For the purpose of this TMA I will firstly introduce the policy that I intend to critically analyze. This is the Operational Policy for Community Services in South and East Dorset. It is a joint policy document created in partnership between Dorset Healthcare NHS Trust, Dorset Social Services and Richmond Fellowship. The document intends to provide a service led program for social interaction for patients with severe and enduring mental health problems as a requirement of the National Service framework and the Integrated Care Program Approach, which aims to offer a holistic package of care to those suffering from mental illness.
Dorset Healthcare NHS Trust and Dorset Social Services funded the creation and implementation of this policy. The managers of the Richmond Fellowship, as the service provider and the manager of the CMHT created the policy in April 2002. Prior to this these services were run by the rehabilitation services within the NHS and they transferred to the CMHT approximately six years ago.
However, the policy was not reviewed at this time and nursing staff within the CMHT continued to run the services on the same lines as the rehabilitation services, not offering variety for service users and being a service that was very much run for them, not with them. The team manager and practitioners within the team defined what they felt was needed from the services, with their aim being to have a more user-centered service that would empower service users by involving them in the day to day running of the groups. The CMHT brought in Richmond Fellowship to run one of the services to provide an alternative to the rehabilitation type services that existed.
A requirement of the National Service Framework is that service users are to be involved in their care. Because of this they were invited to participate in the drawing up of this policy. It was decided by the team that service user feedback was to be collected over a three-month period, in the form of a questionnaire. Unfortunately there was a serious lack of response; the few service users that did respond did so verbally to their key workers. This was probably due to a lack of confidence that they would be taken seriously and achieve a positive outcome and an inability to express themselves confidently when faced with the more powerful voice of social services.
Without the support and opportunity to voice their concerns, this meant that there was very little documentation of service user views. Due to the lack of information staff within the CMHT’s based decisions on requests for services from service users they had worked with in the past. These decisions are an example of how professionals think that they are acting in the best interests of service users by making decisions for them rather than supporting their involvement.
Within this policy there were different priorities; social services wanted services that were financially viable and best value due to the restricted budget. They also wanted service users to be more involved in the day to day running of the services. The Richmond Fellowship manager wanted user centered services, but they were also eager to provide this service cheaply so as not to lose their contract. Richmond Fellowship support workers, who were to implement the policy, were not invited to be involved in the creation of this policy. Due to the requirement for service user involvement in services, the services users were given a tokenistic opportunity to express their views, as the managers decided that their views were to be a part of the appendices of the policy and not be considered within the main policy.
The managers can be seen to have the power to define purpose within this policy. The staff implementing it however are also powerful in that they had operational power (Winstanley cited in book 1, chapter 10, p.217) to choose not to adhere to it. They interpreted it in their own way, probably due to the fact that they did not feel that it was relevant to their day-to-day work. This could have been overcome if they had had the opportunity to input into the policy. Perfect implementation of this policy may never be possible, as a resolution of the conflicting factors between all the stakeholders’ perspectives is not easily achieved, some resolution however can be achieved with Lindblom’s suggestion that – “Practical decision making involved something altogether less grandiose than a rational decision cycle. Policy developed he suggested, through “incrementalism” a policy tried, altered, tried in its altered form, altered again and so forth. (Braybrooke and Lindblom, 1963cited in book 1, chapter 10, p.215).
Colebatch feels that a combination of both the rational decision making model and the rational decision cycle provide a good basis for policy development and implementation. He recommends that all stakeholders be involved in the policy process, not just by managers who then transmit decisions down to the staff for implementation as in this policy. He argues “the job of policy analysis is to understand the multiple and sometimes conflicting facets of the policy process that contribute to multiple outcomes – some intended some unintended” (Colebatch, cited in Book 1, chapter 10, p.216). In order for this to happen within this policy there is a need to support the involvement of the staff, service users and carers.
Enabling their involvement is not an easy process and would need social services to adjust their expectations of policy provision to include other perspectives. In order to achieve this social services would need to adapt their practice to reflect on and reduce institutional oppression, to become open to other perspectives and respect opposing views. In this way they would really be able to empower those they say they want to empower within the aims of this policy. Until this is realized future policy creation and implementation will also be unsuccessful, due to the lack of consideration for opposing stakeholders views within the policy creation. Colebatch (Book 1, p216) suggests services users and those providing services need to be involved in setting standards, aims and objectives, so that there is a balance between client based outcomes i.e. quality of services, and service based outcomes. This would enable service users to contribute to user-centered services as stated within this policy.
One positive aspect of this policy was the successful interagency collaboration (Hudson.B, Book 1, Chapter 12 p.259) created between the CMHT and Richmond fellowship with communication between the two organizations being effective and focused on service user care. They intended to promote progress, achieve objectives, deliver needed changes and to be value for money. (Parsons, 1995, p.77 Book 1, chapter 10, p213). However these decisions were made solely by senior management and then moved downwards for implementation.
The policy does not mention staff training to enable staff to implement the policy and this led to a lack of staff commitment, and sense of ownership of the policy. Confusion about roles was also experienced, with the CMHT practitioners expecting the support workers to provide intensive support to clients that were often unwell; with the support workers not feeling this was their role. This conflict between Social Services and Richmond Fellowship in regard to expectations of the role of the support workers could have been avoided had the expectations of role and supervision arrangements of the Richmond Fellowship support workers been clearly defined within the policy.
Although the CMHT manager wanted a quality service this was measured against the restricted budget with which to provide this service. The service was put out to tender with the successful applicant providing the best value service. It was hoped that this policy would outline the aims and objectives Richmond Fellowship would need to meet to provide a quality service for service users. Due to the lack of clarity within the policy this aim was not realized. There are several possible reasons for this including not enough money being allocated within the budget for staff training and supervision and the difficulty in recruiting workers with experience of working with people suffering mental distress, probably due to low salaries. When this policy was created a separate fund for the training of staff was not created, as it was not thought necessary.
The Richmond Fellowship staff were not employees of social services and were unable to access social services training. The revenue budget was not sufficient for these services, and due to an overspend of 50% on the transport budget for service users to get to and from day services, the social services manager made the decision to cut taxis for service users in receipt of Disability Living Allowance. This was successful in reducing expenditure and allowed for money to be spent on opening the service another afternoon a week, thus improving the service. This did however have an affect on the quality of service provided for some people, as those in receipt of this benefit were unable to afford the taxi service especially those living twenty miles away from the service.
The aims stated in this policy needed to be developed into indicators for objectives, so that these indicators could then be measured and provide a basis for a review. The outcome of the review would indicate whether a refinement of the indicators was needed and suggestions for improvements could be made. If the outcome was positive and the implementation had gone well, the objectives would be clarified and reviewed at a later date. This policy had a review date set for April 2003, however it is now June 2003 and it has still not been reviewed. The policy states that these reviews will be user led, but as yet there is no evidence to support this and no involvement from users in the day to day running of these services.
I have not been informed as to whether or not an external inspection of these services has taken place, but in order that the services are able to meet the quality criteria set by social services and the NHS these reviews need to be held regularly. Therefore at present it is unknown as to whether or not these services have met statistical targets. The review process would need to include speaking to professionals running the services and reviewing the results of the service user questionnaire. Although preparing for an inspection or audit is very time consuming, and staff may feel that this time is better spent on client care, it does ensure quality through set inspections of standards and action plans for improvement.
Not all users were ready for the change aimed for within this policy. Many of them had been attending for a number of years with the expectation that services would be provided for them by a rehabilitation type service. They may have felt threatened by the idea of involving them in running the services, as when new ideas were introduced there were a number of complaints. Others welcomed the new changes but objected to the restructuring of services, as they may not have felt that they were involved in the decisions. The group that the Richmond Fellowship ran closed, although the service users that were motivated however have joined with the Richmond Fellowship to create a new user led service.
Many of the difficulties in this policy were due to the lack of clarity within in its aims and objectives, and members of the groups continue to face difficulty building their links with the local community, instead becoming increasingly dependent on the services provided by the CMHT’s and Richmond Fellowship. This policy aimed to link user groups with community resources such as the local Adult Education College however few members were able to move on successfully to mainstream courses. This may have been due to the lack of experience and training of the staff running these groups. Motivating members to try new experiences was initially encouraged, but floundered when difficulties arose regarding low self-esteem and anxiety. The support workers who lacked skills to support them exacerbated this. What is needed is for this policy to define training for staff, and give them opportunity and the time to attend the regular meetings stated in the staffing arrangements.
I would like to suggest future amendments to this policy, to clarify certain issues, so that the staff implementing it can use it as a guide and tool to their practice. Service users following discharge from the integrated care program approach are not allowed to continue to use the clubs as this policy presently states that services are for clients on ICPA only. This policy could be revised to include these service users so that they can continue to benefit from these groups once they had been discharged from ICPA. However, one draw back to this approach maybe that service users, who no longer benefit from involvement in the groups, could continue to attend and block spaces for those that need them.
This could be prevented with an amendment to the policy to include an expected length of stay once the service user had reached an assessed level of mental health and ability. This would help to motivate service users to move onto use mainstream community services. As well as the involvement of managers this policy needs to encourage input from practitioners within the CMHT, support workers from the Richmond Fellowship and service users and carer’s all of whom have an interest in the policy. This policy created services that are oppressive in that they do not enable service users to develop to their full capacity, and oppress them by maintaining the power imbalance between professionals and service users.
A critical practitioner would be able to facilitate the involvement of service users more through an open and not knowing approach that would not make judgments, but would be able to question all other professionals. They would give all stakeholders the opportunity to represent their views. They would be able to do this, as they would have a sound knowledge based on evidence research, legislation and statistics. The liaison between service users and the CMHT’s would be eased by the critical practitioner’s ability to work in a group.
To conclude I have discussed how crucial it was for all stakeholders to be involved in the policy process so that a definition of quality services can be determined through negotiation and discussion, rather than through managerial decisions. There was a need within this policy to identify the different stakeholders, to involve and understand the differing perspectives, including opposing values, knowledge and skills each offers. I acknowledged that it would be difficult to draw this together but introduce the concept of critical practice that would enable practitioners to listen to, respect and involve others views and experience whilst at the same time remaining clear regarding one’s own perspective. In this way the policy is more likely to be user centered and achieve successful implementation.
How this is a lengthy, difficult process and how service users in particular will need to be supported in expressing their views and other stakeholders will need to adapt their practice to become more open to other perspectives. I suggested amendments that could be made to this policy to improve service user and staff involvement within this policy, so that certain issues can be clarified. I was unsure as to the arrangements for policy review but put forward suggestions as how this could be achieved and the reasons for it. The benchmarks for a review were not evident within this policy and although a review date had been set, there was no evidence to show that this was in process. I suggested that these reviews be a process rather than a set of tasks that would be continuous rather than a one of task every few years. In this way benchmarks could be set and used to ensure quality within the services.
Cited in book 1, Eby.M, p.216
Braybrooke and Lindblom, (1963) cited in Book 1 Eby.M, p.215
Colebatch, cited in Book 1, Eby.M, p.216
Hudson, B. cited in Book 1,Eby.M, p.259
Parsons p.77 (1995) cited in Book 1, Eby.M, p213
Winstanley et al., (1995),”The Stakeholder Power Matrix”, cited in Book 1, Eby.M, p.217
Karen Scorer R2492501 TMA 03 June 2003
The first objective cited in my learning contract was to develop the skills and appreciate the theory of critical practice. Unit 2 and the first TMA gave me the opportunity to explore this, in particular the learning outcomes from unit 2, which I completed with my supervisor in supervision. Together we reflected upon my practice, on how reflection in action was a skill I would build upon to enable me to reflect in crisis situations, and how having an open and not knowing approach within my work would develop my practice as there are not always simple answers to dilemmas. Learning outcome 3, involved discussion and an aim to improve upon my partnership skills, this has meant that I have begun to take more time to listen to and appreciate opposing views, especially in relation to ethical decisions (unit 6).
At work I often face people who have opposing views to mine, this may be from someone with more power than me such as doctors or service users that often feel very powerless and frightened. My practice has adapted to include an awareness of this power differential and the ethical considerations in it. As stated in my original learning contract I intent to complete the second option of TMA 05 enabling me to develop how change can be brought about within my practice through the use of research and critical practitioner skills.
My second objective was to develop the skills and abilities to work with challenging clients, and as already discussed the skills and theory of critical practice have been helpful to me in these situations. Other aspects of the course that I have used to begin to explore this have been units 6& 7. The sections on identifying ethical approaches and ethical decision-making, and the activity on personal values were really helpful. These sections were really helpful in providing me with a theoretical basis to understand some of the practice that I was already doing. I feel that I am more able to identify the approach that I use within a situation. I am beginning to think more in depth about my practice in relation to this and feel that this is an area that I will continue to explore, I hoped to do this through the course specifically with units 20 “producing research ethically “and through my practice.
Another area in the course that I felt I would be able to learn and develop in was the area of accountability. My objective was to develop my understanding and skills as an accountable practitioner. I had some previous experience prior to this course of working within policy and procedure guidelines. There have been aspects of the course that have helped me to explore this including TMA 02 and unit 9, Within TMA 02 I was able to explore the relationship between accountability, risk management and user centered care. Within these learning outcomes 1 and 4 of unit 9 and TMA 02 challenged my thinking about user-centered care. I came to realize that the involvement of patients in the risk management process could empower patients and lead to a more positive outcome for them. How user centered care can break down inequalities in power relationships between practitioners and service users. That accountability, rather than being perceived as a threat to professionalism, is in fact empowering to both service users and practitioners.
My final objective was to develop the skills needed to liaise with the childcare assessment team. Unit 8 and my placement experience has enabled me to achieve this objective sooner than I had anticipated. Whilst on placement I was allocated a referral for a child in need. Initially the intervention was for benefits advice, whilst completing the initial assessment however reports of potential risk to the child of domestic violence from her father were made from the health visitor. I was able to liaise with the childcare assessment team regarding this information and plan in partnership with them and the child’s mother an intervention to support the family in managing the risk to the child. I would however like to explore this further and when I return to the Community Mental Hearth team at the end of my placement I intend to discuss ways in which this interagency working can be built upon.
TMA 03 has enabled me to learn about policy. In particular the theories that underpin policy development, the relevance of stakeholder involvement within policy development, and the ways I can influence policy development and implementation as a critical practitioner. I believe that whilst it is important to based policy development on theories that just as important to have an open and not knowing approach so that I can not discount other perspective or views, because I know that the involvement of all stakeholders is important to policy development and implementation, because both service users and providers need to be able to jointly define user centered aims and objectives, and feel that services are provided are relevant to their needs. I am aware especially in mental health where many services users feel powerless to challenge the system they need to help, that they will need to be supported to do this.
I am really looking forward to the next section of the course, specifically the module on evidence for practice, I hear so much about evidenced based social care and I understand that this will become increasing important within my work. I really hope that this next module and TMA will enable me to provide and use evidence within the work that I do.