‘Talking a different language’: an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services

Organisational culture is ‘that which is shared by members of groups and expressed in patterns of behaviour’ [1] and can be conceptualised as ‘shared values, beliefs, understandings and norms that bind organisational members into a collective endeavour’ [1, 2]. Dimensions of organisational culture as embodied in approaches to cultural assessment can encompass leadership, organisational attributes, attitudes to change, safety, team orientation and working, collaboration, collegial and interdisciplinary relationships [3]. Culture is explicit in patterns of behaviour which can be reflected in working practices and rituals; beliefs, values, attitudes which justify behaviour patterns and are influential in decision making and assumptions based on beliefs, values and expectations [2, 4]. Organisational culture is influential in shaping identities and role enactment by individuals [5]; in turn, professional roles, identities and working practices can create social boundaries which can hinder inter-professional relationships impeding the diffusion of innovation and change within and across organisations [6]. Recent interest has focussed on the possible relationship between organisational culture, performance (quality outcomes) and the potential for reshaping cultures as a lever for health care improvement. Currently, evidence supporting this is limited [2, 7] and no convincing evidence of generalizable strategies to change culture have been found [8].

Although few studies have specifically investigated the influence of cultural factors and working practices, recognition that these could adversely influence the transition of young people from CAMHS to AMHS rests on variable sources of evidence relating to the evolution of separate child and adult mental health systems [9], complexity of organisational structures across which transfer takes place [10], differing provision of services [11–14], espousal of different models of health, illness and service delivery by CAMHS and AMHS [15, 16] and working practices marked by lack of shared planning, poor communication and lack of formal arrangements to support transition [17–21]. Concerns have arisen that failure to manage and integrate care effectively during the process of transition can result in young people losing contact with health and social care systems, with adverse effects on health, well-being and potential [22–27].

Investigation of continuity of care in AMHS has highlighted emergent cultures in patterns of integrated, multi-disciplinary working by community mental health teams (CMHT) within and across organisational boundaries [28, 29]. Integrated working in relation to communication, information transfer and decision making was a facilitator for cross-boundary, team and informational continuity of care. Barriers for cross boundary and team continuity were leadership styles, blurred professional roles, medical models of decision making, lack of training for role development and resources to support information transfer. Service users and carers identified both positive and negative ‘depersonalized transitions’ characterised in negative cases by poor communication and information transfer between services, users, carers and voluntary agencies [30].

Effective management of transition requires CAMHS and AMHS managers to face the challenge of implementing and monitoring uptake of standards and guidelines contained within national service frameworks, recent policy reviews and recommendations of professional bodies [31–34]. These encompass the appointment of key workers to co-ordinate the process, the development of transition protocols and care plans supported by joint strategic planning and multi-agency working aligned with the engagement of young people and families. Intrinsic to successful implementation and change management is an understanding of the influence of organizational cultures and working practices and if necessary, their reshaping through structural reform, to achieve aspirations for transition to be the ‘smooth process offering uninterrupted continuity of care with consideration of the young persons’ physical, social and psychological development [34]’. Given the limited evidence on cultural factors relating to transition, this paper presents findings from an exploratory study designed to illuminate cultures and working practices across the CAMHS/AMHS interface.

This study aimed to explore the influence of cultural factors and working practices on a collaborative endeavour, the process of transition for young people moving from CAMHS to AMHS and the potential impact on continuity of care. Findings have provided some evidence for a cultural divide in terms of different attitudes, beliefs, understanding and misperceptions between CAMHS and AMHS. Positive and negative working practices which could impact on continuity of care and transition were also identified, with reference to a multiaxial definition of continuity [39, 40]. It is evident in these findings that factors other than cultural differences can impact on working practices, transition and continuity of care. Lack of resources, notably in relation to staff transition posts and IT provision were influential and other findings of TRACK identified wider staff shortages and heavy caseloads as problematic for organizational working [43]. It should also be borne in mind that the nature of the boundary between organisations and services can involve cultural, geographical, structural and financial dimensions, all of which can influence collaborative working and other outcomes.

A number of limitations are also acknowledged: these include under-representation in the sample of Trusts from the Midlands region and AMHS. The sample was drawn solely from health professionals and representatives of voluntary organizations; wider findings of TRACK, investigated experiences of service users, parents and other factors influencing transition [36–38].

The existence of a cultural divide in terms of attitudes, beliefs, understanding and some mutual perceptions between CAMHS and AMHS was evident: CAMHS was characterised (by CAMHS) as more person-centred, family oriented, positively focussed in terms of encouraging user resilience and utilizing talking therapies, but ‘talking a different language’ from AMHS. The latter was perceived by others as not such a good service, with a focus on crisis and medication management, problematic attitudes and a skill deficit underpinning staff lack of confidence in caring for young people. These findings extend those of others which have identified cultural differences present at the CAMHS/AMHS interface [15–17] and resonate with other TRACK findings relating to users and carers experiences, that AMHS care was medication oriented, psychiatrists dealt with medication but not emotional issues and that enduring mental health problems and taking medication were significant predictors of transition [36].

Indicators of more positive attitudes were evident in the acknowledgement by some AMHS staff of the importance of family involvement, notwithstanding the need to maintain confidentiality, which other studies have indicated can create an ethical dilemma for inter-professional working [44]. Other TRACK findings [38] established that many young people reported less involvement in care by parents and welcomed the new, post-transition confidential arrangements with AMHS. Given the different understandings, beliefs, mutual misperceptions, problematic attitudes and acknowledgement of skills deficits, a way forward could be to invest in common multidisciplinary training in adolescent health and transitional care, an approach to continuing professional development which has been advocated in guidance issued by policy makers. professional bodies and others [20, 24, 33]. Within a joint educational setting, CAMHS and AMHS professionals could explore cultural values, beliefs and assumptions and achieve a better understanding of their shared endeavour of promoting safe transition and continuity.

In relation to communication and working practices across the CAMHS/AMHS interface, findings revealed a mutual lack of understanding about service structures, location of key personnel and communication. The use of waiting lists was a source of frustration if it hindered further dialogue and different approaches to CPA management, documentation and electronic information transfer were evident. These findings are congruent with others [21] which have identified variable patterns of communication, limited opportunities for joint discussions between services and incompatibility of software systems as problematic, impacting negatively on transition and both information and cross boundary continuity of care [28, 29]. A need to address the delay in national IT systems has been acknowledged [45] and clear accountability for key worker co-ordination of information transfer within care plans is advocated in policy guidance [33]. Enhancement of cross boundary and team continuity by providing training in communication skills as part of a wider educational programme on transitional care should also be implemented.

The challenges faced by young people, parents and carers prior to and during transition were understood by both CAMHS and AMHS staff and the potential for a disruption to established therapeutic relationships, impacting negatively on personal and relational continuity of care has been recognised more widely [29, 30, 33]. Feelings of ‘loss’, being ‘cut out’ of the system and ‘cultural shock’ were identified alongside anxieties evoked by feelings of intimidation at having to attend CPA meetings and meet new caseworkers; resistance to transfer could also be a problem for young people who were reluctant to embrace change. This professional view accords with experiences of parents post-transition who described less involvement in their childs’ care and had difficulties with readjustment. However some young people welcomed change and described positive experiences of gradual preparation for transition backed up by joint CAMHS/AMHS working and continuity of therapeutic relationships [38]. The importance of establishing early joint working to prepare young people and families for transition has also been acknowledged in many key reports [31–34] and the point made that when children enter a service, they should know from the outset when they can expect to leave it [20]. Concerns were expressed in this study about leaving it too late to initiate the transition process and it is interesting that none of our participants referred to the transition protocols, care pathways and care plans advocated in policy and professional body guidance intended to facilitate relational, informational and cross boundary continuity [24, 25, 31–34]. Other TRACK findings confirmed that protocols had been developed but were variable in their content and patterns of use [37]. No protocol specified how young people should be prepared for transition or detailed procedures to maintain continuity of care for those not accepted by AMHS. This is sometimes referred to as the policy-practice gap and raised questions about protocol utility and monitoring implementation in practice. Alternative models of transitional care, designed to overcome the policy-practice gap inherent in a protocol based approach have been suggested, ie the ‘Shared Management Framework’ focused on a transitions team and transitions co-ordinator [46].

A number of working practices were identified which were supportive of smoother and more efficient transition, enhancing cross boundary, information, personal and relational continuity of care and consistent with policy guidance [31–34]. These included the appointment of transition workers who worked across service boundaries, facilitating decision making on referrals, working with new care co-ordinators in AMHS for some time, joint appointments between services, shared meetings, co-working by psychiatrists and periods of parallel working by care co-ordinators. An interesting finding was that where staff had a shared professional identity and previous experience of either working in or managing both services, this was helpful in understanding working cultures and fostering joint working. Other very positive, proactive initiatives had been implemented, including the arrangement of pre-transition visits to AMHS by young people and families, working across organisational boundaries to foster joint working with external agencies and service providers, notably educational services, learning disability teams and family health liaison services; some of the managers who participated in this study had joint responsibilities for managing CAMHS and AMHS which could have facilitated these initiatives.

With emerging evidence that the bulk of adult mental health problems begin at a young age, the current CAMHS AMHS divide has produced a care pathway with maximum weakness where it should be most robust [47]. A radical redesign of youth mental health services has been suggested, but may be difficult to achieve in the short-term. Meanwhile it is imperative on services to improve transitional care and address the organisational factors that produce suboptimal care [36].

Findings have demonstrated evidence of a cultural divide between CAMHS and AMHS, marked by different beliefs, attitudes, understanding and some negative misperceptions. Some working practices could constitute barriers to effective transition, relational, informational and cross boundary continuity of care. However, indications of a shift in bridging the cultural divide were also evident in positive approaches to collaborative working between services and external agencies which can support transition and continuity. Recommendations are that shared, multidisciplinary, continuing professional development should be implemented which is linked to appraisal and competency frameworks and focuses on transitional care. In context, this should encompass updating on service structures, utilisation of protocols, models of ‘best practice’ in transition, multi-agency working, communication skills, networking, and the acquisition of skills in working with young people and carers. Improvements in information transfer could be achieved by standardised approaches to record keeping supported by compatible IT resources.

Bearing in mind the growing independence of young people, family/carer involvement in transition needs to be sensitively negotiated between professionals, young people and families/carers. In the absence of generalizable strategies to foster cultural change [8] it is recommended that managers develop and implement service evaluation frameworks which identify and monitor outcomes of transition and continuity longitudinally. Combined strategies to implement change based on leadership, education and consistent application of guidelines and protocols are also recommended [48–50].