Information provision and choice

Meaningful care planning involvement requires service users not only to be motivated to engage in participatory discussions but also to have the relevant knowledge and resources to do so. Irrespective of setting or publication date, small and larger-scale quantitative surveys have consistently reported gaps in service users' and carers' understanding of care planning procedures and their implementation within secondary mental healthcare. ^{3,Reference Antoniou, Estop and Gilburt22,Reference Wooff, Schneider, Carpenter and Brandon38,Reference Rose46,Reference Webb, Clifford, Fowler, Morgan and Hanson64–Reference Marshall and Solomon71} Although smaller in number, rigorous qualitative studies confirm that service users and carers lack staff and service feedback, ^{21,Reference Goodwin and Happell41,Reference Dobie, Bulia and Swanke42,Reference McDermott72} and often receive insufficient information and support to contribute meaningfully to decisions about their care. ^{21,Reference Goodwin and Happell41,Reference Dobie, Bulia and Swanke42,Reference Schroder, Ahlstrom and Larsson51,Reference McDermott72–Reference Walsh and Boyle77} Specific to carer discourse is the claim that patient confidentiality serves as an effective but potentially ill-used barrier between mental health professionals and themselves. ^{Reference Askey, Holmshaw, Gamble and Gray78,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79} From the patients' perspective key deficits have been identified in their illness understanding, knowledge of the medicolegal aspects of mental healthcare and their awareness and appreciation of medication choices and side-effects. ^{21,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79} Quantitative, survey and national consultation data corroborate these information gaps, ^{27,Reference Rose, Ford, Lindley and Gawith31,Reference Borneo33,Reference Wooff, Schneider, Carpenter and Brandon38,Reference Webb, Clifford, Fowler, Morgan and Hanson64,Reference Sandlund and Hansson66,Reference Bowers68,Reference Svensson and Hansson80,81} additionally highlighting potential deficits in service users' and carers' knowledge of keyworker contacts, ^{28,Reference Bowers68,Reference Simpson82,Reference Wolfe, Gournay, Norman and Ramnoruth83} care planning documentation, ^{Reference Webb, Clifford, Fowler, Morgan and Hanson64} and scheduled dates and processes pertaining to care planning reviews. ^{27,48,Reference Webb, Clifford, Fowler, Morgan and Hanson64}

The persistent failure to provide service users and carers with pharmacological information and choice emerges as one of the most common barriers to meaningful care planning involvement across both quantitative and qualitative research designs. ^{27,28,Reference Rose, Ford, Lindley and Gawith31,Reference Borneo33,Reference Wooff, Schneider, Carpenter and Brandon38,Reference Sandlund and Hansson66,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Magorrian84} Isolated data from one moderately sized survey conducted in a mixed clinical setting purport that individuals who receive such information are significantly more likely to be educated in why their medication has been prescribed than to be informed of their legal right to refuse. ^{Reference Borneo33} Although not directly corroborated by other studies, these data raise the possibility of a deficit not only in the capacity of mental health services to disseminate information, but also in the provision of potential opportunities for service users to exercise decision-making control. Although some empirical support for this hypothesis is available, rigorous data are sparse and biased towards in-patient settings. ^{Reference Cresswell and Lelliott67,Reference Storm and Davidson75,Reference O'Donovan85}

Potential for divergent opinion exists. Although both quantitative and qualitative data have suggested that service users do not routinely receive education about their legal rights, ^{Reference Murphy and Cutts52,Reference Sandlund and Hansson66,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79–81} one national survey has revealed a belief among ward managers that this information is indeed provided. ⁸⁶ Accepting a minimum level of data quality across the studies, this contradiction implies one of two things: either that there is scope for temporal or geographical variation in practice, or that traditional methods of communication between service users and professionals have failed. Current evidence is not sufficiently developed to discriminate between the two. Qualitative and mixed method explorations suggest a need for care planning dialogue that can be more easily understood. ^{Reference Ford and Rose87,Reference Loveland88} National consultation also advocates greater transparency in information provision, with the shared recommendation that information is written by or with service users, ⁸¹ and disseminated in a wider range of formats across multiple service settings. ^3,81

Participatory deliberation

The instigation of a collaboratively defined, mutually endorsed care plan demands not only that service users understand the questions and choices posed to them, but also that they appear sufficiently competent in communicating a response. Survey data collected from two moderately sized samples of users and carers have previously suggested that many lack confidence during care-planning consultations, ^{Reference Rea and Rea89} and that some may express uncertainty regarding their own ability to contribute meaningfully to their care. ^{Reference Rea and Rea89,Reference Chinman, Allende, Weingarten, Steiner, Tworkowski and Davidson90} Inductive qualitative analyses indicate that the predominant factor eroding service user and carer confidence may be a perceived power differential between themselves and mental health professionals. ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Dobie, Bulia and Swanke42,Reference Piippo and Aaltonen43,Reference Allen73,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Magorrian84,Reference Bramesfeld, Klippel, Seidel, Schwartz and Dierks91} Less frequently, this perception is attributed to socially embedded constructs of health professionals as individuals holding superior positions within educational and socio-economic hierarchies. ^{Reference Dobie, Bulia and Swanke42} Much more commonly it is attributed to – and amplified by – negative practice-based experience. ^{Reference Woltmann and Whitley40,Reference Daremo and Haglund45,Reference Amering, Stastny and Hopper54} Community-based service users and carers have described staff who remain indifferent to them, ^{Reference Goodwin and Happell41} and who display an inherent disregard for their views. ^{Reference Allen73} The pivotal role of respect in establishing successful collaborative relationships remains central to users' discourse, and an accumulation of evidence from different clinical settings and research designs belies its significance as one of the more pervasive yet ill-addressed users' needs. ^{Reference Faulkner and Williams23,Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Howard, El-Mallakh, Kay Rayens and Clark29,Reference Borneo33,Reference Schroder, Ahlstrom and Larsson51,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Ferry and Abramson92–Reference Goodwin and Happell95} Advocacy has been proffered as one way in which perceived power differentials between service users, carers and mental health professionals might potentially be reduced, ^{Reference Magorrian84,Reference Loveland88,Reference Diamond, Parkin, Morris, Bettinis and Bettesworth96,Reference Garcia, Kennett, Quraishi and Duncan97} although empirical evidence of its effect is sparse. Limited qualitative enquiry suggests potential cultural variation in acceptability, and a possibility that users will confront multiple implementation barriers, including a lack of suitable agents to arbitrate on their behalf. ^{Reference Amering, Stastny and Hopper54,Reference Van Dorn, Swanson and Swartz98}

Participatory decision-making

Shared decision-making demands not only that different stakeholders attribute value to their own contributions and those of others but also that there exists perceived equality between them. The existing evidence base remains somewhat ambiguous regarding the extent to which service users may wish to and/or are enabled to attain decision-making control. National and localised surveys have previously evaluated levels of user-involved care planning through the quantification of predetermined ‘success’ criteria, often defined in terms of service users' care planning awareness or their signed endorsement of the resulting care plan. Consensus across these studies suggests that too few people had received a copy of their care plan or had prospectively influenced its development in a meaningful way. ^{2,3,28,Reference Warner32} Limitations in the nature and depth of the data obtained prohibit interpretation in terms of the preferences or intentions of individual service users. Systematic synthesis of qualitative and mixed method evaluations suggests that a key factor influencing people's preferences for care planning involvement may be the timing of their decision-making, specifically whether consultation occurs during a crisis episode. Focus groups conducted with 100 community-based service users in Germany revealed that although service users and carers expressed some uncertainty regarding the former's capacity to make decisions during crisis episodes, they nonetheless advocated enhanced involvement outside of these events. ^{Reference Bramesfeld, Klippel, Seidel, Schwartz and Dierks91} A qualitative evaluation of a UK-based local open record initiative also reported that service users desired greater transparency in their clinical notes yet simultaneously remained reluctant to read external appraisals of themselves when they were ill. ^{Reference Alexander, Rogers, Simpson and Rigby99} The onus is thus placed firmly on mental health professionals, who must remain sensitive to a delicate but potentially complex interplay between patient autonomy and dependency. ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Piippo and Aaltonen43,Reference Linhorst, Hamilton, Young and Eckert100}

The nature of the desired involvement is more difficult to ascertain. Although increasing opportunities for shared decision-making has been identified as a key facilitator of service user-led care planning, interview data obtained from a small sample of community service users have suggested that some individuals may ultimately prefer a more blended decision-making style. ^{Reference Woltmann and Whitley40} In this instance service users were observed to seek professional authentication for their own decisions and tended to capitulate to professionals whenever discord was experienced, on the rationale that the provider's perspective was often more compelling than their own. Notably, those interviewed for this study were recruited from a case management service seeking to provide recovery-based care through intensive and sustained contact with service users. The transferability of the data to traditional service delivery models and other clinical settings thus remains unclear. Both national consultation and community surveys suggest that more congruent decisions between service users and professionals are likely to emanate from trusting and respectful relationships developed over time. ^{Reference Woltmann and Whitley40,Reference Sandlund and Hansson66,Reference Shaul, Eisen, Stringfellow, Clarridge, Hermann and Nelson101} Thus, although the net outcome of blended decision-making may approximate that of a professionally led care plan, the processes by which care is determined are arguably very different.

The importance of being respected, listened to and believed emerge as key themes across service user and carer discourse. Pre-empting care planning meetings with informal discussion, ^{Reference Diamond, Parkin, Morris, Bettinis and Bettesworth96} and documenting only plans that have been prospectively endorsed by service users, has been shown to reduce perceptions of coercion and promote a greater sense of user control. ^{Reference Ware, Tugenberg and Dickey102} Qualitative data obtained from in-patient settings contextualises these findings by showing that requests to endorse a paternalistic care plan retrospectively can engender anxiety among service users, ^{Reference Linhorst, Hamilton, Young and Eckert100} who may attribute legality to their actions and fear retribution should they fail to comply. ^{Reference McDermott72,Reference Van Dorn, Swanson and Swartz98,Reference Linhorst, Hamilton, Young and Eckert100} Service users have previously been shown to conceptualise such practices as tokenistic, thereby highlighting a potentially important difference between staff and service users in the way that collaboration is construed.

Care planning at a relational level

Few studies have examined directly the value that mental health staff afford service user and carer involvement in care planning. The only exception is a survey of occupational therapists, which reported that only half of those interviewed intended to involve service users in decisions about their care. ^{Reference Ceramidas, Forn de Zita, Eklund and Kirsh103} Although the reasons for this were not elucidated, evidence from alternative sources suggests a combination of attitudinal and skill constraints. ^{Reference Warner32,Reference Goodwin and Happell41,Reference Murphy and Cutts52,Reference Cresswell and Lelliott67,Reference Storm and Davidson75,Reference Simpson82,Reference Rea and Rea89,Reference Goodwin and Happell95,Reference McCann, Baird, Clark and Lu104–Reference Barnes, Carpenter and Dickinson107} Modest competencies in partnership working have been reported across multiple professional groups. ^{Reference Ceramidas, Forn de Zita, Eklund and Kirsh103,Reference Ennals and Fossey108} Mental health nurses and allied health professionals disclose insufficient experience in patient-led goal formulation and lack knowledge and familiarity with the range of services available to address service users' social needs. ^{Reference Murphy and Cutts52,Reference Storm and Davidson75,Reference Simpson82} A separate body of literature focuses on the potential for service user-centred care to invoke an ethical dilemma for service providers, and highlights variable levels of professional confidence in service users' capacities to cope with increased responsibility for care. ^{Reference Goodwin and Happell41,Reference Ceramidas, Forn de Zita, Eklund and Kirsh103} Mixed method surveys of advanced directives suggest that psychiatrists may be more likely to endorse shared decision-making where they perceive service users to have greater insight, higher levels of alliance or treatment adherence, ^{Reference Antoniou, Estop and Gilburt22,Reference Coffey109} and/or strong family support for their preferences. ^{Reference Elbogen, Swartz, Van Dorn, Swanson, Kim and Scheyett110}

Triangulation of quantitative and qualitative data across a range of service settings underscores the potential for person-centred services to be negated by entrenched perceptions of staff responsibility under statutory mental health law. ^{Reference Warner32,Reference Dobie, Bulia and Swanke42,Reference O'Donovan85,Reference Carpenter and Sbaraini111} Qualified nursing staff express uncertainty regarding their ability to facilitate therapeutic cooperation, and periodically report an overreliance on professional dialogue to reduce the possibility that service users will refuse an aspect of care they are otherwise deemed to require. ^{Reference Corring and Cook112} Small-scale studies in community and in-patient settings have demonstrated that less experienced and preregistration staff value service user involvement more highly than do qualified staff, ^{Reference McCann, Baird, Clark and Lu104,Reference Carpenter and Sbaraini111} although translation of these values into practice is not guaranteed. Cooperative and qualitative enquiry with service users and student nurses suggests these individuals remain driven by their professional role, portraying risk as a key source of tension in their decisions about when and how service users can best be involved. ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference O'Donovan85}

A competing theme emerging from professional discourse is the perception that service users are at times unwilling to participate in decisions about their own care. ^{Reference Allen73,Reference Storm and Davidson75,Reference Chinman, Allende, Weingarten, Steiner, Tworkowski and Davidson90} Alongside incapacity, ^{Reference Chinman, Allende, Weingarten, Steiner, Tworkowski and Davidson90,Reference Hamann, Langer, Winkler, Busch, Cohen and Leucht113} other perceived barriers to participatory decision-making include non-cooperation with treatment, ^{Reference Chinman, Allende, Weingarten, Steiner, Tworkowski and Davidson90} and a lack of interest in mental healthcare. ^{Reference Storm and Davidson75,Reference Chinman, Allende, Weingarten, Steiner, Tworkowski and Davidson90,Reference Linhorst, Hamilton, Young and Eckert100,Reference Hamann, Langer, Winkler, Busch, Cohen and Leucht113} The reality of these perceptions is difficult to establish. Rigorous qualitative studies exploring the perspectives of people using in-patient services indicate that some may indeed refuse participation, either because they lack motivation, ^{Reference Linhorst, Hamilton, Young and Eckert100} or because prior experience suggests that the process will be tokenistic. ^{Reference Daremo and Haglund45,Reference Amering, Stastny and Hopper54,Reference Corring and Cook112} These data juxtapose larger-scale national surveys and qualitative data from more mixed samples that suggest that the majority of service users continue to advocate greater involvement in the care planning process. ^{21,27,28,Reference Rose, Ford, Lindley and Gawith31–Reference Borneo33,Reference Rose39}

Discrepancies between different stakeholder groups and settings raise the long-standing question of whether mental health professionals are intentionally or unintentionally denying service users involvement in their care. Triangulation of quantitative and qualitative data suggests that service users and carers remain steadfast in their requests for respect, ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Howard, El-Mallakh, Kay Rayens and Clark29,Reference Schene and Van Wijngaarden30,Reference Goodwin and Happell41,Reference Schroder, Ahlstrom and Larsson51,Reference Askey, Holmshaw, Gamble and Gray78,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Ferry and Abramson92–Reference Schroder and Ahlstrom94} and perceive some service providers as displaying critical condescension towards them, ^{Reference Goodwin and Happell41} emanating directly from concepts of stigma, ^{Reference Bramesfeld, Klippel, Seidel, Schwartz and Dierks91,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Corring and Cook112} or blame. ^{21,Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference O'Brien93,Reference Shaul, Eisen, Stringfellow, Clarridge, Hermann and Nelson101,Reference Beebe, Harrison, McRae and Asche114} Rigorous qualitative analysis of service user views suggests that some mental health professionals may deliberately seek to retain relational power by presenting themselves as the most knowledgeable group. ^{Reference Dobie, Bulia and Swanke42,Reference McDermott72} Although limited in availability, professional discourse lends some support to this view. ^{Reference Askey, Holmshaw, Gamble and Gray78}

Heterogeneity within the populations and variables studied makes the true relationships between service user and professional characteristics difficult to establish. Select quantitative studies suggest that clinical experience may influence staff attitudes towards service user involvement, with female and less experienced staff more likely to support collaboration. ^{Reference McCann, Clark, Baird and Lu105} Staff may be more reluctant to involve users with thought disturbance or psychoses, ^{Reference Corrigan, Buican and McCracken115,Reference Henderson, Jackson, Slade, Young and Strauss56} and individuals with affective disorders have been shown to report higher satisfaction with treatment influence and involvement than those with schizophrenia. ^{Reference Svensson and Hansson80,Reference Ostman, Wallsten and Kjellin116} The validity of these relationships is difficult to establish. The potential for professionals' views to be influenced by stigma is supported by small studies that suggest service users' and carers' knowledge may be mediated by demographic or ethnic status. ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Alegria, Polo, Gao, Santana, Rothstein and Jimenez57,Reference Allen73,Reference Blenkiron, Mo, Cuzen and Hammill117} Compared with White service users, those from Black and ethnic minority groups may be less likely to be given a copy of their care plan, ^{Reference Allen73} and less likely to have their views and daily needs assessed. ^{3,Reference Warner32,Reference Allen73}

Although controlled trials of joint crisis planning document preliminary evidence of effect, ^{Reference Henderson, Swanson, Szmukler, Thornicroft and Zinkler118–Reference Van Dorn, Swanson, Swartz, Elbogen and Ferron121} process evaluations suggest that these initiatives can attract professional scepticism, be perceived as an administrative burden and be poorly accessed or adhered to by staff. ^{Reference Storm and Davidson75,Reference Garcia, Kennett, Quraishi and Duncan97,Reference Van Dorn, Swanson and Swartz98,Reference Elbogen, Swartz, Van Dorn, Swanson, Kim and Scheyett110,Reference Henderson, Swanson, Szmukler, Thornicroft and Zinkler118,Reference Elbogen, Swanson, Appelbaum, Swartz, Ferron and Van Dorn122–Reference Papageorgiou, Janmohamed, King, Davidson and Dawson126} Once again, however, limitations in the amount and depth of data prohibit any firm conclusions regarding the extent to which this behaviour is underpinned by deliberate or misplaced intent. One small survey of in-patient staff has reported service providers opposing the notion that patients should have unrestricted access to clinical notes and rejecting opportunities for patients to make written contributions to their files. ^{Reference McCann, Baird, Clark and Lu104} Additional data suggest that staff may be more willing to acknowledge service user views and more likely to consent to initiatives aimed at addressing their needs in instances when service users highlight previously unidentified goals. ^{Reference Hansen, Hatling, Lidal and Ruud127} Although premised on a limited evidence base, this observation raises the possibility that professional resistance to service user involvement may depend less upon clinicians' reluctance to foster relational equality per se, and more upon which party is afforded greater status as the original purveyor of need. ^{Reference Hansen, Hatling, Lidal and Ruud127}

Conveying familiarity with service users' preferences has been shown to contribute to an individual's perception of being known. ^{Reference Chan, MacKenzie, Ng and Leung58,Reference Ware, Tugenberg and Dickey102} Increasing opportunities for service users to identify and communicate their needs effectively thus hold promise as an effective means by which to enhance satisfaction with mental health services and specifically with user-involved care. An accumulation of quantitative and qualitative evidence suggests that in order to achieve this routinely, staff may need to engage more intensively and consistently with service users. ^{21,Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Woltmann and Whitley40,Reference Beeforth, Colan and Graley62,Reference Askey, Holmshaw, Gamble and Gray78,Reference Bramesfeld, Klippel, Seidel, Schwartz and Dierks91,Reference Shaul, Eisen, Stringfellow, Clarridge, Hermann and Nelson101,Reference Angell and Mahoney128} Insufficient contact with mental health professionals has previously been shown to erode service user trust and reduce the possibility that this dyad will discuss issues that will augment and extend a medical model of care. ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25}

Care planning at the organisational level

Triangulation of qualitative and quantitative data has already shown that meaningful service user involvement is likely to depend upon the reorientation of the attitudes and practices of more than one stakeholder group. Qualitative synthesis further suggests that this reorientation in turn demands effective and demonstrable organisational support. ^{Reference Cambridge, Forrester-Jones, Carpenter, Tate, Knapp and Beecham44,Reference Daremo and Haglund45,Reference Storm and Davidson75,Reference Linhorst, Hamilton, Young and Eckert100} In order to increase scope for involvement, service users advocate that services should be more critical of their tendency to medicalise service user experiences and their predisposition towards diagnostically driven care. ^{Reference Tee, Lathlean, Herbert, Coldham, East and Johnson25,Reference Goodwin and Happell41,Reference Piippo and Aaltonen43,Reference Daremo and Haglund45,48,Reference Schmidt-Posner and Jerrell50,Reference O'Donovan85} The maintenance and dominance of a service model in which the majority of decisions rest with a psychiatrist, ^{21,Reference Warner32} has specifically been implicated in preventing other mental health professionals from practising in an empowering way. ^{Reference Goodwin and Happell41,Reference O'Donovan85}

System constraints that increase caseloads, ^{Reference Lawn, Battersby, Pols, Lawrence, Parry and Urukalo129} and/or limit staff contact time, have directly been blamed for the failure of mental health services to fully involve service users and carers in their care. ^{Reference Warner32,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Ennals and Fossey108} Qualitative discourse has historically portrayed mental health staff as overworked, stressed and suffering from compassion fatigue, albeit with some variation across clinical service settings. ^{Reference Antoniou, Estop and Gilburt22,Reference Cambridge, Forrester-Jones, Carpenter, Tate, Knapp and Beecham44,Reference Goodwin and Happell95,Reference Corring and Cook112} Interviews undertaken with acute and community care staff highlight practice environments that are ritualised and excessively task-oriented, ^{Reference Piippo and Aaltonen43,Reference Cambridge, Forrester-Jones, Carpenter, Tate, Knapp and Beecham44,Reference O'Donovan85} and it has previously been questioned whether or not these staff have the necessary time and support to meet their clients' holistic needs. ^{48,Reference Goodwin and Happell95} Innovative training initiatives aimed at enhancing nursing skills show preliminary evidence of effect. ^{Reference Barnes, Carpenter and Dickinson107,Reference Richards, Bee, Loftus, Baker, Bailey and Lovell130} In-depth process evaluations report longer-term implementation to be constrained by ritualised care environments, high staff turnover, low organisational support for user-involved care planning and insufficient commitment to professional and team development. ^{Reference Piippo and Aaltonen43,Reference Cambridge, Forrester-Jones, Carpenter, Tate, Knapp and Beecham44,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Goodwin and Happell95,Reference Lawn, Battersby, Pols, Lawrence, Parry and Urukalo129}

Care planning inevitably necessitates interactions between different stakeholder groups and the context and quality of these interactions may directly affect the way in which the meaning of the event is construed. Across clinical settings, administrative and communicative breakdowns have been implicated in services' failures to appoint or make care coordinators accessible to service users. ^{Reference Webb, Clifford, Fowler, Morgan and Hanson64,Reference Bowers68,Reference Brown74,Reference Ford and Rose87,Reference Ryan, Pearsall, Hatfield and Poole131} Service users and carers report insufficient notification of care planning meetings, ^{Reference Loveland88,132} poor documentation of care planning outcomes, ⁴⁸ and a lack of warning regarding treatment changes or scheduled review. ^{28,Reference Perreault, Paquin, Kennedy, Desmarais and Tardif69,Reference Ryan, Pearsall, Hatfield and Poole131} Specific communication failures have been identified between in-patient and community staff, ^{Reference Goodwin and Happell41} and between mental health nurses, psychiatrists and general practitioners. ^{Reference Carpenter and Sbaraini111} Poor interagency communication has been cited both as a reason for low staff attendance at care planning meetings, ^{Reference Goodwin and Happell41} and as a barrier to professionals accessing written evidence of service users' preferences during crisis. ^{Reference Garcia, Kennett, Quraishi and Duncan97} Triangulation of these data suggests that some services may ultimately have reduced care planning to an event in which providers outline their responsibilities to service users, rather than upholding its conceptualisation as a collaborative and prospective process through which both parties can holistically address the service user's recovery-based needs.

Central to discourse is the notion that service users and carers can feel intimidated or ignored during care planning meetings. ^{Reference Allen73} Intimidation arises both from the physical environment in which the meeting takes place and from the formality with which it is conducted. ^{Reference McDermott72,Reference Storm and Davidson75,Reference Simpson82,Reference Magorrian84} By virtue of their very location, care planning meetings conducted within a clinical environment bring with them perceptions of illness and relinquished control. ^{Reference Henderson, Jackson, Slade, Young and Strauss56,Reference McDermott72,Reference Carpenter and Sbaraini111} Other key criticisms include excessive levels of staff attendance at care planning consultations, ^{Reference Cambridge, Forrester-Jones, Carpenter, Tate, Knapp and Beecham44,Reference Allen73,Reference Carpenter and Sbaraini111} the presence of unknown staff or of staff not directly involved in a person's care, ^{Reference Allen73} and the failure of professionals to acknowledge or introduce meeting attenders. ^{Reference Allen73} Restrictions on the amount of time that professionals are able to allocate to care planning, ^{Reference Allen73,Reference Magorrian84} and the subsequent speed with which decisions are made, have additionally been reported to deter service user involvement. ^{Reference McDermott72,Reference Allen73,Reference Chinman, Allende, Weingarten, Steiner, Tworkowski and Davidson90}

Access barriers on the part of service users and carers have also been acknowledged and include geographical distance, competing caring responsibilities and economic constraints that prohibit attendance at care planning consultations within routine hours. ^{Reference Lakeman65,Reference Loveland88,Reference Goodwin and Happell95} Organisational mechanisms that have been postulated to overcome these difficulties include the provision of open accessible care teams, staff who are validated in spending time with service users and carers, and services that offer flexibility in the timing and venue of care planning meetings. ^{Reference Daremo and Haglund45,Reference Perkins and Fisher47,Reference Schroder, Ahlstrom and Larsson51,Reference Henderson, Jackson, Slade, Young and Strauss56,Reference Chan, MacKenzie, Ng and Leung58,Reference Askey, Holmshaw, Gamble and Gray78,Reference McAuliffe, Andriske, Moller, O'Brien, Breslin and Hickey79,Reference Diamond, Parkin, Morris, Bettinis and Bettesworth96,Reference Ennals and Fossey108,Reference Modrcin, Rapp and Poertner133} A proxy indicator for service user satisfaction with care planning involvement may thus be not only the degree to which mental health services recognise the importance of service user and carer participation, but also the extent to which they display tangible commitments to facilitating this process. ^{Reference Cambridge, Forrester-Jones, Carpenter, Tate, Knapp and Beecham44,Reference Daremo and Haglund45,Reference Storm and Davidson75,Reference Linhorst, Hamilton, Young and Eckert100}