For this blog, we asked Implemental’s Managing Director, Tracey Power, to talk us through the process of conducting Implemental service reviews.
Early Intervention in Psychosis (EIP) is a mental health service model which offers early detection, treatment and support for individuals who might be experiencing or are considered at high risk of developing psychosis. In accordance with NICE guidelines, most EIP services in England provide care for those aged between 14 and 65 years of age. EIP services have been in operation at the South London and Maudsley NHS (SLaM) for over twenty years. Despite this, no formal review had previously been conducted. The recent review was driven and overseen by a Steering Group. Implemental were commissioned to facilitate the process over a six-month period.
The Review included four SLaM EIP services operating across different boroughs: COAST (Croydon); LEO (Lambeth); LEIS (Lewisham) and STEP (Southwark). In addition, the Review also covered OASIS services and the former LEO unit, which used to operate as a specialised EIP inpatient service.
As part of the Review, the Implemental team collected a large amount of information across the three main review activities:
They also drafted key findings which informed Review recommendations.
Implemental’s Managing Director
Tracey is currently Implemental’s Managing Director. Tracey worked as a senior manager in the NHS for many years with experience of mental health and learning disability services. For the last fifteen years Tracey has worked with colleagues all over the world to facilitate the development of innovative mental health services and systems.
Tracey explains that Implemental have carried out numerous reviews across London, and whilst most of these had similar methodologies, each organisation had its own unique characteristics and cultures which impacted the reviews.
“I remember that in every review we carried out, some things were really familiar, particularly the pressures and challenges of actually implementing best practice, but there are also real differences in every organisation which make this work really interesting.”
“I thought this review focussing on EIP might be quite different from others that we’ve done but, in the end, it always comes back to the fundamental issue that there’s a finite amount of money and everyone wants to know whether it is being used in the best way possible. In particular, whether there is the appropriate balance between community and hospital-based services and assurances about the compromises that are being made being the right compromises because there’s never enough resource.”
She also discusses her personal experience of working in early intervention services and the lasting impact this has had on her work.
“My career has mirrored the journey of developing mental health services in the UK. I just happened to be starting off at a time when the hospitals were closing and community services were developing. I often think I’ve been remarkably lucky to have been on the crest of the development wave, actively involved in implementing a model of community-based health and social care. I realise that I internalised certain key underpinning principles that remain very important to me, because that’s how I grew up.”
“I am very proud to have been involved in the mental health services that I was operationally responsible for in Lewisham and this included developing early intervention services and thinking about how they would be part of our wider service system. This involved interpreting the national service specification for our local environment and recruiting staff. So, of course I had a particular interest in how the model had further developed over time.”
“I was also working at the Strategic Health Authority, while the NSF was being rolled out across England, with responsibility for developments in South East London. So, I was able to benchmark what was happening in 7 local boroughs. I was very aware of the fact that each of these Boroughs had specific targets that reflected their different demographicsa and we were monitoring progress over time. So, this experience was very instrumental in how I developed a model in my head about how you implement service developments in line with national policy but promoting a local ‘fit’.”
“Having stepped away from operational responsibilities for the last 10 years, it was fascinating to go back and revisit them. Some of the services included in the Review were Lewisham services, and it was a great privilege for me to see what had endured, and indeed speak to some of the staff still part of the team. But it was also quite painful to see the pressure they were under.”
Tracey explains that the stakeholders involved included staff from each EIP services, service users and their families.
“Whenever you talk about involving stakeholders, everyone gets really worried about drawing up the right list of stakeholders and whether it’s representative or not. And that’s an important thing we’ve learned, there is no perfect list of the people that you must speak to. Pragmatism will guide us in the end depending on people’s availability, , there’s no perfect way of doing it. Any attempt you make to talk to a range of people with different views, means you will get the right messages to think about.”
She also highlights that triangulation is key to delivering effective service reviews, for Implemental this means including best practice, documentary evidence and data.
“It is really important to collect data but also you need to speak to people with a wide range of perspectives. Equally, it is very useful to review the status of the evidence base in academic papers and policy guidance, but you also need to check out what colleagues in other services and systems are experiencing.”
She also outlines the importance of benchmarking data.
“It is crucial to benchmark nationally and if possible, internationally. I think it’s an area people often miss, when they’ve got their heads down and they occasionally wonder what other people are doing. But it really is very relevant to ask what the other trusts in London are doing for instance, or asking if there is a big difference between inner city and rural areas. Finding out what challenges people are facing.”
She describes the challenges of synthesising data.
“It is inevitable that if you collect lots of data it means you’ve got to actually synthesize very large amounts of information. You’ve got to be able to turn that into some key messages that can then inform recommendations which in turn inform potential actions. And that in of itself is really tricky and takes time and energy.”
Tracey also discusses the importance of ensuring stakeholder engagement with recommendations.
“This whole review process would very limited without effective dissemination and you’ve got to check the appropriateness of the observations, and reality check the recommendations, and the action plan. That’s a significant challenge in of itself because you can’t come to decisions via committee, and you usually have a large number of different people involved in the process. But you’ve got to involve people enough so that key stakeholders engage with the recommendations.”
“And we always put a lot of emphasis on dissemination, we really want to make sure that the courtesy is paid back to the people that have given their time to contribute their views to the processes.”
Tracey explains that the process of turning observations into recommendations and potential actions can be considered controversial.
“Developing an action plan requires the review report to go through certain governance processes to make sure the recommendations are signed off… So again, there’s some tension about the fact that you want to share the findings with lots of people and help them feel engaged with the process, but, on the other hand, there’s the realities of the political process to sign things off and get them agreed at organisation level.”
Despite this, she believes that however good the review process may be, the final output should be an effective action plan.
“There may be fantasies when you embark on a review, that there is that the right answer, you know what the solution is, or as we joke, you know the answer is 42. It’s quite hard to frame the problem or query you have into a review question and agree what the expected output should be. I thought it was quite helpful that for the EIP review we framed this in terms of possible scenarios: for example, suggesting no real change, modest improvement and changes, and at the other end, suggesting radical change where very significant reconfiguration might be required. I thought that was quite a useful way of thinking about things really, because, there is no binary yes or no, or right or wrong. Action will need to happen along a continuum.”
“And it’s stating the obvious, an effective action plan needs really good programme management resources. You could actually almost do more harm than good carrying out a review if there is no time and energy to address the recommendations identified.”
Tracey outlines the importance of considering the unique character and cultures of local areas as she believes this makes a difference when engaging with stakeholders and finding solutions.
“It really is clear that every service provider has an absolutely unique set of characteristics and cultures. So, it is obvious that even if you’re looking across an organisation you’ve got to be mindful that what you might suggest would work in one particular geography, but might be less relevant for another.”
Tracey also discusses the broader value of early intervention approaches.
“I guess the other thing I thought about EIP services, is that they’re part of that much broader emphasis of early intervention in all aspects of life. Addressing inequalities, preventing mental health problems and also promoting resilience. So, , it is obvious that we would be looking right across health and social care services and focusing on all the contexts where people are likely to be able to have earlier engagement.”
“It is disappointing that resources aren’t prioritised for early intervention approaches in the wider public health field. But it is fortunate in mental health that the idea of early intervention has been completely internalised so that it is seen as an important component of practice.”
Tracey explains that the aspects of the review which were most memorable to her were her conversations with stakeholders.
“The conversations we had with service users and their families, and with frontline staff I really did confirm that there were very many examples of genuine partnerships that were facilitating excellent care. That thrilled me, I was so energised to have those conversations and to think that people are doing some fantastic work, and particularly the partnerships between the service users families and care co-ordinators.”
“We had the family members involved and they made fantastic observations, they were very practical, they understood that the resources were finite and that we had to make difficult decisions. But they were advocating for the service elements that would make the most difference and a number of them are regularly working alongside the services, helping not just with advocacy, but also facilitating peer support groups. It was remarkable.”
“I would like to emphasise that taking time to review services and reflect on practice is very valuable. But it is a really big task to do it properly and right at the start thought needs to be given to the resources needed to implement recommendations.”
The Implemental review team would like to extend their sincere thanks to all the managers, clinical and operational staff, service users and carers at SLaM Early Intervention Services (LEO, LEIS, STEP, COAST and OASIS) and other services, who were keen to contribute to the review and are enthusiastic about future opportunities to improve the services. Their views and contributions were highly appreciated.
Thanks also to the members of the Steering Group and Reference Group who contributed to the review process with their invaluable insights and expertise. The review team would like to particularly thank Dr. Robert Harland, Clinical Director for the Psychosis Clinical Academic Group and Chair of the Steering Group; Professor Philip McGuire, Academic Director for the Psychosis Clinical Academic Group; John Lavelle, Lambeth Adult Service Director and Dr. Michael Holland, SLaM Medical Director.
We wish colleagues the very best as they embark on the process to develop and implement their action plan.
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