Integrated training could be the key to unlocking parity of esteem

A round-table discussion shed light on the importance of training in improving outcomes
Round table session at NHS Confederation conference Manchester 2018

A round-table discussion at the NHS Confederation conference shed light on the importance of training in improving outcomes for people with metal health problems

Parity of esteem between mental and physical health, a long-held ambition of government, still seems a distant dream for staff working in cash-strapped organisations facing increasing demand for their services.

At the recent NHS Confederation conference in Manchester, a group of senior managers got together to discuss how integrated training, and the use of online approaches, might be vital to unlocking the equality of services that everyone is looking for.

Picture: Mark Hakansson

Participants at the NHS Confederation round-table discussion (clockwise from centre top)

Sean Duggan (chair), chief executive Mental Health Network

Colin Parish, editor, Mental Health Practice

Joe Rafferty, chief executive Mersey Care NHS Foundation Trust

Rob Webster, chief executive South West Yorkshire Partnership NHS Foundation Trust

Deanna Roepke, managing director, Relias UK, sponsors of the round-table discussion

Andy Johnson, mental health nurse and independent mental health consultant

Mike Farrar, independent management consultant, former chief executive of the NHS Confederation

Phil Moore GP, chair of the Mental Health Commissioners Network

Carole Spencer, transformation director, the Innovation Agency

Paul Jenkins, chief executive, Tavistock and Portman NHS Foundation Trust


Sean Duggan. Picture: Neil O'Connor 

Sean Duggan opened the discussion

‘The title of our discussion is the Future of Integrated Training, Empowering Staff and Enabling New Models of Care.

'We are in a great period of transition and change, and clearly there is a lot of pressure for effective integrated training that gets results, motivates staff and helps them do their work.

'It is a subject we keep coming back to and I’m pleased we have time to discuss it.’

Deanna Roepke asked how to bring about better integration of care

‘We’ve heard a lot about how imperative integrating care is, with ageing populations, and increasing co-morbidities and multi-morbidities. But the real question is, how do we get the workforce prepared to support that transition? 

Deanna Roepke. Picture: Neil O'Connor

‘That is about behaviour change and changing the way people move around in the system. There are probably big knowledge gaps when you look at what primary care knows about mental health and vice versa, so the question is, how do we fill those gaps?

‘Are there new roles that are required? Can we use training as a way of aligning people around those goals and getting them pointed in the right direction as a cultural change maybe, not just a re-skilling or retooling? Who needs training in the existing workforce and what do they need to know?’

Rob Webster talked about how it was important for health staff to have a general overview, as well as specialist skills

‘It was interesting that, when the Future Hospital Programme came out, the Royal College of Physicians got a lot of flak for saying that they want doctors to be doctors first, and specialists second. They want people to see the whole person in front of them as well as the specialism they are trained to deliver.

‘That's an indication of what we want – a system that treats the mental, physical and social needs of the person in front of them, and therefore, we want everybody to see the whole person first. GPs are good at that and many of the people working in mental health services or community services work in that environment anyway: if they are in someone’s house they see their life as it is. It’s all too clear to them the issues that they face, and often that they are mental, physical and social issues.

Rob Webster. Picture: Neil O'Connor

‘It’s probably less the case for some staff working in physical care and the idea that everybody is a generalist first and then you specialise, is important.’

Mr Webster gave an anecdotal example of a band 3 nursing associate who had benefited from training alongside staff working in physical health settings who. The nursing associate was able to apply his new knowledge and experience directly to a patient who became physically ill with a kidney condition.

‘He said he could tell what the issues were and could speak to him in a different way and get him to the emergency department. He said: “I got him to the emergency department and I got him treatment. The alternative scenario would have been that he would have had some kind of episode, maybe have been in seclusion, would certainly have been in some kind of restraint, physical or chemical, and it would have been difficult to have got his treatment sorted.”

‘So, a band 3, working with other people, bringing their experience and gaining experience, changes the outcomes for people when you see the whole person.’

Phil Moore. Picture: Neil O'Connor 

Phil Moore raised the issue of who should be trained in what

‘I wonder if we shouldn’t be asking who we train, but what we train them in, because everybody needs something but they need different things.

'So, you start with the receptionists: they need awareness training so if somebody comes in stressed, how to manage that; healthcare assistants need a different kind of training and so do nurses; GPs will need some general training but some of them will want additional training; physicians in hospital will need to know enough about mental health, and so on. It’s about what we need to give to each of these groups, rather than which of them we need to train, because we need to train them all.’

Mike Farrar talked about barriers to achieving holistic care

Mike Farrar. Picture: Neil O'Connor 

Mr Farrar said an important way that some organisations have used their budgets more widely is to adopt more holistic approaches to care. But he said the two most important barriers to achieving holistic care are the amount of money available for training and resistance from staff.

‘When mental health revolutionised in the early 1990s on the back of moving to community-based care from long-stay asylums, we had a significant training budget. If you expect people to do a different job, and they are not trained, then you have barriers.  

‘The second thing is there is resistance, which we shouldn’t ignore, around people who’ve worked in mental health for most of their careers. It is largely about some vocational drive – which is positive – about what they are there for.’

Mr Farrar said it is important for individuals and organisations to recognise and accept that they are moving towards a holistic care model.

Paul Jenkins said another structural problem has to be addressed, relating to what training budgets are allocated for

‘We have a dilemma. So much of the money that is hypothecated nationally for training is locked in to long-term programmes for the training of the next generation of the workforce, while we’ve got a pressing need to re-school, retool and re-purpose the current workforce for the present.

Paul Jenkins. Picture: Neil O'Connor 

‘I use the analogy of the orchestra. Integrated care is about an orchestral sound, not just competent violin players or clarinettists. It’s important that we use training as a social experience as well.

'It is partly about skills and knowledge and insights, but it’s also about dealing with more unconscious and unspoken agendas, about professional rivalries, professional boundaries, and professional lacks of confidence. Actually all the best things I’ve done in education and training have been social experiences, and I have got as much out of that, sometimes, as I have got out of the actual knowledge I’ve learned.

‘If the objective of the exercise is integrated delivery of care, we have to focus on how people work together, consciously and unconsciously, to give patients the best joined up care.’

Joe Rafferty talked about models of care and the importance of trust

‘That’s a good point about the way resources are locked in, in the long term, because by the time we train people, we’ve actually usually produced them just in time for a different model. And the way the question is framed is useful in the sense of new models of care. So, it goes back to why we train people. 

'We’ve been developing a new model of care in forensics in Cheshire and Merseyside, which has been an opportunity to think a little bit about zero-basing the system again. What type of people do we want to have for a new model that we are going to produce? Which is different from saying, what’s the model we can produce if we stretch the current workforce, even if we do it imaginatively?

'We can stretch them to the limits of our imagination, but there’s something about unlocking that resource in a different way in relation to training.

Joe Rafferty. Picture: Neil O'Connor 

‘We see all the tangible stuff, but work we are doing around primary care with physical and mental health integration feels like it’s all about trust. Joint training packages are tremendous ways to build trust. The skills you can always [move] around – we can bridge that issue – but trust feels as if it’s not spoken about enough. I suspect if you wrote it in your business case it would get a cursory pass over, but actually it’s probably the thing that is going to make the biggest, most fundamental difference.’

Rob Webster said that other professions could help lead on integrated care

‘Progress moves at the speed of trust and in the system at the moment – an environment where everything is against integrated care – regulations, payment systems, training – it’s got to be about trust and relationships. 

‘I’m always interested in thinking about where have you got natural allies? Where is there some underutilisation where you can build? And I can think of two straight away: occupational therapists are the only dual-trained therapists, but how often do you hear a lobby for occupational therapy to be at the forefront of driving change? Clearly, occupational therapists have got a massive role to play.

‘The second example would be mental health social work. Why not have mental health social workers running your integrated teams within a healthcare system? Because actually the work that’s going on nationally to attract mental health social workers and social work leaders is popular and could be a real force for good if you get people quickly and make change happen.

‘If you change the dynamic – and this is the point about trust – and you build on the professions where you’ve already got a head start, you start to make change happen.’

Paul Jenkins talked about shared understanding of risk

‘One of the important dimensions of that trust is a shared language about risk. In integrated care particularly, what GPs can sometimes see as a risk that is quite tolerable in the community, can be different from what specialist, secondary clinicians think is appropriate, because their world view is governed by other constraints.

‘If you’ve got the same understanding of the risks you can tolerate and trust between the individuals handing over the risk, then you can support people in different ways in the community. It’s those calls that are the critical difference between whether you have remission or not, or how quickly someone comes out of hospital after admission.’

Carole Spencer. Picture: Neil O'Connor 

Carole Spencer said making staff responsible for monitoring long-term conditions could be the way to integrate mental and physical care

‘Many of the physical health diagnostic tests are a transactional point of care. We don’t require a district nurse or GP to be involved that’s something that can be embedded in training and can be let go. 

'How could trusted people within the mental health setting take responsibility for the tracking and monitoring of long-term conditions, and how does that affect the cultural sensibility of the district nurse?’

Mike Farrar on managing the risks inherent of expecting staff to perform more holistic care 

‘If our expectation is that staff will operate increasingly holistically in community settings, and are at different stages on the pathway, the defensibility for error will come back to what effort was put into giving those people the skills and materials capable of delivering something which, ultimately, they didn’t train for 30 years ago.

‘I don’t like that culture, in the sense that it’s led to blame, to risk aversion and defensive practice. But the truth is that if we do have an expectation to get greater productivity out of staff, to treat people holistically, there is a moral obligation, as well as a statutory and financial obligation, to manage risk. 

'Anybody who is expected to behave in that way has to have had proper experience and training in being able to handle a variety of conditions in a variety of ways.’

Joe Rafferty on the integrated training approach and integrated care record

‘That’s an important point because for those of us involved in doing this the most frequent conversation is about an integrated care record, and most people assume the integrated care record keeps it safe. But actually, it tells you what’s gone wrong in a retrospective way.

‘The way to make it truly safe is to make the integrated training approach as important, as frequently talked about and as invested in, as the integrated care record. Put those two things together, and actually you’ve got a system that will draw professionals into a place where they can feel safe.’

Andy Johnson spoke about competences and how they can help individuals and teams to understand what is expected of them

Andy Johnston. Picture: Neil O'Connor

‘If I work in mental health in forensic services, there’s an expectation I know about certain things, not just about mental health, but the physical risks of being in forensic, high-secure services. We know what those risks are, because the evidence is there and we understand them, but how many people in the team understand those risks in an integrated way? 

'I don’t think they do, because it’s not part of a competency, it’s not part of a passport. I’d like to see much more use of passports so you get away from the arguments about associate nurse, and this or that type of nurse training. Let’s have every individual that works in a team have a passport for their continuing professional development (CPD) training, and have that passport spell out what the competences are for my role in my team. 

‘I’m a nurse by background. I’m still a nurse, but I’ve been a clinical director, I’ve managed psychiatric and forensic services, acute services, and for me seeing team members, whether they are consultant psychiatrists, staff grade doctors, nurses, occupational therapists or social workers, have a good understanding of what they need to do their job helps them not just as professionals, but in terms of their registration, their revalidation. It helps them in terms of their CPD organising development programme and it also helps them organise as an integrated team where they need to develop strengths and different types of approaches.’

Mr Johnson welcomed the fact that the Nursing and Midwifery Council (NMC) has included assessment of suicide in its new competency framework, after some debate by the council about inclusion. But he warned that, even though all newly trained nurses will be expected to have those competences, ‘two or three sentences can be interpreted, so it’s about what it will actually mean in practice’.

Rob Webster discussed using core competences to make the right choices for treatment

Mr Webster said that his trust is developing a passport so staff can move around with the same competences, but it has become clear that it is not a straightforward process.

‘The interesting thing we reflected on when we tried to develop this was deciding what are the core competences around restrictive practices, risk management, making the right choices for the person in front of you. There are a complex set of choices to make, and how do you do that in a way that ends up in a safe place, not a blame space?

‘Every time I go out with a district nurse and go to someone’s house, it’s not the leg ulcers that are the problem; it’s the fact they’ve had two cancer diagnoses, or their care package has been changed, or they’ve had two falls and are crying.

‘In that environment, you’ll be making a choice about how is this person being served best? How are we making sure that we are keeping them at the centre, how are we making sure that they are going to thrive? Are we going to empathise with them and say what’s best for them today? Having the competence to do that, and trying to set that out in a way that’s not task-focused is something we can probably learn from general practice, applying that to multidisciplinary teams with different skills.’

Deanna Roepke asked if the panel favoured a national framework that’s focused on integrated care

Mr Farrar said that the the real value a national framework creates is standardising against the unwanted variation of intervention.

‘Although it will never guarantee that an individual will interpret training and go on to practice in a particular way, it allows you to have more confidence that the approach taken by that individual, in that team in that place, is going to have much more consistency with known best practice. That’s the other significant way in which integrated care will deliver added value – because it allows you to get into the management of variability of care.

‘The ability to use training as a vehicle for delivering added value is another asset – you want to know whether your staff that are being deployed have got a set of skills capable of meeting a particular risk criteria or degree of complexity or multi-morbidity, because you are trying to standardise those approaches and get the best evidence-based care.’

Deanna Roepke asked about the use of digital training to ‘get everybody in one system with high levels of consistency’

Mr Johnson said using online training can improve the level of competency among staff, but he warned that doesn’t go far enough.

‘We are not good at monitoring the impact of training – we deliver it and tick a box to say we’ve trained all these people, whether it’s in an integrated way or not. But we don’t go back and say, what was that like?

‘We know that coaching after training is a good vehicle to gather information and support people’s growth. I don’t think we do enough of that.’

Phil Moore said online training should not replace face-to-face learning

‘Mental healthcare par excellence is about the way we handle people, the way we talk to them, the way we understand them, the way we empathise. And I don’t think that can be entirely given digitally. 

'Digital learning can support it, extend it, and it can help, but I wouldn’t want to see all training digitised.’

Mr Rafferty said he would support digital learning proposition wholly, to embed statutory/mandatory training requirements.

‘With a digital footprint, you can have people easily refresh the training with simple prompts. It turns something that is a laborious industry into something that’s relatively easy to do.’

Andy Johnson spoke of the importance of including patients, their carers and family members in staff training, and of sharing training between NHS and local authorities.

‘If we are doing something on suicide prevention, why run ten different courses across ten organisations, when we can do a webinar and have the best people deliver that training in a room and everyone else can log in?’