Clinical Dilemmas in whole system community mental health change: Risk and Diagnosis

Introduction: The Community Mental Health Framework in England (NHSE)  promotes both needs led and person centred mental health care across large communities which encourages different organisations to work together as a whole system.  Whilst this approach is welcomed by many, it has reignited some old clinical dilemmas .

Our aim was to understand the nature and impact of different approaches to assessment, risk management, and diagnosis as a means of understanding mental health and illness. 

 

Methods: ?Realist informed evaluations were conducted across four integrated care systems in England. Researchers-in-Residence, observed real time delivery of care in community mental health services with multiple new teams and interviewed practitioners and managers (n=60+).



Results: We found  that the changing and varied cultures of decision making around risk and diagnosis had a considerable impact upon the delivery of community mental health services.  Some teams were comfortable creating a shared understanding with minimal attention on risk or diagnosis, doing brief work focussed on the concerns of individuals and supporting engagement with social support. Others required fuller clinician led  assessments with diagnosis and would reject referrals due to concerns about ‘holding risk’. This could lead to delays and disappointment for service users, conflict across teams, and inefficiencies in the system. Facilitating change designed to challenge  existing cultural beliefs about clinical care appeared to require strong, consistent collaborative leadership across the integrated system of primary care voluntary sector and mental health teams. Examples of how this was done included promotion of ideals by changing language and modelling different approaches to risk.



Conclusion: How risk and understanding of mental illness operate within and across teams can have wide ranging impacts. The presence of effective collaborative leadership is crucial to promote robust cultural change in mental health service delivery across all levels of a system of delivery.