realising potential: an action plan for allied health

© Crown copyright 2010

ISBN: 978-0-7559-8324-7

This document is also available on the Scottish Government website:www.scotland.gov.uk

The Scottish GovernmentSt Andrew’s HouseEdinburghEH1 3DG

Produced for the Scottish Government by RR Donnelley B63735 06/10

Published by the Scottish Government, June 2010

An action plan for allied health professionals in mental health

Realising potential

Realising potential A

n action p

lan for allied

health pro

fessionals in m

ental health

This hour-long DVD looks in depth atservice user experiences and storiesand the impact of their diagnosis onthem, their families, social networksand the wider community. The clinicaljourney of the therapist is alsohighlighted, demonstrating theircreative partnership in the serviceuser’s journey.

The four stories focus on the keycontributions of AHPs as demonstratedin the action plan.

• “Support When you Need It” –supported self management andrecovery

• “Keeping Well” – promoting physicalhealth and mental well-being

• “Self Discovery and Skills for Living”– designing and deliveringpsychological interventions

• “A Meaningful Life” – integratingvocational rehabilitation in mentalhealth.

AcknowledgementsThe Scottish Government gratefullythanks:

• the service users, carers andprofessionals who took part

• Mindzmatter(www.mindzmatter.org.uk), who produced the DVD

• NHS Ayrshire & Arran, whocommissioned the DVD

Realising PotentialDeveloped in partnership with:


Realising potential


ISBN: 978-0-7559-8324-7





“ I now have a full time job. With your help, I took the plunge and faced myproblems ... I have now continued with my art again realising that I have a gift and that life is worth living for! I still have odd low days but I write orpaint situations down and looking atthem later see it in a different light. ”Service user Experience of art therapy

Contents

PAGE 02

Foreword by the Minister for Public Health and Sport 04

Introduction by the Chief Health Professions Officer 08Need for change 10The action plan 1 1Moving forward 12

Section 1 Context 14Mental health and policy in Scotland 15Allied health professionals in mental health 17Realising the potential of the entire AHP 22workforce

Section 2The way forward 24Early intervention and timely access for 25service users and carersSupported self-management and recovery 26Promoting physical health and mental 28well-being

Physical activity 28Diet and nutrition 30Valuing everyday activities 30Socially inclusive practice 3 1

Designing and delivering psychological 32interventionsIntegrating vocational rehabilitation in mental 34health

Promoting the aspiration to work 37Skills for work 37Vocational rehabilitation 38

Section 3Support for change: making it happen 40Workforce development 4 1

Workforce information 4 1Pre-registration training 4 1Ongoing learning 4 1First graduate post 42Leadership 42

Evidence-based practice and research 44Good practice 44Practice based on best evidence 44Outcomes and impact 44Research 45

Section 4Delivering the action plan 46

Section 5Summary of recommendations 48

The action plan – where now? 52

Appendix 1 57How we got here: the process

Appendix 2 58National AHP Mental Health Action Group membership

Appendix 3 59Web links to AHP mental health resources

References 62

“ I just want toget back to anordinary life that I canfunction in… ”Service user

Foreword by the Minister for Public Healthand Sport

PAGE 04

This document is a first for Scotland in that it brings together the work ofthe allied health professions (AHPs) in mental health in partnership withservice users and carers, professionalorganisations and NHS boards.

This three-year action plan sits besidea wider AHP project currently underway in Scotland that focuses onscoping the AHP workforce in mentalhealth and reviewing the mental healthdimensions of pre-registration AHPprogrammes. In addition, it has beendeveloped parallel to a “refresh” ofDelivering for mental health, providingsupport for the change agenda inmental health and the shift in thebalance of care from hospital tocommunity.

But the action plan has also beendeveloped at a time of significantfinancial pressures for NHS boards. It is therefore imperative that it setsachievable and realisticrecommendations that not onlypromote recovery and strengths-basedapproaches within a framework ofperson-centred practice, but whichalso provide for efficient and cost-effective AHP services.

The action plan is about recognisingthe value AHPs bring and enablingthem to work in different ways toprovide better services. It empowersAHPs to lead the reconfiguration oftheir services to enable earlyinterventions and ensure timely accessto AHPs for service users and carers.

Delivering person-centred practice is the central princ iple of The healthcarequality strategy for NHSScotland and is core to everything we do. The DVDthat accompanies this action plandemonstrates in a very powerful wayhow highly service users and carersvalue person-centred practice, andhow much this dimension of AHPpractice has supported transformationalchange in their lives.

An AHP workforce in mental healththat has its contribution rightlyrecognised and valued, is properlyprepared, supported, motivated anddeployed and which is backed bystrong local and national leadership is a powerful force for progressingperson-centred practice inNHSScotland.

A strong AHP workforce in mentalhealth brings benefits for all.

First and foremost, it brings benefits to service users through the promotionof realistic hope of meaningful recoveryand positive engagement with social,educational and work opportunities.

It brings benefits to carers, many ofwhom provide the vital support thatsustains service users in good timesand bad.

It brings benefits to AHPs and theircolleagues in the multidisciplinary,multiagency team through therecognition and deployment of highly-skilled, clinically effective AHP

PAGE 05

practitioners as part of integratedmental health services.

And it brings benefits to our economythrough providing the support tomaintain people as active, productivemembers of society, capable ofsupporting themselves and theirfamilies.

We know that AHPs make a difference,and we know they are capable ofbringing all these benefits into play.

I am confident that delivering therecommendations in this action plan will prove the springboard fortransformational development of AHP roles in mental health, building on the professions’ core strengths to modernise working practices and adopt new ways of providinginterventions.

Realising the potential of AHPs inmental health is, I believe, a verypositive step towards the aim ofenabling service users to realise theirpotential, reclaiming that “ordinarylife” or, indeed, “extraordinary life” that is so important to all of us andsupporting them to progress asproductive members of their familiesand communities.

Shona Robison, MSPMinister for Public Health and Sport

PAGE 06

“ I feel I am treated with respect [in the occupational therapy service] …The occupational therapist clearly sawexactly what I needed for my recovery,and the encouragement I have receivedhas enabled me to start publishing mywork again, as I was doing before Ibecame ill. ”

Service user Experience of occupational therapy

Introductionby the Chief Health ProfessionsOfficer

PAGE 08

The allied health professions (AHPs) in mental health are a key part of theworkforce and have knowledge, skillsand approaches that are highly valuedby service users and carers. AHPs helpindividuals to maximise their potentialand enable productive andindependent living.

While each profession possesses corespecialist knowledge and skills, AHPscollectively share many commonattributes, such as a person-centredfocus and skills in rehabilitation, whichare vital in the pursuit of recovery from mental illness. The vast majorityof AHPs offer direct interventions toservice users either as individuals or in groups, but increasingly, they also work in partnerships with otherdisciplines and support servicesthrough consultancy.

The AHP “family” represents a diversegroup of professions who, as membersof multidisciplinary, multiagencyteams, provide a wide range ofinterventions and contributions topromote good mental health andrecovery from illness. This constitutes a very important resource for peopleaccessing mental health services, but italso provides a challenge in ensuringthat AHPs’ skills are profiled anddeployed to the maximum benefit ofservice users.

Some AHPs, specifically those whowork in arts therapies, dietitians,occupational therapists, physiotherapistsand speech and language therapists,work in core mental health services,with occupational therapists beingimmersed in mental health issues fromtheir initial preparation for registrationand arts therapists studying mentalhealth approaches at postgraduatelevel. Other AHPs, such as podiatrists,are developing their roles in deliveringvaluable interventions that enhancepeople’s sense of mental health andwell-being and provide specific therapiesthat support people with mental healthproblems as part of their day-to-daywork in mainstream health services.

Regardless of whether AHPs engagewith people with mental healthproblems as part of their core functionin mental health services or meet themas they access mainstream services for other health-related reasons, it isimportant that we acknowledge theimportance of the contribution of allAHPs to improving mental health andwell-being and supporting people with mental health problems and theircarers. The comments from serviceusers that feature throughout thisaction plan, and the testimony of thosewho feature in the accompanying DVD,bear vivid witness to the high valuethey place on their AHP services.

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Level 4Specialist care

Level 3Secondary care mental health

Level 2Primary Care

Level 1Communities and local neighbourhoods

Level 0Education and public awareness

Need for changeSo AHPs play a valuable, sometimesvital, role in mental health. But for too long the focus of their energiesand interventions has tended to be in providing services “downstream” in secondary and specialist caresettings for people whose mentalhealth problems have become well-established and whose abilities and life opportunities have becomecurtailed as a result.

These services are important, and the skill and expertise of the AHPs who provide them are fully recognised. But AHPs have an equally important(or arguably even more important) role in focusing “upstream” on peoplewhose conditions or problems are in the early stages. AHPs need toenable these people to keep active,stay engaged with their families,communities and social networks,avoid hospital admission and, whereappropriate, remain in employment or continue their education.

The vast majority of AHPs in mentalhealth are sited within the“downstream” services in secondarycare and specialist mental healthsettings. A move towards a more“upstream” approach would thereforecall for AHP services to be increasinglyaccessible to service users and carersin community, neighbourhood andprimary care settings, as is shown inFigure 1. This would include enablingservice users and carers to access AHPservices through NHS 24.

The Way Forward (Figure 1)

An AHP focus on early interventionsand timely access, engaging withservice users and carers in communityand primary-care based situations in addition to secondary care settingsand working in partnership with a rangeof statutory and independent agencies,community-based groups and individuals,will play a big part in helping peopleavoid the challenges long-term mentalhealth problems produce.

This will involve AHPs looking anew at the pathways service users follow toaccess their services and reconfiguringthem to ensure access at an earlier pointin the service user journey.

They should also consider what canonly be delivered by AHPs and whatcontribution can be made by supportstaff and staff in third sector andcommunity services. AHPs in mentalhealth, with their understanding of thechallenges service users face and thepotential benefits they would gain

from early AHP interventions, are inthe best position to carry out this vitaltask in their own localities and to workwith local partners to pilot andintroduce change.

The action planThis three-year action plan provides a blueprint for maximising the AHPcontribution to supporting people withmental health problems of all ages,both within mental health services andin mainstream settings. It providesstrategic direction for AHPs in mentalhealth and is designed to promotetheir contribution to the modernisationof mental health services in Scotland.

The action plan’s primary aims are to:

• enhance timely access to AHPservices for service users and carers

• explore and develop the concept of supported self-management forservice users and carers

• promote recovery and strengths-based approaches

• develop partnerships with serviceusers and carers, other disciplinesand agencies

• provide leadership for change• develop the evidence base for practice• promote mental health and

well-being among the population.

It strives to meet these aims through a series of recommendations fordelivery at national and local levels.The recommendations value thecontributions AHPs currently make,but also recognise the need fortransformation in the way theprofessions work to truly realise theirfull potential in improving mentalhealth and well-being. They are basedon what service users tell us worksbest for them and what they wantfrom AHPs. And they reflect importantnational policy objectives in terms of increasing quality, improving access, tackling inequity, promotingself-management and enablingindependence.

The action plan is structured aroundfive key areas in which AHPs can have

the most positive impacts and makethe biggest difference to service usersand carers:

• early intervention and timely accessfor service users and carers

• supported self-management andrecovery

• promoting physical health andmental well-being

• designing and deliveringpsychological interventions

• integrating vocational rehabilitationin mental health.

These areas have been identifiedfollowing interrogation of the evidenceand wide consultation and engagementwith key stakeholders – service usersand carers, AHPs, professionalorganisations, service managers andother professionals in health and socialcare. They build on the rich foundationof existing mental health policy andlegislation in Scotland and reflect the well-recognised underpinnings of a quality mental health service – a service-user focus, partnership workingand an upstream, early-interventionsapproach to promoting meaningfuland purposeful activity for people withmental health problems and their carers.

The action plan also addresses theunderlying infrastructure that isnecessary to drive high-qualitypractice – education and training,strong leadership, evidence-basedpractice and research.

Recommendations for action by NHS boards, AHP leaders and AHPs are presented. The implementation of these recommendations will mark a very positive step in the quest tomodernise AHP services to ensureperson-centred, recovery-based andstrengths-focused services for serviceusers and carers.

The processes of the action plan’screation are described in Appendix 1and the membership of the NationalAHP Mental Health Action Group whooversaw its development is presentedin Appendix 2.

PAGE 11

Moving forwardThe development of this action planhas followed an inclusive process that has been informed by the views,perceptions and aspirations of keystakeholders. I would like to thankeveryone who has contributed, inparticular the National AHP MentalHealth Action Group and the AHPprofessional organisations whosupported its development.

AHPs should now use the action planto lead the reconfiguration of theirservices to promote greater efficiencyand productivity and better use ofresources by maximising the capacityand capability of the existing AHPworkforce.

There is wide confidence among the stakeholders involved in thedevelopment of the action plan thatimplementation of the recommendationswill result in material benefits for serviceusers and carers. But being confidentisn’t enough – we need proof. That’s whythe NMAHP Research Unit is developinga formal framework for measuringimpact which, in combination with theMental Health Benchmarking Projectand resources being produced by theMental Health Collaborative, willenable us to achieve the aims of thisaction plan over time.

Delivering for mental health (1) isdriving change in professional practicetowards the adoption of recovery,strengths-based and self-managementapproaches, and The healthcare quality strategy for NHSScotland (2)demands improved experiences forpeople accessing mental healthservices. The aspirations of these key initiatives dovetail precisely withAHPs’ ambitions for the people theyserve, and they are vividly expressed in the vision for services set out in thisaction plan, which I commend to you.

I hope you will be as inspired by theservice users’ stories on the DVD as I am, and I look forward to many more stories of service innovation andpersonal triumphs supported by theinterventions of AHPs across Scotland.

Jacqui LundayChief Health Professions Officer

PAGE 12

“ I have been using the mental health physiotherapydepartment at the hospital. My physical health hasimproved immensely ... I also sleep better. The moodelement of my illness is greatly helped with the weeklyroutine. I suffer less and [do]not [have] prolonged lows ... I knew previously what to do but could not put it fully into practice. ”

Service userExperience of physiotherapy

Section 1Context

PAGE 14

Mental health and policy inScotland

Mental health problems can affectanyone. Mental health conditions varyin symptoms and severity. Depressionand anxiety is most common, but manypeople live with severe and enduringmental illness, such as schizophrenia.Dementia is more common in olderpeople and numbers are increasing.Developments in mental health servicesmean more people now receivetreatment in the community.

Scotland has a rich policy and legislativeframework underpinning for mentalhealth services and the promotion of mental well-being. Underpinning the policy and legislative agenda is a recognition that mental healthproblems are more liable to ariseamong those who are socioeconomicallydisadvantaged, socially excluded and/or victim to discrimination or abuse.Policy to tackle inequality in Scotlandis set out in Equally well (3), the reportof the Ministerial Task Force on HealthInequalities.

Central to the development of mentalhealth services in Scotland is Deliveringfor mental health (1), which setsspecific targets for service deliveryand calls for whole-system change toenable services to provide recovery-orientated and person-centred careand to support people to manage their own care and carry out everydayactivities.

The “refresh” of Delivering for mentalhealth currently taking place will buildon the original policy statement tofocus on:

• increasing access to psychologicaltherapies

• improving access to child andadolescent mental health services

• rolling out integrated care pathwaysand the National BenchmarkingProject

• promoting improved service userexperiences.

The Scottish Government is committedthrough Towards a mentally flourishingScotland (4) to ensuring appropriateservices are in place to promote goodmental health and to embed mentalhealth improvement in all NHS activity.The healthcare quality strategy forNHSScotland (2) aims to deliverservices around individual preferencesand requirements with a focus onsupporting people to manage theirown conditions, increasing theeffectiveness of care and treatmentand making patient experiences andoutcomes integral to services.

This three-year action plan reflects thefocus of these key policy initiatives andothers, such as Scotland’s nationaldementia strategy (5), Co-ordinated,integrated and fit for purpose: thedelivery framework for adultrehabilitation in Scotland (6) and arange of initiatives being carried out in Scotland on developing child andadolescent mental health services.

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Allied health professionals in mental health

Mental health care is changing, with an emphasis on shifting the balance of care from hospital to communityand the promotion of recovery-focusedand strengths-based approaches. This has led to new ways of workingfor the mental health workforce.

There is currently no detailed analysisof the AHP workforce in mental health,although the Scottish Government is performing a scoping exercise toidentify workforce characteristics inpartnership with NHS Education forScotland (NES). This is expected toreport in Autumn 2010.

The whole AHP workforce in Scotlandhas increased from 8,277.2 whole-timeequivalents (WTE) in 2004 to 9,242.8WTE in 2008 (an 11.7% rise) (7). Keyworkforce issues for AHPs in Scotlandinclude a need for more detailedworkforce data, challenges in capacity-building and succession planning insmall professions and issues in remoteand rural NHS boards (7).

All AHPs, regardless of profession ortheir area of work, have an importantcontribution to make in promotingmental health and well-being andpreventing mental health problems in the populations they serve. That contribution is both valuable, and valued.

Some, however – those referred to in this action plan as “AHPs in mentalhealth” – have, by virtue of their pre-registration preparation or the focus of their practice, a particular locus in providing mental health services.These AHPs work in core mental healthservices and are: those providing artstherapies; dietitians; occupationaltherapists; physiotherapists; andspeech and language therapists (see Table 1). It is fully acknowledged,however, that other AHPs, such aspodiatrists, also make a valuablecontribution to mental health servicesthrough promoting positive mentalhealth and providing direct services.

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Table 1.AHPs in mental health

Arts therapies (art therapy/art psychotherapy* / dance movement psychotherapy** /dramatherapy / music therapy)

Postgraduate qualified psychological therapists who engage with arts activitiesaimed at promoting creative expression and understanding in the context of a therapeutic relationship. Practitioners combine knowledge of their relevant art form (art, dance−movement, drama, music) with knowledge and practice ofpsychotherapeutic techniques which both contain and give meaning to serviceuser experiences and communication. Working with therapists who have expertisein the use of creative media offers service users opportunities to explore verbaland non-verbal material at different levels.

Dietitians

Translating the science of nutrition into practical information about food.Working with people to promote nutritional well-being, prevent food-relatedproblems and treat disease.

Occupational therapists

Emphasising the relationship between occupation, mental health and well-being.Working with service users and carers to develop and maintain a personallysatisfying routine of everyday activities that creates a sense of purpose anddirection to life. Typically, looking at service users’ self-care, leisure and workactivities and the individual’s hopes and aspirations.

Physiotherapists

Using physical approaches to promote, maintain and restore physical,psychological and social well-being, taking account of variations in health status.

Speech and language therapists

Providing detailed assessments of communication skills, difficulties and needs to inform multidisciplinary diagnosis. Developing directly and indirectly deliveredprogrammes for individuals to reduce the mental health impact of communicationimpairment. Advising and supporting others to deliver communication accessibleservices throughout the length of the care pathway. Assessing eating, drinkingand swallowing difficulties and developing programmes to overcome or minimisetheir impact.

* Art therapy/art psychotherapy are synonymous protected titles

** Dance movement psychotherapy is proposed to join the arts therapies part of the Health Professions Council.

The above definitions are provided in agreement with the professional bodies: detail of each profession’scontribution can be accessed via the web links at Appendix 3.

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“ I feel that I now have the information and knowledge that I need to makehealthy choices and changes to my diet. ”

Service user Experience of dietetic services

Like other mental health practitioners,AHPs in mental health treat individualsof all ages in a range of clinical settings.Their skills and expertise, providedwithin team approaches to servicedelivery, help people recover from, ormanage, their mental health problems.

Rehabilitation skills are core to theservices provided by all AHPs in mentalhealth – indeed, this can be consideredthe main contribution of AHPs to mentalhealth services. Their rehabilitationorientation enables them to focusbeyond symptoms to:

• promote psychosocial function and social inclusion

• support emotional, spiritual andphysical well-being

• respect diversity and choice and the absolute right of the individual to self-determine

• focus on what a person can do,rather than what he or she cannot (a strengths-based focus)

• work collaboratively with serviceusers and carers.

Numbers employed and skill mixesvary across the professions, withoccupational therapists currently beingby far the largest single discipline.Occupational therapists and artstherapists are specifically trained in thefield of mental health on registrationand have a long tradition of working inmental health, while others are newerto the field. They work as part ofmultidisciplinary and multiagency

teams, sometimes in small teams,sometimes as sole practitioners, and sometimes on a sessional basis.Some mental health services, however,have little or no AHP resource.

To maintain current roles and toextend AHPs’ contribution, sharingtheir expertise and increasing theiravailability, there is a need to consider:

• where AHPs make the greatest impact• which professional has the appropriate

competencies and is therefore bestplaced to provide interventions.

One way forward is for AHP services to outline their core contribution as either “direct service provision” (the highest proportion of AHPcontributions in the current workforceare delivered through direct serviceprovision), a “partnership-working”role or as providing a “consultancy”function. Table 2 illustrates these three different ways AHPs in mentalhealth can work.

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Table 2.The ways AHPs work

Direct service provision

AHPs working directly with service users and the families, individually or with a group, offering specialist professional assessment and intervention. All AHPsshould operate at this level, which represents the greatest proportion of the AHP contribution.

EXAMPLES: occupational therapist and physiotherapist in a community mentalhealth team; art therapist in a forensic medium secure unit.

Partnership working

AHPs working in partnership with others, combining the skills of the respectivepartners/teams to the benefit of service users. Most AHPs operate at this levelbut there will be differences in the volume of partnership-working amongprofessions.

EXAMPLES: social skills group with a speech and language therapist and amember of nursing staff; AHPs working with voluntary sector support staff.

Consultancy

AHPs working in a consultancy capacity, offering advice, supervision andtraining for staff, service users and/or carers.

EXAMPLES: care home staff developing activities with occupational therapistand music therapist supervision; dietitians setting up nutrition links in an acutesetting; dramatherapist offering group supervision to colleagues.

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Realising the potential of theentire AHP workforce

As Table 2 shows, the AHP workforcehas the capability not only to provideservices directly, but also to work in partnership with other disciplinesand to provide consultancy services.But there are questions around thecapacity of the AHP workforce to meetongoing service demand. Increasingly,therefore, AHPs will need to considereffective ways of building the capacityof the workforce. This will include:

• skilling-up the AHP support workerworkforce in clearly identified areasto ensure that service user and carerneeds continue to be met, particularlyin relation to direct service provision

• more effective use of partnershipworking and consultancymethodologies to avoid the pitfalls of professional dependency amongservice users and promote the chancesof individuals appropriately exitingthe mental health system to pursueindependent lives.

The forthcoming report on the AHP workforce in mental health,arising from the Scottish Governmentand NES scoping exercise referencedabove, will underpin future work toprogress this agenda.

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“ Going to the rock climbing group helps me to tellmy story − and there is a happy ending ... I knowthat I am not at the end yet because I still sufferfrom mental ill health but I know that I am on theright track. If I didn’t have the rock climbing group, I don’t know where I would be at this moment intime. It’s done so much for me. My hope for thefuture is to be mentally well enough to go back tocollege and get myself a good career. The rockclimbing group I see as a major part of that ... it isnot so much a physical exercise − it’s thepsychological benefit that you get from it, thepositive you take away ... I plan to carry that on in all aspects of my life until I do get well enough[and] can take on the world on my own. ”

Service user

Section 2The way forward

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Early intervention and timelyaccess for service users andcarers

Experience across a range of healthsettings suggests that for somepeople, early access to services resultsin better outcomes. Developing systemsto ensure timely access to AHPs forservice users and carers, particularlyduring the transition from hospital careto the community, is therefore likely to result in outcomes that are bothclinically and cost effective.

Despite this, service users and carers in the focus groups convened to supportthe development of this action plansaid that AHP services are actuallydifficult for them to access. They spokeof the challenges of navigating complexsystems and “having to jump throughhoops” before getting to the professionalthey needed to see.

It should therefore be a key aspirationthat services strive, wherever possible,to enable AHPs to facilitate access anddeliver early interventions as close aspossible to people’s homes, promotingrecovery and enabling individuals toself-manage their conditions.

Early AHP interventions that focus on physical and emotional health and well-being should form part of a recognised care pathway both forthose with mild-to-moderate mentalillness and those with severe and/orcomplex mental health problems, suchas dementia. Current referral pathwaystend to avoid direct referral to AHPs,instead taking a route via mentalhealth teams. While this is a well-established referral route, additionalevidence-based models of serviceprovision to enable direct access for service users and carers to AHPsand increase treatment options forgeneral practitioners (GPs) should be developed.

AHP services need to be reconfiguredto provide interventions in differentlocations and at different times.

This calls for:

• a review of the potential for triage• development of fast-track access• the use of technology, such as

tele-health, to improve access, offerinformation and provide treatmentfor people currently not accessingservices.

It is important to stress, however, that no profession has a monopoly of knowledge in mental health. Early interventions from mental healthservices work best for service usersand carers where a strong team andpartnership ethos exists and whereteam members respect each others’contributions, support each others’interventions and communicateeffectively with colleagues in diversesettings and agencies. It will be vitalfor the successful transformation ofthe roles of AHPs in mental health,particularly in primary care settings,that they adopt an integrated,partnership approach to team working,developing new, whole-systems ways of working that can be implementedacross service boundaries.

RECOMMENDATION 1

NHS boards should fully engageAHPs in leading the rehabilitation of people with mental healthproblems, developing new models,systems and ways of working tofacilitate early intervention andtimely access for service users andcarers.

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RECOMMENDATION 2

AHP mental health leads, workingwith AHP leads in community healthpartnerships (CHPs), shouldpromote an integrated approach toservice delivery by encouragingcollaborative working betweenprimary care services and AHPs inmental health and by linkingspecialist, community and socialcare AHP teams to ensure integratedservices and smooth transitionsbetween services for service usersand carers.

Supported self-management and recovery

Self-management is where:

“…the person and all appropriateindividuals and services [are] workingtogether to support him or her to dealwith the very real implications of livingtheir life with one or more long termcondition ... [it is] a person-centredapproach in which the individual isempowered and has ownership overthe management of their life andconditions (8).”

Self-management is the responsibilityof individuals, but it does not mean goingit alone. It is about working together.

Successful self-management relies on people having access to the rightinformation, education, support andservices. It depends on a person-centred, empowering approach inwhich the individual is the leadingpartner in managing his or her own life and condition(s).

AHPs’ contribution to self-managementin mental health is underpinned byknowledge about health behaviourchange. It consists of a range ofapproaches that support health-promoting behaviours, such as providingappropriate information, maintainingsocial connections, maximisingemployment and/or educationopportunities and making connectionsbetween physical, emotional, spiritual,social and economic well-being.

This means respecting the livedexperience, working with individualpreferences and balancing risks so thatthe service user remains integratedwithin the community, is sociallyincluded and has a repertoire ofknowledge and skills to self-managehis or her condition(s) and live well.

All services need to take advantage of existing and new approaches tocommunication technology to ensurepeople have access to the informationand advice they need when they needit, and to support them to maintaintheir health, manage ill health andmake decisions. NHS 24 has a key role in offering information to supportself-management, delivering effectiveevidence-based triage and providinginnovative tele-rehabilitation. It iscurrently developing a strategicapproach to mental health that willinvolve contributions from AHPs,including the employment of an AHPDirector, and will be reviewing thepotential of AHPs in mental health in offering rehabilitation advice, tele-rehabilitation and triage.

The Scottish Government will support theimplementation of a self-managementapproach by AHPs in mental health.Impact evaluation linked to nationalbenchmarking indicators will beundertaken.

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The focus on recovery in mental healthservices involves supporting people to be active in managing their ownhealth care and carrying out everydayactivities, even in the face of ongoingsymptoms.

Recovery is defined by the ScottishRecovery Network as an individual:

“ ... being able to live a meaningful and satisfying life as defined by eachperson, in the presence or absence of symptoms ... [and] having controlover and input into [their] own life”.1

The Scottish Recovery Indicator tool(Box 1) clarifies services’ progresstowards a recovery focus. It helps toidentify the cultural and therapeuticenvironmental change required tofoster a strengths-based approach inwhich hope, self-awareness, respectand understanding are the servicenorm, and not the exception.

The AHP community has embraced the principles of recovery. AHPs haveworked with colleagues and agenciesto develop recovery practice in NHSboards, sometimes taking the lead role in developing recovery servicesand creatively implementing recoveryprinciples. This needs to be featured in all AHP practice in NHSScotland.

BOX 1 Scottish Recovery Indicator (SRI) tool (9)

This tool, developed by the Scottish Recovery Network, enables services togauge their recovery focus in relation to a range of criteria, highlightingissues in relation to inclusion, rights, equalities and diversity. The toolrequires information to be gathered from a variety of sources and for serviceusers, carers and staff to be involved in assessing the service. Indications arethat the SRI is a helpful tool that allows mental health workers to reflect ontheir practice, identify good practice within their own service and highlightareas for development. For more information, access:http://www.scottishrecoveryindicator.net/

1 Access at: http://www.scottishrecovery.net/What-is-Recovery/what-is-recovery.html

RECOMMENDATION 3

AHP services in mental health willuse the Scottish Recovery Indicatorstool as part of team approaches toservice delivery to promoterecovery-orientated services byJune 2011.

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Promoting physical healthand mental well-being

Improving the physical health ofpeople with mental illness is a keycommitment for the ScottishGovernment and those deliveringmental health services (10). Evidencedemonstrates the link betweenphysical activity and improved physicaland mental health. The benefits ofphysical activity and keeping fit arealso recognised by the NationalInstitute for Health and ClinicalExcellence (NICE) (11) as a healthimprovement intervention in olderpeople, and a recent ScottishIntercollegiate Guidelines Network(SIGN) guideline (12) recommendsphysical activity as a first-line approachto tackling depression. There is alsoevidence for the benefit of physicalactivities and arts therapies asinterventions for the treatment andmanagement of schizophrenia inadults (13).

The Scottish Government, in partnershipwith NHS Health Scotland and NES, willcomplete by the end of 2010 a mappingexercise of health improvement activitiesin Scotland for those experiencingsevere and enduring mental illness.

The focus is on smoking cessation,weight management and physicalactivity interventions and initiatives.AHPs in mental health will be integralto promoting health-related behaviours,including increasing physical activity andadopting healthy diets and lifestyles.

Physical activity

Patients with severe mental illnesshave disproportionately high levels of physical health problems such asdiabetes, hypertension and coronaryheart disease (14, 15). Prematuremortality rates are 2.5 times higherthan that of the general population,with the average age at death being10−20 years younger. Physical healthproblems are likely to be related to

modifiable lifestyle factors such as lowphysical activity, poor diet, substancemisuse and smoking (16).

AHPs deploy psychological approachesto help people understand theconnections between physical healthand mental well-being. They useclinical skills such as health behaviourchange and motivational interviewingto enable people to engage withphysical activity opportunities. Some are trained in both physical andmental health care and can effectivelymanage the often complex presentingconditions in this population.

Focus groups with service-users confirmthat being physically fit and active isimportant to them. Recent research,however, identifies potential barriers to the uptake of physical activity forservice users experiencing schizophreniaand living in the community (17),including:

• limited experience of physical activity• the impact of illness and medication

effects• anxiety and the influence of support

networks.

Specialised, tailored AHP interventionscan help service users and carersovercome the barriers they face,supporting gradual transition to, anduptake of, mainstream leisure, sportand outdoor services.

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RECOMMENDATION 4

AHP mental health leads shouldensure the provision of evidence-based, socially inclusive andaccessible physical activityrehabilitation programmes forservice users and carers.

“ Music therapy helps me [to be] free and ... to express myself without havingto talk. ”

Service user Experience of music therapy

Diet and nutrition

Good nutrition is central to physicaland mental health and well-being andhas a key role in prevention, treatmentand recovery from mental illness.

Food affects mood, behaviour and brainfunction and the significance of diet in depression is becoming increasinglyrecognised (18). Some medicines usedin the treatment of mental illness canadversely affect metabolism, appetite,food choice and swallowing function.There is an association betweennutritional status and cognitive functionin older people, exacerbated by thechewing and swallowing difficultiescommon in this age group.

AHPs have a vital role in assessingservice users’ eating behaviours andsupporting them to improve nutritionalintakes, often working together toprovide education and practical advice(such as developing cooking skills andadvising on diet modification for peoplewith dysphagia, for instance). Regulardetailed nutritional assessment withappropriate interventions is necessary.

Valuing everyday activities

There is a well-established relationshipbetween occupation (everydayactivities), health and well-being.Maintaining a personally satisfyingroutine of activities that have meaningand value for the individual providesstructure to the day and creates a sense of purpose and direction. The need to be active does not diminishwith age, but the common effects ofphysical and mental ill health can affectan individual’s ability to participate inactivities. If an individual experiencesdisruption to fulfilling daily routines, or has access to a limited range ofactivities, their overall physical andpsychological health is likely to beaffected.

AHPs have the relevant knowledge and skills to support people to becomeinvolved in a range of individuallyvalued activities. AHPs assess andprovide information and advice tosupport involvement in occupational,leisure and everyday activities thatenhance health and well-being, usingmodels of change to support anybehavioural modifications required.They work with individuals to overcomephysical, psychological, social andenvironmental barriers to participation.

The report Remember I’m still me (19)highlighted the lack of meaningfulactivities for residents of care homes,despite the fact that research hasshown that engaging people withdementia in activities tailored to theircapabilities, with carers trained in theirapplication, results in clinically relevantbenefits to both the people withdementia and their carers (20).Therapeutic activities ranked highestby service users are social andcommunity participation, physical andcreative activities and activities ofdaily living, the last of whichemphasises the need for meaningfulactivity that is focused on everydaytasks (21).

RECOMMENDATION 5

AHP mental health leads shouldensure regular nutritional screeningis available to service users at eachstage of their care journey, withnutritional services working closelywith specialist AHPs.

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Socially inclusive practice

Wherever possible, delivery of physical health and mental well-beinginterventions should be carried out inline with social inclusion policy directives.There is strong evidence to supportthe value of enabling and supportingservice users to access mainstream localfacilities, strengthening their sense ofcommunity and reducing social isolation.

Much AHP work takes place in non-health facilities such as community and leisure centres. AHPs need tocontinue to build networks with third sector organisations to securesupportive pathways to social inclusionin the community for service users.

RECOMMENDATION 6

AHP mental health leads shouldwork with partners to promote andenhance the provision of evidence-based, socially inclusive andaccessible therapeutic activityprovision in a range of settings.

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Designing and deliveringpsychological interventions

Psychological therapies2 have beendefined as:

“... a range of interventions, based onpsychological concepts and theory,which are designed to help peopleunderstand and make changes to theirthinking, behaviour and relationships inorder to relieve distress and to improvefunctioning. The skills and competenciesrequired to deliver these interventionseffectively are acquired throughtraining, and maintained throughclinical supervision and practice” (22).

NHS Education for Scotland (NES) has developed a “matrix” to guide the delivery of evidence-basedpsychological therapies in Scotland (22).The matrix recognises that the deliveryof psychological therapies within NHSboards is complex. It defines therapiesat “highly specialist”, “high-intensity”and “low-intensity” level and emphasisesthat the interventions need not bedelivered by a psychologist: indeed,the engagement of the whole of themental health workforce in deliveringpsychological therapies will be necessaryto achieve the delivery targets beingset out in the “refresh” of Delivering for mental health (1).

The challenge for services is to utilisethe AHP staffing resources at theirdisposal to deliver a range of evidence-based psychological interventions andto maximise AHPs’ potential to promotebetter outcomes for service users andcarers. The challenge for AHPs is toclearly articulate their contribution todelivering psychological interventionsand actively engage in local psychologicalforums and strategy groups, working in partnership with NES psychologicaltherapies coordinators.

AHPs’ core psychosocial skills are uniqueto each profession and vary accordingto undergraduate education andpostgraduate development activity.AHPs nevertheless contributesignificantly to the national psychologicaltherapies agenda by enabling serviceusers and carers to have a choice ofevidence-based, non-pharmacologicaltherapies. AHPs can work at all levelsof the psychological therapies matrixwhile continuing to provide specialistAHP rehabilitation interventions to promote health and well-being,integrating recognised psychologicalinterventions3 into their core practiceand/or directly providing a psychologicaltherapy.4

2 The terms “psychological therapies”, “psychological interventions” and “psychosocial therapies orinterventions” tend to be used interchangeably in the literature.

3 Psychological interventions include: motivational interviewing, anxiety management, cognitive rehabilitation,behavioural activation, problem-solving therapy, mindfulness-based cognitive therapy, and cognitiverehabilitation.

4 Psychological therapies include: using art, music, drama, dance–movement therapies; accredited cognitivebehavioural therapy or interpersonal psychotherapy.

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RECOMMENDATION 7

NHS boards should ensure thedelivery of evidence-basedpsychological interventions byappropriately trained AHPs tosupport rehabilitation, self-management and recoveryapproaches as part of local deliverystrategies.

Whatever the background of the AHP,a “best fit” should be found betweenservice user and carer requirementsand the skills and competencies of theAHP, ensuring service users maintainaccess to specialist AHP skills andinterventions. The key issue is that anyAHP who is delivering psychologicaltherapies at any level should be properlytrained and should have access toappropriate ongoing supervision.

Continuing professional development(CPD) opportunities in psychologicaltherapies should reflect the core skills of the AHP profession and the clinicalneeds of the service as a whole. They can range from learning activityaround brief interventions, to trainingon the implementation of a particulartechnique, to highly specialisedprogrammes in specific therapeuticmodalities. Theoretical CPD activity

must be supported by work-basedsupervision and practice.

There is also a requirement for those who practice an accreditedpsychological therapy as a primaryrole to have supervision from anaccredited psychological therapiessupervisor, ensuring supervisorycontracts and protected time are inplace to support staff governance,clinical governance and effectiveness.

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RECOMMENDATION 8

AHP mental health leads shouldensure that AHPs in mental healthwho deliver psychologicalinterventions as a primary role have access to clinical supervisionwithin protected time.

Integrating vocationalrehabilitation in mentalhealth

Well-managed work opportunities canbenefit personal and family health andplay a positive role in supporting anindividual to increase his or her senseof well-being. In the focus groupscarried out as part of the consultationto inform the development of thisaction plan, service users and carerssaid that they look to AHPs to providethe support to enhance their workopportunities as means of promotingsocial engagement, achieving personalaspirations, raising self-esteem andsocial stature and providing financialsecurity.

There are, however, many barriers toemployment for people with mentalhealth conditions. These include lowexpectations for work, exclusion fromthe wider community, stigma and theenduring effects of symptoms. Despitehigh proportions of people with a long-standing mental illness saying theywould like to work, the proportionemployed is low.

People with a mental health conditionneed to be enabled to access and sustainemployment through coordinated,tailored support. The Governmentrecommends a framework for changeto the way individuals with mentalhealth problems are supported toachieve their vocational potential.

It is not the remit of this action plan to propose the way forward for welfareto work: rather, the aim is to highlightthe unique contribution AHPs in mentalhealth can make to ensuring work is a positive outcome of rehabilitation,building on the strong strategic drivein mental health services to providebetter opportunities for service usersin employment and vocational activities.

Developments in promoting thecontributions of AHPs in mental healthto vocational rehabilitation will reflectand complement actions being takenforward under Co-ordinated, integratedand fit for purpose: the deliveryframework for adult rehabilitation inScotland (6) and specific initiativesbeing developed for people with long-term conditions and adolescents.

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“ [Using movement to look at some of thepsychological trauma of her past] is thebest thing that has ever happened to me.I used to just lie about on my couch, Iwouldn’t want to go out the house … Iwouldn’t get dressed, I wouldn’t put mymake-up on or do my hair ... then I got [a student dance−movement therapist]and she has changed my life … ”

Service user Experience of dance−movement psychotherapy

Promoting the aspiration to work

AHPs have an opportunity to take a lead on improving employmentoutcomes for service users throughvocational rehabilitation. AHPs,working with fellow members of themultidisciplinary, multiagency team, can:

• explore work issues at all initialassessments with service users andfocus the goals of interventions,where appropriate, on return to work

• act as brokers between employersand those in the early stages ofaccessing mental health services

• promote work as a means of recoveryfrom mental health problems

• provide specialist vocationalrehabilitation within clinical teams.

Skills for work

The action plan supports the SainsburyCentre principle that people are “job-ready” when they say they arejob-ready (23) and that the focusshould be on competitive employment.For those with long-term conditions,young people and those with no recentemployment or work skills, AHPs shouldprovide support to help individuals setgoals and learn new skills that will buildconfidence and aspirations. For peoplewho do not see themselves as readyfor work or for whom the IndividualPlacement and Support (IPS) model(see below) has not been available,there should be a range of workrehabilitation options.

AHPs must continue to offer a serviceto people who are unable to engage in paid employment or are not work-ready, but who seek voluntary work or education and training. AHPs have a responsibility to extend the scope oftheir practice across a range of agencies,including local authorities and educationand training providers, to facilitateexperiences of work for this group.

RECOMMENDATION 9

AHPs in mental health, working froma recognition of the importance ofwork in promoting recovery, shouldexplore work issues at all initialservice-user assessments andprovide ongoing signposting orsupport to increase service users’potential for work.

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RECOMMENDATION 10

AHP mental health leads shouldwork with key stakeholders toensure the provision of alternativeoccupational, leisure andeducational activities for serviceusers whose vocational goals arenot employment-focused.

Vocational rehabilitation

Vocational rehabilitation is defined as:

“... a process that enables people withfunctional, psychological, developmental,cognitive and emotional impairmentsor health conditions to overcome barriersto accessing, maintaining or returning toemployment or other useful occupation.The emphasis is on restoration offunctional capacity for work or otheruseful occupation rather than treatmentof a clinical condition” (6).

In short, the outcome of vocationalrehabilitation is work, paid or unpaid.

Models for vocational rehabilitationinclude:

• the Working Health Services Scotlandprogramme (funded through theDepartment for Work and Pensions)which, while not exclusive to mentalhealth, incorporates cognitivebehavioural therapy (CBT) principles,biopsychosocial principles, access to occupational therapy andphysiotherapy services, standardisedclinical assessment tools and anegotiated action plan

• Individual Placement and Support (IPS),an evidence-based mental health modelfor individuals who are work-ready: the principle is “place, then train”,with strong evidence that individualplacement and support is the mosteffective method of helping peoplewith severe mental health problemsto achieve sustainable competitiveemployment − IPS is successful forapproximately 60% of service users.

There are many excellent examples of AHPs developing local initiativesand working with partner agencies. It is essential for AHPs, working withNHS board rehabilitation coordinators,to ensure that people with mentalhealth problems have access to theright vocational rehabilitation support, in the right place, at the right time.

The Scottish Government hascommissioned a review of currentmodels of vocational rehabilitationused by AHPs in mental health and will produce national guidance byspring 2011.

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“ My future is looking really ... it’s bright as the sun because I’ve been given a new house,[which has] taken me away from the area I was in. I’ve got a house that has just beenbuilt and it’s got everything in it. ”Service user

Section 3Support for change:making it happen

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National, regional and local supportfrom AHPs and a number of keystakeholders is required to enhancethe capacity and capability of AHPs in mental health to deliver therecommendations in this action plan.This support is described below.

Workforce dev elopment

Workforce informationAHPs need to understand workforceand workload methodologies and usethem to demonstrate their impact andmaximise their potential. They should be able to articulate the differencethey make to a wide range of serviceuser pathways, ensuring best value andhighest quality care. The Six steps tointroducing a structured approach toworkforce planning resource (24) can be used to support AHP services todevelop and deliver evidence-basedworkforce plans.

The Scottish Government scopingexercise to identify workforcecharacteristics mentioned previouslywill contribute specific mental health-related data to inform workforceplanning for the future.

Pre-registration trainingThe Scottish Government, inpartnership with NES, is scoping thefour Scottish universities who educateAHPs to review pre-registration AHPcurricula for evidence of mental healthfieldwork and academic learningrequirements across mental healthspecialties (children, adolescents,adults and older adults). This will becompleted by autumn 2010, withrecommendations to follow.

Ongoing learningAHPs have a professional responsibilityto pursue ongoing learning activity toretain their capacity to practise safely,effectively and legally within theirevolving scope of practice.

AHPs in mental health must continueto access regular profession-specificsupervision in individual or facilitated-group settings, and are expected to:

• receive clinical supervision from a trained clinical supervisor withinprotected time

• be trained as clinical supervisors • evaluate the effectiveness and

impact of the supervision provided.

Work-based learning opportunities are being supported through the AHP practice education facilitationprogramme supported by NES.5In addition, The Ten Essential SharedCapabilities (ESCs) should be integral to training, induction and ongoinglearning of all AHP professionals andsupport staff (see Box 2).

BOX 2 The Ten Essential Shared Capabilities

The Ten Essential Shared Capabilities (ESCs) (25) set out shared capabilitiesthat all staff working in mental health services should achieve as best practice.The principles have been supported by AHPs in Scotland and have beenadopted by the College of Occupational Therapists (COT) and the CharteredSociety of Physiotherapy (CSP) as their underpinning values. They are nowbeginning to integrate them into their accreditation and re-accreditationprocesses.

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5 Access at: http://www.nes.scot.nhs.uk/allied/projects/facilitators/default.asp

What is not yet clear is the traininginfrastructure required to supportservice change and developing AHProles in mental health. A range of CPDopportunities enabling AHPs to delivereffective treatment interventions needto be available: these should focus onprofession-specific specialist fields,recovery and ESC training, self-management, psychological therapiesand vocational rehabilitation.

The Scottish Government, in partnershipwith NES, will review NHS boards’current and future workforce educationpriorities for AHPs in mental health toensure synergy with the proposed servicedelivery changes. Recommendations willbe produced by autumn 2010.

First graduate postIt is essential that there is support forall newly qualified AHPs who specialisein mental health, ensuring engagementwith Flying Start NHS,6 supervision androtation opportunities. This will alsohave a positive impact on recruitmentand retention of staff.

LeadershipAHPs of all grades need leadershipskills to meet the service change agenda.A range of leadership programmes areavailable in NHSScotland for AHPs inmental health, and AHP leaders andpractitioners should engage with theseprogrammes.

Leadership is critical for effectivechange. Effective leaders motivatestaff to perform optimally, enable team working and collaboration andcontribute to overall organisationaleffectiveness. The development of thisaction plan now offers the opportunityfor NHS boards and AHP directors toreview their current clinical leadershipstructures for AHPs in mental health tocomplement existing board leadershipstructures.

The Scottish Government will establisha national AHP mental health clinicalleaders’ group.

RECOMMENDATION 11

NHS boards and AHP directorsshould identify an AHP mental healthlead, developing a sustainableclinical leadership function thatreflects proposed service deliverychanges.

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6 Access at: http://www.flyingstart.scot.nhs.uk/

“ If I hadn’t started coming to see thespeech therapist, I reckon I’d just havestayed the same or worse. Coming to my sessions gets me out of the houseand interacting [and] I feel better when I leave, too. Talking with her makes iteasier to talk to others [and] it’s made it easier to communicate with the otherprofessionals I see. ”

Service user Experience of speech and language therapy

Geoff Wilson, RCSLT,library picture

Evidence-based practice andresearch

Good practiceThe development process for thisaction plan identified many excellentpractice-based and evidence-basedclinical examples which will bedeveloped as a supportive resource.The AHP community needs to shareand disseminate this good practicethrough online sources such aswww.enablinghealth.scot.nhs.uk andprofessional journals and webresources (see Appendix 3).

The newly formed clinical leaders’ groupmentioned above will set up a communityof practice in the Self-managementand Rehabilitation Managed KnowledgeNetwork (MKN), which connectsgroups, communities of practice andinterested individuals committed tosharing knowledge resources andexpertise specific to mental health.

Practice based on best evidenceThe Health Professions Council (HPC)expects all AHPs to base theirinterventions on the best availableevidence, which calls for AHPs toreview relevant research andimplement accordingly. Time andsupport must be available to ensureAHPs can reflect on their practice to deliver services based on bestevidence.

Outcomes and impactThe challenge for all services in mentalhealth is to develop a culture in whichdata are used to inform improvementwork. There is a need within mentalhealth services to improve the qualityof, and use of, information to driveservice improvement.

AHPs need to measure the outcomesand impact of their interventions usingstandardised assessments and measures.The Mental Health Collaborative,7Integrated Care Pathways in MentalHealth8 and the National BenchmarkingProject (26) allow AHPs access toimprovement methodologies andtechniques to deliver change andshould be utilised to support AHPsduring this period of transition.

AHPs also need to evidenceimprovements in the quality of theservice they deliver by demonstratingimprovement in outcomes. They shoulduse patient-reported outcome measures(PROMs) to monitor the patientexperience; these should be evaluatedand integrated into current practiceand service delivery. AHPs often usePROMs as an underpinning to theirassessment process (the Model ofHuman Occupation Screening Tool(MOHOST)9 and the CanadianOccupational Performance Measure(COPM),10 for instance). These are also often repeated on exit from theservice but are seldom aggregated to produce outcome data regardingservice impact.

RECOMMENDATION 12

AHPs should use informationgathered while providing AHPinterventions to evaluate the serviceuser experience, enhance theevidence base and improve servicesusing patient-reported outcomemeasures and standardisedassessments.

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ResearchAHPs have a growing internationalresearch base reflecting a mixture ofquantitative and qualitative researchactivity.

Consultant AHPs have a stronginfluence on the research agenda formental health AHP practice, with fournew AHP consultant posts having been created in Scotland. These postswill influence the research agenda fordementia care and forensic care andwill be integrated into the ScottishGovernment National Impact Frameworkto evaluate the impact of theconsultant role.

There are nevertheless gaps in thepractice and research agendas. Practiceand research need to be linked, withAHP practice being evaluated throughquantitative and qualitative researchmethods to build practice-basedevidence and evidence-based practice.

The Scottish Government will workwith the AHP research community toexplore how best to develop furtherresearch opportunities in AHP mentalhealth practice to contribute to thedevelopment of clinical guidelines andThe healthcare quality strategy forNHSScotland (2).

7 Access at: http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/Delivery-Improvement/1835/748 Access at: http://www.nhshealthquality.org/mentalhealth/projects/4/Integrated_Care_Pathways_(ICPs).html9 Access at: http://www.moho.uic.edu/assess/mohost.html10 Access at: http://www.caot.ca/copm/

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Section 4Delivering theaction plan

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The three-year action plan needs to be implemented locally but supportednationally. The AHP Adviser in theMental Health Division of the ScottishGovernment Health Directorates willprovide national support for theimplementation of the action plan, andan Implementation Board involving all keystakeholders and an AHP mental healthclinical leaders group will be set up.Three regional events will be held inautumn 2010 to enable local servicesto engage with the action plan.

But fundamentally, it is AHPs in NHS boards who will need to driveimplementation of the action plan. To facilitate this, AHP mental healthprofessional forums should continue to be developed and strengthened in each NHS board, in accordance with NHS board structures. Specificconsideration will be given to how this can be achieved in remote andrural boards. The forums need toreview their membership to ensure fullengagement with all key stakeholders,including service users, carers andcolleagues in social, acute and CHPservices, and that they are working in collaboration with local nursingimplementation forums for the reportof the national review of mental healthnursing in Scotland, Rights, relationshipsand recovery (27).

The action plan recommendations willbe an integral aspect of implementationreview visits to NHS boards by theScottish Government Mental HealthDivision, with a particular focus on earlyaccess, self-management, clinicalleadership and measuring outcomes todeliver effective services.

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Section 5Summary ofrecommendations

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RECOMMENDATION 1NHS boards

Should fully engage AHPs in leading the rehabilitation of people with mentalhealth problems, developing new models, systems and ways of working tofacilitate early intervention and timely access for service users and carers.

RECOMMENDATION 2AHP mental health leads, working with AHP leads in community healthpartnerships (CHPs)

Should promote an integrated approach to service delivery by encouragingcollaborative working between primary care services and AHPs in mental healthand by linking specialist, community and social care AHP teams to ensureintegrated services and smooth transitions between services for service usersand carers.

RECOMMENDATION 3AHP services in mental health

Will use the Scottish Recovery Indicators tool as part of team approaches toservice delivery to promote recovery-orientated services by June 2011.

RECOMMENDATION 4AHP mental health leads

Should ensure the provision of evidence-based, socially inclusive and accessiblephysical activity rehabilitation programmes for service users and carers.


Should ensure regular nutritional screening is available to service users at eachstage of their care journey, with nutritional services working closely withspecialist AHPs.


Should work with partners to promote and enhance the provision of evidence-based, socially inclusive and accessible therapeutic activity provision in a rangeof settings.

RECOMMENDATION 7NHS boards

Should ensure the delivery of evidence-based psychological interventions byappropriately trained AHPs to support rehabilitation, self-management andrecovery approaches as part of local delivery strategies.

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Should ensure that AHPs in mental health who deliver psychologicalinterventions as a primary role have access to clinical supervision withinprotected time.

RECOMMENDATION 9AHPs in mental health, working from a recognition of the importance of work in promoting recovery

Should explore work issues at all initial service-user assessments and provideongoing signposting or support to increase service users’ potential for work.

RECOMMENDATION 10AHP mental health leads, working with key stakeholders

Should ensure the provision of alternative occupational, leisure and educationalactivities for service users whose vocational goals are not employment-focused.

RECOMMENDATION 11NHS boards and AHP directors

Should identify an AHP mental health lead, developing a sustainable clinicalleadership function that reflects proposed service delivery changes.

RECOMMENDATION 12AHPs

Should use information gathered while providing AHP interventions to evaluatethe service user experience, enhance the evidence base and improve servicesusing patient-reported outcome measures and standardised assessments.

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“ [The day centre for older people] is agreat place for [my wife] ... She likes thecompany and she is very good at crafts …she gets a great help here and so do I, I get a tremendous help here from thewhole system. ”

CarerExperience of day care

The action plan –where now?

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A comment from the Chief Executiveof the National SchizophreniaFellowship (Scotland) and the VOX(Voices Of eXperience) DevelopmentCoordinator

The first thing to say is to congratulatethe Scottish Government on developingthis excellent three-year action plan. It reflects the fact that service users,families and carers see AHPs as a veryvaluable resource. We all want to seeaccess to AHPs enhanced and for morepeople to know what they can offer,and the action plan is very muchpushing in the right direction on thisissue, complementing developmentscurrently under way in NHS 24 toincrease AHPs’ triage and tele-rehabilitation capacity.

The action plan sits very well withother important pieces of work referredto in the main text that are supportingservice delivery and new developmentssuch as the “My View” service userself-assessment tool currently beingadapted by NHS Quality Improvementfor use in Scotland.

The creation of the action plan was avery inclusive process, allowing thoseon the receiving end of AHP services –service users, families and carers – tohave a real say in defining the prioritiesfor action. In focusing on issues suchas early interventions, timely access,self-management, the importance ofrecovery (and the SRI), good physicalhealth and meaningful (and appropriate)activity, it reflects the issues the peoplewe work with identify as being important.

But we would take this opportunity tosay to AHP managers and practitionerswho will be implementing the actionplan’s recommendations that in adoptingan understandable and very welcomeperson-centred focus on service users,don’t forget families and carers.

A workshop at the March 2010 nationalconference held as part of theconsultation on the development ofthe action plan asked AHPs to identifybenefits in working with families tosupport the service user. The AHPs wereable to present a long list of “pluses”relating to issues such as increasingservice user confidence, developingrelationships, providing more joined-upservices, reducing stress and enhancingcare package delivery. It showed thatAHPs know service users don’t live in a bubble, and that families and carersare central to their recovery.

But families and carers are alsopotentially vulnerable to the stressescaring brings and need effectivesupport from engaged and informedAHPs. We want to send a strong pleathat in taking this action plan forward,NHS boards, AHP leads and, mostimportantly, practising AHPs maintain a families and carers focus.

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We also want to stress that while AHPsin mental health are doing tremendouswork, supporting service users, familiesand carers is a responsibility for allAHPs, regardless of service setting. We regularly hear stories of how AHPsin so-called “mainstream” settings areproviding important interventions –dietitians working with service users tooffset the weight-gain problems commonwith anti-psychotic medication, forinstance. It is very pleasing to see thisimportant message being emphasisedin the action plan.

The involvement of all AHPs indelivering mental health interventionsalso improves the prospects of enhancingservice users’ abilities to providesupport to fellow service users throughpeer relationships – AHPs have all theskills needed to facilitate this excitingopportunity.

In uncertain financial times, using whatwe have better is a sensible way to go.We believe this action plan sets out aroute to using the AHP resource betterfor service users, families and carers,and we look forward to seeing its fullimplementation over the next three years.

Mary Weir, Chief ExecutiveNational Schizophrenia Fellowship(Scotland)

Wendy McAuslan, Development CoordinatorVOX (Voices Of eXperience)

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“ [The course] gives you a focus [on]something to do every week ... [it is]going to give [me] a qualification at theend to use and the support we get fromthe occupational therapists and theCollege is brilliant. ”

Service user

Appendices

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A National AHP Mental Health ActionGroup (see Appendix 2) was establishedin January 2009 with membership fromNHS boards, professional bodies,service users, carers and education. To engage local services, each NHSboard representative was invited toestablish local AHP meetings to ensurecoordinated service provision andsharing of good practice. Nine NHSboards have set up an integrated local forum.

A national think-tank day was organisedfor all AHPs in Scotland in September2009 to debate and focus on thenational action plan. This providedevidence of strong support from theAHP community for the work and thechange agenda to be progressed.

Scoping visits were completed in 2009in all 14 NHS boards and the specialboard providing clinical services. These visits highlighted examples of good practice and the added valueof the AHP, but identified the need for greater involvement in prevention,early intervention and the developmentof a national vision for AHPs.

Focus groups with service users andcarers were carried out in December2009/January 2010 to gain invaluableinsights into their experience of AHPs.Quotes from service users areincorporated in the document.

At the end of 2009, exemplars of goodpractice were sought from the AHPprofessions in Scotland and the responsewas very positive. These will be collatedand made available as a resource.

The action plan presents a supportingDVD. The DVD links policy to practicethrough demonstrating service users’lived experience of mental illness andhow their stories shape AHPs’ practice.

A national conference for serviceusers, carers, professional bodies,AHPs, AHP managers and servicemanagers took place on 24 March2010, with over 200 participants. Scenes from the DVD andrecommendations were shared at theconference.

Appendix 1How we got here: the process

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Aileen Fyfe NHS Ayrshire and Arran

Alison MeiklejohnNHS Lothian

Anne Joice Formerly AHP Scottish Universities

Anne SuttleNHS Borders

Audrey TaylorNHS Education for Scotland

Carolyn LittleNational Schizophrenia Fellowship(Scotland)

Catherine TottenCollege of Occupational Therapists

Cecilia ThompsonNHS Grampian

Claire RitchieRehabilitation Coordinator, NHS Lanarkshire

Elaine HunterAHP Advisor in Mental Health, Scottish Government

Francis FallanVOX (Voices Of eXperience)

Gill UrquhartThe State Hospital

Jacqui Terrance NHS Lanarkshire

Jane FletcherBritish Dietetic Association

John FultonRepresenting the four arts therapiesprofessional bodies

Kathryn ChisholmNHS Western Isles

Lorna Baxter NHS Orkney

Lorraine ParksNHS Tayside

Mike SkellyChartered Society of Physiotherapy

Morag Geddes NHS Dumfries & Galloway

Norma ClarkNHS Fife

Pamela McNairNHS Forth Valley

Prof Maggie NicolChair, National AHP Mental HealthAction Group

Rosalind JohnstoneChartered Society of Physiotherapy

Samantha FlowerNHS Greater Glasgow & Clyde

Sandra PoldingRoyal College of Speech and Language Therapy

Sarah Muir NHS Highland

Shelagh CreeganNHS Tayside

Susan Munro Royal College of Speech and Language Therapy

Tony CheneryRepresenting the four arts therapiesprofessional bodies

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Appendix 2National AHP Mental Health Action Group members

Arts therapies

The British Association of Art Therapists http://www.baat.org/

The Association for Dance MovementPsychotherapy UK http://www.admt.org.uk/index.html

The British Association ofDramatherapists http://www.badth.org.uk/

The Association of Professional MusicTherapists http://www.apmt.org/

The Scottish Arts Therapies Forumwww.satf.co.uk

Dietetics

British Dietetic Association http://www.bda.uk.com

British Dietetic Association Fact SheetsDiet and depressionhttp://www.bda.uk.com/foodfacts/090420Diet_Depression.pdfFood and moodhttp://www.bda.uk.com/foodfacts/070830FoodMood.pdfAutistic spectrum disorder and diethttp://www.bda.uk.com/foodfacts/0609Autism.pdf

British Dietetic Association MentalHealth Group http://www.dietitiansmentalhealthgroup.org.uk

MUST Nutritional Assessment Tool http://www.bapen.org.uk/must_tool.html

Occupational therapy

College of Occupational Therapyhttp://www.cot.co.uk

Recovering Ordinary Lives (the main mental health document for occupational therapists)http://www.cot.org.uk/Homepage/Library_and_Publications/College_publications/A_Z_listing/

Standards for Occupational TherapyClinical Practicehttp://www.cot.org.uk/Homepage/Library_and_Publications/College_publications/Standards_and_strategy/

Physiotherapy

Chartered Society of Physiotherapywww.csp.org.uk

Recovering Mind and Body (Framework for the Role of Physiotherapyin Mental Health)www.csp.org.uk/uploads/documents/scp_mental_health_framework_v3.pdf

Moving in Mind (the Role of Physiotherapy in MentalHealth in Scotland)www.csp.org.uk/uploads/documents (in print and available summer 2010)

The following web links provide more detailed information on the professions.

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Appendix 3Web links to AHP mental health resources

Speech and language therapy

RCSLT Position Paper on Mental Health Will be published soon (date not yetannounced) and will be accessible fromhttp://www.rcslt.org/

SIG Mental Health (Scotland)http://www.sltmentalhealthscot.site50.net/

RCSLT Clinical Guidelines includingsections on mental health and dysphagia http://www.rcslt.org/members/publications/clinicalguidelines

RCSLT Dementia Position Paper http://www.rcslt.org/docs/free-pub/dementia_paper.pdf

Dysphagia Negative HealthConsequences Risk Assessment Tool http://www.rcslt.org/news/events/NPSA_risk_assessment_document_-_Hannah_and_Karen.doc

RCSLT Adult Support and ProtectionCommunication Toolkithttp://www.rcslt.org/speech_and_language_therapy/Adult_Support_and_Protection_Communication_Toolkit

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“ My hopes for the futurenow are getting mylifeguard qualification,teaching qualificationsand anything that willenhance my chance of gaining employment− getting volunteeringopportunities, working in sportscentres ... just anything sports-related. ”Service user

1 Scottish Executive (2006) Delivering for mental health. Edinburgh, ScottishExecutive (http://www.scotland.gov.uk/Publications/2006/11/30164829/0).

2 Scottish Government (2010) The healthcare quality strategy forNHSScotland. Edinburgh, Scottish Government(http://www.scotland.gov.uk/Publications/2010/05/10102307/0).

3 Scottish Government (2009) Equally well: report of the Ministerial Task Force on Health Inequalities. Edinburgh, Scottish Government(http://www.scotland.gov.uk/Publications/2008/06/25104032/0).

4 Scottish Government (2007) Towards a mentally flourishing Scotland.Edinburgh, Scottish Government(http://www.scotland.gov.uk/Publications/2007/10/26112853/0).

5 Scottish Government (2010) Scotland’s national dementia strategy.Edinburgh, Scottish Government (http://www.scotland.gov.uk/Topics/Health/health/mental-health/servicespolicy/Dementia)

6 Scottish Executive (2007) Co-ordinated, integrated and fit for purpose: thedelivery framework for adult rehabilitation in Scotland. Edinburgh, ScottishExecutive (http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/adultrehabilitation/rehabframework).

7 ISD (2009) NHS allied health professions (AHPs). Report on the results fromthe AHP workforce model and feedback from boards. Edinburgh, ISD.

8 Long Term Conditions Alliance Scotland and Scottish Government (2008)Gaun Yersel. The self-management strategy for long term conditions inScotland. Edinburgh, LTCAS/Scottish Government (http://www.ltcas.org.uk).

9 NHS Education for Scotland/Scottish Recovery Network (2008) Realisingrecovery learning materials. Edinburgh, NES(http://www.nes.scot.nhs.uk/mentalhealth/publications/documents/13875-nes-mentalhealth-coverintro.pdf).

10 Scottish Government (2008) Mental health in Scotland. Improving thephysical health and well being of those experiencing mental illness.Edinburgh, Scottish Government(http://www.scotland.gov.uk/Publications/2008/11/28152218/0).

11 National Institute for Health and Clinical Excellence (2008) Occupationaltherapy interventions and physical activity interventions to promote themental wellbeing of older people in primary care and residential care.London, NICE (http://www.nice.org.uk/nicemedia/pdf/PH16Guidance.pdf).

1 2 Scottish Intercollegiate Guidelines Network (2010) Non-pharmaceuticalmanagement of depression in adults. A national clinical guideline (Guideline114). Edinburgh, SIGN (http://www.sign.ac.uk/pdf/sign114.pdf).

13 National Institute for Health and Clinical Excellence (2009) Schizophrenia.Core interventions in the treatment and management of schizophrenia inadults in primary and secondary care. Clinical guidance 82. London, NICE(http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11786).

14 Brown S, Inskip H, Barrowclough B (2000) Causes of excess mortality inschizophrenia. British Journal of Psychiatry, 177, 212−217.

15 Coglan R et al. (2001) Duty of care: physical illness in people with mentalillness. Perth, Western Australia, Department of Public Health.

16 McCreadie R (2003) Diet, smoking and cardiovascular risk in people withschizophrenia: descriptive study. British Journal of Psychiatry, 183, 534−539.

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References

17 Johnstone R et al. (2009) Barriers to uptake of physical activity incommunity-based patients with schizophrenia. Journal of Mental Health, 18(6), 523–532.

18 The links between diet and behaviour – the importance of diet in mentalhealth. Associate Parliamentary Food and Health Forum, January 2008.

19 Care Commission/Mental Welfare Commission (2009) Remember I’m stillme. Edinburgh, CC/MWC(http://www.carecommission.com/index.php?option=com_content&task=view&id=6927).

20 Gitlin LN et al. (2008) Tailored activities to manage neuropsychiatric behavioursin persons with dementia and reduce care giver burden: a randomized pilotstudy. American Journal of Geriatric Psychiatry, 16 (3), 229-239.

21 Torrington J (2009) The design of technology and environments to supportenjoyable activity for people with dementia. European Journal of DisabilityResearch, 3, 123−137.

22 NHS Education for Scotland (2008) Mental Health in Scotland. A guide todelivering evidence based psychological therapies in Scotland. “The Matrix”.Edinburgh, NES (http://www.nes.scot.nhs.uk/mentalhealth/work/documents/TheMatrix-final.pdf).

23 Sainsbury Centre for Mental Health (2009) Briefing 37: Doing what works.London, Sainsbury Centre for Mental Health(http://www.scmh.org.uk/pdfs/briefing37_Doing_what_works.pdf).

24 Skills for Health − Workforce Projects Team (2008) Six Steps methodologyto integrated workforce planning. Manchester, Skills for Health − WorkforceProjects Team(http://www.healthcareworkforce.nhs.uk/resource_library/latest_resources/six_steps_refresh.html).

25 Department of Health (2004) The Ten Essential Shared Capabilities – a framework for the whole of the mental health workforce. London,Department of Health/NHSU/Sainsbury Centre/NIMHE(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4087169).

26 Scottish Executive (2007) National Benchmarking Project − the NHSScotlandbenchmarking approach. Edinburgh, Scottish Executive(http://www.scotland.gov.uk/Publications/2007/04/02091848/0).

27 Scottish Executive (2006) Rights, relationships and recovery: the report ofthe national review of mental health nursing in Scotland. Edinburgh, ScottishExecutive (http://www.scotland.gov.uk/Publications/2006/04/18164814/0).

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This hour-long DVD looks in depth atservice user experiences and storiesand the impact of their diagnosis onthem, their families, social networksand the wider community. The clinicaljourney of the therapist is alsohighlighted, demonstrating theircreative partnership in the serviceuser’s journey.

The four stories focus on the keycontributions of AHPs as demonstratedin the action plan.

• “Support When you Need It” –supported self management andrecovery

• “Keeping Well” – promoting physicalhealth and mental well-being

• “Self Discovery and Skills for Living”– designing and deliveringpsychological interventions

• “A Meaningful Life” – integratingvocational rehabilitation in mentalhealth.

AcknowledgementsThe Scottish Government gratefullythanks:

• the service users, carers andprofessionals who took part

• Mindzmatter(www.mindzmatter.org.uk), who produced the DVD

• NHS Ayrshire & Arran, whocommissioned the DVD

Realising PotentialDeveloped in partnership with:


ISBN: 978-0-7559-8324-7






Realising potential

Realising potential A

n action p

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fessionals in m

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realising potential: an action plan for allied health

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