London mental health models of care – competency framework - OPM

To assist workforce leads, commissionersand training managers the competencyframework is designed to be used on anumber of levels - at an individual level, ata team level or at an organisational level.Executive summary● ● At an individual level, the competenciescan be used by individuals across a verywide range of services, professions androles for self-development, to reflecton work and practice, and to identifydevelopment and training needs indiscussion with their managers.● ● At a team or organisational level, thecompetencies can be used by providers,clinicians, managers and commissionersto consider requirements within a giventeam, service or organisation, andidentify collective development andtraining needs.The competency framework is designed tohelp clinicians, commissioners, employersand managers when designing local carepathways and commissioning services, toidentify training needs within and acrossworkforces; to inform the developmentof job descriptions and training anddevelopment plans and to support individualself assessment and development.A competency framework for all those working with people with mental health problems in London5

A key objective of the models of care is toenable more people with mental healthproblems to be supported appropriatelywithin primary care and community settings,thereby reduce unnecessary secondary careadmissions. Such an approach should leadto better, more person-centred care, whileat the same time enabling secondary careservices to provide better quality care forthose who need that level of support.The models are intended to contribute tothe delivery of the government’s mentalhealth strategy, suicide reduction strategyand quality, innovation, productivity andprevention (QIPP) plans for mental health.Several national policies and programmesare aimed at reducing variation andensuring continuous improvement in quality,productivity and innovation within healthservices, including mental health. These createthe operational context in which large numbersof staff - within and outside the NHS - willsupport people with mental health problems,and will impact on the way many services arecommissioned and run. The key policies anddevelopments that are driving these changesare summarised in Appendix 2.Staff across a range of health and public andvoluntary sector services need to develop theskills, knowledge and confidence to workin different ways if QIPP benefits are to berealised and this framework defines whatindividuals and teams need to do in order tosupport service users more effectively.The mental health modelsof care can be downloaded attinyurl.com/d7vs967The London population and themental health of LondonersLondon is home to some 8.17m people 1with an extremely diverse and transientpopulation. It is the UK’s most culturallydiverse city; more than 300 languages arespoken in London and over 40% of theUK’s Black and Minority Ethnic populationlive in the capital. London has high levelsof deprivation, with significant variationacross the city: more than half of London’sboroughs are within the 30% most deprivedareas in England, and ten boroughs areamongst the most deprived 10% 2 . Significantnumbers of people come to London andleave London each year, with many innerLondon boroughs having particularlytransient populations.An estimated one in four of the UKpopulation will experience a diagnosablemental health problem at some point intheir lives 3 . At any given time, around one insix adults are experiencing a mental healthproblem, and for half of these people theproblem will last for over a year 4 . WithinLondon the levels of mental health needand demands on mental health services aregreater than the UK average 5 . Prevalenceis greatest in the most deprived parts ofLondon, with social and economic factorsaffecting the incidence and duration of1 GLA Intelligence Update demography team, 2010 mid-yearpopulation estimates, estimates for June 2010, based on dataissued by the Office for National Statistics, and published June20112 Mental health services case for change for London, LondonMental Health Models of Care project, London HealthProgrammes, June 20113 http://www.nhsconfed.org/Publications/Documents/Key_facts_mental_health_080911.pdf4 New Horizons: a shared vision for mental health, Department ofHealth, 2009.5 Mental health services case for change for London, LondonMental Health Models of Care project, London HealthProgrammes, June 2011Introduction and backgroundA competency framework for all those working with people with mental health problems in London7

Introduction and backgroundmental health problems, and worseninghealth inequalities 6 . Dementia is morecommon in outer London due to its olderpopulation.London has higher than average numbersof people with complex needs includingrefugees, asylum seekers, homeless peopleand people with a dual diagnosis of mentalillness and drug or alcohol problems 7,8 . Thenature of the London population, and theneeds of this population is dynamic and willcontinue to change in future years.6 ibid7 ibid8 In March 2011 London had 35,920 statutory homeless householdsin temporary accommodation, out of a total of 48,920 in England,Live Tables on Homelessness, Department for Communities andLocal Government, last updated March 2012The London mental health modelsof care core pathwayTo support the models of care, the projectteam at London Health Programmes,supporting the project clinical leads,has, with a range of other stakeholders,developed a core pathway, setting out thefive essential functions that staff workingwith people with mental health problemsneed to carry out:l Assessmentl Effective referral to appropriate servicesl Planningl Implementation(intervention and treatment)l Evaluation8London Health Programmes

The London MHCFThe London mental healthcompetency frameworkHow the competency frameworkwas developedThe process of developing the competencyframework was very inclusive, as was theprocess for developing the models of care.Significant input was harnessed from mentalhealth specialists in the field – includingthe core professional groups of nursing,occupational therapy, psychiatry, psychology,and social work – and in addition a widerange of other stakeholders were engagedincluding people using mental healthservices, their families, friends and carers,GPs, pharmacists, mental health charities andvoluntary and community sector providers,employer and workforce organisations, andnon-mental health staff. Through a series offocus groups and interviews, over 100 peoplewere involved. This wide-level engagementhas made a substantial contribution to therigour and relevance of the framework.In developing this competency framework,it has been important to be mindful of thepotential linkages with existing frameworks,but also of the complexity of trying to mapa large number of links to many differentdocuments. The aim of such mappingshould always be to assist those using theframeworks, not to confuse them. Appendix3 (Related competency frameworks)summarises the competency frameworks (inchronological order) that are relevant to thebroadest range of staff working with peoplewith mental health problems in London 9 .This competency framework is not aimedexclusively at specialist mental health staff,but at everyone who comes into contact withpeople with mental health problems. Thus,it has been explicitly linked most closelywith those existing frameworks that havethe widest reach and application – the TenEssential Shared Capabilities 10 , and the NHSKnowledge and Skills Framework (KSF) 11 .However, there is, quite rightly, a great dealof consistency and congruence with theother competency frameworks mentioned inAppendix 3.An accompanying document is availablewhich maps the London mental healthcompetencies and NHS Knowledge and SkillsFramework (KSF), linking the competencies inthe framework to the dimensions in the KSF.This document is available attinyurl.com/cn4azcm9 It is also worth noting that the Social Care Institute for Excellence(SCIE) has produced a suite of briefings, guides and othermaterials that are useful to those working with people with mentalhealth problems. See www.scie.org.uk10 The Ten Essential Shared Capabilities – A Framework for theWhole of the Mental Health Workforce, National Institute forMental Health England, Sainsbury Centre for Mental Health, NHSUniversity, Department of Health, August 200411 The NHS Knowledge and Skills Framework (NHS KSF),Department of Health, Oct 200410 London Health Programmes

Rationale for the competencyframeworkThe models of care promote a refocusing ofexisting services and the roles of those whowork in them. They introduce new roles andways of working. Implementing the modelswill require people to do things differently indifferent settings; this competency frameworkidentifies the knowledge and skills required tosupport them.The competencies identified in each of theparts of the framework will support and bringabout some of the changes proposed withinthe models of care:●●Refocusing existing services to do thingsdifferently so as to promote recoveryand enable people who no longer needspecialist services to control the planningand delivery of their own care.●●Introducing shared care approaches formany people with long term mentalhealth conditions: this means a transferof clinical responsibility from secondaryto primary care, with the active supportand collaboration of secondary care, andenhanced information exchange.●●Creating navigator roles to helppeople access services that can supportthem with a range of issues, such asemployment and housing, which may beintegral to their recovery.●●Enabling better partnership workingand drawing on the expertise ofindividuals, family members, friendsand carers, and a range of relevantprofessionals, especially in developingthe most appropriate plan for anindividual’s care.●●Sharing of expertise by specialists tohelp build capacity in non-specialistservices, and to ensure the holisticneeds of individuals can be metwithout the need for them to bemanaged in secondary care.●●Reforming secondary care services toprovide swifter access to people whoneed their input, and improve theircapacity to develop the specialisedmental health services that only theycan provide.The competency framework also articulatesthe means by which the aspirations of themodels of care can be achieved - improvingcommunication between primary andsecondary care, the voluntary andcommunity sector, clinical commissioninggroups and local authorities; ensuringthat physical health needs are properlyassessed and addressed by all servicesand the physical health inequalitiessuffered by people with mental healthproblems are minimised; promotinga personalised recovery approach,involving people’s family, friends andcarers where appropriate; reducing thestigma associated with mental healthproblems, as more people receive supportin non-stigmatising settings; promotingthe routine use of outcome measures inrelation to mental health; and contributingto the delivery of the government’s mentalhealth strategy, suicide reduction strategyThe London MHCFA competency framework for all those working with people with mental health problems in London11

How the framework is structuredThe competency framework is presented inthree parts:●●Part one sets out universalcompetencies relevant to everyone whomay, as part of their day-to-day work,come into contact with people withmental health problems.●●Part two sets out further competenciesfor staff who are not mental healthspecialists, but who work with a widerclient group which may include peoplewith a mental health problem, and/or people who may be experiencing amental health crisis.●●Part three sets out additionalcompetencies for staff working withpeople with mental health problems– either as a main client group, or as asignificant part of a wider client groupfor example mental health cliniciansand GPs.This new competency framework doesnot seek to replicate or replace the rangeof well-developed frameworks providingdetailed coverage of the competenceand capability requirements of differentprofessional groups. Rather the intentionis to articulate a set of knowledge, skills,attitudes and behaviours that are desirableand appropriate for everyone who comesinto contact with people with mentalhealth problems. Very specific or technicalframeworks for certain mental healthprofessionals are placed at the top of thediagram below. These are not examined indetail here, as they have their own rigourand legitimacy. Nothing within this Londonmental health competency framework isintended to contradict or replace theseexisting frameworks.Competencies forspecific professionalgroupsThe London MHCFStructure of thecompetency frameworkPart threecompetenciesPart twocompetenciesPart onecompetenciesA competency framework for all those working with people with mental health problems in London13

The London MHCFHow to use this competencyframeworkThe competencies in this framework arenecessarily generic enough to apply across awide and diverse range of people.Each part of the framework is additionaland complementary to the previous parts:people with part two competencies shouldalso have part one competencies; they arefurther competencies, not alternative ones.The competencies in this framework areintended to be developmental: it would notbe realistic to expect all staff, across such awide range of services and organisations, tohave all these competencies as a minimumrequirement. Rather, they are intended ascompetencies that clinicians, commissioners,managers and staff will aspire to, and willsupport staff to work towards throughtraining and development.In considering these competencies, itwill also be necessary to think about anindividual’s scope of practice – the areaswhere a person has the knowledge, skills andexperience to work safely and effectively.An individual’s scope of practice is likely tochange over the course of their working life,and may expand as they develop new skills,for example through training or education.When using this framework, individuals andtheir managers should pay attention to theirexisting scope of practice, what an individualis currently feeling confident and competentto do, and what impact it would have werethey to gain some of the other competenciesin this framework.organisational level – to assist workforceleads, commissioners and training managers.●●At an individual level, thecompetencies can be used by individualsacross a very wide range of services,professions and roles for selfdevelopment,to reflect on work andpractice, and to identify developmentand training needs in discussion withtheir managers.●●At a team or organisational level,the competencies can be used bymanagers and commissioners toconsider what competencies arerequired within a given team, serviceor organisation, and identify collectivedevelopment and training needs.The competencies in part one should applyto everyone who may come into contactwith people with a mental health problem aspart of their day to day work, and thereforemanagers and commissioners should aspire tosee all individuals within their organisationshaving part one competencies. For part twoand part three competencies however, therequirements will differ according to factorssuch as, for example, the nature of the team,service or organisation, its functions, ways ofworking and overall skill-mix.The competency framework is designedto be used on a number of levels - at anindividual level, at a team level or at an14 London Health Programmes

How might evidence of thecompetencies be provided?There is no single right way to use thesecompetencies as part of an assessment orappraisal process. As they apply across such abroad range of staff and professional groups,they will be assessed in different ways indifferent organisations and situations. It willbe up to individuals, line managers, seniormanagers and commissioners to determine,in any given situation or service, whichspecific competencies are required, and whatevidence they draw on to determine whethera competency is being met, however thefollowing may provide useful examples ofways in which evidence might be gathered:●●Learning and reflections from: informalor formal study and reading; trainingcourses (including accredited courses);attending events or conferences;watching programmes, videos or DVDs;shadowing other staff or visits to otherservices; conversations with peoplewith mental health problems and/or relatives and carers; networkingand conversations with colleaguesand others, membership of groups orforums; use of directories, toolkits andother resources.Using the competency framework●●Reflections on one’s own work andpractice and on interactions withothers.●●Feedback from line managers,informally and/or more formallye.g. through one-to-one meetings,supervisions, appraisals andperformance reviews.●●Feedback from colleagues, informallythrough discussions and/or moreformally, including through 360 0reviews if these are available.●●Feedback received formally orinformally from people who use theservices or the public, about individualsor the service/place of work.A competency framework for all those working with people with mental health problems in London15

Using the competency frameworkUsing the competency frameworkThe competency framework is designed to be used on a number of levels and settings; atan individual, team or organisational level. It will be for local consideration as to how theframework could be most usefully applied in different settingsThe table below provides an overview of a range of possible roles and how they mightapply the framework. It is not intended that either the list of possible roles nor the potentialapplications should be considered exhaustive; they are included to provide guidance.Group definition Possible roles PartPartPartApplication123People who maycome into contactwith people withmental healthproblems as part oftheir day to day workStaff who are notmental healthspecialists, but whowork with peoplewho may havea mental healthproblem, and/orpeople who maybe experiencing amental health crisis,as part of a widerclient groupPrimary care receptionistA&E receptionistsHousing department staffEmployment staffVoluntary sector staffPractice /district nursesHealth visitors /healthtrainersA&E staff /generalhospital staffPoliceLondon AmbulanceService staffHousing support workersAdvice servicesPharmacistsSubstance misuseworkersSocial care staff4 Identifying areas forpersonal developmentIncreasing mental healthawarenessIdentifying individualtraining needsPreparing for appraisal4 4 Personal developmentIncreasing mental healthawarenessIndentifying individualtraining needsPreparing for andproviding staff appraisalInforming policydevelopmentService developmentDeveloping trainingprogrammes16London Health Programmes

Group definition Possible roles PartStaff working withpeople with mentalhealth problems– either as a mainclient group or as asignificant part of awider client groupMental health cliniciansPolice officers withparticular mental healthresponsibilitiesGPsVoluntary sector mentalhealth workersMental health advocacyworkersLondon AmbulanceServiceNavigators/peer supportworkers1Part2Part3Application4 4 4 Indentifying areas forpersonal developmentIdentifying individualtraining needsTeam training needsanalysisDeveloping trainingprogrammesInforming and developingjob descriptions andperson specificationsService design andredesignMental health strategyand policy developmentUsing the competency frameworkDeveloping outcomesframeworksLocal educationand training boards(LETBs)Clinicalcommissioninggroups (CCGs)Local HR, workforceand training leadsHealthcare providers, education and training providers, and professionaladvisory bodies. Collectively commissioning education and training according tolocally determined need.Healthcare providers, clinicians and professional advisory bodies. Collectivelycommissioning clinical services according to locally determined need.Individually or collectively designing policies and tools for organisations andhealth communities, to support recruitment, training, professional and teamdevelopment and appraisal processes.A competency framework for all those working with people with mental health problems in London17

1. Personal orientation and interpersonal skillsDomain and CompetencyheadingEmpathy Being able to understand the thoughts and feelings of otherpeople, to see things from their perspectives, and to givesensitive and appropriate responses to other people's emotionalstates.Respect Interacting with other people with courtesy and respect,irrespective of their status (e.g. health, social, professional status).Not acting in ways which are rude, belittling, patronising,dismissive, or consciously hurtful.Nonjudgementalthem.Accepting and valuing other people as they are, without judgingattitudeEvidence couldinclude beingable toDemonstrate anability to reflecton own work andpractice, includinginteractions withothers (and possiblybe able to describechanges in ownbehaviour or ways ofworking as a result).Part one – universal competenciesHolisticapproachSelf awarenessCommunicationBeing able to see the 'whole person' rather than seeing someonejust in terms of 'a problem' or 'a diagnosis'.Self awareness of the impact of one's own behaviour, language,and body language on others, including people with mentalhealth problems.Being able to communicate clearly, sensitively and effectively; thisincludes communicating both verbally and in writing, and sharingrelevant information appropriately.A competency framework for all those working with people with mental health problems in London19

Part one – universal competencies2. Awareness and knowledgeDomain and CompetencyheadingAwareness of Awareness of the prevalence of mentalprevalence of health problems, and the likelihood thatmental health many people may have experience of mentalproblemshealth problems.Awareness of Awareness of the main kinds of mentalmental health health condition and symptoms (e.g.conditions and depression, anxiety disorders, bipolarsymptomsdisorder, schizophrenia).Evidence could includebeing able to●●Demonstrate an awareness of therange and prevalence of mentalhealth problems.●●Demonstrate an understandingof the potential impact for peopleexperiencing a mental healthcrisis.Awareness ofconcept of mentalhealth crisisAwareness ofconcept of longterm mental healthconditionUnderstandingof mental healthstigma anddiscriminationAwareness of the concept and possibilityof mental health crisis, and the potentialimpact on people's behaviour, feelings andperceptions when experiencing such a crisis.Awareness of the concept and possibilityof long term mental health conditions, andthe potential impact on people's behaviour,feelings and perceptions of living with along term mental health condition.Understanding of the stigma anddiscrimination faced by people with mentalhealth problems.●●Demonstrate an ability to reflecton whether there are gaps in ownawareness and knowledge ofmental health problems and howthese might be addressed.●●Demonstrate an ability to applyown mental health awareness andknowledge in real-life situations,and to identify whether thisknowledge was adequate for thesituation(s).20 London Health Programmes

3. System knowledgeDomain and CompetencyheadingSignposting people Knowledge of appropriatewith a range of sources of help andmental health support for people withproblemsa range of mental healthproblems.Ability to signpost peopleto appropriate support.Evidence could include being able to●●Demonstrate knowledge of mental health resources– including sources of information used to supportpeople experiencing a mental health crisis (localresources and services).●●Demonstrate an ability to identify what additionalresources could be drawn on.Part one – universal competenciesSeeking supportto ensure theimmediate safety ofsomeone in mentalhealth crisisSignposting peoplein mental healthcrisisKnowledge and abilityto seek necessary helpand support to ensurethe immediate safety ofsomeone experiencing amental health crisis.Knowledge andability to signpostpeople experiencing amental health crisis toappropriate sources ofhelp and support.●●Identify any gaps in knowledge of mental healthsystem and resources, include: non-statutory aswell as statutory services, specialist mental healthservices and non- mental health services.●●Demonstrate an ability to reflect how ownmental health knowledge has been applied eitherformally or informally, whether that knowledgewas adequate for the situation and what furtherknowledge would be useful.A competency framework for all those working with people with mental health problems in London21

Part one – universal competencies4. Proactive behaviourDomain and CompetencyheadingNon-discriminatory Non-discriminatory behaviour towardsbehaviourpeople with mental health problems.Evidence could includebeing able to●●Demonstrate ability to reflecton individual work and practice,including any situations wherethis competency has beendemonstrated.●●Understand the nature ofdiscrimination in mental health.●●Demonstrate the ability tochallenge inequality anddiscrimination in own role.TakingresponsibilityWillingness to take responsibility forpositively addressing a situation wheresomebody with mental health problemsneeds support.Demonstrate ability to reflecton individual work and practice,including any situations where thiscompetency has or has not beendemonstrated.22 London Health Programmes

Applying part one competenciesin practiceHow do these competenciessupport implementation of the corepathway and London mental healthmodels of care?These competencies should support staff torecognise that a person may be experiencinga mental health problem, to offer anempathetic and sensitive approach, and tosignpost them to appropriate support.The competencies in part one willsupport staff to have the self-awarenessto understand the impact of their ownbehaviour, language and body language,provide a good understanding of the stigmaand discrimination faced by people withmental health problems, and to demonstratenon-discriminatory behaviour themselves.They should help staff in developing a goodknowledge of local resources both to referpeople formally, and also to signpost peopleto other sources of support, including nonstatutoryservices. This should help peopleaccess support beyond statutory health andsocial care services, for example housing oremployment advice, education or training,self-help groups, support from mental healthcharities, or volunteering opportunities.Stigma and fear of discrimination can leadto reluctance to engage with mental healthservices. It is important that people involvedin any part of the pathway understand thisas it can fundamentally shape the quality ofpeople’s experience of mental health care,treatment and support, and willingness toseek appropriate ongoing help.If staff demonstrate self awareness andan understanding of the stigma anddiscrimination faced by people with mentalhealth problems, they are more likely to buildrelationships of trust and engage in waysthat enable people to play a full and activerole in determining and achieving their owncare goals.Whilst support and signposting are notidentified as a part of the core pathway,they are key to reducing stigma and helpingpeople to access the right support. For somethis will mean entering the care pathwaythrough an assessment, and for othersgetting support through wider communityresources.“Without empathy I don’tbelieve there can be a changein attitude and behaviour.”Highly developed empathy, a respectful andnon-judgemental attitude, and a holisticapproach are all important competenciesfor anyone carrying out any function onthe pathway: the pathway makes clear thatassessments should be done in a holistic,person-centred way, and include a person’sphysical health as well as mental healthThese same competencies remain core for allthe other functions in the pathway: effectivereferral to appropriate services; planning andPart one – universal competenciesA competency framework for all those working with people with mental health problems in London23

Part one – universal competencies“It makes such a differencewhen someone treats you asa normal human being.”development of care plans (and living well,wellbeing and crisis plans, as appropriate);intervention and treatment, and evaluation.They are fundamental to building strong,positive and trusting relationships withpeople with mental health problems, andwith their families, friends and carers.of mental health crisis and of long termmental health conditions will enable staffto feel more confident to support peopleexperiencing mental health problems moreeffectively, in a range of different settings.In some cases, these will be covered bypeople’s professional training and theclinical and profession-specific competenciesrequired to perform these functions.An appropriate awareness of the prevalenceof mental health problems, of conditions andsymptoms, and of the concept and nature“The best doctors are nonjudgemental,compassionate,kind and take you seriously.”24London Health Programmes

Part two competenciesThese are competencies forstaff who are not mental healthspecialists, but who work withpeople who may have a mentalhealth problem, or who may beexperiencing a mental health crisis,as part of a wider client group.There are a large number of roles whosemain focus is not on mental health, butwhere staff need a good knowledge ofmental health issues and to be able toengage supportively and effectively withpeople with a range of mental healthproblems. It is likely that increasingnumbers of staff who are not mentalhealth specialists, or who work outsidetraditional mental health services, willbecome more involved in providing support,care, treatment and services to people withmental health problems. Some non-mentalhealth staff work with people with mentalhealth problems and require the skillsand knowledge to respond and provideappropriate support.In addition, staff in certain roles are likelyto encounter people experiencing a mentalhealth crisis and need to have the knowledgeor training to know how best to respondas safely, effectively and supportively aspossible. They need to recognise whenpeople may be experiencing a crisis andhave the confidence and competence tohelp respond appropriately to that crisisand enable the person to get the care andsupport they need. It may not necessarily betheir role to provide these themselves.The focus of part two competencies is onbuilding skills and knowledge of mentalhealth issues, to increase the confidence ofstaff in a variety of settings and to improvethe support provided to people with mentalhealth problems. Competencies in thispart of the framework may be particularlyvaluable in relation to services/organisationsin which there is a need to have a good levelof mental health knowledge to be able torecognise and respond to people with mentalhealth needs and be able to recognise andrespond to people experiencing a crisis.This may include primary care staff, police,ambulance and A&E staff as well as staffin a range of other settings including somehousing support and employment staff.It will be for commissioners and managersto decide what proportion of staff, andwhich posts or roles, should have thesecompetencies within a given team, service ororganisation.It is important to note that people with parttwo competencies should also have partone competencies - these are additionalcompetencies, not alternative ones.Part two competenciesA competency framework for all those working with people with mental health problems in London25

Part two competenciesPart twoFor staff who are not mental health specialists, but who work with people whomay have a mental health problem, and/or who may be experiencing a mentalhealth crisis, as part of a wider client group1. Personal orientation and interpersonal skillsDomain andheadingWorkingsensitivelywith people indistressWorkingcollaboratively,including in acrisis situationCompetencyAbility to work empathetically and sensitivelywith people in distress, in a way which iscalming and reassuring, and seeks to reducetheir distress.Interacting with other people with courtesyand respect, irrespective of their status (e.g.health, social, professional status). Not actingin ways which are rude, belittling, patronising,dismissive, or consciously hurtful.Evidence could include beingable toDemonstrate an ability to reflect onown work and practice, includinginteractions with others (and be able todescribe changes in behaviour or waysof working, as a result). Demonstrateunderstanding and appreciation of therole of others involved in providingsupport, care, treatment and services topeople with mental health problems.26 London Health Programmes

2. Awareness and knowledgeDomain and CompetencyheadingAwareness of Ability to recognise that someonethe signs that may be experiencing a mentalsomeone may health problem and to respondbe experiencing appropriatelya mental healthproblemAwareness of Awareness of the concept andpossibility of possibility of mental health crisis,mental health and the potential impact on people'scrisis, andbehaviour, feelings and perceptionspotential impact when experiencing such a crisis.on people's(This requires a more detailed levelbehaviour,of awareness than in part one, andfeelings andis linked to the ability to identifyperceptionsimmediate symptoms of possiblemental health crisis, below.)Identifying Ability to identify the immediateimmediate symptoms and behaviourssymptoms of that indicate a person may bepossible mental experiencing a mental health crisis,health crisis and to respond appropriatelyEvidence could include being ableto●●Demonstrate an ability to recognise thesigns that a person may be experiencing amental health problem●●Demonstrate an ability to respondsensitively, safely and appropriately to aperson with a mental health problem●●Demonstrate understanding of the potentialimpact of a mental health crisis on people’sbehaviour, feeling and perceptions.●●Demonstrate an ability to identifyimmediate symptoms and behaviours thatindicate that a person may be experiencinga mental health crisis.●●Demonstrate an ability to respondsensitively, safely and appropriately to aperson experiencing a mental health crisis.Part two competenciesUnderstandingconcepts of risk,risk assessment,and riskmanagementUnderstanding of concepts ofrisk, risk assessment and riskmanagement in relation to mentalhealth crisis and in relation to longterm mental health conditions.Ability to apply these conceptsby making judgements about riskin the immediate situation whendealing with and supporting aperson experiencing a mental healthcrisis, and/or when dealing with andsupporting a person with mentalhealth problems who is not in crisis.Continued uA competency framework for all those working with people with mental health problems in London27

Part two competenciesKnowledge andability to providesupport to ensureimmediate safetyof someoneexperiencingKnowledge and ability to providenecessary help and support toensure the immediate safety ofsomeone experiencing a mentalhealth crisis.●●Demonstrate understanding of theconcepts of risk, risk assessment and riskmanagement in relation to mental healthproblems and mental health crisis, andability to apply these concepts in ownjudgements and actions.mental healthcrisis●●Demonstrate the ability to apply a range ofDe-escalationskillsAbility to apply a range of skillsand learnt techniques – includingboth verbal and non-verbalcommunication skills – with theaim of reducing a person's anger,aggression, agitation, hostility orskills and learnt techniques – including bothverbal and non-verbal communication skills– with the aim of reducing a person’s anger,aggression, agitation, hostility or distressand preventing disturbed, unsafe or violentbehaviour.Suicideintervention skillsdistress and preventing disturbed,unsafe or violent behaviour.Ability to recognise the signs ofdistress, including suicidal thoughtsand intentions, and to provide anappropriate response to support aperson at risk of suicide to remainsafe. Ability to recognise the need●●Demonstrate the ability to recognise signsof distress, including suicidal thoughts andintentions, and to provide an appropriateresponse to support a person at risk ofsuicide to remain safe; and the ability torecognise the need to seek further advice/support as required.to seek further advice/support asrequired.UnderstandingUnderstanding that people can●●Demonstrate understanding of the differentdifferent kindsexperience many kinds of crisis thatkinds of non-medical and non-health crisesof crisis that canare not health or medical crisis,that people can experience, and of the waysaffect mentalbut that can affect people’s mentalin which these can affect people’s mentalhealthhealth (e.g. social crisis, housinghealth.crisis, financial crisis, etc).●●Demonstrate ability to respond to peopleexperiencing such crises in ways that aresensitive to the potential impact on mentalhealth.UnderstandingUnderstanding the relationshipDemonstrate an understanding of the need tothe relationshipbetween mental health and physicalexclude physical causes for mental health.between physicalcrisis and the need to excludeand mental healthphysical health problems (forcrisisexample impact of infection andpain in the elderly).Continued u28 London Health Programmes

Understandingrecovery inmental healthUnderstandingperson-centredUnderstanding of the conceptof recovery and recovery-basedapproaches in mental health care,treatment and services.Understanding the importance ofhaving care and services that areDemonstrate understanding of the concept ofrecovery and recovery-based approaches inmental health care, treatment and services.Demonstrate understanding of the conceptof person-centred care and services, and thePart two competenciescare and servicesperson-centred and based aroundability to apply this in one's own practiceeach individual's needs, preferenceswhen working with people with mental healthand choices.problems.UnderstandingAbility to understand and respect●●Demonstrate understanding of, andand respectingdiversity relating to: age; race;respect for, diversity relating to: age; race;diversityculture; disability; sex, genderculture; disability; sex, gender and genderand gender reassignment;reassignment; spirituality, religion or belief;spirituality, religion or belief; sexualsexual orientation; pregnancy, maternityorientation; pregnancy, maternityand parenthood; marriage, marital status,and parenthood; marriage, maritalcivil partnership and civil partnership status.status, civil partnership and civilpartnership status.●●Understand the impact of discriminationand prejudice on people’s mental health andwellbeing.●●Demonstrate a commitment to equalopportunities for all people, and tochallenging discrimination and prejudice.●●Demonstrate an ability to promote people’srights and responsibilities and recognisepeople’s rights to privacy, dignity, respectand confidentiality.A competency framework for all those working with people with mental health problems in London29

4. Proactive behaviourDomain and CompetencyheadingUnderstanding, Understanding and accepting responsibilitiesacceptingthat accompany own professional role, andand acting on demonstrating ability and willingness to takeresponsibilities responsibility for positively addressing a situationof rolewhere somebody with a mental health problemneeds help, including to ensure their immediatesafety or supportRecognising and acting within the parameters ofindividual/role responsibility(This is a greater level of responsibility than inpart one: it involves recognising that taking suchresponsibility is part of one’s role.)Evidence could includebeing able to●●Demonstrate understandingof own role, and theexpectations andresponsibilities thataccompany the role, inrelation to working withpeople with mental healthproblems●●Demonstrate ability toreflect on individual workand practice, and to giveexamples of situations wherethis competency has beendemonstrated.Part two competenciesA competency framework for all those working with people with mental health problems in London31

Part two competenciesApplying part two competenciesin practiceHow do these competenciessupport implementation of the corepathway and London mental healthmodels of care?The competencies in this part are designedto equip professionals to support people, atwhatever part of their mental health journey,whether they are experiencing mental healthproblems for the first time or whether theyhave been, or are currently, engaged withmental health services.It outlines the competencies which supportdifferent ways of working with people withmental health problems, where the focusis toward more people being supportedin primary care or with greater sharedcare between primary and secondary caresettings. The competencies in part twoidentify the skills and knowledge required toenable people in different settings to workwith people with mental health problems ina different way.They may also be useful for those whocommission services to identify thecompetencies required to support changesin service design and configuration and forworkforce development.These competencies should enable avariety of professionals to support peopleappropriately through all parts of the carepathway by providing a holistic, personcentredassessment in the context of theirlives. This should result in people beingoffered the care, treatment and support theyneed to progress along the next steps of thepathway and towards recovery.The competencies identify the need for goodsystem knowledge so that people can besupported to access the most appropriateservices. The sheer number and complexityof available services in London is vastand ever-changing so good, up-to-dateknowledge of local resources is extremelyimportant. Crucially, professionals’ systemknowledge should include non-medicalservices and support options, as well asmainstream health services.Professionals, such as police officers,paramedics, primary care and accident &emergency staff, may have a particular focuson supporting people experiencing a crisisand the competencies that relate to theskills and knowledge needed to respondappropriately and to provide effectivesupport, including care and treatment,while also ensuring immediate safety andminimising distress.Drawing on the competencies in bothpart one and part two will support agood understanding of these differentcircumstances and the skills and knowledgeneeded to respond in a way which is tailoredto the particular situation and the needs andbest interests of the individual.32London Health Programmes

Heading Competency Evidence could include being able toWorking inpartnership(ESC 1)Developing andmaintainingconstructive workingrelationships withservice users, carers,families, colleagues,lay people and widercommunity networks.Working positivelywith any tensionscreated by conflicts ofinterest or aspirationbetween partners incare.●●Ability to explain own role and working parameters, in a waywhich is understandable to people using services, their family andcarers, and others working in different organisations, disciplinesand sectors.●●Ability to engage people with mental health problemsconstructively and effectively, with a clear focus on the individual’sneeds and choices, including (where applicable) engagingindividuals in a collaborative assessment process.●●Understanding and appreciation of the role of others involvedin providing support, care and treatment to people with mentalhealth problems, including appreciation of others’ roles, expertise,and differing perspectives (including professionals, advocates,volunteers, relatives, carers and friends).Part three●●Knowledge of available local organisations, services and resources(within and outside the NHS) that can provide support, care andtreatment to people with mental health problems, and ability torefer/signpost effectively, and in line with individuals’ specificneeds and preferences. This includes ability to use relevant localdirectories (e.g. covering a local authority or CCG area), Ability tocommunicate with all stakeholders involved in an individual’s care.●●Understanding the role that families and carers can play insupporting individuals with mental health problems, and ability toengage them as active partners in care and support.●●Understanding the specific needs of carers and families of peoplewith mental health problems. Ability to provide support to carersand families and help address their needs, including supportingpeople to receive a carer’s assessment if appropriate●●Ability to communicate effectively across disciplinary, professionaland organisational boundaries.Continued uA competency framework for all those working with people with mental health problems in London35

Part three●●Understanding of the wider determinants of health (i.e. the social,economic and environmental factors that influence the health ofindividuals and populations) and ability to work collaborativelywith partners to address these factors and improve the health ofindividuals and populations.Respectingdiversity(ESC2)Working inpartnership withservice users,carers, families andcolleagues to providecare and interventionsthat make a positivedifference in waysthat respect andvalue diversityincluding: age; race;culture; disability;sex, gender andgender reassignment;spirituality, religionor belief; sexualorientation;pregnancy, maternityand parenthood;marriage, maritalstatus, civilpartnership and civilpartnership status .●●Provide care, treatment and support that recognises theimportance of housing, employment, occupational opportunities,recreational activities, social networks and welfare benefits.●●Understanding and acknowledging diversity relating to: age;race; culture; disability; sex, gender and gender reassignment;spirituality, religion or belief; sexual orientation; pregnancy,maternity and parenthood; marriage, marital status, civilpartnership and civil partnership status.●●Understanding the impact of discrimination and prejudice onmental health and mental health services.●●Demonstrating a commitment to equal opportunities for all peopleand encouraging their active participation in every aspect of care,treatment and support.●●Ability to promote people’s rights and responsibilities andrecognise service users’ rights to privacy, dignity, respect andconfidentiality.●●Ability to contribute to evidence-based programmes of care andtreatment that are sensitive to, and responsive to, diversity.●●Ability to identify, communicate with, and refer appropriately toother (statutory and non-statutory) services designed to addresspeople’s specific needs relating to their identities and cultures36 London Health Programmes

Practisingethicallyand legally(ESC 3)Recognising therights and aspirationsof service usersand their families,acknowledgingpower differentialsand minimisingthem wheneverpossible. Providingtreatment and carethat is accountable●●Understanding of, and commitment to, the legal and human rightsof all people using services, and of their carers and family.●●Understanding of the legal context and framework withinwhich care, treatment and support are given to people withmental health problems, including legislation relevant to ownpractice and services (this will depend on own specific roleand service, but might include e.g. Mental Health Act 1983,Disability Discrimination Act 1995, Mental Capacity Act 2005and Deprivation of Liberty Safeguards, Mental Health Act 2007,Equality Act 2010).Part threeto service users andcarers within theboundaries prescribedby legislationand by national(professional), legal●●Knowledge of, and ability to, apply policies, practices andprocedures concerning the local implementation of mentalhealth and related legislation, including working with conceptsof ‘appropriate services’ and ‘least restrictive options’ for thosedetained under the mental health or mental capacity legislation.and local codes ofethical practice.●●Understanding of principles and practice of debriefing those whohave been detained under mental health legislation, their families,carers and staff.●●Understanding of, and adherence to, local and professionalprescribed codes of ethical conduct and practice.●●Understanding of own and others’ responsibilities in relation tosafeguarding children and vulnerable adults.●●Ability to conduct a legal, ethical and accountable practice thatremains open to the scrutiny of peers, colleagues and appropriateothers (e.g. regulators, HealthWatch, patient bodies, complaintinvestigators).●●Ability to respond to people’s needs in an ethical, honest, nonjudgementalmanner.Continued uA competency framework for all those working with people with mental health problems in London37

Part three●●Ability to promote service users’ (and carers’) rights andresponsibilities and recognise and maintain their rights to privacy,dignity, safety, effective treatment and care based on the principleof informed consent.●●Ability to work as a member of the therapeutic team in makinga safe and effective contribution to the de-escalation andmanagement of anger and violence, including through the use ofcontrol and restraint techniques where these are appropriate toown professional role.Challenginginequality(ESC 4)Addressing the causesand consequences ofstigma, discrimination,social inequalityand exclusion onservice users, carersand mental healthservices. Creating,developing ormaintaining valuedsocial roles for peoplein the communitiesthey come from.●●Ability to work within local complaints management systems, toaddress complaints positively and constructively, including beingwilling and able to adapt and improve own practice, services andway of working in response to complaints.●●Understanding the nature of stigma, and the effects ofdiscrimination and exclusion.●●Understanding the role that mental health services play in creatingand maintaining inequality and discrimination.● ● Understanding the role that services play in fighting inequality anddiscrimination.● ● Ability to challenge inequality and discrimination within own role.● ● Ability to communicate own concerns to others within the caresystem.38 London Health Programmes

Promotingrecovery(ESC 5)Working inpartnership to providecare and treatment●●Understanding the concept of recovery and recovery-based modelsand approaches in mental health care, treatment and services,including understanding that recovery is a process unique to eachPart threethat enables serviceindividualusers and carers totackle mental health● ● Understanding of the evidence-base for recovery-based modelsproblems with hopeand approaches in mental health care, treatment and servicesand optimism andto work towards avalued lifestyle within● ● Understanding of core and evidence-based models of relapsepreventionand beyond the limitsof any mental healthproblem.● ● Ability to explain concept of recovery and recovery-basedapproaches to people who use mental health services, and theirfamily and carers● ● Application of recovery-based approaches in own practice● ● Understanding of the individual’s wider social and supportnetworks and the contribution made by carers, family and friendsto the recovery process.A competency framework for all those working with people with mental health problems in London39

Part threeIdentifyingpeople’sneeds andWorking inpartnership togather information●●Ability to work in a way that acknowledges and values thepersonal, social, cultural and spiritual strengths and needs of eachindividual.strengths(ESC 6)to agree health andsocial care needs inthe context of thepreferred lifestyle andaspirations of service● ● Understanding how the physical and mental health of anindividual can be promoted or demoted, and the impact that anindividual’s mental and physical health needs may have on otherparts of the system.users, their families,carers and friends.● ● Ability to acknowledge and work with a person’s physical andmental health needs in a way that demonstrates understanding ofthe connections between the two, including the vulnerabilities ofpeople with physical long-term conditions.● ● Ability to support people to self-manage physical long-termconditions using psychological methods and interventions, possiblyincluding principles of cognitive behavioural therapy (CBT).● ● Understanding of the impact that other parts of the system mayhave on an individual’s physical and mental health.● ● Ability to work in partnership with individuals’ support networksto collect information to assist understanding of the person andtheir strengths and needs.● ● Carrying out (or contributing to) a systematic whole systemsassessment that has, as its focus, the strengths and needs of theindividual using services and those family and friends who supportthem.40 London Health Programmes

Providingservice usercentredNegotiatingachievable andmeaningful●●Ensuring that all care, treatment and support for peoplewith mental health problems is focused on understandingand addressing the individual’s specific needs, in waysPart threecare (ESC 7)goals, primarilythat take account of individuals’ preferences, choices,from thelifestyles, identities, culture, and support networks.perspectiveof serviceusers and● ● Ability to encourage individuals’ active choices andparticipation in their own care and treatment.their families.Influencingand seekingthe means toachieve thesegoals andclarifying theresponsibilities●●Ability to support individuals with mental health problems in accessingand using existing and emerging mechanisms tosupport and promote personalised approaches to their own care,treatment and support (e.g. personal budgets; personal health budgets;social prescribing; access to navigators, peer supporters, and selfmanagement programmes; choice through any qualified provider;advance directives and advance statements of wishes and feelings, etc.)of the peoplewho willprovide anyhelp needed,includingsystematicallyevaluatingoutcomes andachievements.● ● Ability to provide people with mental health problems andrelatives and carers with information on their conditions andthe services and standards they can expect, including treatmentoutcomes, in the format they find most accessible – includingmulti-media approaches that accommodate varying language andcultural needs. This includes providing information that supportseffective and empowered decision-making by people with mentalhealth problems about their care and treatment options.● ● Ensuring that any goal-setting is driven by theneeds of the individual using services.● ● Working with individuals using services to help them to describe theirown goals as precisely as possible in ways that are meaningful to them.● ● Helping individuals using services to identify and use theirstrengths to achieve their goals and aspirations.● ● Working with individuals using services to identify the strengthsand resources within each service user’s wider network whichhave a role to play in supporting goal achievement.● ● Supporting individuals using services to ensurethat goals are achievable and measurable.● ● Understanding the difference between broader longterm and short term, more specific goalsA competency framework for all those working with people with mental health problems in London41

Part threeMaking adifference(ESC 8)Facilitatingaccess to, anddelivering, thebest quality,evidencebased,valuesbasedhealthand social careinterventions tomeet the needsand aspirationsof serviceusers and theirfamilies andcarers.●●Understanding the concept of evidence-based and values-based‘best practice’ as enshrined in NICE guidance and psychosocialinterventions training, etc. and understanding and applying specificNICE guidance relevant to own role and practice●●Awareness of and ability to apply other best practice guidance froma range of bodies, as appropriate to own role and client group (e.g.from SCIE, Royal Colleges, mental health charities etc.)●●Ability to design, or contribute to the design of, (as appropriateto role) a programme of care based on ‘best practice’ or the bestavailable evidence.●●Appreciation of the value of qualitative evidence, including surveysand other feedback from people who use services, and ability to applylearning from such evidence in own practice and services.●●Understanding own role in delivery and implementation of such aprogramme of care, and the role that others (in statutory services andoutside of statutory services) can plan in such a programme of care.Knowledge and appreciation of the diversity of organisations andservices that can contribute to a programme of care, depending onthe specific needs and preferences of the individual.●●Ability to communicate clearly and effectively with all, includingindividuals using services and carers, who have a part to play in aprogramme of care.●●Understanding the impact of any particular problem on the life of theperson using services and their carers, family and friends.●●Ability to identify physical health needs, and to identify care pathwaysthat will deliver an effective response including, for example, outreachand home based care and treatment.●●Understanding of the range of medical and non-medical approachesto care and treatment available for people with mental healthproblems, and ability to discuss these various approaches, and theirmerits and drawbacks, with individuals to support them in achievingthe care, treatment and support that best meets their individualneeds.●●Understanding the importance of good and ongoing medicinesmanagement in the care and treatment of people with mentalhealth problems, and the potential for polypharmacy (use of multiplemedications) and associated risks (e.g. potential for: drug interactions;side-effects and adverse drug reactions; non-compliance; patientconfusion over medication regime).● ● Where appropriate to own role, ability to support people with mentalhealth problems in reviewing, rationalising or reconciling theirmedication.42 London Health Programmes

Promotingsafety andpositiveEmpoweringthe person todecide the level●●Understanding the value and importance of involving people usingmental health services in assessments of the risks relevant to them,and in agreeing and implementing plans and strategies for managingPart threerisk takingof risk theythose risks. In addition, demonstrate understanding of the value and(ESC 9)are preparedimportance of involving people’s family and carers in assessment andto take withmanagement of relevant risks.their healthand safety.●●Understanding when it is essential for a physical cause of crisis to beThis includesassessed, discounted or treated.working withthe tensionbetweenpromoting●●Promoting understanding of the factors associated with risk of harmfrom others, and risk of harm to self or others through violence, selfneglect,substance misuse, self-harm or suicide.safety andpositiverisk taking,●●Promoting an understanding of the commonest social causes of crisisand how to deal with them.includingassessing anddealing withpossible risks●●Applying a range of skills and techniques with the aim of supportinga person at immediate risk of suicide to remain safe; seeking orproviding further support as appropriate to own role.for serviceusers, carers,family membersand the widerpublic.●●Contributing to accurate effective risk assessments using agreedtools and protocols, identifying specific risk factors relevant tothe individual, their family and carers and the wider community.Contributing to development of risk management strategies and plansthat are developed with involvement of the person they concern,name all the relevant people involved in their care and treatment(including family, carers and other non-clinical and/or non-statutorysources of support), and clearly identify the agreed actions to betaken and by whom, and the goals to be achieved.Continued uA competency framework for all those working with people with mental health problems in London43

Part three●●Contributing, as a member of the therapeutic team, to the safe andeffective management and reduction of any identified risks.●●Knowledge and understanding of national and local policies andprocedures for minimising risk and managing harm to self and others.●●Knowledge and understanding of the Care Programme Approach andits role in ensuring safe and effective care and treatment for serviceusers and carers, particularly those with a history of risks to self orothers.●●Understanding the importance of multi-agency, multi-disciplinaryworking in promoting safety and positive risk taking, and activelycontributing to a constructive, multi-agency approach.●●Awareness of the available spectrum of individual and serviceresponses to help manage crises and minimise risks as they arehappening e.g. diffusion strategies, crisis response services.●●Contributing to use of medical and psychosocial interventions withthe expressed goal of managing a person’s risk behaviours in the longterm (e.g. through use of medication, anger management, supportivecounselling, etc.)●●Educating users and carers about the role, function and limitations ofmental health services in relation to promoting safety and managingrisk of harm.44 London Health Programmes

Personaldevelopmentand learningKeeping upto-datewithchanges in●●Active participation in personal and professional developmentand life-long learning, and commitment to applying new learningin practice.Part three(ESC 10)practice andparticipating inlifelong learning,personal and●●Ability to set personal/professional goals that are realistic andachievable, including through personal/professional developmentplans where this is appropriate to own role.professionaldevelopmentfor oneselfand colleaguesthrough●●Understanding personal responsibility to achieve goals set inown development plan, and understanding responsibilities ofemployer/service to provide support in meeting the goals set inthe development plan.supervision,appraisal andreflective●●Recognition of importance of supervision and reflective practiceand ability to integrate both into everyday practice.practice.●●Ability to be proactive in seeking opportunities for personalsupervision, personal development and learning.●●Ability to identify and reflect on areas of practice where thingshave gone well, and where things have not gone well, toarticulate the reasons why, and to identify and apply learningfrom these experiences in future working practice●●Understanding responsibility for continuous learning to reflectdevelopment and innovations in practice.A competency framework for all those working with people with mental health problems in London45

Part threeApplying part three competenciesin practiceHow do part three competenciessupport implementation of the corepathway and London mental healthmodels of care?Fundamentally, the competencies, pathwayand models of care are all based onapproaches that are about promotingrecovery, seeing individuals holistically, andengaging people as active partners andparticipants in their own support, care andtreatment. In addition the importanceof families, friends and carers, and oftheir involvement in people’s recovery, isrecognised in these approaches, as well asthe specific needs of carers themselves.All ten of the part three competenciesunderpin the effective implementation ofthe pathway. The competencies do not mapdirectly onto one or more specific functionsin the pathway, rather they are all essentialto the provision of high quality support, careand treatment across the entire pathway.The examples of evidence show some ofthe specific ways in which the competenciesare likely to support effective, high qualityimplementation of the models of care andcore pathway.46London Health Programmes

ReferencesReferencesAcknowledgements and thanksThanks are due to The Office for PublicManagement (OPM) who produced thiscompetency framework on behalf of LondonHealth Programmes and NHS London.Thanks go to everyone who helped todevelop this competency framework throughtaking part in interviews, focus groups andworkshops, and contributing commentson various drafts. Particular thanks aredue to the relatives, carers and peoplewith direct experience of using mentalhealth services, many of whom shared verymoving and personal information abouttheir experiences. Their insights and firsthandaccounts were invaluable in shapingthis framework. We greatly appreciate thesupport of the charities Mind, Bipolar UK,and Rethink Mental Illness in helping torecruit participants to the focus groups andinterviews. We are also grateful to the manyprofessionals who generously gave their timeand expertise to support the framework’sdevelopment.Views and experiencesThroughout the process of developing thiscompetency framework people with directexperience of using mental health servicesand those involved in delivering servicesgenerously shared their thoughts andexperiences. A selection of these have beenincluded throughout the document. It wasnot possible to include all the contributionsin the body of the document. We felt thecomments raised important issues and havetherefore included them in Appendix 4.A competency framework for all those working with people with mental health problems in London 47

Appendix 1Appendix1: Terminology used inthis competency frameworkThroughout this competency framework,we use the same terminology as that used indeveloping the London mental health modelsof care:Mental health problem - in line withthe government mental health strategy,in most circumstances, this document usesthe phrase mental health problem as anumbrella term to describe the full range ofmental illnesses and disorders, includingpersonality disorder. When quoting otherdocuments or when other terminology isin common use, the document will reflectthose differences. Mental health problemsmay be more or less common, may be acuteor longer lasting and may vary in severity.They manifest themselves in different waysat different ages. Some people object to theuse of terms such as mental health problemson the grounds that they medicaliseways of thinking and feeling and do notacknowledge the many factors which canprevent people reaching their potential. Werecognise those concerns and the stigmaattached to mental ill health, however thereis no universally acceptable terminology thatwe can use as an alternative.Mental health crisis - a broad definitionof crisis has been adopted: adults who areexperiencing a period of acute psychologicaldistress or disturbance, associated with amental health problem (which may or maynot have been given a formal diagnosis). Thecrisis may be a sudden deterioration of anexisting mental health problem or they maybe experiencing mental health problemsfor the first time. They need immediatetreatment and/or care and/or support toprevent further damage to their mentalwellbeing.Long term mental health conditions- encompasses the likely diagnosesof schizophrenia, bipolar disorder,schizoaffective disorder, recurrent depression,and chronic neurotic, stress related andsomatoform disorders. It was decided toname this group ‘long term mental healthconditions’ as there are important parallels tothe group with long term physical conditionsand it should help to resonate with primarycare teams and to integrate it into more‘business as usual’ for primary care.48 London Health Programmes

Appendix 2: Related competencyframeworksAppendix 2The Capable PractitionerFramework (CPF)This was published in 2001 by the SainsburyCentre for Mental Health. It describes theinputs, knowledge, skills and attitudesconsidered necessary to become a capablepractitioner working within mental health.It sets out five domains: ethical practice;knowledge; process of care; interventions,and applications to specific service settings.All staff are expected to follow ethicalpractice, but there is increasing specialisationas one progresses through the domains. Itwas originally published to support theNational Service Framework (NSF) for MentalHealth.NHS Knowledge and SkillsFramework (NHS KSF)The NHS Knowledge and Skills Framework(KSF) was published in 2004 by theDepartment of Health, and sets out theknowledge and skills required to perform jobroles within the NHS. It is intended to applyto everyone working in the NHS. It is dividedinto 30 dimensions: six core dimensions thatapply to everyone in the NHS, and 24 specificdimensions that each apply to some jobs andnot others.specific dimensions are grouped under fourthemes: health and well being; estates andfacilities; information and knowledge, andgeneral.Each dimension has four levels, with leveldescriptors for each competency to describehow knowledge, skills and behaviour shouldbe applied at that level. The NHS KSF isspecific to the NHS, but it is not mentalhealth specific. It is widely used in the NHS,especially in developing job descriptions.The National OccupationalStandards for Mental Health (MHNOS)These were developed in 2004 and set outdetailed competencies required in providingmental health services. They were largelyintended to support the use of the NHS KSFi.e. by providing the detail and evidence thata practitioner is demonstrating and achievinga particular NHS KSF dimension. They areaimed at all staff working in mental healthservices. However, as they are also intendedto support the NHS KSF, they are more likelyto be used within NHS services, than in socialcare or the voluntary sector.The core dimensions are: communication;personal and people development; health,safety and security; service improvement;quality, and equality and diversity. TheA competency framework for all those working with people with mental health problems in London49

Appendix 2The MH NOS are grouped into three keyareas:●●Operating within an ethical framework(Standard A)●●Working with and supportingindividuals, carers and families(Standards B to J)●●Influencing and supportingcommunities, organisations, agenciesand services (Standards K to O)Closing the GapThis is a capability framework for workingeffectively with people with combinedmental health and substance use problems(dual diagnosis). It is intended for all staffwho come into contact with this service usergroup in a range of settings. It was publishedin 2006, with funding from the Departmentof Health and other partners.Capabilities for Inclusive PracticeStandard A is expected to apply to all staff,with the other standards applying to specificstaff and/or teams, depending on their rolesand functions. The MH NOS are intended toprovide a measurement of performance. Itis expected that the knowledge, skills andbehaviours set out in the MH NOS shouldbe developed as part of pre-qualificationtraining, post-qualification training, andcontinuing professional development (CPD).This was published in 2007 by theDepartment of Health in collaboration witha wide range of partners. It is a capabilityframework for socially inclusive good practicefor those working with mental health serviceusers, and is structured around the tenEssential Shared Capabilities.The Ten Essential SharedCapabilities (ESC)These were developed jointly in 2004 bythe Sainsbury Centre for Mental Health,the National Institute for Mental Health inEngland, and the NHS University (NHSU).They provide a framework for the wholemental health workforce, and thereforeapply to everyone working with people withmental health problems, and not just to theNHS or statutory services. They specificallyaim to set out shared capabilities that allstaff working in mental health shouldachieve, irrespective of whether they hold aprofessional qualification, and of the sectorin which they work.50 London Health Programmes

Appendix 3: Policy context anddrivers of changeAppendix 3The key policies and developmentsthat are driving changes inservices and support for peoplewith mental health problems aresummarised here.Government mental health strategyThe 2011 mental health strategy “No healthwithout mental health” highlights theimportance of mental wellbeing that isholistic and outcomes focussed as opposed tosolely medical. Priorities include increasingthe availability of psychological therapiesfor people with severe mental illness, and afocus on high quality mental health servicesaccompanied by national indicators to judgeprogress.Personalisation and person-centred careThere is growing recognition that peoplewith mental health problems should havegreater choice and control in the supportthey receive, and should be centrally involvedin identifying their own needs, and inplanning care, treatment and support thatmeets their specific needs and preferences.Policies to support personalisation mean thatan increasingly wide range of organisationswill become involved in providing tailoredsupport and services to people with mentalhealth problems. However, some studiessuggest that staff attitudes can still be ahindrance to achievement of personalisationfor people with mental health problems .RecoveryThere are many definitions of recovery inmental health, but in essence it is abouttaking a holistic approach that focuses onrecovering a meaningful life rather thanon cure or elimination of symptoms. Hopeand optimism are central guiding principles.Recovery is seen as a process, not an endpoint, and is about building resilience.Strong systems of support from family,friends and professionals are importantelements, and people from a very wide rangeof groups and services may be involved insupporting a person’s recovery. Recoverybasedapproaches are becoming increasinglycentral to the way mental health services arecommissioned, designed and operate.InclusionMany people with mental health problemslack equal access to opportunities includingpaid employment, volunteering, housing,education, financial services, and socialparticipation; such exclusion can lowerself esteem. Improving opportunities canenhance recovery, bring hope, and reducedependence as people are able to contributeto society. Understanding and promotinginclusive practice is important for everyoneworking with people with mental healthproblems: Capabilities for Inclusive Practicepoints out that “practicing inclusivity iseveryone’s job and some staff may havea particularly strong focus on particularinclusive goals”.A competency framework for all those working with people with mental health problems in London51

Appendix 3Self management and self careThe principles of self management and selfcare are about supporting and encouragingpeople with long term conditions totake greater control, and also greaterresponsibility, for their own care. Again,the ethos is holistic, and includes supportingpeople to learn about techniques andapproaches for managing specific conditions,and the potential impact of lifestyle choicesand changes. Accredited self managementcourses are usually run by specialist charitiesor the NHS, for example Bipolar UK runs selfmanagement courses based on evidence ofwhat works, and delivered by accreditedtrainers with personal experience of thecondition. Self management can help peoplegain the skills, understanding and confidenceto better manage their own condition. Forpeople with mental health problems, thisincludes learning to recognise the earlysigns of a potential decline or crisis, anddeveloping strategies to minimise the impact.In addition to courses, self management canalso be promoted through other mechanismssuch as support groups, peer support,workbooks, etc.skills and practices to people with specificlong term conditions (the self managementprogramme, SMP) and to clinicians (theadvanced development programme, ADP).Both programmes are co-facilitated bysomeone who is successfully managing theirlong term condition and a clinician, andfocus on three enablers: goal setting, sharedagenda setting and goal follow up. Sites aresupported to improve the way their servicesare designed and operated to better supportself management. The evaluation foundthat for people with long term conditionsthere were ‘statistically significant changes inpositive engagement in life, adopting a moreconstructive attitude and approach to theircondition, having more positive emotionalwell being and using self managementskills and techniques’. In addition clinicianscompleting the ADP ‘commonly reportan increased motivation to improve theirpractice and greater belief that improvementis possible, increased job satisfaction, anda greater sense that they are now ‘helpingpeople’ in a way that reflects why they cameinto healthcare’ .Social prescribing or community referralCo-creating healthThis is a self management demonstrationprogramme, funded by the HealthFoundation. It aims at enabling peoplewith various long term conditions, includingdepression, to improve their health and havea better quality of life through taking a moreactive role in their own care. In phase one(2007 – 2010) eight sites received £150k anda package of integrated support; followingevaluation phase two (2011-12) focuses onsustaining and spreading the approach.Based on evidence of what works in enablingself management, the programme teachesThis is a mechanism for health professionalsto link people with mental health problemswith non-medical sources of support withinthe community, with the aim of improvingtheir mental health and wellbeing. Socialprescribing is usually delivered throughprimary care, e.g. through ‘exercise onprescription’, ‘prescription for learning’,or ‘art on prescription’ schemes, althoughthere are a range of models and schemesin different areas. Social prescribing canenable people to access opportunities forarts and crafts, physical exercise, learningnew skills, volunteering, and to accesssupport in relation to employment, benefits,52 London Health Programmes

debt, housing, education, legal issues orparenting problems. Social prescribing formental health provides a framework fordeveloping alternative responses to mentaldistress, while recognising the impact ofsocial, economic, environmental and culturalfactors on mental health and wellbeing. Itcan also be a mechanism to improve accessto mainstream services and opportunitiesfor people with long term mental healthconditions. Social prescribing can be usedin addition to, or as an alternative to,medication and psychological approaches tocare, treatment and support for people withmental health problems. In addition, socialprescribing can be used to prescribe respitebreaks or other support for carers.The Care Programme Approach (CPA)This is intended to provide a high degree ofsupport to people diagnosed with a severemental health problem, or who are at risk ofsuicide, harm to self to others, or have a widerange of needs or are vulnerable. It is alsoavailable to people who have recently beendetained under the Mental Health Act, orhave parenting responsibilities, or a historyof violence or self harm . Under the CPA, aperson with mental health problems is given anamed care co-ordinator. The person shouldbe involved in the assessment of their ownneeds, and the development of a written careplan, including outlines of any risks and whatshould be done in a crisis or emergency. Theyshould be informed about choices available,and treated with dignity and respect. Thecare co-ordinator should co-ordinate theassessment and planning process, ensuring thecare plan is reviewed regularly, at least oncea year. CPA is supposed to be an example ofpersonalisation in care of people with mentalhealth problems, but in practice there is stillvariation in the quality of implementation.Navigators and Peer SupportersNavigators help people navigate their waythrough the complex myriad of health, socialcare, welfare and voluntary sector systemsand services available, so that people canaccess the kinds of advice and support thatbest meet their needs. Navigators need someunderstanding of mental health conditionsand services, and to be familiar with what isavailable locally to reflect the diversity of thelocal population. Crucially, they work acrosssector boundaries to identify and harnessthe best support for any individual. Thusthey may be involved in helping people findaccommodation, employment, education ortraining, access benefits, or identify socialand leisure opportunities. Peer supportersare people with direct experience of usingmental health services who are recruitedand trained – as paid staff or volunteers – toprovide some or all of these kinds of support.There is increasing interest in the potentialof navigators and peer supporters to supportpeople with mental health problems,and these roles are seen as crucial to thesuccessful implementation of the models ofcare.Experts by ExperienceThis refers to people who have insight andunderstanding of services gained from theirexperiences as patients or service users.Experts by experience are recruited anddeployed in a number of ways, such as beinginvolved in service design, development,evaluation or inspection, or participatingin oversight or advisory bodies. The CareQuality Commission (CQC) is increasinglyincluding experts by experience in serviceinspections, as part of a team alongsideprofessional inspectors. Within CQCinspections, experts by experience payAppendix 3A competency framework for all those working with people with mental health problems in London53

Appendix 3particular attention to hearing the views ofcurrent service users. Experts by experienceare likely to play an increasing role in thedevelopment and evaluation of servicesfor people with mental health problems inLondon, thus increasingly staff will need tounderstand how best to work with, deployand support mental health experts byexperience.Personal Health Budgets (PHBs)These are another initiative aimed at givingpeople more control over their services,care and support, as part of a personalisedapproach to public services. Between 2009and 2012 PHBs are being piloted in around 70areas across England, with an independentevaluation due in October 2012. Around athird of pilots - including some in London- are testing PHBs to meet needs of peoplewith mental health problems. PHBs can beused in flexible, innovative ways to meetagreed health outcomes, including forcare and services not provided by the NHS.Each person must have a written care plan(sometimes called a support plan), statingtheir health and wellbeing needs, intendedhealth and wellbeing outcomes, the amountof money in their PHB and how it will bespent. This must be agreed by the leadclinician and lead commissioner, or a panelwhich includes these two people and otherson the basis of being financially and clinicallyappropriate. The aim is to involve peopleas equal partners in planning and choosingtheir own care and treatment. Some peopleare using PHBs to meet needs traditionallyclassed by the NHS and local authorities as‘social needs’ e.g. to undertake classes, goswimming, or enable social interactions.People can use PHBs to ‘shop around’ andchoose their own provider (e.g. a counsellor)rather than just taking one allocated by theNHS. PHBs do not cover core GP servicesor emergency care. Subject to successfulevaluation, PHBs will be rolled out acrossEngland by April 2014 for everyone eligiblefor NHS continuing healthcare (i.e. careprovided outside hospital for people withcomplex medical conditions, or requiringhighly specialist nursing care).Any Qualified Provider (AQP)This government policy is designed to givepeople a choice of providers and servicesto meet their health needs, rather thansimply having one NHS service availablein their area. The AQP scheme startedin April 2012, but is initially limited tospecific conditions in specific PCT areas. Forexample, people are offered a range ofapproved psychological therapy providersin some parts of the country, but not yet inLondon. Services remain free with accessbased on clinical need, just as they are whenprovided directly by the NHS. As this policyis extended, a wider range of approvedproviders – including NHS, independentsector, charities and social enterprises – willbe involved in delivering NHS services. Localcommissioners will control contracts andprices, and providers will need to go througha qualification process and be approved.The government wants people usingsecondary mental health services to havemore choice. It has proposed that by April2013 all service users should be able tochoose any named consultant-led teamwithin their secondary mental healthprovider, as well as any mental healthservices within their secondary mental healthprovider run by other professionals such asmental health nurses, occupational therapistsor clinical psychologists.54 London Health Programmes

Quality and Outcomes Framework (QOF)This is an annual incentive programme forGP surgeries in England, to resource andreward good practice. The QOF consistsof four domains: clinical, organisational,patient experience, and additional services.Each domain contains a set of indicators;GP practices score points based on theirachievement against each indicator. Higherscores result in higher financial rewards, withthe final payment adjusted to take account ofpractice list size and prevalence. The QOF isupdated periodically, and includes a numberof indicators for mental health - relating torecordkeeping and management of patientswith specific mental health diagnoses - andfor depression.Commissioning for Quality andInnovation (CQUIN) payment frameworkCQUIN was introduced in 2009, and enablescommissioners to reward excellenceby linking a proportion of healthcareproviders’ income to achievement of qualityimprovement goals. These goals are agreedlocally between commissioners and providersannually, and written into contracts.Providers of acute services, ambulance,community, mental health and learningdisability services using national contractsare expected to have a full CQUIN schemein order to earn CQUIN money. The CQUINframework is intended to help embed aculture of continuous improvement in NHSservices. The CQUIN framework also coversindependent sector providers on nationalstandard NHS contracts.NICE guidelinesThe National Institute for Health and ClinicalExcellence has produced over 100 guidelineson the care and treatment of variousmental health disorders. All commissioners,providers and GPs should be aware of them,and should be aiming to apply the guidelinesand achieve the standards they set out. NICEguidelines are also useful for patients, serviceusers and the public to understand whatstandards of care and treatment they shouldbe able to expect. The main NICE guidelinesrelating to mental health include:●●Common mental health disorders:identification and pathways to care(2011). www.nice.org.uk/guidance/CG123●●Alcohol-use disorders: diagnosis,assessment and management ofharmful drinking and alcoholdependence (2011) www.nice.org.uk/guidance/CG115● ● Generalised anxiety disorder and panicdisorder (with or without agoraphobia)in adults (2011). www.nice.org.uk/guidance/CG113● ● Depression in adults with a chronicphysical health problem: treatment andmanagement (2009). www.nice.org.uk/guidance/CG91● ● Depression: the treatment andmanagement of depression in adults(2009). www.nice.org.uk/guidance/CG90Appendix 3● ● Promoting mental wellbeing throughproductive and healthy workingconditions: guidance for employers(2009).A competency framework for all those working with people with mental health problems in London55

Appendix 3www.nice.org.uk/guidance/PH22● ● Drug misuse: psychosocial interventions(2007) www.nice.org.uk/guidance/CG51● ● Drug misuse: opioid detoxification(2007). www.nice.org.uk/guidance/CG52● ● Antenatal and postnatal mental health(2007) www.nice.org.uk/guidance/CG45●●Computerised cognitive behaviourtherapy for depression and anxiety(2006). www.nice.org.uk/guidance/TA97●●Obsessive-compulsive disorder: coreinterventions in the treatment ofobsessive-compulsive disorder and bodydysmorphic disorder (2005). www.nice.org.uk/guidance/CG31●●Post-traumatic stress disorder (PTSD):the management of PTSD in adults andchildren in primary and secondary care(2005). www.nice.org.uk/guidance/CG26●●Quality standard on depression inadults: http://www.nice.org.uk/guidance/qualitystandards/depressioninadults/home.jsp●●NICE Pathway on depression: http://pathways.nice.org.uk/pathways/depressionA NICE clinical guideline on social anxietydisorder is under development and due in2013.For the full list of NICE guidelines relevant tomental health, see www.nice.org.uk/Quality, Innovation, Productivity andPrevention (QIPP) programmeThis major transformation programmeis about driving forward quality andproductivity improvements across the NHS,to achieve £20 billion efficiency savings by2015. The Department of Health has set upa number of QIPP workstreams in the threebroad areas of: commissioning and pathways;provider efficiency, and system enablers(covering primary care commissioning).There is a specific workstream on longterm conditions, one aimed at ensuringpeople get the right care in the right placeat the right time, and another on urgentcare and reducing accident and emergencyattendance.Improving Access to PsychologicalTherapies (IAPT)This programme was introduced in 2008by the Department of Health to supportimplementation of NICE guidelines forpeople suffering from depression andanxiety disorders. It was created to offerpeople a realistic and routine first-linetreatment combined, where appropriate,with medication, which traditionally hadbeen the only treatment available. Initially,the programme focused on offering cognitivebehavioural therapy (CBT), but is widening,with therapists being trained so they canoffer other NICE recommended therapiesand counselling (e.g. couples therapy fordepression). Since 2011 the focus of theIAPT programme has broadened, followingpublication of Talking therapies: a four-yearplan of action . The government’s intentionis that by 2014, all services will have sufficientcapacity to offer psychological therapies toat least 15% of people in their communitieswith depression and/or anxiety. Between56 London Health Programmes

2011 and 2015, an additional £400m is beinginvested, and will support:●●Completion of the nationwide roll-outof psychological therapy services foradults across England● ● Extension of evidence-basedpsychological therapies to children andyoung people through a stand-aloneprogramme● ● Extension of IAPT to people withlong-term physical health problems,medically unexplained symptoms andsevere mental illness.Payment by Results (PbR)PbR is a payment system under which NHScommissioners pay health care providersfor each person seen or treated, taking intoaccount the complexity of the patient’sneeds. PbR is intended to improve efficiency,support patient choice, and incentivisebest practice models of care. PbR was firstintroduced for acute hospital care, withnational tariffs being set for admittedpatient care, outpatient attendances, A&E,and some outpatient procedures. Thegovernment is in the process of introducingPbR for adult mental health services from2012/13. Preparation has involved identifyingcare clusters in mental health (based on carepathways) as the currency (unit of serviceactivity that is clinically meaningful and hasrelatively stable costs); then identifying atariff (price) for each care cluster. Tariffs willbe agreed locally between commissionersand providers for mental health, not setnationally. In future, users of adult mentalhealth services will be allocated to a cluster,and packages of care will be defined for eachcluster.Commissioning reforms and ClinicalCommissioning Groups (CCGs)Under the Health and Social Care Act2012, primary care trusts will cease toexist and from April 2013, GP-led clinicalcommissioning groups will becomeresponsible for commissioning the majority ofNHS services worth around £60bn, includingelective hospital care, rehabilitation, urgentand emergency care, most communityhealth services, mental health and learningdisability services. All GP practices will haveto be members of a CCG, formed on ageographical basis. In addition to GPs, CCGs’governing bodies must include at least oneregistered nurse, at least one secondarycare specialist doctor, and at least two laypeople. CCGs will work in partnership withlocal communities and local authorities –including health and wellbeing boards (seebelow) – and must engage with healthcareprofessionals, patients and the public. Theywill be accountable to the new national NHSCommissioning Board, and will be scrutinisedlocally by health and wellbeing boards.Health and Wellbeing Boards (HWBs)These are a key part of the government’shealthcare reforms aimed at ensuringstronger democratic legitimacy andinvolvement, strengthening workingrelationships between health and socialcare, and encouraging the development ofmore integrated commissioning of services.Each top tier and unitary local authoritywill have a HWB, operating in shadow formduring 2012/13 and fully from April 2013.HWBs must have a minimum membershipof one local elected representative, a localHealthWatch representative, a representativeof each local clinical commissioning group,the local authority director of adult socialAppendix 3A competency framework for all those working with people with mental health problems in London57

Appendix 4Professionals told us:Some spoke of the need for “maturity,sensitivity, and judgement” whenworking with people in mental healthcrisis.Professionals spoke of the importanceof working in ways that empowerpeople with mental health problems,supporting them to be activeparticipants, rather than passiverecipients, of treatment and care:● ● “Improved communication betweenservices and teams would make themost difference – knowing moreabout each other, roles and strengths,listening to the other teams. Beingmore open to the views, skills andapproaches of others in the system.”● ● “Any qualified provider will make theinterfaces between services and teamseven more complex, so care navigatorroles – or at least the skills andwillingness – are particularly key.”Many professionals highlighted the widediversity of cultures within London, and theimportance of taking culturally sensitiveand individualised approaches to peoplewith mental health problems from differentbackgrounds. The need for staff workingwith people with mental health problems tounderstand the social determinants of healthand the impact these can have on peoplewith mental health problems.● ● “Knowing how to work collaboratively,in partnership with the service user, andempower them to foster self-care.”● ● “Help people be expert in their ownconditions; provide training for them.”There is a need for greaterunderstanding of relevant legislation,such as the Mental Capacity Act andDeprivation of Liberty Safeguards:● ● “Even if people are detained and lacksome capacity, shouldn’t assume theycan’t make any decisions – even if theseare small at first.”● ● “Recognise that fragmented care (e.g.through lack of communication, lackof appropriate information sharing,delays in referral/transfer of care, etc.)can have a detrimental effect on serviceusers’ quality of experience, quality ofcare, and faith in services and systems”Need to understand the other factors thatcan impact on a person’s mental health, forexample relationship difficulties, financialpressures, employment and work-relatedpressures. Need for more skills and trainingon maintaining factors, and practicalproblems such as housing and finances.60London Health Programmes

Appendix 4A competency framework for all those working with people with mental health problems in London61