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CHAPTER FOUR: CONCLUSIONS AND RECOMMENDATIONS
Key Issues raised by the evaluation
Potential of the tool as facilitator for change
4.1 The purpose of this evaluation was to explore the extent to which the SRI enables practitioners and managers to apply the factors that promote equality, social inclusion and recovery for individuals to support system-level change.
4.2 The SRI appears to have good potential to influence change, at the individual and individual service levels. The pilot has demonstrated how the SRI results can challenge service cultures and point to changes that can be made to promote a stronger recovery orientation. The tool allows service providers the opportunity to test out their assumptions about what service users know, what they want and what they are getting from a service or an intervention. It is not yet clear whether the SRI can influence system-level change, as no pilot sites had reached a stage where they had fed back to strategic planning groups and management.
4.3 Administering the SRI was time-consuming but participants accepted that the resource input was necessary and worthwhile especially when the SRI was part of a development process. A key strength of the SRI was found to be in its level of detail, which made it possible to pinpoint both areas of good practice and areas for improvement, which provided a structure for identifying what should change and how.
4.4 Although considered to be very relevant by most evaluation participants, the SRI requires a thorough review to improve the clarity, quality and comprehensiveness of the content and to prepare guidelines for administration. This would include indicating recommended approaches to issues that proved problematic in the evaluation, e.g. sampling and confidentiality, as well as highlighting where local areas have scope to determine for themselves how best to implement the tool. The balance between standardisation and flexibility requires further consideration.
4.5 Despite the limited time available for the evaluation and the consequent cut-off of data collection between the feedback and action-planning stages of the SRI development process, participants were able to evidence changes already put in place and to highlight key areas that they anticipated would feature in their action plans.
4.6 The range of action points raised by SRI was broad with a high level of commonality across pilot sites and areas. The kinds of actions identified were very much focused on activities that would promote social inclusion, equality and recovery ranging from changing to strengths-based care documentation and procedures, to addressing the issue of ensuring equal employment opportunities for people with mental health problems.
4.7 The SRI seemed to link in well to current service development plans and recovery initiatives within local areas. The SRI enhanced local efforts to improve services by further developing local participants' insights into the recovery, equalities and inclusion agendas. The SRI also fits with the ethos of leading change by promoting and enhancing the ability of practitioners and managers to make changes from below with support and buy-in from above, guided by the views and experiences of service users.
4.8 The multi-disciplinary approach demanded by the SRI development process reinforces the value of the SRI process as much as its output. The process envisaged for the SRI incorporates many of the key principles of effective change management, including:
- Stakeholder engagement
- Top down and bottom up approaches
- Working with multiple perspectives
- Creating opportunity to recognise areas of strengths in services and the service system
- Identifying areas where improvement is needed and planning actions to address these
The SRI as a measure of change
4.9 As there was no re-administration of the SRI within the timescales of the evaluation, the utility of the SRI as a measure of change could not be tested. However, most pilot sites expressed an intention to re-administer the SRI within a year, with the belief that they will be able to measure and demonstrate improvements in their practice.
Completeness and relevance of the SRI
4.10 The SRI was considered by most participants to be sensitive to the recovery, equality and social inclusion needs of the individuals and groups who use the range of services to which the tool was applied.
4.11 Service users in particular felt that it covered the aspects of their care that were important to their recovery. Service providers found the tool provided clarity for them on the components necessary to make up a recovery-focused service, and how well they incorporated these into their everyday practice.
4.12 The SRI pilot also demonstrated its potential to be useful as a tool that can establish the extent to which those working in the pilot sites were identifying and addressing inequalities. However, given that this is a central aim of the SRI, evaluation participants, particularly those in the pilot area that focused on the inequalities agenda, were not completely convinced of the SRI's contribution to this. There may be a need for further work to develop the SRI's potential on this.
Added benefit gained from being involved in the SRI process
4.13 Participation in the SRI pilot brought with it a number of added benefits, including:
- Creating a sense amongst the service users that the SRI places them at the centre of any change processes
- Allowing those working in services to focus completely on recovery as a main issue rather than a bolt on to other development agendas
- Embedding recovery concepts and language into everyday practice and communication
- Improved communication between service users and service providers as well as between different professions
- Beneficial to team-working through group discussions of SRI administration, planning and results
- Service users who took part found the experience motivational in terms of moving forward in their own recovery journeys
- Increasing service users' awareness of the services available to them
- Activities such as audits of patient information and policies are rarely conducted; the SRI highlighted shortcomings and new ways to think about delivering information that meets needs
- Increased service users' sense of peer support from sharing recovery stories
- Provides service users with an opportunity to give their views on services
- Providing a values-based framework within which to assess how the service system facilitates recovery, by encompassing policy, services and practice.
Recommendations for the development and roll-out of SRI
4.14 This final section of the evaluation report includes a set of recommendations for the future development and roll-out of the SRI.
Inclusive approach to developing and rolling out the SRI
4.15 Individuals involved in piloting the SRI as administrators and interviewees should be invited to assist with the re-drafting of the SRI, both directly as members of the re-drafting group and to provide comments on the revised SRI.
4.16 It also recommended that a support and learning network be developed, for those who have used or will be using the SRI.
4.17 It would also be useful to give further consideration to how SRI fits with other initiatives to promote a recovery-orientation locally and nationally, to avoid confusion and promote synergy.
Factors necessary for the successful use of SRI
4.18 The evaluation has identified a number of factors necessary for the successful use of the SRI as part of a development process.
Services SRI should be used in
4.19 The pilot demonstrated that the SRI can and should be used locally within all mental health services (statutory and non-statutory), although some work is required to make the tool less health or medically-focused.
4.20 To gain a more accurate picture of whether service users are being provided with a recovery-focused and inclusive service, it will be important to use the SRI across different service types within a service system; from primary care and specialist community teams, to wards, and not only within the individual services. This should include voluntary organisations too, as their role often fulfils key delivery of mental health services.
Achieving organisational buy-in
4.21 Strong strategic commitment to the SRI will encourage participation from service providers and service users. Creating clear lines of accountability and/or formal approaches to the use of SRI is a helpful way to achieve buy-in. This might take the form of national level DfMH documentation, the SRI being built in to local strategies on recovery and operational procedures or supporting information to set the SRI in current local and national development initiative, policy and knowledge contexts. However, more formalised approaches to the use of the SRI may lead to it being a source of information for performance management which could compromise the positive and developmental ethos that evaluation participants valued so much.
4.22 Another key factor to achieving and sustaining buy-in is a local project manager with time to champion the SRI (and recovery) and be close to the process, providing 'hands-on' support. This needs to be coupled with a non-judgemental and supportive ethos that emphasises SRI as a development process and not an audit, and engender trust amongst participants and those who use, manage and plan the service(s)
Flexibility in application
4.23 The pilot has also revealed that the SRI is flexible enough to be used in a number of different ways, from a benchmarking tool or an impact-assessment tool for new services, to a reference for everyday supervision. The SRI was intended to assess the extent to which organisations and services meet the expectations of DfMH. The pilot has demonstrated that the real value of the SRI is a locality and service-based development tool. How the tool is used in the long term and how often may be better dictated by local development needs rather than prescribed nationally.
Improved preparation
4.24 Preparation days should be improved to:
- Increase time available to cover the extensive ground
- Build in the flexibility required to be responsive to the needs of different individuals
- Include more on the background and evidence behind the recovery concept and the language of recovery
- Include the practicalities of the administration process including teaching of sampling and data collection skills
4.25 In addition, SRI should be supported by local recovery-awareness sessions prior to the administration, to assist with language and preparation for interviews for professionals and service users. It proved invaluable for local areas to have access to central advice and information on the implementation of the SRI, and that this should be carried forward.
A team-based approach to administration
4.26 Consideration should be given to using different people to administer different parts of the SRI, e.g. a non-service based manager for Part 3 and a service user for Part 5, or the Leading Change team. It was also helpful for more than one administrator to be involved in each tool, creating a peer-support system.
Service user involvement
4.27 Service users should be involved in a number of ways including as interview participants, administrators, scorers and action planners. Consideration should be given to paying service users for their involvement in the SRI development process, especially as administrators, scorers and action planners.
4.28 The service user interviews should be:
- Supported by provision of information on the purpose and content of SRI and implications of participation prior to the interview
- Less than one hour long (but may require more than one session)
- Held in a group setting (converse to many professionals' views)
- Conducted by an interviewer with whom service users are familiar
- Open to a carer or representative
- Supportive of practical needs of interviewees including transport, interpreter, childcare and expenses
- Held in a flexible and familiar environment
Service-provider involvement
4.29 Service-provider interviews should be:
- Supported by provision of information on the purpose and content of SRI and implications of participation prior to the interview
- Recruited for through an open invitation to participate
- Held with multi-disciplinary teams with management representation
- More than one hour long
- Supported by release from duties to attend or added on to team meetings
Scoring
4.30 Scoring should be undertaken as a group effort soon after administration so that the findings are fresh in administrators' minds. Additional notes in the SRI should be made at administration and consulted during SRI scoring, allowing further investigation or follow-up of issues as required.
Support with the completion of the change cycle
4.31 There is likely to be value in providing forums for those leading SRI locally to network and exchange experiences, not only in relation to SRI administration, but more importantly in relation to service and system change (see Figure 1.1). Existing support programmes may provide mechanisms to facilitate this.
Improved guidelines for the administration process
4.32 To address the inconsistencies and uncertainty in approach to the administration process guidelines for the administration process should cover:
- Confidentiality on recording data anonymously, clearing administrators for access, i.e. some form of contract with NHS
- Standard information sheets for service users and providers
- Sampling guidance, size and criteria for sampling frame
- Guidance on what specific type of patient data should be included, whilst broadening language
- The type of documentation that should be included in Part 3
Improved guidelines on feedback and action planning
4.33 A feedback report template should be produced, incorporating key aspects of the detail of the SRI results. This should include guidance on qualitative or narrative feedback to complement score sheets. An action- planning report template should also be produced.
4.34 It may be useful to consider producing different report templates for feedback to service-level staff, service managers, strategic managers and groups and service users and their carers.
Improved guidance on scoring
4.35 Detailed guidance on scoring needs to be developed to avoid the inconsistencies in approach and confusion experienced in the pilot.
Improvement to the content of SRI
4.36 The rewriting of the SRI was identified by participants as key to ensuring the SRI is accessible and inclusive to all services and individuals. The detailed evaluation information included in the results section of this report should be used as a guide to revising the content of specific questions and each whole part of the SRI. Sections 4 and 5 in particular need to be simplified and reviewed to eradicate any duplication.
4.37 A crucial aspect of the revision of the SRI content should be adaptations to enable wider service-setting applicability of SRI. The language should be less healthcare-focused and more generic to enable those in non-healthcare services to use the SRI.
Addressing key challenges and barriers to use of SRI
4.38 One key finding was of a common perception amongst interview and focus group participants of a lack of active involvement in and support for the SRI from psychiatrists. These participants acknowledged that psychiatry has a lot to contribute potentially to the SRI development process, and the need to commit further attention to involving this group in the future. A possible way to achieve this would be a top-down approach such as engaging the Royal College of Psychiatrists in the benefits and use of the SRI, building on the profession's existing commitment to the principles and values of recovery and its active participation in SRN.
4.40 It is important to challenge the persisting perception from some nursing professionals on acute wards, working with those under MHA and those with dementia, who consider that aspects of the recovery agenda such as occupation or shelter are not relevant to them and their service users.
4.41 Consideration should be given to engaging foreign language and hearing interpreters to assist administration of the SRI.
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