Aim: To explore the perceptions that managers of community mental health teams have of their role, along with their responsibilities and frustrations.
VOL: 100, ISSUE: 32, PAGE NO: 40
Martin McGuinness, MSc, LLB, RMN, RGN, DMS, is community mental health team manager, community mental health team, Upminster
Aim: To explore the perceptions that managers of community mental health teams have of their role, along with their responsibilities and frustrations.
Sample: Managers of community mental health teams.
Method: The method consisted of using focus groups and a survey questionnaire of CMHT managers in seven mental health trusts.
Results: The study found that the job of the CMHT manager is challenging and demanding, working with adults with severe mental health problems, managing community multidisciplinary teams and meeting the standards of service delivery set out in the National Service Framework for Mental Health (Department of Health, 1999). The data also showed that CMHT managers had a strong commitment to, and positive working relationships with, CMHT staff.
Conclusion: There were significant findings about the pressures that undermined the ability of the CMHT managers to carry out the role effectively. The most notable of these being insufficient resources and poor relationships with line managers, who do not seem to understand the role and its pressures.
The study also found that the role of CMHT managers was reasonably well reflected in their job descriptions, but there were some disparities that may require a review of job descriptions.
The care of people with mental health problems has raised considerable controversy in recent years with a number of tragedies giving rise to media and public concern that care in the community is inadequate and unsafe. The government has taken policy initiatives to allay public concerns, promising to deliver mental health services that are ‘safe, sound and supportive’ (Department of Health, 1999).
Central to this are well-managed community mental health teams (CMHTs) that provide integrated, coordinated community mental health services.
CMHTs are described by the DoH (2001) as the ‘core around which newer service elements are developed’. To achieve this they have to be effectively managed and led. This is the role of the CMHT manager, which is arguably equivalent to a modern matron in the community. The role of the CMHT manager is crucial to driving the government’s agenda for its National Service Framework for Mental Health (DoH, 1999), yet there remains some ambiguity about what the role entails.
The CMHT manager is a relatively new and developing post in mental health services. Peck (1995) found CMHTs originated in the US and were first established in the UK in the 1980s, becoming common by the mid-1980s. They consisted of different mental health professionals - primarily from health and social services - working together.
The management of CMHTs
The DoH (2002) is clear about how CMHTs should be managed. It states that they function best as discrete specialised teams comprising health and social care staff under single management, which have:
- Integrated health and social care staff using one set of notes and clear overall clinical and managerial leadership;
- Staff members whose main responsibility is working within the team.
Research supports managed CMHTs. Morall (1997) in a study of community psychiatric nurses (CPNs) in four CMHTs concluded that CPNs had a high degree of clinical autonomy characterised by unsupervised decision-making.
However, Onyette et al (1995) found CMHTs were ineffectively managed with responsibility for management tasks remaining ‘dispersed or undefined within the team’, with little involvement from outside managers.
The study was triangulated, and consisted of focus groups that were conducted in North East London Mental Health Trust, which provides mental health services to a population of 850,000. The second stage - a survey questionnaire of CMHT managers in seven mental health trusts - was designed to profile the role and to find out what pressures undermined the managers’ ability to carry out their role and how their job was supported.
The purpose of the study was to explore managers’ perceptions of their role and responsibilities and frustrations associated with their jobs using a focus group method. It was also hoped that the focus groups would generate questions for the survey stage.
The focus groups also explored findings about operational CMHT management by a previous study (Onyette et al, 1995) that found responsibility for key strategic and operational management tasks had been ‘dispersed and ill defined’. This was related to current practice.
The study consists of a two-stage approach to exploring the role of the CMHT manager. This combined qualitative and quantitative study is otherwise referred to as methodological triangulation (using multiple methods of data collection and analysis).
The first stage, consisting of two semi-structured focus groups, was held in December 2002 and April 2003. Managers of CMHTs, excluding those with less than six months’ experience, were invited to the focus groups. They were advised as to how the groups would be run and what would be expected of them. Participants were divided into two separate groups that each had an experienced moderator.
The second stage was the survey of CMHT managers from seven NHS mental health trusts. The questionnaire was adapted from that used in Onyette et al’s 1995 study, piloted in North East London Mental Health Trust and then amended. The questionnaire was sent to 62 managers of CMHTs that provide community mental health services for adults.
The qualitative stage
The choice of the focus group method rather than one-to-one interviews was made as it was felt that focus groups better suited the objectives of the qualitative study.
The quantitative stage
Some questions emerged from the qualitative stage of the study, which formed one section in the questionnaire. The final version had six sections, a total of 58 questions and was sent out in May 2003. Three of the sections were fixed response questions on personal details about respondents and the teams they managed.
A combination of six-point Likert scales were used in two sections, one from the focus groups and another on how the respondent felt about their job and the organisation in which they worked.
Finally, there were more open-ended questions about the three greatest pressures and rewards of their job.
The study involved two semi-structured focus groups with analysis of results using an interpretative/phenomenological approach. Analysis of the transcript of the focus groups was carried out to produce qualitative data and to inform additional questions for the survey.
The tape recordings of the groups were later fully transcribed and analysed. The majority of data acquired from the questionnaire was processed statistically. The software package Statistical Package for the Social Sciences (SPSS) was used.
The findings of Onyette et al’s (1995) report relative to CMHT managers were put to the group. They found:
- ‘The team as a whole is seen as carrying out key management tasks.’ Focus group participants disagreed, and expressed the view that key management tasks are now clearly the responsibility of the CMHT manager;
- ‘The allocation of cases is undertaken by the team as a whole in 51 per cent of teams.’ Participants felt that teams need to be involved in the process of deciding whether referrals meet the eligibility criteria for the service, but the manager has the final say and decides to whom the cases are allocated;
- ‘Despite the fact that many CMHTs now have team managers, ultimate responsibility for management tasks remains dispersed or undefined within the team.’ Participants disagreed and were clear that ultimate responsibility lay with the team manager. They also said that the CMHT manager’s role is to lead by example, participate in the duty rota and appreciate everything that is happening within the team.
Regarding the job of being a manager, one participant stated ‘It is completely overwhelming, a crown of thorns. I can’t do it long term’.
Focus groups identified key management roles to be:
- Managing all disciplines (excluding doctors) and administration of the CMHT;
- The day-to-day running of the team;
- Acting as team spokesperson;
- Liaising with other departments/agencies;
- Facilitating the process of interdisciplinary teamwork between professionals working within the CMHT;
- Communication: a key role that requires a lot of effort and attention, especially communication between the organisation and the team;
- Promoting the development of integrated services responsive to the needs of users and carers;
- Creating and maintaining a culture of user involvement;
- Staff recruitment and retention;
- Risk management;
- Providing managerial supervision and appraisals for all staff (excluding doctors);
- Budget management. Although it is clearly cited in job descriptions as a core role it was generally felt that CMHT managers have little effective input in this area;
- Data collection. While it was accepted that this was a core role, serious doubts were expressed as to its usefulness and value due to current data collection practices;
- Strategy development.
The core components of the role as identified by the focus groups were:
- Manager (staff management, resource allocation, budget management, data collection, recruitment and retention, staff appraisals and skill-mix);
- Leader (communicator, strategic development and spokesperson);
- Facilitator (multidisciplinary teamwork and providing integrated user-focused services);
- Clinical and/or professional mentor (managerial supervision and resource person for team members).
A total of 62 questionnaires were sent out. Of these 32 (51.6 per cent) were returned, of which 31 were used. One was discarded as it was returned by a manager of a mental health team for the homeless. A representative profile of CMHT managers based on these replies can be found in Table 1.
The survey results showed that in the view of CMHT managers, the responsibility for operational management of CMHTs has shifted considerably since Onyette’s 1995 survey.
Most of the CMHT managers surveyed:
- Have management responsibility for all staff in the team (79.3 per cent);
- Provide management supervision to all staff in the team (54.8 per cent);
- Are responsible for key management tasks (71 per cent);
- Allocate clients to team members (67.7 per cent).
Principal sources of reward and pressure
In order to better understand what creates job satisfaction and burnout, those surveyed were asked open questions such as: ‘What are the three most difficult to tolerate sources of pressure in your job?’ and ‘What are the three most rewarding aspects of your job?’ The written responses were classified using categories derived from the results (Tables 2-3).
Principal sources of reward
The main sources of reward include multidisciplinary teamwork, supporting staff, developing services, influencing quality and working with CMHT clients.
Most of the comments about teamwork centred on an appreciation for professional motivated staff committed to multidisciplinary teamwork.
Comments on supporting staff described positive feelings about facilitating the development of staff and enabling them to achieve service objectives, for example: ‘Being able to influence staff professional development and working with staff, providing support and supervision.’
Many positive comments on developing services were made about being involved in change processes, for example: ‘Participating in changes that are organisational and result in better quality of care.’
Comments on improving and influencing the quality of care included: ‘Being involved in making beneficial changes to the team - improving care delivery to service users.’ While comments on working with clients expressed satisfaction at continuing a degree of direct client work, for example: ‘Working with vulnerable people to whom our service can make a difference.’
Principal sources of pressure
Lack of resources was a key source of pressure. The most frequently stated shortage was having insufficient staff to meet the needs of service users.
The second greatest source of pressure concerned relationships with and expectations from their own managers. Comments included: ‘The sheer volume of work and the unrealistic expectations of senior managers, health and social services to meet deadlines.’
Several references were made to a failure to establish clear criteria and a remit for CMHTs, leaving them to meet the needs of service users who have been excluded by other services.
Another source of pressure concerned aspects of the job itself. References were made to ‘the sheer volume of work and responsibilities’. Others complained that the remit of the job was too large and of the ‘never ending flow of referrals with no reciprocal increases in staff’.
Other comments convey a sense of unrelenting change that is difficult to manage in an already pressurised job.
There has been little previous research on this relatively new and developing role. This study provides the first profile of the community mental health team manager, examining and describing the role. However, in considering the generalisablity of results it should be borne in mind that this is a small-scale study of two focus groups and a survey of seven mental health trusts.
The job of the CMHT manager is both challenging and demanding. It involves working with adults who have severe mental health problems, managing community multidisciplinary teams and meeting the standards of service delivery set out in the NSF for mental health.
Data on the rewards of the job indicates the existence of a strong commitment to, and positive working relationships with, CMHT staff. The data also suggests that CMHT managers feel they are not adequately listened to by their line managers.
Given the demanding and challenging nature of the job it was surprising that only 29 per cent of managers possessed management qualifications. It seems reasonable that formal management training would better equip CMHT managers to effectively fulfil this challenging and complex role.
The core aspects of the role of the CMHT manager were identified as being manager, leader, facilitator and clinical and/or professional mentor.
Nine years on from Onyette et al’s (1995) research, this study found CMHT managers to be much more confident of their role, taking full responsibility for operational management tasks within CMHTs. It also found useful information on the rewards that motivated them and those factors that most undermined their ability to carry out their role effectively.
Significant findings included the nature of pressures that undermined the managers’ ability to carry out the role effectively - the most notable of these being access to insufficient resources and poor relationships with their line managers. These poor relationships also suggest the existence of poor communication between senior managers and CMHT managers.
The results from the focus groups showed that the role of the CMHT manager was reasonably well reflected in their job descriptions, but that there were some disparities that may require these to be reviewed.
The results also highlighted areas of role ambiguity with respect to policies in some areas that will need clarification, for example on the issues of risk management and staff appraisal.
Managers also seemed to struggle to have a positive influence on areas such as recruitment and retention of staff, particularly retention, which they feel is undermined by issues such as lack of integration of management structures and budgets.
In order to achieve greater involvement of CMHT managers, trust community mental health team management forums should be set up with representatives from both health and social services to review areas of practice in CMHTs and the role of their managers.
The issues revealed by this study that need to be addressed include:
- A review of resources needed for community mental health teams to do their job. The DoH’s policy implementation guide on CMHTs, Mental Health Implementation Guide, provides guidance on this (DoH, 2002);
- Ensuring that eligibility criteria clearly define CMHT client groups;
- Budget management arrangements need to be streamlined and harmonised to reduce unnecessary administrative complexity;
- Agreement on definitions of managerial supervision are needed to ensure consistency and increased quality of service provision;
- Trusts, and particularly partner local authorities, need to make recruitment processes as transparent and efficient as possible;
- CMHT managers should have a formal management qualification to equip them to effectively meet the demands of this challenging role;
- Senior trust managers need to change how they relate to community mental health team managers in order that CMHT managers are adequately recognised, supported and feel involved in the development of the organisation and its services.
- This article has been double-blind peer-reviewed.