Frequently Asked Questions (FAQ) on New Ways of Working

1. New Ways of Working what is it all about?

1.2 Is it really ‘new’ at all?
There have always been organisations which have developed new roles, staff who have sought additional training, and team members who have worked together to optimise their functioning individually and as a unit in the service of their clients. However, it is equally true that in many places traditional models of service delivery persist which do not match service user and carer needs or organisational expectations. NWW is a way of systematising and mainstreaming innovative and forward-looking approaches, and of disseminating and developing good practice that has come from the bottom up, from practitioners who have seen opportunities to improve the service they provide.

1.3 Where has NWW come from?
NWW has been around for some years, but got particular impetus in mental health in 2003. This is when two national conferences for consultant psychiatrists summarised what they saw as the problems in their profession – significant difficulties recruiting and retaining psychiatrists because of the increasing demands of the role, increasing degrees of burnout among consultants, unsustainably high caseloads and crippling expenditure on agency locum doctors to try and plug the gaps. When these problems were examined, it quickly became apparent that because consultant psychiatrists were part of a system, and other parts of that system were demonstrating the same stresses (demonstrated, for example, in a study of social workers), all the parts of that system needed to be considered in order to effect change and produce sustainable jobs for all.

1.4 Who is NWW for?
Everyone: i.e. people working in mental health, in whatever care setting they are based, and the service users and carers they work with. Since 2005, national groups representing all the different allied health profession (AHP) staff, including OTs, applied psychologists, social workers, nurses, pharmacists, psychiatrists, primary care staff and non-professionally affiliated workers, have all been addressing their own particular NWW issues with support from colleagues in the other disciplines and from service users and carers. This work has now resulted in a set of common and specific themes which all groups want to take forward in a multidisciplinary forum.

1.5 Why is NWW necessary?
Back in 2003, NWW was necessary to help solve the difficulties being faced by the psychiatrists, as outlined above. Together, with other levers for change such as the new consultant contract, NWW has contributed to a significant improvement in vacancy rates and the development of fulfilling, sustainable jobs providing effective care. However, reform and regulation, the drive towards Foundation Trust status and, most importantly, the rising expectations of service users, carers and the general public have all focused larger lenses on mental health services now than ever before. This has demonstrated that services need to be more flexible and person centred, at the same time as providing demonstrable value for money, in order to be sustainable. This requires organisations to analyse what skills they need in their teams, and to create capable teams with effective leadership supported by efficient processes and infrastructure. NWW aims to provide tools to help achieve this and the communication necessary to disseminate learning about new approaches.

1.6 Where is NWW happening and how can I find out about it?
Reading the New Ways of Working for Everyone Progress Report (2007) will help to bring you up to date, and the Final Report on New Ways of Working for Psychiatrists (2005) also provides a wealth of information. These can be found on the NWW website (www.newwaysofworking.org.uk). All the professional bodies and key stakeholders who have supported the initiative from the beginning will be posting their workstream products, guidance and positive practice examples there. The workforce leads in the regional development centres (RDCs) of CSIP also have a good overview of the state of NWW in their areas; some have commissioned regular progress reports which are available. Medical directors are linked in to the national programme via the Royal College of Psychiatrists Medical Directors network, as many have the role of Board champion for NWW in their Trusts on behalf of all staff. Some Trusts have now employed NWW leads to co-ordinate and manage implementation of NWW.

2. Where does the support for New Ways of Working come from?

2.1 Is NWW a government policy and will it be replaced by some other initiative soon?
The strength of NWW is that it has been developed by practitioners themselves, by those working on the front line who saw that roles, systems and processes needed to change to be able to cope with today’s and tomorrow’s expectations. This bottom-up innovation has been supported throughout by a national strategy, as evidenced by the support for projects from the Modernisation Agency and the Changing Workforce Programme, and then the NIMHE NWP.

NWW is about a hearts and minds cultural change, about considering ways of working from a person-centred, values-based standpoint and about developing services – and roles within them – which are flexible and responsive. NWW isn’t complicated: much of it is common sense, and many NWW changes can be easily and simply made. As such, it should just become the accepted approach to doing things because it makes sense.

2.2 Is NWW supported by my professional body/trade union?
The National Steering Group on NWW, and the work it has commissioned including all its reports, have been supported by the professional bodies and trades unions that represent workers in the mental health field. NWW is also aligned with the objectives of the regulatory bodies.

2.3 Is NWW supported by my Trust?
If you are not sure about the answer to this question, ask them! Our data gathered from Trusts in England, summarised in the NWW for Everyone Progress Report (2007), indicates that the majority have discussed the Final Report on New Ways of Working (2005) at senior level, and that their ‘average team member’ will have heard about NWW. However, actual NWW initiatives can be patchily distributed within organisations, and we are not yet at the stage where any could say that they have comprehensively introduced NWW throughout the organisation – so there is still plenty of work to do.

2.4 What support and assistance will there be at national level?
The NWW programme has been co-ordinated by the NIMHE NWP, now part of CSIP, and a small team is continuing work in 2007/08. The NWW programme is overseen by the NWW National Steering Group, representing all of the professional bodies, organisations and key stakeholders, including service users and carers. It will continue to provide oversight and guidance at a national co-ordinating level, and there will be a National Operational Group that will focus on implementation issues.

2.5 What support and assistance will there be at regional and local levels?
The vision is that at a regional/local level, the NIMHE/CSIP RDCs, working closely with Strategic Health Authorities (SHAs), commissioners and NHS Trusts, will take the lead. They will do this by continuing to spread the message about NWW, identifying good practice (for example by hosting a conference on NWW), inserting details on the NWW website at www.newwaysofworking.org.uk, articulating this to all stakeholders and providing the immediate support so that all mental health providers, across health and social care, will fully implement NWW. The precise form this will take depends on local circumstances. Specifically, however, the intention is: through collaboration between the College Research Unit/Centre for Education and Training of the Royal College of Psychiatrists and the NIMHE NWP to run a series of collaborative NWW for Everyone learning sets for director level and senior staff (multidisciplinary) within Mental Health Trusts (one per SHA). The purpose will be to accelerate the implementation of NWW countrywide, with the learning to be collected and distributed via the NWW website; and to run workshops for facilitators of the CCTA in each region, with follow-up network meetings to support and collect feedback on CCTA and the implementation of NWW at a team level.

3. What are the concerns about New Ways of Working?

3.1 Is NWW about cutting costs or dumbing down?
No, it is about using people’s skills to the greatest effect, where and when they are needed. It is about working supportively in teams. Cost and skill mix reviews have been a fact of life for a long time and will continue to be so; NWW offers opportunities for not only surviving such reviews, but making positive changes in practice to develop a more efficient service.

3.2 Is NWW about having specialist inpatient consultant psychiatrists, or cutting the number of consultant psychiatrists and other highly paid staff?
There is no single way to develop NWW. Specialist, inpatient consultant psychiatrists, or consultant psychiatrists working across the acute care pathway in crisis and inpatient work, are an example of NWW, and just over a third of Trusts have developed these roles, the so-called ‘functional model’, in at least part of their area. Where they have been implemented, they have been very successful, with demonstrable improvements in the inpatient experience for service users, carers and staff. The trick, then, is to ensure continuity with the community services that will always provide the bulk of care for individuals.

NWW is not about cutting the number of consultant psychiatrists; indeed, there has been a large expansion in the number of consultant psychiatrist posts in recent years. The same is true of psychology. This is unlikely to continue, however, and with an ageing population and significant numbers of staff approaching retirement, alternative ways to meet the continuing rise in expectations and demand have to be developed which involve NWW. In addition, there is more pressure on costs, and staff, therefore, have to be used most effectively to provide value for money. All consultant practitioners will have to prove they are worth the investment made in them, and they will need to be flexible and adaptable in their roles in order to achieve this.

3.3 How does NWW link to Improving Access to Psychological Therapies (IAPT)?
Quite easily. There is a need to develop interventions for people with depression and anxiety at two main levels – steps 2 and 3 as in the National Institute for Health and Clinical Excellence (NICE) guidance. This translates into i) staff delivering lowintensity interventions (bands 4–6), which will bring new people into the workforce at assistant and practitioner levels; and ii) staff delivering high-intensity interventions, which will include existing staff extending their roles (for example, OTs and nurses training to be CBT therapists), with the most senior staff, usually at consultant level and mainly psychologists and psychotherapists, dealing with people with more complex needs and supervising other staff at all levels.

4. What are the risks of New Ways of Working, and what problems can arise?

4.1 Is there a risk of loss of professional identity and role erosion, and ‘genericisation’?
This risk is more likely to be perceived by professions who are either ‘giving up’ certain roles or tasks, or where those roles and tasks can now be performed by a wider variety of people. The prime example here is psychiatry. Non-medics can now prescribe independently and in collaboration with a psychiatrist; the clinical leadership of a team is no longer seen as part of the consultant psychiatrist’s role by right, and the role of the Responsible Medical Officer will be replaced by that of Responsible Clinician in the Mental Health Act 2007.

Psychiatrists needs to respond to these challenges, some but not all of which are related to NWW, not by trying to find a ‘unique selling point’, but by emphasising the development of a broad range of skills based on a firm knowledge and evidence base during psychiatric training, together with a depth of understanding. If the functioning of teams in future is to be based on capabilities, then psychiatrists must have the range of integrated capabilities to offer which make them a valuable part of any team, and an essential part of many.

Training, which includes the development of leadership skills and values-based practice, a degree of technological and managerial competence and the ability to understand and work in complex systems, will produce psychiatrists for whom NWW is the natural way of working, and who also approach their work with flexibility and expect to have to develop new skills throughout their careers.

There is a concern that as the role of consultant psychiatrist changes, training opportunities may be compromised. Leaders, including the Royal College of Psychiatrists, CSIP and the Psychiatric Trainees Committee, need to work together to develop a framework for training which ensures that, instead, the opportunities of NWW for trainees, while training and as future consultants, are realised.

Members of some professions may feel that by taking on extended roles, colleagues are losing their traditional focus and outlook, and that they might perhaps be ‘infected’ with the ‘medical model’, but NWW is about enhancing and broadening capabilities, not substituting them. Social workers in an integrated Trust and MDT should be major culture carriers for a socially inclusive perspective and be valued and value themselves for this. A good medical model is holistic just like a good social or psychological model, so perhaps the time has come to ditch some of the old ways of thinking and describe what we are really aiming to achieve in terms of values-based, person-centred care (necessary, but not sufficient, for high-quality mental health provision). An effective team shares work, demonstrates flexibility while having a clear understanding of and value for the individual professional contribution; all professions should see themselves as integral members of an MDTon this basis. This has been agreed for psychologists from the NWW for Applied Psychologists workstream.

The genericisation debate pre-dated NWW and is also linked to concerns about, for example, the extent of the role of the care co-ordinator; it is recognised that there has not been sufficient guidance on this in the past, and clarification of the role and the competences it requires are part of the CPA national review, with which NWW is linked.

An example of where a team has embraced taking on the roles of other members of the team to ensure continuity of involvement from a single worker can be found on the NWW website – see the Croydon Memory Clinic case study.

4.2 What are the problems around responsibility and authority?
In some ways, this is the obverse of the concerns about loss of professional identity. NWW explicitly endorses a model of distributed responsibility, with practitioners being responsible for the care, treatment or advice they provide, but not for that provided by others. This means that extended roles will carry more responsibilities – if an untoward incident befalls a service user with whom the consultant psychiatrist is not involved, that consultant psychiatrist would not expect to be involved in the investigation afterwards, except in providing appropriate support to colleagues. It also means that practitioners must have the requisite authority to carry out their roles – for example, if a request from a non-medical prescriber is queried because it does not come from a doctor, this should always be challenged, otherwise the culture will not change.

4.3 Won’t NWW increase clinical risk?
NWW has to be underpinned by a culture shift. If working practices are changed by diktat without that underlying shift in culture and attitude having taken place, both active and passive resistance will sabotage the project. Hearts and minds need to be won to a point where there are shared objectives, active collaboration in the project, enthusiasm, and encouragement of constructive criticism and challenge. The involvement of service users and carers from the beginning is a key way to help this happen. It is very easy, perhaps especially so in mental health, to oppose change by raising the spectre of risk, and by asking for ‘evidence’ that cannot possibly be provided to the standards demanded.

NWW is not about replacing people who can do a particular task with people who can’t; therefore it is not about increasing risk. It is about ensuring that everyone working in services is appropriately skilled to do the tasks required of them and that suitable supervision and support are in place for all, irrespective of their seniority. There are many ways in which clinical risk can be reduced by NWW, for example by having more people in the team with a greater awareness of physical health problems and the potential side effects of medication; more people in the team skilled in initial assessment, and risk assessment which is carried out by pairs of professionals; a consistent consultant presence; and leadership on the inpatient unit. These are all examples of NWW which have as one of their aims improving safety and reducing risk.

When people (usually staff) are concerned about increasing clinical risk, it also has to be remembered that the status quo is not a risk-free option, and that NWW is not change for change’s sake, but a method of service improvement.

4.4 What are the risks when there is a lack of clarity of purpose or scope?
If the strategy for NWW in an organisation is not clearly articulated, the projects that come under the NWW banner will also not be clear in their purpose or scope, and this will make them harder to complete successfully and will reduce the opportunities for cross-organisational learning. It is always worthwhile taking the time to really think about what the project is designed to achieve and how this meshes with the overall objectives of the organisation. Utilising project management skills, which clinicians often do not have but which can be found elsewhere in the organisation, will help to keep things on track.

4.5 What are the risks of inadequately resourcing the change process?
It is important that when the Board endorses a vision and strategy for NWW, it understands that service redesign projects require appropriate resourcing if they are to be effective. This may mean freeing up sufficient staff time and having the resources to engage and include service users and carers. This may include paying them for their time; money for elements of the communications plan such as meetings, away days or documents; sufficient administrative support for a project; or bringing in people with particular skills, for example project management, information management or business analysis. The resource will clearly depend on the size, complexity and anticipated duration of the project, and those establishing projects and bidding for resources should be advised as to the best way of thinking about the benefits realisation the project will bring. Organisations should also seek to develop knowledge and expertise in applying for sources of external funding for pilot projects of various sorts.

4.6 What are the risks of lack of leadership and support?
The proposal for a Board-level lead for NWW in an organisation is made so that Trusts can demonstrate their commitment to NWW in this tangible way, and also to give a focus for the activity within the Trust so that it is co-ordinated, and so that the appropriate learning and evaluation takes place. It is not designed to mean that NWW should be ‘top-down’ – the lead’s job will be to ensure that the bottom-up creativity and enthusiasm for local projects are harnessed to the objectives of the organisation as a whole.

4.7 What are the risks when personal development is not aligned with organisational objectives?
Many Trusts will be able to identify examples where particular training courses have been available, and staff have signed up for them and completed them but then not been able to use the new skills they have acquired. This happens when training is simply something that the individual member of staff considers as part of CPD, rather than it being part of the overall workforce and linked learning and development strategy. This inability to practise what they have learnt is very frustrating for staff and a waste of finite resources.

4.8 What are the risks when changes are made in parts of a system and the rest does not adapt?
This risk is related to the one above. In this case, the workforce strategy may include, for example, the recruitment of new types of worker, such as the STR worker, or the promotion of psychosocial interventions (PSI); however, there has been no detailed thinking done about how the new workers, or the staff with new skills, will be able to work within the team (or how they will be appropriately supervised), because there has been no thought given to the whole team having to change the way work is distributed. This requires planning before courses or recruitment take place, so that the person can slot into the role expected of them and has time to do so. Also, the rest of the team must be clear about what the role is and how the skills the person brings will be used, as well as, crucially, any other work that will need to be redistributed.

5. How am I affected by New Ways of Working and how can I help it develop?

5.1 How does NWW affect me as a service user, and as a carer?If NWW is embedded in the team(s) you link with, you should find that they are
flexible and responsive to your needs. Most teams will have a focus on recovery; for some working with different client groups the emphasis will be on rehabilitation and living as valued a life as possible; or, at the end of life, for some a palliative care approach with care and support for patients and their families will be appropriate. The team will be always be looking for ways to improve and will involve service users and carers in that process. Your experience of services may change; for example, you may find that your needs can be met by fewer people, because some staff in the team have acquired additional skills (e.g. in prescribing). You should find it easier to get access to those with the appropriate skills to help you if you become more unwell. You should find yourself reassured and informed and fully part of, not intimidated by, the care planning process. The team will communicate well with you – perhaps offering a variety of methods – and with your general practitioner (GP), and they will be open about sharing information and collect it appropriately. You may find that some aspects of your care can be provided in a primary care setting. If you need to go into hospital you should find that, although different people may care for you, your care co-ordinator ensures continuity and plans with you and your ward team for your discharge from the point of admission, involving your carers at each step. If the providers of your services have embraced NWW there should be some information about it; nationally, leaflets will be produced to highlight the main features and indicate how to get local information.

Your team, and the organisation of which it is part, will be working towards the inclusion and involvement of service users and carers in service development and evaluation as the norm. Programmes such as the CCTA will help to embed this change, by emphasising the active participation of service users and carers throughout.

Trust policies will demonstrate that the practical issues (e.g. expenses, transport and communication) have been thought through.

5.2 How does NWW affect me as a practitioner
NWW emphasises the collaboration of all practitioners within teams to achieve person-centred care for service users and carers. However, within this, as an individual practitioner you will want to review the way you work, to ensure that it is efficient and uses your skills appropriately. You may feel anxious about what might be expected of you but you will have ideas not only about your own practice but also about how the whole team can improve, and it is this bottom-up innovation that will enable your team to develop NWW effectively.

5.3 How does NWW affect us as a team, and what can I do about it as a team manager?
The first step is to look at how the team is organised: is there a model of distributed responsibility, with all members taking responsibility for the care they provide? If you are a CMHT, for any age group, have you moved away from any notion of the consultant psychiatrist being ‘in charge’ of all the ‘cases’? If you are a ward team, are ward reviews truly multidisciplinary, with contributions from all equally valued? What can you do about your team processes, to make them more efficient and reduce duplication and wasted time? Have you looked at the roles of everyone in the team, to ensure that their skills are being used to best effect? What do your service users and carers think? Can you put forward team members for additional training with a clear idea of how you will all utilise the new skills they will bring? Does the team look at its own performance data? You will want to read the CCTA documentation to help you to develop a team competence model or look at the prompt questions in Section 7 of this guide.

5.4 What can I do about NWW as a director?
You should help to ensure that your organisation can affirmatively answer questions like:

• Does your workforce strategy consider the potential for developing or expanding new types of role in your workforce using existing staff more effectively, and is there a plan for delivering this?
• Is there a strategic approach to developing enhanced skills in the workforce, so that the right people are trained, and so that their roles and those of the teams they work with are then adapted to allow them to use their new skills?
• Is NWW discussed in your integrated business plan, and do your commissioners understand its potential?
• Do you have assurance that you are using your workforce, particularly the most expensive elements of it, in the most effective and efficient manner? How prevalent is job planning and appraisal, and do they consider the person in the context of their team?
• Do you know which teams are having the most difficulty managing their workloads, and is the organisation doing something about it?
• Is there a strategy for dealing with a consultant psychiatrist vacancy that involves more than automatic recruitment of a locum and then a straight replacement?
• How efficient are your clinical and administrative processes? Can you demonstrate that you are achieving the 10 High Impact Changes for Mental Health?
• Are there mechanisms for involving service users and carers and frontline staff in generating ideas for improvement, and is the infrastructure there to support implementation if so?

5.5 What do I need to know about NWW as a commissioner?
The core of a mental health service is its staff, and those staff can be developed in three ways: existing staff can work differently; existing staff can be trained in additional skills, beyond their traditional scope of practice; and different roles can be developed to bring new people into the workforce. These staff can then form capable teams if they are deployed within a service model attuned to the needs of its users and carers, supported by good systems (particularly information systems) and adequate resources, and embedded within a values-driven organisational culture with leadership and effective team working modelled at all levels. As a commissioner you will want to know that all these elements of NWW are being developed in the organisations that provide your services, because they are at the core of a sustainable enterprise that provides quality, value for money and choice for your population.

5.6 Do others, for example the public, GPs and coroners, know about NWW?
The amount of knowledge is variable, and it is vital for us all to seek to explain the concepts and therefore increase it. People are perhaps more used to NWW in other branches of the health service, such as emergency care practitioners, new roles in primary care, chronic disease management and even surgery, so it just needs explaining that things are changing in mental health too. The primary care subgroup of the National Steering Group on NWW is actively promoting NWW in mental health across care settings and helping to raise awareness. We are seeking to develop a guidance document with the Coroner’s Society for England and Wales to explain what the changes might mean for them and their work, which will incorporate the new roles in the Mental Health Act 2007.

6. New Ways of Working and the national context

6.1 Is there a link between NWW and Foundation Trust status?All Mental Health Trusts in England are established or aspiring Foundation Trusts and, as such, they must demonstrate not only that they can break even, but that they are sustainable organisations which can generate surpluses. Since most spend about 70% of their resources on staff, creating a sustainable workforce is a key component of their integrated business plans. NWW can help them achieve a balanced, effective, sustainable workforce offering the care and treatment that service users and carers are asking for. Foundation Trusts have Boards of Governors elected by their members, and there are thus real opportunities for service users, carers, staff and other key stakeholders in the local community to influence the development of their local Trust. Lean thinking is also being actively pursued by some Trusts and SHAs, and NWW will be threaded into this process.

6.2 How does NWW link with other developments like Payment by Results? The NIMHE NWP is working closely with the Department of Health and has links with the pilot projects for Payment by Results in mental health. There is a good understanding of the need for any mental health tariff to take account of new working practices. The NWP is also making links with Connecting for Health to ensure that the new clinical information systems are not based on outmoded assumptions about who does what and where.