in higher financial rewards, with the final payment adjusted to take account of practice list size and prevalence. The QOF is updated periodically, and includes a number of indicators for mental health - relating to recordkeeping and management of patients with specific mental health diagnoses - and for depression. Commissioning for Quality and Innovation (CQUIN) payment framework CQUIN was introduced in 2009, and enables commissioners to reward excellence by linking a proportion of healthcare providers income to achievement of quality improvement goals. These goals are agreed locally between commissioners and providers annually, and written into contracts. Providers of acute services, ambulance, community, mental health and learning disability services using national contracts are expected to have a full CQUIN scheme in order to earn CQUIN money. The CQUIN framework is intended to help embed a culture of continuous improvement in NHS services. The CQUIN framework also covers independent sector providers on national standard NHS contracts. NICE guidelines The National Institute for Health and Clinical Excellence has produced over 100 guidelines on the care and treatment of various mental health disorders. All commissioners, providers and GPs should be aware of them, and should be aiming to apply the guidelines and achieve the standards they set out. NICE guidelines are also useful for patients, service users and the public to understand what standards of care and treatment they should be able to expect. The main NICE guidelines relating to mental health include: Common mental health disorders: identification and pathways to care (2011). CG123 Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (2011) guidance/cg115 Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults (2011). guidance/cg113 Depression in adults with a chronic physical health problem: treatment and management (2009). guidance/cg91 Depression: the treatment and management of depression in adults (2009). Appendix 3 Promoting mental wellbeing through productive and healthy working conditions: guidance for employers (2009). A competency framework for all those working with people with mental health problems in London 55

56 Appendix 3 Drug misuse: psychosocial interventions (2007) Drug misuse: opioid detoxification (2007). Antenatal and postnatal mental health (2007) Computerised cognitive behaviour therapy for depression and anxiety (2006). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (2005). org.uk/guidance/cg31 Post-traumatic stress disorder (PTSD): the management of PTSD in adults and children in primary and secondary care (2005). Quality standard on depression in adults: guidance/qualitystandards/ depressioninadults/home.jsp NICE Pathway on depression: pathways.nice.org.uk/pathways/ depression A NICE clinical guideline on social anxiety disorder is under development and due in For the full list of NICE guidelines relevant to mental health, see Quality, Innovation, Productivity and Prevention (QIPP) programme This major transformation programme is about driving forward quality and productivity improvements across the NHS, to achieve 20 billion efficiency savings by The Department of Health has set up a number of QIPP workstreams in the three broad areas of: commissioning and pathways; provider efficiency, and system enablers (covering primary care commissioning). There is a specific workstream on long term conditions, one aimed at ensuring people get the right care in the right place at the right time, and another on urgent care and reducing accident and emergency attendance. Improving Access to Psychological Therapies (IAPT) This programme was introduced in 2008 by the Department of Health to support implementation of NICE guidelines for people suffering from depression and anxiety disorders. It was created to offer people a realistic and routine first-line treatment combined, where appropriate, with medication, which traditionally had been the only treatment available. Initially, the programme focused on offering cognitive behavioural therapy (CBT), but is widening, with therapists being trained so they can offer other NICE recommended therapies and counselling (e.g. couples therapy for depression). Since 2011 the focus of the IAPT programme has broadened, following publication of Talking therapies: a four-year plan of action. The government s intention is that by 2014, all services will have sufficient capacity to offer psychological therapies to at least 15% of people in their communities with depression and/or anxiety. Between 56 London Health Programmes

57 2011 and 2015, an additional 400m is being invested, and will support: Completion of the nationwide roll-out of psychological therapy services for adults across England Extension of evidence-based psychological therapies to children and young people through a stand-alone programme Extension of IAPT to people with long-term physical health problems, medically unexplained symptoms and severe mental illness. Payment by Results (PbR) PbR is a payment system under which NHS commissioners pay health care providers for each person seen or treated, taking into account the complexity of the patient s needs. PbR is intended to improve efficiency, support patient choice, and incentivise best practice models of care. PbR was first introduced for acute hospital care, with national tariffs being set for admitted patient care, outpatient attendances, A&E, and some outpatient procedures. The government is in the process of introducing PbR for adult mental health services from 2012/13. Preparation has involved identifying care clusters in mental health (based on care pathways) as the currency (unit of service activity that is clinically meaningful and has relatively stable costs); then identifying a tariff (price) for each care cluster. Tariffs will be agreed locally between commissioners and providers for mental health, not set nationally. In future, users of adult mental health services will be allocated to a cluster, and packages of care will be defined for each cluster. Commissioning reforms and Clinical Commissioning Groups (CCGs) Under the Health and Social Care Act 2012, primary care trusts will cease to exist and from April 2013, GP-led clinical commissioning groups will become responsible for commissioning the majority of NHS services worth around 60bn, including elective hospital care, rehabilitation, urgent and emergency care, most community health services, mental health and learning disability services. All GP practices will have to be members of a CCG, formed on a geographical basis. In addition to GPs, CCGs governing bodies must include at least one registered nurse, at least one secondary care specialist doctor, and at least two lay people. CCGs will work in partnership with local communities and local authorities including health and wellbeing boards (see below) and must engage with healthcare professionals, patients and the public. They will be accountable to the new national NHS Commissioning Board, and will be scrutinised locally by health and wellbeing boards. Health and Wellbeing Boards (HWBs) These are a key part of the government s healthcare reforms aimed at ensuring stronger democratic legitimacy and involvement, strengthening working relationships between health and social care, and encouraging the development of more integrated commissioning of services. Each top tier and unitary local authority will have a HWB, operating in shadow form during 2012/13 and fully from April HWBs must have a minimum membership of one local elected representative, a local HealthWatch representative, a representative of each local clinical commissioning group, the local authority director of adult social Appendix 3 A competency framework for all those working with people with mental health problems in London 57

58 Appendix 3 services, the local authority director of children s services and the local authority director of public health. In addition, they may expand membership to include other perspectives and expertise, for example through inclusion of charity and voluntary sector representatives. HWBs are expected to engage with local communities and ensure the needs of local people as a whole are taking into account. HWBs will have strategic influence over commissioning decisions about health, public health and social care. They are expected to strengthen democratic legitimacy by involving elected representatives and patient representatives in commissioning decisions, and provide a forum for challenge, discussion and the involvement of local people. They will bring clinical commissioning groups and local authorities together to develop a shared understanding of the health and wellbeing needs of their communities, undertake Joint Strategic Needs Assessments (JSNAs), and develop joint strategies for how these needs can best be addressed, including recommendations for joint commissioning and integration of services. They will have a statutory duty to involve local people in the development of the JSNA, and joint health and wellbeing strategies. HWBs will therefore have a central role to play in improving local populations health and mental wellbeing, and reducing health inequalities. 58 London Health Programmes

59 Appendix 4: views of people with direct experience of using services and those involved in providing services. Appendix 4 What people told us: People with direct experience of using mental health services told us: People said that going to accident and emergency was often seen as the default option for people in mental health crisis, but is not always the best option: We are not a different species all we are asking for is some humanity and some common sense. We are very sensitive to nuance, to what the GP or care worker says. If they are brusque, it can really be difficult or damaging to us. It can undermine trust. At A&E you may not be taken seriously, even when you are having a crisis. I was told by the community mental health team to go to A&E. I was put in a room in the hospital for nine hours, with just a nurse popping in every now and again. It just adds to a disturbed mind. GPs don t always signpost to ancillary services; their knowledge is lacking e.g. of what is available in the local voluntary sector. They should inform the person and their carers of these things. People told of the importance of access to non-medical forms of support, during a mental health crisis: Please provide access to physical activity. At [private hospital] there s yoga, swimming, etc. but nothing at [NHS hospital]. When you re anxious it s good to exercise, to help reduce your anxiety! Physical activity and group activity, rather than just prescribing drugs. Promoting healthy lifestyles e.g. foods, what to avoid. Should include in-patients in this advice too. Lifestylebased support need more of this. A competency framework for all those working with people with mental health problems in London 59

60 Appendix 4 Professionals told us: Some spoke of the need for maturity, sensitivity, and judgement when working with people in mental health crisis. Professionals spoke of the importance of working in ways that empower people with mental health problems, supporting them to be active participants, rather than passive recipients, of treatment and care: Improved communication between services and teams would make the most difference knowing more about each other, roles and strengths, listening to the other teams. Being more open to the views, skills and approaches of others in the system. Any qualified provider will make the interfaces between services and teams even more complex, so care navigator roles or at least the skills and willingness are particularly key. Many professionals highlighted the wide diversity of cultures within London, and the importance of taking culturally sensitive and individualised approaches to people with mental health problems from different backgrounds. The need for staff working with people with mental health problems to understand the social determinants of health and the impact these can have on people with mental health problems. Knowing how to work collaboratively, in partnership with the service user, and empower them to foster self-care. Help people be expert in their own conditions; provide training for them. There is a need for greater understanding of relevant legislation, such as the Mental Capacity Act and Deprivation of Liberty Safeguards: Even if people are detained and lack some capacity, shouldn t assume they can t make any decisions even if these are small at first. Recognise that fragmented care (e.g. through lack of communication, lack of appropriate information sharing, delays in referral/transfer of care, etc.) can have a detrimental effect on service users quality of experience, quality of care, and faith in services and systems Need to understand the other factors that can impact on a person s mental health, for example relationship difficulties, financial pressures, employment and work-related pressures. Need for more skills and training on maintaining factors, and practical problems such as housing and finances. 60 London Health Programmes

61 Appendix 4 A competency framework for all those working with people with mental health problems in London 61