Co-production in mental health care: Insights from an advance choice document facilitator

In part three of this three-part blog, Fiona Crowe, an ACD facilitator, shares her experiences working with service users and mental health professionals to co-produce ACDs and improve treatment outcomes.

If you ever considered becoming a facilitator for ACDs, I’d strongly encourage you to do it. Equally, if you ever wondered how to achieve a true piece of co-production in a mental health setting, not to mention boss the odd consultant psychiatrist around, I would also say do it! That’s because for me, facilitating ACDs is about power, or at least changing the arrangement of power.

Professionals working in mental health are accustomed to multi-disciplinary team decision-making, where often the more senior colleagues chair meetings and take the lead in a service user's health plans. The use of ACDs has changed that. The service-user owns the document, creates the content, and ultimately leads on what they want for their care. As facilitator, my role is simply to write it all down to capture their wishes as accurately as possible. Yes, there is more to facilitating than simply writing, but that is the essence of it.

In the role I introduce myself as the facilitator, describing myself as “your scribe”, here to record your words and what is important to you if ever detained under the Mental Health Act. My first experience was moving and exciting, but I was unprepared for the pain of others in their storytelling, leading me to reflect a great deal on loss of liberty and what it must mean to be detained. There is an intensity about asking deeply sensitive questions about treatment and restraint. You reflect in the moment on the seriousness and privilege of the role. Honestly, I have experienced a low level of panic of: “am I going to record this properly? Will I get this down accurately?” because you understand the enormity of every word and how powerful the document will be when put to purpose. It’s exciting to think about that and I feel proud to talk about my role.

My favourite part of the document is the section called “Who I am”. I often start with that question, since we are all people first. The ACD design helps reinforce that we are working with people who sometimes become unwell and want to make a change to their experience if they need care again. In my experience, professionals initially feel they have this covered in their care plans, but after working through the ACD they realise the essence of the work is to create the voice on paper. The physical act of creating an ACD is empowering for me and must be even more so for the patient.

I feel protective of the facilitator role. In facilitating the completion of ACDs I have been able to provide impartiality and secure power for the patient, which sometimes means disagreeing with the professionals!

Co-production in a mental health setting is the most difficult to deliver. In January 2023, the draft Mental Health Bill recommended the process that the AdStAC project is using to help service users make an ACD. We all know the changes implemented in the Mental Health Act are highly overdue and immensely important. ACDs have been introduced to provide a voice and address power, and I am feeling positive about the opportunity to support this improvement to the Mental Health Act.

I am so glad I became a facilitator because I threw my hat in ring and can now say this is true co-production and I am involved!

The AdStAC team have now received further funding from Maudsley Charity to scale-up the use of ADCs within South London and Maudsley NHS Trust. 

Read part one here.

Read part two here.