Evaluating National Developmentsin Service User InvolvementHow do managers and leaders in the NHS and socialcare respond to user involvement in mental healthservices in both its traditional and emergent forms?
Aims: To produce guidelines and best practice for service user involvement in mental health in a dynamic and changing environment. To contribute to the improvement of mental health service delivery by maximising the potential for user input to service user design, planning and evaluation. Key Audience: Mental health Service Managers, Front line workers and Service Users
Study Sites and Methodology Three NHS Trusts: 2 Metropolitan Sites, 1 Rural Site Mixed Methods Study: Survey In-depth interviews Ethnographic observations User led organisations (ULOs) User governors Deliberative Workshop/Focus group
Survey• Survey of 300 patients using mental health services and 150 front-line staff (Nurses and social workers)• Convenience sample of patients from out-patient settings and day services. Mixed sample of staff (on-line survey and contact with CMHTs)• Place results of qualitative components of the study in a wider context of User Involvement in practice (extent and impact)
Survey Results Service users Staff 46% had experience of SU activity • 57% of staff involved in some form of SUI activity People involved in SUI more likely to • Social Workers and younger members be in long term contact with services of staff more likely to have experience of involving service users User Involvement in shaping community services seen as most • User involvement in Training of Staff likely activity to be effective seen as most likely activity to be effective Service Users less likely to report • Difference in staff and service user positive impacts of SUI than staff views of positive impact of SUI in training staff (68% versus 18%) • Both staff and service users are least likely to have experienced positive impact of SUI in commissioning services (19% and 15%)
Benefits of SUIHigh level of agreement about reasons and benefits of SUI Service users Staff Having a say/ being included Having a say/ being included Improvements in services Personal benefit self-esteem/ recovery Personal benefit self-esteem/ Improvements in services recovery Opportunities for social Patients know more about contact/ group services Acquisition of new skills Other
Ethnography and Interviews In depth interviews with senior managers and professionals: Commissioners Service Managers Trust Directors Senior Clinicians Team Managers Ethnographic observations User led organisations User governors
Current Context of Mental HealthService Delivery: Clinical Commissioning Groups Trust expansion Provider monopoly or diversification? Personalisation Payment by results New service models/service re-design/recovery Cuts Re-organisation SUI ‘mainstreamed’
User Involvement Mechanisms User groups Training User governors Peer support Commissioner initiated User provided services stakeholder forums Third sector organisations Consumer feedback: PALS postcards, surveys, ICT, forums PPI forums, LINks, Healthwatch Service based forums GP practice groups Research/user focused monitoring Locality based health action groups Recruitment
Service user Perspectives (User governors and User Led Organisations Where do we exercise most influence? Uncertainty about new mechanisms of user involvement? Need to be able to adapt and develop new relationships. Relationships not systems are key to effectiveness. “Go-to” individuals and gatekeepers Staff pressures and changing relationships affecting SUI efforts. Value of research as focus for involvement – longer term impact? Satisfying commissioners rather than doing what users want. Top heavy emphasis of involvement initiatives
Service user Perspectives (User governors and User Led Organisations) Difficult for ULOs to have a meaningful and consistent working relationships with the statutory services. Dealing with multiple structures of authority and gatekeepers User involvement can be seen as somebody else’s job Official channels vs tacit learning. Challenging for small under- resourced organisations and activists
Organisational Perspectives (Senior managers) How does feedback at front line delivery level get back to commissioners? We’re generating too much feedback without systems to use this. ‘Formal’ mechanisms such as Trust Boards with SU governors can complicate locally developed SUI mechanisms. Different ULOs take different positions; how do we know which groups to approach? Can’t we get them to co-ordinate?
Organisational Perspectives (Senior managers) The system is too big, the organisation is too complex, SUI can only work well in specific locations. We need to work out how to link SUI at operational level with strategic level. There’s a gap in the middle. We’re under pressure (cuts, evidence based practice, market development, commissioning, service re-configuration, income generation), there is not much influence that service users can have. Unsettling of relationships provide opportunities for user influence: impact on commissioners.
Hierarchies of Discourse and Organisational Non-Alignment Pressure on user group members to adopt corporate discourse. Forms of feedback seen as ‘anecdotal’ Managers - there is a complaints procedure SU groups becoming professionalised, learning corporate/research language and becoming more effective and influential Identity: Adaption through language vs Conveying the lived experience of service users, issues of power.
Key points: ULOs will have to adapt but may be possible without losing all principles SUI moving from collective to individual level? User governors/personalisation SU governors work best when accommodation is reached with ULOs when definite structures are in place when good relations are formed (Board meetings as opportunities for networking) Are we witnessing the ‘death of the user movement’ as we knew it?
Evaluating National Developments in Service UserInvolvement Further information: http://www.kcl.ac.uk/iop/depts/hspr/research/ciemh/sure/projects/Howdo managers.aspx