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PROactive Management of Integrated

Services & Environments


“Physical restraint is an extreme response to managing someone’s behaviour when they are in a mental health crisis. It can be humiliating, cause severe distress and at worst lead to injury and even death” (Mind report 2013) Following the publication of the Mind report we at the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) have been on a journey to define new frontiers of humane mental healthcare. Our aspiration to eliminate reliance on force has empowered frontline staff to take the initiative and go that extra mile. PROMISE collates and celebrates these ingenious implements and innovations that staff have come up. Sharing knowledge and learning from success is the PROMISE ethos. .

However as PROMISE has gone from strength to strength, we have become increasingly aware that our wards are only the tip of an iceberg. Even for those who get admitted to hospital 90% of the recovery journey is in the community. Simple maths dictates that 90% of opportunities to positively influence the patient trajectory lie in the community.

Staff are often focused on the service area they manage, as they want to do their best for the patients at that particular point in their journey. However patients involved in PROMISE maintain that this cross-sectional view of the world is unhelpful and what matters to most patients is the longitudinal journey. Navigating interfaces across various care organisations is a tricky and challenging experience for our patients. Many would point out that mental health care in the statutory secondary care setting only meets a small part of the overall support they need and receive.

These insights set us thinking about the way forward resulting in an expansion in the scope of PROMISE. The I in PROMISE that stood for Inpatients was changed to Integrated because we believe that there is a chance to alter the course of events by working proactively and intervening earlier. Mapping out some patient journeys clearly shows influence from:

If one took a public health approach to eliminating reliance on force, the focus will be on prevention and early detection, assessment and treatment so that patients did not reach a stage where coercive strategies will be needed in the best interest of the patient. If such a strategy was successful all essential treatment could be delivered in the least restrictive setting i.e. the patient’s home and mental health hospitals would become redundant. Most would consider such a stance utopian, however before the advent of home treatment teams, lengths of stay used to be extremely long on our wards. The 3-3-3 system in CPFT successfully discharges 70% of inpatients on the assessment units within 3 days to the care of home treatment teams. Even a couple of years back this would have been a pipe dream. Successes in delivering treatment in the least restrictive environment has made us reflect on ‘what if’ scenarios and how we could push the boundaries of humane mental health care.

However the challenge we face is that of an overstretched system with gaps in the stepped care model through which patients could fall through. The following two are most noticeable:

This gives rise to problems in stepping up and stepping down. So instead of the patient coming first  we spend countless hours on settling boundary disputes and arguing the toss about thresholds and referral criterion. However, if we had confidence in our ability to step people down there would be more opportunities to  fast track step ups and the period of additional support required would be shorter. Enabling patients to seek help earlier encourages them to take responsibility and puts them in the driving seat. One of the key recovery challenges for both staff and patients is letting go (Navigating rocky waters). Patients find it intensely anxiety provoking as they worry about the ability of the system to respond if they hit a crisis and need to get back into the system quickly. Staff find it equally anxiety provoking as they worry about things going wrong and patients slipping through the net. Everyone is acutely aware of how much the system is stretched and thus we all lack confidence in our abilities to work proactively when a crisis starts to evolve. This leads to pathways getting clogged, new patients not getting necessary interventions, patients not getting well and staff always in firefighting mode. The overarching focus is on managing risk in the here and now. We act as fixers rather than enablers.

The goal is to build confidence in the system with the provision of a net so that patients feel empowered and safe to take responsibility for their own care and don’t fall through the gaps. PROMISE local aspires to be the harbinger of an environment in which Irrespective of organisational boundaries we work together to ensure a seamless journey for our patients with rapid access and proactive response

For this to happen the services listed above have to work together as a system. Instead of guarding boundaries, boundary spanning leadership is needed for system transformation. At every level there are unique opportunities work across statutory and 3rd sector, primary and secondary care, health and social care and so on. Education and training regionally could be changed to reflect these aspirations.

To commemorate World Mental Health Day in Cambridgeshire we are working with our partners towards a charter for positive and proactive care, the objectives are:

  1. System transformation that enables seamless transitions across teams and organisations  
  2. A positive and proactive workforce for the future
  3. Communities that are more accepting of mental health challenges

We hope that PROMISE Local will provide a model of how partnership working can transform a healthcare economy from reactive care to one that is positive and proactive.


Person Centeredness Trumps Organisational Boundaries



PROMISE Charter Event

Friday 9th October 2015

Launch of the PROMISE framework and the signing of the Cambridge Charter, Robinson College, Cambridge.