Introduction

It has long been recognised that patients with a variety of chronic and complex health conditions often require long-term care from different health and social care professionals working across community and hospital settings. However, those living with multiple health and social care needs often experience a highly fragmented service, leading to suboptimal care experiences, outcomes and costs.^54,55 Many countries have developed strategies to enable better co-ordination of care; however, evidence suggests that these have often not achieved their objectives.⁵⁶

The aim of this literature review is to give an account of care co-ordination and care planning in CMH settings. The question underpinning the review is: ‘What interventions have proved more or less effective in promoting personalised recovery-oriented care co-ordination for CMH service users?’. The focus of the review is care co-ordination in UK CMH contexts, but some research from non-UK settings will also be discussed.

Background and context setting

High-profile failures in mental health care in the UK during the 1980s led to an unprecedented evaluation of care co-ordination between hospital and community services to ensure better quality care. The most immediate trigger was the recommendations of the Spokes Inquiry⁵⁷ into the killing of a hospital social worker by a psychiatric patient. At the time of the inquiry, care for people with severe mental illness in the community had been described as haphazard and unco-ordinated,⁵⁸ a view reinforced within the Spokes report,⁵⁷ which described how, prior to the killing, the patient had been able to ‘drop out of sight’ of mental health services whenever she was discharged from hospital. This, allied to fears about high levels of mental illness among the homeless and in the criminal justice system,⁵⁹ led to the introduction of a raft of strategies and policies to improve the organisation and delivery of mental health care in the late 1980s to early 1990s.

However, the deterioration in standards of mental health care evidenced in the 1980s can be seen as a culmination of public policy decisions over previous decades. This included a reduction in inpatient mental health beds in the UK from 150,000 in the early 1950s to approximately 50,000 in the early 1990s,⁵⁵ and the medicalisation and professionalisation of mental disorder, which were key themes of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency. The subsequent Percy Commission Report⁶⁰ concluded that mental disorder should be regarded ‘in much the same way as physical illness and disability’ (paragraph 5) and that mental hospitals should be run as much as possible like hospitals for physical disorders. In addition, the 1959 Mental Health Act⁶¹ separated health and social care for people who did not need inpatient treatment by handing over responsibility for social care to LAs and councils.

The shifts described above created ideal incubating conditions for subsequent failures in care co-ordination that became increasingly evident in the 1980s. Such was the disarray that some commentators at the time described CMH care in England as an ‘unwieldy dinosaur with its health and social care brains working independently’.^{62(p. 2)}

In the context of an accelerating, policy-driven shift away from hospital care, the CPA was introduced in England in 1991 and in Wales in 2004 to provide case management and to give shape and coherence to the delivery of CMH services. Case management is a method of working designed to ensure that service users are provided with services that are co-ordinated, effective and efficient. However, the CPA was not developed with a particular model of case management in mind and therefore lacked a single or coherent underpinning philosophy of care.⁵⁸ As a result, the introduction of the CPA was very much shaped by the local context, and differences in local approaches were tolerated provided that the fundamental features of the CPA were implemented.

The fundamental features included systematic assessments of health and social care needs; the provision and regular review of a written care plan; close monitoring and co-ordination by a named key worker; the involvement of users and carers in planning and provision of care; and inter-professional and inter-agency collaboration. A CPA register was also established to record details of those cared for under the CPA.

The role of the care co-ordinator and effective teamwork were identified at the time of the CPA’s inception as key to successful implementation,⁶³ given the previous repeated failures of agencies and professionals to communicate and successfully deliver co-ordinated care.

Search strategy

Initial literature searches were undertaken using the following key words and terms: ‘mental health’, ‘care planning’, ‘care co-ordination’ (and ‘co-ordination’), ‘collaborative care’, ‘recovery’, ‘recovery focus(ed)’, personali*. JE ran a preliminary search from which a random sample of articles was assessed by BH and MC, to identify relevant papers and possible additional search terms/phrases. Further discussions were carried out by BH, AJ and JE on the modification of the search strategy.

As a result, additional key words/search terms were included: ‘mental illness’, ‘care collaboration’, ‘patient care planning’ and ‘person-centred care’. We also included proximity indicators (such as ADJ or N- as appropriate of each database), truncation ($) and wildcard (*) symbols as well as Boolean commands (AND and OR) where appropriate. Key search terms were searched by their subject (MeSH headings) and by keyword. The following databases were searched: Applied Social Sciences Index and Abstracts (ASSIA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database, EMBASE, The Cochrane Library, MEDLINE, PsycINFO, Education Resources Information Center, British Humanities Index, Scopus, Social Care Online and Web of Science. The search was limited to the period 1990 to date and included articles in the English language only. This search was rerun on the databases ASSIA and CINAHL and the search strategy was verified by a health and social care librarian working for the Information Sciences service at Cardiff University.

During a meeting on the 20 November 2012 with the LEAG and the PAG, it was suggested that the term ‘user experience’ be included in the search strategy. Further discussions among the PAG advised that the addition of terms such as ‘recovery’ or ‘recovery focused’ to the search strategy would narrow the focus too much and that research covering these topics in CMH settings should be captured by using the existing search terms. The issue of rejecting papers where research was considered low quality was weighed against an interest in a broad representation of approaches and views. However, some studies were excluded on the grounds of insufficient detail about the research process undertaken within each study.^64,65

Following removal of duplicate cases, 811 references were retrieved and entered into an EndNote version X7 (Thomson Reuters, New York, NY, USA) library. These references were then screened by BH and MC to identify key papers for the meta-narrative synthesis focusing on papers about care planning and co-ordination in mental health in the community. The papers were labelled as Y (Yes), N (No) and M (Maybe). In the end, there were 45 papers labelled Y, 617 labelled N, and 94 labelled M. There was an agreement among the team on the papers excluded. A further snowball search on the web and using Google Scholar (Google, Mountain View, CA, USA) produced 81 references. From this there were none labelled Y, 69 labelled N and 12 labelled M. A final review of the M papers and back-chaining revealed a further three papers that were added to the original 45, giving a final total of 48.

Meta-narrative review

Meta-narrative review looks historically at how particular research traditions have unfolded over time and shaped the kind of questions being asked and the methods used to answer them. As outlined by Greenhalgh and Wong, a research tradition is a ‘series of linked studies, each building on what has gone before and taking place within a coherent paradigm (that is, within a shared set of assumptions and preferred methodological approach shared by a group of scientists)’.^{66(p. 4)}

Given the wider social, political and historical context outlined above it is unsurprising that the ‘unfolding plot of the research’^{67(p. 423)} from the UK is dominated by researchers’ efforts to understand whether or not the CPA has led to changes in management, service organisation and delivery (Tradition 1). Although our searches were limited to the period 1990 onwards (when the CPA came in), there is little history of research into care planning and co-ordination within CMH settings prior to this date. There are no pre- and post-evaluation studies of the introduction of the CPA, comparing changes, if any, in care planning and co-ordination in CMH settings.

Instead, researchers initially framed their studies within the findings of public inquiries or governmental reviews into difficulties and failures within CMH settings. It seems reasonable to conclude, therefore, that the CPA resulted in changes both to working practices within clinical CMH settings, and also to research priorities and practices within the UK, creating a hitherto unseen tradition of research within mental health services with a focus on care planning and co-ordination.

Another narrative and tradition of research focuses on service-users’ and carers’ experiences of CMH provision (Tradition 2). Although its emergence may not be surprising given that one of the primary aims of the CPA was to increase the involvement of service users and carers in care planning and provision, this focus was rare in the context of the early to mid-1990s. Another notable feature of this tradition is the emphasis on involving service users and carers in the design and execution of research projects^68–71 at a time where both government policy promoting service user involvement and the ‘service user movement’ were in their infancy.^72,73 It is within this tradition that the current study most comfortably sits.

Service-user involvement within this tradition includes involvement in some aspects of conventional research projects (such as question setting or data collection) as well as collaborative research where service users work on most if not all aspects of projects as co-investigators alongside academic researchers. There is less evidence of there being user-controlled research in which service users set the agenda, design and conduct the research.⁷³

Finally, several studies have sought to determine whether interventions have improved the functioning and performance of the CPA (Tradition 3) in terms of improved care co-ordination and care planning. This tradition of research focuses on processes and outcomes of care, and the prevailing language positions the CPA and CMH work as being driven by requirements to demonstrate organisational efficiency. For example, some studies frame mental health work as requiring standardisation owing to its complex nature and the mental health workforce as having a deficit of knowledge as regards effective care co-ordination and planning.

The three research traditions identified are summarised in Table 2.

TABLE 2

Care co-ordination and planning in CMH settings: overview of research traditions

Striking in the review was the increase in non-UK research into care planning and co-ordination in community settings with only two studies appearing before 2005, at which point the number increases and surpasses UK research output. These non-UK studies were also aligned with the three research traditions described above but are not included here due to space restrictions.

Tradition 1: community mental health care co-ordination and planning, the care programme approach and the organisation, management and delivery of services

The first tradition of research consists of a series of studies primarily from the 1990s that seek to understand the impact of the CPA on the organisation and delivery of CMH services. This tradition of research draws on a range of methodological approaches (see Appendix 4). The CPA is often discussed as a uniform approach, yet it is noticeable that the earliest study of the CPA⁶⁸ undertaken in three English health districts demonstrates clear variation in CPA interpretation and implementation. Adherence to the principles of care programming within each district’s community care plans ranged from minimal mention of care programmes to the wholesale adoption of the concept into mental health planning and service evaluation. Later published studies also draw attention to the degree of variation in the implementation of the CPA between different trusts within the same health authority and within the same trust.^16,74–78

Variable implementation of the CPA may well contribute to inconsistency in research findings within and across sites. For example, Schneider’s⁶⁸ study of three health authorities describes how staff perceived the CPA as offering ways of working that were both creative and flexible as well as rigid and lacking flexibility. Similarly, more rigorous documentation and better care planning are reported in some studies,^68,79,80 whereas others report a lack of coverage of psychosocial aspects^16,77 or risk assessments not completed fully or jointly.⁷⁶ Claims that the CPA led to improved continuity of care,⁶⁸ better team-working across professions^16,68,79 and overall effectiveness of care^68,70,81,82 also need to be balanced with findings that most general practitioners (GPs) had not heard of the CPA,⁸³ that the role and function of the CPA had not been explained properly to staff,^16,70,83 leading to managers not knowing which patients were on the CPA.⁸¹

Uncertainty also exists in terms of the relationship between the CPA and inpatient bed occupancy rates, with Tyrer et al.’s⁶² claims of increased admission to hospital following the introduction of the CPA being contradicted elsewhere.⁸² The use of hospitalisation as an outcome measure has been criticised as inadequate for assessing programme success in this population, given that rates of hospital admission and length of inpatient stay can be influenced by other factors, such as local service configuration and bed availability.⁸⁴

Such uncertainty and variability raise crucial questions regarding the use and effectiveness of the CPA in practice, especially where researchers attempt to make judgements on programme outcome or cause–effect comparisons across more than one research site. The lack of clarity regarding the exact nature of the CPA in practice reflects a similar vagueness globally about the concept of care co-ordination. For example, a review of research found over 40 heterogeneous definitions and models of care co-ordination to be in existence.⁸⁵ The lack of clarity and homogeneity has also been identified as an explanatory factor for the failure of many strategies that seek to improve care co-ordination.⁵⁶

Sociopolitical factors partly explain the large variations in the way organisations adapted or assimilated the CPA’s requirements. For example, the CPA was introduced with no or limited additional resources,^68,83,86 at a time when health and social care spending was being cut and the vast majority of resources for mental health services were allocated to inpatient care rather than day and community services.⁸⁷ As a result, little or no staff training was provided, no particular philosophy of care emerged to underpin CPA implementation and employees were left to manage a change in process as best they could.⁵⁸

In an era of increased managerialism in the NHS, the introduction of the CPA was experienced by practitioners as a ‘top-down’ policy imposition that failed to build on the existing knowledge, skills and abilities of the workforce, and resulted in tensions over clinical values and cultures. Staff perceived the CPA as leading to more work^16,68,82,83 and a sense of being overworked^16,68 especially owing to increasing levels of bureaucracy.^16,68,71 Staff also reported that the additional burden of work that accompanied the implementation and day-to-day operation of the CPA led to increased time being spent away from patients.^16,68,83

The unintended consequence of a lack of detailed, national policy implementation strategy for the CPA was a considerable variation in the delivery of services, as well as variation in staff and patient experiences both within and across health authorities. A review of CPA implementation links the ‘paradoxical effect’ (p. 24) of burgeoning levels of local bureaucracy to the national policy decision not to be overly prescriptive about CPA documentation.¹

Overall, this tradition of research has been firmly focused on developing a better understanding of how the introduction of the CPA influenced the organisation and delivery of nascent and arguably inadequate CMH services. Researchers frame the CPA as a policy intervention that attempted to reverse several decades of deteriorating mental health services characterised by, among other things, inadequate co-ordination and organisation of care within and across different professional groups. There is little research that seeks to delineate or explore developments in multiprofessional and multiagency working in the wake of CPA implementation; studies undertaken in this tradition perpetuate the status quo of multiprofessional working at that time, failing to mention or merely hinting at different ways of working within and across teams. However, Simpson’s¹⁶ study describes some of the effects of team working in CMHTs, such as finding that care co-ordination was enhanced within teams when members demonstrated respect for co-workers.

The combination of three decades of profound changes in the policy definition of mental health and illness, together with the broader context of large-scale change towards managerialism within the health and social care sector during the late 1980s and early 1990s, leaves the impression that the CPA was destined to fail before it had been launched.

Tradition 2: service users’ and carers’ experiences of community mental health care co-ordination and planning and their involvement in research

Until the 1990s there were few attempts to involve service users in the planning and delivery of their care and treatment. As Perkins and Repper⁸⁸ point out, service users were excluded from service planning meetings and were only involved via demonstrating their symptoms and hearing the doctor’s prescription. Implementation of the CPA was fairly novel in responding to service user and carer demands for greater involvement in the care planning process, both of which began to be more explicitly promoted as indicators of good practice.⁸⁰

Alongside these developments, a view also emerged that service user involvement in research could make an important contribution to the empowerment of mental health service users. For example, service users have long argued that dominant research approaches to mental illness can perpetuate patients’ inequality and disempowerment.⁸⁹ Consequently, the coproduction of new knowledge and the transformation of the terms and concepts used by mental health researchers have been promoted as a potentially influential means to achieve broader social and political change.⁹⁰

A tradition of undertaking research that involves service users and carers is rooted in the origins of research into care co-ordination and care planning in CMH work (see Appendix 5). Early studies not only focused on service user and carer experiences of CMH but also involved service users and carers as collaborators in the design and implementation of research studies. For example, Carpenter and Sbaraini⁸⁰ involved service users and a carer in a PAG and in formulating a questionnaire to explore users’ perceptions of the extent to which the CPA empowered user and/or carer involvement. Rose et al.⁷¹ not only involved service users in designing a data collection instrument (semistructured interview schedule) but also extended service user involvement to data collection, with 12 service users being trained to undertake interviews alongside researchers.

Interestingly, Rose et al.⁷¹ describe how, on many occasions, the project team were warned about the potential negative consequences of service users’ involvement in research. In particular, care co-ordinators worried that users were unable to sustain confidentiality about other users. No such difficulties emerged during the study, leading the authors to conclude that ‘users can be successfully interviewed by other users who have been trained to do this. We argue that, in fact, the user interviewers elicit more open and honest responses than professionals do.’^{71(p. 29)} Subsequent studies in this tradition of service-user involvement in research have since reached similar conclusions.^91–94 The narrative within this research tradition positions service users and carers as having much ‘insider knowledge’ to share and that, as a result, questions are framed and studies conducted in ways that are most relevant to users of CMH services.

A moot question is whether or not this makes any difference in terms of the quality and relevance of data collection and interpretation. For example, Rose et al.⁹⁵ conclude that the literature is ambivalent about whether or not service-user researchers obtain different quantitative data to conventional mental health researchers (e.g. Rose⁹¹ suggesting differences but Rose et al.⁹⁶ finding none). However, there is evidence that service-user researchers both collect and interpret qualitative data differently from conventional researchers and in a way that is more in tune with the priorities of service users themselves.^94,97

It is also important to note that most studies of service users’ and carers’ experiences did not involve them in study design and implementation.^{70,80,81,86,98–102} However, a commitment to learning more about service users’ and carers’ experiences resonates throughout these studies. This research tradition has also contributed significantly to the debate about whether or not policy changes that were meant to embed principles aimed at increasing service user and carer involvement in CMH practices actually resulted in the desired changes to carers’ and service users’ experiences.

Overall, this corpus of research demonstrates that the introduction of the CPA has mostly failed to deliver on the promises of increasing service-user understanding^70,71,86,91 and involvement^{71,75,77,86,91,92,94,98,101} in care planning and care co-ordination. Research also suggests that other fundamental aspirations of the CPA have similarly had a limited effect on the actual practices of CMH workers. For example, studies show that service users were not aware of, or not allocated, key workers or care co-ordinators^70,71,81,92 and had not seen or were not in possession of a care plan or CPA documentation.^{70,71,81,86,92,98,101,103}

However, the variation in approaches to CPA implementation noted earlier is also apparent when reviewing research findings in this tradition. For example, a small number of studies running counter to the findings listed above have suggested that service users were well informed about their care and treatment plans^92,98,103 leading to service users having more trust in staff^68,80 and influence and choice in their care.^68,80,103 However, it is worth noting that a considerable weight of evidence suggests the lack of desired impact made by the CPA on service-users’ experiences.

A similar picture emerges in research on carers’ experiences. Studies demonstrate that carers lacked information about the CPA^70,100,103 and that carers felt frustrated and isolated⁷⁰ by not having their views sought or taken seriously.^70,75,86 These findings are not surprising in light of evidence that suggests health authorities often had no formal policy for carer involvement, instead relying upon ad hoc arrangements.^70,75,100 On a more positive note, the CPA had the effect of generating more contact with carers in some areas,^68,80 which resulted in greater levels of carer satisfaction.^68,100

None of the studies reports overt organisational and professional strategies of resistance that served to suppress the involvement of service users and carers. Instead, indicators of professional or medical dominance are more subtle but arguably just as profound in diminishing the opportunities for user or carer involvement. For example, Newbigging et al.⁷⁷ describe how Independent Mental Health Advocates (IMHA), who play an important part in representing and advocating for service users’ best interests in CPA meetings, are frequently not invited to CPA meetings through apparent lapses in effective communication and diary planning by care teams.

Similarly, when IMHAs were invited, the CPA meetings were poorly organised and often overrun, with the result that IMHAs had to leave meetings before they had finished owing to other commitments. Foucault neatly captures the fact that subtlety is often an overlooked essential for the effective operation of power, stating that ‘Power is tolerable only on condition that it masks a substantial part of itself. Its success is proportional to its ability to hide its own mechanisms’.^{104(p. 86)}

The CPA has been described as encouraging a focus on service users’ problems rather than their strengths^71,92 and as a way of working that prioritises a preoccupation with illness,^16,82,94 which is indicative of an approach to caring that creates patient dependency on practitioners through ‘pathologising’ individuals. It is also an approach that means illness comes to define the totality of the person. The nature of the CPA has arguably reinforced a reluctance in some practitioners to move away from an illness model towards a more person-centred and participative mode of mental health practice.

Very few studies explored whether aspects of workplace culture or organisation were prevalent in resisting, frustrating or promoting policy objectives to increase service-user and carer involvement. How far underlying cultural change has kept pace with the more obvious structural reforms in CMH care remains a matter of debate 20 years after the introduction of the CPA. A number of important questions remain about the conditions responsible for promoting or suppressing service-user and carer involvement, the relationship between hierarchies and power structures within CMH workplaces, and the most conducive ways of navigating these to ensure greater participation.

Although those who introduced the CPA deserve praise for encouraging and promoting the development of service-user and carer involvement, this research tradition demonstrates that taking action to involve users requires a willingness to change attitudes and practice, not merely the introduction of policy or best practice imperatives. The danger otherwise is that, without a genuine commitment, calls for greater involvement merely become ‘an exercise in rhetoric’ that leaves existing power relations between professionals and service users/carers untouched.

Many in this research tradition have pioneered approaches to service-user and carer involvement. As a result, service users and carers have contributed greatly to changing how mental ill health is conceptualised and have aided in the production of new knowledge, which has led to a better understanding of methods for improving the lives and advancing the rights of people with mental health problems. It has challenged a model of mental illness as simply deficit and pathology of a psychiatric diagnosis as a ‘master status’¹⁰⁵ that swamps any other aspects of the person.

Tradition 3: interventions to improve the care programme approach

The demonstration of clinical effectiveness of health-care interventions has had an increasing role in the UK and devolved governments’ health strategy since the mid-1990s.¹⁰⁶ At the same time, national policy at the macro-level has focused on the CPA as a means of systematically assessing the health and social care needs of those in greatest need, leading to the development of an individual care plan, co-ordinated by a keyworker. As already discussed, however, very different versions of the CPA were implemented at the level of service delivery within and across regions of England. A tradition of research therefore emerged during the late 1990s that reflected both the perceived need to demonstrate and improve clinical effectiveness, as well as capturing the early difficulties and variation in the implementation of the CPA (see Appendix 6).

As already discussed, the CPA led to diverse, often time-consuming, bureaucratic practices that meant staff spent less time with patients.^16,68,83 CPA documentation is framed by researchers and clinicians as problematic, since poor documentation increases the risk of vital patient and treatment information being missing when planning and co-ordinating care. Consequently, the third research tradition describes how the elimination of variation in documentation processes can lead to improved performance and reliability in care planning and outcome measurement.

Macpherson et al.¹⁰⁶ provide an example of a study that encompasses issues related to variation and effectiveness; stating that standardised documentation for individual care planning should be combined with outcome measurement, to give a meaningful measure of the effectiveness of care. To better understand the relationship between care planning and patient outcomes, a formalised space was introduced to the CPA documentation for establishing and standardising treatment goals. Goals were set within a care planning assessment and review meeting and agreed with patients (n = 139), relatives, professionals and advocates prior to the meeting’s conclusion. One year later a clinical review meeting found that 68% of goals were fully and 11% partially achieved (43% of goals were partially or not achieved). Goals targeting drug treatment of psychiatric syndromes were most likely to be fully successful (84%), whereas approaches to self-care skills, side effects, physical/medical problems and family relationships were moderately successful.

Recent UK mental health policy has emphasised the need for services to adopt a ‘recovery orientation’ to improve service users’ experience of care, social inclusion and recovery. An attempt to standardise outcome measurements for recovery was undertaken by Killaspy et al.¹⁰² who assessed a measure of recovery, the Mental Health Recovery Star (MHRS) for acceptability, reliability and convergent validity. Recovery was defined by the authors as ‘a personal and dynamic process of adjustment and growth following the development of a mental health problem’ (p. 65).

Although the MHRS was relatively quick and easy to use and had good test–retest reliability, inter-rater reliability was inadequate. Furthermore, convergent validity suggests that MHRS assesses social function more than recovery, leading to the conclusion that it cannot be recommended as a routine clinical outcome tool but may facilitate collaborative care planning. Interestingly Gould’s⁹⁴ study reviewed in Tradition 2 also suggested that the MHRS operated more as a measure of social functioning than recovery. Others saw the MHRS as too complicated, putting too much pressure on service users with long-term problems to find employment and being a rigid tool.

Both Lockwood and Marshall¹⁰⁷ and Marshall et al.¹⁰⁸ researched interventions aimed at standardising patients’ needs assessments; the first of these studies was a pilot study, which led to the second study. The intervention in both studies is relatively convoluted and complex, initially involving a research nurse undertaking a baseline assessment of the patient to identify needs. Data from these assessments were then entered into computer software to determine which of the practitioner-identified needs or problems required action. When needs required action, the research nurse and consultant psychiatrist considered a list of pre-defined interventions provided by the software, before deciding whether or not the patient was likely to benefit from any of the interventions. The research nurse then provided the keyworker with a report of the needs identified, which were then used to guide care plan discussions between the keyworker and the patient.

In the pilot study significant reductions were seen in ‘unmet’ needs and the level of anxious/depressive symptoms, suggesting that needs feedback improved the quality of nursing assessment and care planning within the CPA. However, the follow-up study¹⁰⁸ found that standardised needs assessment did not substantially enhance care planning. The process of using an independent registered nurse, who was not a keyworker or a member of the clinical team to undertake the needs assessment, allied to having to search a computer database for interventions associated to needs, would have made transferability of these findings into clinical practice difficult, as the trial intervention differed greatly from usual practices.

The CUES-U tool (Carers’ and Users’ Expectations of Service – User version) tested by Blenkiron et al.⁹⁹ consisted of a 17-item service user outcome scale in booklet form developed by academics, clinicians and service users. CUES-U was described as an ‘important tool’ (p. 334) because it focuses on issues of quality of life and satisfaction that mental health service users (rather than professionals) identified as priorities. Service users (n = 86) completed the CUES-U booklet before returning and discussing the contents of the booklet with care co-ordinators, who then recorded changes made to care plans as a result of receiving the CUES-U feedback.

The CUES-U mediated discussion led to a change in clinical care for 49% of respondents. Care co-ordinators rated CUES-U as a good use of their time in 64% of cases. A large proportion (84%) of service users were satisfied with the level of control and consultation they received; 87% were satisfied with their relationships with mental health workers and > 70% were satisfied with levels of information and advice and access to services. However, a significant limitation of high levels of satisfaction was that patients knew that their care co-ordinator would see their replies, although many did write negative comments in free text boxes. The authors concluded that CUES-U can be an effective and practicable tool for increasing users’ involvement in their care and for service benchmarking.

A move from paper documentation towards electronic CPA (eCPA) records was proposed by Howells and Thompsell.¹⁰⁹ The eCPA consisted of a computer-based CPA system for care planning and documentation – using a Microsoft Word template – designed to improve the quality of information in CPA care plans in a CMH team in London. Completed eCPA care plans were e-mailed to the acute ward, the hospital’s emergency clinic and any other agencies. The CPA manager received the original signed copy, a copy was filed in the case notes and the GP, the patient and carer were given a copy. The eCPA was welcomed by staff with a take-up rate of almost 100%. Patients welcomed the legibility and detail of the forms and expressed no concerns about the change to the eCPA. Care plans were longer and more detailed, being no longer constrained by fixed-size boxes on paper forms. Care plans were also adjusted more frequently by CMHT staff, who did not have to completely rewrite the forms by hand. As a result, the plans better reflected the changing needs of patients.

To summarise, attempts to improve needs assessment and/or care planning processes by changing documentation featured in all of the interventions, either through amending features of existing documentation^106,109 or introducing new assessment and planning documentation and processes.^{99,102,107,108} Some of the interventions were described as leading to more collaboration with service users during care planning,^99,102,106 whereas Howells and Thompsell¹⁰⁹ reported greater collaboration within CMH teams. However, Lockwood and Marshall¹⁰⁷ and Marshall et al.¹⁰⁸ reported marginal or no improvements in needs assessment and care planning during a pilot study and trial of an intervention that bore little resemblance to usual clinical practice.

Interestingly, those who developed the interventions via an inclusive, multidisciplinary and/or service-user involvement approach reported most success,^{99,102,106,109} although the quality of research in this tradition is generally weak with no long-term studies of the effects of these interventions on improving care planning and patient outcomes.

Health policy from 1990: changes to community mental health working in England and Wales

Initial moves towards a different way of organising and delivering CMH services can be located within a brief health and LA circular policy document for England.¹¹² Produced in the context of an accelerating, policy-driven shift away from hospital care, the circular emphasised the importance of ‘systematic arrangements for deciding whether a patient referred to the specialist psychiatric services can, in the light of available resources and the views of the patient and, where appropriate, his/her carers, realistically be treated in the community’. To this end, the document specified that health and social care needs should be assessed and planned and a ‘keyworker’ appointed to oversee and review the delivery and co-ordination of interagency and interprofessional services.

The circular appeared shortly after the publication of plans for an across-the-board reorganisation of community care via the White Paper Caring for People. Subsequently incorporated within the NHS and Community Care Act,¹¹³ this placed a responsibility on LAs to implement ‘care management’. With their parallel systems of care co-ordination, for many years thereafter the health-led CPA, and the social care-led care management, ran in unhelpful parallel.

Uppermost in the minds of policy-makers in the early 1990s was the management of the risks associated with the community care of people with severe, long-term, mental health problems. As a result, ‘supervision registers’ were introduced, this again being an initiative within England only, where they were implemented as an add-on to locally structured CPA arrangements.¹¹⁴ Supervision registers promoted care planning and co-ordination as a mechanism for risk assessment and its management. However, as with the introduction of the CPA, no additional resources were provided to support those appearing on supervision registers.

Building Bridges¹¹⁵ was a detailed document produced for NHS England in 1995, which promoted the importance of interprofessional CMH teams and the CPA as the ‘cornerstone’ of care.^{115(p. 45)} A year later guidance on the community care of people with mental health problems in Wales was published,¹¹⁶ which formally introduced into the Welsh mental health system the ideas of health and social care assessment, care planning, review and key-working. Neither this nor subsequent additional guidance¹¹⁷ mentioned this as the introduction of the CPA into Wales.

Meanwhile, the election of New Labour to government in 1997 coincided with a significant raising of the profile of mental health as an area for policy action in England, with new guidance on ‘modernising’ the CPA being introduced towards the end of the decade.¹¹⁸ This reaffirmed the central place of the CPA in modern systems of care but also highlighted where changes needed to be made, noting professionals’ complaints that the CPA resulted in a significant administrative burden for time-pressed care co-ordinators and service users’ views on patchy and inconsistent experiences of care planning.

In post-devolution Wales, a new national strategy for adult mental health services included a section on care planning and co-ordination and on the imperative for all users to have a written plan of care overseen by a ‘keyworker’.¹¹⁹ Two years later came the formal introduction, for the first time in Wales, of something directly referred to as the CPA.² This talked, very clearly, about the CPA as a vehicle assisting service users towards recovery, supporting empowerment and the embracing of holistic care.

The current situation in England and Wales

In England, a further review and ‘refocusing’ of the CPA was undertaken¹ which was strong on minimising bureaucracy and on simultaneously driving up the quality of care planning via a commitment to national-level consistency. The CPA was presented as a values-based process through which care is tailored uniquely to the individual and serves to promote social inclusion and recovery. For the first time a set of approved training materials were produced to support practitioners.¹²⁰ In current mental health policy for England, represented most completely in the cross-government No Health Without Mental Health¹²¹ and its ancillary documents, the CPA takes something of a back seat as the focus shifts to cross-sector and cross-government action to improve mental health across the board.

Meanwhile, in Wales, care planning and co-ordination have taken a distinct turn in recent years. An influential, critical, review of the CPA¹²² contributed to the power to make new mental health law devolved to the National Assembly for Wales. This process led to the eventual passing of the Mental Health (Wales) Measure [MH(W)M] and its attendant documents, including a code of practice¹²³ and a raft of training material. Part 2 of the Measure obliges health and LA services to produce CTPs for all users of secondary mental health services. The phrase ‘CTP’ supersedes ‘CPA’, although each is required to be developed by a care co-ordinator working collaboratively with the service user and other providers. CTPs must be in writing, and kept actively under review by care co-ordinators who must now be drawn from a prescribed range of professional groups. Since the passing of the Measure, a new overarching strategy for mental health across the lifespan in Wales has been produced,⁵ along with an initial plan for delivery.¹²⁴

Current policy frameworks across both England and Wales emphasise the importance of mental health services in promoting recovery and tailoring care to the needs of the individual. Where the biggest difference remains is in the context of arrangements for care planning and co-ordination, and in the use of a statutory instrument in Wales within which CMH care is overseen. Current mental health policy in England also heavily features the term ‘personalisation’, with no use of this term appearing within current mental health policy in Wales.

Personalisation, through service users holding personalised budgets, is portrayed in policy documents from England as a means of ‘giving people greater choice and control over their care and treatment’.^{121(pp. 32–3)} In Wales, an Independent Commission on Social Services rejected this view of personalisation, stating that ‘We believe that the label ‘personalisation’ has become too closely associated with a market-led model of consumer choice’.^{6(p. 15)} The Commission is clear that the focus instead should be on personalised budgets offering the means of establishing patient and public ‘voice’ as a force for improving services that meets the diverse needs of the population of Wales, rather than promoting individualised consumerist choice as a means of improving services through market forces. Peckham et al.¹²⁵ similarly identify that different political ideologies are increasingly apparent in policy rhetoric, objectives and mechanisms introduced within devolved national policy, although the question of how visible such differences are at the level of mental health service organisation and service delivery remains to be seen. Such is the focus of this study.