8 Influence on policy and practice
8.1 The previous four chapters have examined the SRN's various initiatives, their reach, effectiveness and impact. These initiatives have largely been targeted at secondary mental health services and service users. However, at the same time, the SRN has worked closely with policy makers at a national level to take forward the recovery agenda in Scotland.
8.2 In this chapter we set out our findings on: (a) the influence of the SRN on national policy and (b) on engendering recovery values and practices in Scotland - and how has this been achieved.
8.3 Our evidence comes from a review of policy documents and a review of the SRN's reports to the Scottish Government; interviews / focus groups with the Network Director, his team and the SRN strategy group; local network case studies; and interviews with strategic partners and national policy leads.
Influence on national mental health policy
8.4 The SRN was established in the context of a new mental health and wellbeing policy which, for the first time, highlighted recovery as a priority in Scotland. The National Programme for Improving Mental Health and Wellbeing was launched in October 2001, and the SRN was launched just over three years later in December 2004. Subsequent policy development in this area has been rapid, and recovery has had, and continues to have, a prominent role.
8.5 Recent policy documents have reinforced the value and importance of recovery and made commitments to support implementation. 27,28,29,30 Since the Director of the SRN was involved in developing all of these documents, some interviewees cited this as evidence of SRN's influence on national policy. Others saw it more as a reflection of the SRN's central role in implementing policy commitments, although these individuals also acknowledged the importance of SRN's profile within the Scottish Government.
8.6 Members of the SRN Strategy Group described the current political and policy climate in Scotland as one of the factors that has enabled the SRN to pursue and achieve its objectives. One of SRN's partners echoed this view: "The National Programme provided an environment in which SRN could flourish."
8.7 Indeed, in considering the influence of the SRN on national policy, it is important to reflect, as some interviewees did, on the context in which they were operating. The National Programme had included recovery as one of its main strands. This was the result of an interest in recovery in Scotland arising from work being done in other parts of the UK and internationally. The recovery approach has been embraced by many professionals and mental health organisations.
8.8 Many of the participants in this evaluation felt that it was difficult to assess the influence of SRN in light of this more general interest and activity, in particular to disentangle sources of influence and to assess the level of progress that could be considered to be directly attributable to SRN. Nevertheless, the continued focus on recovery and on pieces of work being led by the SRN clearly show that there has been a positive working relationship between the SRN and the Scottish Government.
8.9 When asked how the SRN had influenced policy, interviewees (policy officers, the SRN's partners and other stakeholders) felt it had done so through:
Stimulating and sustaining a dialogue and debate about recovery and what it means for individuals, and by engaging with stakeholders at all levels (policymakers, professional bodies, practitioners and service users). This "inclusive" approach was felt to be the key characteristic of the SRN.
Having responded efficiently and effectively in delivering policy commitments (particularly around the SRI, peer support, values-based training, and WRAP).
By getting the voices of service users heard and taken into account in policy development (for example, through the Narrative Research project).
8.10 Overall, the evidence suggests that the SRN has influenced the continuing focus on recovery in mental health policy. It has achieved this through the strength of its own work, but has also been helped by a good working relationship with Scottish Government and a supportive policy environment.
8.11 At the same time, there was evidence to show that the SRN has also been influential in other areas of policy - in particular in the substance misuse field. The work of the SRN, and the perceived "great success" of the recovery movement in mental health were specifically cited as one of the influences leading to the promotion of a recovery approach in the Road to Recovery (2008) 31 and the creation of the Scottish Drugs Recovery Consortium. The document, Mental health in Scotland: Closing the gaps - making a difference (December 2007) also highlights the role of recovery in the care and support for people with co-occurring substance misuse and mental health problems. 32
8.12 Some interviewees suggested that the SRN had also had an influence on policy developments related to other aspects of health, such as chronic illnesses like diabetes. Furthermore, the policy document, Mental health in Scotland: Improving the physical health and wellbeing of those experiencing mental illness does not specifically mention the SRN, but one (policy) interviewee considered that this document had been informed by the concept of recovery. 33
8.13 Some interviewees commented that the SRN were proactive in looking at new policy developments to ensure that recovery was included where appropriate.
Influence on practice
8.14 In addition to examining the extent to which the SRN has influenced mental health (and wider) policy in Scotland, we also sought to assess the extent to which the SRN has had an influence on engendering recovery values in mental health practice in Scotland.
8.15 As noted above in relation to influence on policy, some of the changes that have been observed by interviewees may be the product of a general increase in interest in recovery. Most interviewees, however, believed that SRN has played a significant part in effecting change by creating a Network where ideas and information can be developed and exchanged, and by developing an evidence base, training materials, resources and practice tools. One interviewee commented that the SRN has helped with thinking about culture, attitudes, values and behaviour of staff and with practice developments in nursing and social care. As another individual said: "Recovery is becoming part of practitioners' vocabulary."
8.16 Senior managers were asked whether (in the last 2-3 years) the notion of recovery had led to any changes in the approach their services take to supporting people with mental health problems. The majority said that substantial or fundamental changes had taken place in their services during that period. More specifically, managers pointed to:
- A more collaborative way of working with clients
- More of a focus on strengths, rather than deficits
- Better integration between hospital and community services, and between NHS and voluntary sector services
- Services that are more responsive to clients' needs
- An emphasis on encouraging people to be independent and take responsibility for their own recovery.
8.17 The senior managers who were interviewed in this evaluation indicated that recovery is a main focus of mental health services in their areas. Many gave examples of how their services had adopted recovery-oriented practices, and spoke about changes in thinking among staff. One senior manager said that the local hospital mental health day service had even changed their name to "The Recovery Centre", which they felt better reflected what the service was about.
8.18 Senior managers also indicated that the SRN's publications and resources were being widely disseminated in their services, and SRN interventions ( WRAP, the SRI and peer support schemes) appeared to have been adopted by many services.
Areas of greatest influence
8.19 Areas where the SRN was seen to have had the greatest influence were in:
Mental health nursing: The SRN was seen to have had a strong influence on Rights, Relationships and Recovery. SRN has also had a significant influence on practice through working with NES to develop the Realising Recovery learning materials which are being used extensively in training mental health nurses, and through the roll-out of the SRI.
Social work: One senior social work manager felt that the SRN was having a "transformational effect on health and social care". Another senior manager, representing the Association of Directors of Social Work, also considered that SRN was having an effect on practice on the ground, particularly through the development of tools that translated the values of recovery into a "workable and sensible form". Some interviewees identified a 'synergy' between recovery values and the person-centred ethos of social work as a key factor in helping the SRN to influence practice in social work and social care. This view was echoed by senior managers of mental health services who held joint posts in social work and health.
Voluntary sector:VOX, the national organisation which promotes the voice of the services user, supports all the SRN's work and advertises opportunities to work with recovery networks. Many VOX members are involved in running recovery networks. VOX also shares information about recovery, for example, via its website, and the organisation has members' meetings 3-4 times a year where recovery is normally one of the topics chosen by members for discussion.
Mental health services in general: The SRN has been involved in working with Quality Improvement Scotland ( QIS) in relation to developing standards for Integrated Care Pathways for mental health services. 34 The SRN was also part of the reference group for a separate QIS project on developing a best practice guide for adults admitted to mental health in-patient services. 35 The latter document makes a number of references to the SRI and to WRAP.
Areas where the SRN has had less influence
8.20 There were other groups where recovery was reported to be less well understood or accepted. These were:
- Primary care: It was felt that the SRN had made little progress in engaging with primary care. At the same time, primary care has not been one of the main target groups for the SRN. Nevertheless, the SRN acknowledges that it is important to reach primary care providers with the message of recovery, and there have been greater efforts to do so, for example through targeted publication and poster distribution. The difficulty of getting GPs to take part in recovery-related training was highlighted by interviewees and by the local network workshops. However, these issues have been raised in other evaluations of mental health improvement initiatives. 36
The Royal College of General Practitioners in Scotland has not taken any specific action to promote recovery to its members, and the view was expressed that, in any case, GPs would see very few people with serious mental health problems, since these individuals would ordinarily be referred to secondary mental health services. There is also an issue of capacity, as GPs are already required to have an in-depth knowledge of several conditions.
However, mental health service users (attending local recovery workshops) commented that people in the first stages of their illness are most likely to be seen in a primary care setting. The view was that it was crucial, even at this stage, to be given a positive and optimistic message of recovery.
- Psychiatry: There were mixed views about the extent to which psychiatrists had engaged with the idea of recovery and with the SRN. At a UK level, the Royal College of Psychiatrists ( RCPsych UK) supports and promotes the notion of recovery. 37 It was reported by a representative of the RCPsych in Scotland that the SRN would be able to have little influence on the RCPsych at a UK level. However, in fact, SRN staff have spoken at three RCPsych UK conferences, and work undertaken by the SRN is specifically cited in a paper jointly published by the RCPsych UK, the Care Services Improvement Partnership and the Social Care Institute for Excellence. 38
The representative of the RCPsych in Scotland suggested that the SRN had had some influence on psychiatrists, but there was also a perception of some "anti-psychiatric" feeling among groups promoting recovery which has inhibited greater engagement by psychiatrists in the past. It was not suggested that the SRN had been involved in creating such feeling. Nevertheless, a constructive debate was thought to be the way forward to build on the interest that many psychiatrists do have in recovery.
Barriers and levers to influence
8.21 Interviewees identified a number of barriers to taking forward a recovery approach in practice. These included: constraints on time (particularly for GPs and other clinicians); money and staff shortages; entrenched attitudes; and in some cases, a mistaken belief within certain sectors that having a "person-centred" approach is equivalent to practising recovery. There was also some concern about the short timescales for Towards a Mentally Flourishing Scotland, which runs only until March 2011.
8.22 On the other hand, national policy drivers have all helped to support the SRN in its efforts to influence mental health practice in Scotland.
The SRN's influence on practice: The perspective of service users
8.23 There are obvious difficulties in attributing changes in service practice solely to the SRN. The SRN may provide excellent support and tools to promote practice change; however, ultimately changes in practice are the responsibility of local service commissioners and providers. Nevertheless, one would expect that an increasing adoption of recovery practices within services would be one of the outcomes of the work of the SRN, and indeed the SRN has identified "more recovery focused mental health services" as one of their medium-term outcomes. (See again Annex C.)
8.24 It could be argued that the best perspective on whether or not services are increasingly adopting recovery-focused practices is not that of the service providers, but rather of service users.
8.25 In relation to this, it should be noted that there is evidence from the bi-annual Well? surveys which shows that people with mental health problems are increasingly receiving positive messages of recovery from the professionals with whom they come in contact. 39 Furthermore, there is some evidence that people with mental health problems may increasingly be receiving positive messages of recovery from the people around them (friends, family). 40
8.26 Importantly, results from the Well? survey also showed that people with mental health problems who had received a positive message from professionals were more likely than those who had not to have above average mental wellbeing. While a survey of this nature can not determine direction of causality, this finding is consistent with findings from the Narrative Research undertaken by the SRN which reported that being given an optimistic message of recovery can lead to positive outcomes for people in their own journeys of recovery.