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Seeing the Wood for the Trees – Promoting Recovery With Effective Care Planning
You can find plenty of material in the Care Management News section on the QCS website about the importance of effective care planning , and a comprehensive toolkit to design care plans in the QCS Care Management System, but let us take one step back and consider what we are aiming to achieve when we plan someone’s care. It might seem an obvious question, but a training exercise that the writer has run with workers in mental health services provided some inspiring results.
The Care Programme Approach
The principles of care planning with mental health service users are essentially the same as care planning principles for all vulnerable groups including older people. What is different is there has been national policy guidance on the framework for care planning in mental health for more than 20 years. The Care Programme Approach (CPA) is the framework for care for people with mental health problems.
This familiar cycle of assessment of need, drawing up a care plan, monitoring and review is at the heart of CPA, with the additional key feature of the appointment of a care co-ordinator for each service user to ensure the cycle of care planning runs effectively. An excellent article by Geoff Shepherd  examines the origins of the CPA as a response to failings in community care in the United States. What Shepherd argues is that the CPA addresses the issue of what he calls the 3Cs (Comprehensiveness, Co-ordination and Continuity). What the CPA can do is identify a worker who can provide these 3Cs. Clearly health and social care workers do not work every hour of every day, so the support of a care team working alongside the care co-ordinator is crucial. Essentially the care co-ordinator’s role is one of organising services for someone, as well as providing care and support themselves. It is helpful for health and social care workers to understand the theoretical basis of this approach.
The aims of care planning
So what happened with the training exercise that asks workers to say what their aims in care planning with someone were? Running an exercise like this a trainer might anticipate feedback such as ‘we want to make sure our manager has the right paperwork completed’ or ‘we want to cover our backs in case something goes wrong’. We might expect answers like these if workers were hard-pressed or feeling overwhelmed by work pressures. The experience of the writer in conducting this exercise is exactly the opposite. Participants, working in pairs, and writing just a couple of aims each, produced some very high order aims. The majority of the responses could be summarised as promoting independence and recovery. Here were a group of workers, planning care for some very vulnerable people, who offered the following as examples of what they wanted to achieve:
- Enable people to feel in control of their care and recovery
- Ensure that diagnosis is not the final point of involvement with that person
- Help clients access what they want to make their lives better
- Support clients cope with daily challenges by giving them tools to do so
So in spite of the pressures of complex caseloads, increasing demands of computerised and paper-based documentation, these workers were able to see the real benefits of care planning. They really could see the wood for the trees.
This might sound very idealistic, and of course workers will also identify more basic aims reflecting effective practice such as managing risk, ensuring safety, promoting collaborative joint working, as well as following principles of recording. After all, if a care plan is not recorded properly how can we monitor and review someone’s care needs and meet goals?
Watkins illustrates the importance of the role of the care co-ordinator in planning care and maintaining meaningful contact. He says ‘clinical case management requires mental health workers to establish and be committed to long-term relationships with clients, staying with them on their fluctuating journey of recovery. Contact is maintained during crises and through more settled periods’. This is what care planning should be about, working with people, not just for them. It acknowledges people with mental health problems may need support from workers and other resources, but good care planning should have a role for the service user themselves in managing their own lives.
Planning for recovery
A recovery based approach for care planning in mental health sounds good in theory, but for people severely disabled by mental health problems, what can recovery mean for them? The answer is that recovery does not mean necessarily becoming completely well again. Crowson analyses the literature about recovery in mental health and identifies a number of key themes as to what it can mean. These include:
- Being believed in by someone else such as a friend or loved one
- Changing other people’s expectations, and encouraging others to look at someone’s potential, not just their illness or disability
These are things that we as workers can influence. Let us consider some examples of recovery through care planning, for a young person with mental health problems, it might mean getting back into employment after many years of little meaningful daytime activity with support from a voluntary organisation’s employment adviser. For an older person with dementia living in a care home , it might mean being able to reminisce about things they used to enjoy with a care worker using materials and photographs. So recovery is about achieving potential, however limited that may be, and not underestimating people’s abilities, whatever the nature of their illness.
Barriers to Effective Care Planning
There are clearly some barriers to all this. Since 1991 there have been two major reviews of the Care Programme Approach precisely because implementation was patchy, and there have been some very serious failings regarding people in the care of mental health services. One notable inquiry into the care and treatment of MN highlighted a number of failings. So concerned were the inquiry team that they held a seminar following the inquiry to consider the future of mental health care planning . The message from this seminar, and Government reviews of the CPA in 1999  and 2008  was that the principles of the Care Programme Approach were sound, and the approach should be kept in place. What these reviews said was needed were measures in place to ensure care planning is carried out consistently and effectively throughout the country. The MN inquiry looked at the causes of a terrible tragedy, and concluded that proper care planning could have made a difference. The report suggested the following:
- Complex diagnosis issues could have been addressed
- Gathering information and a plan for monitoring would have helped a team approach
- Opportunities to refer to experts would have been identified
- Regular contact would have ensured proper review
- Missed appointments would have been responded to
The MN Inquiry seminar into the CPA looked at some of the barriers to effective care planning, including poor information systems, lack of commitment to the CPA from professionals and a lack of administrative back-up. However the seminar said these were not insurmountable. They were operational problems that needed to be managed.
In conclusion, the message of this article is that for health and social care workers, the Care Programme Approach or any other framework for assessment and care planning, should not get in the way of achieving the very highest aims in planning and delivering care. In fact the opposite, effective care planning can achieve these aims for us and the services users and families we work with.
 Shepherd G Multi-Disciplinary team working: the essential background to the Care Programme Approach in Developing the Care Programme Approach Building on Strengths NHS Training Division London 1995
 Watkins P Mental Health Nursing: The Art of Compassionate Care. Butterworth-Heinemann, Oxford (2001)
 Turner-Crowson J & Wallcraft J The Recovery Vision for mental health Services and Research: A British Perspective Psychiatric Rehabilitation Journal Winter 2002 Volume 5 Number 3
 Avon and Gloucestershire Strategic Health Authority Independent Inquiry into the Care and Treatment of MN June 2006 (esp. Chapter 6 The Care Programme Approach and Appendix D)
 Dept of Health Effective Care Co-ordination in Mental Health HMSO London 1999
 Dept of Health Refocusing the Care Programme Approach: policy and positive practice guidance HMSO London 2008