Reviewing Peer Working A New Way of Working in Mental Health A paper in the Experts by Experience series Scottish Recovery Network: July 2013
Introduction The Scottish Government s Mental Health Strategy for Scotland 2012-15 contained a commitment to commission a short review of work to date in Scotland on peer support working as a basis for learning lessons and extending the use of the model more widely. This paper brings together a range of information and intelligence on peer working to improve understanding of the role and its benefits, and to encourage more organisations to develop paid peer worker roles as an integral part of their service provision. It has been developed by Scottish Recovery Network informed by the experiences and voices of peer workers and those who have developed, or are developing, peer worker posts. Recovery focused services are about involving people and using all available expertise, including lived experience, to ensure the help and the support available best meet the needs of people to both lead their own recovery and develop a fulfilling and satisfying life. Peer working is a key component of a recovery focused system. We are currently in a period of public service transformation with a range of strategies, bills and reports acknowledging the need for radical change in the way services are designed and delivered, irrespective of the challenging financial climate we operate in. This paper sits within this framework and seeks to inform thinking of what services will look like in the future. It is clear that more or less of the same will not help us fully achieve our policy objectives. New ways of working, including new types of jobs and approaches will be needed. This short paper will: Define the peer working role; Outline current peer working activity in Scotland; Set out the evidence base and policy context for peer working; Consider how peer working roles are being, and can be, developed, supported and sustained. Scottish Recovery Network: Reviewing Peer Working Page 1
What is Peer Working? s are people who have personal experience of mental health problems who are trained and employed to work in a formalised role in support of others in recovery. s are willing and able to share their personal experiences on an equal level that supports, empowers and brings hope to the people they partner with. The peer worker role involves: Developing mutually empowering relationships; Sharing personal experiences in a way that inspires hope; Offering hope and support as an equal. For many years people who experience mental health problems have described the importance and value of support from others who have had similar experiences and how it brings something different to what is found in professional support relationships. Employing s provides an opportunity to enrich the provision of mental health services through the direct participation and expertise that people with personal experience of mental health problems and using services can bring. Service provision has traditionally been developed with practitioners expertise developed through knowledge or education based approaches whereas peer workers expertise is experiential, grounded in their personal experience. By bringing together this wealth of expertise, peer workers bring something additional and complementary to the services currently provided. s have a unique and distinct role, offering mutuality, empowerment, modelling hope and the sharing of lived experience with people using services. The type of activities that peer workers undertake depends on the setting they are working in but includes: There is a great deal of strength gained in knowing someone who has walked where you are walking and who now has a life of their choosing. In this way it is different from support work. I look at peer support on the wards as looking at wellness, there are plenty of people on the wards to focus on an individual s illness. Peer Worker I feel that showing that there is hope for everyone, people can and do recover, going on to lead full and productive lives. Working one to one with people; sharing experiences and learning together; Running recovery education and mutual support groups; Supporting people to use self management tools including Wellness Recovery Action Plans (WRAP); I can offer alternative problem-solving skills and promote self-confidence to confront issues and manage stress. Supporting people through transitions; Raising awareness and influencing the practice of other staff. There is an increasing identification of the potential for peer roles to improve services and outcomes. For example, the recent report of the Schizophrenia Commission stated 1 : We believe there is a case for using peer workers in supporting people with schizophrenia and psychosis. Their experience of living with the condition and achieving a good quality of life, and of navigating their way through the mental health system, is extremely it s not walking in front leading or from behind pushing - it s walking alongside. 1 The Schizophrenia Commission, (2012). The abandoned illness: a report from the Schizophrenia Commission. London: Rethink Mental Illness. Scottish Recovery Network: Reviewing Peer Working Page 2
valuable as a supportive resource. The recent report Peer Support in mental health care (Trachtenberg et al, 2013) 2 assesses whether peer support provides value for money through looking specifically at whether peer support workers can reduce psychiatric inpatient use, either by preventing admissions or by shortening lengths of stay. The findings suggest that the financial benefits of employing peer support workers do indeed exceed the costs, in some by a substantial margin. 2 Trachtenberg T, Parsonage M, Shepherd G, Boardman J. (2013) Peer Support in mental health:is it good value for money? London:Centre for Mental Health Scottish Recovery Network: Reviewing Peer Working Page 3
Current Peer Working Activity There has been a growth of peer working since the pilot projects which emerged from Delivering for Mental Health in 2006. Across Scotland there are currently 53 peer worker posts in a variety of settings and the chart below shows where they are currently employed. Over 75% are employed in the voluntary sector including five posts located in user and carer organisations. Development of posts in the statutory sector has been slower to date. There is a strong commitment at all levels of the organisation to develop peer working and make it part of the fabric of what we do. Voluntary organisation It was felt the timing offered a positive opportunity for change in the type of services we offer and how they are delivered. Local authority Recently we noted average absence rates for peer workers were lower than the organisational average. Voluntary organisation The majority of peer workers work between 20-30 hours per week. Based on current information the average working week is 23 hours. Scottish Recovery Network is committed to supporting and promoting peer working roles and to do this we have developed a range of information, support and resources based on our research and experiential learning. This includes: Experts by Experience a guide to support the development of Peer Worker roles in the mental health sector; Professional Development Award (PDA) in Mental Health Peer Support a qualification developed in partnership with SQA and now available for SQA approved learning centres to deliver; Values Framework for Peer Working a framework of values and behaviours developed with those currently involved in peer working to increase understanding of the role and maintain its distinctiveness; Tailored advice, guidance and support to organisations seeking to develop peer working roles. SRN are currently supporting a pilot of the PDA Mental Health Peer Support in Lothian starting in September. The pilot will be evaluated with learning shared as a means to encourage further development and wider access. Using a peer-to-peer model can complement existing health care support making a positive impact in providing a recovery focused approach which is beneficial to individuals in an acute hospital setting. User & carer organisation partnering with NHS Much of our learning, planning development and review processes have been underpinned by the SRN Experts by Experience guidelines, the Peer Values Framework and from networking with other peers and colleagues. Local authority Scottish Recovery Network: Reviewing Peer Working Page 4
Why should we develop Peer Working roles? With the continued promotion of recovery approaches in mental health policies and practices in Scotland, comes an increased recognition of the potential contribution of Peer Workers to recovery focused service systems. Peer Workers are particularly well placed, in comparison to non-peer providers, to deliver on a number of elements that have been identified as central to recovery including, hope, empowerment, self-management and social inclusion (Repper & Carter, 2011 3 ). At the same time the development of peer roles is justified by an increased evidence base that, while documenting the challenges in role development, is clear about the benefits of employing Peer Workers. In a thorough review of research in relation to all aspects of Peer Working Repper and Carter (2011) identified a range of benefits for people in receipt of peer provided services. These findings are summarised in the following table. People describe their stay in hospital as different, more focused on wellness. Many have commented that they now leave with a plan to be well through using the self management techniques that we work on with individuals. Evidence in relation to Notes and examples Hospital admission, readmission and discharge Evidence of reduced admission and readmission rates and longer community tenure - one study identified a 50% reduction in readmissions. Study of peer involved discharge programme identified 300 bed days saved in first three months of programme. Randomised control trial evidence suggests improved or at worst similar outcomes between peer and non-peer provided services. Empowerment Raised empowerment scores reported in several studies of peer support. Improvements attributed to new ways of relating in peer to peer relationships. Social support and functioning Studies show enhanced community integration for people using peer provided services compared to non-peer, as well as development of improved social supports. Being exposed to peer role models and new perspectives can improve problem solving, coping skills and social functioning. Empathy and acceptance Studies identify more relational focus in peer services compared to a more task oriented approach in non-peer services. RCT evidence identified greater feelings of acceptance and understanding for people receiving peer provided services. Reducing stigma Those receiving peer services are less likely to identify stigma as an obstacle. Hope Essential benefit gained and inspiration provided in peer to peer relationship is hard to overstate. Table 1: Evidence for peer working 3 Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of mental health, 20(4), 392 411. Scottish Recovery Network: Reviewing Peer Working Page 5
A 2013 Cochrane review 4 of peer working effectiveness concluded: employing past or present consumers of mental health services as providers of mental health services achieves psychosocial, mental health symptom and service use outcomes that are no better or worse than those achieved by professional staff in providing care. It suggested future research be more closely aligned to intended recovery outcomes. In addition to benefits identified for people who engage with peer provided services, research literature is clear that there can also be significant benefits for people providing peer services. As well as offering employment opportunities where disclosure is positively encouraged, becoming a Peer Worker can aid people in their own recovery through improved self-esteem and, for some, the enhanced social status accrued through having a valued and contributing role. More widely a number of UK studies have identified benefits for the services and systems in which Peer Workers are placed. These include: An increased focus on, and understanding of, recovery; Better awareness of the value of lived experience in service settings and relationships; Reduced stigma in staff teams and an associated reduction in them and us attitudes. The development of peer working roles will also assist organisations to embrace the goals set by the wider policy landscape within which mental health services operate. This policy landscape is informed by a wide range of strategies and reports including the Mental Health Strategy for Scotland 2012-16; The Commission on the Future Delivery of Public Services; the NHS Quality Strategy; the National Strategy for Self Directed Support; the recent consultation on the Integration of Adult Health and Social Care and the Employability Framework for Scotland. Despite the variety of these strategies and reports there is a clear consensus emerging on the essential components of effective service development, design and delivery. As summarised in table 2 (over) peer working clearly fits with the current policy agenda and provides one way to achieve the key objectives of involving people in the design and delivery of services; changing the way services relate to those who use them; providing a wider range of responses and maximizing the strengths and assets of all those involved in delivering and using services. Peer working also provides high quality employment opportunities for people with lived experience of mental health problems and as such can play an important role in their continuing recovery. As the peer working role is extended there will also be opportunities for those already working in services to build on their skills and contribute to the further development of roles in service management and design and in peer education. This job aids my wellness and provides financial and benefit free living Peer work without a shadow of a doubt has given me even more determination to stay well and continue learning from others The great thing about working as a peer worker is I can utilise what I used to recall as 20 years of very negative experiences into something constructive with positivity to benefit other people and offer hope Greater awareness of people s own efforts in the recovery journey and what professionals can do to support their efforts. Consultant psychiatrist As a peer support worker I have the chance to change and challenge bad practice in the workplace, by keeping others focused on recovery based practice and the use of positive language. I have found working with a peer support worker challenging my own practice but immensely rewarding. Head Occupational Therapist 4 Pitt V, Lowe D, Hill S, Prictor M, Hetrick, SE, Ryan R & Berends L. (2013) Consumer-providers of care for adults clients of statutory mental health services. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD004807 Scottish Recovery Network: Reviewing Peer Working Page 6
Component Contribution of Peer Working New care and treatment models Different way of engaging with and supporting people Emphasise the holistic needs and experiences of the person not the illness or symptoms Involving people Role for those with lived experience in service delivery and development Demonstrating that the skills and views of those with lived experience is valued Improves understanding of how people experience and understand their health and how they can best be supported Self Management s are living examples of how individuals can take ownership of and direct their recovery s embody the benefits of self management Asset based approaches Maximises the use of all available resources and expertise including lived experience Nurtures the skills and strengths of those receiving and delivering services Empowers people to take control of their futures Shift from institutional to community Builds capacity in individuals and the community Transfers focus from illness and treatment to people s hopes, goals and support needs Co-production Allows the knowledge and resources of those with lived experience to be used to develop and deliver solutions Provides a basis for an equal relationship between service users and providers Allows services and people who use them both to become agents for change Personalisation People decide how to use services that best meet their aspirations and needs Peer information, advice and support are key to assisting people to direct their own support New way of delivering services valued by people with lived experience Employment Demonstrates that people with mental health problems can get and keep work Values the lived experience and expertise of those with mental health problems Helps to tackle discrimination and address stigma in the work place and wider society Table 2: How peer working fits the policy agenda Scottish Recovery Network: Reviewing Peer Working Page 7
Next Steps Peer working provides an opportunity for mental health services across all sectors to not only involve those with experience of mental health problems and using services but also to maximise the use of expertise and resources and to improve the outcomes for those using services. Peer working is already in place and in development in a range of services and organisations across Scotland where it is assisting in improving service quality and outcomes and meeting policy objectives. The current operating environment provides an opportunity for peer working to be extended more widely across Scotland. Many mental health services are reviewing what they do, the way they work and the outcomes they hope to achieve for those using the services and as a result are embarking on a process of service development and re-design. Those organisations who have peer worker posts in place have taken a variety of approaches to developing the role. These include: Making a strategic commitment to developing peer working through re-designating existing posts as peer worker posts as they become vacant and also by creating new posts as part of bids for new services; Creating posts as part of a service re-design exercise; Utilising resources made available through pilot programmes or through changes in staffing to create posts; Joint working between the NHS and local user and carer voluntary organisations to develop and deliver peer worker posts where the staff are employed by the voluntary organisation and work in and with the NHS. While service user groups continue to advocate for peer approaches and professionals from voluntary organisations, local authorities and the NHS grow more assured of the value of peer working the Scottish Recovery Network is available to advise, guide and support role development, backed by a range of resources and information. Peer working will become an increasingly important part of recovery focused services and a way for services to value lived experience; maximise the use of resources and improve outcomes for people with mental health problems. This way of working and the benefits it brings have been established and the infrastructure is now in place to support services to plan, develop and implement peer working. Now, the challenge for services is to ensure that they embrace peer working and embed recovery focused approaches in all that they do. Scottish Recovery Network: Reviewing Peer Working Page 8