Ó 2009 National Public Health Service for Wales

National Public Health Service for Wales Rapid review of Care Programme Approach in Wales

A rapid review of the Care Programme Approach in Wales Authors: Julie Caffel & Stuart Bartley Date: 030909 Version: 1 Status: Final Draft Intended Audience: Welsh Assembly Government Purpose and Summary of Document: This discussion paper outlines the initial findings of a rapid review of the Care Programme Approach. The report examines the evidence base, the effectiveness of its implementation in Wales (utilising information from relevant reports and reviews), and also includes views and opinions gained from discussions with key stakeholders. Initial conclusions and recommendations based on these emerging findings on possible ways forward are included.

Publication/Distribution: For WAG and NPHS website.

Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 1 of 23 Care Programme Approach National Public Health Service for Wales Rapid review of Care Programme Approach in Wales

Contents

Summary and recommendations 3

1 Purpose 4

2 Introduction 4

3 Background 4

4 Care Programme Approach 5

5 Types of case management 6

6 Brief summary of evidence base, literature, reviews and 7 reports 6.1 Review and studies 7 6.2 Inspections, inquiries and reviews 10

7 Stakeholder feedback 12 7.1 Key messages 12 7.2 Specific feedback from stakeholders 13 7.2.1 Service user 13 7.2.2 CPA process and implementation issues 13 7.2.3 Transitions and joint working 14 7.2.4 Co-ordinator role 14 7.2.5 Training 14 7.2.6 Other key issues 14

8 Discussion 15

9 Conclusions and recommendations 17

10 References 19

11 Appendix 1 Revised Care Programme Approach in England 23

Ó 2009 National Public Health Service for Wales

Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context.

Acknowledgement to the National Public Health Service for Wales to be stated.

Summary and recommendations

 The Care Programme Approach (CPA) as a process has been subject to different interpretation and implementation in England and Wales with concerns expressed about its impact on patient care and administrative costs.

 Whilst there is a consensus that the current process should be changed the available evidence and opinion does not support moving away from the CPA framework in Wales.

 Retaining the status quo is not an option if CPA is to be a credible and effective vehicle for improving mental health care within Wales.

To make progress it is suggested:

 Revised policy guidance should be developed by the Welsh Assembly Government which sets out clear definitions and standards for CPA delivery.

 Alternatives to the CPA criterion of enhanced or standard, should be considered as the current distinction is open to wide interpretation.

 There needs to be common approach to standards within the CPA and a standardised approach to application.

 Further integration of health and social care systems has to take place and processes developed for improved joint working across health, social care and the third sector.

 The Unified Assessment / CPA fit needs to be re-examined with all Wales best practice identified and implemented.

 A single set of minimum documentation for Wales (which can be supplemented locally) should be developed.

 Consideration should be given to using a standardised risk assessment and management of risk protocols.

 Care planning needs to be redefined with a focus on recovery based outcomes.

 There needs to be clarification on the role of the care coordinator and guidance developed as to where the role should reside; serious consideration being given to the potential of the third sector.

 CPA training needs should be re-assessed with national competency based programmes developed to agreed standards.

1. Purpose

This report outlines the initial findings of work requested by the Welsh Assembly Government (WAG) to undertake a rapid review of the Care Programme Approach (CPA). The report examines the underpinning evidence base, the effectiveness of its implementation in Wales, utilising information from relevant reports and reviews, with views and opinions gained from high level key stakeholders. Conclusions and recommendations based on these emerging findings on possible ways forward are included.

2. Introduction CPA was originally introduced in England in 1991 to provide a model of clinical case management to underpin the delivery of effective mental health care for those people with severe mental illness and to improve their continuity of care. 1 It was driven by both the changing mental health agenda (with the move to community rather than hospital focused care) and the public safety agenda. The aim of CPA was to ensure that all adults in contact with secondary mental health services received an appropriate assessment and care plan to stop them from falling through the cracks.2 Services were to be prioritised in relation to need and risk. Within this CPA framework, and until recently, two levels of provision, standard (sCPA) or enhanced (eCPA) were prescribed in both England and Wales. Although CPA applies to adults of working age the principles also apply to those over 65 and under 18 when CPA is recommended to those who meet the criteria.3

The strategic direction for mental health services in Wales was set by the Adult mental health services strategy4 and further developed in the National service frameworks for adult mental health.5,6 Guidance on the use of CPA was issued in Wales in 20033 and WAG reinforced their commitment to the CPA being integrated with the social services unified assessment (UA).7 CPA was set as a target for full implementation by WAG in 2004/05.

3. Background

The CPA is a co-ordinated system of case management and is based upon a person centred approach determined by the needs of the individual. It combines care planning with case management and requires agencies to work together to provide integrated services as appropriate.5

The core components of CPA are a comprehensive assessment of need and risk, a written care plan, user and carer involvement, a designated care co-ordinator and regular reviews.

Care planning is the point at which the service user and carer voice is best articulated. To promote recovery and independence care planning should be based

Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 4 of 23 Care Programme Approach National Public Health Service for Wales Rapid review of Care Programme Approach in Wales on an individual’s strengths as well as their needs. It should include all aspects of an individual’s life where support is required e.g. physical, social and psychological.8

4. Care Programme Approach

The original concept of CPA was that it provided a framework for underpinning the delivery of good practice around broadly accepted key principles:3  a person centred approach determined by the needs of the individual  a framework to prevent service users from falling through the net  recognition of the role and support needs of carers  facilitation of the movement of users through the CPA process according to need and service availability  embracing of best practice  involvement of all relevant agencies  full integration of health and social care where appropriate  copies of the care plan available to all relevant parties  an assessment that includes risk and unmet needs  monitoring of the role of the care co-ordinator and effectiveness of this approach.

Since its introduction however, the CPA has been the subject of considerable discussion and review. A number of key criticisms of the approach have emerged which can be grouped into three main headings:

 the absence of an evidence base to justify its use9,10  it is seen as an unnecessarily bureaucratic process9,11  there has been a disparity of use and implementation has been patchy10

One author describes CPA as being like that of a child having reached adolescence i.e. stage of fraught development with potentials and conflicts.

“The CPA hardly experienced an auspicious childhood, seen by many as an unwanted child. Staff who were doing good practice saw it as an unnecessary addition to what they were doing and staff not necessarily doing good practice saw it as...well an unnecessary addition”12 p19

In practice, It would appear that for many the CPA has seen by to be a bureaucratic process which is in danger of becoming a tick box exercise rather than the vehicle for good practice for which it was developed.13 Recent reports have identified problems with implementation, and following a 2006 review,14 new guidance was issued in England in 200815, which revised the CPA to just those individuals who met the criteria for enhanced CPA).

5. Types of case management

Mental health case management emerged in the 1960’s as a response to the shift from inpatient to community focused care. The term case management describes a range of approaches and strategies in mental health rather than a single model of care.16

A number of case management models have evolved but within practice it is often difficult to distinguish clearly between them. Whilst each model emphasises different aspects there is nonetheless an emerging common thread i.e. the co-ordination of care.

It can be argued that although care co-ordination is a common feature, the case management relationship remains ever changing with the need for adaptability, refined clinical skills and practical problem solving skills being the essential prerequisites of an effective case manager. Therefore attempts to try to define this within any one model may miss the point.17

Case management emerged as a model for delivery care in the United States. Since the introduction to case management approaches to mental health services several different styles have evolved:2,16

 brokerage  clinical  assertive/intensive  strengths/rehabilitation

Case management within mental health services has been adopted in many countries despite ongoing questions about its efficacy, its role as either a brokerage system for managing care or a therapeutic tool.18

In England it is suggested that CPA lies somewhere between the brokerage and clinical case management model,2 and in Wales it would appear to be the same.

Case management takes different forms which includes delivery through both team and individual approaches as well as with varying levels of intensity and frequency. The core functions of clinical case management have been described as:19  promoting service user engagement/involvement in treatment  acting as primary service user contact within the community mental health team  brokering of services  advocacy and liaison  psychotherapeutic work

The following have been identified as some of the key components of effective case management:  comprehensive assessment of need Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 6 of 23 Care Programme Approach National Public Health Service for Wales Rapid review of Care Programme Approach in Wales

 development of a care plan or package of care to meet identified need  ensuring the individual has access to or receives the care identified  monitoring the quality of the care  ongoing review

A 2004 paper 20 identified ten principles or active ingredients of case management that were common to interventions that produced statistically significant positive outcomes for people with serious mental illness. They concluded that a case manager is integral to success. They further recommended that the broker model should not be used.

The ingredients they describe for effective case management include:20  case managers should deliver as much of the help or service as possible  community resources are the primary partners  work is in the community  individual and team case management works  case managers have primary responsibility for a person’s services  case managers can be para-professional. Supervisors should be experienced and fully credentialed  caseload should be small enough to allow for a relatively high frequency of contact  case management service should be time-unlimited (if necessary)  case managers should foster choice  people need access to 7 day a week, 24 hour service.

A 2004 nationwide trial of case management within Japan was undertaken.21 It acknowledged the criticisms of the broker model and constructed specific guidelines that included the effective components that had been identified.

It has also been suggested that to impact on the successful implementation of CPA there needs to be a better understanding of the training, supervision and support needs of case managers.22

6. Brief summary of evidence base, literature, reviews and reports.

6.1 Reviews and studies

Research into the effectiveness and validity of case management approaches have often proved inconclusive with conflicting results across different studies.23

A 1998 Cochrane systematic review identified that case management ensures that more people remain in contact with mental health services but it also increases hospital admission rates. In summary the author concluded that case management is an intervention of questionable value, to the extent that it is doubtful whether it should be offered by mental health services.24

The authors of a 2000 systematic review found that clinical case management and Assertive Community Treatment (ACT) were both effective in reducing symptoms of

Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 7 of 23 Care Programme Approach National Public Health Service for Wales Rapid review of Care Programme Approach in Wales illness, improving social functioning, increasing user and carer satisfaction and reducing drop out rates. As with the Cochrane review this study also found that case management increased hospital admission rates.25

A 2001 scoping review of the effectiveness of mental health services identified that CPA was not an effective intervention.26 However it raised a number of issues regarding the strengths and weaknesses of systematic reviews. A key limitation identified that if the studies in the review are poor or do not measure appropriate outcomes, systematic reviews cannot overcome these limitations. A further problem is that results of this type of review may not be generalisable to the UK setting. The report also recognised that not all questions relating to mental health service delivery can be answered by systematic reviews as there are confounding factors which impact such as social/environmental.

A 2002 study by the same authors who undertook the 2000 study 25 compared theirs and the Cochrane reviews and the different conclusions reached. They identified that the conclusions reached were due to differing inclusion criteria such as non- randomised trials, data from unpublished scales and data from variables with skewed distributions. The authors suggest that systematic reviewers may face a trade off between the application of strict criteria for the inclusion of studies and the amount of data available for analysis and hence statistical power. The report concluded that from the available research case management is generally effective.27

A 2005 Welsh health evidence bulletin on mental health included a section on client assessment and care pathways.28 Evidence on the impact of clinical case management was variable. Caveats for the above studies24,25 were included which were that the literature search in the Cochrane review was conducted in 1997 and therefore included old trials , and for the 2000 study only English language papers were included and evidence of publication bias was found.28

One study concluded that the introduction of clinical case management through CPA was associated with an increasing focus on patients with the most severe disorders.29

A lack of co-ordination amongst health professionals and across the health service may contribute to the poor general healthcare of people with mental illness. Case management should include aspects addressing the physical health needs of mental health service users.30

A study examining care management in learning disability and mental health services identified a lack of integration of the CPA and care management processes. It concludes that the balance of evidence suggests poor implementation and guidance alongside poorly constructed policy on care management form and function.31 However, another study found that the CPA had acted as a catalyst to joint working and that its strength was in the development of co-ordinated care packages and codified practice and also assisted in clarifying both agency and individual responsibility.32

Where CPA arrangements are more successfully implemented and where service users experienced increased participation in their care, greater levels of satisfaction

Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 8 of 23 Care Programme Approach National Public Health Service for Wales Rapid review of Care Programme Approach in Wales are expressed. Paradoxically whilst workers complain of the bureaucracy of the CPA service users value the written care plans and information that the care co-ordinators are mandated to deliver.33

Findings of a report which examined involving users and carer in the CPA include:34

 users with a care programme felt more involved in the planning of their care and treatment  most mental health professionals were committed to the idea of involving users and carers and were positive about its effects however, half thought the process was time consuming and over 80 per cent thought it difficult to implement within existing resources.

A 2003 survey on partnership and user involvement suggested that only a small number of respondents were fully aware of what CPA entailed. The report concludes that central policy initiatives largely intervene at a level above that of individual care and assume that staff/patient relations will alter in line with higher organisational change. If the question of CPA being fully implemented in the eyes of services users is based on meaningful involvement then the conclusion has to be it does not . On the occasions where it does happen it makes a difference.35

“ if user satisfaction is regarded as a weak outcome measure, it might be pointed out that satisfied customers tend to be brand loyal.”35 p69

CPA can work well where it is implemented effectively. Integration of health and social care does seem to be preferred by service users, carers and practitioners. Lack of knowledge seems to be the biggest barrier to users exercising their rights to complain and this has clear implications for managers as well as practitioners.36

A 2005 Sainsbury Centre for Mental Health review of the literature on CPA identified the following with regard to the evaluation of its implementation:37

‘A number of research studies have examined the implementation of the CPA on a local or wider scale. Some benefits of the system have been identified along with a number of difficulties in fully implementing the CPA, although a few authors have been unremittingly negative.’

Conclusions of this review included:37  service users experience of the CPA are variable, however where they are properly involved in the process they are happier with the services that they receive and there is evidence that service users welcome the care co- ordination aspects of the CPA  care planning is crucial to the process of discharge from hospital to ensure continuity of care.  CPA documentation should include a comprehensive assessment of needs which includes a risk assessment and a clear plan of actions and interventions that are to be provided alongside necessary factual information. This should be contained within a concise format to encourage completion.

A 2008 literature review on managing mental health care suggests: 38

“There is a strong indication that whatever the approach to managing care, this needs to be adequately resourced in order to proceed although resources are not the sole factor that has influenced the gap between the theories of managing care and the reality.

It is described in the literature that there has been a longstanding discrepancy between the theory of each approach and the actual reality. For example the care in care plans is not always offered, the adequacy of evidence underpinning clinical guidance is disputed, and the co-ordination of care within the CPA has been sporadic.”

6.2. Inspections, inquiries and reviews

Since its introduction the CPA either as part of overall mental health services or alone has been subject to a number of reviews and inspections both in England and in Wales.

A Department of Health (DH) Social Services Inspectorate report found that:39  assessment systems varied significantly between professional groups, different agencies and within agencies  there was a lack of risk assessment altogether in some authorities; different models of risk assessment were being undertaken within the same agencies and a lack of acceptance by different professionals that everyone has a contribution to make in undertaking risk assessments.  care planning and regular reviews were expected in most social services department’s procedures. There were examples of good co-ordination between agencies but in some authorities staff were expected to work within two separate systems causing duplication and unnecessary paperwork.

Key messages from a 2005 Sainsbury Centre for Mental Health Briefing on CPA for service users who are repeatedly detained identified that:40  service users should be at the heart of the CPA process  effective implementation of CPA is vital to ensure that appropriate services are planned and delivered to service users who are repeatedly detained under the Mental Health Act  local systems should ensure equitable treatment of service users  staff from all agencies and disciplines should work together to ensure continuity of care  assessment and care planning should be comprehensive and include all factors that contribute to health and well being.

The Wales Audit Office Adult mental health services in Wales: A baseline review of service provision41 identified a number of issues regarding the implementation of CPA in Wales.

“A change in working practices and culture is needed if the Care Programme Approach is to be fully implemented”41, p10 Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 10 of 23 Care Programme Approach National Public Health Service for Wales Rapid review of Care Programme Approach in Wales

The report identified that significant progress had been made with implementation, however many areas struggled to meet the implementation target. There were indications that the increased workload associated with CPA and care plan reviews were causing difficulties in some areas. There was also some concern that the focus of action to date has been on the introduction of new documentation rather than the changes in working practice and culture that CPA is designed to stimulate.41

A 2006 Welsh Assembly Government report reviewing the implementation of the CPA in Wales found that:42  significant progress has been made in implementing CPA in all parts of Wales however systems for recording unmet need are embryonic, risk assessment tools vary, and there is variance of use across NHS trusts of the levels of CPA  the lack of embedded information technology (IT) systems across health and social care services capable of supporting CPA was significantly hampering progress.  developing an integrated system to support CPA/UAP across health and social care services provides a serious challenge.

The 2006 Avoidable deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness identified a number of key areas relevant to prevention as well as offering potential solutions to services.43 The report made several recommendations regarding CPA under the following headings:43

 transition from inpatient ward to community  use of the CPA and management of risk  responding when a care plan breaks down  dual diagnosis

In 2006 the Department of Health (DH) issued a consultation Reviewing the Care Programme Approach to which approximately 300 responses were received.14 Some key points raised in the responses included:

 general support for the CPA and underpinning it with values and principles and the inclusion of recovery and positive risk taking were perceived as positive  transitions and out of area placements were raised as an issue  mandatory competency based training was suggested for care co-ordinators to include involvement of the third sector user/carer  how best to manage physical health needs  need to standardise systems and processes across providers  consensus that significant improvements were needed to integrate health and social care- in terms of policy, information systems performance review and reporting.

Following the consultation in 2008 the DH issued Refocusing the care programme approach. Policy and positive practice guidance15. This moved the CPA in England to just one level that of eCPA.

Within Wales some of the key recommendations within recent Health Inspectorate Wales (HIW) reviews into homicides identified:44,45  training needs for staff  need for CPA to address transitions  CPA links with UAP  care co-ordination role must be discharged effectively  NHS and social service should have jointly agreed risk management procedures as part of the UAP and CP processes in respect of both the policies and training offered  Improved communication and information sharing

A recent review of the CPA in Wales46 found that:

 there was general consensus that the CPA was a valuable framework  the review came to similar conclusions as above HIW reviews particularly with regard to risk assessment and risk management.  training is required into risk assessment and management as well as outcome focused care planning.  there is evidence of an increase in dual diagnosis but this is not reflected in documentation  IT systems are problematic  there is a need for common eligibility criteria  no common targets across health and social care agencies  care co-ordinators need a better understanding of their roles  need for standardisation of CPA process and documentation across Wales  clarification is needed of the role of the doctor as care co-ordinator or not  physical health needs is not routinely monitored  transitions and out of area placement require work

7. Stakeholder feedback

This section summarises feedback from a range of high level key stakeholders following a series of one to one and small group meetings.

7.1 Key messages

Key messages from all feedback included:

 CPA itself is seen as positive by all stakeholders  service users are felt to be supportive of CPA  there is a need to reduce the bureaucracy or perceived bureaucracy that has developed  service users should be at the heart of the process  needs to be commitment to the CPA  the interpretation and application is variable across Wales  there needs to be common approach to standards with the CPA and a standardised approach to application

 integration of health and social care processes and for improved joint working across health, social care and third sector  CPA criterion of enhanced or standard is open to interpretation and despite staff guidance and supervision the CPA level attributed to the service user is often inconsistent, this can lead to patchy relapse/contingency planning.  risk assessment and management of risk needs standardising  need to focus on outcomes rather than the process  ongoing training on the CPA is required with specific training on the role of the care co-ordinator  concerns about the interface of CPA and UAP and unwieldiness of the process.  use/development of common IT systems (although an example was provided where this has been undertaken and there have still been issues regarding unwieldy and over bureaucratic processes)  more effective joint working to avoid duplication of work  unmet need should be recorded  reviews are not necessarily multi- agency e.g. social services representatives are not always invited to reviews (even for Section117).  need for an effective caseload management tool  greater clarity of role of the care co-ordinator role  changes needed to attitudes on the process

7.2 Specific feedback from stakeholders

In addition to the above feedback stakeholders identified a range of issues:

7.2.1 Service user  service users want to retain the CPA although the experience of the process varies significantly  not necessarily seen from the service users perspective and it should be empowering recovery/discovery focused  anecdotally service users can find systems difficult to navigate and care planning process can be disempowering  services must be drive by service user need and should be responsive and personalised

7.2.2 CPA process and implementation issues  local authority and NHS have different drivers and priorities  CPA framework is valuable, problem has been its implementation o CPA is a local affair and therefore implementation varies underlying quality issues  not currently goal/outcome focused or holistic application o need for CPA care plans to become outcome focused, driven by service user and underpinned with recovery  rationalisation of the process is needed  need for a standardised tool for Wales o needs to be a simplified process

 criteria for two levels is subject to local/individual determination o could be continuum rather than two levels o two levels are helpful  CPA should define general standards o need for consistency of process and application o should be a minimum standard framework which includes core information and locally add ones can be made as required o code of practice areas should be included o can be seen as a tick box exercise  CPA and UAP not working together effectively o UAP and CPA problematic in some areas requiring repetition/duplication of work  CPA process not necessarily fully involving key participants e.g. engaging support staff etc to ensure that all relevant information is recorded and used within CPA process of planning and review  management of the process is an issue e.g. waiting list for assessment, waiting list for care co-ordinator

7.2.3 Transitions and joint working  strengthening of partnership working issues  transitions in all areas are an issue e.g. in and out of services, across specialist services, age barriers  perceived exclusion criteria e.g. learning disability  dual diagnosis issues not necessarily adequately addressed  primary care - secondary care interface requires work

7.2.4 Co-ordinator role  who should be care co-ordinator o should doctors be care co-ordinators- is this the best use of their skills and time? o role of third sector  clarity required and training needed on role of the co-ordinator  could be used as a performance management tool  needs to be a method of sharing good and innovative practice across Wales

7.2.5 Training  need for training and guidance for staff and more information for service users/carers o should be part of mandatory training e.g. induction  lack of joint training

7.2.6 Other key issues  IT compatibility  need for caseload management tools  need to log unmet need as it is not necessarily recorded  variable high level priority within Trusts

8. Discussion

Evidence on the impact of case management is often contradictory or equivocal. However, the evidence and review base identify some interesting issues. A consistent theme identified is a disparity in the use of and patchy implementation of CPA.10,39,41 This ongoing issue of problematic implementation was identified in older and recent reports as well as highlighted by stakeholders.

If full implementation has not been achieved then reviewing the evidence will not necessarily provide a comprehensive picture of the impact of CPA. Some studies were undertaken prior to the implementation of realistic community developments being available as an alternative to hospital admission.

Historically community services worked 9-5pm and weren’t necessarily geared to offer comprehensive support. Furthermore continual developments within mental health services, particularly within community settings, are now providing real alternatives to hospital admission. Increased admission rates should not necessarily be perceived negatively but as part of the care package rather than service failure and with the developments of alternatives to hospitalisation within the community new studies may have different outcomes using this as an indicator.

Within England the DH revised CPA guidance15 states:

“ It is clear all service users should have access to high quality, evidence- based mental health services. For those requiring standard CPA it has never been the intention that complicated systems of support should surround this as they are unnecessary. The rights that service users have to an assessment of their needs, the development of a care plan and a review of that care by a professional involved will continue to be good practice for all.

So, from October 2008 the term CPA will no longer be used to describe the usual system of provision of mental health services to those with more straightforward needs in secondary mental health services (formerly standard). However, as a minimum, service providers must continue to maintain a short central record of essential information is maintained on all individuals receiving secondary mental health services and that reviews take place regularly.”15, p11

This suggests that although there is now only eCPA in England, service users not subject to this level of care will still have an assessment, someone to facilitate care, a minimum data set completed, and a statement of agreed care and regular reviews. An assumption is that for new referral an assessment, including risk etc, will need to be completed to decide on whether eCPA or non CPA is required. It is unclear at present how this new CPA will impact on the service users’ experience, or provider organisations. Whether it significantly reduces bureaucracy has yet to be seen, although it will result in a reduction of the completion of the core CPA documentation that Trusts have developed and also a reduction in reviews.

It is clear however that the process of care delivery , whatever it is called, it must have an underpinning framework . This framework should ensure continuity rather than fragmentation of provision and the avoidance of duplication . It should also impact on quality and equity for delivery ensuring the service user is at the centre of the process. Appendix 1 identifies the difference of those requiring the new CPA in England and those not.

It is early days within the implementation of the new CPA process within England and its impact on service users and providers is unclear.

Many of the studies and reports examined, identified that when working well CPA was beneficial in terms of outcomes and service user experience. It could be argued that much of the bureaucracy and perceived bureaucracy, surrounding the CPA would appear not to have been driven by the policy itself but by the interpretation and implementation of it at a local level.

CPA for some is seen as outside of the normal working processes rather than an integral underpinning framework of good practice to underpin mental health care which is what it should be used as it was designed for. There would appear to have been an industry created around the CPA which has led to it being seen as an addition rather than the framework to underpin quality mental health services reinforcing what should be seen as good practice.

It has been suggested that the role of the care co-ordinator role within CPA was not designed to support the provision of psychosocial interventions. As a result those in the role of CPA co-co-ordinator face competing roles and demands and are not necessarily able to provide the range of evidenced based interventions required. This may partially account for increased bed use that has been associated with case management.47

An article on how to make the CPA effective and credible suggests that the focus of CPA changes emphasis away from what is perceived as a paperwork exercise to one that is based on clinical case management and the emphasis moves to the positive clinical and therapeutic focus. Furthermore the article suggests skilled provision of a range of therapeutic interventions needs to be recognised as a core component of the care coordinator role rather than an add on after their CPA duties are met.48

It is argued that case management is in itself not an effective treatment for major mental illness. It is the method for organising service delivery and future research and practice regarding case management should focus on the development of services that include specific targeted interventions aimed at improving clinical outcomes.2

9. Conclusions and Recommendations

This rapid review of the CPA has suggested;

 CPA as a process has been subject to different interpretation and implementation both within England and Wales.

 findings on the efficacy of case management are variable but there does appear to be a consistent view that it is appreciated by service users.

 there appears no support from stakeholders for moving away from the CPA framework in Wales but there is a consensus that the current process needs to be changed. (However, this was a small and not necessarily representative stakeholder sample).

 there appears to have been a loss of focus on the key values and principles that underpin the CPA and there is need to shift attitudes to refocus on the CPA’s original intent. Whatever model or framework for care assessment, planning and delivering is in place clear definitions and standards should underpin it.

 the fundamental changes required suggest that the CPA should be seen as an individualised framework for good practice and an integral and underpinning process of mental health care delivery. There is a need for a consistent approach to implementation and a cultural shift from the CPA being seen as primarily an administrative process.

 retaining the status quo is not an option if CPA is to be a credible and effective vehicle for improving mental health care within Wales. The process needs to be reclaimed as a non bureaucratic process, redefined, stream lined and standardised.

In order to move forward this review recommends :

 revised policy guidance should be developed which sets out clear definitions and standards for CPA delivery.

 CPA criterion of enhanced or standard is open to interpretation so further consideration is needed on whether to keep current levels or consider alternatives

 there needs to be common approach to standards with the CPA and a standardised approach to application

 further integration of health and social care processes has to take place and processes developed for improved joint working across health, social care and third sector

 the UA/ CPA fit needs to be re-examined with all Wales best practice identified and implemented

 a single set of minimum documentation for Wales (which can be supplemented locally) should be developed

 consideration be given to using a standardised risk assessment and management of risk

 care planning needs to be redefined with a focus on recovery based outcomes

 there needs to be clarification of the role of the care coordinator and guidance developed as to where the role should reside - serious consideration being given to the input of the third sector.

 CPA training needs should be re assessed with national programmes developed to agreed standards with consideration given to make it part of mandatory training for all relevant staff.

 work is needed on defining good practice in all areas of transitions and transfer

 robust systems of unmet need should be in place to inform service developments.

 WAG could consider undertaking or commissioning further research into appropriate models of providing care accepting the broad principles of the CPA approach

10. References

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Appendix 1

Table 1: English new CPA Service users needing (new) CPA Other service users

An individual’s characteristics

More straightforward needs; one Complex needs; multi-agency input; higher risk. agency or no problems with access to other agencies/support; lower risk

What the service users should expect Support from CPA care co-ordinator Support from professional(s) as (trained, part of job description, co-ordination part of clinical/practitioner role. support recognised as significant part of Lead professional identified. caseload) Service user self-directed care, with support. A comprehensive multi-disciplinary, multi- A full assessment of need for agency clinical care and assessment covering the full range of needs treatment, including risk and risks assessment An assessment of social care needs against An assessment of social care FACS eligibility criteria (plus Direct Payments) needs against FACS eligibility criteria (plus Direct Payments)

Comprehensive formal written care plan: Clear understanding of how care including risk and safety/contingency/crisis plan and treatment will be carried out, by whom, and when (can be a clinician’s letter) On-going review, formal multi-disciplinary, On-going review as required multi-agency review at least once a year but likely to be needed more regularly At review, consideration of on-going need for On-going consideration of need for (new) CPA support move to (new) CPA if risk or circumstances change

Increased need for advocacy support Self-directed care, with some support if necessary Carers identified and informed of rights to Carers identified and informed of own assessment rights of own assessment Source: Department of Health. Refocusing the care programme approach. Policy and positive practice guidance. London: DH; 2008 p16.

Author: Julie Caffel / Stuart Bartley Date -03/09/09 Status: Final Draft Version: 1 Page: 23 of 23 Care Programme Approach