Professor Peter Huxley 4 th National Social Work CPD Conference Institute of Psychiatry, 14 th...

Integration of Social Care Staff in Community Mental Integration of Social Care Staff in Community Mental Health TeamsHealth Teams

Professor Peter Huxley

4th National Social Work CPD Conference

Institute of Psychiatry,

14th September 2010

• RESEARCH QUESTIONS

• What determines the social care composition of CMHTs?

• Does team culture and climate vary by composition?

• Are service users experiences effected by team climate and culture and composition

THREE PHASES• PHASE 1 - National survey of MH trusts –

reasons for team composition• PHASE 2 - Four location study of culture and

climate in teams• PHASE 3 - Two locations impact on user

experience

RESEARCH QUESTION 1• What determines the social care

composition of teams?

• Data were collected from 42 out of 79 Trusts (response rate 53.2%).

• 381 Community Mental Health Teams (CMHTs).

• Managers provided details of:– the numbers, sizes and composition of

community teams– Reasons for CMHT composition, drivers of

planned changes, reasons for social care component

Table 1: Average CMHT team composition by data source (for major staff groups only)

Source CommunityPsychiatric Nurse

SocialWorker

OccupationalTherapist

Psychologist Doctor Social Care SupportWorker

Onyett et al. 1994 3.3 1.9 1.0 1.0 1.0 0.9

Policy Implementation Guidance 2001

4 3 1.5 1.5 2.5 3.0

Boardman and Parsonage 2005

4.9 2.7 1.6 1.0 3.0 4.0

National mapping data 2007

6 3.5 0.9 1.1 1.5 1.7

Present study 2007 6.1 3.5 0.9 0.8 2.1 1.4

Growth since 1994 +84.8% +84.2% -10% -20% +110% +55.6%

Surplus (+) or deficit (-) over Guidance

+52.5% +16.7% -40% -46.7% -16% -53%

CMHT

0

1000

2000

3000

4000

5000

6000

2001 2002 2003 2004 2007 2008 2009

Nurses

Social W

Doctors

Support

0

200

400

600

800

1000

1200

2001 2002 2003 2004 2008

Nurses

Social W

Doctors

Support

Assertive Outreach Teams

Early Intervention Teams

0

100

200

300

400

500

600

700

800

2001 2002 2003 2004 2008

Nurses

Social W

Doctors

Support W

Crisis Resolution Teams

0

500

1000

1500

2000

2500

3000

2001 2002 2003 2004 2008

Nurses

Social W

Doctors

Support

Reasons for team composition

Reason n (%) (% main reason)

History 30 (27) (46)

Policy guidance 25 (22.5) (20)

Demand 24 (21.6) (16)

Financial 22 (19.8) (14)

Multi-disciplinarity 10 (9.1) (4)

Total 111 (100)

Determinants of social care composition

Reason n (%)

Workload complexity 15 (16.5)

History 15 (16.5)

Policy guidance 5 (5.5)

Financial 9 (9.9)

Integration requires it 20 (22.0)

Team needs (eg multi-disciplinarity)

8 (8.8)

Social services determined 11 (12.0)

Other 8 (8.8)

Total 91 (100)

• Team membership and composition, in terms of total staffing and social work and social care numbers is largely unrelated to the rationale given by managers.

• Despite more than 15 years of policy guidance

relating to the mental health workforce (and increasing staff numbers over the same period) team staffing and composition was not associated with guidance or demand.

• Financial resources emerged as having some influence on team staffing and composition.

• Smaller Trusts appear to struggle to populate policy prescribed specialist teams and were more likely to have to consider redeploying CMHT staff for this purpose.

• Supply, historical and resource factors have an undue influence on the composition of CMHTs compared to need and demand factors.

UK Mental

Health ServicesSocial CareServices

MHSW

Health and Social Care Integration

Mental Health Services

Social CareServices

MHSW

Health and Social Care Integration

RESEARCH QUESTION 2

• Does team culture and climate vary by composition?

• Phase 2 four location study of culture and climate in teams

• Workforce dynamics questionnaire (Susan Nancarrow)

• Karasek job content questionnaire

• 42 TEAMS• 300 WDQ RESPONSES

Social care staff as a proportion of team

Location Percentage (sd)

1 27.6 ( 8.3)

2 17.4 (10.6)

3 21.0 ( 8.7)

4 52.2 (16.0)

All 29.0 (17.2)

Inter-professional working and role overlap in the whole sample

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0Dietician

Geriatrician

GP

Other nurse

OT

Physiotherapist

Podiatrist

PsychologistSocial worker

Approved Social Worker

SLT

Support Workers

Secretary/Admin

CPN

Psychiatrists

Closness of working

Role overlap

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00Approved Social Workers

GPs

Psychiatrists

Other Nurses

OTsPsychologists

Social Workers

CPNs

Support Workers

Closely with Role overlap

Inter-professional working and role overlap by location Area A

-

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50


GPs

Psychiatrists

Other Nurses

OT'sPsychologists

Social Workers

CPNs

Support Workers

Closely with

Role overlap

Area B

-

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50


GPs

Psychiatrists

Other Nurses

OT'sPsychologists

Social Workers

CPNs

Support Workers

Closely with

Role overlap

Area C

-

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50


GPs

Psychiatrists

Other Nurses

OT'sPsychologists

Social Workers

CPNs

Support Workers

Closely with

Role overlap

Area D

-

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50


GPs

Psychiatrists

Other Nurses

OT'sPsychologists

Social Workers

CPNs

Support Workers

Closely with

Role overlap

Inter-professional working and role overlap by professional group

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5CPN

GP

Psychiatrists

Other nurses

Occupational TheapistsPsychologists

Social Workers

Approved Social Workers

Support Workers

Work closely with

Role overlaps with

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5Social Workers

GP

Psychiatrists

Other nurses


CPNs


Support Workers

Work closely with

Role overlaps with

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5Approved Social Workers

GP

Psychiatrists

Other nurses


Social Workers

CPN

Support Workers

Work closely with

Role overlaps with

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5Support Workers

GP

Psychiatrists

Other nurses


Social Workers

CPN


Work closely with

Role overlaps with

Proportion of sample with no overlapping role

Psychiatrist n=30 (11.9%) Psychologist n=27 (10.3%)GP n=98 (38.1%) CPN n=15 (5.7%)Other nurse n=85 (35.0%) OT n=23 (9.0%)

Social Worker n=12 (4.7%) ASW n=37 (14.4%)Support Worker n=22 (9.0%)

Social Care Composition

n (%)

≤10% 35 (11.6)

Up to 20% 62 (20.6)

Up to 30% 105 (35.0)

Up to 40% 41 (13.6)

40 – 60% 28 ( 9.3)

>60% 31 (10.3)

Variance explained Predictor variables β p

R2 = 0.338AR2 = 0.296

Not being in a CMHTBetter managementRated higher by ‘other’ staff than nursesFewer job demands

-0.38 0.29 0.11-0.10

0.0000.0000.0430.071

Possible interaction effects between team typology and independent variables

Team typology 1: Social care component <20%R2 = 0.285AR2 = 0.196

Not being in a CMHTBetter managementRated lower by support workers than nursesCo-location & Site 4 dropped

-0.31 0.29-0.22

0.011 0.0070.059

Team typology 2: Social care component 20 -

40%R2 = 0.459AR2 = 0.408

Not being in a CMHTBetter managementRated higher by ‘other’ staff than nurses Rated lower by support staff than nurses

-0.59 0.38 0.24-0.13

0.0000.0000.0020.099

Team typology 3: Social care component >40%R2 = 0.409AR2 = 0.291

More autonomyRated higher by ‘other’ staff than nursesRated higher by support workers than nursesFewer job demandsBetter managementRated higher by social workers than nursesCMHT & Sites 3, 4 dropped

0.46 0.37 0.32-0.33 0.24 0.24

0.0080.0190.0460.0540.0730.095

Normal distribution and no outlying residuals.Final model includes: autonomy, management, job demands, professional group and CMHT.

INTEGRATION

TEAMWORKINGVariance explained Predictor variables β p

R2 = 0.691AR2 = 0.685

Greater role perceptionBetter managementGreater role flexibilityGreater social supportNot co-locatedFewer job demands

0.36 0.29 0.23 0.21-0.10-0.10

0.0000.0000.0000.0000.0030.004

Significant interaction effects between team typology and independent variables


Greater role perceptionBetter managementGreater role flexibilityGreater social supportFewer job demandsCo-location dropped

0.32 0.30 0.24 0.17-0.17

0.0000.0000.0010.0240.010

Team typology 2: Social care component 20 - 40%R2 = 0.725AR2 = 0.712

Greater role perceptionBetter managementGreater role flexibilityGreater social supportNot co-locatedFewer job demands

0.38 0.32 0.20 0.26-0.19 0.00

0.0000.0000.0000.0000.000NS


Better managementGreater role perceptionGreater role flexibilityFewer job demandsGreater social supportCo-location dropped

0.34 0.33 0.27-0.23 0.16

0.0060.0010.0120.012NS

QUALITY OF CAREVariance explained Predictor variables β p

R2 = 0.527AR2 = 0.485

Better teamwork>60% social care in teamBetter managementLarger team size40-60% social care in teamLess autonomyMore overlap with social work role

-0.561

-0.23 -0.19 -0.15 -0.14 0.11 -0.11

0.0000.0110.0030.0800.0900.0570.076



Better teamworkBetter management

-0.42-0.41

0.0000.000


Better teamworkBetter managementLess autonomyMore overlap with social work role

-0.55-0.21 0.13-0.11

0.0000.0130.045 0.085


Better teamworkLarger team sizeLess autonomy

-0.91-0.34 0.20

0.0000.0020.070

All model square-root transformed hence negative symbol for positive resultTeam typology models similar in untransformed data, and when including area.Final model includes: teamwork, management, job demands, overlap with nurses, overlap social workers, professional group, team typology, team size, co-location and cmht

JOB SATISFACTIONVariance explained Predictor variables β p

R2 = 0.513AR2 = 0.461

Fewer job demandsWorking closely with nursesBetter managementMore decision latitudeMore uncertaintyLess overlap with nurse roleBetter training & career oppsBeing co-locatedSite 2 cf Site 1

-0.35 0.28 0.21 0.18 0.15-0.16 0.21 0.14-0.15

0.0000.0000.0010.0050.0060.0100.0440.0500.068



Fewer job demandsBetter training & career oppsGreater role flexibilityLess overlap with nurse roleMore uncertaintySite 2 & co-location dropped

-0.48 0.36 0.25-0.24 0.20

0.0000.0000.0220.0550.058


Fewer job demandsWorking closely with nursesBetter managementBeing co-locatedGreater decision latitudeSite 2 cf Site 1

0.35 0.31 0.26 0.18 0.17-0.14

0.0000.0010.0050.0240.0650.094


Failed to fit a model

INTENT TO LEAVE EMPLOYERVariance explained Predictor variables β p

R2 = 0.422AR2 = 0.376

Less likely if in CMHTLess likely - larger team sizeLess likely – better trainingLess likely – higher job satisfactionLess likely – poor role perceptionSocial Worker more likely than nursesLess likely in Site 3

-0.51-0.23-0.17-0.17 0.16 0.13-0.18

0.0000.0190.0050.0130.0070.0210.089



Less likely if in CMHTSocial Worker more likely than nursesSupport workers more likely than nurses

-0.64 0.20 0.16

0.0000.0270.056


Less likely if in CMHTLess likely – higher job satisfactionLess likely – poor role perceptionSupport workers less likely than nurses

-0.39-0.17 0.18-0.14

0.0000.0470.0490.088


Less likely – higher job satisfactionLess likely – more uncertaintyLess likely – better trainingLess likely – poor role perception

-0.39-0.32-0.28 0.27

0.0090.0280.0630.072

One outlying residual: log transformation and residual removal produced identical resultsFinal model includes: role perception, training, uncertainty, integration, management style, professional group, overall satisfaction, team size, CMHT, area, team typology (social care composition), co-location.

RESEARCH QUESTION 3• Are service users experiences

effected by team climate and culture and composition

PHASE 3 TWO LOCATIONS IMPACT OF CULTURE

AND CLIMATE ON USER EXPERIENCE

• 41 SERVICE USER INTERVIEWS• CUES• MANSA• SUQ

Relationship between worker and user views

WORKER (WDQ) USER (CUES)TEAMWORK AVAILABLE CHOICE

QUALITY OF CARE NURSE COMPETENT & KNOWLEDGABLESOCIAL WORKER LISTENED UNDERSTOODSUPPORT WORKER LISTENED UNDERSTOOD

TRAINING/CAREER NEEDS METSOCIAL WORKER LISTENED UNDERSTOODSOCIAL WORKER COMPETENT KNOWLEDGABLESUPPORT WORKER LISTENED UNDERSTOODSUPPORT WORKER COMPETENT AND

KNOWLEDGABLE

OVERALL JOB SATISFACTION AVAILABLE CHOICE SATISFACTION WITH CHOICE

INTEGRATION NOTHING

Conclusions• Variable proportions of social care

per team from 0% to 65%,88% (lower in new teams)

• Narrow conception of social care being integrated

• Regressions – new teams more integrated than CMHTs

Conclusions continued• Regressions – integration makes

no contribution to teamwork, to quality of care, job satisfaction or intention to leave

• Social workers are more likely to want to leave

Conclusions Continued• Culture and climate can be shown to be

related to user outcomes• But integration is not• Composition is also unrelated (as tested

here with CUES or MANSA or SUQ but n is small)

• Integration is not a useful construct for implementing the New Horizons agenda, personalisation may be preferable.

Acknowledgements

• SDO Funding Acknowledgement:This project was funded by the National Institute for Health Research Service Delivery and Organisation programme (SDO114).

• Department of Health Disclaimer:The views and opinions expressed are those of the author and do not necessarily reflect those of the NIHR SDO programme or the Department of Health.

Professor Peter Huxley 4 th National Social Work CPD Conference Institute of Psychiatry, 14 th...

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