Sprinter or marathon runner?

Sprinter or marathon runner?

I wrote this in response to Dave Healey’s blog The future is?.

Bear with me here folks, I have just spent the last few hours writing a response to this. And by the way my own contract is up on March 31st (it was a fixed term strategic role within the NHS).

I’m glad to say however their were about 40 addiction nurses, also on fixed term till the 31st, but their posts have been rolled over for another year whilst the workforce development and service redesign get underway.

Despite the many and varied initiatives taking place across the UK, and the national policies in England and Wales and Scotland’s emphasis on recovery, we know that the recovery reorientation has not been widely adopted and implemented.

There is a long way to go before a recovery orientation is standard practice for addiction and mental health services and there remain significant barriers to changes in service reorientation that will not simply be swept away just because some folks demand so. These barriers are not just about belief systems, inertia, vested interests or attitudes – to a certain extent these are the easy ones to tackle.

The more difficult barriers are cultural, systematic and structural. Consumers, clients, patients – whatever you want to call us – are still often unable to access mental health/addiction care as and when we need it. Service availability does not meet population needs in many places, particularly in rural and remote areas and for some demographic groups (such as older people).

The social and emotional well-being of many older people in services remains a source of national shame and I fear history will judge our field very harshly for the lack of care given to so many over such a long period of time.

A change in attitude among service providers is fundamental to working within a recovery orientation I agree. And we know many service providers, particularly of clinical services, still hold outdated beliefs that a diagnosis of mental illness/addiction is a life sentence to an incurable condition that invariably will have only negative consequences for a person’s life course.

Workforce training and development is fundamental to the roll-out of a recovery orientation. All sectors of the addiction/mental health workforce need to be trained to enable them to operate within a framework that supports the empowerment of consumers/clients and personal capacity building.

Also required is better understanding of the factors that impact on recovery, rehabilitation and relapse, along with coordinated provision of the support services that are essential to recovery. Equitable access to and better coordination of support services must be achieved, particularly for accommodation, disability, and employment services.

We all know that addiction services/mental health services will need to make significant changes to practice, services, structures and culture in order to be more supportive of recovery processes. And of course that means radical changes to the workforce. e.g. Whitely et al. (2009) studied implementation of Mueser’s ‘Illness management and recovery programmes’ across 12 community settings and found 4 important factors:

1. Quality of training
2. Quality of management (particularly supervision) 
3. Local leadership
4. A culture of innovation

When all 4 of these are present together, acted synergistically it works. But training in itself is ineffective without good supervision, local leadership and a receptive culture.

So whilst we do see resistance to the recovery reorientation, we have to consider that probably most of that resistance is coming from expertise and concerns around the nature and speed of the shift . If not done throughly, comprehensively and with integrity we will be in a bigger mess than were we are now.

After all we are talking about massive change here. We are talking about changing the very nature of day-to-day interactions between consumers – I keep using that word consumers because I’m thinking of the changes in the English NHS. Thankfully in Scotland we are still patients/clients for the moment.

We are also talking about developing and delivering mational “people in recovery and user-led” education and training programmes. I know some organisations are probably tackling some of this but usually in isolation from each other, so there has to be some sort of national centre involved in this to ensure quality over all the different geographical regions and perhaps even across the UK, to drive this forward.

Transforming the workforce is not a simple or straightforward task. We have to change the way we approach risk assessment and manage and support the staff in their own recovery journeys.

We must therefore ensure we have an ethical framework, acknowledging the various philosophies of care, and a service framework identifying the systemic elements and their interconnection. We have already seen the work of theSMMGP update and reorientation of their clinical and practice guidelines. Which are tremendous progress considering the time span.

We still have a data infrastructure measuring various aspects of performance outcomes and indicators based on the old goals and we have to ensure that these too are influenced by those in recovery and who have recovered. Otherwise it’s nonsense.

A peer influenced (or even peer led ) regulatory framework of necessary governance and standards covering systems, services and individuals is key to the success of the new strategies undoubtedly.

When I say peer led here, don’t forget many folks in long term recovery across the UK have experience not just working in services as addiction workers. I know policy makers, strategic co-ordinators, performance evaluators, clinical directors and many more skilled folks in long term recovery who (given half the chance) would jump to be involved.

We have made a noble start in building a unity between patients, workforce and the public to meet the challenge of integrating a variety of recovery approaches and beliefs into a coherent mainstream strategy. Whilst trying to being vigilant in remembering the critical and vulnerable state of some of the users of these systems and services.

Again given the weight of the responsibility and scope of the depth of change required to move towards a recovery orientation, resistance is enievitable but also conscientious.

Putting the principles of recovery into practice and ensuring that the real developmental opportunities afforded by the strategies are maximised requires cultural change. Which needs to be supported and developed at every level of our organisations.

Recovering people and health professionals will be key in bringing about cultural change, and individual professionals need to take responsibility for engaging with the process.

To make the principles work in practice, the capacity for values-based care needs to be supported and developed. Values-based practice recognises that decisions taken in mental health/ addiction (you know I wish I didn’t have to keep doing this ‘mental health/ addiction’ as I see addiction as a mental health issue) but for the sake of clarity I will continue to do (it).

Anyway what was I saying? Oh yes….

Values-based practice recognises that decisions taken that are based on values as well as evidence. And that practitioners, service providers, service users, families and carers may have differing and sometimes conflicting values.

It aims to support workers to provide care and services that reflect people’s rights and the underpinning principles of practice. And to achieve the space to reflect on their practice, understand different values, negotiate conflicts, make decisions based on strong value systems, reaffirm, shape and challenge roles and practices.

It’s the people at the most senior levels in organisations delivering mental health/addiction services who need to acknowledge this. Ensuring that values and principles are embedded in organisational policy, and facilitate the change necessary to translate values and principles into practice.

Training in values-based practice should be a central feature of all health/addiction workers. The exploration and development of values-based practice also needs to be embedded in individual practitioner’s personal development plans and clinical supervision.

We need to:

Develop a national framework for training in recovery-based practice to support the dissemination of recovery-focused models into practice.

Support all professionals involved to review and revise assessment and care planning frameworks and documentation in their organisations to ensure they reflect the key elements of a recovery orientated system of care.

Acknowledge and promote people’s central role in assessment of their own needs and in planning and evaluating their care, decreasing their need to rely on formal services and support.

Respect people, value their contributions and views and preserve their dignity.

Focus on people and maximise individual choice, enable people to take greater control of their lives and instill hope and belief that recovery is possible.

Encourage people to retain or regain social networks, work, education and community connections as early as possible.

Build on people’s strengths and aspirations, emphasising strengths rather than deficits or dysfunction.

Foster authentic partnerships between people who need support and people who support them, acknowledge the key role played by families and carers in the person’s recovery.

Shift the emphasis of interventions and services from managing organisational risk towards therapeutic management of the individual.

In summary, at a national level, the UK has explicitly adopted recovery as a basic principle for mental health/addiction services.

I think the whole field would agree that change can be frustratingly slow, however, we need to get this right, we have a real window of opportunity.

Most folks in a variety of fields don’t get the chance in their lifetime to shape or shift their field. We have the chance!

Probably only one chance!

Right here! Right now!

Our emphasis must be on making that shift the very best it can be, not only because of the opportunity, but as a duty to the people we serve now and in the future.