Introduction
National policy on care planning in mental health services in Ireland was initially outlined in A Vision for Change (Department of Health and Children (DOHC) 2006), which endorsed the involvement of service users (SUs) and families/supporters in the development of their own care plan in conjunction with the multidisciplinary team (MDT). Over the intervening years, guidance on care planning has been elaborated in a series of reports from the Department of Health (2020), the Health Service Executive – HSE (Writing a Person-Centred Individual Care Plan – Guidance Document 2021) and the Mental Health Commission – MHC (Guidance Document for Individual Care Planning and Mental Health Services 2012, The National Quality Framework: Driving Excellence in Mental Health Services 2023). These documents set out the principles of recovery-focused care planning that are to be applied across all secondary level mental health services but primarily address the inpatient setting and do not provide specific guidelines for translating policy from the inpatient setting to a model of best practice for community mental health. This paper is the first in a two-part series and describes the development and operation of the Collaborative Care Pathway (CCP-9), an innovative approach to delivering recovery-focused community mental health care which has been piloted and implemented in a community-based secondary level service in Ireland, while the companion paper II (Keogh et al. Reference Keogh, Doyle, Higgins, Van Gelderen, Duggan, Jackson, Matthews, Gribben, McAndrew, Daly and Gibbons2025) reports on satisfaction with the CCP-9 process from the perspectives of SUs, family members and mental health practitioners (MHPs).
Beginning in 2010, the development of the CCP-9 was prompted by a mandate from local service managers to standardise best practice across the two community mental health teams (CMHTs) then operating in a mental health service serving a largely urban population with a large rural hinterland. The process of developing the CCP-9 was guided by “A Vision for Change” (DOHC 2006 p.81), which provided a general recommendation that “the needs of each SU should be discussed jointly by the team, in consultation with users and carers, in order to construct a comprehensive care plan.” As the CCP-9 was reviewed over subsequent years by the CMHTs, further development was informed by the evolving policy and guidelines in the field. The most recent iteration of care planning guidelines are outlined in Standard 6.1 in the Quality Framework Document (MHC 2023 p.12), which states that SUs should be “active participants in planning and delivering their own care” and which goes on to outline ten criteria for meeting this standard (see Table 1 for an adapted summary).
Quality framework criteria for meeting Standard 6.1: “Service users are active participants in planning and delivering their care.”
In 2011, the CMHTs began a series of planning meetings which representatives of each MDT and mental health discipline were encouraged to attend, and which were held on a bi-monthly basis over approximately two years. As SU and family member peer workers had not yet been employed by the HSE, peer representation was not available to contribute to the initial development process. Working groups were established to prepare operational guidelines in relation to the assessment of need, care planning and the delivery of care (e.g. MDT working and family support) which were then presented to the joint meetings for further discussion and agreement by consensus. In this way, a standard set of operational procedures was developed in stages and agreed by the sector teams, which informed each step of the care pathway from referral through to ultimate discharge and which were implemented incrementally over the following 2 years.
The development of the CCP-9 was also informed by invaluable experience gained by the relevant sector teams of collaborating with SUs and families through the contemporaneous co-production and piloting of the EOLAS Mental Health Information and Support Programmes (Higgins et al. Reference Higgins, Hevey, Gibbons, O’Connor, Boyd, McBennett and Monahan2016). Building on this experience and informed by emerging public policy and practice in relation to care planning, further review and ongoing adaptation of the CCP-9 was undertaken collectively by the MDTs in each of the three CMHTs which now operate in the sector. This allowed the specific procedures followed in each area (e.g. for psychosocial assessment) to evolve organically in response to changing service needs and available resources (especially personnel and skill-set availability), while aiming to respect the nine-step structure of the pathway and the core principles on which the CCP-9 is based.
Description of the 9-Step Collaborative Care Pathway (CCP-9)
The CCP-9 is an elaboration of the 6 stages of the care planning process outlined in the MHC Guidance Document (p.14, MHC, 2012) and adapted in Fig. 1:
MHC care planning process.
Each step of the CCP-9 from referral through to discharge is outlined as follows:
Step 1 – Initial triage of all referrals to the community mental health service (by the consultant psychiatrist and MDT)
Initial triage allows further information to be sought from the referring agent as needed and an assessment appointment offered where appropriate.
Step 2 – Initial psychiatric assessment of needs and goals (by service user and psychiatrist or clinical nurse specialist (CNS))
This is a standard psychiatric assessment interview and includes a risk assessment using a standardised tool e.g. FACE Risk Assessment (Clifford Reference Clifford2017).
Step 3 – Advanced triage of cases (by assessing clinician and consultant psychiatrist)
The initial assessment is reviewed with the consultant psychiatrist (CP) to plan next steps. Where the presenting difficulties are not considered severe or complex, advice is offered to the person about symptom management strategies, lifestyle issues and psychotropic treatment options. Relevant support services in the community and online resources are signposted, telephone feedback offered to families/supporters (with SU consent) and the SU is discharged to primary care follow-up. In some cases, a trial of psychotropic treatment may be started and reviewed before discharge.
Step 4 – Comprehensive psychosocial assessment (by service user and key nurse ± family)
This step aims to provide further understanding of diagnostic issues as well as of the psychological, social and environmental factors impacting on the person’s mental health and is offered to those with “complex” needs e.g.
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major mental illness of moderate/severe degree
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complex psychological difficulties e.g. personality disorder
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acute risk to self/others arising from mental illness
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diagnosis is unclear.
The purpose and nature of the psychosocial assessment process is explained by the assessing clinician and verbal consent obtained. At this point in the process, a key worker is identified (usually a mental health nurse working in the day hospital or home care team) who undertakes the psychosocial assessments. Standardised assessment tools are used, although the specific instruments used may vary between teams and over time. These include self-completed questionnaires, particularly the Personal Goals Assessment (which provides the SU an opportunity to describe their personal goals and priorities in recovery – Appendix 1) and the SCID-II (a widely used measure of personality function (First et al. Reference First, Gibbon, Spitzer and Benjamin1997)). Observer rated scales are also completed by the key worker e.g. Montgomery Asberg Depression Rating Scale – MADRS (Montgomery and Asberg Reference Montgomery and Asberg1979) for depressive symptoms, Hamilton Anxiety Rating Scale – HARS (Hamilton Reference Hamilton1959) for anxiety symptoms and the Functional Analysis of the Care Environment – FACE (Clifford Reference Clifford1997) for social functioning.
Additional assessments are completed where specifically indicated e.g. for the assessment of psychotic or manic symptoms/experiences, and baseline physical health measures and blood screen are completed. In addition, a semi-structured narrative history is completed with a family member/supporter to outline family views on relevant aspects of the personal and social history, presenting symptoms/challenges, and family concerns and priorities in recovery.
Step 5 – Comprehensive case review (by service user and consultant psychiatrist)
A further detailed review is carried out jointly by the SU and CP of assessments completed to date, presenting difficulties, developmental/life history and diagnostic issues.
Step 6 – Formulation of difficulties and drafting of treatment and care recommendations – TCR (completed by the MDT)
The person’s history and standardised assessments are reviewed collectively by the MDT, and the main points summarised utilising the 5-Ps model (Macneil et al. Reference Macneil, Hasty, Cous and Berk2012) under the following headings: 1. Positives and strengths, 2. Presenting problems, 3. Predisposing factors (renamed “Vulnerabilities”), 4. Precipitating factors (renamed “Triggers”) and 5. Perpetuating factors (renamed “Maintaining factors”). These factors are recorded in the “Understanding Difficulties” Summary Page (see Appendix 2 for a representative fictional example), which is entered via laptop onto a digital template during the MDT case review. This format allows the MDT to document the presenting difficulties (under the heading “The Problem”) in a way that allows the interplay of psychological, physical and behavioural difficulties to be explored. The risk assessment is updated by the MDT at this stage.
Based on the “Understanding Difficulties” summary, the MDT completes a psychosocial formulation of the case which provides a basis for identifying appropriate interventions to support recovery in conjunction with the diagnostic process. These interventions are agreed by consensus within the team and recorded in the MDT Treatment and Care Recommendations summary (TCR – a fictionalised example is outlined in Appendix 3). Responsibility for delivering specific interventions is allocated to named team members where these interventions are adopted by the SU as part of their care plan.
Step 7 – Feedback and drafting of the action plan for recovery (by service user and key nurse, ± family and MDT)
The key worker provides comprehensive feedback to the SU through a two-stage process (and can be supported by other team members when needed). In the initial stage, the key worker and SU jointly review the “Understanding Difficulties” summary formulation, to provide insight into the factors contributing to mental ill-health and also to allow for correction of any discrepancies or misinterpretations that the SU identifies in the formulation. In the following stage, the diagnostic and MDT formulation and TCR care recommendations are reviewed. Explanation of diagnostic terms (such as “psychosis” or “personality disorder”) is offered by the key worker as well as information on treatment options e.g. psychological and pharmacological treatments which may help. Based on these discussions, the key worker and SU work together to agree a recovery-focused individual care plan, called an “Action Plan for Recovery” – APR (Appendix 4), which outlines the actions that the SU agrees to undertake. Risk issues are reviewed and a longer-term Crisis Plan to mitigate identified risks to self or others is agreed and documented. The SU is offered a copy of all summary documentation i.e. “Understanding difficulties” summary, TCR, Crisis Plan and APR.
At this point in the pathway, SUs are invited to accompany family members/supporters to a further feedback meeting where the key worker, CP and other relevant MDT members (such as an occupational therapist) are present. This provides an invaluable opportunity to engage families in understanding SU difficulties, to bolster SU commitment to following up on their APR care plan and to agree actions families can take to support recovery e.g. family therapy or family support from voluntary sector agencies, recovery colleges or information and support programmes such as EOLAS.
Step 8 – Implementation (by service user, key worker, MDT)
SUs who have not presented with a major mental illness (e.g. psychosis or major mood disorder) or a severe psychological condition (such as borderline personality disorder), may opt to undertake short-term interventions with the CMHT such as WRAP – Wellness Recovery Action Plan (Copeland Reference Copeland1997) or anxiety management therapy. Information will be offered on managing and optimising psychotropic medication treatment e.g. management of side-effects. Where appropriate, these SUs are supported by their key worker to access further individual therapy with community support and counselling services.
Step 9 – Discharge (involving SU, key worker, psychiatrist ± family)
Progress in the completion of agreed steps in the individual’s APR care plan is reviewed at the weekly MDT meeting, to identify obstacles to recovery and to support the key worker and SU to overcome difficulties identified and thereby progress to discharge. Once the person has completed agreed interventions with the MDT and contacted relevant community services for any follow-up care, a discharge appointment is arranged with the CP or an NCHD psychiatrist with consultant supervision to review progress and confirm the discharge plan. Copies of relevant case formulation and care planning documentation may be copied to the GP as part of the discharge summary.
In situations where people experience more complex conditions, the SU may opt for longer-term interventions with the CMHT as part of their APR e.g. referral for dialectical behaviour therapy for those with a diagnosis of borderline personality disorder or to the ongoing care clinic for those with a psychotic disorder. In this case, the key worker role is transferred to the MDT member who will be working most closely with the person during the period of extended care (e.g. clinical nurse specialist, psychologist or DBT therapist) and discharge is postponed for the duration of ongoing care.
A summary flow diagram of the CCP-9 care pathway is presented in Fig. 2:
Summary flow diagram of CCP-9 care pathway. Abbreviations: service user (SU), mental health nurse (MHN), multidisciplinary team (MDT), non-consultant hospital doctor (NCHD), consultant psychiatrist (CP), clinical nurse specialist (CNS).
Discussion
The CCP-9 is, to our knowledge, the first description of a complete care pathway designed to meet the quality standards of recovery-focused care planning in community mental health in Ireland. The key innovative features which characterise the CCP-9 are the following:
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development of the CCP-9 has been “bottom-up,” developed by community mental health staff across disciplines working collaboratively and by consensus.
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assessment of relevant psychological, social and environmental factors is front-loaded and carried out in parallel with diagnostic assessment.
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the depth of assessment and care planning is graded (step 3) according to SU need and preferences.
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family input in the assessment, feedback and support process is emphasised (with SU consent).
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the MDT has an enhanced role in case formulation and in identifying potential interventions to address psychosocial issues impacting on mental health.
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a streamlined pathway is provided through assessment, care planning, treatment and review, leading to prompt discharge to community/primary care services for those with less severe difficulties.
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the role of the key worker is central in coordinating psychosocial assessment, care planning and delivery of care, and in supporting the SU and family members through the process.
The experience of the Care Programme Approach (CPA) in England and Wales provides a useful point of reference for reviewing the operation of recovery-focused care planning, as CPA has been extensively evaluated over the several decades since its introduction in England in 1991. As in the Quality Framework (MHC 2023), SU empowerment and recovery principles are prioritised in CPA guidelines (Department of Health (UK), 2008, p.7). However, in practice, care planning in the UK is often clinician-led, with the care plan being presented to the SU retrospectively for their endorsement (Grundy et al. Reference Grundy, Bee, Meade, Callaghan, Beattly, Olleveant and Lovell2016). This approach is frequently experienced by SUs as tokenistic, disempowering and irrelevant to recovery, leading to high levels of dissatisfaction and even refusal to participate in the process (Brooks et al. Reference Brooks, Lovell, Bee, Sanders and Rogers2018, Simpson et al. Reference Simpson, Hannigan, Coffey, Jones, Barlow, Cohen, Vseteckova and Faulkner2016, Bee et al. Reference Bee, Price, Baker and Lovell2015). SUs express a clear preference to be consulted in advance of a care plan being documented (Bee et al. Reference Bee, Price, Baker and Lovell2015), but this only occurs in a minority of cases (Health Inspectorate Wales, 2019, Brooks et al. Reference Brooks, Lovell, Bee, Sanders and Rogers2018, Simpson et al. Reference Simpson, Hannigan, Coffey, Jones, Barlow, Cohen, Vseteckova and Faulkner2016). Families have also reported that their input into CPA is very limited or disregarded (Health Inspectorate Wales, 2019, Cree et al. Reference Cree, Brooks, Berzins, Fraser, Lovell and Bee2015). In consequence, CPA is felt by SUs, families and MHPs to prioritise procedure and format (e.g. documentation and risk management) over process (e.g. quality of collaboration) and to serve organisational agendas (particularly risk prevention) rather than being driven by personal recovery (Brooks et al. Reference Brooks, Lovell, Bee, Sanders and Rogers2018, Simpson et al. Reference Simpson, Hannigan, Coffey, Jones, Barlow, Cohen, Vseteckova and Faulkner2016). In the CCP-9, focus on SU-defined priorities is addressed through the Personal Goals Assessment (step 4) in which the SU identifies their main concerns prospectively. The care plan (APR) is co-produced (step 8) by the service user and key worker (albeit informed by the MDT recommendations outlined in the TCR – step 7). Families, in turn, are invited to participate in the assessment (step 4) as well as the care plan feedback, intervention and discharge planning stages of the pathway (steps 7, 8 and 9). As the CCP-9 was developed using a “bottom-up” approach, the process is driven primarily by the focus of MHPs on the care needs of the SU and family rather than by organisational agendas such as the measurement of performance indicators.
An additional obstacle to meaningful SU and family engagement in care planning is posed by their lack of access to information about the process. In one survey of SUs attending community mental health services in Ireland, 58% reported being unaware of having a care plan (de Burca et al. Reference de Burca, Flood, Armstrong, McCurtain and Saunders2007), while in Wales, less than half of SUs reported being given a copy of their care plan (Health Inspectorate Wales, 2019). This information deficit undermines the confidence of SUs and family members in participating in care planning and contributes to the perceived power differential in their relationships with clinicians (Bee et al. Reference Bee, Price, Baker and Lovell2015). Shared decision making (SDM) is a widely accepted and effective approach to redress this imbalance by strengthening the mutual exchange of information and supporting the SU to use this information in making decisions around their care (Elwyn et al. Reference Elwyn, Forsch, Thomson, Joseph-Williams, Lloyd, Kinnersley, Cording, Tomson, Dodd, Rollnick, Edwards and Barry2012, Joosten et al. Reference Joosten, DeFuentes-Merillas, de Weert, Sensky, van der Staak and de Jong2008). SDM is considered to be a “guiding principle” of CPA and emphasises the process of how choices about treatment are made rather than the end product i.e. the documented care plan (Lovell et al. Reference Lovell, Bee, Brooks, Cahoon, Callaghan, Carter, Cree, Davies, Drake, Fraser, Gibbons, Grundy, Hinsliff-Smith, Meade, Roberts, Rogers, Rushton, Sanders, Shields, Walker, Bower and van Wouwe2018). The CCP-9 pathway reflects the core features of SDM in providing an early opportunity for the SU to identify their goals and priorities in recovery (step 4) and in utilising mental health education (such as the EOLAS Programmes) as an essential tool to support the SU in making choices in relation to recovery strategies (step 7). The successful navigation of the challenges faced at each of these steps will depend in large part on the quality of the therapeutic relationship and collaboration between the SU and key worker, and the survey results (paper II) suggest that this is a strength of the CCP-9.
It is striking that while clinicians report openness to delivering more recovery-focused care, converting policy on SDM into effective practice has proved challenging despite intensive training and didactic teaching of clinical staff (Joseph-Williams et al. Reference Joseph-Williams, Lloyd, Edwards, Stobbart, Tomson, Macphail, Dodd, Brain, Elwyn and Thomson2017, Lovell et al. Reference Lovell, Bee, Brooks, Cahoon, Callaghan, Carter, Cree, Davies, Drake, Fraser, Gibbons, Grundy, Hinsliff-Smith, Meade, Roberts, Rogers, Rushton, Sanders, Shields, Walker, Bower and van Wouwe2018). This may reflect the fact that obstacles to implementing SDM can be more cultural than technical, as the attitudes of both SUs and clinicians appear to have a greater impact on the effectiveness of SDM than specific practitioner skills or the specific tools/procedures utilised in implementation (Slade Reference Slade2017, Joseph-Williams et al. Reference Joseph-Williams, Lloyd, Edwards, Stobbart, Tomson, Macphail, Dodd, Brain, Elwyn and Thomson2017). Congruent findings have been reported in a study of clinicians who have co-facilitated the EOLAS Programmes, where the experience of collaboration with services users and families promoted second-order (i.e. cultural) change around recovery-oriented practice within mental health services (Higgins et al. Reference Higgins, Murphy, Downes, Barry, Monahan, Doyle and Gibbons2020). These studies suggest that one of the main strengths of the CCP-9 approach may lie in providing clinical staff with an opportunity for “experiential” learning in relation to SDM (e.g. through the practice of skills in supporting SUs in deciding which interventions from the TCR to adopt in their APR care plans) which can be more effective in embedding recovery principles and changing the culture of clinical practice than the usual didactic approach (Slade Reference Slade2017). Cultural change is therefore potentially more important in the longer-term impact of the CCP-9 model than the specific procedures utilised.
In CPA, the assessments on which care planning is based are considered by SUs to be superficial and overly focused on diagnosis, with insufficient attention to relevant psychosocial context (Brooks et al. Reference Brooks, Lovell, Bee, Sanders and Rogers2018, Bee et al. Reference Bee, Price, Baker and Lovell2015). This approach risks “pathologising” life difficulties, such that illness comes to define the person’s identity rather than their strengths, undermining autonomy and increasing the risk of long-term dependency on practitioners (Simpson et al. Reference Simpson, Hannigan, Coffey, Jones, Barlow, Cohen, Vseteckova and Faulkner2016). The most effective approach to achieving balance between the diagnostic and psychosocial aspects of assessment and care planning is likely to be through reinforcing the role of the MDT throughout the process. However, a range of obstacles to effective MDT involvement in care planning in Ireland have been identified in the National Mental Health Services Collaborative Report on Individual Care Planning (Mental Health Strategies, 2011), including “professional separatism” (e.g. in the continuing use of separate nursing care plans) and a relative lack of medical support for collaboration. Care planning is also potentially impacted by impaired communication within the MDT, as well as between clinicians, SUs and families (Bee et al. Reference Bee, Price, Baker and Lovell2015), such that care coordinators can experience feelings of isolation and a lack of support and involvement by the MDT (Simpson et al. Reference Simpson, Hannigan, Coffey, Jones, Barlow, Cohen, Vseteckova and Faulkner2016). The CCP-9 addresses these challenges by ensuring that detailed psychosocial assessment occurs concurrently rather than after completion of the diagnostic process and that diagnosis is embedded within the MDT formulation rather than superseding it. The MDT also plays an enhanced role in collectively agreeing the therapeutic interventions to be included in the TCR, in supporting feedback and psychoeducation, in delivering care interventions that the SU has adopted in their APR and in reviewing progress weekly up to discharge. This degree of MDT involvement in the CCP-9 minimises the risk of “professional separatism” and obviates any need for separate care plans for each discipline.
Implementation of the CCP-9 is likely to have a downstream impact on the delivery of other components of care by the CMHT. The main concern raised by mental health practitioners (MHPs) in relation to the CCP-9 (paper II) is the significant amount of time invested in assessment, care planning and feedback, which generally amounts to 16–18 hours of clinician time. To some degree, this investment of time can be offset by the emphasis in the CCP-9 on prompt discharge of people with less complex difficulties from CMHT follow-up, thereby easing pressure on the outpatient service. The CCP-9 can also provide more effective anticipation and proactive management of crises by the CMHT (e.g. with duty staff having access to a detailed formulation and care plan to guide the management of “out-of-hours” crises), potentially decreasing acute presentations to the outpatient service or Emergency Department. Time-management may arise as a particular challenge for the CP, given the reliance of the CCP-9 on consultant input at multiple points of the pathway. This is balanced to some extent by the increased autonomy with which the key worker can practice when guided by the formulation and care plan, so that psychiatric review may be required less frequently once the care plan is in place. In addition, some tasks such as the pre-discharge review (step 9) can be delegated to other team members such as NCHDs with consultant supervision, depending on local circumstances. For SUs and family members, the main concern of both groups relates to the difficulties experienced by SUs in accessing community therapy and support services following discharge from CMHT care (paper II). We suggest that MHPs respond to this concern by collaborating with other stakeholders to advocate for gaps in community provision to be filled, rather than by expanding the remit of CMHTs to include the follow-up care needed by those with less severe conditions. SU and family feedback also highlights the need to continue CMHT support for a sufficient interim period to allow SUs establish a therapeutic relationship with community support services prior to discharge from CMHT follow-up.
The CCP-9 marks a significant shift in practice and culture from the standard mental health care delivery model and for effective operation depends on “buy-in” and engagement at all levels of the CMHT. The positive response of MHPs to the practice of the CCP-9 (paper II) suggests that this constructive engagement can be effectively achieved and maintained over time. Nevertheless, a potential risk to the sustainability of the team culture and organisational memory of the CCP-9 can arise through frequent staff rotation, extended leave and other changes in personnel that can be unavoidable in community mental health services that are chronically under-resourced. This risk can be mitigated to some degree by close attention to the induction of new staff in the CCP-9 approach. A detailed handbook outlining the principles and procedures of the CCP-9 is available to staff on joining the service, with experienced colleagues providing close mentorship and support during the induction period. An ongoing dialogue between the CMHT and service managers in relation to staff rotation can help ensure that service culture, skill-set and ethos is not overwhelmed by rapid turnover in personnel. This can be difficult for service managers to sustain in “real-world” settings where there is a constant need to balance competing demands for limited resources. A pertinent example is provided by the experience of one of the relevant sector CMHTs which lost access to the Home Care Team (which has the most experience of operating the CCP-9) as a result of structural changes within the sector service. This has led the CMHT to curtail the practice of the CCP-9 for now, although the team remains committed to the principles on which the CCP-9 is based and is reviewing options for reintroducing an adapted form of the pathway. Given the key role of the CP in clinical team leadership, changes in consultant staffing are potentially of particular importance to the sustainability of the CCP-9 approach over the longer-term. Continuity of practice following the appointment of a new CP to lead the CMHT will depend on the support of service managers and HR personnel in ensuring that the compatibility of candidates’ experience and ethos with the CCP-9 model of practice is given due consideration in the recruitment process, while respecting clinical autonomy. This potential risk to sustainability has already been tested in one of the three relevant sector CMHTs, where a change of consultant leadership has not disrupted the practice of the CCP-9, with only minor subsequent adjustments reported in the threshold of complexity for comprehensive assessment, the mechanism for MDT participation in the process and in the format for documentation.
Conclusion
While there is a consensus at policy level that care planning in community mental health service settings should be delivered in keeping with recovery principles of collaboration, SU empowerment, family involvement and multidisciplinary care, there is no consensus as to the best model of practice to deliver on these principles in Ireland or internationally. The experience of the CPA approach in the UK highlights the many pitfalls that can arise in attempting to translate recovery-focused policy to clinical practice. In Ireland, current care planning guidelines have not adequately addressed the marked differences that exist in care pathways between inpatient and community care, the importance of the assessment model on which the care plan is based or the need to balance the psychiatrist-led diagnostic process with meaningful MDT input. In order to minimise the risk of tokenism e.g. in relation to MDT involvement in the process, care planning is best framed as part of an integrated pathway of care from initial assessment through to discharge, in which the principles of recovery-focused and multidisciplinary care apply throughout. The CCP-9 provides one such model, in which MDT care planning is embedded as the fundamental building block for the provision of care to SUs presenting with complex needs. The core elements of the CCP-9 address the quality criteria for care planning set out in the Quality Framework (MHC 2023) through the collaborative approach to SU and family engagement, the explicit focus on SU priorities and goals, the focus on a broad psychosocial assessment process, integrated involvement of the MDT, and the emphasis on the person’s therapeutic relationship with the key worker. In keeping with a core feature of effective shared decision-making, the CCP-9 aims to maintain an appropriate balance between protecting key therapeutic relationships and adherence to procedures and documentation. Indeed, while the CCP-9 utilises standardised tools and documentation in relation to assessment, case formulation and care recommendations, these are not prescriptive and are subject to ongoing review and change according to the circumstances of each clinical team, further iterations of relevant Mental Health Commission guidelines and SU feedback.
Multiple challenges to the sustainability of the CCP-9 can be identified, principally those of balancing time invested in assessment and care planning with other demands on the CMHT, the impact of staff turnover on team culture and ethos and the limited availability of therapeutic services at community and primary care level following discharge from CMHT care. The satisfaction expressed by key stakeholder groups with the experience of the CCP-9 offers some reassurance that these challenges can be successfully managed, with the key conditions for sustainability being “buy-in” to the CCP-9 model by the clinical leadership and wider CMHT, careful attention to the induction and support of new staff unfamiliar with the CCP-9 model, flexibility in adapting the pathway procedures to local circumstances and changing MHC guidelines, and consistent support from local service managers in addressing challenges such as limited resources of personnel and staff turnover.
The development of the CCP-9 pathway can be critiqued for having been clinician-led rather than being a co-production with peer representatives, and it would be appropriate and timely to include SU and family/supporter stakeholders in future reviews and further development of the pathway.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ipm.2025.10143.
Acknowledgements
The authors would like to thank Dr Allen Bulfin for sharing his experience of the CCP-9 since taking up a post as consultant psychiatrist with (name of service withheld).
Author contributions
All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors have contributed and are in agreement with the manuscript.
Funding statement
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Competing interests
The authors have no conflicts of interest to declare.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
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