Scottish Government

7 Conclusions and recommendations

Introduction

7.1 The local sites who participated in this pilot have been at the forefront of the introduction of one of the most innovative approaches to supporting mental health service users through their recovery journey in Scottish mental health services to date. This evaluation suggests that peer support working, in combination with the range of recovery based initiatives ( e.g. Scottish Recovery Indicator, TIDAL) already in place has the potential to make a significant contribution to effecting a fundamental shift in the way traditional statutory mental health teams operate and interact with their service users.

Evidence supports roll-out of peer support working

7.2 The evidence from the pilot would indicate that the roll-out of peer support working across mental health services in Scotland and beyond would have a positive impact for service users. However, given the considerable challenges associated with setting up, delivering and sustaining a peer support worker service, 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 local and national level combined with practical support is also an essential ingredient for successful roll-out.

7.3 This chapter revisits the key objectives of the evaluation and explores the possibilities for the future of peer support in mental health services in Scotland. Based on the evaluation findings, a range of factors necessary for the effective implementation of peer support working are then identified. Finally, as one evaluation participant commented there is no black and white in mental health services, and introducing peer support has raised a number of important (but as yet unresolved) matters which are set out for further consideration by those who will be involved in the roll-out of peer support working and other interested parties.

Impact on service users

7.4 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 service users with hope of recovery and aspirations for the future at all stages of mental ill health and recovery.
• Act as a conduit between service users and clinical staff, providing both groups with further insight into each other's perspectives and enabling them to approach recovery using new strategies which are helpful to service users.
• Empower service users to take more control of their own recovery through enabling activities and using WRAP.

7.5 Service users on the whole seemed to welcome the option of working with a peer support worker at any stage of mental ill health and / or recovery. In a few cases, service users who did not understand the role of the peer support worker and objected to their enabling approach rejected the peer support worker's help.

Impact on peer support workers

7.6 The impact on peer support workers of taking on the role and the extent to which they are able to promote and maintain their own recovery has also been explored in detail. Peer support workers were faced with a number of challenges, such as:

• Adjusting to employment after many years of not working.
• Developing their role from scratch.
• Learning about their new working environment.
• Integrating with teams whilst challenging non-recovery focussed practice within those teams.
• Being confronted with service user problems that reminded them of their own most difficult times.

7.7 Dealing with these challenges (with the support of supervisors) 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, and peer support workers tended to make constructive use of their experiences of recovery, refreshing their knowledge.

Impact on service system

7.8 The impact upon the service system and the service culture, values and practice has been considerable given the short space of time peer support workers have been in place. Peer support workers have learned about the art of influencing change by trial and error and raised this as an important learning curve. Peer support workers seem to have been effective in breaking down barriers around the 'them and us' culture that still exists within many NHS services. Even those teams which are quite progressive in terms of their recovery approach have found that the peer support worker has helped them to be mindful of the principles of recovery and develop more effective strategies for applying this to their practice.

7.9 A conclusive finding was that the type of organisation within which the peer support worker should be based does not seem to matter as the peer support workers thrived and had positive impacts on service users and culture in a range of settings. What really matters is that the service or team in which peer support workers are based must be open to and starting to implement a recovery focussed approach to their practice.

Uniqueness of peer support

7.10 Many factors make the peer support worker approach distinctive and positive, the main one of which is the way in which peer support workers are able to use their lived experience as a strength and share this with service users and other mental health specialists with positive impact. Another key feature is the ability to use their great insight, empathy, and commitment to mutuality in their relationship with service users which has helped teams to overcome the 'them and us' relationship which is prevalent in mental health services and be more effective in the service they offer. Peer support workers were viewed by many of their staff colleagues as a unique and essential part of the multi-disciplinary team.

Factors that contribute to the effective implementation of peer support working

7.11 The experience of the pilot teams has provided the opportunity to learn from good practice examples, mistakes and strategies that have contributed to and hindered the process of implementation of peer support at a national and local level. From this 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. These factors cover the set-up of peer support working as well as the conditions required to ensure the integration of the peer support worker into the wider team. They are particularly applicable when an organisation is introducing peer support working for the first time, but should also be used to further develop and assist the roll-out of peer support working in the sites involved in this pilot.

Deployment

7.12 When deciding on which organisations and settings to deploy peer support workers it is important to consider that:

• Peer support can be based in any setting that is recovery focussed in ethos and starting to apply that focus to their practice.
• Some settings are more challenging than others and those that are more challenging such as acute inpatient wards might suit peer support workers with more experience and confidence.
• Partnerships between voluntary sector service providers and the NHS have advantages in providing peer support workers with a supportive base and enhancing 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, however caution should be exercised if peer support workers having to 'follow' patients through their care journey as psychiatrists do, as this could be too intensive a workload for some.
• Placement of peer support workers in environments where they can build longer term relationships is likely to increase their opportunities to introduce WRAP and effect a more lasting impact on the service users that they work with.

Employment conditions

7.13 Peer support workers should be treated the same as any other employee in relation to their employment terms and conditions. Where support for peer support workers is felt to be insufficient, this may highlight that employment conditions would likely be best reviewed in relation to the whole staff team. In addition, however, arrangements for when a peer support worker becomes mentally unwell may need to be developed on a case-by-case basis.

Recruitment

7.14 The following factors will be important in assisting the recruitment process:

• 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 within different NHS boards and the voluntary sector.
• 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 (in particular integration within a multi-disciplinary team and working with individuals with severe and complex needs) and emphasise the importance of peer support worker applicants being at an appropriate stage in their recovery to handle the pressures involved.
• National information and guidance for Occupational Health professionals regarding raising awareness about the peer support worker role should be put in place to avoid misunderstandings that can be difficult for peer support workers.

Preparation

7.15 Preparation for employment is essential for peer support workers to be equipped to integrate well with their new team. The following aspects of preparation are essential:

• Peer support workers should be formally trained on a nationally recognised course.
• Training needs to involve preparation for return to employment, including addressing the management of benefits, if not through providing information then by facilitating good links to appropriate supports.
• Peer support workers need to be provided with training or information that can help them to understand what it is like to work in the NHS or wherever else they will be employed, taking into account ethos as well as systems and procedures such as line management and note taking.
• An essential element of preparation should relate to being an agent for change, with an emphasis on the apparently successful strategy of having 'peerness' with colleagues - taking a gradual approach to influencing change, rather than taking a confrontational approach.
• 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, taking into account the above points and those below relating to integration.
• Further in-house training should be considered for peer support workers such as suicide prevention training ( e.g.ASIST⁶,Safe TALK), values and recovery based training ( e.g. Realising Recovery, TIDAL) and management of aggression particularly in acute and intensive treatment settings.

Integration to the team and organisation

7.16 Integration of peer support workers with teams created multiple challenges for peer support workers, their teams and managers. The following recommendations should ensure that many of these challenges are addressed head on 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.

Support and Supervision

7.17 Good support and supervision is required for the peer support worker to be effective in their role, and the following recommendations are offered:

• 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.
• Peer support workers must have access to trained peer support supervisors internally and (where appropriate) externally. In addition there needs to be clarity amongst all involved about the differences between the roles of supervisors and line managers and how these can complement each other.
• Additional support should be available if it is needed when challenging events occur.
• Peer support workers should have ways to connect to other peer support workers and/or those who are very knowledgeable about peer support to be able to reflect on working with peer working principles. This might take the form of local or national learning sets or more informal local approaches to sharing good practice.
• Supervision should be challenging as well as supportive to peer support workers in order to allow them to reflect on their own practice objectively and develop from this.

Building in sustainability

7.18 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.

7.19 Peer support workers' absences from work could 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.

7.20 Employers will also need to build in strategies to provide cover for long term absences.

National support

7.21 The pilot helped to identify a number of ways in which national support for the rollout of peer support working could be delivered, including:

• A number of evaluation participants (especially those involved in employing peer support workers) identified a need for a clearly identified national champion for peer support within the Scottish Government Mental Health Division. 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 should be available for peer graduates, employed peer support workers and non-peer trained people such as clinical service managers involved at pilot sites and in other areas where they want to introduce peer support working.
• A lead should be taken on providing outline information and 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

7.22 A number of issues remain unresolved and should be considered by those who will be involved in the roll-out of peer support working within Scottish mental health services and with other interested stakeholders. These issues are:

• To what extent should there be standardisation of the peer support worker job description? Which elements of the role are core and which are interchangeable?
• Should / can there be a standard pay scale for the basic peer support worker role?
• To what extent should peer support workers share information with their team colleagues about their work with service users? (Taking into account issues around service user confidentiality and trust as well as bridging the gap between clinical staff and service users).
• In what ways should peer support workers access and use previous clinical and risk assessment information about service users?
• What level(s) of responsibility can peer support workers take on in their basic role and in what ways and to what extent can/should this develop as peer support workers become more experienced?

Future for the peer support worker role and peer support in general

7.23 The long term objective of how peer support should feature within mental health service delivery in the future is not clearly defined and those involved in the pilot offered different perspectives on this, including:

• Lived experience becoming an essential element of any multidisciplinary team in mental health services.
• Peer support workers become 'professionalised' with formal training and qualifications and remaining a unique part of a multidisciplinary approach to care.
• All mental health professionals providing an element of peer support at different levels, drawing from their own lived experiences.
• Peer support workers playing a key role in service planning committees.

7.24 It will be important to develop thinking on this issue as it does seem to have an impact on the way in which the different stakeholders within this pilot have approached the deployment and integration of the peer support worker role. Some teams have sought full integration and others maintained a sense of autonomy around the peer support worker role as slightly separate from the rest of the team.

7.25 The way in which the peer support worker role can develop in the future in terms of responsibility and remuneration is also dependent on a shared long term goal for the future of peer support in mental health services in Scotland.