Transitions of care from child and adolescent mental health services to adult mental health services (TRACK Study) : a study of protocols in Greater London

Background: Although young people's transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) in England is a significant health issue for service users, commissioners and providers, there is little evidence available to guide service development. The TRACK study aims to identify factors which facilitate or impede effective transition from CAHMS to AMHS. This paper presents findings from a survey of transition protocols in Greater London. Methods: A questionnaire survey (Jan-April 2005) of Greater London CAMHS to identify transition protocols and collect data on team size, structure, transition protocols, population served and referral rates to AMHS. Identified transition protocols were subjected to content analysis. Results: Forty two of the 65 teams contacted (65%) responded to the survey. Teams varied in type (generic/targeted/in-patient), catchment area (locality-based, wider or national) and transition boundaries with AMHS. Estimated annual average number of cases considered suitable for transfer to AMHS, per CAMHS team (mean 12.3, range 0–70, SD 14.5, n = 37) was greater than the annual average number of cases actually accepted by AMHS (mean 8.3, range 0–50, SD 9.5, n = 33). In April 2005, there were 13 active and 2 draft protocols in Greater London. Protocols were largely similar in stated aims and policies, but differed in key procedural details, such as joint working between CAHMS and AMHS and whether protocols were shared at Trust or locality level. While the centrality of service users' involvement in the transition process was identified, no protocol specified how users should be prepared for transition. A major omission from protocols was procedures to ensure continuity of care for patients not accepted by AMHS. Conclusion: At least 13 transition protocols were in operation in Greater London in April 2005. Not all protocols meet all requirements set by government policy. Variation in protocol-sharing organisational units and transition process suggest that practice may vary. There is discontinuity of care provision for some patients who 'graduate' from CAMHS services but are not accepted by adult services

Working and learning across professional boundaries

This paper focuses on a context where interdisciplinarity intersects with interprofessionality: the work of children's services professionals who address the needs of children identified as vulnerable. It draws on evidence and perspectives from two disciplines - educational studies and health care - to consider the issues and challenges posed by learning and/or working across disciplinary boundaries and why these have proved so obdurate

Multidisciplinary teams, and parents, negotiating common ground in shared-care of children with long-term conditions: A mixed methods study

Background: Limited negotiation around care decisions is believed to undermine collaborative working between parents of children with long-term conditions and professionals, but there is little evidence of how they actually negotiate their respective roles. Using chronic kidney disease as an exemplar this paper reports on a multi-method study of social interaction between multidisciplinary teams and parents as they shared clinical care. Methods. Phases 1 and 2: a telephone survey mapping multidisciplinary teams' parent-educative activities, and qualitative interviews with 112 professionals (Clinical-psychologists, Dietitians, Doctors, Nurses, Play-specialists, Pharmacists, Therapists and Social-workers) exploring their accounts of parent-teaching in the 12 British children's kidney units. Phase 3: six ethnographic case studies in two units involving observations of professional/parent interactions during shared-care, and individual interviews. We used an analytical framework based on concepts drawn from Communities of Practice and Activity Theory. Results: Professionals spoke of the challenge of explaining to each other how they are aware of parents' understanding of clinical knowledge, and described three patterns of parent-educative activity that were common across MDTs: Engaging parents in shared practice; Knowledge exchange and role negotiation, and Promoting common ground. Over time, professionals had developed a shared repertoire of tools to support their negotiations with parents that helped them accomplish common ground during the practice of shared-care. We observed mutual engagement between professionals and parents where a common understanding of the joint enterprise of clinical caring was negotiated. Conclusions: For professionals, making implicit knowledge explicit is important as it can provide them with a language through which to articulate more clearly to each other what is the basis of their intuition-based hunches about parents' support needs, and may help them to negotiate with parents and accelerate parents' learning about shared caring. Our methodology and results are potentially transferrable to shared management of other conditions. © 2013 Swallow et al.; licensee BioMed Central Ltd

An exploration of mothers' and fathers' views of their identities in chronic-kidney-disease management: Parents as students?

Aim. To explore parents' views of their identities as they learn to manage their child's chronic kidney disease. Background. Parents are expected to participate in management and usually learn necessary skills from the multidisciplinary team. Research highlights the importance of professionals defining parents' management roles in chronic disease; but little is known about parents' views on their own identities as the complex and dynamic process of teaching and learning unfolds around their child's condition. According to positioning theory, identity development is a dynamic and fluid process that occurs during interaction, with each person positioning themselves while simultaneously positioning the other person, yet this concept has not been considered in relation to parents' contributions to disease management. Design. A longitudinal, grounded theory study conducted in a UK Children's Kidney Unit. Method. This paper focuses on one aspect of a larger study exploring family learning in disease management. Six mothers and two fathers of six children with a recently diagnosed chronic kidney disease participated in a total of 21 semi-structured interviews during the 18 months after referral to the unit. Interviews included discussion about the parts they played in relation to professionals during the management process. Findings were interpreted within a framework of positioning theory. Results. Parents participated in teaching/learning/assessment that was both planned (involving allocated clinical lessons and tasks) and spontaneous (in response to current situations), to facilitate their participation. They positioned multidisciplinary team members as teachers as well as professionals, simultaneously positioning themselves as students as well as parents. Conclusion. Parents' clinical duties and obligations are not an automatic part of parenting but become part of the broader process of sharing disease management, this can lead to them assuming the additional identity of a 'student'. Relevance to clinical practice. Involving parents in ongoing discussions about their positions in management may help promote their active and informed participation. © 2008 Blackwell Publishing Ltd

Harnessing Social Enterprise for Local Public Services

The government’s public service reform policy emphasises the collaboration of local authorities with a network of other agencies in the locality, either through contracts or through partnership arrangements. Strong encouragement is currently being given to the involvement of ‘third sector’ organizations (including social enterprises) in such partnering arrangements. This environment has opened up new opportunities for social enterprises. However, as the DTI has asserted in relation to social enterprise, ‘rhetoric rather than a robust evidence base continues to inform many arguments for its growth and support’ (DTI, 2003a: 49). This paper examines one of the most widespread examples of social enterprise in the provision of public services: ‘new leisure trusts’. It asks whether the combination of entrepreneurial skills and social purpose in social enterprises such as new leisure trusts provides a useful model upon which public service partnerships could be based. Findings show that these social enterprises can work to create synergy through improved input/output ratios, commitment to meeting social objectives and wider stakeholder involvement. However, there are issues of incentivisation and relative autonomy that must be resolved within such partnerships, and more work to be done in some cases to build genuine social inclusion

The Grit in the Oyster:Professionalism, Managerialism and Leaderism as Discourses of UK Public Services Modernization

The representation of organizational agency in UK policy discourse on public service modernization is analysed in order to disclose the legitimation of elite organizational centres and the structuring of organizational peripheries and their potential for resistance. Three discourses are identified and explored: the residual, but still potent, discourse of professionalism; the dominant discourse of managerialism; and the emergent discourse of leaderism. The emergent discourse of leaderism is shown to be linked to an imaginary of neo-bureaucratic organizing, which represents an evolution of New Public Management. As such, the analysis of leaderism, a new form of privileged agency, contributes an insight into the dynamics of public service modernization. This is developed through exploring leaderism’s tension between its strong affinity with unitarist managerialism and its weaker linkages to quasi-pluralist stakeholder networks which create potentialities for new forms of active resistance