Driving Improvement: Implementing Realising Potential

Realising Potential - telling the story

Some of the key players in the Realising Potential story speak of their experience of implementation of the action plan in their areas

Lisa Greer: improving services, empowering service users and staff, and developing partnerships

Lisa Greer's experience of Realising Potential is spread over her three roles. She is not only the seconded national lead for vocational rehabilitation in mental health for Scotland - a role that emerged as a direct consequence of Realising Potential - but is also an occupational therapist in NHS Lanarkshire, where she is responsible for developing a vocational rehabilitation pathway in mental health and providing wider AHP leadership for the board.

Lisa's national role has seen her deliver on the pledge in Realising Potential to scope models of vocational rehabilitation in mental health in Scotland, develop guidance then lead on introducing changes to implement evidence in AHP practice. She recognises that Realising Potential has raised the profile of vocational rehabilitation and has had a big impact on the way it is implemented.

"The main model we now use with people with severe and enduring mental illness is Individual Placement and Support (IPS)," she says.^[2] "Despite having a robust international evidence base, this wasn't a well-known model for AHPs in practice before Realising Potential, but it's starting to become embedded in mental health services and AHPs have led the way. Two of its main principles - and attractions - are partnership-working and empowerment of staff and service users."

IPS originated in the United States and is geared towards helping people with severe and enduring mental health conditions into paid employment. It challenges perceptions that people using mental health services are unable to work.

"Before the recovery movement and Realising Potential," Lisa says, "services tended to recommend voluntary or sheltered work or training to service users who said they wanted to work. The key thing about IPS is that if people say paid employment is what they want, then that's what we go for."

Central to the success of the IPS approach is specialist employment support and advice, and this is now being provided from within mental health teams in Scotland, as Lisa explains.

"The IPS concept of having employment specialists who are not health workers integrated within mental health teams was pretty much unheard of before Realising Potential, but it's happening now, reflecting the policy's strong partnership approach."

Occupational therapists have been trained to be employment specialists in some IPS services; others have taken in secondees from Job Centre Plus or employment agencies, and some have recruited employment specialists. Lisa believes this represents an example of how the model is being implemented in new and innovative ways. "People in mental health services are thinking creatively about how they can work in partnership with limited resources to achieve best outcomes," she says.

A key principle of IPS is the provision of time-unlimited support. "This can be challenging for services that are under pressure to discharge people who are clinically stable," Lisa explains. "However, we think creatively about how we can offer people ongoing support when they are working and help to identify what wider support is available to them."

AHPs have been leading on this change in attitude and aspiration about what is possible for people with severe and enduring mental illness and have been changing their own attitudes and aspirations as a result.

"It's really only in the last year that the ball has started rolling, but it's really exciting," says Lisa. "Realising Potential has been a powerful catalyst for change. It has enabled us to set up a national vocational rehabilitation network with an AHP vocational rehabilitation lead from practically every health board, which means the work we do nationally can have a local identity. NHS boards aren't working in isolation and having to reinvent the wheel each time - we're working together. That's the value of Realising Potential.

"It has also provided a framework that allows the newest, most inexperienced AHP and support worker colleagues to engage with policy, contribute to national work and see the benefits," she continues. "For example, vocational rehabilitation leads in most boards have been supported by their strategic mental health AHP leads to create local special-interest or peer-support groups on vocational rehabilitation. This has enabled clinicians to take part in something that is changing and developing and which is producing positive outcomes. That's very exciting."

Lisa recognises that the gains made by Realising Potential are vulnerable without ongoing commitment.

"Realising Potential could only give us a start - it could never be the complete answer," she says. "It helped us to really understand where our strengths as AHPs lay and what we needed to do going forward. It has enabled us to get our own identity sorted, so we can more confidently say 'this is what we can do and what we can offer'. But we're only three years down the line - it's still early days.

"Hearts and minds have to be won, and we're still having to convince people that 'asking the employment question' is a positive way forward for people with severe and enduring mental health problems. But the evidence of AHP impact is growing all the time and is lending strength to the Realising Potential case. The more service users and carers experience the benefits, the more AHPs will spread the word."

Samantha Flower: a perspective from an NHS board

As one of three mental health AHP leads in NHS Greater Glasgow & Clyde, Samantha Flower led on the roll-out of the Realising Potential action plan in the board.

"We are a big health board, so ensuring coverage is always an issue," she says. "We needed to make sure everyone was aware of the action plan and what it meant for their service, but our heads of mental health were very keen that implementation didn't follow a 'top-down' approach - they didn't want me producing an action plan for the board and imposing it on their services.

"Rather, they wanted people to define their local priorities and see how they fitted with Realising Potential before developing their own local action plans and informing us centrally about them. So we had a bottom-up, top-down approach, which meant we had to ensure effective communication across the board area around implementation."

Samantha understood that some local teams might need support to develop action plans that were achievable and which highlighted the elements of Realising Potential that were most relevant to individual teams, service users and families. She asked the board's AHP educational projects leads to support teams in action plan development and help them to focus on what they could actually deliver. The action planning process therefore took on a professional development, as well as a professional delivery, focus.

"The teams responded very positively," Samantha says. "We set up a process for reporting back to us on how the plans are going, and it has worked really well. It helps us to understand how the recommendations are being implemented in different parts of the board area."

Samantha also set up a rolling programme in which members of different teams feed back on what they had been doing to the board's central executive group, using an agreed template. "This is good from a developmental point of view, as it allows people who perhaps aren't accustomed to speaking to bigger formal groups the opportunity to spread the word about their progress," Samantha says.

Samantha believes the implementation model she and her colleagues introduced is sound and fit for purpose.

"The model has given us enough of a handle to spot not only where things are progressing well, but also where they may be stalling," she says. "A lot of what we do as AHPs is not about working in our own little corner - we engage with a wide range of agencies, and sometimes problems can occur that are outside our immediate control. The model helps us spot these problems early and respond accordingly."

Samantha believes that AHPs in mental health in the board have embraced Realising Potential and have used it as a government-driven justification for working the way that they, service users and carers want them to work.

"I've been involved in Realising Potential from the beginning, and we've reflected what AHPs were telling us at every step," she says. "That meant the final report and recommendations resonated with AHPs across all health boards."

And it isn't just those in mental health who could see its relevance. Samantha made a number of presentations to her acute physical health colleagues, explaining what Realising Potential was and why it had been developed in an effort to raise awareness of the mental health aspects of AHPs' work in physical health services.

"These colleagues were much more receptive and excited than you might think," she says. "They used the Realising Potential concept to try and encourage their own physical health AHPs to be much more mental health focused. The physiotherapy practice development lead in acute services, for instance, worked with the GIPSI [Glasgow Institute for Psychosocial Intervention] psychological therapies team to train physiotherapists in the musculoskeletal service, increasing their awareness of the effects of musculoskeletal problems on mental health. So Realising Potential's impact has stretched further than mental health AHPs, in line with its original intention.

"I've now got operational managers asking me about Realising Potential, rather than me telling them about it," she continues. "I think this reflects the fact that we were committed as a group to taking it forward, and that Realising Potential is such an easy-to-understand policy that produces results on the ground."

The Realising Potential action plan technically completed in June 2013, but Samantha and her colleagues are determined that the momentum it has created in the board will be sustained.

"It's always challenging to maintain momentum, but my hopes for my health board are that Realising Potential will help not only to continue improvements in services for people with mental health problems and others, but will also make a contribution to the board's implementation of the national mental health strategy and other policies. So I'm hoping it will act as a springboard for taking forward new policy."

Samantha is confident this will happen, because teams are still reporting on progress on their action plans and important related work, such as developing a best practice toolkit that reflects Realising Potential's key principles and recommendations.

"We've achieved important progress, and we can achieve more by continuing to link Realising Potential to other policy initiatives," she says. "It's about synergy, continuity and having the confidence to step up to the plate."

Graham Morgan and Sarah Muir: a joint service user/AHP mental health lead perspective

Graham Morgan, Advocacy Manager for HUG (Action for Mental Health), a campaigning network of people with experience of mental health problems in the Highlands, has been an active proponent of Realising Potential in his advocacy work since its launch.

"HUG works at a very grassroots level," he explains. "We were involved from the beginning with Realising Potential and have used it when working on a day-to-day basis with occupational therapists and other AHPs to ensure our voice is heard and to influence the way they work. We don't walk around with the report and constantly refer to it, but that doesn't mean we haven't been responding to it, or working with it."

Graham and his colleagues' experience over the last three years since the launch of the action plan have been very positive, he reports.

"We've made all sorts of links with AHPs, building bridges and challenging assumptions, but always learning from each other," he says. "We've also launched a number of projects - a creative writing group is an example. It was set up initially when I was a patient in hospital just over three years ago with Maggie, a speech and language therapist. Once I left, Maggie and Sarah kept the group going, and I still play a part.

"That's been enormously positive," Graham continues. "It provides a link and a bridge between inpatient and community patients, facilitating peer support and sharing of stories of recovery and well-being for people who may be in a difficult position in hospital, and showing them what they might be interested in doing once they're discharged.

"Quite apart from that is the great sense of liberation being able to express yourself in a warm and homely environment gives you, and the feelings of pleasure and achievement at having written something and having it acknowledged by the group. For many of us, it's not only the first time we've written creatively, but also the first time we've read our work out to other people."

Instrumental to these kinds of projects is Sarah Muir, AHP and Occupational Therapy Lead for Mental Health at New Craigs Hospital in Inverness.

"Realising Potential has been enormously influential for us, not just in terms of innovations and interesting projects like the creative writing group Graham describes, but also in the fantastic way it has pulled us together as AHPs," she says.

"We were all in separate AHP departments before, but Realising Potential has created leadership to enable us to sign up to a plan together. We were ready for the kinds of things it promotes - co-creation, co-production and assets-based approaches - but I don't think we would have been able to integrate them into our work so effectively without Realising Potential. It has given us a sense of joint ownership and has provided the encouragement we need to develop wider relationships with organisations like HUG and other voluntary groups. It has been the main influencer."

Now that the Realising Potential action plan has completed, Graham and Sarah could be forgiven for being concerned that innovations and joint projects might fall off the agenda, but no such doubt crosses their minds. Instead, what they show is a determination to keep going.

"We have the relationships now, and that's what's most important," says Sarah, who featured in the original Realising Potential DVD. "The policy has supported us to develop experiences, relationships and a renewed sense of partnership and joint working that will endure."

"Our group is committed to influencing change in the NHS and promoting the health and social care integration agenda - we won't stop doing that," asserts Graham. "Austerity and pressures on the NHS can make it hard to progress, but we have lots of things we want to do in partnership with AHPs, and documents like Realising Potential can provide the framework for liberation of the time and resources to make things happen."

"I absolutely agree," says Sarah. "We need to make sure that the priorities we've set under Realising Potential continue to be our priorities as we move beyond it."

Derek Barron: a view from nursing

Derek Barron, Associate Nurse Director, Mental Health Services for NHS Ayrshire & Arran, doesn't have to look far to see the positive impacts Realising Potential is having on mental health services locally and nationally.

"One of my occupational therapy colleagues in Ayrshire & Arran, Aileen Fyfe, now sits on the national psychological therapies strategy group," he explains. "Before Realising Potential, I don't think AHPs would have automatically been considered for that position. AHPs' key roles in supporting people's physical rehabilitation had been recognised for decades, but I don't think there was a strong perception that they also have a key role in promoting psychological recovery."

Derek believes that AHPs like Aileen are making personal journeys with Realising Potential, developing their confidence and competence and having a big impact not only on service users and carers at care interfaces, but also nationally. "This is a strong example of the additional involvement and influence AHPs are now having," he says. "It provides evidence of change in their thinking and impact and sets an important benchmark of the momentum Realising Potential has created."

Psychological therapies is an area that is also close to nursing's heart, and Derek believes the shared skills sets nurses and AHPs now possess in the field are helping to create even stronger bonds between the professions.

"Scotland's Psychological Therapies Matrix sets out quite clearly the different levels of interventions and the skills and competencies required of therapists at each level," he explains. "This has opened doors to nurses and AHPs to really add value to the quality of services they provide after accessing appropriate training, support and ongoing supervision. It reflects an approach that is about meeting people's needs, not about promoting one profession over another, reflecting a true embodiment, I feel, of the concept of 'NMAHPs' - nurses, midwives and allied health professionals - that we hold dear in Scotland, with all the professions bringing their diverse skills together to benefit service users and carers."

Nurses and AHPs who can appreciate the psychological impacts of illness and disability and who have skills to support people psychologically - meaning that they adopt a "psychological mindedness" approach to service delivery - are in a much stronger position to really make a difference, Derek feels. "The more professionals who can competently provide these services, the better enabled we will be as a board to deliver the service improvements in psychological therapies the Scottish Government seeks," he says.

Derek acknowledges the key part mental health teams play in supporting AHP and nursing colleagues to provide effective psychological therapies. "We are now seeing whole teams emerging who are psychologically minded," he says. "Psychologists have always delivered psychological therapies, nurses have had greater engagement since Rights, Relationships and Recovery, the report of the national review of mental health nursing in Scotland, and many more AHPs are active in the area with Realising Potential. But mental health teams are providing a platform for them to practise their skills by placing psychological mindedness at the heart of what they do.

"Team members recognise the input and value of adopting psychological ways of working and practising psychologically in their day-to-day work, without necessarily having specific skills in delivering psychological therapies," he continues. "It's changing how nurses, AHPs and their teams are relating to service users and carers and driving more ambitious aspirations about what it is possible to deliver within services."

The focus on people's thoughts and feelings, as well as behaviours, that teams practising in psychological ways promote is creating a greater sense of compassion in services, which Derek welcomes. "It also means that whichever member of the wider mental health team a service user meets at any part of their journey, the same positive principles, understandings and approaches are underpinning the interaction."

Derek recognises Realising Potential's "fit" with the wider policy context in Scotland by promoting integration, partnerships and self-managed care, reducing inequalities and breaking down the barriers that impede service users' and carers' access to services, emphasising the important part it is playing in pushing these agendas. Ultimately, however, he feels Realising Potential's most significant achievement can be condensed to a single word - confidence.

"For me, Realising Potential has more than anything given AHPs the confidence to change," he explains. "It is supporting AHPs to recognise that they can move beyond the immediate traditional confines of their professional group and contribute in different ways - a physiotherapist going beyond a focus on a person's movement and mobility to address the psychological impacts of disability, for instance. AHPs see the added value they bring and have the confidence to ask: 'I know what I can do - now what else can I do?' "

June Wylie: a focus on quality and improvement

June Wylie is well known throughout Scotland as a champion of the benefits AHPs can and do provide for the people they serve. June was instrumental in her previous role in the Scottish Government in laying the foundations for what was to become the Realising Potential action plan, working with the AHP National Officer to provide opportunities for AHPs in mental health to work nationally within the government.

She remains strongly committed to promoting the AHP agenda in her current role at Healthcare Improvement Scotland (HIS), but her career trajectory has now taken her into a broader remit focusing on quality and improvement.

June is Head of Implementation and Improvement at HIS. "It's very much about trying to help people in the service to drive improvement and building capacity and capability for improvement," she explains. "There are four workstreams - networking, capacity and capability, implementation and improvement, and measurement. The scope includes designing and creating new ideas and supporting existing initiatives, like the national person-centred care collaborative."

Which leads to the obvious question to someone in June's position - has Realising Potential been a driver for improvement?

"For me, there is no doubt that the existence of a policy acts as a significant driver for change and improvement," she replies. "If you don't have a policy, it's much more difficult to initiate change, particularly at national level. The fact that Realising Potential exists and presents a series of cogent and achievable recommendations is important."

June believes Realising Potential has been especially effective in two crucial areas - promoting the evidence base for practice, and increasing the visibility and confidence of AHPs in mental health.

"Corralling people around an evidence base is very important, whatever form that evidence may take," she says. "Realising Potential has energized AHPs and given focus to what they do, creating enormous potential for the service users and carers they work with. So developing the policy, identifying the evidence base, then providing the opportunity to improve practice through facilitative leadership has undoubtedly moved services on and increased the profile and confidence of AHPs in mental health. Their contribution has been acknowledged and they've been in the spotlight for three years - that's helped them to galvanise their energy and create positive networks and learning opportunities."

Looking forward, June feels that learning and experience from the wider quality and improvement field signals the need to define the impacts individual AHPs can have on service users as a key benchmark for future improvement.

"Realising Potential was launched the same year as the Healthcare Quality Strategy for NHSScotland," she says. "Three years down the line, we now have a much better understanding of how you need to support people to take improvement forward. There's an increasing recognition that if we want to be successful, we need to focus on the human dimensions of change - the beliefs and motivating factors that underpin it. And this is in tune with the mind-sets of AHPs in mental health services, as so much of what they do is about getting to the core of individuals and identifying what works for them."

June recognises that substantial change takes time and understands the challenges of gathering evidence of positive change through interactions that are often highly personalised and not conducive to "traditional" research and evaluation methods. But she nevertheless believes AHPs need to start collecting the evidence to provide proof of their impacts.

"Realising Potential is only three years down the line, and we often speak about improvement in terms of decades," she notes. "But it's important that AHPs look at capturing how all the examples of good practice that have emerged since its launch are translating into positive outcomes. They need to continue to build on what's been achieved by evidencing the outcomes of their interventions. And Realising Potential will have played a big part in creating the conditions for AHPs in mental health to take it to the next stage, driving greater improvement through evidence of impact."

June believes there is great potential for AHPs to push the improvement agenda, supported by policies like Realising Potential.

"We now have three AHP improvement advisors nationally who have gone through an accredited course - it was zero a year ago," she says. "It's a start, but we need more to help support the creation of conditions for improvement at system level, making it is easier for people treating patients to do the right thing every time."