I work in a unit that looks after young people with complex mental health problems and uses a care programme approach that involves a multi-professional group as well as the young person and their family in weekly meetings. Despite having a range of dedicated, highly skilled professionals who are striving to do their best for the young person and their family, the perverse incentives, structural dis-integration, and lack of alignment between performance measures and budgeting arrangements mean that we don’t always provide a good-quality service to these young people. The current system is so clunky that a seamless patient-centred journey is a bit of a pipe dream.
On a positive note, after years of real-term cuts, the government has pledged £12.5 billion to child and adolescent mental health services (CAMHS) by 2020 partially to support the delivery of ‘Future in mind’ – the Department of Health and NHS England joint plan for improving CAMHS – offering us what could be one of the best opportunities in our working life to make things significantly better for our young people. However, I don’t think money and a good transformation plan alone are enough to provide the solution: we need to include the experience of patients and clinical leaders.
This was borne out recently at the launch of our local i-THRIVE Community of Practice, part of the NHS Innovation Accelerator programme. The day brought together local representatives from clinical leadership, clinical commissioning groups, local authorities and education to start thinking through how best to approach the task of transforming local mental health services for children and young people. Time and time again it was pointed out that although the cash is a critical boost, it alone will not be enough to bring about the changes that are needed. All agreed that success ultimately depends on how the transformation is designed and led locally and that clinicians are crucial to this.
So in these days of collaborative working, wide participation and shared decision-making, why do we emphasise the importance of clinical leadership? First, without the detailed insights that clinicians bring (such as pointing out the issues in the system that incentivise behaviours counter to the patient’s best interests) transformation efforts are unlikely to overcome the challenges to good-quality care that are experienced on the front line.
Second, improvement cannot be delivered solely through re-designing levers, payment systems, joint budgets, measurement goals and outcomes because it’s the decisions that clinicians make day to day, when face to face with their patients, that really make the difference to quality and value. There is no point to having innovative new ways of signposting peer support and enabling self-care, without clinicians advocating these approaches and supporting patients to use them. At a recent parent-to-parent training we ran, parents loved hearing from other parents who could speak direct to their experience, as long as there was also a clinician in the room to answer questions when the parent-trainers were stuck.
And that’s really the crux of it. As clinicians, we are the lynchpins in the cultural transformation that is core to the successful delivery of any structural re-organisation. But for clinicians to lead change, we need to believe in it as something that will help us to support our patients better. So without us sitting alongside commissioning and management colleagues, providing our insights and experience, and bringing together our knowledge of clinical need plus experience of what can make the system work more effectively, transformation plans can’t succeed – something that was evident to all at the i-THRIVE Community of Practice meeting.
And it seems to me that this story is not just about CAMHS transformation. Many of the challenges described above seem to resonate with colleagues working in other parts of the health system, and, with the vanguard sites and the New Care Models programme focusing on whole-system transformation, it feels like there is a real opportunity to find solutions to some of the key structural barriers.
While each service user brings their invaluable and unique personal experience, we, as clinical leaders, bring the accumulated experience of the hundreds or even thousands of patients we have seen over the years. Sometimes we may not recognise this implicit knowledge or credit ourselves with having a point of view that is as relevant as those of systematic reviews and management consultants, yet we all know that clinical observation is a key component of evidence-based practice.
Medical leadership must step up and bring experience, and the priorities born of it, to the discussion around integrated care if we are to design services that will improve the patient’s journey.
- These guest blogs explore issues and opportunities for clinical and medical leaders. Read the other blogs from the series.