Welcome to the ImROC Peer Support Training area. We provide training for Peer Support workers, training for teams welcoming peer support workers, one to one coaching and consultancy for individuals and organisations wishing to develop their peer support practices and services. Please click here to find a full report of the 2023 independent evaluation of ImROC’s Peer Support Worker Training.

Peer support is a founding pillar of ImROC’s work and we are committed to providing co-produced training for peer support workers that is  values led alongside bespoke support for the organisations that employ them so they are equipped to create healthy environments for Peer Support work to form and flourish.

ImROC’s peer support training aims is to improve the lives of people living with long term conditions by expanding access to peer support that is accessible, meaningful, effective and empowering, all centred around the person they support. We also aim to ensure that peer support is fully understood by employers as a distinct and complementary contribution, by peer support workers who are well supported and supervised in work, and supporting organisations to influence and grow recovery focused, trauma informed and equitable culture and systems.

Learner Support

For trainees, with enquiries, contact your personal tutor or log into Moodle below.

Free Discovery Call

Email us through the link below to book a free discovery call with us today.

Our Peer Training courses offer a pathway of development to support individuals on their journey from someone in the receipt of support through the transition to supporter and then as their career progresses.

Courses can be accessed in any order, and you can complete them all or just one.

Our 40 hour course is co-produced for Mental Health using the HEE competencies and separately for Autism using the HEE capabilities framework.

In addition to, or in place of the above courses, our team co-produces bespoke training for your unique needs and organisation. Some examples of this include but are not limited to:

  • Peer support in Crisis services
  • Combatting discrimination in your work
  • Equity and Inclusion
  • Cultural competency and intersectionality
  • Young persons Peer support
  • Peer support for Veterans
  • Peer support for substance misuse
  • Setting up Peer support services
  • Peer support for long terms conditions
  • Peer support in older Peoples services
  • Parent/carer Peer support
  • Sharing your story as a peer support worker
  • Supporting non-peer staff to bring their lived experience into practice – safely, appropriately and effectively.
  • Supervision for the whole workforce

Introduction to Peer Support
2 hours

Foundation in Peer Support
20 hours

Peer Support Theory and Practice
40 hours

Peer informed Supervision Training
15 hours

Management skills as a Peer Support worker
15 hours

BS/ MSc Lived Experience/ Peer Leadership

ImROC provides coaching to individuals and organisations via one to sessions and courses that can be adapted to your group.

  • Coaching one to one to work through blocks and barriers
  • Coaching with Julie Repper for lived experience leads
  • Coaching approaches training
  • Coaching and Recovery
  • Coaching and organisational transformation

To discuss your training needs, understand how to book on to courses, which training course to choose, costings and further information get in touch with peertraining@imroc.org to book a free discovery call with our Peer Training Lead.

We strive to support organisations to co-produce their own pathways and training and become self-sufficient and successful in their Peer Support programmes.

ImROC provides many cost free resources to get you started in considering the multilevel preparation that might need to be considered when developing peer roles in your organisation. We know this includes:

  • Recruitment, policy and HR prepared for the needs of lived experience folk
  • Understanding how to run equitable recruitment, employment and development that reflects the demographic of the service reach
  • Buy in from a strategic level
  • Understanding of the peer role, how it thrives and what are the challenges.
  • Team preparation for all teams welcoming peers
  • Peer informed supervision
  • A career path and progression for Peers
  • Peer role descriptions reviewed for each team
  • A critical mass of peers
  • Designated people to run the peer programme, not just an add on

Influencing culture and practice to be more person centred and recovery focused is challenging.

The ImROC team are here to offer you support to work through the unique hurdles and blocks each organisation could face.

Booking a free discovery call with one of our consultants and we can support you to explore what you might need to carry out your next steps.

ImROC is keen to develop more working relationships with like minded, value driven organisations through our training partnerships.

The aim of these is to work together to utilise both our expertise. To create co-produced, up to date, relevant and meaningful training that is carried out in the most accessible way.

Organisations we partner with can benefit from access to events and training at ImROC, coaching and supervision from a named consultant at ImROC and we learn from you and your unique perspective and experience, we work together to plan, implement and deliver co-produced training that is mutually approved within each partnership.

Get in touch with us at
peertraining@imroc.org to begin the conversation.

We welcome feedback and if you would like to provide us with any comments, concerns or complaints please fill out our feedback form below.

We are currently commissioning an external evaluation of our Peer Support Training through an organisation called Matter of Focus.

Matter of Focus is a values-led company and certified B Corp based in Edinburgh that works with organisations to explore, map, analyse, and assess the outcomes that matter to them.

We will share the results of this evaluation around Autumn 2023.

Why ImROC for your Training and Support?

ImROC has been delivering training since 2007 and has worked internationally in supporting organisations to embed and develop their peer workforce. The knowledge and understanding gained from supporting 100s of organisations and training 1000s of individuals means we can draw on this varied experience when working with you.

In 2020 ImROC responded to the global pandemic and transferred training into the online space and since then has trained over 1000 trainees in this way. We have learnt from each cohort of training and continuously adapt and evolve our materials, our wraparound support, the way we engage and include each trainee in ways that are led by them, with one main approach remaining the same and that is a strong values-based core to all delivery.

Our end goal it to support organisations to co-produce their own pathways and training and become self-sufficient and successful in their Peer Support programmes as we know that the organisations who are closest to those they support can be the best placed to provide the most meaningful and tailored support and connection into local communities.

Who delivers ImROC training?

A dedicated team of peers and practitioners deliver training from ImROC, training teams are created in response to the needs of the organisation and individuals. Trainers draw on their lived and life experience, their experience of working in practice, and on their extensive experience of delivering ImROC training in a way that meets the learning aims whilst adapting to include all individuals in the group.

The ImROC training team meets biweekly to reflect in a safe space where they can grow their understanding and knowledge of key debates, research, and skills and retain strong values focus to their work.

If you would like to express an interest in joining the team you can complete this form.

What approach does ImROC training take?

We will ask everyone to complete a pre-course questionnaire to ensure we are aware of the best ways to support you, this is also a commitment to a shared responsibility for coming into the training space and being prepared to consider and plan for how you can attend the course.

We have certain requirements for accessing and completing our training and they vary for each course. Requirements consider the course aims and outcomes, protecting a safe learning space, the needs of the individual, the trainer and the organisation(s) involved.

We avoid labels and diagnosis and use strengths based and inclusive language that focuses on the whole person and their unique experience.

We practice reciprocity, our trainers are not here to teach all the answers, rather facilitating learning from the whole group.

Sessions are in manageable chunks with regular breaks.

All training is delivery by experienced peers and practitioners and overseen by our Peer Leadership and Curriculum team.

All training is co-produced by service users, peer support workers, clinical staff and our curriculum and design team.

Co-production – sharing our experiences, reflecting on our learning.

How much do courses cost?

Some of our courses are free – such as the Introduction to Peer Support webinar. We also provide some free offers to our training partners.

We do charity work with small unfunded organisations.

We are currently delivering a contract of training where organisations can access free Peer Support and Supervision and Team Preparation training through Health Education England. Organisations also gain a grant to build robust Peer Support pathways and structures when a peer support worker accesses our training.

We also offer a sliding scale of costings for some courses to ensure they are as accessible as possible.

As costing for organisations is such a bespoke process and we want to ensure you are making the most of any funding, grants, or partnerships we can offer or are aware of please get in touch and we can provide you the costings you require.

The Training and Employment of Autism Peer Support Workers

By Liz Walker – ImROC Senior Consultant / Autism Peer Support Programme Lead

The Context

ImROC was awarded the NHSE National Contract for training Autism Peer Support Workers and Peer Support Worker Supervisors across England in 2022 and 2023 having supported earlier work co-producing training materials and curriculum planning.

Health Education England (now NHSE) has developed an autism workforce strategy which includes the development of highly-specialist autism teams. These teams offer enhanced health services directly to autistic people in the community, providing specialist diagnostic, and focused, time limited, aftercare support services for people with autism.

The Contract

The NHSE contract requires 200 Peer Support Workers with lived experience of autism to be trained as Autism Peer Support Workers across the NHS and non NHS services. In addition 100 supervisors have been trained along with the peers themselves.

It is recognised that peer support roles can make a significant contribution to new and emerging autism services and NHSE has undertaken a substantial piece of collaborative work with ImROC in the writing of new training in context of the existing capability framework.  The new training identifies the skills and the capabilities required for a new role of Autism Peer Support Worker.

The focus of the new Autism Peer Support Worker roles is for autistic people to provide support to other autistic people, using their own lived experience to support those who are experiencing health and care challenges

ImROC celebrates that Autism Peer Support may also extend to carers and parents of autistic people. Carers may be employed to support family, friends and carers of autistic people using services. Therefore Autism Peer Support is not only being prepared for the NHS workforce but also for voluntary, community and social enterprise organisations.

The offer for Peer Support for Autism is sizeable across England and the UK. ImROC has counted many hundreds of large and small organisations that offer individual and group peer support in localities cities and regions. Many organisations are networked with the National Autistic Society.

ImROC is aware of the privileged position it is in with the unique opportunity to train Autism Peer Support Workers and Supervisors across England. We aware that across the country there are already advertisements seeking employment for trained ImROC Peer Support Workers within specialist autism teams.

Whist ImROC is excited about this work we would and will never seek to minimise the commitment that organisations already show to offering individual autism peer support whether that is offered by someone trained or not but where and when appropriate ImROC would love to engage with autism organisations across England that provide Peer Support and may be interested in more formal training.

Mid-Point Evaluation

A mid point evaluation of the training programme has been shared with NHSE in early 2023 with the following highlights

Feedback from trainers, trainees and organisations employing trainees demonstrates an early positive impact of the training. The report includes personal stories and reflections of those involved to illustrate the felt impact of engagement in this project.

Central to the design, delivery, receipt and evaluation of the training is coproduction.  Bringing together lived experience, educational experts, peer support experts and autism expertise;  acknowledging that people bring expertise from many different experiences, and  valuing everyones contribution through generative and appreciative conversations – and underpinning everything with research.

Although training is crucial it delivers greatest positive impact on peoples lives when offered in conjunction with support to the teams and organisations in which people will work. The opportunity to receive this type of support can be funded by the grant from NHSE which is allocated to each Autism Peer Support trainee.

The Autism Peer Support Worker Training Team

The ImROC autism training team predominantly comprises of people who identify as neurodiverse. Over 90% of ImROC trainers have either a formal diagnosis of autism, are family or carers of autistic children or family and carers of autistic children with a diagnosis themselves. All trainers bring experience and expertise from different aspects of their lives, as trained teachers, managers, campaigners and health professionals.

ImROC’s Autism Peer Support Worker training has been developed through co-production. The work to create contemporary training opportunities is led by the Autism Training Team with the lived experience of being autistic valued and celebrated. The Autism Peer Support Worker training programme has been produced in partnership with ImROC and is unique in its offer.

Celebrating Success and Sharing Stories

The ImROC evaluation of the delivery of the NHSE contract and establishment of the training team has brought together a wide range of life stories and lived experiences.

The delivery of ImROC Autism Peer Support Worker Training is creating new partnerships new friendships and a very real set of human connections. ImROC has invited its partners to share their stories and over the next few weeks we will add blogs to this introduction.

ImROC’s training provides learning space aiming to equip trainees with a strong understanding and commitment to providing values led support.

Our training rooms are a safe place for everyone to practice and adopt our values that are fully aligned with the HEE peer support competency framework.

View the HHE Peer Support Competency Framework

Mutuality

The experience of peers who give and gain support is never identical, but peer support is based on connections born out of shared experience. Peer workers bring experiential understanding of living with mental health challenges and/or long-term conditions, the meaning of being defined as a ‘patient’ in our society and the confusion, loneliness, fear and hopelessness that can ensue.

Reciprocity

Traditional relationships between mental health professionals and the people they support are founded on the assumption of an expert (professional) and a non-expert (patient/client). Peer relationships involve no claims to such special expertise, but a sharing and exploration of different world views and the generation of solutions together.

Non-directive

Mental health professionals often prescribe the ‘best’ course of action for those whom they serve. Peer support is not about introducing another set of experts to offer prescriptions based on their experience, e.g. “You should try this because it worked for me”. Instead, they bring their own belief in others to support them  to recognise their own resources and seek their own solutions. “Peer support is about being an expert in not being an expert and that takes a lot of expertise.” (www.recoveryinnovations.org)

Recovery-focused

Peer support engages in recovery-focused relationships by: Inspiring HOPE and belief that things will get better: they embody possibility and are in a position to say ‘I know you can do it’ to help generate personal belief, energy and commitment with the person they are supporting. Supporting people to take back CONTROL of their personal challenge, the way they understand, cope and manage them and define their own destiny. Facilitating access to OPPORTUNITIES that the person values, enabling them to participate in roles, relationships and activities in the communities of their choice.

Being recovery-focused means, we are seeing the whole person, their goals and ambitions, the language they like to use, and supporting them to heal from what has happened to them at their own pace in the ways that are meaningful to them and understanding that this looks different to everyone.

It doesn’t mean we are expecting anyone to ‘recover’ or that ‘recovery’ is the end goal, but journeying with someone and knowing that no journey is linear.

Creating a recovery focused culture

Strengths-based

Peer support involves a relationship where the person providing support is not afraid of being with someone in their distress. But it is also about seeing within that distress the seeds of possibility and creating a fertile ground for those seeds to grow. It explores what a person has gained from their experience, seeks out their qualities and assets, identifies hidden achievements and celebrates what may seem like the smallest steps forward.

Community facing

Being a ‘peer’ is not just about having experienced mental health challenges, it is also about understanding the meaning of such experiences within the communities of which the person is a part. This can be critical among those who feel marginalised and misunderstood by traditional services. Someone who knows the language, values and nuances of those communities obviously has a better understanding of the resources and the possibilities. This equips them to be more effective in helping others become a valued member of their community.

Progressive

Peer support is not a static friendship, but progressive mutual support in a shared journey of discovery. The peer is not just a ‘buddy’, but a travelling companion, with both travellers learning new skills, developing new resources and reframing challenges as opportunities for finding new solutions.

Safe

Supportive peer relationships involve the negotiation of what emotional safety means to both parties. This can be achieved by discovering what makes each other feel unsafe, sharing rules of confidentiality, demonstrating compassion, authenticity and a non-judgemental attitude and acknowledging that neither has all the answers.

Risk, Safety and Recovery

We feel that working with these 8 core values is a great barometer of how these 8 values are the foundation of peer to peer relationships, they provide the parameters and the barometers of our training, but all are grounded in a culture of equity.

Equity

Equity means making sure that everyone has access to the support they need in the way that they need it and actively working to remove barriers that prevents them getting their needs met. Without equity, peer support work cannot take place.

Welcome to the ImROC Peer Support Training area.

We provide training for Peer Support workers, training for teams welcoming peer support workers, one to one coaching and consultancy for individuals and organisations wishing to develop their peer support practices and services.

Peer support is a founding pillar of ImROC’s work and we are committed to providing co-produced training for peer support workers that is  values led alongside bespoke support for the organisations that employ them so they are equipped to create healthy environments for Peer Support work to form and flourish.

ImROC’s peer support training aims is to improve the lives of people living with long term conditions by expanding access to peer support that is accessible, meaningful, effective and empowering, all centred around the person they support.  

We also aim to ensure that peer support is fully understood by employers as a distinct and complementary contribution, by peer support workers who are well supported and supervised in work, and supporting organisations to influence and grow recovery focused, trauma informed and equitable culture and systems.

Peer Support: A Call for a National Strategy Executive Summary

Foreword – Sean Duggan OBE – Chief Executive of the Mental Health Network, NHS Confederation

The Peer Support Worker role is one of the most exciting new roles that are being deployed across England as part of the Long Term Plan. Both employed and voluntary Peer Support Workers are now found in most adult mental health teams across the country and Health Education England continues to fund an accessible and effective training programme that ImROC along with others is delivering.

In these times of acute pressure on services, it can be difficult for staff to find time to develop safe, supportive and empowering relationships with people who use services. This is exactly what peer support workers are trained and employed to do. Because they know what it feels like to be on the receiving end of services, they constantly remind us about how to make our routine language, practices and processes more recovery focused. I have seen the inspiration and hope that peer support workers bring to others; to staff as well as people using services. I am continually impressed by the courage and resilience that peer support workers have shown in achieving their own recovery goals.

I am pleased to add my personal endorsement of the peer support worker role and the call for a national workforce peer support strategy.

Celebrating 10 Years of Peer Support

Within ten years the role of peer support has evolved in UK health services in a dramatic way. From being an informal, peripheral role, peer support workers are now employed within most mental health trusts, and there are plans to expand these numbers further and at scale. Peer support workers are employed to use their lived experience of having a mental health or long-term condition in order to support others. The approach is underpinned by a specific values base, which pays attention to equality and emotional safety within relationships.

For decades, people who use services and survivors have campaigned for the inclusion of people who explicitly use their lived experience into the health workforce, and for many, the expansion of peer support is a huge achievement. It is hoped that their inclusion into the workforce will contribute to a culture change away from an expert-patient, illness based paradigm, and toward a strengths based, trauma informed approach, where the individual is truly seen as the expert in their own life.

The key milestones in the development of peer support in the last decade include:

● The values that underpin peer support have been well- defined, are becoming increasingly well-articulated, with different iterations for different cultural/geographical and service groups

● The evidence base for peer support is well established, with findings showing that it brings about the same or better outcomes as traditional approaches. Qualitative and user- led research demonstrates a clear need for peer support, and highlights the most effective methods for researching peer support

● Peer support workers are included in local and national workforce plans, with numbers set to grow up until 2024

● The peer support worker Competency Framework has been developed by Health Education England, with ImROC and other organisations to support the commissioning, development and training of peer support workers/peer worker roles

● There is growing clarity and acceptance of peer support within inpatient and community mental health services

● The development of a peer worker apprenticeship is a further step in formalising the peer worker role and offering a different route for progression and development for some peer workers

The Challenges that Peer Support Continues to Face

While for many, these milestones reflect a true acceptance and investment in peer support on a national level, for others they are signs of something more troubling. As peer support becomes more formalised, and peer workers are increasingly described in the same way as other professional groups, challenges to the original vision of peer support are presented. The ImROC evaluation of peer support in 2022 is that…

● There is risk that peer support will be homogenised with specific competencies that are expected to work within all settings when peer support needs room to evolve and be tailored to different service and geographical contexts

● Peer support may be co-opted by professionally led institutions, even while they are attempting to invest in its success. There has been disagreement with the methods used to develop the national competency framework, and subsequently with the competencies themselves

● As peer support is introduced into challenging, illness based, expert led services, peer workers struggle to maintain a connection to their own values base and unique way of working and risk emulating being consumed by the cultures that they work in

● Peer support workers continue to report that they have negative experiences within their working contexts due to stigma and lack of understanding about their role

● There is a noticeable lack of leadership and progression opportunities for peer workers

● There is a need to focus on cultural competency within peer support, which can define lived experience narrowly as relating to mental health, rather than acknowledging how broad experience intersects with other experiences of oppression or privilege

Planning the Peer Workforce for the Next 10 Years

With the endurance of the peer support role and increasing numbers of peer support workers it is time for a clear overarching vision for peer support in England and across the United Kingdom.

For peer support to truly develop ImROC is recommending that the current focus on training peer support workers (in terms of numbers) should now lead to strategic thinking and planning, taking into account the bigger issues of culture and systemic contexts that peer support workers find themselves in.

● Strategy both at an organisational and national level to enable infrastructures that support the introduction of peer support into the workforce as part of current transformations

● Peer Leadership, also at an organisational and national level, with meaningful and supported peer leadership roles at every level of services. This should include the development opportunities to enable progression into peer leadership roles within mental health services. Peer leaders need to recognise the roots of peer support and be enabled to speak from these roots to support wider cultural change

● Reuniting with the roots of peer support

● Critical focus on diversity and inclusion in the development,
delivery and reach of peer support

● Peer support co-ordinated at a locality level with all services that offer peer support

Peer Support – A Vision for the Longer Term

We believe in a future where every person using health and social care services is able to be met and benefit from working with a person with
shared lived experience. These services will welcome peer support as a new occupation and there will be clear strategies in place that support peer workers in their training and ongoing development.

Peer workers will be supported by senior peers, offered co-reflection from within their organisation and feel connected to the bigger picture of peer support through national networks developed for this purpose. We seek to support the cultures of services in the future that will:

● Welcome peer support as new occupation

● Recognise the complementary values of peer support across all sectors

● Adjust the values and principle-based peer support role across different groups

● Recognise the evidence for peer support

● Welcome and support peer leaders

● Be led by a national strategic vision for peer support working

Given the exponential rise in numbers of peer support workers trained and employed in mental health services, the significant funding commitment from Health Education England (HEE) and the inclusion of peer support workers in current mental health policy implementation documents it is time to assess the current position of peer support workers in mental health and social care services in England. This paper considers progress and pitfalls; sources of successes and challenges; the gaps and the future possibilities. It ends with recommendations for policy, funding and practice which we believe are essential if peer support workers are to achieve all potential benefits for those whom they support, the services they work in and for their own personal wellbeing and professional development.

22. Peer Support in mental health and social care services: Where are we now?

Emma Watson and Julie Repper

Introduction

We are living in exciting times for peer support. The role of peer workers seems to be poised on the edge of a great height, having worked incredibly hard to get there. If the conditions are favourable, peer support may be about to take flight into a horizon of culture change and widespread acceptance of this new role. At such an altitude, there are also challenges; the conditions and context surrounding peer support are crucial.

This paper seeks to outline the progress that has been made in peer support in recent years, as well as to present a vision for a future of peer support within services which lays out the conditions needed for it to thrive.

The past 15 years have seen phenomenal change in the employment of people with personal experience of mental health challenges in services. This has built on the benefits of mutual support developed in self- help, user led community groups and natural relationships to become a role within mental health services across the world. From a largely informal approach between people who share similar struggles, peer support has been formalised, and the presence of Peer Support Workers, who are employed within mental health services to use their lived experience of mental distress to support others, is now commonplace.

Peer Support Workers were first employed in UK mental health services in 2009 in small numbers by some NHS Trusts. Early implementers were supported by ImROC, who advocated for the employment of peer workers as part of a wider cultural change toward recovery orientated services (see Shepherd et al., 2010). From here began a long climb, not only for peer support as a concept, but also for individual peer support workers, to become accepted, to find their identity and a coherent role within the challenging environment of mental health services.

In the past 15 years, the calls for an evidence base for peer support, for training and support for peer workers, and for greater employment for peer workers have been, and continue to be answered. In 2019, the HEE peer support benchmarking report found that 862 peer support workers were employed in services (with approximately 86% directly employed by the NHS and the remaining 14% employed by external parties – for example, organisations within the voluntary sector).

In England, peer support workers are valued as a new role by NHSE (HEE/NHSI) with funding provided for peer support worker training, peer supervisor training and infrastructure support during 2021-4.

The employment of peer support workers is a requirement of the NHS long-term plan included in the mental health implementation plan (which envisages numbers of peer support workers growing by 170 in 2019/20 to 2,780 new peer workers employed in mental health services in 2023/4). Some NHS Trusts have already developed a peer workforce that exceeds policy expectations with peer support workers employed across the whole range
of services from Childrens and Adolescents to Older People’s and Dementia Services, in Primary care and Forensic services, in specialist services like substance misuse, perinatal mental health and gender clinics.

Peer support in statutory health and social care services has taken root in a way that seemed unlikely just 10 years ago. The next decade will see a further increase in the number of peer support workers employed within mental health services, with more being employed in a more diverse range
of services than ever before. The HEE national competency framework for peer support workers and the development of an apprenticeship pathway have served to further legitimise and support the peer worker role. However, these successes also present challenges.

In the following section, we frame the current position of peer support around the progress that has been made in the employment of peer support workers in mental health and social care services, and the pitfalls that challenge the future of peer support.

“And the peer support worker was just like a breath of fresh air on the ward. She was just so…she didn’t share a lot of what she’d been through but she shared enough to know that she’d been through things that had been really difficult for her, and now look at her she’s working, that’s incredible. And it just gave me that hope that…I could do that. And I think it like, saved my life [laughs] because she was just…she told me…about some experiences and they were very very similar to mine, and…the fact that she was working was so inspiring to me. And she’d come and see me and sit with me and encourage me to do a little bit and then a little bit more, and then it just build up from there. Umm and I just thought, I just want to do that, that’s what I want to do. And I sort of kept my eyes out”. (Excerpt of interview transcript, Watson 2021)

The peer support worker I had, sort of validated my existence as a person and my purpose in life. And they were someone who believed in me and my place in the world and the importance of my existence, and they didn’t want to get rid of me, they wanted to watch me fly, and saw me as an ability and not a disability. If she hadn’t have had that [shared lived experience] and was just trying to interact with [me] in a way that was supportive but…without getting it, it wouldn’t have worked, and I wouldn’t be sat here now. Because I would never have found trust in my psychologist, in anyone. I think back then I didn’t trust anybody, not even 10%. Somebody asked my name… ‘why do you need to know my name? F*** off’, simple as that. And I think what I needed at that time was to find somebody that I could actually trust. And when I found that trust in [the peer support worker], it kind of helped me to think maybe there’s trust elsewhere too. (excerpt of interview transcript, Watson, 2021)

Progress, Pitfalls and Moving Forward

The table below summarises the progress and pitfalls that currently characterise peer support. The far-right column includes some possible ways forward in each area. Following this table, each point is discussed in more detail below.

1. Defining peer support and it’s values

a) Progress

It has long been recognised that the distinctiveness of peer support lies in a unique set of values that sets it apart from professional support (Watson, 2019). Peers – who have some experiences in common – are able to establish safe, mutual, trauma informed relationships with each other;
they spend time together exploring ways of understanding what has happened, ways of coping, and ways of communicating that might be helpful. These relationships are not framed by the offering of advice, but about learning together using the safe, non- judgmental connection as a platform.

While lived experience is essential to peer support, this alone is not sufficient to build the empathetic relationships that are necessary for healing. The values of peer support have roots within the survivor and hearing voices movements, which have campaigned for mental health services that position the person as the expert in their own wellbeing, rather than the disempowering expert-patient hierarchies which have traditionally defined psychiatric services. It was recognition of shared experiences within these campaigning groups that culminated in the service user led redefinition of ‘Recovery’ as a process of people taking control of their own understanding and management of
their own conditions (Chamberlain, 1978). These activist groups have also raised awareness and driven change in relation to the human rights of people with mental health problems – both in terms of social issues (like employment, housing, education, financial resources and adaptations to facilitate full inclusion), and in terms of their rights within the mental health system. Belonging to such user-led groups is not just about mutual support centred on personal challenges, it is also about gaining an empowering identity, being part of a movement, experiencing solidarity alongside others.

As the value of naturally occurring mutual (peer) support has been recognised, it has inevitably become more formalised in a bid to replicate its benefits. Shery Mead, the founder of Intentional Peer Support (IPS) in the US was one of the first to describe the process of peer support and explain its value in mental health services. She developed the notion of Intentional Peer Support (IPS) to differentiate it from that which occurs naturally in an informal support group. IPS is defined by a shift in the focus of relationships (Filson & Mead, 2016) from helping (problem solving or fixing) to a focus on learning together; from a focus on the individual to a focus on the relationship; from fear-based responses to a focus on hope-based responses.

In 2013, ImROC identified eight core principles of peer support that were observed in the practice of peer support workers employed in adult mental health services (through Health Foundation funded research with Nottinghamshire Healthcare NHS Foundation Trust). These principles were described and illustrated with quotations and practice examples, they include: Mutuality, Reciprocity, Safety, Recovery Focus, Progressive, Inclusive, Strengths-based and Non-directive (see Repper et al., 2013) Similar values and principles of peer support have been suggested by many charity, government and consumer led services in the US, Europe and the UK. The resulting frameworks have been used to evaluate and understand peer support projects. While there are differences in the values frameworks established within different cultural, systemic and geographical contexts, they share some common themes. These include establishing emotional safety, addressing power imbalances, and refraining from fixing or offering solutions.

b) Pitfalls

As the values of peer support are articulated in ever more sophisticated ways, there is a risk of these values becoming prescriptive, or being used to lay claim to certain forms of peer support as more legitimate than others. In practice, context is hugely important in defining the nature and emphasis of peer support. For example, within community based, user led services, there is far greater emphasis on collective activism, with explicit resistance to traditional psychiatric approaches and less emphasis on ‘outcomes’ or ‘progress’ with Recovery. Many argue that the mutual nature of peer support cannot be faithfully applied within mental health services. Where peer workers are paid, are required to assess risk or write notes on/with the people they support, mutuality must be redefined, and compromises must be made. However, it does not mean that peer support has failed if all of the values are not loyally maintained. In fact, we believe that the strength of individual peer workers to apply these values in the most difficult and unlikely circumstances should be celebrated.

c) Moving forward

One of the most beautiful things about peer support is that it can be informed, developed and delivered in a wide range of contexts:
in statutory services and in voluntary sector services, informal spaces and natural relationships. Using their values-based way of working, peer support workers can offer much needed time, hope and self-belief to those using mental health services and peer support offered by community based groups can facilitate positive identities, roles, support and skills to rebuild relationships, roles and activities. These different contexts require different iterations of the values of peer support, so that it can be adapted to best suit the environment and the people involved in offering and receiving it. Rather than seeing areas where the peer support values seem to have mutated as areas of failure, we can look at this, to some extent, as a natural evolution of peer support.

There is an opportunity within current ‘place’ based policies and plans for mental health service provision to grow and develop peer support in all its forms across a given locality. All those individuals and organisations offering peer support might usefully come together to learn from one another, debate key questions, raise awareness of critical issues and potential solutions.

Understanding how peer support is offered in different contexts, and how the values are articulated will improve our understanding of peer support, and increase its influence within the system. This approach has been demonstrated through the development of the Sussex peer support partnership;
a collaboration between 13 different organisations offering peer support (Faulkner, 2021). This partnership provides a model for good practice that has the potential to deliver peer led peer support across a system with
a range of options available for people with different life and lived experience. It works towards four overarching goals:

• to provide peer leadership to define, deliver and influence peer support in the locality;
• to established a shared understanding of what is meant by peer support;
• to ensure that people experiencing mental distress have a choice about the kind of peer support they would like based on the range of services available;
• to influence commissioners so that they recognise the diversity and depth of peer support on offer.

We see huge value in this collaborative model, where peer support services offered in different settings and with different kinds of experience and expertise, work together to provide peer support across a given locality.

2. The evidence base for peer support

a) Progress

There is an ever-increasing body of evidence providing accounts of the impact of peer support. The most positive research comes from first person accounts, narrative research and explorations led or coproduced with people receiving and/or offering peer support. These describe the values based relationships that underpin mutual interactions between people who support each other in their emotional distress (Mead & MacNeil, 2006). Trauma-informed approaches to peer support focus on whole life experiences rather than on an individual’s problems (Blanch et al., 2012), and there is a focus on community and connection rather than simply individual change (Faulkner and Kalathil, 2012). In an exploration of the mechanisms underpinning peer support, Watson (2017) found that people value peer support because of the opportunity it provides for normalizing, nontreatment-based relationships, and Gillard et al. (2015) suggest that it is through relationships that peer support works to strengthen wider connections to community (Gillard, Gibson, Holley, & Lucock, 2015).

Professionally led randomized controlled trials (RCTs) of effectiveness offer more restrained accounts of the benefits of peer support, concluding that peer support workers are broadly as effective as other professionals. They find that peer workers do not appear to achieve better outcomes on traditional indicators of improvement: severity of symptoms, length of hospitalisation, levels of functioning (Bellamy et al., 2017). These studies are largely unclear about the role of peer workers and do not specify how their role differs from that of other professionals. Given the provenance, meaning and nature of peer support, and the difficulty extrapolating the contribution of peer workers when they work as a member of a multidisciplinary team, it is hardly surprising that neither the difference they make, nor the way in which they make a difference, show up in this kind of research.

There are increasing studies into the effectiveness of professionally designed interventions being delivered by peer support workers: cognitive behavioural therapy, self-management strategies, medication adherence, case management (Bellamy et al, 2017) – and in relation to physical health conditions, illness specific education (Repper and Walker, 2019). This may or may not be helpful, but it is not peer support. It replicates and reinforces the traditional expert/patient relationship and illness management approach of psychiatry and is at odds with the core values of peer support: equal power relationships, reciprocal roles of helping and learning and a ‘whole of life’ rather than illness-focused approach).

There is a further body of evidence that demonstrates how the delivery of peer support is influenced by the context, the role of peer workers, their training, support/ supervision, and the opportunities they have to spend time with the people they support. Where peer workers are not supported to develop peer to peer relationships founded on their values then the extent to which they can offer peer support is limited (Gillard et al., 2015b) and peer workers either burn out or conform to the team values and practices. There are exceptions however, Watson found that peer support workers found innovative and imaginative ways of remaining ‘peer’ in their relationships against all odds (Watson 2020).

b) Pitfalls

What is the purpose of amassing evidence about the effectiveness of peer workers? The calls for evidence have not died down since peer workers began to be employed in NHS services. This might serve to calm the fears of those who are wary of the introduction of people with lived experience into the workforce – there now exists far more evidence for peer workers than there are for mental health nurses or psychiatrists (Slade et al., 2017), whose professions are unquestioned.

The evidence might also be used to mount peer workers as the solution to a workforce crisis which at first appears to be win-win: more peer workers and a happier mental health system. However, the calls for evidence into the effectiveness of peer workers and their cost-saving potential risk moving the focus away from the moral and political motivations for employing peer workers. Peer workers not only provide hope and model the possibility of recovery for individuals, but also seek to shift reliance on traditional models of practice that depend on one expert ‘fixing’ one recipient, to a more mutual, human relationship in which peers work together to make sense of events and find their own ways of coping and building meaningful lives. This ultimately challenges current perceptions about the potential and status of people with mental health conditions – social outcomes that are not considered in traditional research. Indeed, the nature and expectations of funded research risks fitting a whole diverse group of supporters working in a range of settings and with non-traditional goals and approaches into a standard research paradigm designed to measure traditional services in terms of service-related outcomes.

c) Moving forward

If further evidence into peer support is needed, it might usefully focus on considering the distinctive contribution of peer support in terms of the identity, role, status, rights, community engagement and/or collective empowerment of peer workers, those they support and people who experience mental health challenges as a whole. What are the ingredients of peer relationships that make it so acceptable, accessible and empowering? And how do we create contexts that are supportive and conducive to peer relationships? These are more relevant questions to be posing than continuing to search for evidence for peer workers’ effectiveness.

A more pertinent area of research still would be to examine the context that surrounds peer workers. It is no secret that there are particular service settings and cultures which peer workers find more difficult to work within than others, and yet this is not well articulated within research. Building a clear understanding of what contributes to a recovery focussed culture and how changes can be brought about will support not only peer workers but the wider workforce, which is in need now more than ever. This is a much more complex question to ask, and would reveal the multi-faceted nature of the cultures to which we are introducing peer support; cultures that are currently struggling with austerity, staff-mix, staff shortage, increasing acuity and increasing workload among many other things.

3. Peer support as a new role in the NHS

a) Progress

Health Education England (HEE) have laid out their ambition to support the development of peer support workers nationally, and have identified opportunities to support the growth of the peer role up until 2024. They focus on peer roles across perinatal mental health, adult severe mental illnesses (SMI) community care, adult crisis alternatives and problem gambling mental health support. Their report, Stepping Forward to 2020/21: The Mental Health workforce Plan for England (HEE, 2017) outlines plans for a significant increase in peer support roles, and the Mental Health Implementation Plan 2019/20 – 2023/24 outlines the aim of training an additional 4,730 mental health peer support workers over five years.

To accompany the workforce plans described above, HEE commissioned the development of a national competency framework for peer workers (HEE, 2020). This document is designed to support the commissioning, training and development of peer worker roles in the NHS. Within the framework, HEE have outlined the expectations of the peer support worker role, the training and developmental support needs that organisations must take into account. They emphasise that work is needed to translate the framework into different mental health settings, and that the competencies themselves should not be seen as a mandate, encouraging organisations ‘to steer away from over professionalising a role which, at its heart, is about human connection and relationships.’ (p.1)

The competency framework has the potential to provide long-sought clarity to organisations employing peer workers. It remains the case that the peer support role is sometimes confusing to teams and organisations. Since peer support is a values-based way of working, it is less easy to articulate the duties a peer worker might undertake or the wide range of skills that they may draw on. Providing a competence framework may help to frame the peer worker role in terms which employers can easily understand, and help peer workers to be accepted into roles which are within their capabilities to undertake.

In addition to the competence framework, work is also being undertaken to develop an apprenticeship pathway for peer workers. To date, the lack of academic accreditation within peer support training has preserved the accessibility of the peer worker role for applicants regardless of their previous levels of educational attainment. However, in the longer term, this can also act as a barrier to those peer workers wishing to move into more senior roles or access professional training. The apprenticeship pathway will provide an opportunity for aspiring peer workers to gain a peer support qualification whilst in employment, accredited at Level 3 allowing for academic recognition and progression and professional recognition as a distinct occupation.

Although peer support workers are included in national workforce planning, there is very little mention of peer support in current policy documents. They are generally included in lists of new roles in the NHS and in lists of the different professional groups expected to be employed. However there is nothing about their role or their distinct contribution within mental health teams – or in relation to physical health services.

b) Pitfalls

i) Practice moves faster than policy Whilst it is heartening to see the investment in peer support by HEE, their focus on particular mental health services for the first three years of funding means that other services, many of which are developing peer roles, will do so without investment, guidance or support. Peer support workers are increasingly employed in primary care teams; as link workers, social prescribers, health coaches, community navigators for people with long term conditions including mental health problems, long covid, as well as frequent attenders at GP surgeries, frequent callers of emergency services, frequent attenders at Emergency Departments. Peer support is also developing in services providing support for long term physical health conditions, for people with learning disabilities and autism, people with eating disorders, those using substance misuse services and people with mental health problems in prisons.

Moving forward
In every area where peer support is newly developing particular attention needs to be paid to how it should be offered and what people using these services tell us is helpful in these specific settings. For example, peer support is growing in forensic services, where debates about boundaries, what type of lived experience makes one a peer, and level of access/ security clearance are beginning to emerge. At the present time there are many diverse peer support projects developing in communities, across the whole range of health and social care services and thought needs to go into how to employ, train and supervise peer workers for different settings. There is no forum for sharing learning, no evaluation framework to assess or compare approaches; there is a competitive culture because different groups are rivals for the same funding. We suggest that funding is made available for a national community of practice to enable us to collaborate, share progress, generate new ideas, agree leadership for new projects together and coproduce evaluation frameworks that can be used across different services. This would be a powerful way of sharing learning, one of the cornerstones of peer support, and enable areas where peer support is in its infancy to learn from the successes and challenges of more developed projects.

ii) Co-option

The HEE competence framework has been a controversial development within the peer support community. National Service User Survivor Network (NSUN) have stated that ‘the Competence Framework is a product of deeply flawed processes and, as such, a lot of its content is problematic. The wider issue here is who led the Competence Framework – and this, our key demand, was not up for negotiation’ (Hart, 2020). The development of such a framework has magnified debates surrounding ownership and co-option in peer support. These debates have been live for as long as peer workers have been employed in statutory mental health services, but with the current expansion of peer support and the development of frameworks and pathways, often without adequate involvement of people with lived experience themselves, they take on a new urgency.

Many believe that peer support may be misused within mental health services, so that peer workers will be expected to conform to the practices that the survivor movement continues to campaign against. While some have welcomed the introduction of peer workers as a sign that cultures are becoming more open to valuing lived experience, others have viewed it as ‘co-option’ or misuse of survivor knowledge to serve mental health systems, while they leave their controlling practices intact (Penney & Prescot, 2016). Voronka (2017) questions: ‘to what effect are we [peer workers] deploying our work to orient clients toward feelings and responses that actually encourage compliance and cooperation with dominant conceptual models of mental illness?’ (p. 335). Many survivors have questioned how possible it is to maintain the mutual philosophy of peer support within highly structured organisations such as the NHS (Faulkner, 2020).

All too often, projects employ people with relevant lived experience to deliver professionally developed interventions, rather than to draw on experiential knowledge to support and empower people to make their own decisions about how to manage their condition, their treatment and their lives as a whole. In addition, debates remain about how the peer worker role should be used in conjunction with risk assessments, medication and physical restraint, with some peer workers seeing these as tasks that they support within their role and others believing these to be philosophically at odds with their values base.

Moving forward

In their HEE thought piece, Ball and Skinner (2021) describe how the debates about ownership and co-option within peer support can imply that peer support workers in particular settings such as the NHS deserve estrangement and alienation from the broader peer support community external to statutory organisations, because the support they offer is less ‘pure’. They, and others, have argued that rather than viewing peer support in statutory services as inferior or compromised, it should be acknowledged as an equally legitimate form of peer support in what is a broad spectrum of approaches. We too believe that peer support is essential within statutory services; the presence of peer workers to offer support when people are at their least empowered within mental health systems is a huge achievement, that has been long campaigned for. Of course, this only remains an achievement if peer workers are trained with an awareness of the activist roots of their role, if they are supported to uphold the values of their ‘profession’ and if there is leadership and strategy in place to provide a structure for progression and ongoing development. These points are discussed further below.

iii) The experience of peer workers in health and social care systems
Despite the role of peer workers becoming ever more recognised, there is a huge body of literature which testifies to the difficulty experienced by peer workers working within mental health systems. The narratives of peer support workers consistently emphasise themes of feeling stigmatised by other staff, being viewed through a diagnostic lens, experiencing poor support structures, a lack of credibility in peer support and unclear working roles. While many of these poor experiences relate to the ongoing stigma attached to the peer (service user) identity, there are also testimonies of the difficulty of adopting any new role in the context of over-stretched, under-funded mental health systems where there never seems to be enough time to properly think about how best to harness the strengths of the workforce.

These working environments, coupled with the desire to uphold the values of peer support can create profound professional dissonance among peer support workers. The sense of being unsupported within a system which does not subscribe to the values of peer support is exacerbated by the lack of strategy or structure within these systems to support peer support workers. Currently, there is no nationally established career structure for peer support workers and there is little peer leadership. Most peer support workers are managed and supervised by health professionals rather than leaders in peer roles.

Some organisations are appointing experts by experience to lead coproduction and service user engagement and to sit on boards and senior decision-making committees. This is all done without any explicit clarity or agreement about the distinct knowledge that lived experience brings, the value that it adds, or the reason why it is sought. As numbers of peer workers are set to swell, there is a risk of more and more organisations employing and training peer workers without a clear understanding of the reasons for doing so. This will only add to the poor experience of peer workers within these systems, who may begin to adopt traditional ways of working to fit in with their professional colleagues, or may feel isolated in their values base without support from a wider team and culture.

Moving forward

Mental health organisations with greatest success in employing peer workers are those that are already committed to shifting the culture of services to be more focused on enabling people using services to recover and live well in their communities. As part of this they have a clear understanding of the importance and value of the lived and life experience of all staff, and are actively developing practices that empower people using services through shared decision making and coproduction at every level. It is increasingly challenging to maintain momentum in this movement as staff shortages and continual changes in structures and processes place almost impossible demands on front line providers. Where teams are well prepared for peer workers they recognise the value and contribution that they can make to the experience of people using services and take steps to enable them to build mutually supportive relationships. There is, however, in all services, a notable lack of peer leadership for the peer workforce and no agreement about the role of peer leaders as another professional lead at senior management level, this is discussed in the following section.

iv) Peer leadership and career progression

The progress that has been made in developing peer support workers within mental health services has largely been led by professional groups, and those who identify in other ways than through their lived experience. It has taken these people in positions of power to ‘sell’ peer support, their voices carrying more authority than those of people using services within many statutory service contexts. While this has undoubtably led to progress, the lack of people with lived experience leading the direction and vision for peer support has impacted (impaired) the course that developments have taken at a national level and within organisations. There now exist many peer support workers with many years of experience of working within services. These peers remain within the positions they were first recruited to, as few organisations are employing peer workers in leadership posts. It is difficult not to see this as an indication of the low trust and value placed in peer support workers nationally.

One of the key criticisms levelled at the HEE competency framework is that people with lived experience were not able to own, or even co-lead on, its development. Price (2020) argues that this has resulted in a framework which creates a version of peer support that conforms with the existing NHS ideology, based in clinical knowledge and treatment pathways. Both at a national and local level, the establishment of peer leader roles, and a clear route for progression for peer workers which does not entail joining an existing profession such as nursing, is vital in preserving the identity and integrity of peer support in health and social care.

Peer leadership roles have been created by some NHS and social care organisations. Sometimes these posts are paid at the same level as other service managers, and sometimes the job descriptions, which lack a professional registration, are matched at a lower level because lived experience is not valued in the same way as professional expertise. Peer leaders have reported having little support in the face of unrealistic expectations about their role and a need to present themselves as credible and competent in sceptical systems (NSUN & Mind, 2021). They have also described feeling attacked from within their peer communities, partly because the nature of peer leadership is still up for debate, but also because of the perceived compromises involved in working in senior positions within statutory organisations. These conditions have led to peer leadership roles often coming with a personal cost to those employed within them. Of course, when peer leadership roles have been created, it is with quite the opposite intention to this: often they are created with the hope of embedding a wider vision for recovery orientated change across services. However, especially in the context of ongoing austerity, recovery focused practices have struggled to occupy a central position in the prevailing socio-cultural practices of mental health organisations.

Moving forward

The challenge of changing cultures is often one of the expectations of peer support workers, who generally occupy one of the lowest paid roles in mental health organisations. A peer support leadership structure, where lived experience is valued as an equally legitimate form of knowledge as professional expertise, would be a true sign of culture change. Just as other professionals have a professional lead, peer support workers need leadership to continually clarify their distinct contribution to services; to consistently articulate the difference that they make to the experience of people using services; to work with other staff to prioritise the voice and experience of people using services and to promote peer approaches at all levels of services. Further to this, there needs to be support for peer support workers to develop their skills as leaders and this development must be rooted in the experience and expertise of grassroots peer support and activism rather than in professionally informed health service leadership that exists in different paradigms and practices. Indeed, peer leaders need to develop the skills to work across boundaries and beliefs, to practice co-productively and to remain faithful to peer values. Without this, the employment of peer leaders risks being tokenistic and will not bring about meaningful culture change.

v) Cultural competence and diversity with peer support

Socially excluded communities, which experience the poorest health outcomes, are over-represented in mental health services and under-represented in formalised peer support. Although peer support has long existed in marginalised communities, the concept of lived experience in workforce plans often fails to take into account the multiple different kinds of lived experience a person has, including the experiences of racism, sexism, heterosexism, oppression and discrimination and their intersection. The word ‘peer’ is increasingly used to describe a person with lived experience of mental health challenges, while failing to take into account the other qualities that make us peers to each other.

Some have referred to this filtering of the peer concept as a form of ‘strategic essentialism’; uniting under our shared characteristics to bring about social change. This can be a powerful tactic for collective change, however it may also serve to reinforce the stigma associated with the experience of mental distress, by failing to consider the other, equally important, elements of a person’s being.

Faulkner and Kalathil (2012) found that for many people, the shared experience of mental distress is not enough to identify with someone else as a peer. Their report surveyed people from a diverse range of peer support projects and found that more than half of the respondents said that peers should share characteristics including gender, ethnic background, sexual orientation, age, religion and faith. Sixty-six per cent of respondents from BME communities felt that a shared ethnic and cultural background would be important in a peer.

The HEE benchmarking report (2020) found that 84% of peer workers were White or White British, a population which had some of the lowest rates of detention under the mental health act between 2019-20 (NHS digital, 2021). This is clearly a failure to adequately consider what diversity in peer support actually means, and how it can be supported. It is an alarming thought that peer support within statutory mental health settings is being distorted by the institutional racism inherent within these services, but we must collectively, repeatedly guard against such a future unfolding.

Moving forward

There is no straightforward way of addressing systemic racism. It takes active and continued work on every level, using a wide range of approaches. A starting point would be to actively recruit peer workers from diverse communities, and aim to recruit peer workers who reflect the diversity of the people they will be supporting. Peer support training should always be offered within a human rights based frame, given the history of the survivor movement, but it is essential that this also includes a broader understanding of inequality and oppression to account for the intersectionality experienced by many using health services.

The most meaningful way of addressing these issues is to step back and listen to the people who are most affected by them. We need to actively seek out the voices that we have marginalised and listen to what they have to say. Much of the recovery movement has been characterised by co-production, and this must continue within peer support, so that we may consider diversity within the peer support population a source of pride, and not of failure.

Recommendations

In order to provide the most beneficial environment for the next stage of peer support, we suggest that the focus needs to develop rapidly from the current focus on training peer support workers to focused consideration of the cultural and systemic contexts in which they work. With this in mind, we suggest that the following considerations are essential:

1. Strategy both at an organisational and national level to enable infrastructures that support the introduction of peer support into the workforce as part of current transformations.
2. Peer Leadership, also at an organisational and national level, with meaningful and supported peer leadership roles at every level of services. This should include the development opportunities to enable progression into peer leadership roles within mental health services. Peer leaders need to recognise the roots of peer support and be enabled to speak from these roots to support wider cultural change.
3. Reuniting with the roots of peer support
4. Critical focus on diversity and inclusion in the development, delivery and reach of peer support.
5. Peer support co-ordinated at a locality level with all services that offer peer support.

1. BEYOND TRAINING AND EMPLOYMENT: INFRASTRUCTURE AND STRATEGY IN HEALTH AND SOCIAL CARE SERVICES

The peer support competency framework commissioned by HEE has provided a foundation for training peer support workers and as a result, large numbers of peer workers are completing the training ready for work. For those wishing to work in NHS and social care services, there are two challenges: first, securing a job; second, sustaining a peer identity and role within their job so that they can bring added value to existing services. Peer workers themselves have limited control over either of these challenges, responsibility lies mainly with the organisations within which they work.

We have previously written extensively about the importance of organisational support the wide- ranging commitment that is necessary for successful employment of peer workers (Repper et al., 2013). This remains the key to maximising the impact of peer support on those with whom they work and on the culture of services, enabling them to thrive in work and utilise their experience and skills as a distinct and complementary occupation. To build on the existing published best practice for supporting peer workers, we suggest that the coming decade requires the following:

Coproducing organisational understanding of peer support

Although work with individual teams might improve the day to day work experience and impact of peer support workers, we need to recognise the importance of whole organisation commitment to peer support workers if they are to realise their full potential. Peer support is only one aspect of the cultural change that is needed for services to become truly focused on the Recovery of people using services (see ten organisational challenges; Shepherd et al., 2010). But in itself it is an effective vehicle for effecting that cultural change: the collective voice of peer support workers and staff with lived experience is invaluable in informing, modelling and coproducing services and practices that are person centred, Recovery focused and support people to live well in their communities.

Organisations wishing to employ peer support workers need to demonstrate their commitment to peer support and the value they afford lived experience in all their staff if their commitment to peer support workers is to carry any credibility. The free of charge peer support training currently offered by HEE brings with it a grant attached to each student which is intended for infra-structure support and to enable trainees to complete the training. However, this can also provide a perverse incentive for organisations to
send peer staff (or potential peer staff) to the training, reaping significant financial reward but never developing their organisational
or workforce strategy for peer workers, nor addressing the cultural barriers to effective peer support. By contrast organisations that invest in coproducing a peer worker strategy that includes all levels, professions and departments begin to see how peer support workers offer solutions to many of the challenges currently facing them. Given the evidence that people using services value their relationships with peer support workers for increasing their hope, self confidence and self efficacy (Corrigan, 2006; Ochocka et al., 2006; Salzer, 2002), shouldn’t everyone have the opportunity to receive peer support? Since peer support workers are associated with reduced levels of restraint on inpatient wards (SAMSHA, 2010), we need to work out how to utilise their approach more widely to improve the experience of people using services. We have a number of long standing vacancies, would it be possible to improve the service offered by making these peer support worker posts? We have a number of new teams created through the new transformation plans which require peer support workers, how are we going to recruit and support peer workers in these posts, and what will their role be? Such questions clarify the importance of including peer support workers in Workforce Strategy with clarity about role, job descriptions, banding, supervision and management.

Frequently, coproducing a peer support strategy raises wide-ranging questions about culture and practice: surely what is good employment practice for peer support workers is good for all staff? So, what about proactive employment support for everyone? Should all teams use staff wellbeing plans? Isn’t Recovery focused supervision using the co-reflective approach of peer support an improvement on current supervision practice? Why are we worried about peer support workers hearing staff talking about patients? Maybe we need to mindful of how we talk and write about people? Don’t we all need to know more about trauma informed relationships? How are we going to enable all staff to use their personal experience safely and appropriately in their practice? …. These discussions drive forward changes across the whole organisation – in HR and workforce planning, in Learning and Development and staff training, in documentation and record keeping.

Preparing and supporting teams with peer support workers

Extensive research demonstrates that peer support workers need to be absolutely clear about their role within the team, and other staff and people using the team’s services also need to be clear about why peer workers are being employed, what their role is, how they have been trained and the fact that their employment contract is the same as other staff – they are a member of the staff team, not a patient or a member of staff who needs special support or who cannot be trusted. The kind of support available for peer workers is available for all staff (many of whom will also have lived experience of mental health problems, but they are not employed to use this as their primary point of reference). Team preparation is essential for clarity about the role and contribution of peer workers in the team (see Repper, 2013).

A one-off workshop with teams prior to the employment of peer workers is necessary but not sufficient. Too often the culture of teams that are short staffed, continually responding to crises, implementing changes in structure as policy dictates, coping with rapid staff turnover … is reactive, rushed, problem focused and risk averse. This is in stark contrast to the expectations and training of all staff, but perhaps it is most marked in relation to the role of peer support workers. Their training focuses entirely on using their own personal experience to enable safe, trauma informed, non-judgmental relationships in which the people they support have space to make sense of what has happened and work out what might help them. Given the time and opportunity to work in this way, peer workers offer hope that things can get better, they help build self confidence and reduce shame and self stigmatisation, they can support people to re-engage in communities, activities and relationships. Where this sort of work is not valued, peer support workers all too easily conform to the routine practices of the team – or they can resist and this quickly leads to burn out. Not only do teams benefit from ongoing support to maintain and develop their peer support workers, but the peer support workers themselves require regular, recovery focused supervision.

A national strategy to underpin the development of peer support

It is not a new idea to talk about organisational strategies for peer support workers, or about preparing the mental health workforce to support the development of peer support. While it is becoming more and more commonplace to acknowledge the importance of peer support at these organisational levels, what is lacking, and what is now needed, is a national strategy for peer workers.

As HEE continue to invest in the development of peer training and support the growth of the peer workforce across some health contexts, there needs to be much more consideration of a bigger picture. A national strategy needs to lay out answers to key questions, including, why we are growing the peer workforce, how this is best done without compromising the values of the approach, how organisations can start, what we know about best practice and what success looks like in employing and supporting peer workers.

This national strategy needs to be written and owned by peer workers and people with lived experience, and not professional bodies or departments. Failing to do this would result in further co-option of peer support and would only offer a vision for peer support which supports existing ideologies rather than a vision which might offer radical challenge to these, as peer support has always intended to do.

To support the development of this strategy, there needs to be well positioned peer leaders, including a peer support lead within the Department of Health, with a team around them who can amplify the collective voice of peer workers and advocate for the complex needs of this diverse group of people.

In addition, the development of national peer support forums for peer workers is long overdue. While other mental health roles have access to a professional body, external support, literature specific to their role and development/peer support opportunities, peer workers do not. Some forums of course exist, and local initiatives have led to the establishment of peer support collectives, but with further consideration to the national development of peer support, this can be offered to every peer worker, including those who are isolated in their role or in their organisations. These forums should offer a place for peer workers to support and learn from each other, but also to speak about national developments and to inform the course of peer support at a broader level. Without such platforms, peer workers will be unable to foster a sense of their collective power, and will be more likely to find themselves at the mercy of the psychiatric/ medical systems that employ them.

2. PEER LEADERS FOR THE PEER WORKFORCE

Lack of career progression and low pay among peer workers are examples of structural powerlessness; while peer workers may have a sense of their own power within peer support relationships, and may be valued within their teams, there needs to be a greater commitment to embedding peer leadership structures within organisations in order to truly value people with lived experience. To enable meaningful peer leadership within mental health systems, there must be posts available for peer leaders to take up, and there must be support, training and mentorship for peer workers to progress into these roles with the required skill set. In relation to these needs, the following factors should be considered:

– Peer leader roles must be continuously funded and not short-term contracts. Relating to the points made on peer worker strategy, short term funding undervalues peer workers in a symbolic and actual way. Peer leaders require time and stability in their role to make effective change and
this is not possible on short term contracts, even where these are likely to be extended

– The peer leader job description should be robust, written to meet the needs of the peer workforce, and to support the organisation to welcome and nurture lived experience in their staff mix. It should include any requirements that are thought to be needed relating to additional training, project/people management and supervision skills. The job description should be taken to job evaluation panels with supporting information which describes the national context of peer support, and the value of lived expertise as equal to professional knowledge. On occasion, the lack of professional registration and other elements such as not being a budget holder, has led peer leader job descriptions to be banded as lower than the colleagues that peer leaders work alongside. This does nothing to empower peer leaders, but also does not acknowledge the actual demands of their role.

– Peer leaders should not be employed in isolation; there needs to be a community or team of senior peers who support and work alongside each other. The employment of a single peer leader is, at worst, tokenistic, and does not recognise the size of the task of peer support implementation and culture change.

– As with any role, peer leaders need role clarity; the beauty of peer support is that the values can influence all other organisational agendas, including least restrictive practice, involvement, service developments, trauma informed care and staff wellbeing to name a few. There is a temptation for peer leaders to become involved in all of these agendas out of a desire to support widespread culture change. However, with limited resources, this dilutes what peer leaders are able to offer to the peer workforce. There needs to be clear expectations about how much of a peer leader’s time can helpfully be used for projects outside of peer support

– There should be strategic consideration of how a peer support worker might progress through different levels of the organisation, perhaps into a senior peer role and then into a central peer support development role, and then as a peer leader. The use of an apprenticeship pathway might support this depending on how organisations choose to position this (for some, the apprenticeship might be an entry level requirement, for others it might be required for peer workers to progress into a senior peer role). Other pathways should also be available for peer workers where the apprenticeship is not suitable. Supervision and peer trainer training, as well as development opportunities and work experience should be offered to all peer workers.

– There should also be training focussed specifically on leadership skills. This should not be generic leadership training; the skills required to be a peer leader are complex and require applying the values used within peer support relationships to an organisational setting. The role of peer leaders to challenge and influence culture can feel like a heavy task. Training should include practical approaches to positively challenge within a clear context of the roots of peer support. Education on the history of the survivor movement and the associated philosophy is essential to support peer leaders to retain a clear sense of purpose and to understand the importance of the values of peer support to the organisations they work in

– Peer leaders require ongoing support both from colleagues within their organisation and from fellow peer leaders. Developing strong working relationships with peer leaders from other organisations, including user led, voluntary and grass roots projects can provide peer support to leaders, to help them to feel supported by a collective, and to ensure that their peer identity is not stifled by their organisational setting

3. REUNITING WITH THE ROOTS OF PEER SUPPORT

‘It is a difficult task to make recovery and peer support centrally relevant to mental health organisations in times of austerity without their original intentions being subverted and co-opted. It is only in the process of constant resistance, revisiting and reframing of the way that peer support is offered that we can preserve its radical intentions.’
(Watson, 2020, p.280)

As we outlined above, the inclusion of peer support workers into statutory mental health services has been controversial for many lived experience campaigners who argue that mutuality cannot be sustained within these settings. As the ‘recovery movement’ has become a ‘recovery model’, which can be further broken down into ‘recovery interventions’, many of
the radical intentions of peer support have been smoothed or lost. These arguments have been enough for many critics to abandon hope for peer support within NHS services. However, to frame peer support as co-opted, and peer support workers as disempowered would be to ignore the ways that peer workers resist and challenge the systems they work in.

It is less important to debate whether or not peer support has been co-opted than it is to acknowledge that the nature of peer support within mental health services is something different (and not worse or better) than the nature of peer support outside of these. Peer workers are changed by the contexts they work within, and do often feel disempowered within these, but they also resist and subvert these cultures, and they can be more effective at doing this with the right support. Peer workers are largely unanimous in their belief that the culture of mental health services needs to change, and often enact all the power at their disposal in order to both be a part of the positive changes they believe are necessary, and to protect themselves from cultures which they believe would compromise their values base.

While the resistance of individual peer workers is clear, what is less clear is a strategic resistance, and this is what is needed to continue to move in a direction of culture change. To enhance the possibility of peer workers contributing to culture change, there are some pre-conditions that support this:

– Alliances between organisations using different approaches to peer support. To see these as opportunities to learn rather than to compare different types of peer support and find some inferior. Seeing the differences as a symptom of the context that peer workers work within, and an essential means of peer workers surviving in those contexts

– Organisational cultures that genuinely welcome challenge, and peer workers that can offer positive challenge and practical solutions rather than solely criticism

– Support for peer workers who do struggle to work within systems which leave them feeling compromised, in the form of supervision and peer to peer co-reflection from peers within and outside the systems they work in

We should all be prepared to challenge existing practice where we see that it could be improved, but the impact that austerity, understaffing and service change has on working practices and staff wellbeing should also be acknowledged. Many peer workers have spoken out of concern for their
colleagues who they described as also undervalued and struggling to cope in their roles. True culture change requires us to collectively, repeatedly highlight the unacceptable demand placed on mental health services

4. CRITICAL FOCUS ON DIVERSITY AND INCLUSION

Now is the time for the inclusive value of peer support to be truly realised. Inclusivity needs to be re-politicised, and the focus should shift toward the circumstances and groups which create exclusion. The following approaches support the development of peer support which reflects the diverse communities that peer workers serve, and ensures that people using mental health services are offered peer support by those they truly consider to be their peers:

– Partnerships should be built between mental health organisations and peer support providers within social excluded communities including refugees, LGBT, BME, service user-led groups and be inclusive of the experience of many different stories of recovery and intersectionality. The peer support offered by these communities should be valued and inform the implementation of peer support within organisations

– Peer support strategy should clearly communicate a broad definition of lived experience, which acknowledges the impact of multiple oppressions on mental health and recovery

– Any peer support co-production/ implementation groups should include people from socially excluded communities

– Peer support and peer leadership training should include an appreciation of intersectionality, institutional racism and anti-racism. The use of safe spaces should be considered when covering these topics

– Where peer support roles at any level are advertised, adverts should be circulated within socially excluded communities and should consider their use of language to minimise the barriers to people from these groups applying

5. PEER SUPPORT CO ORDINATED AT A LOCALITY LEVEL WITH ALL SERVICES THAT OFFER PEER SUPPORT

In line with the long term plan and community transformation, we are increasingly working across localities and communities in an integrated manner: all health and social care services are working with Voluntary, Community and Social Enterprise (VCSE) providers, mainstream facilities and activities to offer clear pathways of support within a defined locality. Peer support in all its guises has an important role to play in this: in prevention, primary care, community navigation, specialist services and longer-term community based support. It makes sense for people and organisations offering peer support to come together: to share learning about how best to support people, to find out more about each other so that those using these services can access other relevant support; to establish pathways and clarify roles and relevant expertise, to make their services and their successes better understood so that they are valued and funded. The shift from a competitive to a collaborative peer support alliance at a locality level, represented at integrated care boards, included at ICP and PCN levels, clear about which peer organisation/team is best placed for what provides better support for individuals needing it, wider opportunities for peers offering it, and more likelihood of greater understanding of the value that peer support can offer at individual, community and societal levels.

A VISION FOR THE FUTURE

The next decade of peer support development requires us to progress beyond focussing on the introduction of peer workers. The training, development and supervision that is most helpful for peer workers requires us to shift our focus onto the systems that surround them, in order to create conditions in which peer workers can thrive. In addition, peer leadership and career progression for peer workers is essential and there needs to be many more senior roles for peer workers. This would demonstrate that lived experience is genuinely valued in a similar way to professional expertise. Peer workers positioned at all levels throughout our health and social care systems begins to shift the dominant narratives about mental health, and provides us all with examples of recovery, embodied by people who bring their lived experience and a range of other leadership and culture change skills to the table. Changes of this kind require health systems and society to address discrimination in all its forms, and to hold a vision of a radically different future in mind. We can offer such a vision.

Imagine if the next ten years of peer support contained as much change and growth as the previous ten. In the next decade, it might be possible for any person who requires the support of health or social care services to be met by people who had shared lived and cultural experience, who could offer emotionally safe relationships where power is relatively balanced. Peer support should be available to any person regardless of the service they find themselves using, and it should be offered by people who reflect the diversity of the people using each service.

The systems that peer workers are employed within will welcome peer support as a new occupation and there will be clear strategies in place that describe how peer workers should be supported, how the workforce will grow, and why peer support will benefit teams and systems. These strategies will highlight the need for a diverse peer workforce and acknowledge that part of the peer worker role is to positively challenge mental health cultures. Clarity over how the HEE training grant attached to each student is used will ensure that people with lived experience, who are ready for peer work are able to access the peer support training to support their move into peer support roles.

For those of us wishing to become peer workers, the future will be empowering. There will be ways to become involved in shaping services and ways to access peer support training and employment support. At no point in the journey to becoming a peer worker should a person feel stigmatised
or unwelcomed within health and social care services, not least because they will be surrounded by other peer workers, and offered co-reflection by peer leaders. There will also be opportunities to link into nation-wide networks of peer workers to seek support, learn from each other and shape the future direction of the role. Organisations will value lived experience as an important asset that supports culture change; peer leaders, positioned at all levels of the health and social care system will hold a vision for peer support within their organisation, and ensure that the values of peer support are translated into these contexts without being co-opted or compromised. Leaders will be offered training and mentorship, and be paid and valued in the same way as other professional leads. A professional lead at the Department of Health, supported by other peer leaders will be a good starting point for the co-production of a strategy which is owned by peer workers and people with lived experience. This will support the development of a ‘professional’ body for peer workers, one that will be able to hold the critical debates which define peer support, and amplify the voices of peer workers, even where these are complex or disparate.

We are hopeful that this future can become a reality, if we continue to shift focus away from interventions or service level change, onto culture change, diverse communities and human rights.

Conclusion

The next decade will be an era of rapid development within peer support. We have already seen an increased recognition of the value of lived experience informing the development, delivery and evaluation of all services. As peer worker numbers grow, particular attention should be paid to ensuring that their growth is supported, and their inclusion into the workforce is meaningful. Peer support workers bring a particular and distinct form of support, underpinned by a clear values base. They model a different way of ‘being’ with people that supports the self confidence, self efficacy, hope and essential for living well. The experience of feeling safely supported by a peer should not be under-estimated; everybody should be offered the opportunity to access this support in times of distress and when managing long term conditions.

We are still early in the journey of introducing peer support, and the diversity of thought within peer support communities means that several debates continue to be had. How exactly peer leaders should operate, how to maintain the values of peer support in struggling systems and how to ensure peer workers are able to both challenge and support their colleagues within services are critical discussions. As the next decade of peer support unfolds, it is important to continue to revisit and reflect on the debates surrounding peer support and to establish some national infrastructure to support the development of this new sphere of the health workforce. This paper is by no means a definitive ‘answer’ to the current pitfalls, but we hope to have offered some possible solutions, particularly for those organisations whose task is to implement the Long Term Plan, and wish to do so in a meaningful, sustained way. By moving the focus back onto organisational cultures, we hope that the conditions will be provided to enable peer support, in all its diverse forms, to take flight.

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Whilst most peer support practice, research and publications have focused on peer support by and for people with mental health problems, informal support between people who have shared experiences has always occurred across the whole spectrum of health and social care settings. There is, however, no existing guidance for the employment, training or role definition of peer support workers who focus on physical health problems either in physical health settings, or with people who also have mental health conditions.

The questions that 18 ImROC Peer Support Physical Health Briefing Paper seeks to address are:

  • Whether and how mental health peer support can be extended to address the physical health of people with mental health problems.
  • Whether formal or intentional peer support has been introduced in physical health services (statutory, voluntary or private), whether it is beneficial, how it differs from mental health peer support and what additional training might be required.

18. Peer Support for People with Physical Health Conditions

 Julie Repper and Liz Walker

Acknowledgements

We would like to thank Heath Education England (HEE) for funding the coproduction and writing of this paper.

ImROC has previously written on this subject in our earlier Briefing Papers: Briefing Paper 5 Peer Support Workers Theory and Practice and Briefing Paper 7 Peer Support Workers: A Practical Guide to Implementation

Introduction

The development and expansion of new roles to support the mental health workforce was set out in the NHS Long Term Plan and Health Education England’s report, Stepping Forward to 2020/21: The Mental Health Workforce Plan for England. A significant area of expansion is the development and implementation of the peer support worker role, in which people with lived experience of mental health problems and services provide support and deliver interventions to others who are experiencing similar problems (UCLP/NCCMH 2019, Peer Support Competency Framework – Background Information).

Whilst most peer support practice, research and publications have focused on peer support by and for people with mental health problems, informal support between people who have shared experiences has always occurred across the whole spectrum of health and social care settings.

A brief scan of any community newsletter reveals countless examples of peer support initiatives from carers groups offered at a hospice to meetings for siblings of bereaved children, from Al-anon meetings for families of people with drinking problems to the Parkinson’s Disease Society…. shared experience clearly provides a strong foundation for mutual support in all areas of life.

There is, however, no existing guidance for the employment, training or role definition of peer support workers who focus on physical health problems either in physical health settings, or with people who also have mental health conditions.

The questions that this paper seeks to address are:

• Whether and how mental health peer support can be extended to address the physical health of people with mental health problems.
• Whether formal or intentional peer support has been introduced in physical health services (statutory, voluntary or private), whether it is beneficial, how it differs from mental health peer support and what additional training might be required.

Background

Support offered by peer workers is distinct from that provided by other professionals. Rather than relying on a professional knowledge/theory base, peer support is based on experiential knowledge: knowing what these experiences can feel like and the impact they can have on your life; having experience of gaining an understanding of what has happened and working out ways of understanding, coping and recovering a life with or without ongoing difficulties.

Rather than focusing on directing, prescribing or fixing a person, peer support is about ‘being with’: offering support within an equal and reciprocal relationship, providing space, time and opportunity to share with someone who can provide a level of empathy and understanding based on their own lived experience.

And peer support goes beyond simply listening and sharing, to demonstrating the possibility of self-management and recovering a meaningful life; working with people to enable them to find their own solutions, to identify their own goals and to work out how to achieve these; addressing personal, social and relational barriers in a manner that fits the individual, their resources and their background – culture, religion, sexuality, childhood experiences, social situation etc.

Peer support can occur in an informal relationship between people who have experiences or goals in common, it can occur in community settings – like self-help groups, voluntary sector support groups, in groups of people with similar interests, using similar services or seeking similar solutions. It can also occur in a more intentional and formal manner, through the employment of people with similar experiences as peer support workers or peer specialists in services on an unpaid or paid basis.

Research into peer support consistently demonstrates the importance of particular values to underpin and inform effective practice. It is these values that define peer support, distinguish it from other forms of support, and that appear to be associated with the effectiveness of peer support (see Box 1).

Box 1. the Values underpinning Peer support (Adapted from Repper 2013)

Empathy and respect

Understanding another’s experience from their perspective and being genuinely interested in them as a person.

Being non-judgemental, not making assumptions about or pathologising the person’s experiences or beliefs.

Inclusive

Respecting the diversity of each person’s experience and their particular back- ground or culture that might influence this. Ensuring support is available to everyone.

Mutual

Each person’s experience is of equal value; both people can learn from each other within an equal, accepting, and respectful relationship (based on sharing and shared experiences)

Non-directive

Helping people to find solutions which work for them (rather than suggesting solutions).

Validating people’s experiences; acknowledging that each person is the expert in their own experience.

Progressive

Helping people to learn from their experience and to equip themselves to move forward.

Reciprocal

Both people benefit from sharing their experience; everyone learns from one another and everyone’s contribution is considered to have equal value

Strengths based

Focusing on a person’s strengths, helping them build them up and develop their ability to make use of the resources available to them.

Community facing

Working with assets and resources
in local communities to build their confidence and capabilities and develop initiatives where they are needed. Supporting people to engage in communities of their choice.

Recovery-focused

Creating hope and a sense of control, empowering the person to define, lead and own their recovery,

Safe

Offering support that is safe and non- judgmental, sharing personal experience in a safe, appropriate, and effective manner, working in a safe, supportive environment.

It is among people with mental health conditions that most peer support development, research and evaluation has taken place. Within the UK, many communities-based and voluntary sector services are either peer-led or coproduced and co-delivered with both support workers and professionally qualified staff.

Peer support occurs within these groups in a less structured, ‘rule-bound’ and professionalised manner than within statutory services, often providing a sense of solidarity and a shared voice, a feeling of belonging to a movement, of empowerment and community (Faulkner and Kalathil 2012).

In contrast, although many statutory mental health services now employ peer workers, their role is generally to support people using those services on a one to one or group basis alongside professionals. Research into mental health peer support has demonstrated that, when provided in services, it is at least as effective as support provided by other workers. Peer support has been shown to benefit those supported by reducing the incidence of crises, reducing the length and frequency of inpatient stays, improving engagement with community resources and increasing sense of empowerment and hope for the future (Slade et al, 2019).

PEER SUPPORT FOR PEOPLE WITH PHYSICAL HEALTH CONDITIONS

There are two interlinked sources of evidence/research underpinning peer
support for people with physical conditions. The first refers to peer support focusing on the physical health of people with mental health problems. The second concerns peer support by and for people with physical health conditions.

There is inevitable overlap between these two subject areas owing to the high levels of mental health problems experienced by people with physical conditions and the poor physical health of many people with serious mental health problems.

This paper does not provide a systematic review of the literature but seeks to summarise the evidence in both of these areas to address the question: what is the role of peer support for people with physical health conditions?

Peer support to improve the physical wellbeing of people with mental health problems

It has been well established that people with serious mental health problems die between 10 and 20 years earlier than the general population due mainly to cardiovascular, respiratory, and metabolic diseases. This population is also less likely to have a primary care provider, and attendance at primary
care appointments is lower than the general population (see Box 2).

There is some evidence that one to one peer support interventions with people who have more serious mental health problems can improve self-management and physical wellbeing. Stubbs et al (2016) conducted a systematic review of research into peer support interventions to improve the physical health of people with mental health problems to establish whether peer support improved physical health, appointment attendance and adherence to a healthier lifestyle. They identified 7 studies (only 2 of these were RCTs), all conducted in the US, totalling 220 participants receiving formal peer support which involved sharing personal experience and delivering an intervention. These studies describe a number of different approaches: weight loss, personalised fitness, confidence in primary care appointments and broad- based self-management (including exercise, healthy eating, medication management, sleep and behaviour management).

Outcomes were generally positive with significant improvement in attendance at outpatient appointments (2 studies) and increased fitness and physical activity (1 study). Although there were also improvements in weight loss, reporting of physical symptoms, physical health related quality of life, physical functioning, and pain, these were not statistically significant.

Whilst this review is cause for some optimism, it demonstrates the need for more high-quality research into peer support. Variation in the interventions offered raises questions about the nature of peer support for physical health conditions. Not one of these interventions offered support based
on experiential knowledge alone. Instead peer support workers offered professionally designed interventions which, arguably could have been provided by workers without lived experience.

Further evidence suggests that peer-led education and groups for people with mental health problems lead to benefits in self- management. Research conducted, once again, in the US, reports improvements in; self-management attitudes; skills and behaviours using group based Wellness and Recovery Action Planning (Cook et al, 2010); and the provision of group based information, skills and support can lead to increased engagement in physical health care (Pickett et al, 2012).

Within the UK, coproduced (peer and professionally led) education, delivered
in Recovery colleges has been shown to enhance sense of hope, reduce use of services, improve engagement in community activities including work, volunteering and mainstream education (Perkins et al, 2018).

Although these interventions are offered by peers – either alone or in combination with professionals – none of them are strictly speaking ‘peer support’ because they involve the delivery of a specific intervention or training. Rather, they are peer delivered interventions or peer led/coproduced education.

Peer support for people with physical health problems

Where peer support is offered for physical health conditions, it appears to focus on those with long term or complex physical conditions. Interest in the feasibility and efficacy of peer support for this population is highly relevant given the prevalence and high levels of need among those with long-term conditions.

More than 15 million people – 30% of the UK population – live with one or more long- term conditions, and more than 4 million of these people will also have a mental health problem. People with cancer, diabetes, asthma and high blood pressure are at greater risk of a range of mental health problems such as depression, anxiety and Post Traumatic Stress Disorder.

A systematic review of the literature was undertaken by The Chronic Illness Alliance in Victoria, Australia (2011) to identify effective models of peer support for ‘chronic conditions’ and their effectiveness. 55 articles were included describing seven different models of peer support: professionally led groups; peer led groups; peer coaches; community Health Workers; support groups; telephone-based peer support; internet and email peer support.

These were offered to people with a range of long-term conditions including musculoskeletal, respiratory, endocrine, pulmonary, renal, and cardiac conditions. Although the nature of the support provided was poorly defined and effectiveness was difficult to assess, the most commonly cited benefit was improved self-efficacy, and greater effectiveness was reported in socially disadvantaged groups or in culturally specific services. The main conclusion of this paper was a plea for more research of a higher quality.

One UK based qualitative study of one to one peer support, designed to help people at the stage of adapting to chronic renal illness and making treatment choices, reported benefits similar to those found in mental health peer support: talking to someone ‘who’s gone through what you’re going through’; answers to questions and practical information; reassurance, encouragement and increased confidence; support with coming to terms with starting treatment; help making or confirming treatment decisions; hope for the future.

Respondents contrasted peer support favourably with clinical consultations: the encounter itself was perceived as not subject to constraints imposed by limited time or differences in status; interaction was facilitated by the peer supporter’s empathy; and respondents felt more in control. These findings have been echoed in studies of peer support for diabetes (Smith, 2011), breast feeding mothers (Ingram, 2013) and in cancer care (Hoey, 2014) and terminal care (Samuels, 2014).

Most studies of peer support in physical health conditions report groups run by peers. Similar benefits to those above are reported by participants in cancer and HIV support groups, who found peer supporters to be positive role models who helped to normalise illness and demanding treatment regimes – this appears to have increased their sense of empowerment and agency.

Perhaps the best-known peer-led intervention is the Chronic Disease Self-Management Programme (CDSMP) or the Expert Patient Programme (EPP). This comprises peer led education for people with a range of long-term conditions utilising a Programme originally licensed from Stanford University, US. Currently running as a Community Interest Company, the Programmes offered are delivered either by voluntary sector organisations or NHS providers commissioned through CCG’s, or local Public Health Departments.

The EPP and CDSMP seek to enable people to understand and gain confidence and skills to manage their own condition. It is estimated that over 5,000 courses have been delivered to over 70,000 participants through contracts with NHS Primary Care Trusts and other commissioning bodies across England. Many of its service users go on to become accredited tutors, some paid and some volunteers. Evaluation of reports improvements in self-efficacy and quality of life are likely to be cost effective.

Recovery College courses focusing on physical health differ from EPP in that
they are coproduced and co-facilitated by people with physical health conditions and professionals, they are more flexible and experiential in content. They report similar findings to those of the EPP (Perkins et al, 2018). However, such group and educational initiatives are examples of peer led interventions rather than peer support per se.

Whilst there is no shortage of examples of peer support for people with physical conditions, the quality of published research is varied so it is not possible to draw conclusions. It is not always clear how the support offered is distinct from that offered by non-peers. In many of the published reports, peers are employed to provide professionally designed and developed interventions with little description of how they draw on their own lived experiences. Yet studies reporting peer support based on sharing of personal experience (such as EPP and one to one peer support for renal disease) describe the benefits derived from mutuality and reciprocity including normalisation of experiences, increased sense of agency and control, and improved hope.

More detailed information about the evidence for EPP/ CDSMP can be found on the Talking Health Taking Action website (https://www.talkinghealth.org/)

PEER SUPPORT: A HOLISTIC APPROACH

Given the co-existence and interactive effect of mental health problems and long term physical conditions (see Box 2), it is not surprising that the findings from research into peer support are much the same whether services focus primarily on people with mental health problems or people with long term physical conditions. The benefits reported for both groups are primarily improved levels of self-efficacy and engagement in care; with additional benefits of improved acceptance, hope and agency where peer support is based on sharing lived experience and building coping strategies together.

These findings corroborate the findings of research into mental health peer support. Taken together they suggest that the provision of support based on common experiences and focusing on working together to find ways of understanding, coping, and living well can be helpful whatever the shared experiences are. This makes sense particularly since research into community-peer support suggests that shared cultural backgrounds, shared experiences of trauma, adverse childhood experiences and/or bullying and exclusion also provide a basis for effective peer support (Faulkner and Kalathil).

Indeed, peer support workers appear to be well positioned to bridge the gap between physical, mental, social and community based services and resources as part of a whole person, integrated, place based, recovery orientated system of care as envisioned in the NHS Five Year Forward View (2014),
the NHS Five Year Forward View for Mental Health (2016) and the General Practice Forward View (2016), and as recommended by Naylor et al (2012) see Box 2.

The Local Government Association guide to community capacity and peer support (LGA/ NHSE, 2019) envisages peer support as an integral part of an asset-based approach to supporting people as valued and active citizens in their communities. It provides a summary of the functions of (largely unpaid) peer support accessible for all local citizens, whether they have physical, mental or social needs, including: assistance in daily management (via skills development sessions, support to overcome personal barriers, and regular prompts and reminders); social and emotional support (via space to talk about worries, wellbeing and motivational issues); linking to community and clinical resources (via signposting to community resources, locating projects in community settings, referring to/’pulling in’ practitioners as appropriate); and ongoing support (via setting up support groups that are flexible and convenient, offering informal support between meetings, and evolve according to participants’ wishes and motivations).

Mind provides an online toolkit to support community-based peer support to develop in flexible ways to meet the needs or mutual experience of group members. The values that they coproduced to underpin any peer support include: experience ‘in common’; safety; freedom to be oneself; human connection; and choice and control. These are not only very similar to those given in Box 1, but also apply equally to mental and physical health conditions. Crepaz-Keay (2017) reflects on his experiences of peer support in community settings and sees it as having the “capacity to address social isolation, build skills and self-esteem, and give individuals a better quality of life – it can also add value to whole communities and reframe the way entire groups are considered within them”.

This reflects the findings of many social prescribing services initially set up to meet the emotional/mental health needs of people using primary care services, and increasingly finding themselves working with people who have multiple long-term conditions (both mental and physical), and who are often inactive and isolated. Increasingly, social prescribing services are employing staff (link workers) who themselves live with long term conditions, and training them to provide active listening, problem solving, coaching and empowerment. (Repper, 2019).

In the US, the National Academy for State Health Policy (2016) proposes employment of peer support to promote physical and mental health integration by: linking to community resources; group facilitation; skills building; mentoring; goal setting; and individual wellness planning. In three states Medicaid health insurance funds integrated peer support. Interestingly, funding guidance for these services includes key service design components including peer supervision, individualised care plans including specific personal goals, and competency-based peer training.

Box 2. the mental health of people with long-term physical conditions (naylor et al, 2012)

Many people with long-term physical health conditions also have mental health problems. These can lead to significantly poorer health outcomes and reduced quality of life.

Costs to the health care system are also significant – by interacting with and exacerbating physical illness, co-morbid mental health problems raise total health care costs by at least 45 per cent for each person with a long-term condition and co-morbid mental health problem.

This suggests that between 12 per cent and 18 per cent of all NHS expenditure on long- term conditions is linked to poor mental health and wellbeing – between £8 billion and £13 billion in England each year. The more conservative of these figures equates to around £1 in every £8 spent on long-term conditions.

People with long-term conditions and co-morbid mental health problems disproportionately live in deprived areas and have access to fewer resources of all kinds. The interaction between co-morbidities and deprivation makes a significant contribution to generating and maintaining inequalities.

Care for large numbers of people with long-term conditions could be improved by better integrating mental health support with primary care and chronic disease management programmes, with closer working between mental health specialists and other professionals.

Collaborative care arrangements between primary care and mental health specialists can improve outcomes with no or limited additional net costs. Innovative forms of liaison psychiatry demonstrate that providing better support for co-morbid mental health needs can reduce physical health care costs in acute hospitals.

Clinical commissioning groups should prioritise integrating mental and physical health care more closely as a key part of their strategies to improve quality and productivity in health care.

Improved support for the emotional, behavioural, and mental health aspects of physical illness could play an important role in helping the NHS to meet the Quality, Innovation, Productivity and Prevention (QIPP) challenge. This will require removal of policy barriers to integration, for example, through redesign of payment mechanisms.

Peer support is more than the employment of people with lived experience in paid support roles; it is the employment of people who share some of the experiences of people using services  (peers) specifically to draw on these shared experiences and ways they have found to live well (their experiential knowledge) – to provide support based on shared understandings, mutual problem solving, a belief in the possibility of recovery, and time together to find hope, solutions  and connections.

17 ImROC Preparing Organisations PSW Briefing Paper outlines how organisations can enable PSWs to work to their full potential, to give careful consideration to the role: why are they PSWs? Who are they seeking to employ and how will recruitment and selection ensure that this is achieved? What is the role of PSWs? Where are they going to be employed to enable them to fulfil this role? How will they be supported, supervised and developed within the organisation? What structures are needed to enable them to have a collective voice so that they can influence improvements in the quality and effectiveness of services?

This guidance draws on research and guidance papers as well as the experience of PSWs and employers from NHS, Local Authority, third sector and voluntary sector organisations. It begins with the reasons why organisations might employ PSWs and why organisational preparation is so important, and goes on to provide guidance for organisations including: managers, team members/colleagues, Human Resources and Occupational Health, Learning and Development provision (for all staff), peer
supervision and support.

ImROC offers a range of peer support training and consultancy. We support organisations to employ peers within their workforce and train Peer Support Workers for their new role.

Download 17. Preparing organisations for peer support

17. Preparing Organisations for Peer Support: Creating a Culture and Context in which peer support workers thrive

Julie Repper, Liz Walker, Syena Skinner, Mel Ball

Acknowledgements

We would like to thank Heath Education England (HEE) for funding the coproduction and writing of this paper. ImROC has previously written on this subject in our earlier Briefing Papers: Briefing Paper 5 Peer Support Workers Theory and Practice and Briefing Paper 7 Peer Support Workers: A Practical Guide to Implementation

1. INTRODUCTION

This paper provides information and guidance for organisations that employ, or are considering employing, peer support workers (PSWs). Peer support is a new role within many mental health services. It is not merely the employment of people with lived experience in paid support roles; it is the employment of people who share some of the experiences of people using services (peers) specifically to draw on these shared experiences and ways they have found to live well (their experiential knowledge) – to provide support based on shared understandings, mutual problem solving, a belief in the possibility of recovery, and time together to find hope, solutions and connections.

If organisations are to enable PSWs to work to their full potential, they need to give careful consideration to the role: why are they employing PSWs? Who are they seeking to employ and how will recruitment and selection ensure that this is achieved? What is the role of PSWs? Where are they going to be employed to enable them to fulfil this role? How will they be supported, supervised and developed within the organisation? What structures are needed to enable them to have a collective voice so that they can influence improvements in the quality and effectiveness of services?

This guidance draws on research and guidance papers as well as the experience of PSWs and employers from NHS, Local Authority, third sector and voluntary sector organisations. It begins with the reasons why organisations might employ PSWs and why organisational preparation is so important, and goes on to provide guidance for organisations including: managers, team members/colleagues, Human Resources and Occupational Health, Learning and Development provision (for all staff), peer supervision and support.

2. Why employ peer support workers?

There is increasing evidence that, where peer support workers are employed in a supportive environment with appropriate supervision and support, they contribute to improvements in the experience and outcomes of the people they support; they report benefits for their own recovery, and they can help to drive forwards a more recovery focused culture.

2.1 Benefits for people supported by peer support workers

In a recent review of the evidence about Recovery, Slade and his colleagues concluded that there is “substantially more randomised controlled trial evidence supporting the value of peer support workers than exists for any other mental health professional group, or service model”1. They summarised this research evidence as follows:

In no study has the employment of peer support workers been found to result in worse health outcomes compared with those not receiving the service. Most commonly the inclusion of peers in the workforce produces the same or better results across a range of outcomes.

The inclusion of peer support workers tends to produce specific improvements in service users’ feelings of empowerment, self-esteem and confidence. This is usually associated with increased service satisfaction.

In both cross-sectional and longitudinal studies, patients receiving peer support have shown improvements in community integration and social functioning. In some studies, they also bring about improvements in self-reported quality of life measures, although here the findings are mixed.

When patients are in frequent contact with peer support workers, their stability in employment, education and training has also been shown to increase.

NESTA and National Voices2 undertook a meta-analysis of a much broader range of over 1000 peer support studies and found that peer support is a term that includes many different approaches, contexts, components and beneficiaries. Nevertheless, the overall picture is one of benefit. They found that peer support:

  • has the potential to improve experience, psycho-social outcomes, behaviour, health outcomes and service use among people with long-term physical and mental health conditions
  • can improve experience and emotional aspects for carers, people from certain age and ethnic groups and those at risk, though the impact on health outcomes and service use is unclear for these groups
  • is most effective for improving health outcomes when facilitated by trained peers
  • is most effective for improving health outcomes when delivered one-to-one or in groups of more than 10 people
  • works well when delivered face-to-face, by telephone or online
  • is most effective for improving health outcomes when it is based around specific activities (such as exercise or choirs) and focus on education, social support and physical support
  • works well in a range of venues, including people’s own homes, community venues, hospitals and health services in the community.

2.2 Benefits for peer support workers

While these findings indicate clear benefits for people who receive peer support, there is also evidence that peer support can benefit the peer support workers themselves. It brings all of the benefits of employment (pay, structure, social contact, self esteem), for some it is helpful to be able to ‘give back’ to services that have helped them or to contribute to the improvement of services; for others it is helpful to be able to contribute to others’ recovery, and for many becoming a PSW allows them to turn an often difficult experience into positive skills.

2.3 Benefits for Organisational Culture

At an organisational level, PSWs can drive forward a change in culture. They bring a different perspective into the workforce, they have not been trained or socialised into traditional practices, rituals, routines and beliefs but operate from their own experience.

This is invaluable in delivering services that are acceptable, accessible and effective for people using services: PSWs have been in this situation, they know what it feels like and given support, encouragement and appreciation of their perspective, they can contribute to the development of more sensitive, person centred and recovery focused practices, language, documentation and relationships.

Finally, the inclusion of peer workers in the workforce can be a powerful way of the addressing negative staff attitudes that still exist in places3. The most effective approaches to reducing stigma are those that include direct contact to allow both groups to identify and share their common humanity. Employing peer workers has been shown to work in this way, contributing towards more positive attitudes with higher expectations and greater hope for Recovery among staff4. Thus, peer workers can contribute towards creating an organisational culture that is more recovery focused.

3. Why Prepare the Organisation?

3.1 Creating a safe environment for PSWs

There are many reasons why organisational preparation for PSWs is essential. Of primary importance is the emotional and physical of safety of the peer workers themselves and the people with whom they work.

PSWs, by definition, draw on their own experience to support others. In order to do this, they are open about aspects of their life in ways that other staff rarely are. This places them in a vulnerable, potentially stigmatising position. Athough attitudes towards people with mental health problems have improved over the past decade5 too often assumptions are made about peer support workers based on ill-informed and negative beliefs about people who experience mental health conditions.

Research demonstrates that within the workplace context, people with mental health problems are perceived as less competent, dangerous, and unpredictable and that work itself is not good for these people6 and this is mirrored among healthcare providers who tend to hold pessimistic views about the reality and likelihood of recovery7,8.

This is particularly the case among those professional staff working on inpatient settings who rarely see people who use services other than when they are at their most distressed9. It is in these teams that attitudes show most improvement once peer workers are employed10, perhaps not surprising given working alongside PSWs gives them the positive contact that is known to improve attitudes. However, the potential for discrimination and the evidence that many existing staff with mental health problems do not disclose their condition for fear of repercussions clearly demonstrates the need for careful preparation before employing PSWs11.

Organisational preparation needs to ensure that all staff are aware of why PSWs are being employed, how they will be recruited and prepared, what employment conditions and sickness absence arrangements are for PSWs.

3.2 Gaining shared understanding of the meaning and purpose of peer support

Organisational understanding of peer support must go beyond practical considerations to recognise political and philosophical debates about what peer support means, how decisions about what PSWs do are integral to their identity, effectiveness and ‘fit’ in the organisation, and how the introduction of PSWs is not merely the introduction of a new role in the workforce.

Rather, it heralds new discussions and developments in organisational culture and practices. Peer support is underpinned by principles such as mutuality, equality, freedom, safety…. which cannot be implemented in settings where PSWs are expected to implement coercive, compliance-focused and restrictive practices.

This places PSWs in an impossible ethical predicament “either follow the organisational line and fail your own heart, or leave …”. Organisations need to consider how they can employ PSWs who are genuinely in a position to offer ethical and effective alternatives, otherwise there is a risk of organisations “using peer workers to create the appearance of recovery orientation, human rights compliance or community integration12” when this is far from the reality.

The employment of PSWs is only one way of working towards the development and delivery of recovery-focused, rights-based, person-centred, community-integrated services. If they are seen as the only way of changing services they run the risk of becoming crushed by the responsibility.

3.3 Ensuring shared understanding about the role of PSWs

The most common difficulty reported by both peer support workers and their non-peer colleagues is lack of clarity about their role. Both peer workers themselves and the staff with whom they work express confusion about what PSWs are employed to do and whether this should differ from the role of other support workers.

PSWs are not employed to deliver therapies or treatments based on professional training, nor are they employed to undertake all of the duties of non-peer care/support workers. They are employed to offer time, care, support, active listening, problem solving, ideas, suggestions and practical help within trusting, mutual, unconditional relationships with people using services – based on their experiential knowledge rather than on the traditional psychiatric knowledge taught to other professional groups.

While training for PSWs should provide clarity over how PSWs work (the values underpinning their approach), it is the organisation or team in which they are employed which needs to define precisely what is expected of them in that setting. In order to both create appropriate job descriptions, and to ensure that the whole team/organisation understands the nature of peer support, it is essential to provide all team members with information, preparation and time to discuss possibilities and opportunities for the team to define and understand everyone’s roles: the values and tasks that are shared as well as their distinct contributions. To date, most evidence of the impact of PSWs has been generated in settings where peer workers support transitions into and out of services, such as facilitating discharge or movement into community groups or employment, or into other services (such as transitions between Children and Adolescents’ services and adult mental health services).

However PSWs are increasingly working across the whole spectrum of services – forensic, substance misuse, intensive care, assertive outreach, crisis teams ….13 Wherever they work, it is essential for them and the team to respect their peer values and to support them to offer their distinct knowledge and skills to complement other members of the team.

3.4 Learning from peer led groups and VHSE organisations

The vast majority of peer roles exist within third sector and voluntary community groups, user led groups, self-help groups, housing services and organisations for homeless people. Much has been written about the risks incurred in ignoring the wealth of experience about peer support that has accumulated in these settings14.

Many of these groups have their roots in civil rights, in developing alternatives to psychiatric services, protesting against current practices and treatments, in believing in one another and finding ways forward through mutual support and solidarity.

They often have a closer understanding of the issues that are most important to people who experience mental health problems: issues like social justice, human rights, understanding diversity and appreciating the implications of traumatic life events, that are too easily overlooked in professionally led statutory services where greatest emphasis is often placed upon treating symptoms.

When organisations are preparing to employ PSWs, they are well advised to work in partnership with (other) user led and third sector groups within their locality, this can help to ground developments in first-hand experience and to resource and inform training, supervision and recruitment.

3.5 Enabling teams to understand and support PSWs role and contribution

Wherever PSWs are employed, team members need time to think through the implications of changing the relationship to a collegial relationship of equals. Often there is genuine concern for the wellbeing of PSWs, how they will cope with the demands of the work and exposure to others’ distress; how they will demonstrate/embody recovery and hope if they relapse at work; there is also concern about their ability to maintain professional boundaries and respect confidentiality when they are supporting people who are their peers – indeed they may be friends, or have shared time on an inpatient ward.

Team members need to be clear about how PSWs have been trained, recruited, selected and how they will be supervised. This cannot be achieved simply through giving information, it will only be understood through discussion and freedom to share personal views in a safe space.

Staff may also have concerns that PSWs won’t understand ‘why we do the things we do’: having first-hand experience of using services means that PSWs are likely to be sensitive to non-recovery focused practices and documentation, negative language, assumptions and ‘gallows humour’.

When employed in a context that welcomes feedback they can have a significant positive influence on team culture15. However, without preparation, team members may find feedback from PSWs difficult to hear and may become defensive. With preparation of the whole team, with time for reflection, discussion and development of a whole team approach to welcome and facilitate peer support workers to contribute to team development, team members can be supported to recognise the ideas and suggestions from peer workers as helpful and constructive.

Peer workers are trained to work within different relational boundaries from other staff. Since they will, by definition share more of their own stories, they are likely to hear more about the experiences of those whom they support. The team needs to prepare for this, consider what it means for the way they work, how they can value the lived and life experience of the whole team, how to share information and where confidentiality is critical.

Members of the team who bring lived experience of mental health problems may wish to undertake additional training on how to use their own experience appropriately and effectively in their relationships (although their role, power, code of conduct and professional source of reference means that they can never substitute for PSWs). Conversely, without careful preparation, organisations and teams can create a context in which PSWs comply with current practices, adopt the values and principles of other workers and lose their distinct identity, role and capacity to improve the culture.

3.6 Creating supportive, accessible and effective recruitment processes

Some people applying for PSW roles will have been out of paid work for some time – often many years. This can make the process of applying for a job, filling in application forms, completing DBS applications (police checks) and preparing for interviews stressful and off-putting. Care needs to be taken to recruit PSWs with a range of experiences and cultural backgrounds, recruiting from grassroots community groups, third sector organisations and services for groups that find services difficult to access – it is with these groups that peer support can be most effective16.

Personal support and information, feedback about the process as well as appropriate adjustments will help to make application less daunting and more accessible. Although this, once again, reflects good practice with all staff, it is often not available for any potential applicants and by improving HR and Occupational Health processes for peers, lessons can be learnt to improve the experience for everyone.

Once in post, support, supervision and development opportunities are essential. Training for PSWs is frequently quite brief and, as with many professions, learning really begins once they are in post. Accessible support on a day to day basis is helpful to reduce anxiety and answer questions as they arise, but peer specific supervision is essential to facilitate development and ensure that they maintain their ‘peerness’. Organisations need to make decisions in advance about who will provide managerial and peer supervision and how critical issues will feed back into organisational development, training available and specification of peer support roles.

4. Preparing the Organisational Context

4.1 Making Peer Support everybody’s business

Any organisation considering the employment of PSWs, needs to ensure that this is not a ‘niche’ discussion happening in one team; something that is slipped ‘under the radar’ in order to make it happen without the potential for barriers, or something that is considered insubstantial and a tick box activity to gain funding or achieve CQC approval.

The employment of PSWs does not happen as a separate, one-off event. It will trigger wide spreading ripples across the whole organisation, raising questions with far reaching implications. For example, an organisation cannot employ people specifically to use their own lived experience (PSWs) if it does not explicitly value the contribution of all staff who bring personal lived experience.

It is not enough to simply state that these staff members are valued, this has to be demonstrated in recruitment, selection and employment policies practices; managers need to be able to access training so that they can provide appropriate employment support; training must be available to clarify how these staff can use their personal experience safely, appropriately and effectively.

If implemented carefully, the employment of people with lived experience explicitly to draw on their own experiences in order to support others has the potential to significantly change the experience of people using services and shift the culture of the organisation.

If implemented without care and attention it has the potential to harm the PSWs employed, reduce the readiness of all staff to disclose their own lived experience, damage staff attitudes and belief in recovery, reduce the likelihood of recovery focused cultural change and ultimately it is people who use services who will suffer. It is preferable not to do it at all than to do it badly.

This means that the first step is to set up a peer support advisory group with membership from all levels of the organisation (for example, senior service manager, executive sponsor, HR/OH representatives, learning and development representative, user and carer involvement lead, service user representatives and where possible Recovery lead), and from any userled or peer support organisations working within the geographical system of services who can offer experience of employing PSWs.

This advisory group needs to make itself aware of what PSW means, the potential benefits and pitfalls, organisational requirements (eg for development of new training courses) and implications (eg for funding of project lead, funding for new posts, review of employment support for staff with mental health challenges).

At an early stage, the decision can then be made about whether the organisation is ready to embark on this process or not, and if they are, who else needs to be invited to join the advisory group (eg local voluntary and third sector peers; experts from other organisations with prior experience, team leaders where peers may be employed …) and who will take on the role of project manager.

4.2 Board level support for peer support workers

Even at this early stage, there are potential action points for all members of the steering group. Since the employment of PSWs is a significant decision with wide ranging ramifications, the Executive Sponsor for PSW (or a designated link person with the board) will need to present a proposal to the Board and both ask and answer questions from the Board.

Of primary significance is Board level recognition that the employment of PSWs signifies that the organisation recognises the benefits and value of experiential knowledge. At Board level, it is essential to consider what this means for organisational strategy and whether changes are required to ensure that this message is clear and consistent in all aspects of the organisational vision and strategy.

The employment of PSWs is a necessary but in itself insufficient element of overarching transformation towards services in which relationships between service providers and service users become more equal as they work more collaboratively in shared decision making, coproduction, collaborative care planning, joint safety planning and cultural shift towards valuing the preferences and wishes of people who use services.

If there is no organisational commitment to this overarching shift then the opportunities for PSWs to work in distinct person focused, experientially informed ways is likely to be limited to a role in which all that is shared between peers and those they support is their mutual powerlessness. Alternatively, if the organisation is prepared to value the perspective of PSWs and people using services, opening itself to new ideas and willing to try innovative coproduced practices, then the pool of resources available is expanded to include all those using services17; practices become more recovery focused and the experience and outcomes of people using services are likely to improve18.

4.3 Funding

An important element of organisational commitment to PSWs is allocation of adequate funding. PSWs employed within an organisation must have the opportunity to apply for paid posts, banded according to job descriptions. They are not a cheap alternative to professional staff, they are an effective complement to multidisciplinary teams. As with any professional group the PSW budget needs to cover costs of developing PSW training, preparing teams, providing supervision, and professional leadership.

4.4 Leadership

It will take time for numbers of PSWs to reach a critical mass – able to present a case or provide effective support – within a single organisation. This makes the appointment of a peer support leader essential. It cannot be assumed that PSWs will be appropriately led by other professional leads.

Peer Support arose in a totally different philosophical and practical tradition; one which largely developed as a response to poor treatment and neglect within services19,20. It may be helpful for an existing user and carer engagement lead, or a Recovery lead to be appointed to lead the development of peer support but thought needs to be given to the experience and capabilities of the appointee. A peer support lead must bring their own lived experience and demonstrate appropriate and effective disclosure of this, ideally with working experience as a peer support worker themselves. More information on this can be found in the Thought Piece on Career Pathways for peer support workers.

They need to understand the politics and practice of peer support and have strong links with networks of peers locally and nationally.

But they also need to understand how organisations and traditional professions work. They need to have excellent communication skills to gain the respect of other professions and above all strong leadership skills to take forward new peer roles and enhance their influence across organisational culture (see Case Study 3).

This is a demanding and potentially isolating position as a central aspect of the role is to provide challenge at all levels (including the Board) from a lived experience perspective. There are organisations that recruit service user/peer leadership from external organisations, this has the advantages of proving a more independent voice when challenging the system; however the person may feel of a lone voice if they operate from within a separate organisation; they can discuss, test and develop a service user perspective within a collective of peers (see Case Study 1).

Case Study 1: Trust wide Lived Experience Practitioner & Peer Support Lead role within Central and North and West London NHS Foundation Trust (CNWL)

My role as Trustwide Lived Experience Practitioner & Peer Support Lead for a large NHS Trust in London is nothing if not large and varied. I hold responsibility for the strategic development of our workforce, which includes developing infrastructure, and advocating for the creation of new roles.

I also supervise a large (and growing!) team of senior peer support workers and advanced lived experience practitioners, and co-deliver our Level 4 accredited ‘Developing Expertise in Peer Support’ training at London South Bank University. I frequently present our services both internally and externally, and liaise with stakeholders, such as colleagues within other professional groups, HR, recruitment, volunteering, service user and carer involvement, our employment services, and the Recovery and Wellbeing College. Much of my work, therefore, is about building relationships and communicating vision.

I am amazed at how critical my previous experiences of working within a variety of peer roles serve me day to day. Prior to my current role, I have worked across both inpatient and community settings, in both statutory and User Led Organisations and the third sector. This varied experience of peer roles across my career feels absolutely integral in being able to provide credible, and experientially informed leadership to my colleagues.

Furthermore, I often speak about holding a caseload of one – my organisation.

At CNWL we define recovery as “the purposeful pursuit of a good life, irrespective of the absence or presence of symptoms, organised around the pillars of hope, opportunity and control, with social inclusion and self management at the heart.”

Much like many of us who have experienced mental health difficulties, my organisation has come a long way and done well in working towards developing a focus on recovery. However, it is on an ongoing journey of recovery, which we all know is a non-linear journey by nature. From having skills honed in ‘front facing’ work, I am able to think about how to use myself, a relational way of thinking and some smatterings of self disclosure to support the system to consider another way of considering its contemporary circumstances.

Using a similar approach to staff supervision, I work by focusing on sharing a relationship where we can both learn from each other, neither of us is positioned wholly as the expert, though we have different useful perspectives to communicate and tasks to achieve in our respective roles. This allows an ongoing development of this perspective and keeps alive my skills as a lived experience practitioner. I am always keen to learn from my colleagues, and I usually find that my grounding in approaching people I work with as keepers of their own wisdom fosters a mutually curious and open way of us both relating to each other.

5. Organisational Preparation: A checklist of questions to address

Any organisation planning to employ PSWs will need to consider a number of key questions. These are summarised below and more information to inform responses is provided in the following sections.

What do you want to achieve by employing PSWs? (see Section 3) As an organisation are you committing to working in partnership with people who use services in every way possible? Are you employing PSWs to demonstrate your belief in people who have experience of mental health challenges? To improve the experience of people using services? How are you going to make this commitment understood, shared and ‘real’?

How will PSWs be employed? (see Section 6.1) There are various different models for employing PSWs and no conclusive evidence about which works most successfully. Have you considered whether you will work in partnership with an external organisation to train, supervise and/or employ PSWs, or whether you are going to employ them in house? (see section 6 for more details about different options).

Where will PSWs be employed? Are you working towards employing peer workers across the whole service, one part of the service, or one team…? Where are you going to start and what is the goal? This may be informed by where funding is available, where new services are being developed, where quality improvement initiatives are being implemented.

However, decisions made by managers about where, how and how many PSWs will be employed are unlikely to be as successful as engagement with teams about what peer support is, what it can achieve, whether they are interested in employing PSWs on their team. It is essential to include members of teams where PSWs will be employed in the planning process, ideally as members of the advisory group. The employment of two or more PSWs in each team is strongly advised so that they are not isolated and have some mutual support from other peers whilst they are carving out a role and a distinct identity for PSWs in the team.

How many posts will be developed? Whilst it is advisable to start with a small group of PSWs so that sufficient care can be given to refining processes and support mechanisms, the PSWs will feel less isolated and alone if the first group includes around 12-18 peers.

This allows mutual peer to peer support, meaningful experiential learning, sufficient numbers to have a collective voice and a sense of solidarity – and it thoroughly tests processes and practices from the start. Some PSWs do not feel ready for full time posts from the start of their employment so, as a rough guide, it is likely to be necessary to train up to 18 PSWs to fill 6 FTE posts.

How will PSWs be recruited, selected and supported during and following the application process (see Section 7) Decisions need to be made about HR leadership for the safe and effective recruitment, selection and employment (support) for PSWs, including occupational health support.

How will PSWs be trained? (see Section 9) Provision needs to be made about the training of the first cohort of PSWs and then for ongoing learning and development of this cohort as well as new recruits.

How PSWs will be supervised (see Section 10) Since peers are much more likely to retain their peer identity and role if practice supervision is offered by an experienced PSW, arrangements need to be made for this to be offered whether in-house (possibly with support or through an external organisation), or by an external organisation from the start.

How will development opportunities be created for PSWs? (see Section 10) Consideration needs to be given to the ongoing career pathways for PSWs, opportunities need to be developed within the organisation for PSWs to progress into (eg senior peer roles, team leader roles, lived experience practitioners, peer specialists). In addition, PSWs bring lived experience to the whole organisation and some of their time might be set aside for coproduction activities alongside the user and carer involvement service or for developing coproduced learning opportunities either in the Recovery College or in staff learning and development courses.

How will existing staff with lived experience be supported? (see Section 9) The employment support provided for PSWs should not be exclusive to these members of the workforce but must be extended to all staff members so that everyone can work to their full potential and stay well in work21. Additionally, although PSWs are employed specifically to draw on their experiential knowledge, many other members of the workforce will have experience that could be used in their practice to enhance the support that they provide. This has implications for Human Resources, Occupational Health, Learning and Development and managerial roles.

How will observations, perspectives and suggestions of peer workers be responded to? (see Section 11). PSWs are employed not only to support people using services, they also bring a different but equally valued perspective to services and service development. Whilst individual peers working in teams might find it difficult to make their voices heard, a forum where PSWs can join together to share experiences, develop their views and suggestions and take them forwards for consideration by relevant forums is an important indicator of the real value that is afforded lived experience.

Who will employ, train and/or supervise the PSWs working in your organisation? Peer support has its roots in peer run organisations and where there are local peer run organisations it is essential to work in partnership with them to ensure that the original values and principles of peer support continue to inform PSW practice. Without this, PSWs too often become no more than ‘peer staff’ who end up complying with traditional psychiatric practices rather than bringing their distinct and unique peer contribution.

The experience and solidarity of peer led groups not only support the integrity of peer practice, they can also provide a safe place for PSWs to share their experiences, discuss challenges and develop responses. However, employment in paid roles within large, often statutory organisations does bring different challenges, expectations and limitations. The governance, bureaucracy, hierarchies and power relationships within these organisations can make the employment of PSWs a tightrope act – trying to retain peer principles within settings in which many people using the services are highly distressed, may be on involuntary sections of the MHA, where (professionally defined) safety is the priority.

While partnership between peer-led organisations and statutory organisations is always preferable, decisions have to be made about where and how PSWs will be employed.

6. Who will employ, train and/or supervise the PSWs working in your organisation?

6.1 Employment of PSWs by an external peer support organisation.

The training, role, employment and supervision is all undertaken by an external (peer-led or experienced in peer support) organisation and PSWs are placed in posts in a mental health service. This requires close collaboration between the two organisations so that expectations are consistent. Communication needs to be clear to anticipate and prevent problems arising, pathways for conflict resolution need to be set up in advance. (see Case Study 2)

Case Study 2: Dorset Wellbeing and Recovery Partnership

Dorset Healthcare University NHS Foundation Trust and Dorset Mental Health Forum have been working in partnership, as the Dorset Wellbeing and Recovery Partnership (WaRP), for the past 10 years. At the heart of this Partnership has been the exploration of lived experience and clinical expertise co-existing to provide a range of perspectives.

Dorset Mental Health Forum is a local peerled organisation, employing approximately 80 people all of whom have their own lived experience of mental health challenges, or that of supporting partners or close family members. The aims of the Partnership are to change the culture of mental health services and promote wellbeing across the whole of Dorset. Through this work, the Partnership promotes and models shared humanity and the belief that Recovery as a philosophy is common to us all.

In Dorset, peer specialists are independently recruited, employed and supported by the Dorset Mental Health Forum and they then work into Dorset HealthCare. Peers work at different levels into inpatient settings, CMHTs, CAMHS, specialist services (such as Forensic, Perinatal), the Retreats (open access crisis service), Learning and Development, and the Recovery Education Centre. The Forum do not just provide peers to deliver services, but also work strategically on the Mental Health Integrated Programme Board and at team leader level to support service development, as well as influencing at Board level and as system leaders within the local Integrated System (ICS).

The Forum has developed a career structure, referred to as a lived experience infrastructure with peer specialists, peer coordinators and lived experience lead posts. Over the past 10 years, the Partnership has been able to test and demonstrate that this independent way of working adds value and also provides an additional mechanism for peer support within the organisation itself. Much of the work independent peers do, includes compassionate challenge and building a sense of collective community informed from a range of perspectives.

The work is underpinned by a codeveloped partnership agreement, which acknowledges both organisations as stakeholders and partners in decision making and planning. This enables explicit conversations to happen around power and the direction of services. The partnership agreement also covers how risk is managed, data sharing and confidentiality.

Before peers work into a new area of service, the Dorset Wellbeing and Recovery Partnership leadership team (with a representative from the Forum and a representative from the Trust) engage in some team preparation and culture focused work. This also provides an opportunity to provide assurance of how peers are supported to do their work. Wellbeing at Work plans and Advanced planning documents are discussed, as well as details and descriptions of ongoing training, supervision and support mechanisms that are in place.

It is often important to teams that they are able to explore how they can build capacity from within their own services, so we discuss how we might engage with people who have previously accessed their service and how a pathway may be developed.

6.2 An external organisation provides the whole service

The whole service is commissioned from a peer run organisation which runs independently. (see Case Studies in HEE thought pieces on a) Crisis Services where the Cellar Trust is commissioned to provide peer led services, and b) VCSEs and Peer Support).

6.3 The organisation recruits, trains and employs its own PSWs

The organisation that wishes to offer peer support develops systems and processes for recruiting, training, employing and supervising peer support workers. PSWs are employed either in selected multidisciplinary teams or from a central peer support team. Wherever peers work, staff are given preparation so that all members are clear about the role and employment conditions of PSWs. Practice supervision is provided by peer supervisors (who may come from external organisations) whilst their team leader provides managerial supervision as with other members of staff. (See case study 4)

Case study 3: Central & North West London NHS Foundation Trust

In 2009, as an ImROC Pilot Site, CNWL began its journey to transform our workforce through establishing peer support activities in a statutory service at a time when such an endeavour was considered innovative. As an organisation, with executive support, we aligned the development of our Recovery College and peer support to work closely together. Subsequently the staffing resource for both was strongly linked; peers were trained together via an in-house provided training programme, and initially some staff worked across both workstreams – as both peer trainers and peer support workers.

As time has gone on, we are glad to have initially ventured forward with the model of in-house employment. The influence of peer support workers being embedded within the organisation has paid dividends in terms of our organisational culture shifting towards a recovery focus.

Though there is still work to be done, one of the huge benefits of all peer support workers being employed directly by CNWL, is the way in which ownership and pride for these roles is rooted in many colleagues at all levels of our organisation. It is hard to say whether we would have quite the same level of support for the work we are doing to improve, upscale and innovate, if our efforts were all located within an external partnership organisation.

We have found that what follows embedding peer support organisationally, is broad support for the recovery focused agenda. Issues that peers advocate for, such as coproduction, informed and shared decision making, reducing restrictive practice and trauma informed care for e.g; are increasingly being considered ‘everyone’s business’.

Additionally, the feeling of ‘us and them’ between peer workers and other colleagues is reduced as our staff feel the benefits of working alongside their peer colleagues. As ‘mentally healthy’ workplace cultures are required for our peer workers to thrive, our working practices and policies continue to evolve with benefits of improved workplace wellbeing and job satisfaction for all staff.

Some NHS Trusts have successfully achieved a similar level of embedded presence via strong partnership working with local VCSE’s. For us at CNWL however, considering the sprawling geography and size of our Trust, we feel our peer workforce, located within the organisation, allows us to effectively work collaboratively across the whole organisation. In such a large organisation it is critical that our peer colleagues are not forgotten or undervalued. By developing an in-house workforce; we work alongside each other, ensuring delivery of services that reflect our Trust’s values.

7. Human Resources and Occupational Health issues

7.1 Developing the job description – what will PSWs do?

It is advisable for the whole PSW advisory group to be involved in determining the role of PSWs by contributing to the development of their job description. There are critical decisions to be made about what will be expected of PSWs. It is helpful to start by reaching agreement about how your organisation wants to define peer support, what you want to achieve by employing PSWs and how their job description can be crafted to stay true to your goals.

The literature suggests that peer support workers make at least three distinct contributions that differ from other staff22. The first is the development of a relationship characterised by mutual understanding, acceptance, trust and a genuine belief in the person’s ability to recover. The second is the inspiration of hope through self-disclosure; demonstrating that it is possible to gain control over mental health challenges, from being defeated and disabled by the condition to understanding it and believing that it is possible to live well in spite of, or even because of the condition.

The third lies in sharing experiences within this trusting and more equal relationship, exploring ways of coping and managing the condition and life more generally. This might include identifying life goals and working out steps to achieving them, it might mean problem solving together, developing a personal recovery plan, or practical help to address barriers – both within services and the social situations that stand in the way of living well – things like debt, poor housing, relationship problems.

While PSWs might not have the answers to these problems, their job description needs to allow them to spend time with people, help them gain understanding, work out what their experiences mean to them, work with them to think about what they want, find out what is available, what might help them, and then to take action together.

Having agreed on the purpose of PSWs in the organisation, it can be useful to look at a range of job descriptions developed by other organisations and then to consider key questions about the role of PSWs in relation to certain tasks and whether they will they be included in the ‘numbers’ on a shift.

Will PSWs be expected to undertake the routine duties of other support workers (like making beds, serving meals…) or will their role be confined to supporting Recovery through one to one support, running groups, coaching, recovery planning, goal setting, action planning….?

There are different ways of addressing these questions. Whilst the question of whether PSWs will be included in the ‘numbers’ is largely informed by finances, questions about the nature of their role are largely addressed by considering the values underpinning the role. PSWs are not employed to carry out tasks and duties defined by other professionals but to engage with people in a mutual and reciprocal manner. They may be able to achieve valued relationships whilst undertaking such tasks as making beds together, attending meetings together, taking a walk together or planning action together, but these tasks must not take precedence over relationship building and peer support.

More contentious questions must be addressed in relation to the role of PSW in coercive practices: the values and principles of peer support mean that PSWs should not take part in restraint or in giving medication – or other treatment – against a person’s wishes.

However, there are ambiguous situations in which a PSW may be involved in preventing a person from harming themselves or someone else; they could have a role to play in reducing a person’s distress, de-escalating a crisis, taking them for treatment that they have agreed to but may well be frightened about…. It is essential that a wide range of stakeholders are involved in discussions about the role of PSWs in your organisation so that a deep understanding is achieved and well justified decisions are made.

7.2 Person specification – what do you mean by ‘peer’?

One further crucial question to be considered relates to the person specification: what do you mean by ‘peer’? Whilst PSWs working in mental health services might be expected to have personal experience of mental health problems, it is important to think about how this will be defined. Will people define themselves as having this experience or will they be expected to have used services? if so, will they need to show they have used primary or secondary services? Will you consider people who have sought personal therapy to have the shared experience necessary to provide peer support?

Given that so many people using mental health services have experienced trauma, homelessness, poverty, unemployment … will these factors be taken into consideration when recruiting PSWs? Will your definition of ‘peerness’ depend on the service that you are recruiting to? For example, when recruiting PSWs for forensic services, will PSWs be expected to have used forensic services? When recruiting PSWs for homeless services will they be expected to have experienced homelessness and/or mental health problems?

An advisory group which includes people with a range of experiences, perspectives and a deep understanding of peer support will be helpful in reaching well justified answers to these questions.

7.3 Recruitment

However many peer support workers will be employed and in whatever part of the services, consideration needs to be given to the recruitment and employment process. Since PSWs bring added benefit for the engagement and recovery of people who find services difficult to engage with, it is advisable to recruit some PSWs from groups who themselves have difficulty accessing and engaging with services.

Recruitment needs to reach people who have experience of adverse life circumstances and mental health problems who are no longer using services, so advertisement of posts needs to go beyond NHS Jobs to provide relevant and accessible information to local voluntary sector, local authority and primary care groups and services.

For recruitment processes to be accessible, it is helpful for clear and welcoming advertisements to give the name and phone number of someone to call if they are interested in finding out more about the post. Calls must be returned quickly and supportive – and honest – responses given to inquiries. Peer support is not an easy job, it is not well paid and it does require people to talk about their own experiences.

However, if you want to use your experiences to help others, if you have found ways of managing your own condition and living well, then it might be for you.

The application process for large organisations can be a deterrent in itself. It requires access to a computer and the internet, a high level of literacy – and it asks questions about past employment and experience. All of these might be particularly difficult for people who could make very good PSWs.

It can therefore be helpful to offer individual support to people interested in applying to become a PSW, enabling them to access the right form and giving them the confidence to respond to questions appropriately. This might be undertaken by a member of the HR team or the employment support team, or once there are PSWs in post, it might be possible for a member of the PSW team to provide this support.

7.4 Selection

Just as applicants for PSW posts have often had little experience of applying for work, they may also find the prospect of an interview very anxiety provoking. It can be helpful to arrange a selection process that allows applicants to demonstrate their skills, values and behaviours in different scenarios.

An assessment centre approach in which all shortlisted applicants are given the opportunity to meet, ask questions, take part in a large group discussion, answer selected challenges in a small group and take final questions in a brief individual interview can be a more effective approach to selection. It is essential for the selection team to include at least one person with lived experience, ideally already in post as a PSW, and for an HR representative to sit on the panel to answer questions about process and expectations, as well as a service manager/team leader from the service the successful applicant will work in.

As with all recruitment, it is necessary for the panel to agree set questions and criteria beforehand. In order to work well as a PSW, applicants do NOT need to be symptom free, but they do need to demonstrate an understanding of their condition, what they do to keep themselves well, how they know when they are not so well and what they do when they need additional support.

Indeed, it is the learning that has occurred through their own experience that will be most helpful in their role as a PSW, so selection does need to assess what they have learnt and how this might enable them to support another person. Since peer support is built on strong values, it is helpful to observe group discussions and problem solving for evidence of applicants’ values in action.

All applicants, whether they are offered a post or not, should be given feedback so that they are clear why they were successful or unsuccessful and for those not offered a post, support should be offered to enable them to develop their skillset (for example an introduction to Recovery College to learn more about personal recovery planning, an introduction to the Volunteer team for opportunities to gain more experience in supporting others).

7.5 DBS checks

For people who have been involved in the criminal justice system during difficult periods in their life, the prospect of completing a police check form is yet another barrier to negotiate. Personal support and information can help them to see this as just one part of the process of applying for a job. However, at an organisational level, the employment of PSWs may well trigger a review of the DBS checking process.

7.6 Employment support

The introduction of peer support workers in the workforce provides an opportunity to consider and develop new strategies, policies and procedures for the benefit of all staff. Line managers and leaders should be supported to adopt a zero tolerance towards discrimination. Policies as part of a wider plan to implement and communicate the importance of wellbeing could be introduced.

  • Occupational Health assessments are a routine part of NHS and larger organisations usual recruitment processes. While they are designed to assess the health needs of a new employee and offer support to fufill the duties of their new role, they can be particularly anxiety provoking for peers who may have been denied employment because of their health condition or been “retired” from previous employment due to their health condition.

The success of these assessments depends on the level of understanding of the person carrying out the assessment ie do they understand the role? Do they understand the duties expected? Do they appreciate/ understand why the person may not have been in work previously. It is Occupational Health who will make recommendations about reasonable adjustments, again the nature of the adjustment recommended will depend on the OH professional truly appreciating the role and context in which the person will be working.

  • Reasonable adjustments. Employers have a duty of care under the Equality 2010 and Reasonable Adjustments DWP 2017 give some guidance on employing people with mental health conditions. DWP suggest flexible work patterns, changing the work environment where possible, creating action plans to help manage their condition and allowing leave to attend appointments and so on as helpful strategies but these do not go far enough. Reasonable adjustments can and should be made throughout the recruitment process as suggested in 7.3 and 7.4 of this paper to ensure peers are supported appropriately to successfully apply for roles and survive and thrive in work.

 

  • ‘Wellness at Work’ plans. Peer support workers benefit from understanding how ‘Wellness at Work’ can help them in their employment, so this should be an integral part of their training as well as part of a more general approach to having open and honest conversations about mental health in the workplace (something which all staff would benefit from). A wellbeing plan helps to build a picture of why a person may react in unexpected ways to situations and enables support to be provided based on shared understanding, regularly reviewing the plan is important and can be done as part of ongoing supervision.

 

  • Occupational Health Support. Ongoing support from OH may be necessary for the peer support worker to remain in work. OH may be best placed to recommend and signpost PSWs (and others) to additional support Eg Employee Assistance Programmes, and initiatives like the “Green Hour” implemented at CPSL MIND that encourages all staff to have an hour a week in “work time” to play sport go far a walk, read a book etc.

7.7 Financial considerations for peer support workers

Due to the complexities and individual nature of our current benefits system we would recommend that ALL peers applying for peer support worker role should seek individual benefit advice.

Many peers work part time or on “bank” arrangements which further complicates how peers can be paid and employed. Some peers choose to begin their employment under permitted work and assume that they will be able to work for 16 hours and earn under a set amount per week that is usually 16 hours times the national minimum wage.

For entry level Agenda for Change band 3 PSWs this isn’t the case. The hourly rate of pay for a band 3 PSW is higher than the national minimum wage which means currently peers are only able to work about 12 hours / week to meet the requirements of permitted work.

Again, we would advise seeking the advice of an employment advisor if you have access to one or the Disability Engagement Officers at DWP. NHS Trusts will have access to pensions advice to support peer support workers to think about their future pension and to understand the importance of national insurance contributions in safe guarding their future financial security and we recommend that PSWs are encouraged to meet with their advisor as part of their induction programme.

Trusts are used to employing staff who are managing long-term conditions or have a disability, and, therefore, it will be helpful when employing PSWs for the first time to apply similar “rules”.

8. Team Preparation

The success of PSWs is largely attributable to the teams in which they work. Where the team understands why PSWs are being employed, how they will contribute and what additional specific support they are able to offer to people using the service PSWs can settle in without confusion, negative judgements or blame. Where team members actively seek out PSWs to provide mutual support to people who are isolated, disengaged, inactive or experiencing distressing experiences, then peers use their skills in a targeted way, they feel valued and appreciated by staff and people using services and given support and supervision they will enrich the team, improve the experience of people using the service and develop their own skills and confidence.

8.1 Team Preparation workshops

Once decisions have been made about where PSWs will be employed, then each team needs some careful and bespoke preparation. Where possible the whole team (including all professions and non-clinical staff) needs to spend at least half a day sharing, learning and planning together.

The session needs to be facilitated by the peer support lead, a senior service manager and a peer support worker. It is helpful to cover the following areas in an experiential, non-judgmental, and developmental manner and to create a safe space for all participants to contribute openly23:

  • Peer support: What is meant by peer support, what is a PSW, what do they do, what difference do they make (input by PSW lead).
  • What are the hopes and fears of team members about a PSW joining their team (generation of ideas to be done confidentially so that participants can be honest) (exercise facilitated by PSW trainer)
  • Which of these fears can be addressed here and now? What further information is required to address all the concerns raised? (Manager to lead discussion of feedback)
  • How can the team ensure that all their hopes about PS are realised? (Manager)
  • What is the role of PSWs in a team like this (PSW lead drawing on examples from literature and practice)
  • How will this work in your team? How could a PSW enhance the support that you offer? (exercise facilitated by PSW trainer) Collect a team specific list of PSW tasks/duties
  • How can you, as a team set up processes and support to enable your PSWs to work to their full potential (eg how to refer/ engage PSWs in specific work with people using the service; identifying a mentor for PSWs…) (exercise facilitated by PSW lead)
  • Making an Action Plan, identifying who is responsible for what and when.

8.2 Can PSWs work in any mental health team?

Since PSWs bring experience of using the whole range of mental health services (some have used acute inpatient services, some community, some substance misuse services, others child and adolescent or forensic services; some have avoided using services but have sought different types of support , therapy and/or treatment …. ), in theory they can be employed to work in any of these services so long as they potentially share some of the experiences of people currently using those services.

However, it is particularly challenging for PSWs to be employed in very traditional, hierarchical or coercive teams where there are no plans or attempts to introduce more Recovery focused practices. If a PSW is employed in a team where there is frequent restraint, where the emphasis is on giving medication and treatment against the will of people using the service and where there is little attempt to share decision making or facilitate personal Recovery planning, then PSWs will not be able to work in a manner consistent with their role.

Too often, PSWs employed in contexts such as this become disillusioned, frustrated, burnt out; it is not fair or ethical to place them in contexts which will either be bad for their wellbeing – or require them to adapt and adopt accepted practice.

This is why the introduction of PSWs cannot be a standalone initiative: the only intervention implemented to challenge current practice. This places huge responsibility on individual PSWs and essentially sets them up to fail in their role. Organisations introducing PSWs need to consider how other initiatives might support and strengthen the influence of PSWs in changing the culture of the organisation.

8.3 Team Recovery Implementation Planning (TRIP)

One approach that complements the introduction of PSWs in teams is Recoveryfocused quality improvement using the TRIP as a set of benchmarks for the team to assess themselves against, identify 3-5 priorities for action, and agree a comprehensive team recovery action plan that can be reviewed regularly.

The introduction of TRIPs to improve the Recovery focus of teams has been a CQINN target in a number of areas (including high secure services) and used in outcomes-based commissioning. It is worth considering the use of TRIPs in organisations where teams are not actively working towards Recovery before employing peer support workers24.

8.4 Ongoing support for teams employing PSWs

A single workshop to prepare a team for PSWs is unlikely to provide sufficient understanding of what will be required, nor will it facilitate the ongoing development of structures to support and develop PSWs in practice.

Where PSWs are employed, team leaders need to have access to support, problem solving, coaching and development to enable them to continue to develop a supportive context for PSWs and to manage any challenges that occur in an appropriate Recovery focused manner (see also Section 9).

9. Learning and Development Opportunities to support the employment of PSWs

9.1 Training in peer support

It is essential for all PSWs in paid roles in organisations to undertake high quality training in peer support that enables them to understand the values and principles of peer support, implement these in developing relationships and to work safely, appropriately and effectively. Organisations may wish to access PSW training provided by respected organisations, and they may wish to work with these organisations to develop their own PSW training course.

HEE is currently working with UCL partners and the NCCMH to develop and approve a competency framework for PSWs which clearly outlines the areas to be covered by training. Once this has been ratified, trainers will have a shared consistent and agreed framework to inform the development of training. (Contact HEE for information about training providers.)

A number of different organisations offer PSW training at different levels, some accredited, some not. (See ImROC Training Prospectus and ImROC Peer Support Brochure).

Case Study 4: PSW Training provided by ImROC

ImROC coproduced the first training course for PSWs working in NHS services in 2008 working with local peer led NGOs and drawing on an extensive review of the literature. This course has developed over the past 12 years and is now offered as organisational development support rather than simply a training course.

A team of experienced peer and professional trainers (from statutory NHS, LA, and Voluntary Sector services) work with organisations interested in employing PSWs to ensure that they have a full understanding of what this means, why they are embarking on it, and whether they have the funding, structures and culture necessary.

Support is offered at organisational level, with teams where PSWs will be employed, with Learning and Development Departments and with HR departments to develop a training and development plan fit for their organisational context.

This includes support with selection and recruitment of trainees, organisation of pastoral support during training, preparation of placement mentors and delivery of a ten day training course with additional specialist modules for PSWs working in specialist placements; assessment of competency of PSWs and advice on employment support.

ImROC offers an accreditation system which examines the organisational context including training and is renewed annually following annual peer review.

9.2 Training before or after employment?

Organisations need to decide whether PSWs will be employed and then offered training, or recruited to training which enables assessment of their competency and readiness to work before they are recruited to a post.

The advantage of offering training prior to employment is that it enables the student to fully understand the nature of the role and gain experience of working as a peer support worker during a student placement; it ensures that they have the skills and understanding to keep themselves and those whom they support safe; and it offers the organisation greater confidence in the ability of the recruit to undertake the work.

Since other professional groups undertake training prior to employment it seems to make sense.

9.3 Ongoing development of PSWs

PSW training only provides the basic knowledge and skills for peer working. As with any job, most development takes place with practical experience over time, and further training is necessary to gain more advanced and/or specialist skills.

PSWs may wish to learn more about Recovery and Wellness Planning, Coaching Skills, Problem Solving, Co-Reflection, Community Development, Peer-to Peer supervision, Supporting family members, Training to be a trainer, Survivor research skills, and more.

These training needs may be identified in their personal development plan, supervision or appraisal system – (importantly all primarily based on and informed by their own experience). Whilst some of these courses will be relevant and available to all staff, others will be specific to PSWs. Organisations need to plan ways of enabling PSWs to access appropriate ongoing education – either through inhouse courses or in the Recovery College (if there is one locally) or by accessing external trainers.

There is often a period of time when organisations are building their capability in peer support and investing in the development of staff who will become peer supervisors, peer trainers, peer researchers and senior PSWs as the peer workforce expands (see HEE paper on career pathways).

9.4 Offering relevant courses to all staff

The employment of PSWs is only one way of shifting the culture of services. Organisations that employ PSWs need to ensure that all staff have access to courses that enable them to play a part in delivering more Recovery focused services. Personal Recovery and Wellness planning, shared decision making, coaching approaches, solution focused approaches, shared crisis planning, joint safety planning, collaborative care planning …. are all fundamental aspects of practice in Recovery focused services so training needs to be available for all staff to understand and implement these approaches.

Similarly, team leaders and managers need to adopt a strength based, facilitative and supportive style of management to enable all staff to work to their full potential, to build on their strengths and cope with external stressors. Everyone has the right to employment support and reasonable adjustments to their role. Training must be available for managers to learn these skills – not just when working with PSWs, but for the benefit of everyone in their service.

9.5 Non-peer staff with lived experience

As previously referenced, between 30 and 60% of staff working in mental health services have been found to have personal experience of mental health problems. Traditionally, they have been advised not to disclose their own stories.

However, Recovery focused services are all about breaking down barriers between ‘them’ and ‘us’, sharing more about ourselves, demonstrating our shared humanity.

Staff are already beginning to feel more confident about disclosing their own experiences to their colleagues and people who they support; this appears to be even more the case where PSWs are employed.

Although PSWs have received training in how, why, when and how much to share of their own stories, other staff have not. Training departments need to lead the way in ensuring that organisations have clear policies and expectations about whether, how and when all staff can safely, appropriately and effectively disclose aspects of their own life and lived experiences.

10. Supervision for peer support workers

Regular supervision is absolutely essential for all practitioners including peer support workers. The CQC defines supervision as “a safe and confidential environment for staff to reflect on and discuss their work and their personal and professional responses to their work. The focus is on supporting staff in their personal and professional development and in reflecting on their own practice” (CQC 2013)

The challenge for organisations employing PSWs is to consider what supervision means for a profession that is based on personal experiential knowledge and experience rather than a recognised theoretical and professional knowledge base.

Leaders in the field of peer support in the US have defined peer supervision in some detail. Sherry Mead (the author of Intentional Peer Support (IPS) draws on the principles of peer support in describing supervision as a process of co reflection where the supervisor and supervisee help each other to reflect on their practice, where expertise is created together through a process of learning, practicing and reflecting.

She describes this co reflection approach as “referring to reciprocal arrangements in which peers work together for mutual benefit where development feedback is emphasised and self directed learning and evaluation is encouraged” (Mead 2012)

Lori Ashcraft, the originator of peer specialists in Recovery Innovations Arizona, describes peer support supervision as “a strengthsbased process that supports the role of peer specialist. Feedback is important, promotes trust in the relationship, and supports professional development. All supervision must occur within the framework of existing human resource standards and procedures” (Ashcraft, L 2015)

10.1 Why focus on supervision for peer workers?

Peer roles are unique. There is no other occupation in the NHS that requires postholders to share aspects of their personal experiences and it is this that makes supervision both essential and distinct in the following ways:

  • Working with people who disclose personal experiences of trauma and mental health challenge is demanding for everyone. For people with their own lived experience it can trigger distress, lead to reliving traumatic events and even lead to vicarious trauma.
  • Recalling and referring to personal experience of trauma, mental health problems and Recovery in itself is demanding emotional labour
  • Open acknowledgement of personal experience of mental health challenges has the potential to render PSWs vulnerable to discrimination by other staff
  • Reference to personal experience is a huge strength and asset in relationships with people using services and can lead to closer connections, greater trust, more disclosure and higher/different expectations from clients.

This brings with it continual questions for each peer about relational boundaries with the individual (e.g. what is the difference between peer support and friendship?) and with the team (what parts of the story I have been told should be shared with the team?); about their own role (I feel more connected to the views of this individual than with other staff … what do I do about this?; I do not feel comfortable with the language used to describe this behaviour…).

Skilful supervision can support PSWs to maintain quality, integrity and safety of peer practice; provide coaching/problem solving to address challenges in practice, develop personal practice and repertoire; enable safe and appropriate sharing of emotional burden of the role; help them to integrate within their workplace, and provide a forum to raise concerns about organisational policies and practice and share decisions about next steps.

10.2 What sort of supervision do PSWs require?

Much of the literature that describes supervision required in the NHS describes three types: managerial, professional and clinical. Within the context of peer working these headings could translate into administrative, educative and practice or supportive supervision. Arguably these headings are better as they describe the “type” of supervision they can expect.

Traditionally supervision models fall into three categories: developmental, integrated and orientation specific. All of these have relevance for the supervision of PSWs, but PSW supervision requires consideration of an additional category which defines whether the supervisor has their own lived experience and expertise in peer support.

Developmental supervision refers to the different stages of a supervisee’s development from “novice to expert”. Each stage consists of discrete characteristics and skills; the key is for the supervisor to accurately identify the supervisee’s current stage, and offer feedback and support appropriate to that level alongside facilitating the supervisee’s progression.

The model uses a process of “scaffolding” to encourage the supervisee to use prior knowledge to produce new learning which fosters the development of critical thinking skills. The Integrated Development Model is by far the most researched development model. For more detail please see Stoltenburg (1981), Stoltenburg & Delworth (1987) and finally Stoltenburg, McNeil & Delworth (1998).

Integrated Supervision relies on more than one theory or technique in much the same way as clinicians describe their practice as eclectic; that is, integrating several theories into consistent practice. One well-recognised model is Bernard’s Discrimination Model originally published 1979.

This model comprises three areas of focus (intervention, conceptualisation and personalisation) and three supervisory roles (teacher, counsellor and consultant). What this means in practice is that the supervisor can respond in one of nine ways. For example, the supervisor can respond as teacher, while focussing on specific intervention; or respond as counsellor whilst focussing on intervention and so on.

Orientation specific supervision model adopts a “brand” of therapy that is selected based on an analysis of the supervisee’s role (for example, CBT informed supervision for a CBT practitioner). Within peer support, Mead’s co-reflection based on principles of mutual support and reciprocity is closest to a brand specific type of supervision for peer support.

Peer to Peer Supervision refers to supervision for PSWs provided by a supervisor with their own lived experience and expertise in peer support. Kopache (1995) describes the difference in impact that supervisors who have lived experience can have in relation to role modelling, support, trust and the building of knowledge based on their experiences. She goes on to emphasise the importance of both planning and developing peer roles and believes they should be embedded in job descriptions and training for supervisors (see HEE thought piece on Peer Development Pathway).

Two commonly used models in peer to peer supervision are Proctor (1991) and Sherry Mead (2005) Proctor’s model describes 3 aspects of the tasks and responsibilities of the supervisor and supervisee. Formative / educative which has a focus on development of knowledge and skills, an opportunity to become increasingly reflective upon practice and is all about learning and growth. Normative / managerial which essentially monitors and evaluates the quality control aspects of supervision.

And finally Restorative/ support which explores elements of psychological support for the supervisee. That is, it explores work life balance, feelings and concerns, it challenges ideas and encourages and enhances good working relationships.

Sherry Mead’s co-reflection guide for supervising in Intentional Peer Support describes the process of creating expertise together through a cycle of learning, reflecting and practising. The model is designed to reflect the principles of peer support and to enhance personal development of PSWs.

10.3 In summary…

Given the role of PSWs, it is essential a) for PSWs to receive regular supervision, and b) for this to be provided by someone with clear understanding of the provenance, role, purpose and potential challenges of peer support, preferably someone who has lived experience themselves.

Beyond this, decisions about supervision will depend on the addressed:

  • Who will provide supervision for PSWs?
  • How will supervision be provided?

The following tables summarise the advantages and disadvantages of different decisions as suggested by the HEE peer support implementation group which includes employers, trainers and practitioners of PSW as well as user led organisations.

11. Creating a context for PSWs to develop a collective voice

  • While individual peer support workers might have an influence on the culture of the team that they work within, this is a huge expectation to place upon them. They have limited positional power and whilst they may have the confidence and skills to influence language, practice and attitudes within a receptive team, this cannot be assumed or expected.

However, if all the PSWs working in an organisation are provided with opportunities to come together at regular intervals, to learn together, generate ideas, solutions and plans, then they have a more powerful collective voice. This forum can also become a space to debate contentious issues, invite external speakers and meet organisational managers and leads to discuss the case for changing particular practices.

  • Nottinghamshire Healthcare NHS Foundation Trust has been running PSW Development Days for more than ten years. These run quarterly and membership not only includes all of the peers working within the Trust but is open to PSWs working in local VCSE and user led groups. Issues nominated by the group are placed on the agenda for the following meeting and addressed in detail with expert speakers invited where appropriate.

The group is facilitated by the Trust Peer Development Lead who facilitates open debate and discussion and where agreed, issues will be taken forward to relevant forums to become part of relevant agendas for change (eg PSW role in care planning, note writing, reducing the use of restraint will be taken to relevant decision making groups; PSW led cases to change policies and procedures will be taken to relevant managers).

  • In effect, this sort of forum not only amplifies the voice and influence of PSWs within the organisation, increasing their influence on cultural change, it also provides learning opportunities and facilitates personal development of PSWs.

The system wide membership ensures awareness of wider agendas and keeps members of the group informed of relevant events and opportunities for PSWs. Importantly it also provides a space to raise concerns and risks to the integrity of peer support within the organisation.

ImROC’s Vision

For systems, services and cultures to support Recovery and wellbeing for all locally, nationally and internationally.

ImROC’s Mission

ImROC works in partnership with communities to develop systems, services and cultures that support recovery and wellbeing for all. ImROC has been leading the way in recoveryoriented service and practice improvement since 2011.

Originally established on behalf of the Department of Health to champion its ‘Supporting Recovery’ initiative, through a collaboration between the Centre for Mental Health and the NHS Confederation’s Mental Health Network, ImROC is now hosted through Nottinghamshire Healthcare NHS Foundation Trust. This innovative new partnership allows us to cement our close working relationship with frontline providers of care, ensuring that our work remains relevant and useful to practitioners, managers, system leaders, local communities and ultimately, the people who access services.

Our role is about enabling people (who use services, work in services and live in communities) to unlock and pool the strengths and talents they take for granted, explore new ways to make use of them, share knowledge and learning, and facilitate recovery-oriented improvement in the outcomes and experience of health and social care. We rely on and embrace the expertise, experience and collective wisdom of everyone we work with, and encourage communities to develop as a result. Our job is about using our expert knowledge to inspire others to believe that change is possible; pursue their dreams, and most importantly to act: changing attitudes and behaviours. This ethos of working in co-production is at the heart of our organisational work, and role models what we seek to achieve at a practice level too.

1 Slade, M.; McDaid, D., Shepherd, G., Williams, S., Repper, J. (2018) Recovery: The Business Case. ImROC Briefing Paper 14.(imroc.org)
2 NESTA and National Voices (2015) Peer Support: What is it and does it work? London: NESTA and National Voices
3 Thornicroft G. Shunned: Discrimination against People with Mental Illness. Oxford: Oxford University Press 2005.
4 Dixon L, Hackman, A., Lehman,A. Consumers as Staff in Assertive Community Treatment Programs. Administration and Policy in Mental Health and Mental Health Services Research 1997;25:199-208.
5 National Attitudes to Mental Illness Survey (2020) London, Institute of Psychiatry.
6 Krupa, T, Kirsh, B, Cockburn, L, Gewurtz, R. Understanding the stigma of mental illness in employment. Work. 2009;33(4):413–425.
7 Henderson, C, Noblett, J, Parke, Ha. Mental health-related stigma in healthcare and mental health–care settings. Lancet Psychiatry. 2014;1(6):467–482.
8 Schulze, B . Stigma and mental health professionals: a review of the evidence on an intricate relationship. Int Rev Psychiatry. 2007;19(2):137–155.
9 Hansson L., Jormfeldt H., Svedberg P., etal. (2013) Mental health professionals’ attitudes towards people with mental illness: do they differ from attitudes held by people with mental illness? The International Journal of Social Psychiatry 59, 48– 54.
10 Solomon, P. (2004). Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. Psychiatric Rehabilitation Journal, 27(4), 392–401.
11 Devon Partnership NHS Trust (2009b), Recovery Coordination: Policy Implementation Guide and Practitioners Handbook, Devon Partnership NHS Trust, Exeter.
12 Penney, D and Stastny, P. (2018) Peer specialists in the mental health workforce: A critical reassessment. Mad in America. October 16, 2018.
13 Watson, E. (2019) What is peer support? History, evidence and values. Chapter 2 in Watson,E and Meddings, S. (Eds) Peer Support in Mental Health, London: Red Globe Press.
14 Penney,D. and Prescott, L. (2016) The co-optation of survivor knowledge: the danger of substituted values and voice. In J Russo and A Sweeney (Eds) Searching for a rose garden: challenging Psychiatry, fostering mad studies (p.35-45) PCCS Books.
15 Solomon, P. (2004). Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. Psychiatric Rehabilitation Journal, 27(4), 392–401.
16 Faulkner,A. and Kalathil, J. (2012) The freedom to be, The chance to dream. Preserving user-led peer support. London: Together
17 Many reports describe the net gain of working in collaboration with people who use services, PSWs, family members and community groups. A good example of innovative partnerships with people who use services Slay, J. and Robinson, B. (2013) In this together: Building knowledge about co-production. London: New Economics Foundation.
18 Slade et al (2018) The business case for recovery. Nottinghamshire Foundation Healthcare Trust: ImROC Briefing paper 14.
19 Chamberlain,Mead
20
21 Morgan,P. and Lawson, J. (2015). Developing guidelines for sharing lived experience of staff in health and social care, Mental Health and Social Inclusion, Vol. 19 Iss 2 pp. 78 – 86 A survey was undertaken in the Mental Health Directorate of DHC, with a response rate of 31 per cent; 53 per cent of staff self-identified as having lived experience of mental health problems. A similar survey in Devon Partnership Trust had similar results. Of a 23 per cent response rate, 43 per cent identified as having lived experience of mental health problems. One third of respondents with lived experience felt unable to be open with their managers and colleagues with the most frequent reason being fear of stigma, misunderstanding and rejection
22 Davidson
23 Repper, J & Perkins, R (2013) The Team Recovery Implementation Plan: a framework for creating recovery-focused services. ImROC.
24 Repper, J & Perkins, R (2013) The Team Recovery Implementation Plan: a framework for creating recovery-focused services. ImROC.

Peer support is based on offering and receiving help based on shared understanding, respect and mutual empowerment. Whether paid or voluntary and working in statutory, private or independent services, peer support workershave a valuable role to play. The introduction of people with lived experience of mental health problems into the mental health workforce is a hugely significant step in a service becoming more recovery focused.

This paper sets out four phases for an organisation looking to introduce peer worker posts: preparation; recruitment; employment; and ongoing development.

Download 7. Peer Support Workers: A Practical Guide to Implementation

7. Peer Support Workers: A Practical Guide to Implementation

Julie Repper with contributions from Becky Aldridge, Sharon Gilfoyle, Steve Gillard, Rachel Perkins and Jane Rennison

INTRODUCTION

Our experience with the ImROC programme has led us to the conclusion that the widespread introduction of people with lived experience of mental health problems into the mental health workforce is probably the single most important factor contributing to changes towards more recovery-oriented services. In the first paper on this topic (Repper, 2013) we discussed the theoretical background, core principles and the range of potential benefits. In this paper we will discuss practical issues of implementation in more detail.

When developing peer worker posts, it is useful to think of four sequential phases. The first involves preparation – of the organisation as a whole, of the teams in which peers will be placed, and, perhaps most obviously, of the peers themselves. The second phase involves recruitment of peers to the posts that have been created or existing posts that have been modified for peer workers. Given the likelihood that peer applicants may have not worked for some time, nor been through an interview process with all of the formalities and checks that this brings, the whole process needs careful support. Thirdly, there is the safe and effective employment of peer workers in mental health organisations. Finally, the ongoing development of peer worker opportunities and contributions needs to be considered in the context of the wider healthcare system and the changing culture of services. These different phases are shown in Box 1 below.

Box 1: Developing peer worker posts: four phases

1. Preparation

  • Preparing the organisation
  • Preparing the teams
  • Defining roles
  • Common myths and misconceptions
  • Preparing the peer workers (training and work placement opportunities)
  • Developing job descriptions and person specifications

2. Recruitment

  • Advertising
  • Benefits advice
  • Applications
  • Interviews
  • Occupational health
  • CRB checks
  • Supporting people who are not offered posts

3. Employing peer workers

  • Selecting placements
  • Induction/orientation
  • Supervision and support
  • Maintaining wellbeing

4. Ongoing development of the role

  • Career pathways
  • Training opportunities
  • Wider system change

ACKNOWLEDGEMENTS

Advances in recovery-focused practice arise from collaborative partnerships between individuals and organisations. The ImROC briefing papers draw upon this work. Each paper in the series has been written by those members of the project team best placed to lead on the topic, together with contributions from other team members. In this case we particularly wish to acknowledge the contribution of those individuals who have been prepared so generously to share their materials and experience on this important topic. We particularly want to acknowledge the contribution of Becky Aldridge (Dorset Mental Health Forum), Sharon Gilfoyle (Cambridgeshire and Peterborough NHS Foundation Trust), Liz Walker, Emma Watson and Marissa Lambert (Nottinghamshire Healthcare NHS Trust) and Jane Rennison (Central and North West London NHS Foundation Trust).

PHASE 1 – PREPARATION

Preparing the organisation

The development of peer worker posts must begin with consideration of the context in which they will be employed. Although peer workers are, by definition, vulnerable to mental health problems, this does not necessarily mean that they have different needs to existing staff. Therefore, preparing an organisation for peer workers generally involves improving systems and supports so that they are more supportive for all staff.

The development of peer roles requires engagement and commitment from many different parts of the organisation. A project steering group will therefore need to be established and its membership should include representatives from the various parts of the organisation that will be affected, for example HR, management, professional groups, communications, etc. It is also important to include people who use the services, their family and friends, and members from relevant local partner organisations.

Once established, the project group then needs to develop a clear plan, within the identified financial resource, with specific actions, accountabilities and timescales. This will change as the project evolves, but clear planning from the start is essential to keep the project on track. It may be assisted by having some external monitoring of progress.

This group needs to work through a number of critical issues, beginning with the fundamental questions, ‘Why do we want to employ peers?’ and ‘What differences do we hope they will make?‘. For example, in Nottingham, the peer support service was developed in order to, “improve the recovery orientation of mental health services and to improve the recovery outcomes of people using services, and where applicable, their carers. We envisage that service users will relate better to the mental health system as a whole by seeing it as an entity that is more accessible, approachable and relevant to their needs. We PHASE 1 – PREPARATION hope that by working alongside peer workers, current staff members will be inspired to work in a more recovery-focused manner and see the whole person in terms of their potential rather than as a presentation of distress, problems and diagnosis”.

In the current climate, it is particularly important to be aware of the danger of creating peer support roles for the sole purpose of saving money, or simply to carry out tasks that other staff are unwilling to do.

To deliver on these ambitions requires commitment from the senior executive team. This vision needs to be communicated to relevant departments and teams through a variety of methods including information workshops, staff briefings, newsletters, etc. Potential peer workers must work in partnership in these exercises.

  • Human Resources (HR) – At the heart of establishing successful peer support worker progammmes will always be the support of HR departments (indeed, some of the most successful schemes have been led by HR professionals). Ensuring that HR colleagues understand the aims and philosophy of peer support and are in a position to offer their guidance regarding the recruitment, job descriptions, interviewing and supervision of peer support workers, is therefore essential. (Further detail about HR issues is provided in Phase 2 on recruitment).
  • Workforce planning – Predicting the future balance of traditional professionals and peer workers, in line with developments in practice, commissioning targets and financial constraints is a key challenge. The issue is not that peers could – or should – replace all professionals, but there is a question of balance to be addressed. Should the workforce comprise 10, 20, 30 or 50 per cent peer workers? Local services need to agree local targets and prepare to work towards them.
  • Occupational health (OH) – Occupational health services have a critical role to play in providing advice regarding appointments of new staff (peers) and return to work plans for peers who have periods of absence due to recurrence of illness. Although the same rules should apply to peer workers as to other staff, OH clinicians may be particularly anxious regarding fitness and ‘return to work’ issues when the person is known to have had mental health problems and is returning to work in a mental health service setting. They may be less familiar with the concept of ‘reasonable adjustments’ to the workplace as applied to people with mental health issues (see Perkins et al., 2009; Royal College of Psychiatrists, http://www.rcpsych.ac.uk/usefulresources/workandmentalhealth.aspx). Members of the project team will therefore have to ensure that OH colleagues are fully involved in the project from the outset and that their continuing engagement is secured. (Again, these issues will be discussed further later in the paper).
  • Finances/Management – Where new posts are to be created, or existing posts redefined, there may be financial implications. Funding needs to be identified to cover basic salary and oncosts, recruitment, training, peer-led advice/supervision, relief cover, travel, administration and equipment costs. If comprehensive costs are not identified at the beginning of the project they will inevitably return to haunt the project team at a later date and may determine the extent of the success of integrating peer workers into the workforce.
  • Involving staff ‘learning and development units’ – The employment of peer workers may create new opportunities for learning and development departments to work collaboratively with peers in developing and delivering training to a variety of staff groups (and groups outside the organisation, e.g. police, GPs, etc.).
  • Developing relationships with local social services departments and nonstatutory partners – Peer roles can usefully transgress the artificial boundaries often found between services, so any steering group is likely to need to include relevant partner organisations. For example, social services departments may provide funding for joint training; local peer-led or voluntary sector organisations might be involved in the preparation, training and supervision of peers. This is particularly important in the early stages of the project as user-run organisations may have considerable existing experience relating to the topic and may be able to provide advice, support and active collaboration regarding training and supervision. However, it may also give rise to conflicts (see Box 2).
  • The role of commissioners – At the moment the role of commissioners is still unclear. Broad policy is set by NHS England, but local clinical commissioning groups are likely to retain a considerable amount of autonomy over what services are sought and from whom. This offers opportunities as well as challenges. Similarly, as the health and wellbeing boards develop, there is likely to be room for influencing commissioning decisions at a local level.

Box 2: Conflicting agendas in user-run groups and statutory providers

In Nottingham, external user-run groups have been vital in the development of peer worker posts within the trust. Making Waves (see www.makingwaves.org) co-produced the peer worker training and provided supervision for the first peer workers. However, this collaboration became difficult when the Trust’s expectations of peer workers conflicted with the beliefs of Making Waves.

At the heart of the dispute was a difference of view regarding whether certain standard training elements (specifically ‘control and restraint’ training) which is mandatory for Trust staff, should be included in the role of peer support workers. The view in Nottingham was that peer workers should have a clear role in influencing the culture of the organisation by demonstrating recovery-focused practice, expressing their views and challenging poor practice (indeed their slogan has become ‘Inspire to Influence’). In addition, if they do not wish to restrain a person or take part in the forced use of medication, they should be able to choose to take the role of supporting others in the area, and not necessarily become involved themselves. However, if it was an emergency and someone’s safety was threatened, it could not be guaranteed that this might not be overridden. This seems a reasonable compromise and has encouraged the Trust to commit to a policy of ‘No Force First’ moving towards the abolition of unnecessary restraint. This difference of view regarding the role of peer support workers thus provoked a very helpful debate.

Preparing the teams

If the introduction of peer workers is to be successful then the preparation of the teams in which they are to be placed is essential. The whole team must understand and own the process and it should form part of a broader, recovery-focused, transformation of services. In several pilot studies of peer workers, it has been reported that they are less likely to be successful or effective in teams that are not already working in a recovery-focused manner and not committed to engaging with peers as team members (McLean et al., 2009; Repper & Carter, 2010). Therefore, it is strongly recommended that teams in which peer workers are placed have already accessed training in recovery-focused practice and have a commitment to making the service more recovery-focused.

In practical terms, it is most helpful if the team is given an opportunity to work together, with the peer support workers and other mental health practitioners, from teams which have successfully integrated peer worker roles within their team. Ideally, a day should be set aside to:

  • consider the nature and role of peer support and how it differs from other roles in the team (see Box 3)
  • meet, and hear the stories of, peer workers and mental health practitioners from other teams where they have been successfully introduced
  • honestly discuss hopes, fears and concerns
  • consider the different sorts of expertise within the team
  • review peer worker job descriptions and person specifications to ensure that they embody the core principles of peer support
  • develop a sense of collective ownership by coming together to think about the relative roles and responsibilities of peer workers and other team members in their own particular context
  • provide reassurance from senior managers that there is a commitment to these developments from the top and that they will respond to questions and concerns.

This will need ongoing follow-up support. At the heart of these discussions should be an acknowledgement that all staff bring a different balance of contributions from three essential sets of skills and abilities:

  • their personal experience of life outside the mental health arena (skills, interests, culture, values, education etc.)
  • their personal experience of trauma, distress and mental health difficulties
  • professional/mental health training and experience.

The core role of a mental health professional is based on their professional expertise and this shapes their relationships. However, the core role of a peer support worker is based on their lived experience of mental health challenges and this informs a different kind of relationship.

Box 3: Defining the roles of peer workers, mental health practitioners and support staff

Common myths and misconceptions about peer workers

When working in traditional mental health services, peer workers (paid or voluntary) often meet with various myths and misconceptions regarding their role. Indeed, a recent study of peers’ experience found that the greatest difficulty reported was the lack of understanding of other workers about their role (McLean et al., 2009; Repper & Carter, 2010). Some of the most common myths are set out below.

Myth #1 – Peer support is just a way of saving money

As indicated earlier, this is where many of the debates about peer support workers generally begin. We have argued consistently that promoting recovery requires a great deal more than traditional therapeutic approaches. Providing hope, helping people make sense of their lives, finding meaning in what has happened, helping people take control over their destinies and manage the challenges of everyday life to pursue their aspirations: these do not require professional expertise and intervention. Those who have faced similar challenges are often far better equipped to support these endeavours. To extend the domain of professionals to work with all facets of life not only risks de-skilling everyone else, such as friends, families, carers, persuading them that all facets of our lives require the specialist expertise of professionals; but is also wasteful of the considerable resource involved in training and employing specialist professionals. Although traditional mental health practitioners have always provided more than the specialist treatments, this is what they are primarily employed to do. The use of peer support workers is simply an attempt to complement these ‘professional’ skills with ‘life experience’ so as to ensure that both are provided (hopefully in at least equal measure) to those who need them. It is therefore clearly not simply a case of ‘saving money’; rather ensuring services optimise value for money, and the added value, of all staff groups.

Myth #2 – Peers will be too fragile, they are likely to ‘break down’ at work

People with lived experience of mental health challenges have long been employed in mental health services in a variety of positions from chief executive and consultant psychiatrist to support worker and secretary. (Recent surveys conducted in Devon and Nottingham showed that some 30 per cent of staff disclosed experiences of mental health challenges prior to appointment). Does this mean that all these workers are ‘too fragile’ and ‘likely to break down’? The evidence actually suggests that, if provided with appropriate support, employees with mental health challenges may take less time off sick than those without (Perkins et al., 2000).

Myth #3 – Peers cannot be expected to conform to usual standards of confidentiality

Anyone working in a mental health service – from statutory to voluntary to peer-led will be required to observe formal rules relating to confidentiality. Peer workers are no different. Indeed, because of their lived experience, peer workers are often particularly sensitive to issues relating to confidentiality. Our experience is that issues of confidentiality have been more frequently raised by peer workers complaining about other staff breaching confidentiality by chatting about the clients with whom they work outside the workplace.

Myth #4 – There is no difference between peer support workers and other staff who have personal experience of mental health problems

Introducing peer workers into the workforce raises the issue of how best to support people in traditional roles who have their own lived experience of mental health issues. They sometimes report discrimination and exclusion (Disability Rights Commission, 2007) and if this occurs then it must be tackled under the requirements of the Equality Act (2010). Acknowledging the prevalence of ‘lived experience’ of mental distress in the existing workforce is not only ‘healthy’ in terms of recognising the reality of human experience as applied to those who are labelled ‘staff’ as well as those who are labelled ‘service users’; it can also enhance the quality of service delivery by encouraging traditional mental health staff to use this experience to inform their work. However, a psychologist, or a psychiatrist or a nurse with lived experience of mental health challenges remains a psychologist, psychiatrist or nurse, employed primarily to use their professional expertise rather than their life experience. The power imbalance, and professional boundaries (perceived and real), resulting from the formal status of their profession also remains a potential obstacle to establishing a relationship based on mutuality, reciprocity and a shared journey.

Myth #5 – The presence of peer support workers will make staff worried about ‘saying the wrong thing’

Everyone, peer or professional has, at some time, said or done something that they later regret. Without the capacity for humility – and the courage to accept and accommodate feedback to reflect on our behaviour – any relationship, whether it is between partners, friends, or the providers of services, is likely to break down. Thus, the willingness to reflect and learn from our behaviour is a key process for improving the quality of interactions and most groups have some mechanisms (formal or informal) for reflecting on these problems as they arise. Opportunities for supervision and reflection on practice are therefore an essential and necessary aspect of good practice.

Myth #6 – The only way to be sure of getting a job these days is to say you have a mental health problem

Within mental health services many types of expertise are required: professional expertise, expertise resulting from experience outside the mental health arena, and the expertise of lived experience of mental health challenges, trauma and recovery. To date, pride of place in mental health services has been accorded to professional expertise at the expense of the other two. But formal treatment and therapy constitute only a part of the support we may all need in our journeys of recovery. Therefore, there is a continued need to break down barriers and actively value the expertise and insights that experience of mental distress brings. It is not the case that this is the only thing that is important, but it should be valued and not be a source of stigma and discrimination.

Box 4: Common myths and misconceptions about peer workers

Myth #1 – Peer support is just a way of saving money.

Myth #2 – Peers will be too fragile, they are likely to ‘break down’ at work.

Myth #3 – Peers cannot be expected to conform to usual standards of confidentiality.

Myth #4 – There is no difference between peer support workers and other staff who have personal experience of mental health problems.

Myth #5 – The presence of peer support workers will make staff worried about ‘saying the wrong thing’.

Myth #6 – The only way to be sure of getting a job these days is to say you have a mental health problem.

Myth #7 – Peers get to do all the nice things – talking to patients, taking them out, going home with them – the rest of us have to do the boring admin and medication, handing out meals, making beds etc.

Myth #8 – Peers don’t know the difference between friendships and working relationships.

Myth #9 – Peers will be subversive, they will be ‘anti-psychiatry’ and ‘anti-medication’.

Myth #10 – Peers will take up so much time that traditional staff roles will be made much harder, not easier.

Myth #7 – Peers get to do all the nice things – talking to patients, taking them out, going home with them – the rest of us have to do the boring admin and medication, handing out meals, making beds etc

In any relationship, group or service there are tasks that have to be done. What distinguishes peer relationships is not what is done, but the nature of the relationship: ‘peer to peer’ rather than ‘expert to non-expert’. Peer support can thus occur in the course of any activity whether it is making a bed, going for a walk or just sitting and talking. It is not the case of peers getting to do all the ‘nice things’, it is simply that peers may have greater opportunities to use their relationships productively. The key question this raises for staff is actually how to engage in the ‘nasty things’ while preserving as positive a relationship as possible.

Myth #8 – Peers don’t know the difference between friendships and working relationships

As indicated in the first paper, there are many differences in the relationships between peer support workers and peers and those of friends, particularly in terms of self-disclosure, the degree of choice involved and the explicitness of ‘rules’ (conventions of behaviour). But formal rules don’t obviate the need for judgement and sensitivity. Peer support worker relationships do involve more judgements than friendships – when and what to disclose, when and what ‘rules’ to obey, etc. The judgements need to be considered as part of the training of peer support workers and reinforced by reflection and supervision (individual and/or peer group).

Myth #9 – Peers will be subversive, they will be ‘anti-psychiatry’ and ‘anti-medication’

The essence of peer support is not to prescribe what others should think, feel or do. Peers should not be telling people whether or not to take medication, or instruct them to use conventional services, complementary therapies, etc. Rather, peers should be aiming to help people explore different ways of understanding, ways of coping and growing that make sense to them. Such exploration may involve challenges to orthodox views, but orthodox views are nearly always limited by the attempt to generalise from the performance of a group to the experience of an individual (for example, in large scale treatment trials). Individual exploration is facilitated by the diverse narratives of others who have faced similar challenges.

Myth #10 – Peers will take up so much time that traditional staff roles will be made much harder, not easier

As indicated earlier, peer support workers may require additional employment support, particularly when the roles are being established. But these should not be different from any other worker. Peer workers may then make the jobs of other practitioners easier by relieving them of aspects of support that do not require their specialist professional expertise. This potential is clearly there if the roles are well defined and challenges properly addressed at the outset. If peer workers are simply ‘thrown into the mix’ then they will save neither time nor money.

Preparing potential peer workers: training and work placement opportunities

Supporting individuals to prepare for a peer worker role is essential and can be achieved through a number of routes. Peer support training, prior to employment, is considered an essential criteria in some organisations; whereas in others it is a requirement once a peer worker has commenced employment. Either way, when introducing peer worker roles in an organisation there must be clarity regarding peer support training opportunities for potential peer workers.

“The peer support training took me on a massive journey of discovery about myself and gave me an appreciation for my strengths. Through it I came to realise that all those scary places I had been during my time of being unwell were going to allow me to hold up a torch for others during their dark times and help them on their road to recovery – it wasn’t wasted time”. (Rand evaluation of CPFT peer workers)

Peer worker training has been developed and delivered in many different countries and settings: Working to Recovery in Scotland (www.workingtorecovery.co.uk); Recovery Innovations in Arizona US (www.recoveryinnovations.org); Mental Health Kokua in Honolulu (www.mentalhealthkokua.org); University of Texas, US (http://blogs.utexas.edu/mental-healthinstitute/) and Institute of Mental Health Nottingham (www.institutemh.org.uk). It is interesting to see that a high degree of consistency exists across the content of courses, the style of teaching and intended learning outcomes. However, marked differences exist in the intensity (‘depth’) of the teaching and length of courses. For example, Recovery Innovations offers a four week fulltime course, Working for Recovery offers a three-day training and Nottingham Institute for Mental Health offers a training of 11 days.

All peer worker training should be a facilitative, experiential process which empowers students to learn from one another how to support recovery using an interactive format. Training should aim to build on students’ strengths, offering constructive feedback, celebrating success, valuing difference and opportunities for everyone to learn, whatever their language, literacy, experiences or beliefs. The core skills required for peer support are active listening and problem solving; the core knowledge and understanding required are clarity about how to facilitate recovery and about the role and relationships of the peer worker. Thus, courses generally cover communication skills (particularly active listening); mutual problem solving/solution-focused skills; wellness and personal recovery planning; managing challenging situations; valuing difference; code of conduct and ethical considerations; team working and managing personal information/telling your own story.

At the moment there are few empirical grounds to differentiate between these different training options, organisations are therefore advised to look into available training courses and determine whether they have the capacity to develop their own to meet their needs or to look elsewhere. Further information about the three best established training courses are given in boxes 5,6 and 7.

While this kind of basic introductory training in peer work is sufficient for safe practice, peer workers, like all other staff, will benefit from access to other training courses, mentorship schemes and workshops.

Box 5: Nottinghamshire Healthcare NHS Trust peer support worker training

The peer worker training developed in Nottingham has now run in 15 different organisations with almost 400 graduates to date. It is an 11 day experiential course that is co-produced and co-delivered and assessed by a reflective essay demonstrating learning and application of skills. Student feedback is very positive and the drop-out rate is low. Students find the course “challenging”, a “roller-coaster” and “transformational”. It is recommended that students are interviewed for the training to assess their readiness and resilience; also all students are asked to take their own recovery and wellness plan to the interview to demonstrate an understanding of recovery and what it means to them. All have to be willing to explicitly use their own experience of mental health problems in their practice as peer workers, and for those to be employed in Nottingham, all have to be willing to spend four days in practice during the course where their competency as peer mentors will be assessed by a placement mentor.

Further details are available from: marissa.lambert@nottshc.nhs.uk

Box 6: Cambridgeshire and Peterborough NHS Foundation Trust peer support worker training

Cambridgeshire and Peterborough Foundation Trust (CPFT) procured Recovery Innovations (RI) from the USA to deliver four cohorts of their peer specialist training. During this time RI also trained and accredited two peer educators to enable them to continue to deliver the training after the RI input had finished. The peer educators are now able to deliver training to all future training cohorts. The CPFT training is delivered full-time over four weeks. Students complete assessed role plays, a mid-term and final exam, and a reflective diary. Following successfully completing the training, students attend a graduation celebration to share their successes with their family and friends. In addition, students undertake a four-day work experience.

Further details are available from: sharon.gilfoyle@cpft.nhs.uk

Box 7: Central and North West London NHS Foundation Trust peer support worker training

Central and North West London (CNWL) NHS Foundation Trust benefited from the expertise of Nottingham who initially delivered it to two cohorts of students. The trust then worked in partnership with London South Bank University to co-produce this ten-day, level 4 accredited training programme, which is now established.

As the trust has adopted a ‘recruit and train’ model for peer support workers, all peer support workers and peer trainers are expected to successfully complete the training within six months of their appointment.

Undertaking the training when already in post provides a valuable opportunity for peer support workers to draw upon and bring their work situations and experiences from the clinical setting to the training. Students report this has enhanced the richness of the learning experience and promoted the transfer of skills and knowledge into the workplace.

Further details are available from: debbie.lane-stott@nhs.net

Developing job descriptions and person specifications

The final key area of preparation concerns the development of job descriptions and person specifications. Samples are given in Appendices II and III. These were developed by CPFT and Nottinghamshire Healthcare, based on the available literature at the time, adapted for use in an English NHS context. They meet a number of different criteria:

  • reflect all of the core principles of peer support
  • allow flexibility for this new role to grow and develop
  • accommodate individual skills, interests and development
  • meet the organisational ambitions in relation to peer support
  • include the specific circumstances of the team/locality in which they are based
  • meet internal HR guidance
  • meet equality legislation with regard to specification and definition of ‘lived experience’ as a requirement for the post.

A key question underlying the formulation of person specifications is what constitutes ‘lived experience’? (i.e. whether all peer workers will have accessed secondary services, or whether peer workers might have used primary care or experienced challenges but avoided using services). This is for local discretion, but it is essential to work with HR to ensure that all aspects of the formal paperwork comply with the relevant legislation, in particular equality laws.

PHASE 2 – RECRUITMENT

All the preparation work may seem long and complicated – but if not done thoroughly then these new posts will not succeed and flourish. Assuming all the necessary preparation is undertaken, then the process of recruitment can begin.

Advertising

The project team needs to consider the options for advertising opportunities. If applicants are required to have completed peer worker training then obviously there will be an available pool of ‘graduates’ to approach. If the post is open to people who are willing to undertake peer training but have not already done so, then there will be a need to consider wider advertising. Prospective peer workers who are not in active contact with specialist mental health services are unlikely to read professional journals and may not access newspapers so other options for local publicity may need to be considered (for example, direct communication with local user groups). However, simply contacting local user groups may exclude many people who have experience of mental health problems, but have not chosen to join a local group. These processes of how and where to advertise need careful consideration by the local project team and a relevant strategy developed accordingly.

Whichever advertising strategy is adopted, local ‘orientation sessions’ may be a useful way of pre-selection (see BOX 8 below).

Benefits advice

If the organisation does not offer an orientation session, it is important to provide benefit advice for people or to signpost them to appropriate agencies (JobCentreplus, Citizens Advice). The benefits system is complex and highly individual, so it is important for people to get an expert, personal ‘back to work’ or ‘better off’ calculation to be clear about the financial benefits or challenges of being in paid employment. Many peer support workers may choose to be employed part-time or in some kind of ‘jobshare’.

Box 8: Cambridgeshire and Peterborough NHS Foundation Trust ‘orientation sessions’

CPFT introduced ‘orientation sessions’ for prospective students/employees. This proved to be an excellent way of ensuring that people were fully aware of all the training and post requirements prior to making an application and attending an interview. The session gave an overview of the training content, the application form, CRB process, post availability and benefits advice. On all occasions the attrition rate for this session was 50 per cent. Initially this felt disappointing, but we soon learned that this is the first phase of self-selection for the training. The majority of people who did not attend, did not make contact again. If they were ill, we would simply re-book onto a future orientation. On the whole, the majority of people who attended the orientation subsequently then attended for an interview and were keen to start on the peer employment training. One student said, “The orientation session was extremely comprehensive: it helped me think about the amount of work that was required and if this was the right time for me, it was also helpful to have the benefit issue highlighted, I got a back to work calculation done immediately”.

Applications

Because of the nature of the likely applicants, it is necessary to consider how best to support them in the recruitment process. Some applicants may have been out of employment for some time and will lack the confidence and skills to apply. Applications can be particularly challenging for people who have spent periods of time in hospital, homeless, or in prison. The process usually assumes familiarity with IT, an ability to explain interruptions in employment and housing, and to answer questions about criminal history. All of these can be very offputting for some people and may constitute a real barrier to the very people who could be the most helpful peers – those with most in common with the average person using services. Support for prospective applicants can be provided either within the organisation, or delivered by a partner agency specialising in employment support. For example, Central and North West London NHS Foundation Trust has a designated part-time ‘senior peer support employment specialist’ who is available to guide and support prospective applicants through the recruitment process, including navigating the benefit system, writing job descriptions, applying for post online and interview preparation.

For example, one of the challenges Cambridgeshire and Peterborough NHS Foundation Trust peer worker applicants faced was not having sufficient employment references. Often applicants had not worked previously, or had been unemployed for a long period of time and previous referees were difficult to trace. In these instances, the Trust decided to consider alternative sources, for example care coordinators, consultants, volunteer supervisors or teachers from educational facilities.

Interviews

Given the complex and sensitive nature of the role, applicants need to be interviewed to assess their communication skills, their understanding of recovery, and their ability to share constructively their own journey and what helps them to stay well. Interviews can be conducted on an individual or group basis. Each has advantages and disadvantages. A combined approach developed in Nottingham is illustrated in Box 9.

Since interviews – whether for a place on the training course or for employment – can provoke great anxiety, applicants may benefit from support at various stages: to complete their application form, to plan for their interview, and in the waiting room on the day of the interview.

Box 9: Individual and group interviews

The number of applicants for peer worker training in Nottingham has risen from just ten people expressing an interest in 2010 to 195 applicants in 2011. This is due to the visibility of peer workers and the inspiration they give to people using the service – many of whom see peer work as something that they can do in spite of – not just because of – their mental health problems. Given the difficulty in shortlisting from such a large number, a group interview format is used with three applicants in each group. This mirrors the peerto-peer relationship and allows relationship and communication skills to be observed. Each applicant is rated on relevant dimensions (communication skills, active listening skills, understanding of the role, recognition of considerations important in personal disclosure, relationships with others in the interview). Although only 18 of these applicants could be offered a place on the training, every single applicant was offered detailed feedback and at least one face to face meeting to discuss support to find an alternative way forward towards their goals.

Occupational health

As indicated earlier, the support of occupational health colleagues is central to the success of peer worker programmes. We need to ensure that applicants with a history of mental health problems are assessed in an appropriate and helpful manner and this approach should benefit all staff with mental health problems. Peer applicants need to be prepared for correspondence from occupational health and, hopefully, will find this helpful in examining the organisation’s staff wellbeing plan. The plan should enable the peer worker to identify the sort of adjustments that are necessary to enable them work to their full potential. ‘Reasonable adjustments’ might include things like:

  • specifying work hours to take account of particular problems with early mornings, rush hour traffic, or side-effects of medication
  • offering support with aspects of the role that are particularly difficult due to the nature of their mental health challenges (for example, sealing envelopes may be difficult for people who feel compelled to check)
  • increasing feedback to people who tend to repeatedly worry over possible mistakes ensuring that they are thoroughly debriefed at the end of each shift.

DBS issues

Peer support workers – like any other new employee – will need to have a Disclosure and Barring service (DBS) check, previously known as a Criminal Records Bureau (CRB) check. This will reveal any recorded crimes. The NHS is clear that it cannot employ people who have a serious criminal history and yet it is not unusual for applicants to peer posts to have a criminal history. The challenge for the service is to assess the risk involved in employing the person and make judgments about the likelihood of criminal acts being repeated. This has to be undertaken on a case-by-case basis and the decision needs to take into account the seriousness of the offence, when it occurred and its potential relevance to the role. Some decisions will be easy, some will not. Where the incidents are clearly related to periods of mental ill-health, it is easier to put safeguards in place to prevent re-occurrence. However, where the incidents are more serious, more frequent, or unrelated to periods of mental instability, then it may be more difficult to identify triggers and develop effective safety plans. The project team needs to be clear at the outset how these decisions will be taken and by whom.

Disclosure and Barring service checks can be very stressful for peer applicants and they often need support to complete the DBS form. This requires a full five year address history, plus paperwork to confirm current identity and address. This can be a real challenge for some people with mental health problems who have spent time out of work, or who do not own a passport or have a bank account. Some people will automatically assume that any criminal record will exclude them from peer support work, this is not necessarily the case and it may be helpful to clarify this at interview. Several services employing peer workers have now developed new processes for assessing criminal history. For example, CPFT has developed an ‘objective assessment framework’ which ensures that a comprehensive range of factors are taken into account when assessing risk. Nottinghamshire Healthcare NHS Trust has set up a panel including a peer worker, an HR representative, a general manager and the volunteer services manager to assess DBS returns and make a decision regarding whether or not to offer employment.

Supporting people who are not offered posts

Finally, it is important to consider how best to support unsuccessful candidates. Following an intensive training programme, then an unsuccessful interview, people will naturally feel despondent and their confidence will drop. It is helpful to offer them a face-to-face appointment to discuss the reasons for not appointing and to explore alternative options. For some this will take the form of further interview practice, for others a period working as a peer volunteer, or doing some courses in the recovery college might help.

PHASE 3 – EMPLOYMENT

Finally, once in employment, a number of elements need to be considered.

Matching peers with posts

Where there is a choice of peer worker posts, peers can be allocated according to their personal attributes, experiences and preferences. It is worth thinking more broadly than simply matching people in terms of their mental health problems. By placing a peer with a specific diagnosis on a unit that specialises in this particular set of difficulties, there is a danger of perpetuating a narrow diagnostic categorisation. Of at least as much value is the placement of a peer in a team that has identified a gap in certain skills or interests that the peer can fill (for example, membership of a particular age or ethnic group). Wherever possible, peers should be employed in groups of at least two per team, with some overlapping working hours. This will help prevent isolation, provide support and help create a greater impact on the team culture. There are specific challenges if the peer is employed in a team that is currently providing their mental health support or has done so in the recent past (see Box 10 below). However, if this is agreed, then arrangements need to be made for where the peer will be treated if they become unwell and all their notes/records need to be made inaccessible to other team members.

Induction/orientation

In terms of induction for new workers, it is helpful to allocate a staff mentor to each peer (possibly the team recovery champion) to organise this and to devise an induction plan. They will be able to provide information, support, and to give informal tips about routines and informal procedures (‘how we do things around here’). Many peer workers who have not been employed for some years – and even those who have – can be daunted by the number of tasks involved in beginning to work in the NHS. As the peer support team coordinator reported on the first few weeks in Nottingham:

“Returning to work was a daunting issue in itself and it became clear that peers need tailored support during this period. Even though I described processes such as sickness reporting, how to apply for annual leave, using information systems (RIO), whereabouts sheets, client records, etc. many times; for some peers embedding this into their everyday working life proved very difficult. Even basic tasks like organising telephones and computer access and how to obtain diaries, keys, ‘pigeon holes’, etc. was time consuming and the team would have benefitted from a slow induction period to ensure that each peer was fully confident and familiar with these processes before they started working”.

Box 10: Placing a peer in the team that currently provides their mental health support – experience in Nottingham

A peer was appointed to a post in the team currently providing her mental health support (early intervention). She put in a request to be placed in this team as she felt she could bring most benefit using her personal experience. Time was spent with the team talking through the issues involved. They felt she would, indeed, inspire both the staff and clients with the possibilities of recovery. The care coordinator also spoke to her about how she would find seeing her in a new role and discovering a different perspective on her character. Her records/notes were removed from the usual location and put in a different place to protect her and staff from inappropriate use. This then proved an effective and useful placement.

Supervision and support

Whether it is delivered on a group or individual basis, supervision and support is vital for peers – just as it is for other staff. Ideally, this should be provided through a combination of ‘managerial’ supervision (from the team leader or a care coordinator) and ‘professional’ supervision (from a senior peer or through contact with a group of peer workers). It is likely that in the early weeks of employment, peers, like any other new workers, will need reassurance, feedback and support to think things through, but that this will rapidly diminish over time. Individual and group supervision offer opportunities to model and practice the principles of mutuality: sharing strategies, challenges and successes, developing skills, knowledge and expertise in the group and creating confidence that difficulties are not unique and can be overcome.

The value of bringing all peer workers together for group supervision and mutual support cannot be over-estimated. Once together, peers become more confident about sharing their hopes, fears, their personal stories and challenges. As a group they gain strength and solidarity, they can support each other effectively and solve problems together. It is in this context that it is clear just how skilled, interesting and inspiring they are, how much they have in common, and how much diverse talent they bring as a group. Even when peers are working in separate parts of the service, it is helpful to provide opportunities for them to meet together from time to time so that they can continue to develop their identity and retain clarity about their distinctive features and unique roles.

There are some aspects of peer working that need particular attention. These are specific to the role and do not lend themselves to clear rules or black and white solutions. First, there is how to use personal experience. There is a stark difference between telling your own story in the classroom setting and using your experience whilst building a relationship with someone who you are supporting. Peers workers often need additional support in the early days to clarify their own boundaries and develop a personal account or narrative that feels safe. This entails working out what they want to share, what they feel safe about sharing, and what they do not want to share however tempting it might be in the moment. The second challenge for peers lies in their double role and identity as both a practitioner (staff) and a patient (service user). Peers may be accustomed to relating to mental health workers as the expert – or even the enemy – but not as a colleague with whom they can work as equals, in a relationship based on mutual respect. Similarly, they are more used to relating to service users as friends rather than peers, so it can be challenging for them to maintain the ‘professional’ boundaries that are appropriate in the workplace.

Other staff can also find this difficult. Too often the challenges reported by peer workers focus on the problem of gaining the respect of staff. In some instances, staff are reluctant to refer to peers, unclear about what peer workers offer, or lack confidence that peer workers can cope with people who might present complex challenges. Thorough preparation of the team can help engender clarity, ownership and pride, but peers should really only be placed in teams that are actively supporting recovery and are keen to integrate the peer support worker role to support this endeavour.

Maintaining wellbeing

All employees need support to remain well at work. Working with people who are experiencing disabling and distressing emotional problems can be upsetting and stressful; observing or helping in critical incidents can be particularly traumatising and distressing. The impact of these experiences can be amplified for peer workers if they resonate with their own lived experiences. Their own anxiety might trigger recognisable symptoms and this can lead to fear of impending relapse and prompt them to take time off sick. But peer support workers who are employed in paid posts in statutory organisations work to the same policies, procedures and regulations as everyone else; this includes the sickness absence policy.

It is helpful for all staff to take their own wellbeing seriously and a wellbeing plan can support this process. By considering what they need to do to stay well, what sort of events make them stressed, anxious and potentially unwell, and how they can manage or minimise these situations, all staff can begin to develop their resilience, anticipate and manage stressful times and maintain their own wellbeing. For peers, as with all staff, it is helpful for managers to work with them to optimise their wellbeing; to make adjustments wherever possible to allow them to work to their full potential, to find solutions to aspects of work that they are finding stressful, to encourage them to seek support when they need it rather than trying to manage alone.

PHASE 4 – DEVELOPMENT OF PEER WORKER ROLES

Increasing peer employment opportunities

Given appropriate training, support, supervision and development opportunities, peer workers will be their own best advocates and become increasingly valued throughout services; posts will be created or converted and numbers will grow. Organisations are finding various ways of increasing employment opportunities for peer workers. For example:

  • requiring all new services to include peer worker posts
  • reviewing all vacancies to consider the possibility of creating a peer worker post (for example, replacing healthcare assistant post with a peer/healthcare assistant post – doing the same things in a different way)
  • providing training for professionally qualified staff to use their personal experience of trauma/mental health problems in their work and thereby work as a professional/peer worker
  • employing carer peer workers in dementia services (Central and North West London) and in adult mental health community services (Nottingham).

Alongside the development of new posts, potential peers themselves are creating demand for change. As people using services receive peer support, they recognise a possible career pathway for themselves, so numbers of applicants for peer worker training have grown exponentially. There are various ways of both supporting and developing these budding peers whilst they await opportunities to train or work as peer workers.

  • They might attend various courses in the recovery college to help them consider steps back into work; using their own experience in work; recovery principles; problem solving skills; peer research skills; peer training courses.
  • They might be interested in volunteering as a way into work or peer training when that becomes available.
  • They could be offer supported internships in various departments within the organisation so that people who have used services can experience a structured, supervised work experience in a range of different areas.

Career progression

All peers in employment need support and encouragement to pursue their own personal and professional development. As they gain experience in post they will become clear about the sort of training they want to help them become more effective as peer workers. As they develop further they may decide to apply for professional training or to gain more specialist qualifications in project management; training, research or therapy skills. Whilst there may be specialist peer worker positions in peer supervision, peer management, peer training or peer research, these are unlikely to reach high bandings. Once peers are working as a team leader or a project manager, then their primary identity and role is likely to be developing beyond their lived experience, and whilst their personal experience of mental health problems will always have an influence on their work, it will not be their primary qualification.

Wider system change

The employment of peer workers drives forward changes across the whole organisation. As already described, it becomes necessary to review recruitment, occupational health and staff wellbeing processes in order to provide appropriate support for peer workers. And once in post, peers themselves will begin to challenge policies, procedures and language used. They see the world through different eyes and they need encouragement and support to remind others about how it feels on ‘the other side of the drug trolley’. For example, peer workers employed in various organisations have:

  • reviewed risk assessment documentation to develop a negotiated safety plan
  • developed guidance for all staff on how to use their lived experience in clinical practice
  • co-produced and co-delivered staff training
  • developed guidance for outpatients to plan the questions they want to ask in appointments
  • developed an aide memoire to guide questions about medication.

Such contributions are not to criticise and challenge existing practice, more to inspire and influence through modelling, suggesting and supporting others to find new ways of working.

NEXT STEPS

We are only at the beginning of a long journey. Although we have learnt a great deal about the employment of peer workers in a very short time, there are many more questions to answer. Perhaps the first step lies in demonstrating the difference that peer workers make – not just to those whom they support, but to the whole organisation. More research is needed to compare teams with peers workers with those without; to explore the experience of people receiving peer support; to understand how peer support makes the differences that it appears to, and to be clear about how to facilitate high quality peer support across the whole range of mental health services.

REFERENCES

Disability Rights Commission (2007) Maintaining Standards: Promoting Equality, Professional regulation within nursing, teaching and social work and disabled people’s access to these professions. London: Disability Rights Commission.

Equality Act (2010) London: HMSO.

McLean, J., Biggs, H., Whitehead, I., Pratt, R. & Maxwell, M. (2009) Evaluation of the Delivering for Mental Health Peer Support Worker Pilot Scheme. Scotland: Scottish Government Social Research. Available at: http://www.scotland.gov.uk/Publications/2009/11/13112054/0

Perkins, R., Evenson, E. & Davidson, B. (2000) The Pathfinder User Employment Programme. London: South West London and St George’s Mental Health NHS Trust.

Perkins, R., Farmer, P. & Litchfield, P. (2009) Realising Ambitions: Better Employment Support For People With A Mental Health Condition. Norwich: TSO.

Repper, J. (2013) Peer Support Workers: Theory and Practice. London: Centre for Mental Health and NHS Confederation Mental Health Network.

Repper, J. & Carter, T. (2010) Using personal experience to support others with similar difficulties: A review of the literature on peer support in mental health services. London: Together/University of Nottingham/NSUN.

APPENDICES – SAMPLE DOCUMENTS

I. Advert for recruitment
II. Job description
III. Sample person specification
IV. Framework for CRB assessment
V. Ethical Code of Conduct

I. ADVERT FOR RECRUITMENT

II. JOB DESCRIPTION

II. JOB DESCRIPTION continued

II. JOB DESCRIPTION continued

II. JOB DESCRIPTION continued

II. JOB DESCRIPTION continued

III. PERSON SPECIFICATION (BAND 2)

III. PERSON SPECIFICATION (BAND 2) continued

III. PERSON SPECIFICATION (BAND 2) continued

IV. FRAMEWORK FOR DBS ASSESSMENT

IV. FRAMEWORK FOR DBS ASSESSMENT continued

V. ETHICAL CODE OF CONDUCT

Peer Support Workers: a practical guide to implementation

This briefing paper has been produced for the Implementing Recovery through Organisational Change programme, a joint initiative from the Centre for Mental Health and the NHS Confederation’s Mental Health Network.

The pilot phase of ImROC ran from 2011-12 and was supported by the Department of Health, together with contributions from the participating services. The continuing work of ImROC is endorsed by the Department of Health and managed and supported by the Centre for Mental Health and Mental Health Network.

For more information on the current work of ImROC, please visit imroc.org.

ImROC, c/o Mental Health Network, NHS Confederation, 50 Broadway, London, SW1H 0DB
Tel: 020 7799 6666
imroc@nhsconfed.org
imroc.org