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CHAPTER SIX INNOVATIVE PRACTICE

6.1 Introduction

The Choose Life action plan and supporting guidance contained an expectation that local areas would use a proportion of their funding allocation to support innovation in the voluntary and community sectors and that this would include self-help initiatives.

Innovation was seen in two main ways: first, in terms of interventions, as a means to introduce new ways of working and widen the range of available options; and, second, as a means of promoting partnership development and local 'ownership' and engendering learning and wider system change.

The scope of this chapter is to illustrate examples of innovative practice underway in local areas, as defined by Choose Life coordinators. In the survey, coordinators were asked to provide examples of innovative practice indicating: types of activities; factors that influenced decision making; progress towards implementation; factors that influenced success; barriers to implementation; and key learning points. The survey also gathered information about how these practice examples were being evaluated.

We are able to report on the extent to which innovations were perceived to be based on evidence of what is known to be effective. However, we cannot assess the effectiveness of innovative developments initiated in phase one. The use of evidence as a part of decision making is discussed in chapter eight and will therefore not be covered in detail here. Similarly, findings relating to the monitoring and evaluation of initiatives are also provided in chapter eight.

Where possible, this chapter provides contextual information about initiatives (e.g. location and target group). However, this is not possible in all examples as the detail was dependent upon the level of information fed back in the survey.

6.2 Innovative community, voluntary and self-help practice

This section considers examples of innovative community, voluntary and self-help practice as defined by local coordinators.

6.2.1 Community and voluntary initiatives

In the first survey, 21 local areas provided examples of locally defined innovative community and voluntary practice. In the majority of cases, the activity was thought to be innovative because it was new to the client group or to the local area.

Prevention/promotion activities

Highland has funded the continued implementation of a STIGMA play delivered to 15-18 year olds across high schools. The main aims of the project were to help young people gain a greater understanding of a range of mental health issues that affected their age group, to challenge young people's misinformed views about people who experience mental health problems and to inform young people about where and how to access help and support. Workshops for professionals on the topic of self-harm for professionals were linked to the 2005 tour of the STIGMA play, to ensure that there is a whole package of support, preparation and debriefing with both pupils and teaching staff.

In two areas (Moray and Midlothian), links were established to existing Healthy Living Partnership projects. In Midlothian, this involved linking to a new Healthy Living Partnership project /information service. In Moray, alternative therapies were provided as part of the healthy living leisure centre for people with mental health problems.

Intervening/supporting vulnerable groups

Innovative approaches identified also included group and one to one support for people who self-harm, a counselling service for carers, support groups for people with mental health problems, and extended services supporting people misusing substance:.

• In West Lothian, the Hawthorn project was a new project to the area. This supported young people (aged 12-25 yrs) who self-harmed though individual and group work. The project is jointly funded by Penumbra and Choose Life West Lothian. Key activities of the Hawthorn project included: support to young people; counselling; education/awareness raising with professionals, carers and family/friends (email, phone, 1-1, drop in) ; training; signposting into other resources; one to one support services; and group work.
• In East Ayrshire, funding was allocated to East Ayrshire Carers' Centre to develop and fund counselling services. Funding was used for counselling in order to work with young people at particular risk.
• In Shetland, two drug and alcohol support teams extended the hours of their outreach workers to provide a full-time service to people with substance misuse problems.

Developing new partnerships better to support those at risk

Areas had developed new partnerships in service delivery in order better to target those at risk.

In Fife, an initial intervention outlined in a local action plan was to support men with depression by linking a mental health worker into the local Opportunity Centre. The activity was based upon the results of a previous local pilot. Changes were made to the delivery model of this intervention.

East Renfrewshire funded implementation of a schools-based youth counselling service, jointly managed by a mental health association and the local education department. Intended outcomes of the project were to provide earlier and easier access to counselling and associated services for young people; to provide effective counselling that clinically reduces the level of stress experienced in young people's mental health; and engage and encourage families, parents, teachers and other staff in a dialogue that promotes the emotional well-being of young people.

Work was also underway to link voluntary organisations such as the Samaritans and Citizens Advice Bureau with clinical services. In East Lothian, direct Citizens Advice Bureaux support was provided to the psychiatric admission ward and local mental health resource centre.

Funding was provided for the local branch of the Samaritans to upgrade equipment and obtain support and training to allow the organisation to introduce an e-mail service in the Western Isles. In Angus, the Samaritans were promoting their service locally, and one proposed development was to build direct contact arrangements to the Samaritans into the A&E department locally.

In North Lanarkshire, the Association for Mental Health was initially funded to develop a support programme for adults who have attempted suicide/adults at early risk of suicide and support for people affected by suicidal behaviour. Again, there had been changes to this model of delivery.

Improving capacity of those working with vulnerable groups

There were examples of activity that were intended to improve the skills and knowledge of those working with risk groups.

• Glasgow stated that they were considering the gender and race equality dimensions of their work, initially through the development of voluntary sector liaison groups.
• In Dumfries and Galloway, voluntary organisation staff groups were invited to become trainers for ASIST.
• In Inverclyde, a local Practitioners' Forum was established with the aim of facilitating multi-agency working and sharing of expertise from different fields. The forum focused activity upon two key tasks in phase one that included workplace health and stress and bereavement.
• In East Dunbartonshire, the area had linked coordination with community and voluntary developments by placing the Choose Life coordinator within a key local voluntary sector organisation.

Factors influencing decision making

Commonly, multiple factors influenced the decision to develop particular interventions. One stimulus was an identified gap in service provision highlighted in local needs assessment, while other factors included local demand, the wish to build on pilot work or the need to provide support to existing groups which were unable to sustain themselves. Fewer areas highlighted evidence of effectiveness as a rationale, either locally generated (e.g. results of local evaluation) or from published research evidence.

In a number of examples, activities focused upon developing new ways of working between existing services such as clinical and voluntary organisations. In some case study areas, informants highlighted that building capacity within existing services offered a more sustainable approach as it harnessed local expertise and skills. (This issue is discussed in chapter eight, along with other key decision making factors, e.g. use of evidence).

Perceived progress made in community and voluntary initiatives

In the second survey, almost all areas that had provided examples of community and voluntary initiatives reported that they had achieved what they set out to do or exceeded this. For example, an evaluation of the East Renfrewshire schools counselling service was able to demonstrate the positive results achieved for young people using the service, which led to expansion to all local secondary schools. A key facilitator was said to be the good working relationships developed between the counselling service and other local agencies.

In Midlothian, there had been an extension of the Information Officer's hours to develop a suicide prevention and mental health information bank.

East Ayrshire counselling service was fully operational and additional support work with young people was ongoing to enable vulnerable young people to participate in a range of activities and access additional support as appropriate to their needs.

In East Lothian, the Citizens Advice Bureau support service was reported to be operational. A weekly service was held at local psychiatric hospital and monthly contact at a local mental health resource centre. In the first six months, 25 patients accessed the service which involved 163 client contacts. Here, it was though that the holistic service provided by Citizens Advice Bureau was helpful in dealing with multiple and complex problems of clients.

Three sites identified changes to their original plans, including changes with regard to the initial target group, and a new scoping exercise to determine the level of need and current service response. For example, Lanarkshire Association for Mental Health identified that that there were some barriers to developing and using support programmes both from professionals and people who had attempted suicide/people affected by suicidal behaviour. The proposal was changed and a scoping exercise carried out to examine the level of need and service response for adults who present to frontline services where suicide is an issue. It was felt that the close working arrangement between the development coordinator and Lanarkshire Association for Mental Health allowed the proposal to be revised when it became clear that the original formulation was not workable.

Glasgow had stated that they were considering the gender and race equality dimensions of their work and initially voluntary sector liaison groups were to be established. By the second survey, it was decided that creating specific structures for equality aspects of Choose Life would be less effective and less sustainable than taking an integrated approach to link into broader work on equalities issues as part of existing equalities and diversity work undertaken by the Council and NHS.

6.2.2Approaches taken to self-help initiatives

Fifteen areas provided specific examples of self-help activities underway.

Links to primary care

In four areas, links were established with the local Doing Well by People with Depression project. East Renfrewshire funded a primary care liaison worker to offer guided self-help to patients with mild to moderate depression and anxiety.

Supporting risk groups

Group support was a common approach and included mental health service user-led support groups; groups in arts, drama, poetry and writing; and support for those who had experienced childhood sexual abuse.

Factors influencing decision making

Supporting the development of self-help initiatives tended to be regarded as means to add value to existing interventions and services e.g. DWBPWD or primary mental health care teams. In one area, the introduction of a self-help initiative was thought to provide a more strategic approach to targeting risk groups. In another area, it was anticipated that the development of capacity at primary care level would divert people away from services and empower people to take responsibility for their own recovery.

Developments were often initiated in response to local need or demand. In Inverclyde, bereavement work was already an identified priority in the local JHIP. In another area, self-help groups were viewed as a more practical way of providing support due to the rurality of the area (although the area was not able to identify an example of a self-help development underway). In West Dunbartonshire, research and discussion with national organisations had informed the development of a support group for people bereaved by suicide.

Progress made in self-help initiatives

In eleven areas, the planned self-help services or resources were operational by the time of the second survey. In three of these, services were also making links with other organisations or inputting into strategic planning structures, multi-agency partnerships and joint fora, or were expanding their activities. For example, in Highland, collaboration locally with the funded groups for survivors of sexual abuse resulted in a Sexual Abuse Survivors forum for Highland and a successful conference aimed at clarifying level of need, provided services and future requirements. Subsequently, two members of the forum were invited onto a national group to determine the allocation of funding by the Scottish Executive to support people affected by sexual abuse.

Appointment of a manager of the Western Isles Association for Mental Health was thought to provide a better structure to the organisation and more certainty for clients about the availability of services. The services had been extended to allow the drop-in centre to open more frequently and for organised activities such as art and gardening groups to take place.

Publicity and/or events had taken place in two sites, and one area pointed to an increased local recognition of the benefits of self-help in the area. For example, the multi-media group developed in East Lothian had attracted new volunteers and had developed a range of performance and visual material highlighting issues around mental health, stigma and suicide. A performance about mental health issues had been offered to all East Lothian Secondary schools by the group, and was performed at mental health/community care networking events. Supporting a mental health service user group to produce their own material and vision was identified as a key success factor in this initiative.

The process of designing the website undertaken by the support group in Shetland was thought to have been therapeutic. It had enabled some members to express and explore issues and other members had learned new coping strategies.

In the other four areas work remained at the planning/assessment stage.

6.2.3 Key factors contributing to success in community, voluntary and self-help initiatives

In the second survey, coordinators highlighted the following key factors as contributory to the success of their initiatives:

• Partnerships and coordination: in particular the presence of good partnership working arrangements, stakeholder willingness to collaborate and negotiate on decisions, consistent commitment and motivation of stakeholders, and time to build and establish trusting relationships between partners
• Increasing capacity: new services were increasing capacity by filling gaps and offering acceptable alternatives as demonstrated by good up-take of self-help initiatives
• Service implementation: better working practices within organisations combined with enthusiasm, motivation and commitment of staff to develop projects.

6.2.4 Identified challenges in set up and implementation of community, voluntary and self-help initiatives

Delays in setting up projects and lack of progress were highlighted by around one quarter of areas.

• Set up issues: In one area, the parent organisation for an activity had to temporarily close due to alleged criminal behaviour within the organisation. For another project there were delays in the disclosure forms process for staff in a group seeking to develop a self-help model with adults who experienced childhood sexual abuse.
• Implementation issues associated with the functioning of a service user-led group, such as an unclear role for the group and difficulties in providing staff supervision. Low level of up-take and infrequent attendance of the service and inability to provide quality assurance were highlighted in relation to self-help projects. There were also some reported challenges in the evaluation of community, voluntary and self-help activities.
• Funding issues: several different funding problems had affected the success of local community and voluntary and self-help developments, including an over-reliance on Choose Life funding and lack of alternative funding of individual projects, and potential imbalance in funding allocation to particular priority groups. Obstructions in delivering training caused by charging for training were also highlighted in two instances.
• Understanding/buy-in: some sites had encountered resistance from managers over staff involvement in Choose Life, or differences of opinion among partners leading to disruption of joint work.

6.2.5 Perceived learning points

For coordinators, the process of setting up community, voluntary and self-help initiatives had generated important learning points, as follows:

• It is important to bring agencies together at an earlier stage to decide on priorities
• It can be worth allowing time for needs assessment before commissioning in order to establish requirements for a service prior to funding
• Proactive engagement with national/established organisations is valuable
• It is important to support the infrastructure of self-help groups and budget for unanticipated costs associated with this.

Coordinators also stressed the importance of securing 'buy-in ' from the early stages using a range of tactics such as:

• Encouraging better awareness of national and local Choose Life strategic objectives within the voluntary sector
• Focusing less on formal administration and more on informal sharing of ideas
• Awareness raising activities around local initiatives
• Strengthening monitoring and evaluation of activities to provide more regular feedback.

6.3 Innovative ways of working

This section outlines how funding was used for innovative ways of working. Fifteen areas offered examples of approaches that included: partnerships to delivery training or provide services, and support for new types of interventions, to reach new client groups, as follows:

• Training: In South Lanarkshire, a new partnership was formed with a voluntary sector organisation to prove ASIST. West Lothian was instrumental in moving the ASIST training forward in Scotland and was the local host for the first Scottish training for trainers' event in 2004.
• Grant scheme in Dumfries and Galloway had attracted interest from a wide range of local organisations and led to the establishment of a range of projects designed to increase capacity and improve mental health and well-being, including the redesign of the Women's Aid hostel in Stranraer and a self-help group for young women at risk of self-harm in an area of deprivation in Dumfries
• Networking opportunities were created in several areas, for examples in Borders, voluntary organisations came together to share learning from their activities
• Supporting risk groups: in Western Isles, an existing men's health project has been visiting communities throughout the Isles conducting health screen . A 'Headstrong' pack for mental health promotion in schools was developed in East Lothian and sessions were delivered in schools with a range of socio-economic profiles.

6.3.1 Factors contributing to the establishment of innovative working practices

Innovative activities were sometimes developed in response to identified need/gaps in service and based on discussions in subgroups, the Choose Life partnership and anecdotal evidence from practitioners. In two areas, the work evolved based on an original pilot undertaken in the local area. One area taking forward work in relation to ASIST had taken ideas from the LivingWorks website. Three areas highlighted that the activity was developed as a way of promoting local innovation.

6.3.2 Perceived progress made in innovative ways of working

Coordinators reported that good progress had been made in respect of innovative partnership working. Partnerships with and between voluntary organisations continued to be seen to reap benefits. For example:

• In Edinburgh, the joint supervision/peer support for three schools projects led to the sharing of best practice for the school projects.
• In Inverclyde, the out of hours service had expanded a local stress management project and this offered a service to previously unknown clients. Common reasons for referral include anxiety, relationship problems, bullying and bereavement.
• In East Ayrshire, large cross-sections of interests were brought together in suicide prevention week including Kilmarnock Football Club, bars, clubs and pubs. Partnership with Dumbarton Football Club and Clydebank Football Club led to distribution of Choose Life postcards at two games early in 2005. This had had a good response from fans; local agencies were making use of the cards in day to day work and the idea and design had been adopted nationally.

6.3.3 Factors contributing to success

Improved partnership working within local authorities and across the neighbourhood authority was commonly highlighted as a factor contributing to success. For some areas, learning how to work together and how others work was an on-going process with improvements being made continually.

Some areas pointed to an improved ability to impact on vulnerable risk groups through the development of new ways of working. In one area, there had been success in changing working practices (e.g. in a men's health project, project workers had initially focused on physical health assessments but now recognised the impact of mental ill-health). A positive response from the local community, including schools, parents, football fans, and clubs, had facilitated the delivery of activities, such as football postcards in Dunbartonshire. Cooperation from schools and parents had helped facilitate the Headstrong pack for mental health promotion in schools in East Lothian.

6.3.4 Identified challenges in set-up and implementation of activities

There was less feedback provided from local areas in relation to this issue and reasons for this are not stated in the survey. Challenges that were noted included a lack of sustained funding for innovation and lack of capacity to make the most of opportunities or further develop activity. An additional challenge for some had been inadequate publicity to attract applicants to development schemes, and clients to new services. Some areas reported problems within individual projects (e.g. finding rooms to meet young people and staff turnover).

6.3.5 Perceived learning points

Eight areas cited learning points from implementation of innovative activities:

• Three areas highlighted increasing awareness of initiatives, e.g. using the press to celebrate achievement rather than to publicise the scheme; issuing an advertisement in advance of the training and holding a launch event
• Two areas noted the need to include a wider range of partners at an earlier date in the decision making process
• Two areas cited the appointment of a coordinator at an earlier stage in order to lead and develop links and networks.
• Need for closer follow up of impact of mental health initiatives was cited in relation to a men's health project that had been unsuccessful in achieving further funding for the initiative

6.4 Progress towards innovative practice

Table 6.1 provides a summary of progress and remaining gaps and issues in targeting innovative and effective practice.

Table 6.1 Progress towards innovative practice

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