Is it time to abandon care planning in mental health services? A qualitative study exploring the views of professionals, service users and carers

Abstract Background It has been established that mental health‐care planning does not adequately respond to the needs of those accessing services. Understanding the reasons for this and identifying whose needs care plans serve requires an exploration of the perspectives of service users, carers and professionals within the wider organizational context. Objective To explore the current operationalization of care planning and perceptions of its function within mental health services from the perspectives of multiple stakeholders. Settings and participants Participants included 21 mental health professionals, 29 service users and 4 carers from seven Mental Health Trusts in England. All participants had experience of care planning processes within secondary mental health‐care services. Methods Fifty‐four semi‐structured interviews were conducted with participants and analysed utilizing a qualitative framework approach. Findings Care plans and care planning were characterized by a failure to meet the complexity of mental health needs, and care planning processes were seen to prioritize organizational agendas and risk prevention which distanced care planning from the everyday lives of service users. Discussion and conclusions Care planning is recognized, embedded and well established in the practices of mental health professionals and service users. However, it is considered too superficial and mainly irrelevant to users for managing mental health in their everyday lives. Those responsible for the planning and delivery of mental health services should consider ways to increase the relevance of care planning to the everyday lives of service users including separating risk from holistic needs assessment, using support aids and utilizing a peer workforce in this regard.


| INTRODUCTION
The need to incorporate principles of service user and carer involvement in the planning and delivery of care is predicated on the idea that this can lead to positive outcomes for health-care systems and their users. [1][2][3][4][5] Benefits include increased engagement with and a more positive experience of care, [5][6][7] improved service quality, 8 reduced rates of enforced treatment and readmission 9 and reduced stigma and social isolation. [7][8][9] Care planning is an area of identified contemporary practice in which user involvement principles are suboptimal but can, in principle, be realized in practice. [5][6][7][8][9][10][11][12] Mental health-care planning has been defined as the process through which services in relation to an individual's care are "assessed, planned, co-ordinated and reviewed". 13 In the United Kingdom, current NICE guidelines state that "people using mental health services [should] develop a care plan with mental health and social care professionals, and [be] given a copy with an agreed date to review it.". 14 Despite the embedding of engagement and involvement principles in policy and practice ideologies, current evidence suggests that service users and carers feel unsupported by and distanced from care planning processes and consistently report a desire for greater involvement. 8,15,16 This applies across a variety of service settings and professional roles. 12,17 Barriers to service user and carer involvement in mental health services include a lack of a shared definition of involvement, 5 the administrative burden of care plans, 12 poor information exchange, 5 limited opportunities for involvement, 5,15 ritualized practices 5 concerns about confidentiality 15 and inhibitions based on historical use and contemporary associations of potential coercion within mental health services. [18][19][20] Current care planning practices should not be considered in isolation from the wider contextual agenda which shapes systems and processes. For example, care planning forms part of a number of elements that are subjected to quality assurance. The use of such quality indicators is driven by demands for transparency and accountability with organizations placing emphasis on the need for measurement and evaluation of performance. 21,22 This demand for evidence of performance management in mental health services has been accentuated by the introduction of the Joint Commissioning Panel for Mental Health and local commissioning groups. 23 The increased significance of such indicators within health services has produced unintended consequences. 24,25 In the context of primary care, this has included the tendency to focus on isolated aspects of care, which may lead to poor care for service users. 24 Other negative consequences include overtreatment and "tunnel vision" whereby professionals focus on problem areas inherent in quality indicators to the detriment of other areas of practice. 24,25 Thus, the way in which needs assessments and care planning are framed and executed as part of quality assurance, improvement and governance agendas is relevant to understanding the perception of their primary use as a means of organizing and planning care in a way which meets patient need. For example, we know that service users and carers themselves attach priority value to relational aspects of care planning compared to professionals who focus instead on service-led outcomes. 5,26,27 Current quality indicators associated with the processes of mental health-care planning are gathered from a variety of sources.
They include experience surveys and feedback from service users relating to the number of users who report having a jointly agreed care plan, the proportion reporting being given a care plan and the number who report being given an agreed date to review their care plan. 14 This study sought to understand service user and carer involvement in care planning by exploring the current use of care planning processes within mental health services and the impact of contextual factors on the quality of care planning provided. Perspectives of multiple stakeholders including service users, carers and professionals were elicited to this end.

| Aim
To explore the current operationalization of care planning within mental health services from the perspectives of multiple stakeholders.

| Study design
A qualitative study utilizing semi-structured interviews formed part of a wider programme of research designed to improve service user and carer involvement in mental health-care planning. The presentation of methods and results is informed by the Consolidated Guidelines for the Reporting of Qualitative Data. 28

| Participants
Inclusion criteria included mental health service users, carers or professionals from community secondary mental health-care services already recruited to a randomized controlled trial testing the effectiveness of a training package for professionals to improve service user and carer involvement in care planning. Service user participants from the trial were invited to take part in this study through a written invitation. Interested participants returned a consent-to-contact form to the research team who then contacted them directly via email or phone. Staff members who were interested in taking part in the study responded to an email invitation and service users were asked to identify relevant carers for inclusion in the study. Additional criteria included being aged 18 or over. The study utilized purposive sampling to ensure adequate representation across gender and geographical area.
In total, 87 participants (31 professionals, 47 service users and 9 carers) expressed an initial interest in taking part. HB contacted participants to ascertain eligibility and to arrange an interview (see Table 1 for further details of study participants). Fifty-four participants (21 professionals, 29 service users and 4 carers) from seven Mental Health Trusts in England provided informed consent to participate (Table 1).
Reasons for non-participation included non-response and participants no longer wishing to take part in the study because of, for example, illness, changes in circumstances or a lack of time.
Participants were provided with an information sheet and given the opportunity to ask questions about participation prior to completing consent forms. Those undertaking the interview over the phone (professionals = 10, service users = 4, carers = 3) returned consent forms prior to data collection. Participants took part in three interviews over 12 months. This study reports on findings from the baseline interviews only.

| Data collection
Self-reported demographic information was collected prior to data collection in order to contextualize the data presented. Interviews were conducted by HB at a convenient time and place for participants and the option to complete the interview via the telephone was offered. Face-to-face interviews were carried out on trust or university premises, in participants' homes or at another convenient community location. Two female service user participants had a significant other present during the interview at their request. These individuals were present during interviews but were not participants and did not contribute to interview data.
Digitally recorded semi-structured interviews lasting between 20 and 70 minutes were undertaken between August 2014 and January 2016. Interviews were semi-structured in nature to allow for the introduction of new themes by study participants. Interview schedules informed by existing literature 5,8,12,[15][16][17][18][19][20] explored experiences of contemporary care planning within mental health services and organizational processes and systems related to care planning (see Appendix 1). Data collection stopped when consensus amongst the research team was reached that data saturation had occurred.

| Data analysis
Digital recordings were transcribed verbatim by an independent and experienced transcription company before being anonymized and allocated to a member of the study team (HB or AR). The first 10 transcripts were coded independently by HB and AR who familiarized themselves with the data before starting the inductive coding process. 29 The authors then met to discuss emerging themes and to produce a provisional framework. 30 The remaining transcripts were coded by HB using NVivo to organize the data. Over the course of this coding, all data relevant to a category were identified and examined using constant comparison where new categories were added to the framework to reflect as many nuances within the data as possible. 31 Emergent findings were presented to the wider study Service User and Carer Advisory Group (SUCAG) to ensure interpretations of data were grounded in the experience of mental health services.
The study team discussed revisions arising during the analysis process before agreeing a final framework to present the results, which was considered representative of the entire data set. An excel document detailing basic demographic information for each study participant was used to contextualize and organize data.

| Findings
Despite being aware of the care planning process, the majority of service users and carers included in this study had neither seen their care plan nor been involved in its development. The minority who did report having seen a care plan did not consider the plan to be useful to the management of their mental health conditions or their future recovery. There was a general consensus amongst all participant groups that care plans were of most relevance to professionals and mostly inconsequential to the everyday lives of service users. One of the main reasons identified for this irrelevance was the lack of the required multidisciplinary working to adequately address managing the complexity of mental health conditions or to take on board holistic or broader contextual and environmental influences impacting on a person's ability to manage their condition. Rather, care planning processes prioritized organizational and risk agendas which further distanced and alienated the process of care planning from the everyday lives of service users. There were no discernable differences in this regard from the data collected from service users and carers. Care planning was seen as something that "had to be done" to serve bureaucratic expediency rather than any dynamic user centred needs. The majority of targets related to care planning identified by professionals were presented as a set of binary outcomes such as "is the care plan in date?" rather than any indication of substantive content (eg the quality and utility of information contained within the care plan

| Risk prioritization and the perceived vulnerability of the role of care coordinator
Both service users and professionals described a predominant focus on risk management within current care planning processes.

| DISCUSSION
The risk, this is understood in terms of a professional priority that may lead to loss of liberty. 33 The current study adds to this by highlighting that the focus on quality indicators along with the inclusion of organizational risk assessments within current care planning structures also detracts from meeting the expectations or expressed needs of service users.
"Measurement fixation" is an unintended consequence of systems designed to measure performance of professionals. 24 There is increasing recognition of the need to consider better ways of capturing patient and care experiences in a more meaningful way in specific care contexts. 22 This study adds to existing literature through demonstrating that the unintended outcomes of quality indicators are manifest within mental health-care planning systems with the consequence that the intended focus of care plans, responding to needs in a holistic and patient-centred way, is thwarted and preference is given instead to feeding organizational imperatives for measuring performance. This consequence is reinforced by the original impetus of the care planning approach as a mechanism to feedback to commissioners in relation to activity and risk management. 19 Organizational processes reported in the current study focussed on paternalistic, formulaic approaches to risk, serving organizational accountability agendas related to the origination of care planning as a result of concerns about safety and fragmented community care. 12 The findings support the recent literature demonstrating that actuarial risk assessments can be used by professionals to manage uncertainty in a manner that distances service users from potential solutions. [33][34][35] To better integrate care plans with people's everyday lives, risk management should be separated from holistic needs elicitation. The latter could be elicited through tailored dialogue between service users and professionals with the former developed separately through formulaic and less engaging processes.
In order to reorient care plans to the everyday lives of mental health service users, planning discussions could be supported by evidence-based tools designed to open up opportunities for accessing resources to help manage a condition and meet need. 36 Given their fit with an individual's real-world environment and everyday management of mental health conditions, such interventions may address the perceived invisibility of care plans in relation to meeting the needs of service users. Using a peer workforce to complement that provided by health professionals may be useful to take care planning in a different, more user-focused direction away from the organizational constraints, paternalistic culture and clinical norms of surveillance and control associated with statutory services. [36][37][38] The study gains its strengths from the insightful data gathered from the in-depth nature of the methods employed and the ability to compare data across multiple stakeholder groups. However, the data reflect the experiences of stakeholders at one point in time and do not purport to reflect the experiences of all mental health service users, carers and professionals. Generally, the negative experiences recalled by participants speak to a wider discontent with mental health services, which has been documented previously, 5,15,16 but the focus on the current use of care planning within services has illuminated some of the potential structural factors underlying this discontent and has identified potential areas for intervention. Whilst carer participants' views coalesced with service user views and their concerns supported those reported previously, 15 only four carer participants took part in the study so their views may be under-represented in the data presented. o Any alternatives?

| CONCLUSION
• How is care planning understood by other staff and service users across services?
• What are staff and professionals attitudes towards current care planning?
• What elements currently missing in context to make it work properly for professionals?
• What would make the biggest difference to improving mental health services currently? o Can you describe the format of a meeting? (Make this in general first and then ask them to focus on one key one or the last one.

SERVICE USER/CARER
Get them to identify it before asking in depth about it.) o Who is involved in these meetings? (Again typically and last one attended). o Are there any alternatives to care planning that you know of or have had experience of?
• What are staff attitudes towards current care planning?
• Are there any differences between inpatient and community care?
• What elements currently missing in context to make it work properly for you?
• What would make the biggest difference to improving mental health services currently?