Section 2 The way forward
Early intervention and timely access for service users and carers
Experience across a range of health settings suggests that for some people, early access to services results in better outcomes. Developing systems to ensure timely access to AHPs for service users and carers, particularly during the transition from hospital care to the community, is therefore likely to result in outcomes that are both clinically and cost effective.
Despite this, service users and carers in the focus groups convened to support the development of this action plan said that AHP services are actually difficult for them to access. They spoke of the challenges of navigating complex systems and "having to jump through hoops" before getting to the professional they needed to see.
It should therefore be a key aspiration that services strive, wherever possible, to enable AHPs to facilitate access and deliver early interventions as close as possible to people's homes, promoting recovery and enabling individuals to self-manage their conditions.
Early AHP interventions that focus on physical and emotional health and well-being should form part of a recognised care pathway both for those with mild-to-moderate mental illness and those with severe and/or complex mental health problems, such as dementia. Current referral pathways tend to avoid direct referral to AHPs, instead taking a route via mental health teams. While this is a well-established referral route, additional evidence-based models of service provision to enable direct access for service users and carers to AHPs and increase treatment options for general practitioners ( GPs) should be developed.
AHP services need to be reconfigured to provide interventions in different locations and at different times.
This calls for:
- a review of the potential for triage
- development of fast-track access
- the use of technology, such as tele-health, to improve access, offer information and provide treatment for people currently not accessing services.
NHS boards should fully engage AHPs in leading the rehabilitation of people with mental health problems, developing new models, systems and ways of working to facilitate early intervention and timely access for service users and carers.
It is important to stress, however, that no profession has a monopoly of knowledge in mental health. Early interventions from mental health services work best for service users and carers where a strong team and partnership ethos exists and where team members respect each others' contributions, support each others' interventions and communicate effectively with colleagues in diverse settings and agencies. It will be vital for the successful transformation of the roles of AHPs in mental health, particularly in primary care settings, that they adopt an integrated, partnership approach to team working, developing new, whole-systems ways of working that can be implemented across service boundaries.
AHP mental health leads, working with AHP leads in community health partnerships ( CHPs), should promote an integrated approach to service delivery by encouraging collaborative working between primary care services and AHPs in mental health and by linking specialist, community and social care AHP teams to ensure integrated services and smooth transitions between services for service users and carers.
Supported self-management and recovery
Self-management is where:
"…the person and all appropriate individuals and services [are] working together to support him or her to deal with the very real implications of living their life with one or more long term condition ... [it is] a person-centred approach in which the individual is empowered and has ownership over the management of their life and conditions (8)."
Self-management is the responsibility of individuals, but it does not mean going it alone. It is about working together.
Successful self-management relies on people having access to the right information, education, support and services. It depends on a person-centred, empowering approach in which the individual is the leading partner in managing his or her own life and condition(s).
AHPs' contribution to self-management in mental health is underpinned by knowledge about health behaviour change. It consists of a range of approaches that support health-promoting behaviours, such as providing appropriate information, maintaining social connections, maximising employment and/or education opportunities and making connections between physical, emotional, spiritual, social and economic well-being.
This means respecting the lived experience, working with individual preferences and balancing risks so that the service user remains integrated within the community, is socially included and has a repertoire of knowledge and skills to self-manage his or her condition(s) and live well.
All services need to take advantage of existing and new approaches to communication technology to ensure people have access to the information and advice they need when they need it, and to support them to maintain their health, manage ill health and make decisions. NHS 24 has a key role in offering information to support self-management, delivering effective evidence-based triage and providing innovative tele-rehabilitation. It is currently developing a strategic approach to mental health that will involve contributions from AHPs, including the employment of an AHP Director, and will be reviewing the potential of AHPs in mental health in offering rehabilitation advice, tele-rehabilitation and triage.
The Scottish Government will support the implementation of a self-management approach by AHPs in mental health. Impact evaluation linked to national benchmarking indicators will be undertaken.
BOX 1 Scottish Recovery Indicator (SRI) tool (9)
This tool, developed by the Scottish Recovery Network, enables services to gauge their recovery focus in relation to a range of criteria, highlighting issues in relation to inclusion, rights, equalities and diversity. The tool requires information to be gathered from a variety of sources and for service users, carers and staff to be involved in assessing the service. Indications are that the SRI is a helpful tool that allows mental health workers to reflect on their practice, identify good practice within their own service and highlight areas for development. For more information, access: http://www.scottishrecoveryindicator.net/
The focus on recovery in mental health services involves supporting people to be active in managing their own health care and carrying out everyday activities, even in the face of ongoing symptoms.
Recovery is defined by the Scottish Recovery Network as an individual:
"... being able to live a meaningful and satisfying life as defined by each person, in the presence or absence of symptoms ... [and] having control over and input into [their] own life".1
The Scottish Recovery Indicator tool (Box 1) clarifies services' progress towards a recovery focus. It helps to identify the cultural and therapeutic environmental change required to foster a strengths-based approach in which hope, self-awareness, respect and understanding are the service norm, and not the exception.
The AHP community has embraced the principles of recovery. AHPs have worked with colleagues and agencies to develop recovery practice in NHS boards, sometimes taking the lead role in developing recovery services and creatively implementing recovery principles. This needs to be featured in all AHP practice in NHSScotland.
AHP services in mental health will use the Scottish Recovery Indicators tool as part of team approaches to service delivery to promote recovery-orientated services by June 2011.
Promoting physical health and mental well-being
Improving the physical health of people with mental illness is a key commitment for the Scottish Government and those delivering mental health services (10). Evidence demonstrates the link between physical activity and improved physical and mental health. The benefits of physical activity and keeping fit are also recognised by the National Institute for Health and Clinical Excellence ( NICE) (11) as a health improvement intervention in older people, and a recent Scottish Intercollegiate Guidelines Network ( SIGN) guideline (12) recommends physical activity as a first-line approach to tackling depression. There is also evidence for the benefit of physical activities and arts therapies as interventions for the treatment and management of schizophrenia in adults (13).
The Scottish Government, in partnership with NHS Health Scotland and NES, will complete by the end of 2010 a mapping exercise of health improvement activities in Scotland for those experiencing severe and enduring mental illness.
The focus is on smoking cessation, weight management and physical activity interventions and initiatives. AHPs in mental health will be integral to promoting health-related behaviours, including increasing physical activity and adopting healthy diets and lifestyles.
Patients with severe mental illness have disproportionately high levels of physical health problems such as diabetes, hypertension and coronary heart disease (14, 15). Premature mortality rates are 2.5 times higher than that of the general population, with the average age at death being 10-20 years younger. Physical health problems are likely to be related to modifiable lifestyle factors such as low physical activity, poor diet, substance misuse and smoking (16).
AHPs deploy psychological approaches to help people understand the connections between physical health and mental well-being. They use clinical skills such as health behaviour change and motivational interviewing to enable people to engage with physical activity opportunities. Some are trained in both physical and mental health care and can effectively manage the often complex presenting conditions in this population.
Focus groups with service-users confirm that being physically fit and active is important to them. Recent research, however, identifies potential barriers to the uptake of physical activity for service users experiencing schizophrenia and living in the community (17), including:
- limited experience of physical activity
- the impact of illness and medication effects
- anxiety and the influence of support networks.
Specialised, tailored AHP interventions can help service users and carers overcome the barriers they face, supporting gradual transition to, and uptake of, mainstream leisure, sport and outdoor services.
AHP mental health leads should ensure the provision of evidence-based, socially inclusive and accessible physical activity rehabilitation programmes for service users and carers.
" Music therapy helps me [to be] free and ... to express myself without having to talk. "
Service user : Experience of music therapy
Diet and nutrition
Good nutrition is central to physical and mental health and well-being and has a key role in prevention, treatment and recovery from mental illness.
Food affects mood, behaviour and brain function and the significance of diet in depression is becoming increasingly recognised (18). Some medicines used in the treatment of mental illness can adversely affect metabolism, appetite, food choice and swallowing function. There is an association between nutritional status and cognitive function in older people, exacerbated by the chewing and swallowing difficulties common in this age group.
AHPs have a vital role in assessing service users' eating behaviours and supporting them to improve nutritional intakes, often working together to provide education and practical advice (such as developing cooking skills and advising on diet modification for people with dysphagia, for instance). Regular detailed nutritional assessment with appropriate interventions is necessary.
AHP mental health leads should ensure regular nutritional screening is available to service users at each stage of their care journey, with nutritional services working closely with specialist AHPs.
Valuing everyday activities
There is a well-established relationship between occupation (everyday activities), health and well-being. Maintaining a personally satisfying routine of activities that have meaning and value for the individual provides structure to the day and creates a sense of purpose and direction. The need to be active does not diminish with age, but the common effects of physical and mental ill health can affect an individual's ability to participate in activities. If an individual experiences disruption to fulfilling daily routines, or has access to a limited range of activities, their overall physical and psychological health is likely to be affected.
AHPs have the relevant knowledge and skills to support people to become involved in a range of individually valued activities. AHPs assess and provide information and advice to support involvement in occupational, leisure and everyday activities that enhance health and well-being, using models of change to support any behavioural modifications required. They work with individuals to overcome physical, psychological, social and environmental barriers to participation.
The report Remember I'm still me (19) highlighted the lack of meaningful activities for residents of care homes, despite the fact that research has shown that engaging people with dementia in activities tailored to their capabilities, with carers trained in their application, results in clinically relevant benefits to both the people with dementia and their carers (20). Therapeutic activities ranked highest by service users are social and community participation, physical and creative activities and activities of daily living, the last of which emphasises the need for meaningful activity that is focused on everyday tasks (21).
AHP mental health leads should work with partners to promote and enhance the provision of evidence-based, socially inclusive and accessible therapeutic activity provision in a range of settings.
Socially inclusive practice
Wherever possible, delivery of physical health and mental well-being interventions should be carried out in line with social inclusion policy directives. There is strong evidence to support the value of enabling and supporting service users to access mainstream local facilities, strengthening their sense of community and reducing social isolation.
Much AHP work takes place in non-health facilities such as community and leisure centres. AHPs need to continue to build networks with third sector organisations to secure supportive pathways to social inclusion in the community for service users.
Designing and delivering psychological interventions
Psychological therapies 2 have been defined as:
"... a range of interventions, based on psychological concepts and theory, which are designed to help people understand and make changes to their thinking, behaviour and relationships in order to relieve distress and to improve functioning. The skills and competencies required to deliver these interventions effectively are acquired through training, and maintained through clinical supervision and practice" (22).
NHS Education for Scotland ( NES) has developed a "matrix" to guide the delivery of evidence-based psychological therapies in Scotland (22). The matrix recognises that the delivery of psychological therapies within NHS boards is complex. It defines therapies at "highly specialist", "high-intensity" and "low-intensity" level and emphasises that the interventions need not be delivered by a psychologist: indeed, the engagement of the whole of the mental health workforce in delivering psychological therapies will be necessary to achieve the delivery targets being set out in the "refresh" of Delivering for mental health (1).
The challenge for services is to utilise the AHP staffing resources at their disposal to deliver a range of evidence-based psychological interventions and to maximise AHPs' potential to promote better outcomes for service users and carers. The challenge for AHPs is to clearly articulate their contribution to delivering psychological interventions and actively engage in local psychological forums and strategy groups, working in partnership with NES psychological therapies coordinators.
AHPs' core psychosocial skills are unique to each profession and vary according to undergraduate education and postgraduate development activity. AHPs nevertheless contribute significantly to the national psychological therapies agenda by enabling service users and carers to have a choice of evidence-based, non-pharmacological therapies. AHPs can work at all levels of the psychological therapies matrix while continuing to provide specialist AHP rehabilitation interventions to promote health and well-being, integrating recognised psychological interventions 3 into their core practice and/or directly providing a psychological therapy. 4
Whatever the background of the AHP, a "best fit" should be found between service user and carer requirements and the skills and competencies of the AHP, ensuring service users maintain access to specialist AHP skills and interventions. The key issue is that any AHP who is delivering psychological therapies at any level should be properly trained and should have access to appropriate ongoing supervision.
NHS boards should ensure the delivery of evidence-based psychological interventions by appropriately trained AHPs to support rehabilitation, self-management and recovery approaches as part of local delivery strategies.
Continuing professional development ( CPD) opportunities in psychological therapies should reflect the core skills of the AHP profession and the clinical needs of the service as a whole. They can range from learning activity around brief interventions, to training on the implementation of a particular technique, to highly specialised programmes in specific therapeutic modalities. Theoretical CPD activity must be supported by work-based supervision and practice.
There is also a requirement for those who practice an accredited psychological therapy as a primary role to have supervision from an accredited psychological therapies supervisor, ensuring supervisory contracts and protected time are in place to support staff governance, clinical governance and effectiveness.
AHP mental health leads should ensure that AHPs in mental health who deliver psychological interventions as a primary role have access to clinical supervision within protected time.
Integrating vocational rehabilitation in mental health
Well-managed work opportunities can benefit personal and family health and play a positive role in supporting an individual to increase his or her sense of well-being. In the focus groups carried out as part of the consultation to inform the development of this action plan, service users and carers said that they look to AHPs to provide the support to enhance their work opportunities as means of promoting social engagement, achieving personal aspirations, raising self-esteem and social stature and providing financial security.
There are, however, many barriers to employment for people with mental health conditions. These include low expectations for work, exclusion from the wider community, stigma and the enduring effects of symptoms. Despite high proportions of people with a long-standing mental illness saying they would like to work, the proportion employed is low.
People with a mental health condition need to be enabled to access and sustain employment through coordinated, tailored support. The Government recommends a framework for change to the way individuals with mental health problems are supported to achieve their vocational potential.
It is not the remit of this action plan to propose the way forward for welfare to work: rather, the aim is to highlight the unique contribution AHPs in mental health can make to ensuring work is a positive outcome of rehabilitation, building on the strong strategic drive in mental health services to provide better opportunities for service users in employment and vocational activities.
Developments in promoting the contributions of AHPs in mental health to vocational rehabilitation will reflect and complement actions being taken forward under Co-ordinated, integrated and fit for purpose: the delivery framework for adult rehabilitation in Scotland (6) and specific initiatives being developed for people with long-term conditions and adolescents.
" [Using movement to look at some of the psychological trauma of her past] is the best thing that has ever happened to me. I used to just lie about on my couch, I wouldn't want to go out the house … I wouldn't get dressed, I wouldn't put my make-up on or do my hair ... then I got [a student dance-movement therapist] and she has changed my life … "
Service user : Experience of dance-movement psychotherapy
Promoting the aspiration to work
AHPs have an opportunity to take a lead on improving employment outcomes for service users through vocational rehabilitation. AHPs, working with fellow members of the multidisciplinary, multiagency team, can:
- explore work issues at all initial assessments with service users and focus the goals of interventions, where appropriate, on return to work
- act as brokers between employers and those in the early stages of accessing mental health services
- promote work as a means of recovery from mental health problems
- provide specialist vocational rehabilitation within clinical teams.
AHPs in mental health, working from a recognition of the importance of work in promoting recovery, should explore work issues at all initial service-user assessments and provide ongoing signposting or support to increase service users' potential for work.
Skills for work
The action plan supports the Sainsbury Centre principle that people are "job-ready" when they say they are job-ready (23) and that the focus should be on competitive employment. For those with long-term conditions, young people and those with no recent employment or work skills, AHPs should provide support to help individuals set goals and learn new skills that will build confidence and aspirations. For people who do not see themselves as ready for work or for whom the Individual Placement and Support ( IPS) model (see below) has not been available, there should be a range of work rehabilitation options.
AHPs must continue to offer a service to people who are unable to engage in paid employment or are not work-ready, but who seek voluntary work or education and training. AHPs have a responsibility to extend the scope of their practice across a range of agencies, including local authorities and education and training providers, to facilitate experiences of work for this group.
AHP mental health leads should work with key stakeholders to ensure the provision of alternative occupational, leisure and educational activities for service users whose vocational goals are not employment-focused.
Vocational rehabilitation is defined as:
"... a process that enables people with functional, psychological, developmental, cognitive and emotional impairments or health conditions to overcome barriers to accessing, maintaining or returning to employment or other useful occupation. The emphasis is on restoration of functional capacity for work or other useful occupation rather than treatment of a clinical condition" (6).
In short, the outcome of vocational rehabilitation is work, paid or unpaid.
Models for vocational rehabilitation include:
- the Working Health Services Scotland programme (funded through the Department for Work and Pensions) which, while not exclusive to mental health, incorporates cognitive behavioural therapy ( CBT) principles, biopsychosocial principles, access to occupational therapy and physiotherapy services, standardised clinical assessment tools and a negotiated action plan
- Individual Placement and Support ( IPS), an evidence-based mental health model for individuals who are work-ready: the principle is "place, then train", with strong evidence that individual placement and support is the most effective method of helping people with severe mental health problems to achieve sustainable competitive employment - IPS is successful for approximately 60% of service users.
There are many excellent examples of AHPs developing local initiatives and working with partner agencies. It is essential for AHPs, working with NHS board rehabilitation coordinators, to ensure that people with mental health problems have access to the right vocational rehabilitation support, in the right place, at the right time.
The Scottish Government has commissioned a review of current models of vocational rehabilitation used by AHPs in mental health and will produce national guidance by spring 2011.
" My future is looking really ... it's bright as the sun because I've been given a new house, [which has] taken me away from the area I was in. I've got a house that has just been built and it's got everything in it. "