The implementation of new roles in mental health trusts in England: a qualitative study of workforce leaders’ perspectives

The workforce crisis in the English NHS is widely recognised and most acute in mental health (MH) services where demand has risen, impacting on other parts of the system. In response, new investment aims to expand the MH workforce through introducing new roles (skill-mix change). Outside MH, evidence suggests that skill-mix change disrupts systems, bringing significant organisational challenges as well as potential benefits. The study aimed to examine the perspectives of leaders involved in new roles change in English mental health trusts (MHTs) on the rationale for and process of introducing new roles, and key factors affecting implementation. A two-phase qualitative design examined purposively sampled leaders’ perspectives on the implementation of new roles in MHTs. Phase 1 involved semi-structured online interviews with MHT leaders. Phase 2 comprised a series of online stakeholder reflection groups informed by Phase 1 findings, with leaders from provider, policy and professional bodies. Template Analysis assisted initial data coding followed by comparison of the template with the domains of the Consolidated Framework for Implementation Research (CFIR) to identify the most influential issues affecting implementation. Leaders from 31 of 51 MHTs participated in Phase 1 (response rate 61%; 33 leads in total); 18 leaders participated in one of three reflection groups in Phase 2. Three cross-cutting themes were generated: (1) MHTs’ motivation for implementation including drivers and concerns; (2) the challenging MHT implementation context and consequences arising (largely unintended); (3) the strategies that some leaders were employing in MHTs to support implementation despite challenges. The study provides valuable insights for implementers on the challenges and opportunities associated with introducing new roles in mental health services to help plan and conduct strategic, operational and relational implementation efforts. The policy/commissioning context (outer domain) was less controllable, however all remaining domains (the innovation, inner setting, attitudes of individuals, and process of implementation) were amenable to adaptation to some degree through the implementation work of leaders. Skill-mix change should be recognised as a process of adaptation and system change over time requiring multi-level implementation work tailored to local needs.