The importance of relationships: Care planning and care coordination in mental health.

Abstract

Research and evidence from service users have consistently reported that service users are not involved in care planning, despite mental health policy that advocates a collaborative process and evidence that involvement facilitates recovery (Bee, Price, Baker, & Lovell, 2015; Simpson et al., 2016). Service users want the care plan to go beyond being a record of clinical decisions and include aspects of their lives in which they need support, such as housing, employment and benefits. Grundy et al. (2016) looked at what “user-involved” care planning might look like. They found that meaningful relationships were key to the successful involvement of service users in care planning. Key messages for practice included that professionals need to engage with, explain to and involve service users throughout the whole process of care planning. Simpson et al. (2016) found that service users regarded their relationships with key workers as central to their recovery. And yet, still we focus on care plans and paper and recording procedures, partly in order to contain the risks that people fear about mental health, but also to regulate practice. Many discussions in the literature about the value of care planning, and in particular about the involvement of the service user in care planning, fail to acknowledge the power differential that exists at this intimate level of “involvement”. Thinking about admission to hospital, the power differential can be magnified by the potential for control to be taken away from the service user by the use of the Mental Health Act. It is always present in the background, but at this key point, it will be looming rather larger than usual. In this situation, how is it possible to be actively and equally involved in your own care? Whilst thinking about this editorial, I have been writing a short piece about stigma and discrimination for inclusion in a forthcoming journal. One of the issues raised by researchers and through the Time to Change antistigma campaign is that mental health professionals themselves can be a source of stigmatisation, which is not exactly grounds for a meaningful relationship. This finding included GPs, mental health nurses and psychiatrists and was to some extent influenced by diagnosis, with borderline personality disorder attracting the most negative attitudes amongst professionals (Bonnington & Rose, 2014). My own psychiatrist once said to me following admission “You just can't cope with your life, can you, Alison”. I had to engage in what I now think of as a form of cognitive behavioural therapy in order to cope with this: lying on my bed and reminding myself of what other people in my life might think of me and say to me at that moment. So, what is a meaningful relationship and how is it formed? At the National Survivor User Network (NSUN), we have developed a framework for involvement over the last few years (NSUN, 2015). The 4Pi framework has five standards to help people think about involvement: principles, purpose, presence, process and impact. It is a simple framework, which aims to get people thinking about the basic questions that might make involvement work well. Although the standards are often discussed in relation to service user involvement in services and organisations, they also have something to offer when thinking about the individual level of care. The first standard “Principles” asks that people think together about their principles and values and recommends establishing a baseline of transparency, trust and respect in order for involvement to work well, the essence of trusting relationships. Purpose requires that everyone is clear about the purpose of involvement, which might help to overcome the tendency for a tick-box approach where the service user signs but does not contribute to the care plan. The presence asks who should be involved in the care plan: are there friends or family who need to be included? Process engages people in thinking through the “how” of involvement: what are the practical elements that will help it to work. Finally, impact asks what difference did involvement make—to the service user but also to the care plan, the other people involved in it and the system as a whole. What is most important to you and how might we achieve that with you (ROLE Network (Relating Outcomes to Lived Experience), 2010)