Original The development of community based adult mental health services

Service initiatives such as the decentralisation of adult mental health care by way of multidisciplinary patch teams have wide-ranging implications for pro fessional practice. The successful development of community based services demands that staff adopt different roles from those appropriate to the hospital setting.Ina we early findings of the process of imple menting a policy of community care for people with mental health problems in Cosham, the northern part of the City of Portsmouth. We draw attention to the need for further consideration of the role of a community based acute residential facility, and wider aspects of team organisation, in particular workload management and priority setting in a developed service. In June 1989,eight months after the initial, partial move, which had involved only the 'community team', the residential unit and its staff also moved from the hospital site into the community, thus uniting the Cosham service in a shared base. While important developments place during the par tial move period, notably the setting up of services for continuing care clients, it was really only when the whole service finally came together that many crucial issues concerning team organisation could be fully addressed. the service, broadly based from early on, has become diverse and comprehensive through the integration of its 'community' and 'residential' components and the development of activity and work the people with longer term mental

Service initiatives such as the decentralisation of adult mental health care by way of multidisciplinary patch teams have wide-ranging implications for pro fessional practice. The successful development of community based services demands that staff adopt different roles from those appropriate to the hospital setting.
In a previous paper (Powell & Lovelock, 1989), we reported early findings of the process of imple menting a policy of community care for people with mental health problems in Cosham, the northern part of the City of Portsmouth. We draw attention to the need for further consideration of the role of a community based acute residential facility, and wider aspects of team organisation, in particular workload management and priority setting in a developed service.
In June 1989,eight months after the initial, partial move, which had involved only the 'community team', the residential unit and its staff also moved from the hospital site into the community, thus uniting the Cosham service in a shared base. While important developments took place during the par tial move period, most notably the setting up of specific services for continuing care clients, it was really only when the whole service finally came together that many crucial issues concerning team organisation could be fully addressed. Since that time the service, broadly based from early on, has become increasingly diverse and comprehensive through the integration of its 'community' and 'residential' components and the development of collaborative activity and joint work with other local agencies.
Changes and developments in service policy and provision are mirrored in the day-to-day practice of front line professionals. While direct work with clients has continued to be an important focus of activity, a detailed descriptive account of their work, based on a logging exercise carried out during the pre-move phase and repeated after a settling-in period indicates that many team members were extending their activities, for example by setting up and running new service initiatives. The establish ment of the Cosham Continuing Care Group, work ing exclusively with people with longer term mental health needs, provides the clearest example of how team members have evolved new ways of working with individual clients and other workers in the local community.

Professional views
This paper examines team members' attitudes towards developing community based services and working as part of a multidisciplinary team. A specially designed self-complete questionnaire was used on two separate occasions: once just prior to the first stage of the move and again some five months after the whole service had come together on the same site. Individual accounts of practice given by staff in interviews support the findings presented.
Staff attitudes changed very little as the Cosham service moved to and began its further development in a community base. All members saw their direct work with clients as a continuing area of activity, and shared a wish to further develop specialist coun selling skills, primarily in one-to-one working. Some staff expressed more specific interests in developing skills in working with people who had been sexually abused, or with poorly motivated clients with longer term needs.
Most team members shared a view of the service as appropriately based on a multidisciplinary team approach and requiring collaboration with other agencies and local networks. However, there was less consensus on the types of skills required to provide a comprehensive community based service. This diversity of views reflected both the different experi ences and interests of team members and their own individual assessments of their main training needs.
For some members, the development needs of the overall service and their own professional training needs were interwoven. They saw themselves as keen to develop further expertise in working with others in the development of new services, as well as wanting to extend their skills in direct work with individuals and their families. This overlap in professional goals and service goals was most evident in the views of members of the Continuing Care Group.
One increasingly significant activity was the super vision of either students engaged in professional training, mainly student nurses, or the growing number of support workers. To a large extent, the successful involvement of support staff in the main tenance and development of the service rests with the quality of supervision provided by the professionally qualified team members. However, the latter also needed the support which comes from competent and appropriate supervision. Thus the acquisition of skills in giving and receiving staff supervision has become an important area of professional development for many team members.
While team members were in agreement about the value of teamwork, there was substantial lack of clarity and unanimity about decision making in this context. Whereas on the first occasion when the ques tionnaire was used there was a tendency to support the view that team members should have equal power in decision making, this was reversed later, with a shift towards the view that team members with par ticular expertise or experience should be more active in this process. The team's difficulty in responding to the growing number of competing demands made on the service also reflected its uncertainty about how and by whom decisions concerning priorities and workload should be made.

Comment
In the context of moving an overall service away from a parent hospital to a shared local base, import ant issues are raised around the changing nature of professional practice and concerning management in a decentralised setting.

Multidisciplinar) teamwork
There are longstanding issues surrounding the organisation and operation of multidisciplinary teams. Not the least important of these focus around the distinctions and inter-relationships between questions of professional/clinical judgement and managerial authority and accountability, which of course have wider relevance within human services agencies. Particular difficulties arise in multidisciplinary teams, where some professions have vertical and some have horizontal forms of organis ation. Thus a consultant will have a considerable degree of autonomy while other team members will be responsible in line management terms to superiors outside the team. The Cosham Mental Health Team has the added factor of its social workers alone being employed by a different agency from the other mem bers of the team who are employed within the health service. The need for professional supervision and support and the question of leadership within the team are two further dimensions of this complex of issues.
A key issue around which difficulties have arisen, despite the substantial progress made is the changing role of the psychiatrist in the context of the multidisciplinary team. Aspects of this were evident at several points in our study, for example concerning the referral process and the move of the residential unit away from the hospital. In the recent setting up of its new duty team, the Cosham service has acknowledged the importance of a regular medical input into the group. However, this contribution has been seen primarily as clinical expertise rather than as 'sapiential leadership' (Soni et al, 1989). How and by whom decisions should be made, both on a dayto-day basis and concerning the overall development of the local service, was an area of uncertainty throughout the study period and continues to demand careful consideration at all levels of the organisation.

Roles and responsibilities
One set of issues basic to team organisation concerns where responsibility for assessment and treatment decisions are located, and how decision are made and reviewed about treatment programmes (0vretveit, Temple & Coleman, 1988). All members of the Cosham team have enjoyed a relatively high degree of professional autonomy. A lack of clarity sur rounding the issues of accountability and leadership, both within the multidisciplinary team and among those professionals and clients in contact with it, has contributed to this. The value of involving other team members in joint consultations and shared work has, however, been widely accepted and prac tised. While progress has been made in defining individual team members' responsibilities and estab lishing procedures for the referral and allocation of cases, further work concerning the different but overlapping professional roles is necessary.
Future work on the team's operational policy will need to consider relationships and mechanisms of accountability in team members' direct work with clients, as well as to general professional supervision. During our study period, members of the Cosham team were increasingly recognising supervision of their own work and the work of others as an import ant activity: particularly the supervision of col leagues without professional training. However, the ongoing review of cases was generally undertaken in the context of individual professional supervision aimed at ensuring good practice, rather than on a team basis and as a mechanism of accountability. Some of the GPs interviewed as part of the wider study touched on this area when discussing the issue of team accountability and decision making.

Managing priorities and workload
A second key set of organisational issues identified by 0vretveit and his colleagues (1988) concerns responsibility for limiting or extending individual and team workloads, and the setting and changing of service boundaries and priorities. These are ques tions of overall policy and managerial accountability and authority, rather than being matters of pro fessional or clinical judgement. In the context of services such as those provided by the Cosham Mental Health Team, the main areas to be balanced are specialist psychiatric help, counselling in the broad sense, support for continuing care clients, and general educative and preventive work. To varying degrees, more than direct work with clients is involved in each of these areas. During our study period a number of service devel opment initiatives took place, each of which had a significant impact on other aspects of the Cosham service. In particular, maintaining a balance between the demands -predominantly from GPs-for a counselling service, and those of ongoing work with continuing care clients, has raised questions about setting priorities and managing workload. It is therefore important that in the planning of further development initiatives consideration is given to their impact on other aspects of the service. Deter mining the priorities of the service and keeping them under review, with the consequent limiting or extend ing of both individual and team workloads, can be seen as a matter both for the team itself and for senior managers (0vretveit, Temple & Coleman, 1988).

Concluding remarks
Our study of decentralising one mental health service provides much evidence concerning the key features of'a good quality community mental health service' as outlined by Jones (1988, Chapter 8). Although subject to the constraints imposed by limited resources, there was growing diversity within the 75 overall service. Our findings suggest that the Cosham team has acquired considerable experience of direct work with clients in a multidisciplinary and com munity setting, and of developing local resources in collaboration with others.
It is important that these and other practitioners are encouraged and enabled to articulate the nature of their changing professional practice, so that a core of practice skills necessary for the development of community based services may be identified. The articulation of what constitutes 'good practice' is an important step in identifying staff development and training needs and is thereby a contribution to the establishment of high quality locally based services. Without this, as Lavender & Holloway (1988, p. 299) confirm: ".. there is no reason to believe that the quality of care outside the traditional institution will be any better than within it." Understanding of this sort gained in the mental health field is more broadly applicable. It should therefore be of considerable interest to all agencies providing social care, as they develop more respon sive community based services: not least to social services departments as they explore the 'enabling' role which recent legislation foresees for them.