Care and Support Planning in Mental Health Services – Is this what CPA was meant to be?

17 July 2015

Yesterday Helen and I spent the day in Luton, working with East London NHS Foundation Trust, Tower Hamlets CCG, Luton Borough Council, Think Local Act Personal (TLAP) and Tees, Esk & Wear NHS Foundation Trust. We were looking at how the Care and Support Planning requirements under the Care Act 2014 can be combined with the Care Programme Approach, which is used across the country for Mental Health Services.

I’ve mentioned the Care Programme Approach (CPA) in relation to Mental Health services in a couple of previous blogs, but I’ve not explained what it is. So before going any further, here’s some of what Rethink Mental Health say about CPA in their factsheet.

‘The Care Programme Approach (CPA) is a national system which sets out how ‘secondary mental health services’ should help people with mental illnesses and complex needs.’

‘If you are eligible for CPA then you should get a full assessment of your health and social care needs, a care plan and regular reviews.’

‘Your care coordinator should fully involve you in producing your care plan. It should set out what support you will get to meet your needs, and who is responsible for meeting each need.’

Imran2

When you get past the terminology, CPA is about planning and providing support for people with more complex mental health needs. It’s not radically different from any care and support planning process.

At least that’s the theory. In practice, CPA is a maligned process, not thought of well by people who use services or by the staff who work with them. Common complaints are that CPA is not person-centred, does not allow a holistic view to be taken and is frequently reduced to a ‘box-ticking’ exercise; something you do because you have to.

At yesterday’s workshop, we stretched ourselves to imagine the best experience of CPA that someone with mental health needs could have. We used a fictitious person for this exercise – a 40 year old man called Imran, who has a diagnosis of paranoid schizophrenia. We used the 5 steps for Care and Support Planning that have been developed with TLAP. These are ‘Prepare’, ‘What Matters’, ‘Record’, ‘Make it Happen’ and ‘Review’.

Imran and CSP

It is the ‘what matters’ conversation where we get to the heart of the support plan.

We ask questions like ‘What is Important to you? What is working and not working about how things are at the moment? What do you want for the future? What needs do you have now? What have we tried and learned? What Outcomes are we working towards? What resources are available to help make this happen? What do we need to do in a crisis?

When we started discussing the ‘what matters’ conversation, there was a lengthy debate about how this should take place. Would there be a meeting with everyone involved in a person’s support to look at what matters? Would there be a ‘professionals meeting’ beforehand, with the recommendations from the meeting being taken for discussion with the person concerned? Wouldn’t this be very difficult to organise? The focus in the room turned quite quickly from what the best we could imagine was, to what the problems of implementing change would be.

Part of the reason for this debate is that as soon as we start talking about change, there are immediate concerns over two things: resources and culture.

We think doing things differently takes more time, costs more money, causes more work and duplicates effort.

We are also concerned about the seemingly radical change from the current way of planning support to the ‘what matters’ conversation. Asking something as simple as ‘what is important to you?’ rather than ‘what is wrong with you’ seems like a huge step, which will in some way cause trouble and ruffle feathers.

This second concern is often described in terms of being at odds with the ‘medical model’ of support, which is thought of as something prescriptive, authoritarian and done ‘to’ rather than ‘with’ a person. Yet one of the striking things about the discussion yesterday was that when we looked at the questions we asked, professionals in the room said ‘this is what CPA was meant to be!’ CPA was supposed to be holistic, person-centred and forward looking. It was supposed to bring together all aspects of a person’s support needs and create a cohesive, practical plan.

So this got me thinking, is it really a ‘medical model’ we are trying to change? Doctors will have designed CPA, and the ‘model’ is entirely consistent with what we want to do now. The benefits of a holistic approach are accepted in all aspects of medicine. Maybe it is more a case of habit and culture that needs to change, rather than anything intrinsic to medical services? Has a mistaken belief that person-centred practices and a medical model are somehow at odds with each other, made progress in Mental Health more difficult?

The upshot of all this, was that when I saw the list of questions we were going to ask as part of the ‘what matters’ conversation I was encouraged, as I didn’t see any one of them that could be left out if you wanted to be able to support someone well. This makes getting people to accept something new easier, and also makes challenging sceptics easier too.

 

Once we’ve accepted that this is the right approach, the only concern left is about resources. Dealing with that concern is easy; if you want to save time on support planning, just let me know which information that we think we need, can you do without?

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