Reshaping Community Services with service users in East London
If a mental health community team could have an open hand at improving care delivery, what would their service users focus on? Discover how teams from directorates at East London Foundation Trust worked together with service users to reshape services in this blog by Senior Improvement Advisor Francisco Frasquilho.
The Early Days
In late 2016, following a successful Trust Wide Quality Improvement (QI) collaborative to reduce in-patient violent incidents, East London NHS Foundation Trust (ELFT) began to look at supporting other parts of its care system through QI, including the community mental health teams (CMHTs). This culminated in a Trust wide project board created in early 2017 to govern a QI approach to CMHT development and care delivery. This project board also provided a space for discussion of other ongoing innovations including the training of Recovery Champions, the rolling out of the streamlined Electronic Care Program Approach (ECPA), and supporting the use of the DIALOG+ approach in facilitating recovery focused work. At around a similar time, the ELFT Tower Hamlets Directorate was about to complete a task and finish group of their community mental health teams, engaging in another Trust wide approach looking at ways to strengthen the functions of CMHTs and establish clarity around the different team processes. These processes included new referrals, first assessments, brief treatment, and managing the transition into as well as out of medium to longer-term recovery work. The Isle of Dogs CMHT in Tower Hamlets was the initial pilot site chosen for developing a QI specific approach to improving these systems, followed some month later by the Newham South Community Recovery Team.
Pilot Teams and the journey towards a QI design
Much of the initial QI pilot work focused on a recovery approach, mostly from the service and operational perspective. Process mapping with operational leads and senior team members helped explore the flow of work through team systems from initial contact to potential discharge. Appreciative enquiry workshops with the teams looked at surfacing what mattered to staff around delivering care, as well as identifying experiences that “ground the staffs’ gears”, naming sources of stress or issues that acted as potential barriers to work. Initial change ideas corresponded with this system-focused framing, e.g. looking at improving referrals processing, reducing clinic wait times, while also improving timeliness of decision-making around care delivery, signposting, and distributions of workload.
A key issue during this phase was that no team or system could own a concept such as recovery, which can be an intensely personal and individual experience. In order to support a joint conversation around such work, as well as hoping to amplify congruence with other Trust innovations, the QI design focused on improving service user and staff satisfaction with care delivery. After a number of initial driver diagrams, the pilot teams and project board settled on the learning model identified in Fig 1, based on a combination of service user surveys, Family and Friends test (FFT) results, and the staff-service users workshops held at the two pilot teams.
Fig 1.1 Reshaping Community Service High Level Driver Diagram, with aim statement.
Satisfaction with service delivery, while not without its own issues, was our best attempt to create a compelling focus for change. In addition to being the basis for our aim statement, it also identified the main project outcome measures for this priority work, namely the FFT and DIALOG item for service user satisfaction with mental health professionals meetings. However, a crucial challenge remained around achieving fundamental and direct involvement with service users at multiple levels of this work. It was clear that unless service users were at the centre of the improvement work, the possibility of transformative change would remain out of reach.
Service User Co-design and Learning: a doorway into co-production
As this work evolved, the pilot teams improved not only the quantity of data received through standard collection surveys such as the Family and Friends test (FFT), but also the nature of service user involvement in the QI work. The real transformation for this work came from the commitment of a handful of service users who joined the original pilot teams as full members of the QI projects. Alongside improvement work, these service users also participated in the Learning Sets with the Trusts central QI team, bringing together all the project teams in one place to share learning and progress. Both pilot teams also created their own regular spaces to have co-design conversation with service users and staff, as part of change ideas geared to developing an environment for co-production. These local “Co-production Workshops” have become a space where service users and staff work together, but equally, if not more importantly, they also are becoming opportunities to exchange knowledge and experiences (see the videos and blogs below!). Now these workshops are part of the business as usual of the pilot CMHTs. They hold a promise of becoming a means to transform the relationships between staff and service users.
Next steps
We have had a number of teams join this journey since the early days of working with the Tower Hamlet and Newham pilots. The City and Hackney Team were the next team to join and now have a number of service users involved in developing their change ideas around information sharing, and therapeutic use of reception areas. More teams in Luton and Bedfordshire have also taken the offer of this work.
In the newsletter below we have stories and blogs from these teams. It is a pleasure for us to share these with you, and we hope in doing so you can both enjoy and be inspired by this work.
Bedfordshire and Luton
Dunstable CMHT, Bedfordshire
The team were one of the three new teams to join the Trust high priority Reshaping Community services programme of projects a year after the initial work started. The team found that time constraints were a challenge at the start of the project due in part to high staff turnover and high agency use. The team also experienced some difficulties with data collection due to technology. The team have really got going since the new year and are testing some interesting change ideas including allocated depot clinic times to reduce unnecessary waiting and reduced MDT meeting length. The team are hopeful that these and other changes will have an effect on the overall aim of increasing the satisfaction of both staff and service users.
Wardown CMHT, Luton
Wardown joined in July 2018 and has had very active carer and service user active involvement from the beginning, driving the work. The carer and service user team members identified communication as an area they wanted to improve. This has led to different change ideas focused on how information is provided, recorded, accessed and updated to ensure care is more joined up. Anna Bartlett, a member of the QI project team and a carer for her son, said “Using QI, the communication between the Trust and service users/carers is helping to increase the quality of service offered by the Trust.”
