1. Delivering for Mental Health was produced in December 2006 by the (then) Scottish Executive's Mental Health Division 1 to provide guidance and set targets for the development of mental health service delivery in Scotland. The promotion of a wellbeing and recovery-based mental health service model is central to this policy document. Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009 - 2011 (Scottish Government) supports the promotion of the principles of recovery and the implementation of peer support championed by the work of the Scottish Recovery Network.
2. A pilot scheme of pioneering formalised peer support working was put in place in January 2008 2 in five Health Board areas (yielding six separate sites) and led nationally by the Scottish Government's Mental Health Division in partnership with the Scottish Recovery Network. The peer support workers at these sites were required to have a lived experience of a mental health problem/illness and/or be living in recovery which they would draw on to deliver a range of supports which would assist individuals with their own process towards living in recovery. They were deployed in a range of diverse service and geographical settings.
Evaluation aims and objectives
3. The overarching aims of the evaluation were to assess the impact of the peer support pilot on service users, peer support workers and the wider service system as well as assessing the process of implementation at national and local levels.
4. Using mainly qualitative research techniques the evaluation tracked the process of implementation and the impact of the new peer support workers on the service teams and systems within which they worked. This was conducted through pre and post appointment in-depth interviews with peer support workers, interviews with supervisors and professionals who could provide an informed perspective on local implementation and the impact on the wider service system, and those involved in providing support at a national level.
5. Service users were invited to participate in a satisfaction survey and in-depth qualitative interviews. Finally a significant events analysis was carried out with each pilot team to gain an indication of the ways in which the peer support worker approach has impacted on team values and practices and the implications for service and practice development locally, including sustainability. Qualitative data was analysed using a thematic analysis approach.
6. The roll-out of peer support working across mental health services in Scotland, and beyond, would be beneficial for service users, peer support workers and mental health teams. However key challenges remain for developing best practice in relation to defining and implementing peer support roles.
Impact on service users
7. The impact of the role of the peer support workers on service users has been on the whole positive, with peer support workers able to provide hope to service users by modelling recovery, provide service users and staff with further insight into each other's perspectives enabling them to approach recovery using new strategies which are helpful to service users and encourage service users to take more control of their own recovery.
8. Service users on the whole welcomed the option of working with a peer support worker at any stage of mental ill health or recovery. In a few cases, service users did not understand the role of the peer support worker very well, or did not engage with the peer support approach.
Impact on peer support workers
9. Peer support workers were faced with a number of challenges including:
- developing a new role without previous infrastructure or clear role definition
- adapting to a new and challenging work environment
- adjusting to employment after many years of not working
- integrating with teams whilst challenging non-recovery focussed practice within those teams
- being confronted with service user problems that reminded them of their own difficult experiences.
10. Dealing with the implementation challenges, with the support of supervision, helped peer support workers to gain confidence and self esteem regarding their contribution towards helping others and influencing NHS culture. For many peer support workers this contributed to their going further in their own recovery journeys. Although some peer support workers became unwell during their period of employment, this was approached by them and their employers in a positive light. Peer support workers tended to make constructive use of their peer skills to aid in facilitating their own recovery, and integrated further lived experience into the skills and knowledge they could offer in the role of peer support worker.
Impact on the service system
11. The impact upon the service system and the service culture, values and practice has been considerable. Peer support workers have learned about the art of influencing change and have been effective in breaking down barriers around the 'them and us' culture that still exists within many NHS services. The peer support workers have helped even the most progressive teams to be more mindful of the principles of recovery and develop more effective strategies for applying this to their practice.
12. A conclusive finding was that the type of organisation within which the peer support worker should be based does not seem to matter as much as the team in which peer support workers are based. The best type of team to base peer support workers is one that is open to and starting to implement a recovery-focussed approach in their practice. Across the pilot sites there were a number of commonalities and differences in approach and each site demonstrated both strengths and weaknesses as they were faced with a range of implementation challenges. Peer support workers thrived and had positive impacts on service users and culture in a range of settings.
13. The pilot demonstrated the ways in which peer support can offer a unique and distinctive role, which was viewed as complementing and strengthening teams. In particular:
- Peer support workers were able to use their lived experience as a strength and share this with service users and other mental health specialists with positive impact.
- Peer support workers have the ability to use their insight, empathy, and commitment to mutuality in their relationship with service users.
- Peer support workers can help teams to overcome the 'them and us' relationship which is prevalent in mental health services and hence be more effective in the service they offer.
14. The main implementation challenges during the pilot included:
- Addressing awareness raising in Occupational Health about both recovery in mental health and the peer support worker role.
- Lack of awareness of the role of peer support workers amongst team staff and lack acceptance leading to difficulties in integration.
- Resolving information-sharing boundaries between peer support workers and the team, and associated confidentiality issues.
- Ensuring the line management and supervision system works to provide peer support workers with the necessary support.
- Acknowledgement of the long haul required in achieving recovery-focussed services.
- Sustaining and rolling out the service with no trained peer support workers to recruit to new posts.
- Identifying and overcoming the challenges in working in partnership across statutory and voluntary sectors.
- Peer support workers becoming unwell after being in post for a short time, bringing one pilot to a stand-still.
Strengths in approaches to implementation
15. Pilot sites demonstrated a number of strengths which assisted the implementation process including:
- Efficient systems for grading of jobs and recruitment for the new and untested role of peer support worker.
- Full support from nursing staff for involvement of peer support workers in the systematic and formalised approach to developing their role and service provided.
- Strong support from senior management and psychiatry.
- Excellent pre-existing strengths in service delivery structure and commitment to recovery with a close and supportive team, leading to good integrated working.
- Clear positive impacts for service users and team approaches to care delivery, recognised by clinical staff and service users as uniquely valuable.
- A gradual culture shift and acceptance of peer support workers amongst staff who were initially sceptical through joint team discussions, observation of peer support workers in action and opportunities for staff to ask them questions.
- Strategic vision about sustainability e.g. the development of a volunteer peer support scheme, and a locally developed training course in peer support.
16. The considerable implementation challenges that arose during the pilot suggest that it will be important to develop a clear set of national guidelines for the effective implementation of peer support working within both statutory and voluntary services. Clear and consistent championing of peer support from senior managers and policy makers at a local and national level combined with practical support is also an essential ingredient for successful roll-out.
17. It has been possible to identify a number of factors which should contribute to the effective implementation of peer support working leading to improvement in services.
Recruitment, preparation and set-up
18. There were a number of recruitment, preparation and set-up issues. These included:
- Peer support can be based in any setting that is recovery-focussed in ethos although more challenging settings such as acute inpatient wards might suit peer support workers with more experience and confidence.
- Partnerships between voluntary sector service providers and the NHS provide a supportive base and enhance joint working between these sectors.
- To ensure continuity and maximum impact for service users, peer support should be available in acute and rehabilitation inpatient and community-based teams.
- Opportunities to introduce WRAP and affect a more lasting impact on the service users are maximised when there is time for peer support workers to build good relationships with service users.
- Peer support workers should be treated the same as any other employee in relation to their employment terms and conditions.
- Standardisation of a core peer support worker job description that fits with 'Agenda for Change' requirements would assist efficient recruitment and fairer grading of jobs.
- The criteria required for peer support working, alongside a lived experience, should include good communication skills, positive attitude to recovery, and knowledge of a range of self management strategies. Employers should be open about the potentially stressful nature of the peer support worker role and emphasise the importance of peer support worker applicants being at an appropriate stage in their recovery to handle the pressures involved.
- Guidance for Occupational Health professionals regarding raising awareness about the peer support worker role should be provided.
- Peer support workers should be formally trained on a nationally recognised course which covers preparation for return to employment, working in the NHS and influencing change.
- Staff on teams that will be introducing peer support should be given some training on the peer support worker role and how it will fit in with their role as well as general awareness raising about the advantages and challenges associated with peer support.
- A full and thorough induction should be offered to all new peer support workers and in-house training should be considered e.g. suicide prevention training, values and recovery-based training and management of aggression.
Integration to the team and organisation
19. The following recommendations should ensure that integration challenges are addressed prior to and during the employment of peer support workers:
- Strong support from senior service management and psychiatry should create the conditions necessary for a supportive and progressive working environment for peer support workers.
- Peer support workers should only be placed in supportive environments as a way to enhance, but not introduce, recovery.
- Teams should be clear about how the peer support worker role will fit in with their current practice and team working systems including information sharing, and where possible, operational policies should be reviewed to accommodate the peer support worker role.
- Documentation should be produced for referral processes, note keeping or writing inpatient user notes, to promote the service.
- Systems to manage information about peer support worker activity should be developed.
- Room should be left for the peer support worker and their team colleagues to develop the peer support worker role gradually but systematically.
- Opportunities should be provided for teams to discuss and review the potential and actual impact of peer support on team and individual working and practice prior to and following the introduction of peer support workers.
- Peer support workers must be fully involved in any team reviews following significant events e.g. suicide.
- Information materials (such as leaflets) about the nature of peer support, how it can be of help and how to access the service should be made available to service users with contact details of an individual(s) who can provide further information
- Peer support workers require supervision and support in two main areas. They need support to help them maintain their recovery and wellness during employment as well as support from within their team to address the development of their role and any operational and employment issues.
Building in sustainability
20. Sustainable and available training for peer support workers is required to ensure that new peer support workers can be employed. Until then, it is not expected that a rollout of any magnitude will be possible.
21. Peer support workers absences from work should be viewed constructively by them, their employers and colleagues in that when an absence is due to mental health problems, the process of the peer support worker regaining their recovery can enhance the approach they take to drawing on their lived experience to support others.
22. Employers will also need to build in strategies to provide cover for long term absences.
23. The pilot helped to identify a number of ways in which national support for the roll-out of peer support working could be delivered including:
- A clearly identified national champion for peer support (the Scottish Recovery Network currently provides a national lead for peer support developments within Scotland and this role should be reinforced).
- National facilitation of networks/learning sets.
- Providing guidance that can be used by local employers to raise awareness of the peer support role within periphery services such as Occupational Health who will be less directly involved in the recruitment and employment of peer support workers but still play a crucial role.
Issues for further consideration
24. A number of issues remain unresolved including standardisation of job descriptions, pay scales, sharing information within multi-disciplinary teams, levels of responsibility and career development. The long-term objective of how peer support should feature within mental health service delivery in the future is also not clearly defined. Continuing the debates required to resolve these issues is important for ensuring the ongoing development of this innovative and important role for mental health services in Scotland.