1. Professor Peter Huxley 4 th National Social Work CPD Conference Institute of Psychiatry, 14 th September 2010

2. RESEARCH QUESTIONS What determines the social care composition of CMHTs? Does team culture and climate vary by composition? Are service users experiences effected by team climate and culture and composition

3. THREE PHASES PHASE 1 - National survey of MH trusts – reasons for team composition PHASE 2 - Four location study of culture and climate in teams PHASE 3 - Two locations impact on user experience

4. RESEARCH QUESTION 1 What determines the social care composition of teams?

5. Data were collected from 42 out of 79 Trusts (response rate 53.2%). 381 Community Mental Health Teams (CMHTs). Managers provided details of: –the numbers, sizes and composition of community teams –Reasons for CMHT composition, drivers of planned changes, reasons for social care component

6. Table 1: Average CMHT team composition by data source (for major staff groups only) SourceCommunity Psychiatric Nurse Social Worker Occupational Therapist PsychologistDoctorSocial Care Support Worker Onyett et al. 19943.31.91.0 0.9 Policy Implementation Guidance 2001 431.5 2.53.0 Boardman and Parsonage 2005 4.92.71.61.03.04.0 National mapping data 2007 63.50.91.11.51.7 Present study 20076.13.50.90.82.11.4 Growth since 1994+84.8%+84.2%-10%-20%+110%+55.6% Surplus (+) or deficit (-) over Guidance +52.5%+16.7%-40%-46.7%-16%-53%

7. CMHT

8. Assertive Outreach Teams

9. Early Intervention Teams

10. Crisis Resolution Teams

11. Reasons for team composition Reason n (%) (% main reason) History30 (27) (46) Policy guidance25 (22.5) (20) Demand24 (21.6) (16) Financial22 (19.8) (14) Multi-disciplinarity10 (9.1) (4) Total111 (100)

12. Determinants of social care composition Reason n (%) Workload complexity15 (16.5) History15 (16.5) Policy guidance5 (5.5) Financial9 (9.9) Integration requires it20 (22.0) Team needs (eg multi-disciplinarity)8 (8.8) Social services determined11 (12.0) Other8 (8.8) Total91 (100)

13. Team membership and composition, in terms of total staffing and social work and social care numbers is largely unrelated to the rationale given by managers. Despite more than 15 years of policy guidance relating to the mental health workforce (and increasing staff numbers over the same period) team staffing and composition was not associated with guidance or demand.

14. Financial resources emerged as having some influence on team staffing and composition. Smaller Trusts appear to struggle to populate policy prescribed specialist teams and were more likely to have to consider redeploying CMHT staff for this purpose. Supply, historical and resource factors have an undue influence on the composition of CMHTs compared to need and demand factors.

15. UK Mental Health Services Social Care Services MHSW Health and Social Care Integration

16. Mental Health Services Social Care Services MHSW Health and Social Care Integration

17. RESEARCH QUESTION 2 Does team culture and climate vary by composition?

18. Phase 2 four location study of culture and climate in teams Workforce dynamics questionnaire (Susan Nancarrow) Karasek job content questionnaire

19. 42 TEAMS 300 WDQ RESPONSES

20. Social care staff as a proportion of team Location Percentage (sd) 127.6 ( 8.3) 217.4 (10.6) 321.0 ( 8.7) 452.2 (16.0) All29.0 (17.2)

21. Inter-professional working and role overlap in the whole sample

22. Inter-professional working and role overlap by location

23. Inter-professional working and role overlap by professional group

24. Proportion of sample with no overlapping role Psychiatrist n=30 (11.9%) Psychologist n=27 (10.3%) GP n=98 (38.1%) CPN n=15 (5.7%) Other nurse n=85 (35.0%) OT n=23 (9.0%) Social Worker n=12 (4.7%) ASW n=37 (14.4%) Support Worker n=22 (9.0%)

25. Social Care Compositionn (%) 10% 35 (11.6) Up to 20% 62 (20.6) Up to 30%105 (35.0) Up to 40% 41 (13.6) 40 – 60% 28 ( 9.3) >60% 31 (10.3)

26. Variance explainedPredictor variablesβp R 2 = 0.338 AR 2 = 0.296 Not being in a CMHT Better management Rated higher by other staff than nurses Fewer job demands -0.38 0.29 0.11 -0.10 0.000 0.043 0.071 Possible interaction effects between team typology and independent variables Team typology 1: Social care component <20% R 2 = 0.285 AR 2 = 0.196 Not being in a CMHT Better management Rated lower by support workers than nurses Co-location & Site 4 dropped -0.31 0.29 -0.22 0.011 0.007 0.059 Team typology 2: Social care component 20 - 40% R 2 = 0.459 AR 2 = 0.408 Not being in a CMHT Better management Rated higher by other staff than nurses Rated lower by support staff than nurses -0.59 0.38 0.24 -0.13 0.000 0.002 0.099 Team typology 3: Social care component >40% R 2 = 0.409 AR 2 = 0.291 More autonomy Rated higher by other staff than nurses Rated higher by support workers than nurses Fewer job demands Better management Rated higher by social workers than nurses CMHT & Sites 3, 4 dropped 0.46 0.37 0.32 -0.33 0.24 0.008 0.019 0.046 0.054 0.073 0.095 Normal distribution and no outlying residuals. Final model includes: autonomy, management, job demands, professional group and CMHT. INTEGRATION

27. TEAMWORKING Variance explainedPredictor variablesβp R 2 = 0.691 AR 2 = 0.685 Greater role perception Better management Greater role flexibility Greater social support Not co-located Fewer job demands 0.36 0.29 0.23 0.21 -0.10 0.000 0.003 0.004 Significant interaction effects between team typology and independent variables Team typology 1: Social care component <20% R 2 = 0.690 AR 2 = 0.671 Greater role perception Better management Greater role flexibility Greater social support Fewer job demands Co-location dropped 0.32 0.30 0.24 0.17 -0.17 0.000 0.001 0.024 0.010 Team typology 2: Social care component 20 - 40% R 2 = 0.725 AR 2 = 0.712 Greater role perception Better management Greater role flexibility Greater social support Not co-located Fewer job demands 0.38 0.32 0.20 0.26 -0.19 0.00 0.000 NS Team typology 3: Social care component >40% R 2 = 0.675 AR 2 = 0.636 Better management Greater role perception Greater role flexibility Fewer job demands Greater social support Co-location dropped 0.34 0.33 0.27 -0.23 0.16 0.006 0.001 0.012 NS

28. QUALITY OF CARE Variance explainedPredictor variables βp R 2 = 0.527 AR 2 = 0.485 Better teamwork >60% social care in team Better management Larger team size 40-60% social care in team Less autonomy More overlap with social work role -0.56 1 -0.23 -0.19 -0.15 -0.14 0.11 -0.11 0.000 0.011 0.003 0.080 0.090 0.057 0.076 Significant interaction effects between team typology and independent variables Team typology 1: Social care component <20% R 2 = 0.534 AR 2 = 0.504 Better teamwork Better management -0.42 -0.41 0.000 Team typology 2: Social care component 20 - 40% R 2 = 0.550 AR 2 = 0.532 Better teamwork Better management Less autonomy More overlap with social work role -0.55 -0.21 0.13 -0.11 0.000 0.013 0.045 0.085 Team typology 1: Social care component >40% R 2 = 0.580 AR 2 = 0.531 Better teamwork Larger team size Less autonomy -0.91 -0.34 0.20 0.000 0.002 0.070 All model square-root transformed hence negative symbol for positive result Team typology models similar in untransformed data, and when including area. Final model includes: teamwork, management, job demands, overlap with nurses, overlap social workers, professional group, team typology, team size, co-location and cmht

29. JOB SATISFACTION Variance explainedPredictor variablesβp R 2 = 0.513 AR 2 = 0.461 Fewer job demands Working closely with nurses Better management More decision latitude More uncertainty Less overlap with nurse role Better training & career opps Being co-located Site 2 cf Site 1 -0.35 0.28 0.21 0.18 0.15 -0.16 0.21 0.14 -0.15 0.000 0.001 0.005 0.006 0.010 0.044 0.050 0.068 Significant interaction effects between team typology and independent variables Team typology 1: Social care component <20% R 2 = 0.601 AR 2 = 0.498 Fewer job demands Better training & career opps Greater role flexibility Less overlap with nurse role More uncertainty Site 2 & co-location dropped -0.48 0.36 0.25 -0.24 0.20 0.000 0.022 0.055 0.058 Team typology 2: Social care component 20 - 40% R 2 = 0.548 AR 2 = 0.473 Fewer job demands Working closely with nurses Better management Being co-located Greater decision latitude Site 2 cf Site 1 0.35 0.31 0.26 0.18 0.17 -0.14 0.000 0.001 0.005 0.024 0.065 0.094 Team typology 1: Social care component >40% R 2 = 0.468 AR 2 = 0.167 Failed to fit a model

30. INTENT TO LEAVE EMPLOYER Variance explainedPredictor variablesβp R 2 = 0.422 AR 2 = 0.376 Less likely if in CMHT Less likely - larger team size Less likely – better training Less likely – higher job satisfaction Less likely – poor role perception Social Worker more likely than nurses Less likely in Site 3 -0.51 -0.23 -0.17 0.16 0.13 -0.18 0.000 0.019 0.005 0.013 0.007 0.021 0.089 Significant interaction effects between team typology and independent variables Team typology 1: Social care component <20% R 2 = 0.551 AR 2 = 0.498 Less likely if in CMHT Social Worker more likely than nurses Support workers more likely than nurses -0.64 0.20 0.16 0.000 0.027 0.056 Team typology 2: Social care component 20 - 40% R 2 = 0.363 AR 2 = 0.314 Less likely if in CMHT Less likely – higher job satisfaction Less likely – poor role perception Support workers less likely than nurses -0.39 -0.17 0.18 -0.14 0.000 0.047 0.049 0.088 Team typology 3: Social care component >40% R 2 = 0.489 AR 2 = 0.376 Less likely – higher job satisfaction Less likely – more uncertainty Less likely – better training Less likely – poor role perception -0.39 -0.32 -0.28 0.27 0.009 0.028 0.063 0.072 One outlying residual: log transformation and residual removal produced identical results Final model includes: role perception, training, uncertainty, integration, management style, professional group, overall satisfaction, team size, CMHT, area, team typology (social care composition), co-location.

31. RESEARCH QUESTION 3 Are service users experiences effected by team climate and culture and composition

32. PHASE 3 TWO LOCATIONS IMPACT OF CULTURE AND CLIMATE ON USER EXPERIENCE

33. 41 SERVICE USER INTERVIEWS CUES MANSA SUQ

34. Relationship between worker and user views WORKER (WDQ)USER (CUES) TEAMWORKAVAILABLE CHOICE QUALITY OF CARENURSE COMPETENT & KNOWLEDGABLE SOCIAL WORKER LISTENED UNDERSTOOD SUPPORT WORKER LISTENED UNDERSTOOD TRAINING/CAREERNEEDS MET SOCIAL WORKER LISTENED UNDERSTOOD SOCIAL WORKER COMPETENT KNOWLEDGABLE SUPPORT WORKER LISTENED UNDERSTOOD SUPPORT WORKER COMPETENT AND KNOWLEDGABLE OVERALL JOB SATISFACTION AVAILABLE CHOICE SATISFACTION WITH CHOICE INTEGRATIONNOTHING

35. Conclusions Variable proportions of social care per team from 0% to 65%,88% (lower in new teams) Narrow conception of social care being integrated Regressions – new teams more integrated than CMHTs

36. Conclusions continued Regressions – integration makes no contribution to teamwork, to quality of care, job satisfaction or intention to leave Social workers are more likely to want to leave

37. Conclusions Continued Culture and climate can be shown to be related to user outcomes But integration is not Composition is also unrelated (as tested here with CUES or MANSA or SUQ but n is small) Integration is not a useful construct for implementing the New Horizons agenda, personalisation may be preferable.

38. Acknowledgements SDO Funding Acknowledgement: This project was funded by the National Institute for Health Research Service Delivery and Organisation programme (SDO114). Department of Health Disclaimer: The views and opinions expressed are those of the author and do not necessarily reflect those of the NIHR SDO programme or the Department of Health.