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19. Creating a Recovery Focused Culture: changing the nature of conversations from the bottom up

Rachel Perkins, Julie Repper and Kirsty Giles

What sort of conversations? From the ‘patient in our services’ to the ‘person in their life’

If we are to change the nature of our conversations, we must first ask, what is the purpose of our service and the conversations within it. Traditionally it has been assumed that the purpose of services is to reduce and eliminate problems, deficits and dysfunctions. In this context we have focused on ‘the patient in our services’ and their needs in terms of what we have to offer (inpatient care, a day service, psychological therapy etc.). Our primary goal has been diagnosis, treatment and symptom reduction so our conversations have focused on the nature and aetiology of their difficulties. We have then used our expertise to prescribe solutions for them. Their personal history, strengths, goals, social circumstances, activities, values, beliefs etc. have been considered only in so far as they inform decisions about diagnosis, treatment, support and prognosis. The purpose of a recovery focused service is to help people to rebuild their lives. As surgeon, Professor Atul Gawande, said in his 2014 Reith Lectures ‘The Future of Medicine’:

“We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being – and well-being is ultimately about sustaining the reasons one wishes to be alive… Medicine must shift from a focus on health and survival to a focus on wellbeing – on protecting, insofar as possible, people’s abilities to pursue their highest priorities in life.”

In order to do this we must understand what drives the person, the nature of their ‘highest life priorities’. This means that, in thinking about recovery we need to start in a different place, not with the ‘patient in our services’ but the ‘person in their life and community’ – where they have been, what has happened to them, who and what is important to them, what they have got going for them and what they value – the ‘reasons they wish to be alive’. Symptoms, diagnosis, prognosis, treatment, support and services must all be considered not just in terms of how much they reduce problems but how far they enable the person to do the things they want to do and live a satisfying, meaningful and valued life as part of their community. We cannot understand the person in their life and community through a ‘one size fits all’ checklist. If we are to begin to understand the person, and if they are to feel heard, they need a chance to tell their own story in their own words. Simple questions like ‘What has happened?’ (rather than ‘what is wrong?)’, enable people to tell their story; taking time to listen, believing their account, exploring their experiences … can be very powerful. Personal narratives form the basis of recovery. We can learn a great deal about the person, their culture and their life if we let them tell their story about what happened to bring them to services. There will be some information that we have to collect but much may be covered in the course of the person telling their story when we take the time to actively listen.

Over time we may want to explore a number of areas:

• What the person sees as their most pressing concerns/needs. This may not be their mental health problems it could be money, housing, safety, children, relationships … it is important not to jump to conclusions and people’s concerns usually change over time.

• What the person has done to try to cope with problems they are facing. Many people have tried lots of ways of dealing with difficulties, some of which may have been quite effective. Together we can build on these and avoid replicating things they have not found helpful. What help are they already receiving? Is there anything else that they think might help?

• Their situation and the meaning for them of what has happened. The way in which they understand what has happened and how it has affected their life, relationships and roles. The practicalities of their life including their living arrangements, employment/education, finances, general health, transport/getting around, relationships community, and how these may help or hinder their recovery.

• Hope and fears. Anything that the person is frightened of, anything that makes them feel unsafe (or frustrated, or angry, or hopeless …), anything that keeps them awake at night. What might alleviate their anxiety and help them to feel safe? Who might best provide this?

• Their courage and strengths. People often understandably focus on their shortcomings and perceived deficits, weaknesses, but amid these lie a great deal that is worthy of respect:

– the courage it takes to recognise problems and seek help

– the courage and ingenuity it has taken to keep going with such difficulties

– the creativity in working out ways of keeping going

Whilst acknowledging the magnitude of the challenges they face, we must spend time discussing their own strengths and resources – and those available to them within their family, friends and communities. Solutions do not lie exclusively in services. Services can help identify, support and develop a person’s resources rather than be the sole provider. Such discussions can help people to recognise that they have some agency:

• Their personal resources: coping strategies, sources of strengths, protective factors, experiences of coping with adversity, values and activities that are important to them, inner resources that the person draws on.
• Things that make the person ‘tick’: values and beliefs, things that are important to the person, give them a sense of purpose and a reason to get up in the morning.
• Their diverse range of strengths: skills and talents, personal virtues, educational qualifications, work and work experience, interpersonal skills and resources, overcoming adversity, spiritual/faith resources.
• Their social resources: family, friends, neighbours, colleagues, support networks, services, faith communities, other communities of which they are a part and the resources within these.
• Their sources of security and hope: people to whom the person turns when they need help or solace, sources of hope and strength, spirituality and philosophy.

We cannot help people in their journey of recovery by understanding their problems and resources alone. We cannot help someone to get somewhere in their life unless we know what is important to them and where they want to go. We need to understand and help the person to explore:

• Short term goals: not just ‘getting rid of symptoms’ – what would be different? What would you be able to do that you cannot do now?
• A vision for the future: hopes and dreams for the future – what do you want to do with your life? Have these changed? What did you want to do with your life before your problems started/when you were young? If you could wave a magic wand, what would be different/how would you know things were different?

We all know that the people who are close to us often understand a great deal about our strengths and resources, our hopes and dreams, and our most pressing concerns. Sometimes they can help us to articulate these when we are not able to do so ourselves. As mental health workers we always need to recognise that, while recovery may be a personal journey, it is not one travelled alone. It is one travelled in the context of friends, families and communities. Those who the person sees as important to them may have valuable information to impart and may be valuable allies in the person’s journey.

Little things make a big difference

Probably the most difficult aspect of working as a mental health practitioner is understanding how each little thing we say or do is received by the people we are there to support. When the ward is very busy, the telephone is ringing and the doctor wants to go through the drug charts and someone comes to the office door wanting to speak to you for the third time that morning it is very easy to wave them away or tell them that you are too busy at the moment. It is all too easy to expect them to be able to see how things look from your perspective – being harassed on all sides. However, there is another perspective. The person may have lost all their friends, no-one from their family visits, they are not allowed off the ward because they are a suicide risk, and have only the staff with whom to share their loneliness and distress. You are the only person who is there for them, and you are too busy. The sense of yet another rejection is immense. There is no easy answer. You have the unenviable task of deciding which is most important: to speak to the person, answer the phone or talk to the doctor? Your instinct tells you that the person’s needs are paramount, but the doctor tells you how busy they are and you have no idea how important the telephone call might be. Perhaps you can ask the doctor to wait for a moment while you speak to the person? Perhaps you can ask the doctor to answer the phone while you do so? Perhaps you can then apologise to the person for keeping them waiting … answer the telephone and tell the caller you will ring them back … It is difficult to think through the options and their implications in the split second you have to make the decision. But perhaps the essence of taking a recovery-oriented perspective is to change some of the traditional hierarchies.

How often do we, as a team, discuss such dilemmas together? Consider how to balance priorities. ‘People before paperwork’ may be a good maxim, but this does not make the paperwork go away. There have been numerous initiatives around ‘protected time’ for staff to spend with people, perhaps this is looking at things the wrong way round?

Perhaps we should be talking about ‘protected time’ for paperwork and assume that for the majority of our time we are available to people using the service? Would we wave away, or ignore the doctor when they want our time? Probably not, we may apologise and give an explanation, arrange another time to see them … treating the people that our service is there for with the same respect as we accord colleagues is the least we can offer, but we do need to discuss and agree this as a team?

Similar dilemmas arise in every part of the service. In a busy community team, how do we respond to the person who calls several times a day asking for help? Too often the traditional response is to ‘set limits’ (‘your care worker will come and see you next week’) in an attempt to discourage ‘inappropriate attention seeking’. But how does this feel for the person who is calling you? They feel at the end of their tether, they have no-one to talk to. They really do value your help. They really do feel that they will have to take drastic action if they do not get help, even though you do not believe their situation to be critical. It is not easy. We cannot talk to a single person all the time, but from where the person sits they are continually being rejected, they feel no-one recognises how difficult things are for them. Any one of us knows how important it is that our friends and colleagues acknowledge our distress. How often do we call them to check they are OK? If we reached out on a regular basis – proactively recognising their distress rather than passively rebuffing or ignoring their approaches – then we demonstrate that we care, that we are interested, that we are there for them … if we arrange to call them regularly (daily if necessary) rather than waiting for them to call us then distress ceases to be the only way they can get the attention that we all crave. If we call them we can talk about their achievements as well. But again, this requires us to discuss and agree this approach as a team. It requires all of us to think through the person’s situation, what our role is and the consequences of different courses of action. If we rebuff the person’s approaches, all too often they do escalate their calls for help until we are unable to ignore them. What are our values? What are our attitudes to the person?

In both of these examples, the challenge is to move beyond our perspective, appreciate how things look from the other person’s shoes and recognise our common humanity. Treat the person on the ward as we would treat the doctor and treat the person who calls us repeatedly as we would wish to be treated ourselves, or how we would treat our own family members.

This latter example also illustrates the importance of the language we use and the relationship between language and thought. If we label someone as ‘attention seeking’ this defines their behaviour as a ‘problem’ to be eliminated. If instead we label them as distressed or frightened these are emotions that all of us share. Every one of us needs acknowledgement, recognition, attention, someone with whom to share hard times as well as good times. Most of us have friends, family, colleagues to provide us with this. Too often the people who use services have no-one to turn to but services. Once we start to recognise our common humanity and label their behaviour differently our response changes.

The language we use to speak and write about people has a significant influence on the way in which we respond to them. Although many services aspire to a strengths based approach, the reality often falls short. A brief perusal of the records of anyone using services reveals that the number of words describing deficits, dysfunctions and problems far outweighs the space devoted to strengths, possibilities and personal aspirations. Given the pressure of work in mental health services it is hardly surprising that we develop shorthand language. Given the prevailing focus, this short hand invariably describes problems: ‘non-compliant’, ‘difficult’, ‘attention-seeking’, manipulative’, ‘lacking motivation’. This has two consequences.

First, it describes the person and their behaviour in negative terms. Someone who does not agree with what we think is best for them may be described as ‘non-compliant’, but they could equally be described as ‘knowing their own mind’. Someone who tries to get us to do what they think is best may be labelled ‘manipulative’ while a member of staff who tries to get the person to do what they think is best is more likely to be described as a good clinician.

Second, it robs the behaviour of its context and meaning. It tells us little about the person’s situation and how they see the world, both of which are critical if we are to help them. As the ‘Independent investigation into the care and treatment of Daniel Gonzales’ (2009) says “The recovery … philosophy requires the professional to be curious about what drives the service-user, what is meaningful to him, and why..” If we say that the person is ‘non-compliant’ this tells us nothing about why the person’s perspective differs from our own and what is important to them.

Although most services aspire to offering choice, the language we use frequently assumes that our way of looking at things is the correct one and that we have the answers about how to put things right.

Typically we use ‘you’ language: you have schizophrenia, you are suicidal, you are vulnerable. This implies that our construction of events is correct and too often leads to the polarised confrontations (‘you have schizophrenia’, ‘no I haven’t’, ‘yes you have’ …) that mitigate against the formation of collaborative, recovery focused relationships. If we instead use ‘I’ language (‘I think you might have schizophrenia’, ‘I am worried that you might hurt yourself/that about other people taking advantage of you’) then we introduce the possibility of discussion of different perspectives (‘I think this, what do you think?’) that allow us to understand each other’s perspective, even if we end up agreeing to disagree.

Often we tell people what to do to make progress (‘my advice to you is …’, ‘You need to …’ , ‘You should …’). This assumes that we know what is best for the person. Just as there is no single correct construction of events, there is no single correct road to recovery. Each person must find their own way, work out what helps them and develop their own ‘personal medicine’:

“When describing their use of psychiatric pharmaceuticals or “pill medicine”, research participants also described a variety of personal wellness strategies and activities that I have called “personal medicine”. Personal medicines were non-pharmaceutical activities and strategies that served to decrease symptoms and increase personal wellness” (Deegan, 2005, p.30)

If we are to assist people in doing this our role is not to tell people what to do but to help them explore different possibilities: from ‘my advice to you is …’ to ‘some people have found X helpful, some people have found Y helpful, have you had any thoughts about what might help you?’.

As well as exploring the language we use, we also need to examine some of our accepted ways of doing things. Often we have ‘one size fits all’ rules (‘no visitors in your room’, ‘you cannot have your mobile phone’) which often reflect a kind of ‘lowest common denominator’ approach to safety: if one person is ‘not safe in the kitchen’ then no-one can use the kitchen unsupervised. Alternatively, such rules may be reinforced by ideas about fairness: it is difficult to ask Jane to get up at 8 am so she can go to a therapy group if Fred is allowed to stay in bed until 11am. Whether through ideas about safety or fairness, blanket rules prevent us tailoring services to individual needs and preferences. For example, the general rule may be ‘no visitors between 12 noon and 2pm’. If a person’s relatives have to drive a long way to reach the ward, maybe this is the only time they can visit. Keeping in touch with family and friends may be more important that sticking to blanket rules.

It is important not only to think about what we do but the way in which it is done. The rule ‘no mobile telephones’ can be delivered in different ways. The person could simply be told to hand over their phone because they are not allowed on the ward. It would be equally possible to apologise for not being able to let them have their telephone, explain why the rule exists, and how they can make a call if they want to. Common courtesy is at least as important to people using services as it is to the staff who work in them!

It is also worth thinking about the messages that our services convey about how we value those whom we serve. How do we welcome people? What do our initial appointment letters say? What messages do our ‘zero tolerance of violence’ posters, or our separate ‘staff’ and ‘patient’ toilets, convey? How does it feel to have to speak to the receptionist through a hatch or holes drilled in Perspex? How different does it feel if you are offered a cup of tea when you arrive? If the letter you are sent offering you an assessment says something about what this might entail and what a ‘Community Mental Health Team’ is? While it is important to convey the message that violence cannot be tolerated, there are lots of ways of doing this. For example, in a ward in a state hospital in the USA, the notice read “We understand that you may feel frustrated and angry at times. If you feel like this, come and talk to a member of staff – we are here to help. Our job is to keep everyone safe. Violence will be prosecuted.”

Supporting mental health workers in developing their recovery focused talents

Individual supervision and appraisal

Teams need to empower staff to work in a more recovery-oriented way. It is important to create a context in which they can develop and grow – explore all facets of their practice and contribute to their full potential. In this context, supervision and appraisal that discuss, support and encourage recovery-oriented practice are central. How can we better develop relationships that reflect our common humanity and enable people to develop and grow? How can we think about the language we use and the way in which we understand people’s challenges? How can we explore different ways of understanding why someone behaves and feels the way they do – how might things look from their perspective? How can we explore the way we do things – from initial assessments to ongoing individual work – to better foster hope, enable people to do the things they value in life and become experts in looking after themselves?

“Contrary to previous research on patients’ experiences, the themes that predominated related to the emotional not physical environment in which they stayed … relationships form the core of service users’ experiences of psychiatric hospital admission …” (Gilburt, et al, 2008)

Such supervision and appraisal needs to involve both the celebration of success and addressing challenges. We must learn from success as well as from that which is not working well. It is as important to explore why some relationships are successful – and what has contributed to this success – as well as examining how challenges might be addressed. Indeed the former can inform the latter.

Some services have used the ’10 top tips for recovery focused practice’ as the basis for recovery focused supervision2 . This list provides clear guidance for recovery focused conversations and a useful structure for identifying approaches and techniques that the individual might want to develop or improve (see Figure 1).

Figure 1: Ten top tips for Recovery focused interactions

After each interaction, the mental health professional should ask her/himself/themself, did I…

• actively listen to help the person to make sense of their mental health problems?
• help the person identify and prioritise their personal goals for recovery – not professional goals?
• demonstrate a belief in the person’s existing strengths and resources in relation to the pursuit of these goals?
• identify examples from my own ‘lived experience’, or that of other service users, which inspires and validates their hopes?
• pay particular attention to the importance of goals which take the person out of the ‘sick role’ and
• enable them actively to contribute to the lives of others?
• identify non-mental health resources – friends, contacts, organisations – relevant to the achievement of their goals?
• encourage self-management of mental health problems (by providing information, reinforcing existing coping strategies, etc.)?
• discuss what the person wants in terms of therapeutic interventions, e.g. psychological treatments, alternative therapies, joint crisis planning, etc., respecting their wishes wherever possible?
• behave at all times so as to convey an attitude of respect for the person and a desire for an equal partnership in working together, indicating a willingness to ‘go the extra mile’?
• while accepting that the future is uncertain and setbacks will happen, continue to express support for the possibility of achieving these self defined goals – maintaining hope and positive expectations?

(cited in Shepherd, Boardman, & Slade, M., 2008, p.9)

The possibility of introducing 360 degree appraisal at team level might also be considered, including the experience and contribution of people who are using the service in this process. For example, feedback might be provided by using the INSPIRE assessment tool (Williams et al., 2011) which focuses on the relationship the person has with a mental health worker and the extent to which they feel this supports their recovery as part of a person’s appraisal. Alternatively, people who use services might be trained to provide clinical supervision with groups or teams of staff.

Recognising and rewarding individual expertise and effort

Recognition and reward for achievements is critical and cannot be left to supervision and appraisal alone.

In their ‘effort-reward’ model of job stress, Siegrist et al (1990) describes the problems that arise if effort and reward are out of balance; people are working very hard and receive little acknowledgement or reward for their efforts then well-being, morale and health are compromised. Reward in this context is not all about pay – it is also about status and recognition. Clearly pay and promotion are one way of recognising achievements, but alone they are a rather crude and infrequent mechanism that ensure that most people’s efforts, most of the time, go unacknowledged.

Some services have recognised this by instituting various forms of awards for teams. While these may be an important way of acknowledging success, they too are infrequent and leave the day to day initiatives and successes of most staff uncelebrated.

Little things make a big difference and are the building blocks of recovery-oriented culture and practice. These little things often take a great deal of effort and ingenuity that goes unacknowledged. If no-one recognises the effort you are making then you rapidly stop making the effort. What motivates most of us is the sense of having achieved something – made a difference. If the effort-reward imbalance is to be restored then it is critical to acknowledge these successes. We need to build in ways of recognising and celebrating these day to day successes and relationships as part of our routine work.

On a day to day basis, simply noticing what others in the team have done is critical. A simple ‘well done’ or ‘thank you’ from a colleague or team manager can go a long way. Reflective practice sessions, care plan review meetings, ward rounds and staff handovers offer a real opportunity to do this. Typically these are problem-focused: problems are identified and solutions sought. If the course of action decided is successful it is rarely noted, we simply move on to the next problem. This leaves everyone with a sense of failure ‘nothing we do works’. In order to recognise and celebrate success, some teams have started identifying a specific time in review meetings and ward rounds for discussing successes and exploring what can be learned from these. One ward decided to finish the handover at the end of each shift by going round and asking each staff member to describe something that they had achieved in the shift: a success, however small, or something of which they were proud. This not only recognised what staff had achieved but it left them going home after work on a positive note. Similarly, the manager of a community team instituted a ‘little miracles’ meeting at the end of each week. Towards the end of a Friday afternoon, all team members of the team who could make it were invited to come together for ‘tea and cakes’ and share the ‘little miracles’ that had happened during that week: these were written down on a sheet of paper and left on the wall as a reminder for the rest of the week. Tokenistic as such initiatives may sound, their impact on enabling people to recognise what they have achieved should not be underestimated.

As well as celebrating success within teams, it is important that these successes are recognised at a management level. Too often middle managers feel besieged from all sides – told from on high to make sure that cost and performance targets are achieved and from below that there are insufficient resources. Managers are more likely to recognise success if they know what individuals and teams have achieved. How often do individuals and teams feed-back their small but important success stories to offer a different narrative to that of performance targets? Providing feedback on the things that are important can do much to create a more recovery-oriented discourse within the service that can do much to change culture.

This might be achieved via newsletters that contain brief reports of progress and success in individual work with individual people using services. For example, one ‘snippet’ related how someone on an admission ward had refused to have a bath or wash: numerous confrontations and abuse followed when the person was repeatedly exhorted to bathe and relationships deteriorated. A member of staff spent time talking to the person and discovered that she thought it was unhygienic to bathe in facilities used by lots of strangers and ascertained that she would be happy to have a bath in her own home … so when the ward was quieter at a weekend the staff member took the person to her home to have a bath. One organisation started including narratives of success as a routine part of its Key Performance Indicator reporting systems. At the start, some cynics thought that these would go unnoticed – that ‘they’ would only be interested in the numbers, not the people. This proved wrong: the brief narratives brought the figures to life and reminded managers and commissioners what the service was really about.

As well as acknowledging achievements, recognising and using expertise of individual staff is also important both in making services more recovery oriented and improving job satisfaction. Staff often have a range of professional training and experience (for example, working with families, addictions, trauma informed care etc.) which they are not able to use in their day to day work. In many teams, people only work with their designated ‘caseload’, so the input available to people using the service depends on the skills of their designated care co-ordinator. This is both a waste of skills and limits the options available to people using services. We need first to have a register of the skills that are available within the team and second, ways of enabling people using the service to access the skills within the team that they need. The creation of ‘lead’ roles can go some way to addressing this. For example, someone with family work training might be the ‘family, friends and carer’ lead and offer family interventions offer this to people across the team, not just to those on ‘their own’ caseload. Staff also bring a range of other talents and expertise from outside their professional careers: interests, hobbies, community networks and contacts and a range of cultural competencies. Staff satisfaction, and the experience of people using the service, can be enhanced by recognising the talents and interests of staff and using these. For example, a nursing assistant had been a journalist in the country of her birth – once these skills had been recognised she worked with service users to produce accessible, ‘plain English’ leaflets about the ward and the activities/ supports available. A staff member who had qualifications as a personal trainer used these to help individual clients to develop their own, individual exercise regimes. Identifying staff interests and talents enables a matching of clients and staff with similar interests and backgrounds can create a ‘win-win’ situation by fostering improved relationships and improving job satisfaction.

Building on strengths at team level: Using Team Recovery Implementation Planning

While it is important that each mental health practitioner reflects on their own practice, we all work together in teams and the whole is more than the sum of its parts. To work together effectively to promote recovery, and support the endeavours of individual workers, the whole team needs to reflect on their purpose and approach.

A service cannot promote recovery unless recovery focused principles and practice are embedded and owned at the grass roots. We need to work together to create more recovery oriented services and bring together the collective expertise, creativity and ingenuity of those at the front line – both mental health workers and the people who use services – with that available among relatives friends and communities. The Team Recovery Implementation Plan (TRIP) offers a framework for doing this. Initially developed in Nottingham, it has been refined in use across the UK and beyond (see Repper and Perkins, 20133 ). It has proved a useful approach to the development of recovery focused practice in the full range of services (from high secure settings through acute inpatient wards and community teams to voluntary sector services) and has assisted in breaking down ‘them’ and ‘us’ barriers by changing the relationship between staff and people who use services.

The TRIP is founded on co-production. It involves recognising people as assets and building on the strengths within the team: the resources of both staff and people supported by the service. It is founded on the principles of mutuality and reciprocity – breaking down barriers and blurring roles: staff and people using the service share responsibility for both designs and delivery of the plans. It extends the resource base by including peer, personal, professional and community networks. The service becomes a catalyst for change rather than a creator of change by enabling people to lead their own recovery and the development of recoveryoriented services and empowering people to develop a range of resources in peer networks and communities to support them in their journeys. Not only does coproduction result in better services by harnessing additional capacity and expertise it also promotes the recovery of those involved by enabling them to move from passive recipient of services to active agent.

The TRIP involves four key components⁴ :

1. Identifying assets: the resources that exist within the team among staff and people using the service: not just the experience of using/providing mental health services but a) ‘hidden talents’ (other skills, qualifications, interests, experiences) and b) contacts and networks within communities. For example, one Early Intervention Team had someone using the services who was interested in the development of ‘apps’. Using this talent, and the team manager’s knowledge of sources of funding, the team developed ‘My Mind Western Trust’ app⁵ to support people with mental health conditions and help them take back control as part of their TRIP. In a ward in a secure psychiatric service, a band was formed using the musical talents of a number of staff and inpatients as part of their TRIP.
2. Benchmarking progress in recovery focused practice. Based on good practice statements drawn from the Recovery SelfAssessment – Provider Version (O’Connell et al, 2005) and ImROC’s 10 Key Organisational Challenges (SCMH, 2010), teams discuss and rate their progress. This is a collaborative process in which staff and people using the service recognise and celebrate what they have achieved and identify ways of moving forward and building on what they have done. For example, one voluntary sector service had already introduced people using services onto interview panels and decided they could build on this by coproducing job descriptions and person specifications with people using the service.
3. At the end of the benchmarking process, front line staff and people using the service, alongside people who are close to them and community partners, come together to identify priorities and develop action plans. These might best balance impact and ease of implementation by including some ‘quick wins’ and some longer term projects. The challenge is not just about ‘doing more’ it is about ‘doing differently’. The range of targets identified by teams is extremely broad, from making waiting areas more recovery focused, to the collection of recovery stories, changing the format of review meetings, shared entries in notes, ‘trip advisor’ style ratings of community facilities, co-producing information booklets about the service; inviting external agencies to run activities on wards; changing the initial assessment letter to make it more friendly and give people information about what the assessment would entail and what questions would be asked … Whatever the priorities identified it is important that these are co-delivered. Each priority is co-led by a staff member and someone using the service, assisted by other staff, people using the service, relatives/friends and community partners/agencies as appropriate. Many teams have found that not everything has to be done by staff. Tapping the expertise of people using the service is equally important. For example, one community team have decided to provide an ‘information corner’ in their waiting room. Staff have not got the time to run this, but there are people using the service who are keen to help on a voluntary basis. The team has made available resources to collect information leaflets about a range of issues (from opportunities in the local community to self-help materials) and people using the service introduce people to these and help them to use them. There exist a wealth of talents among service users that can be tapped!

The TRIP has also been used by corporate services and non-clinical teams to help them focus on what coproduction means in their own area and how they can better support the development of recovery focused practice at the front line. For example, one Business Development Department set up a group of people who had used services to assist in tendering for new services; and one executive team decided to introduce ‘recovery impact assessments’ of all new policies and service developments; a Finance Department produced a ‘simple to understand budget statement’ for hostels so that this could be shared easily with staff and residents in deciding how some of the available budgets should best be spent; and an IT Department worked with people using services to enable them to have access to the organisation’s intranet.

Critically, Team Recovery Implementation Planning is not a ‘one-off’ exercise but an ongoing process of co-producing and co-delivering action plans. Neither is it a quality rating scale or a ‘tick box’ exercise but a way of supporting recovery-oriented ways of working in teams: an heuristic tool to promote collaborative, ‘bottom up’, service development. Just as recovery is about recognising and building on strengths, TRIP provides a framework for bringing together the wisdom and resources of staff, people using the service, those who are close to them and community partners to create an environment in which all can grow and develop. Experience suggests that it is the collaborative process of using TRIP, rather than the specific content of the action plans, that is most critical in creating a more recovery focused culture and practice and changing the nature of interactions within teams.

Maintaining and developing recovery-oriented practice: the centrality of leadership

Whitley’s (2009) research into the core components of Recovery focused services demonstrated the importance of recovery focused leadership. Although recovery is now a central tenet of policy and practice guidance for all professional groups, in order to be enshrined in organisational culture it needs to be an explicit part of a shared vision that is understood and clearly led at every level of the organisation.

The principles of recovery translate effectively into principles for leadership. If services are to realise the changes in conversation discussed in this paper then they need leaders who inspire hope and belief in the possibility of improving services; facilitate a sense of personal control or agency among staff in the development and delivery of recovery focused initiatives, and create opportunities for personal development based on strengths, interests and experiences. These characteristics bear an uncanny resemblance to ‘transformational leaders’ (see Bass, 1997; Burns, 1978) who are recognised by their commitment to working with their organisation/team to identify needed change, creating a vision to guide the change through inspiration, and implementing the change in tandem with committed members of a group. Unlike transactional leaders who work within the status quo, transformational leaders strive for culture change to drive improvement and performance and stir their employees to look beyond their own self-interest for the good of the group (Investors in People 2017).

Bass (1997) identified four key components of transformational leadership. These have direct relevance to leading recovery focused culture change:

Idealized Influence – the leader serves as an ideal role model for followers; the leader “walks the talk,” and demonstrates the aspired behaviours of the whole team consistent with the overall vision. Within any mental health team, the influence of a leader who clearly models recovery focused behaviour; prioritises the needs of people using the service over paperwork, explicitly appreciates the contributions, ideas and achievements of staff members; always uses recovery focused language and maintains a strengths based perspective, is invaluable in transforming the culture.

Inspirational Motivation – Transformational leaders have the ability to inspire and motivate followers. By embodying recovery principles even in the most stressful situations, displaying an unwavering belief in the potential of people, recognising the challenges of competing demands but consistently seeking creative solutions, the transformational leader motivates others to share their beliefs and actively change their own behaviours.

Individualized Consideration – Transformational leaders demonstrate genuine concern for the needs and feelings of their team. This appreciative approach chimes with the strengths based and personalised aspects of recovery. If every member of the team feel that they are valued and supported as an individual then they are empowered to perform to their full potential.

Intellectual Stimulation – the leader challenges followers to be innovative and creative and constantly seeks higher levels of performance. Although transformational leadership has been criticised for being too ‘soft’, in reality it is about constantly striving Conclusion to achieve a shared vision and ensuring that everybody is fully committed to this: challenging their mindsets, ideas and beliefs to drive growth and performance, encouraging creativity, collaboration and the pursuit of excellence.

Whilst critiques of transformational leadership focus on the possibility of dependence on the leader and the need for a certain personality type to take up this role, research demonstrates the effectiveness of the approach. Transformational leadership is associated with greater leader effectiveness, higher staff commitment, role clarity and wellbeing and more positive outcomes than other leadership styles (Investors in People, 2017).

Conclusion

Although the culture of any organisation is highly influenced by the values and aspirations of Senior Managers, we contend that the experience of people using services is crucially dependent on the values, behaviours and beliefs of all practitioners. In order to change the conversation at the front line, it is essential to recognise, celebrate and develop both people who use services and the staff members with whom they have closest contact. It is also essential to develop relationships with community resources and facilities so that people using services have opportunities to build roles, relationships and meaningful lives beyond services.

All of this requires a a shift in priorities, practices and critically relationships so that everyone’s contribution is valued and there exists a collective vision that is owned and shaped by people working in and using services, their family members and the communities in which they live. This inclusive, valuing and supportive culture needs to place an emphasis on strengths and achievements and learning from success rather than problems and things that have not worked out as we had hoped. It replaces excluding, technical, pathologizing and professionalised language with personal, accessible, appreciative conversations. Relationships are underpinned by courtesy, respect and mutual learning. A recovery focused culture is led at every level, in every part of the service with genuine partnership and value afforded to everyone who uses the service and works in it.

References

Bass, B. M. (1990). From transactional to transformational leadership: Learning to share the vision. Organizational Dynamics, (Winter): 19-31

Boorman, S. (2009) NHS Health and Well-being Review. Interim Report, London: Department of Health

Burns, J.M (2010) Leadership. Harper Perennial Political Classics

Deegan, Patricia E. (2005) The importance of personal medicine: A qualitative study of resilience in people with psychiatric disabilities Scandinavian Journal of Public Health. 33 (66 suppl): 29–35.

Dunlop, B.J., Woods, B., O’Connell, A., Lovell, J., Rawcliffe-Foo, S. & Hinsby, K. (2021) Sharing Lived Experiences Framework (SLEF): a framework for mental health practitioners when making disclosure decisions. Journal of Social Work Practice https://doi.org/10.1080/0 2650533.2021.1922367 Accessed 7.7.21

Department of Health (2011) The Public Health Responsibility Deal, London: Department of Health

Department of Health (2015) The NHS Constitution, Department of Health Dorset Wellbeing and Recovery Partnership (2013) Framework for Using and Sharing Our Lived Experience within Health and Social Care.

Dorset Healthcare NHS Foundation Trust and Dorset Mental Health Forum. http:// www.dorsetmentalhealthforum.org.uk/pdfs/ other/supporting-staff-recovery.pdf

Gawande, A. (2014) ^The Idea of Wellbeing. Lecture 4 in the Reith Lectures 2014: The Future of Medicine, Indian International Conference Centre New Delhi, 20th December 2014

http://downloads.bbc.co.uk/radio4/openbook/2014_reith_lecture_4_delhi.pdf accessed 25/9/2021

Investors in People (2017) https://www. investorsinpeople.com/transformationalleadership-what-is-it/ accessed 17 September 2018.

Perkins, R. (2021) Valuing and using personal experience in IPS practice. London: IPS Grow

Perkins, R., Rinaldi, M. & Hardisty, J. (2010) Harnessing the expertise of experience: Increasing access to employment within mental health services for people who have themselves experienced mental health problems, Diversity in Health and Care, 7, 13-21

Repper, J., Aldridge, B., Gilfoyle, S., Gillard, S., Perkins, R. and Rennison, J. (2013a), Peer support workers: theory and practice ImROC briefing paper, London: ImROC, NHS Confederation Mental Health Network/Centre for Mental Health, London. http://www.imroc. org/media/publications/

Repper, J., Aldridge, B., Gilfoyle, S., Gillard, S., Perkins, R. and Rennison, J. (2013), Peer Support Workers: a practical guide to implementation, ImROC briefing paper, London: ImROC, NHS Confederation Mental Health Network/Centre for Mental Health, London. http://imroc.org/media/ publications/

Seligman, M. E. P. (1972). “Learned helplessness”. Annual Review of Medicine. 23 (1): 407–412.

Shepherd, G. Boardman, J. and Slade, M. (2008) Making Recovery a Reality. Nottingham: ImROC/London: CMH)

Whitley, R., Gingerich, S., Lutz, W.J. & Mueser, K.T (2009) Implementing the illness management and recovery program in community mental health settings: facilitators and barriers. Psychiatric Services, 60, 202- 209.

1 https://www.safewards.net/interventions/know-each-other

2 http://imroc.org/what-is-recovery/recovery-top-tips/

3 http://nhsconfed.org/~/media/Confederation/Files/public%20access/ImROC_briefing6_TRIP_for_web.pdf

4 http://imroc.org/media/publications/imroc_team_recovery_implementation_plan-3/

5 https://itunes.apple.com/gb/app/my-mind-western-trust/id802203395?mt=8

16. Developing Primary Care Networks and Community Focused Approaches: A Case Study

The Let’s Live Well in Rushcliffe Team

The ‘Live Well’ Model Report: An integrated approach to support, enable and empower people who are lonely, inactive and/or have long term conditions(s) to live well in their communities. The Let’s Live Well in Rushcliffe Team, April 2019

Acknowledgements

A big thank you to the very many people who have contributed to LLWiR.

This paper describes the model we have developed by working together as a large heterogeneous group of people with a passion for our local communities and a commitment to developing a community focused approach to support people who are isolated, inactive and / or have long term conditions.

Many of us live with ongoing health conditions or care for a family member who does; some of us offer medical services, health or social support; others work in local community services and facilities, others volunteer or are employed within the team. Some have received support from the Live Well team, others have worked on the evaluation and others have provided managerial support to the project.

1. Introduction

The Live Well model brings together best evidence for community development, social prescribing, health coaching, health education and volunteering – all linked and developed through a core coproduction forum. This paper describes the development and outcomes of the pioneer Live Well service – Let’s Live Well in Rushcliffe (LLWiR).

LLWiR was developed to meet the needs of people living in Rushcliffe who have complex long term physical and/or emotional health conditions and/or who are isolated, excluded and/or find services difficult to engage with. The service is open to self-referrals as well as referrals from any primary care services, social services, the voluntary sector, family members and community facilities. It offers initial engagement, assessment and health coaching based in GP practices, and where appropriate this leads on to an introduction to a link worker who supports people to engage in activities related to their personal goals and works with community resources to extend and develop opportunities in the community.

The coproduction group is the core of the project. Regular meetings with a large group of stakeholders not only co-constructed the initial model, but facilitates an ever expanding range of additional initiatives including a learning network offering educational opportunities in a range of facilities, multiple community cafes (where people can meet others in a safe place, attend learning opportunities and buy refreshments); a volunteer pathway and strong links into existing services. Additional features of the model include the provision of a small funding resource for new initiatives; employment of peers (people with their own experience of long term conditions) in all roles within the team; and external facilitation and project management from a Recovery focused organisational development organisation (ImROC).

A full evaluation of the project was undertaken by Nottingham Trent university to assess impact on health and service use. 1483 referrals were received in the first 13 months of service provision . This study reported significant improvements in patients’ physical and mental wellbeing after the initial four month period which were maintained after eight months. There was also an increase in community group membership at 4 months which reduced slightly by 8 months. There was a decrease in both primary and secondary care usage over the evaluation period. The economic evaluation of the programme attached savings to the improvements in health as well as the changes in health and social care usage. Projected over a year post-baseline assessment, this estimates a ROI of £1.00. In other words, if the patient benefits recorded for the first four months are continued for the rest of the year, the programme will recoup 100% of its costs by January 2020.

“Well, most of a population’s health and wellbeing is determined by environmental factors, and things that are not to do with healthcare. And, you know, sometimes the traditional medical model, if you like, has been very, you know, our role is to just do the medicine and that’s it. But we work in a system, we work in… All these things are interdependent, and if we want to, we might not be the experts on it, but if we want to help our patients more and help the population, then we need to access these sort of broader things”.

GP

“I think social prescribing is having the time to explore an individual’s needs regarding their wellbeing and then tailoring support to the individual’s needs, rather than just saying, ‘You can go to X, Y or Z’. Not assuming that just because somebody has a diagnosis of X that they’ll need X, but really exploring an individual’s needs and seeing and supporting the individual to achieve those goals while promoting self-management. There is no point providing a wonderful service and then, when we go, the person is back at square one”

Health Coach

I think as we work with individuals to get them engaged more with the community, the community itself then benefits by having more people engaged with it, so it becomes almost organic and it can grow and develop itself, just to help to meet the needs of its members, I guess.

Link Worker

“… theory’s all very well, but I see the patients I’m referring coming to see me less. I can have a look at their notes and see what’s been written and see that they’re making connections”.

GP

The health coach and the patient, we work together to assess a way forward, essentially looking, in very broad terms, at goals and areas for goals to be placed in. This could be over one, two or three sessions, there’s no time limit on it [lines omitted] the end result is to come up with goals and then to break those goals down into achievable steps. If that needs some support in the community, in terms of physical support to help them get to a new group, for example, or to help look at the way they shop differently or something like that, then we have link workers.

Health Coach

2. The Context

2.1 The National Context

The pressures on todays’ health and social care system are well documented: life expectancy is increasing and numbers of people living with long term conditions now account for 70% of the healthcare budget; there is a widening gap in health inequalities largely due to social factors (like finances, education, housing and isolation) – issues which are not routinely addressed by health services; public expectations of services are rising and new treatments are continually developing, placing ever greater economic pressures on services.

Solutions to this complex picture have been proposed in the 5 year forward view¹ and further detail is provided in the 5 year forward view for mental health² and the GP forward view³. All of these documents place an emphasis on primary prevention through public health initiatives; secondary prevention through primary and secondary health care and self-management as people are further enabled to manage their own wellbeing through education, coaching and personal budgets. In addition these visions for a healthier future call for greater integration of primary and secondary services – including acute and urgent care; health and social care, mental health and physical health services, and far stronger partnerships between statutory services and the voluntary sector alongside the development of more confident, capable communities.

Many new structures and approaches are developing to support the transformation of health and social care services, for example Multi-speciality Community Providers that integrate expertise in one place based team; HiAP (Health in All Policies) informed by the Marmot review⁴, with localities seeking to reduce Health Inequalities by actively addressing the health implications of all developments in a community: transport, industry, housing, environmental issues, education etc. Vanguard sites to lead innovative new developments in health and social care with dedicated funding for pilot projects; Sustainable Transformation Plans, recently replaced by Integrated Care Systems working across systems in an area based approach to integrate and synthesise services and sectors to meet the needs of the local population. Yet the simultaneous development of integrated approaches, alongside the generation of evidence to demonstrate their effectiveness and efficiency, whilst ‘the aeroplane is in flight’ – continuing to provide treatment and care for the local population -is a huge ask for even the most motivated and well-resourced teams.

2.2 The Local Context

When NHS England published ‘Next Steps on the Five Year Forward View’⁵ it signalled the intention to move to Accountable Care Systems (ACS) in the NHS. NHSE describes a key duty of an ACS to: “Deploy (or partner with third party experts to access) rigorous and validated population health management capabilities that improve prevention, enhance patient activation and supported self- management for long term conditions, manage avoidable demand, and reduce unwarranted variation ….”. Nottinghamshire (specifically the Greater Notts STP) has been identified as an area that will adopt this way of working in the first wave.

Principia is a key element of the Greater Notts STP situated in Rushcliffe, a rural and suburban area to the south East of Nottingham city with a population of 125,076⁶. Although the proportion of the population aged over 65 years in Rushcliffe is 15% higher than the average in England, the CCG area has the least deprived population in Nottinghamshire. In terms of its Index of Multiple Deprivation (IMD) score, Rushcliffe (with a score of 8) is also better than the England average of 22 (England worst – 51; best 6) and it has a lower unemployment rate (0.8% compared to the England average of 1.8%), lower child poverty rates 7.2% compared with the England average of 18.6%. As expected with significantly lower levels of deprivation, Rushcliffe displays good health outcomes as compared to the England average despite its older population. Deaths from all causes in under 65 years is at 73.9 compared to the 100 England; hospital admissions caused by injuries in children (0-14 years) is 68.2 compared to the 109.6 England average and obesity and excess weight prevalence’s are significantly better in Rushcliffe compared to England across all ages, and in many instances have the best levels in the country.

As a Multi-specialty Community Provider (MCP) organisation Principia is a local partnership of GPs, patients and community services which has been selected as one of 50 ‘Vanguards’ across the country with funding to lead significant changes in the way local health and social care services are delivered. As part of this, Principia MCP is a registered intensive “Empowering People in their Communities” (EPC) site (see appendix 1). This involves an implementation plan that includes the following elements:

1. Work with communities to grow these resources to meet health and wellbeing needs.
2. Build a network of supported volunteer roles.
3. Deliver of systematic self-care support for people with COPD, diabetes and with 3 or more long term conditions.

Principia’s ambition is to support its communities and clinical teams to begin to change the culture and approach to health and wellbeing. There is recognition that although many good areas of practice exist, but there is disconnection, fragmentation and sometimes duplication between health, local authority and third sector services. There have been tangible successes in delivering improved care and outcomes for people with physical health problems, supported by coordinated and motivated primary care services. However the “disparity of esteem” still exists for people with serious mental illness, whose life expectancy remains far lower than the rest of the population. Advances in healthcare have not been matched by progress in services to prevent illness and support self-care.

Principia aim to address these issues by investing in people and services to address this fragmentation, encourage systematic assessment of patient activation, and support routine referral of people all along the spectrum of health “risk” for self-care support. At the same time, gaps in provision will be identified with a view to further investment and development in years to come.

Principia Vanguard MCP divided population health management into 10 programmes, under the leadership of different clinical and managerial teams. However, there was a recognition that supported self-care and activation is needed across the whole population, and incorporated five MCP workstreams 1-5 (primary prevention, self-care, secondary prevention, ambulatory care sensitive conditions and mental health). The objectives of these workstreams included:

• Increase patient activation in people who see health coaches and community connectors
• Increase uptake of local authority and 3rd sector services provided to support selfcare
• Identify gaps in these services
• Reduce the financial impact on the NHS of people who access these services

3. Developing the ‘Live Well’ Model

3.1 Our Approach

The Live Well model developed through an ongoing co-productive process, continually drawing on the expertise and experience of a range of stakeholders (including General Practitioners and CCG staff with MCP roles for primary prevention/self-care), Local Authority staff including public health, reenablement, parks and leisure and IT staff, voluntary sector groups, emergency services, housing, employment, sports and leisure organisations) and increasingly, as the project progressed, responding to the experiences of staff working in the Live Well team, their clients and the community members with whom they worked. The power of coproduction has been well described (see Box 2): it is about bringing together all available expertise and experience around a shared challenge, to agree on goals, consider research evidence, share personal and professional experience and suggest possible courses of action. A coproduction group can discuss, debate, develop, test, amend and evaluate ideas over time. New solutions are generated, new group members are identified, everyone can both contribute and benefit in a synergy that is not possible in exclusive, closed or solely professional groups.

The overall model was informed by the ‘The Triangle that Moves Mountains’ philosophy that has been successful in developing complex social policy transformation in Thailand⁷. This focuses on three factors: providing relevant evidence, research and examples of practice from elsewhere; working with local people, organisations and resources to develop a ‘community sensitive’ approach over time; and engaging and influencing local leaders to create political pressure to transform systems, (see Box 1).

The Live Well coproduction group met regularly throughout the project. Initially agreeing on the nature of existing challenges, the values, aims and objectives to be met (see Box 2). Subsequently reviewing research underpinning potential approaches along with the expertise and experience presented by different members to determine the values of the project, an outline service model and a profile of the people who the project would target. There was a strong commitment to making the service accessible to anyone who felt they might benefit from it so the service initially targeted anyone over 18 years that is registered with a GP Practice in the Rushcliffe.

The ideas of the coproduction group were developed into a proposal which was successfully submitted for funding from Rushcliffe MCP Vanguard Site. The implementation of the model was then considered by the group and the project goals, objectives and time plan were agreed; values were developed. Relevant expertise within the group was utilised in the recruitment of staff (who were required to bring diverse lived and life experience which they could explicitly apply in their practice); the training of project staff (with input from coproduction group members for example Public Health England; NHS England; Local Authority leads for coproduction and for community learning.

Perhaps the most innovative aspect of the coproduction process was the ongoing influence of the group on emerging challenges and the development of new initiatives for the whole community (for example the development of new learning opportunities across the whole patch and the development of community cafés in rural areas, a university campus and small towns). These partnership initiatives – involving religious groups, local public houses, sports centres, libraries, subject specialists and self-help groups – attracted an ever increasing group of coproduction group members, including key influencers, leaders and funders so that the model gradually infiltrated and strengthened a widening range of opportunities with the synergy to impact on the whole population in the locality.

“I came along to the Co-production meeting yesterday … and what a wonderful meeting it was! I found myself reflecting on the meeting last night and how powerful the sharing of stories, backgrounds and passions were … I fully appreciate that it took time but I feel it was incredibly valuable in developing those vital relationships and genuinely coproducing a community endeavour – full of admiration for you and what Lets Live Well in Rushcliffe is achieving!”

Newark Mind – co production partner

3.2 Project Leadership

One of the counter-intuitive aspects of any coproduction is the need for leadership. Although coproduction is all about partnership on an equal basis, unless the process is informed, facilitated, led and ‘serviced’ then it will stagnate as everyone waits for someone else to speak up or develop some rules or make a decision…. Yet the challenge facing any local provider who leads the coproduction process is the inevitable competition that exists between themselves and other members: all are likely to be chasing the same limited funding and the elevation of a local group to lead a project can exacerbate rivalry. Commissioning of services is generally based on a competitive tendering process which means that some services win and others lose out on funding. Coproduction, on the other hand, is all about mutual benefit generated in an open, transparent, sharing culture: win-win.

ImROC initiated the coproduction process in the LLWiR project well before any funding was won. Following an approach from a local GP for ideas about meeting the needs of people with severe depression, it was ImROC who suggested that rather than prescribing any solution, we should seek the views of the local community and relevant services and groups about what might work – in a co-productive process. The success of the early coproduction meetings led to increasing commitment to the project by service providers, commissioners, local citizens and ultimately funders. This has driven the ambition and momentum of the project, which has been sustained by well organised, engaging, relevant and mutually beneficial coproduction meetings which reliably lead to inclusive action and progress. The role of ImROC (see Box 2) has been to:

• manage the project in line with the project plan identifying and mitigating potential risks;
• facilitate coproduction meetings and ensure that decisions and plans made in the group are implemented as agreed enable the project to evolve organically over time in response to the experiences of project staff and clients and in line with the decisions made in the coproduction group;
• seek relevant evidence and expertise to ensure that the coproduction group is working with best research evidence and practice guidance rather than relying solely on local people’s experience (as required in the Triangle that Moves the Mountain);
• lead the recruitment, training and employment of staff;
• enable and oversee the evaluation of the project within the defined budget.

Overseeing the project, a steering group (with local and national representation from all sectors as well as ‘patient’ and peer worker representation ), chaired by a local GP met regularly to review progress, challenges and risks against the project plan.

Box 3. Coproduction

Coproduction is all about bringing together everybody involved in an issue to work in partnership, make decisions, deliver solutions, evaluate, review and respond together. As Nesta¹ point out: “Co-production challenges the conventional model of public services as a ‘product’ that is delivered to a ‘customer’ from on high, and instead genuinely devolves power, choice and control to frontline professionals and the public”. By facilitating reciprocal and equal relationships, coproduction enables all participants to both contribute and benefit from the process so that change becomes more relevant, inclusive and effective. The New Economics Foundation² have claimed that coproduction is an effective way of building up the local economy engaging, enabling and expanding the resources available. In his introduction to the NEF report, Edgar Cahn explains how coproduction is the root of community development:

“If social capital is critical to the well-being of society, then we must ask what its home base and source is. Social Capital is rooted in a social economy – and surely, the home base of that economy is the household, the neighbourhood, the community and civil society. That is the economy that co-production seems to rebuild and to reconstruct”.

NEF describe the elements of co-production within public organisations as:

• See people as assets, not burdens on an overstretched system – people are the real wealth (and wasted resource) in society – more than passive recipients in services.
• Invest in the capacity of local communities – so that communities shift from expecting professionals to have all the answers and take greater responsibility for themselves, building social and cultural capital, nurturing economic and mental capital.
• Use peer support networks to transfer/develop knowledge and capabilities so become a networked organisation with multiple partners.
• Reconfigure services to blur the distinction/change the power balance between producers and consumers of services – value work differently and create a demand for all contributions and reward appropriately.
• Public service agencies thus become catalysts for change rather than simply providers.

ImROC has described their experience and learning about coproduction and conclude with Ten Top Tips for Coproduction³:

1. Gather the right people for the job.
2. Just get started and build momentum around your shared purpose.
3. Spend time agreeing the structure and the values of meetings.
4. Support every member to contribute to their full potential.
5. Tackle the challenge in small steps.
6. Listen, listen, listen.
7. Back up decisions with evidence.
8. Beware the comfort zone.
9. Look to the bigger picture.
10. Cherish what you create.

1 NESTA (2010)Public Services Inside Out. London: NESTA
2 Ryan-Collins, J. and Stephens, L. (2008) New Economics Foundation: Co-production – a Manifesto for growing the core economy
3 Lewis, A., King, T., Herbert, L. and Repper, J. (2017) 13. Briefing paper 13. Co-Production – Sharing Our Experiences,Reflecting On Our Learning. Nottingham: ImROC

3.3 Developing project goals and agreeing underpinning values

The Live Well model aims to empower and enable local people to live well within their communities drawing on local resources and meeting local needs. It has the potential to target different groups within the population (for example older people, younger people, people with specific conditions; people from different minority ethnic groups); to focus on prevention (through health education, smoking cessation, weight reduction, community inclusion) and/or ongoing support (for people with existing conditions); to prioritise different activities (such as workplace wellbeing, access to employment and engagement with services). The specific goals of every project will be different – depending on the funding opportunities, local priorities and the local situation. However, it is important for the whole community, represented in the coproduction group, to be clear and united in setting the goals and values of the project.

The process of agreeing goals and values is an effective way of bringing together the coproduction group in productive relationships. The agreement of goals provides a clear focus and parameters for the project and is key to the establishment and ongoing membership of the coproduction group. The agreement of underpinning values for the project set the culture of the coproduction process, the values are the guiding principles that are most important to the group about the way that they work together. They guide decision making, influence the nature of conversations, inform the training and supervision of project staff and the ongoing development of the project.

3.3.1 The Goals of LLWiR – developed and agreed by the Coproduction Group:

We aim to improve the lives of people in Rushcliffe who are isolated, inactive and/ or have long term condition(s) by:

• Supporting and enabling them to do the things they want to do – demonstrating an increase in roles, relationships and activities and improvement in personal goal attainment scales.
• Increasing their understanding of their own condition and improving their ability and confidence in managing their own condition – demonstrating improvement on PAM Scores.
• Reducing their reliance on health services – demonstrating reduction in crises, unplanned admissions and frequency of GP attendance.
• Increasing engagement in local communities – demonstrating increase in activities, engagement with local community amenities, and achievement of personal goals.
• Increasing partnerships between different organisations and sectors to reduce duplication and gaps between services – demonstrated in discussions at coproduction meetings.
• Identifying gaps and developing new, accessible opportunities – demonstrated by collecting weekly updates about their community development activities from link workers.

3.3.2 The Values underpinning LLWiR – developed and agreed by the coproduction group

Live Well draws on the extensive experience of coproduction group members. Their collective belief in the potential of all citizens reflects a ‘Recovery’ approach. The term Recovery has been reclaimed by people with mental health problems to refer to their ability to live well in the presence or absence of symptoms of their condition⁸. For services to focus on Recovery they need to shift their focus from symptoms and problems to strengths, assets, experience and goals. For people to achieve recovery they need to identify their own goals – and work out what sort of information and support will enable them to achieve these goals. For communities to support recovery they need to become more confident about their own abilities to accommodate, support and benefit from the contributions of people who experience different conditions. Our values are quite simply:

To always inspire Hope by demonstrating our belief in people: everyone has the potential to live a more fulfilling and satisfying life.

To empower people to take Control of their own condition, their own treatment and their own lives.

To enable people to access the Opportunities (facilities, activities and resources) that will enable them to achieve their life goals⁹.

3.4 Integrating the service into GP practice

Living Well was originally conceived as part of the Rushcliffe NHS new care models vanguard- Principia MCP -and a business case was written and accepted to fund a pilot project that has evolved to become Lets Live Well in Rushcliffe. The return on investment was predicated on a reduction in the use of NHS services by people supported by the service. It was designed to be integrated and colocated with NHS GP services: this was necessary to get the service up and running, using the regular contact that people have with GPs and health centres to drive uptake and visibility.

In the first phase there have been three different referral pathways. Firstly people who are opportunistically identified during consultations with GPs are offered a health coach assessment. Secondly, patients attending for their annual long term condition health check, usually with a nurse, can be offered a referral. Finally, GP computer disease registries were analysed for people with characteristics suggesting they may benefit from the service, and invited by letter. Examples included people with serious mental illness at risk of developing further long term conditions.

Referrals have been made as easy as possible using a simple “E-referral” system embedded in the clinical IT system used by health care professionals every day. Health Coaches and Link workers use the same system to record their activity, making it simple for NHS professionals to see what has happened.

General Practice teams continuously recognise people who’s health wellbeing are influenced by psychological and social factors more than medical issues. It has been a source of frustration for GPs and nurses that they have had neither the time to address these problems, or any places to direct patients for support.

As GPs on the steering group have reflected, many clinicians have felt it is their job to deal with medical problems alone, with many very reluctant to explore concepts such as activation, address the social determinants of health, or support lifestyle change. With these factors in mind, there has been a concerted effort to communicate the benefits of Living Well during the first few months. GP leaders have visited practices, attended MDT meetings and presented at educational events. The evidence base for this approach, detailing the potential improvements in quality of life for Rushcliffe citizens, alongside reductions in use of NHS services has been emphasised. Real-life stories of local patients whose attendance at the GP surgery has dramatically dropped following their introduction to the service has helped support this message.

‘There is a feeling, supported by the early evaluation interviews, that hearts and minds are changing amongst medical teams. All practices, and most GPs have made at least one referral to Living Well. Stories of people’s lives being transformed are being discussed in clinical teams. The early adopters and enthusiasts are delighted to have an option to help people in a truly holistic way’

GP on steering group

4. Components of the Live Well model

4.1 Community Development

The Live Well model seeks to address the needs of the local population not only by changing local services, but by engaging and developing the communities that they serve. This allows health and social care services to focus on those people requiring specialist treatment and support, whilst communities offer roles, relationships and supports to maintain the wellbeing of the whole population. All communities offer a wealth of untapped resources, expertise and interest. There is ample evidence of the generosity, expertise and support that exists within communities, perhaps most marked in those facing crises – seen most recently in the UK following the Grenfell disaster. Community development approaches have rapidly developed over the past three decades (although different names have been used to describe this work – increasing social capital, community empowerment, improving social value, participatory and action research methods…). They essentially refer to working with communities to identify and build on existing resources, develop new resources, give everyone the opportunity to both engage and benefit from their community and contribute to it (see Box 6).

Within the Live Well project, new relationships have been developed in the coproduction group leading to partnership initiatives to meet the need of Live Well Clients and local communities. For example the Local Authority funded Library service has worked with link workers to a) increase the range of learning opportunities accessible and relevant to Live Well clients (including selfmanagement courses); b) increase the use of existing library facilities and opportunities by Live Well clients; and c) develop new courses and groups running in libraries. These new courses and groups are available to everyone in the community, not only Live Well clients – thus benefitting the whole community.

‘Following a ‘meet your village’ event in East Leake, LLWiR will be working with the Rotary Club, Lings Bar hospital and others to establish a Dementia café in East Leake and Kegworth. Rushcliffe Golf club want to meet with LLWIR and have offered use of their facilities to support a dusk time walking group. They are approaching Sport England to explore opportunities for golf to be more accessible in the community.’

Health Coach

Link workers and Health coaches are employed in one specific CCG care delivery group (localities of North, Central and South) and an early priority for each of these ‘placebased’ teams was community asset mapping. This involved visiting local resources and facilities and sharing the nature and purpose of the Live Well team as well as gaining an understanding of the resource: who it serves, what it offers, how accessible it is, whether they would like any further information or engagement with the Live Well team. This work was invaluable in the success of the Live Well project. Local teams were able to signpost clients to appropriate activities and to the right people within those activities. Local resources were able to join the coproduction group if they were interested. They might receive training and other types of support from the Live Well team to improve their accessibility and confidence (so, for example training on ‘working with people who hoard’ was offered at the request of the Fire Service and Housing Associations). Some worked in partnership with the team to develop new activities; others offer material support to the team (for example free facilities for groups).

Since starting the Notts County Football in the Community groups in Cotgrave and East Leake, we have had one gentlemen who has really benefitted from the groups who struggles with anxiety. He said: “I have opened up more to you guys in two sessions than I have with any therapist”

Link Worker Community Development

Setting up the East Leake Walking Group

I met with an individual at a health week event in December 2017 in East Leake Library. This individual and her daughter were keen to start a local walking group as there was nothing around locally with the nearest group being in Ruddington. Together, we agreed to make this idea a reality and begin building the group together. I met with the two on several occasions and helped them with creating a digital flyer to advertise the group as well as getting the group onto the Notts Help Yourself website. I helped to get the advertising material printed and distributed. On the 11th of January the group had its first walk with a good group of people turning up. I supported this group continuously on the walk each week thereafter. The walk commences each Thursday at 1.30pm and ends with a cup of tea or coffee and a chat in the local café. It has been fed back that the group is a really brilliant way to be active for those who want gentle exercise, but also a fantastic group of people to socialise with who are very welcoming and generally nice.

Anne, the walking group lead had this to say recently:

“Last week we had a bumper turn out with 9 people walking, two new people and 10 for tea!

We have now had 19 walks, 18 different people involved and 111 attendances which average out at about 6 people each week.”

This group is looking like something that will be around for a long while in the future.

Box 4. Community Development

What is community development?

Community development is variously defined as either a process or an outcome; a socio-political movement or an interpersonal phenomenon¹. It includes:

• Empowering communities by strengthening the capacity of people as active citizens through their community groups, organisations and networks, and
• Empowering institutions and agencies to work in partnership with citizens to shape and determine change in their communities.
• Promoting the voice and action of disadvantaged and vulnerable groups by working with excluded groups in active process of participation, learning, action and reflection.
• Promoting strong communities by facilitating full active partnership in a mutual and reciprocal solution focused process focused on common problems or the prevention of such problems; increasing the confidence and capacity of local communities to understand, accommodate and appreciate everybody in the local population.
• Facilitating collaboration between individuals, interest groups, government, local organisations and funding agencies.
• Supporting the local population to define and voice their own wishes and needs and maximise their political influence (to achieve funding, support, recognition…).

In practice these processes redefine the relationship between the secondary and primary stakeholders so that the role of the outside agent shifts from ‘expert’ to enable; from advisor to catalyst releasing the ‘power-from-within’ the primary stakeholders².

What do we mean by Community?

Within the Live Well model, we are primarily focusing on the population of a defined geographical locality, within this locality we focus on specific communities – these might be defined by interest, condition, profession, religion, politics, gender, culture or age, and we prioritise those whose needs are not being met with existing resources. The people who we work with are often multiply excluded on the basis of different characteristics such as (dis)ability, personal resources, race, religion, reputation and age. People with mental health problems, particularly schizophrenia, are among the most excluded in Western society so particular attention is paid to their inclusion in all Live Well coproduction processes.

Asset-Based Community Development³

(ABCD) “While deficit approaches focus on problems and deficiencies and designs services to fix these problems, they create disempowered and dependent communities in which people become passive recipients of services rather than active agents in their own and their families lives”. The Live Well model draws on ABCD as it is a well tried and tested approach which: Identifies health enhancing assets in a community; Sees citizens as co-producers of health and wellbeing rather than passive recipients; Promotes community networks and relationships that provide caring, mutual help and empowerment; Supports individuals wellbeing by increasing selfesteem, coping, resilience, relationships and personal resources; and Empowers communities to take control over their own future and values and create tangible resources such as services, funds and buildings.

1 Wallerstein N. Empowerment to reduce health disparities. Scandinavian Journal of Public Health, 2002, Suppl 59:72–77
2 Fetterman DM. Empowerment evaluation: building communities of practice and a culture of learning. American Journal of Community Psychology, 2002, 30(1):89–102
3 http://www.assetbasedconsulting.net/uploads/publications/A%20glass%20half%20full.pdf

4.2 Social Prescribing

Many people in the UK live in situations that have a detrimental effect on their health, indeed, it has been estimated that around 20% of patients consult their GP for what is primarily a social problem and 15% of GP visits are for social welfare advice¹⁰. Social prescribing is a way of linking primary care patients who have ‘psycho-social problems’ with sources of appropriate, non-medical support in the community. This has been seen as one way of making General Practice sustainable¹¹ an approach to integrating health and social care with the voluntary and community sector.

Social prescribing began as a way of engaging people with mental health problems with activities and supports within their communities as a non-medical referral option to improve health and wellbeing¹². It has developed into various forms, all offering support to people who are inactive, isolated and/or struggling with a long term condition. Whilst there are social prescribing initiatives that focus solely on ‘prescriptions’ for nonmedical support from general practitioners, others are based entirely in the voluntary sector. Whilst some focus entirely on arts or exercise prescriptions, others offer prescriptions for broader social support. Whilst some have narrow referral criteria, targeting people with certain conditions or levels of disability, others offer support to anyone who is referred or self-refers. Whilst some link people to a few selected groups, others link people with a range of resources determined by the person’s personal interests and goals. Whilst some offer information and signposting, others offer face to face practical support.

Social prescribing schemes generally have three key components:

i) a referral from a healthcare professional,

ii) a consultation with a link worker and

iii) an agreed referral to a local voluntary, community and social enterprise organisation.

“After working with the link worker I swim regularly which helps me manage my pain, I drive to new places unsupported, which helps me do the things I want to do! My next step is to volunteer with LLWiR”

Studies into the effectiveness of social prescribing are generally small, conducted over short time periods with different outcomes measured, however results are promising. The most recent systematic review of research into social prescribing concludes that: “Such interventions have been found to be cost-saving¹³, able to address the mental health needs of hard-toreach populations¹⁴, ¹⁵and help to combat loneliness¹⁶. Importantly, the provision of care outside clinical settings can facilitate the development of social relationships and widen individuals’ social networks. … Social relationships are positively associated with better physical and mental health, and have been shown to reduce mortality risk to an extent that is comparable to stopping smoking and reducing alcohol consumption¹⁷”,¹⁸.

The Live Well approach to social prescribing has been developed in the coproduction group. Rather than providing a service that simply connects clients with existing groups, this has focused on link workers engaging with people to identify their own goals. Using our ‘Green Book’ (another coproduced product, see Box 9), people are supported to develop their own wellbeing plan, working out how they can keep themselves as well as possible, how to recognise and respond to signs that they are having a bad day or ‘relapsing’, and planning action they can take to prevent a crisis. The Green Book also draws on the Five Ways to Wellbeing¹⁹ to support people to generate personal goals and prioritise ‘SMART’ action plans to begin working towards these goals. Link workers will support people over 6-8 sessions; for some people, support will include identifying and engaging in existing local groups or activities, for others it will focus on changing their behaviour – in relation to diet, daily routine, exercising or socialising; for others it will involve considering their employment – diary/time management, organising appropriate adjustments to their role, accessing relevant training. Where there are no appropriate groups or resources locally, the local Live Well team will consider how and whether to set up a new group, or they may come back to the coproduction group for their advice and ideas about how to respond – asking the group: who can help with this, what exists elsewhere, where is there relevant expertise and experience in this area.

An individual was referred to me via the GP. The individual struggles with managing their Type 2 Diabetes as well as feeling lonely due to the passing of their partner. The individual was not routinely taking their medication to best manage their Diabetes as they didn’t see the point. Since my contact with the individual, we have sorted home delivery of her medication to help her to be better organised in taking them at the correct times. We also discussed using weekly tablet trays and this individual has since not missed any of her medication. We worked a lot on motivation and have seemed to make good improvements. They feel much better in themselves and we are now working with them to join a walking group, something the individual wants to do to meet new people and get some exercise to help the management of their condition. Very positive steps are being made and I can see the difference in this individual’s attitude myself. They are much more positive now since our contact.

Box 5. The Green Book

Everyone referred to Live Well is provided with a ‘Green Book’. This is a self-completion tool with information and encouragement to work out how to keep well, prevent relapse, identify personal goals and make a plan to achieve these goals.

The Green Book draws on Wellness and Recovery Action Planning (WRAP)¹ to help people recognise their own understanding of their condition and build on this to keep themselves well. It begins by supporting people to identify what makes them feel well, what seems to make them unwell, stressed or miserable (triggers) and how they recognise signs that they are becoming unwell. It goes on to help them use this information to make a plan to increase the things that keep them well and mimimise or avoid makes them, then to make a plan for managing early warning signs.

The Green Books uses the Five Ways to Wellbeing² to help them to identify some personal goals that are meaningful them and build on their interests and experiences. Evidence suggests small changes in these areas can help to improve personal wellbeing:

• Connect – There is strong evidence that indicates that feeling close to, and valued by, other people is a fundamental human need and one that contributes to functioning well in the world.
• Be active – Regular physical activity is associated with lower rates of depression and anxiety across all age groups. Exercise is essential for slowing age-related cognitive decline and for promoting well-being.
• Take notice – Reminding yourself to ‘take notice’ can strengthen and broaden awareness. Studies have shown that being aware of what is taking place in the present directly enhances your well-being and savouring ‘the moment’ can help to reaffirm your life priorities. Heightened awareness also enhances your self-understanding and allows you to make positive choices based on your own values and motivations.
• Learn – Continued learning through life enhances self-esteem and encourages social interaction and a more active life. Anecdotal evidence suggests that the opportunity to engage in work or educational activities particularly helps to lift older people out of depression. The practice of setting goals, which is related to adult learning in particular, has been strongly associated with higher levels of wellbeing.
• Give – Individuals who report a greater interest in helping others are more likely to rate themselves as happy. Research into actions for promoting happiness has shown that committing an act of kindness once a week over a six-week period is associated with an increase in wellbeing.

The Green Book helps people to think about ways they could increase their activities in these areas and uses this process as a way of enabling them to set personal goals and make more detailed action plans.

Since the Green Book is a loose leaf booklet, individuals can add their own notes, and they can insert specific tools and information (coproduced by the Live Well team) as relevant to their own condition and lives.

1 http://mentalhealthrecovery.com/
2 http://issuu.com/neweconomicsfoundation/docs/five_ways_to_well-being?mode=embed&viewMode=presentation

4.3 Health Coaching

One of the underlying problems of our time is the construction of all health and social care problems as requiring professional help – from health and social services. We are increasingly a nation of ‘consumers’ socialised into believing that the best sources of help for our problems – whether long term pain, disability, mental health and physical problems or housing, employment and isolation – comes from public services. We have lost confidence in our own abilities to manage our own lives and conditions, and the breakdown of traditional communities contributes to a lack of confidence in communities as a resource to which we can contribute and from which we can gain meaningful roles and relationships. Many people who are house bound, disabled by ongoing mental and physical conditions, anxious about going out and meeting people, lacking confidence following diagnosis or illness have no understanding of their condition and how to manage it, they are not aware of what is possible for them or of what sort of supports and activities exist in their local community. In reality, we can all make a difference to our own health – whether preventing conditions arising or managing a long-term health conditions. It has been estimated that as many as 70 per cent of premature deaths are caused by behaviours that could be changed (Schneider, 2007). Clearly, huge benefits could be realised if people felt able to take a more active and engaged role in their own health care.

Research into ‘patient activation’ demonstrates the positive impact that empowering people to manage their condition and thereby continue a more active and meaningful life can make on health inequalities, outcomes, the quality of care and the costs of services (Box 10). A new role has developed to support patient activation: ‘health coaching’, which focuses on enabling the person to gain new skills in managing their condition, encouraging a sense of ownership of their health, considering changes to their social environment to support their wellbeing, and linking with relevant education, activities and opportunities.

Within the Live Well Model, the Health Coaches receive training in coaching and patient activation; they work closely with primary care teams to clarify their role and the sort of people who might benefit from health coaching. They supervise the link workers in their area and are the local contact point for anyone wanting to contact the team or considering making a referral. Health coaches see all new referrals to the service, initially engaging and assessing their situation and agreeing a way forwards that is most suitable for that person. Health coaches are not experts in long term conditions and their treatment, rather, ‘they are experts in not being the expert’²⁰, they work in partnership with the client to find out the information and gain the skills the person needs. This might be through locating relevant literature either on the internet or in paper form; it might involve finding a relevant course or self-help group in the locality, it might be solution focused work or problem solving to work out a plan of action. The focus is largely on health related behaviour, with support being provided over 1-5 sessions. Where ongoing or social support is needed the health coach introduces the client to a link worker.

Saw a 54yr old in Jan 2018…BMI 35, 40u /week daily drinker, hypertensive with a new diagnosis of type 2 diabetes. Offered meds for the DM but he declined saying he wanted to adjust his lifestyle. He’s been working with the health coach on goal setting for the past 4 months. In 12 months, he has dropped his Hba1c from 63 to 44, drinks lightly now on only two days /week and has lost a decent amount of weight.

It’s all going really well, I’m drinking less, I’ve not had a cigarette for 4 weeks and my link worker is supporting me to become a volunteer– Thank you!”

Feedback from GP

Box 6. Patient Activation and Patient Activation Measure (PAM)

In the Kings Fund’s review of the research into patient activation, Hibbard and Gilbert¹ conclude that patient activation is a better predictor of health outcomes than known socio-demographic factors such as ethnicity and age, with people who are more activated being significantly more likely to attend check-ups, adopt positive behaviours (eg, diet and exercise), and have clinical indicators in the normal range (body mass index, blood sugar levels, blood pressure and cholesterol); and people who are less activated being significantly less likely to prepare for a medical visit, know about treatment guidelines or be persistent in clarifying advice. Not surprisingly, patient activation scores are related to cost to services with less-activated patients costing approximately 8 per cent higher than more-activated patients. Studies of interventions to improve activation (such as Health Coaching) show that people who start with the lowest activation scores tend to increase their scores the most, suggesting that effective interventions can help engage even the most disengaged.

The Patient Activation Measure² (PAM) is a simple, evidence-based tool for establishing the capacity of individuals to manage their health – and then using that information to optimise the delivery of care. PAM scores have been demonstrated to be related to most health behaviours, many clinical outcomes, health care costs and patient experiences. The Principia Vanguard applied to NHS England to be an intensive pilot site for “Empowering People & Communities” and as a result were accepted to use PAM, one of three intensive EPC sites across East Midlands. Within the Live Well model, the PAM is included in all baseline assessments to establish the intensity and focus of subsequent support. It is measured at three monthly intervals to provide both the health coach/link worker) and the patient with feedback about progress.

The PAM consists of 13 statements about beliefs, confidence in the management of health-related tasks and self-assessed knowledge designed to assess the extent of a patient’s activation. Patients rate the degree to which they agree or disagree with each statement giving a combined single activation score of between 0 and 100. For the purpose of intervention, these scores are divided into four groups or levels of activation, each requiring a different level and type of support.

• Level 1 – Individuals tend to be passive and feel overwhelmed by the idea of managing their own health. They may not understand their role in the care process.
• Level 2 – Individuals may lack the knowledge and confidence to manage their health.
• Level 3 – Individuals appear to be taking action but may still lack the confidence and skill to support their behaviours.
• Level 4 – Individuals have adopted many of the behaviours needed to support their health but may not be able to maintain them in the face of life stressors.

1 Hibbard, J. and Gilbert, H. (2014) Supporting People to Manage their Health: An introduction to Patient Activation. London: Kings Fund
2 Hibbard JH, Collins PA, Mahoney E, Baker LH (2010). ‘The development and testing of a measure assessing clinician beliefs about patient self-management’. Health Expectations, vol 13, no 1, pp 65–72.

4.4 Education

Education is central to personal ‘power’, identity and autonomy, status and life choices, so inevitably it is closely linked with health and wellbeing. In relation to general education, an additional four years of education lowers five-year mortality by 1.8 percentage points; it also reduces the risk of heart disease by 2.16 percentage points, and the risk of diabetes by 1.3 percentage points. People who are better educated report having lower morbidity from the most common acute and chronic diseases (heart condition, stroke hypertension, cholesterol, emphysema, diabetes, asthma attacks, ulcer) and are substantially less likely to report that they are in poor health or have anxiety or depression and spend fewer days in bed or not at work because of disease. Whilst we can rarely address a lack of general education, we can offer health related education to enable people to understand how to keep themselves well. In a review of the impact of health education, Lawn et al (2011) report improved self-management, reduced crises and unplanned admissions, reduced frequency of service use, improved social networks and greater confidence and self-efficacy. The development of Recovery Colleges (Perkins et al, 20011; 2018) offering coproduced, experiential and recovery focused education, primarily for people with mental health problems – but increasingly open to the whole population – has demonstrated the huge popularity, accessibility and benefits of learning with and from peers (see Box 11).

The Live Well project did not set out to provide self-management courses or group based learning opportunities, but it became apparent that many clients wanted to learn about their condition and how to manage their lives with their condition, but accessible, condition specific courses were not always available. Whilst a Recovery College does exist in Nottingham this is only open to people using secondary services and in primary care teams funded to provide courses.

The coproduction group considered this challenge and the Local Authority funded Inspire²¹ project offered to work in partnership with link workers to enhance the accessibility of courses and the range of learning opportunities already offered in local libraries to meet the needs of Live Well clients. In addition, specific courses were developed in response to identified need, for example healthy eating courses have been developed in partnership with a local nutritionist to provide dietary information alongside cookery classes for people who want to develop their own understanding and skills but do not feel able to join mainstream education.

As the project progressed, it became clear that local groups and services would also like to be able to access training to enable them to maximise their contribution to local people with long term conditions. This challenge was discussed at the coproduction group who drew on their expertise, networks and experience to focus on the best way of strengthening learning opportunities within the locality. The group were able to produce a list of learning opportunities already available and identified the need for additional courses focusing on self-management. It was agreed that a part time trainer should be employed to coproduce (with a peer link worker) bespoke training in subjects nominated by the coproduction group, like ‘mental health awareness’, ‘setting up community groups’, ‘understanding and managing hoarding behaviour’, for any member of the coproduction group, any of the Live Well team and any clients who would like to attend. In addition, to sustain the provision of training, Live Well staff were offered ‘training for trainers’ an accredited training course that enabled them to coproduce and co-facilitate training wherever it was needed.

Box 7. Recovery Colleges – Core Principles and Evidence of Effectiveness

Recovery Colleges have developed over the last ten years to become a key feature of mental health services in the UK and beyond. More recently they have developed in primary care, forensic, homeless, housing and third sector services. They offer courses based on the wishes and needs of those who use them and embody a shift from a focus on therapy to the inclusion of education to enable students to learn how to manage their own condition and their own life – housing, diet, sleep, activity, relationships …. They explicitly bring together the expertise of lived experience and professional expertise in an inclusive learning environment in which people can explore their possibilities.

Although there are now more than 85 Recovery Colleges in England, to date there are no formal controlled trials exploring their effectiveness. However, there is a strong and consistent body of evidence from an increasing number of uncontrolled studies of the positive impact of Recovery Colleges in several areas.

• The effectiveness of Recovery Colleges on people facing mental health with the vast majority of students achieving personal goals, moving on to volunteering, training, open employment and education.
• The quality of recovery-supporting care: Recovery Colleges are popular and students are highly satisfied with their experience.
• Positive evaluation of the staff attending Recovery Colleges
• Recovery Colleges are an effective vehicle for driving a change in the culture of organisations with improved staff attitudes and understanding and a higher value placed on coproduction and peer support.

Perkins et al²² review the development and research into Recovery Colleges and conclude with 6 key principles that both define them and account for their success.

1. They are based on educational principles but do not replace formal individual therapy or mainstream educational opportunities.
2. Coproduction, co-facilitation and colearning lie at the core of their operation: they bring together lived/life expertise with professional/subject expertise on equal terms.
3. They are recovery-focused and strengths-based in all aspects of their functioning. They do not prescribe what people should do but provide a safe environment in which people can develop their understanding to keep themselves well and build skills and strategies to live the lives they wish to lead.
4. They are progressive, actively supporting students to move forwards in their lives both by progressing through relevant courses that enable them to achieve their identified goals ,and by identifying exploring possibilities outside services where they can move on in their lives and work.
5. They are integrated with their community and can serve as a bridge between the services and communities: serving as a way of promoting a recovery-focused transformation of services more generally, and creating communities that can accommodate people with long term conditions.
6. They are inclusive and open to all. People of different ages, cultures, genders, abilities and impairments, as well as people in local communities who have health conditions/physical impairments), people who are close to them and people who provide services.

Education – Case example

I have been supporting an individual in the Rushcliffe South area to reconnect with their local community in the hope that this will support them to further manage and reduce their anxiety. This anxiety has adversely affected employment and living arrangements, and social circumstances.

The individual wants to start gaining some more independence and manage her anxiety throughout the whole day. I have worked with the Individual to explore their needs and identified the possibility of attending courses which would benefit wellbeing, ideally close to home and with small class sizes. We have researched some local groups with smaller class sizes and closer locations.

Part of this work has been to liaise with Inspire (the library education service) to see if they could extend their courses to more local libraries. Inspire have now offered a taster course at the local library, with a possible view to expand. The individual has been accompanied to first few courses and says that accessing the course at their local library helped them to build friendships and networks with people in their local community. Further joint investigation of what the Community can offer is underway regard a range of activities. All the time the team is allowing the individual to express her needs and then look to see what the community can offer.

4.5 Peer Support

There is increasing evidence that support from a person who shares similar experiences and is managing their own wellbeing improves outcomes when compared with standard support²³. Although this evidence draws on research undertaken exclusively in mental health services, the LLWiR team and the coproduction group agreed that employees providing health coaching and link working would bring their own experience of living with a long term condition themselves, or caring for someone who does – in addition to the other desirable and essential characteristics of community support workers. This built on ImROC’s experience of developing opportunities for peer support (including training, supervision, supportive employment and development of peers), it also provided an inspirational example for people using the service to follow and was consistent with the coproduction approach at the heart of the project.

Peer support refers to the explicit use of personal experience in the support of others who share similar experiences. The core characteristics of effective peer support have been identified (see Box 8) and the training provided for all employees focused on them understanding and applying these principles in their practice.

Employing peer workers ensures that the project remains true to its values with integral reflection on the accessibility, appropriateness, relevance and likely effectiveness of the developing approach. People who live with a long term condition and manage it on a daily basis bring practical expertise and experience to every aspect of their work. However, the successful and effective employment of peer workers requires exemplary employment support so that they stay well in work and contribute to their full potential. This is not ‘special’ support, but the kind of consideration that every employee would benefit from. For example consideration of reasonable adjustments, a personal wellbeing at work plan, access to additional supervision when times become difficult for an employee.

The preparation and training of all team members was given careful consideration within the coproduction group, and by the ImROC team. An over view of their training is given in Box 9. This was supplemented with monthly team meetings which provided a forum for ongoing development as training needs arose. Issues addressed in this way included: Supporting people in acute crisis; Supporting people to set personal goals; Starting and ending relationships with people you work with.

“The service is one of the major big things that helped me to get better. In fact, I would say that it has been the most important thing in me getting better. I had never spoken to anyone on that level before or with someone who knows what it feels like. Whenever my link worker left I would always feel massively better and like a weight had been lifted off my shoulders. It has taught me how to be compassionate to myself and look after myself”

Case example – Peer Support

In the first meeting with this A, they were very negative. They believed nothing could help them and that they were unable to physically do anything and therefore felt like they had no purpose and no belonging. This person suffers from depression as well as some physical conditions that mean they cannot use their hands, which is how they used to earn their living.

In the second meeting, I tried to keep the conversation as positive as possible. However, the individual kept bringing the conversation back to the past and everything they had lost. I explained through a diagram that things in the past can feel like a large chunk of your life and that we think these feelings will get better in time and that the impact of the past on our lives will get smaller with time. However, I understand that this is not the case. I gave an example of a time when I experienced loss myself and explained that for me, the impact of that on my life didn’t get smaller as time went on. Therefore, to make the impact of that loss in my life smaller, the only thing to do was to grow my life in other areas. Make sure I was seeing friends/family, make sure I was active and doing things, make sure I was taking notice of what I did have and making sure I was trying and learning new things. This seemed to resonate with the individual quite well. The meeting from that point on seemed very positive and we spoke of things they were looking forward to and came up with a plan of what we could discuss in future meetings to help produce of ideas in which the individual could try to ‘grow’ their life to make the past seem smaller in comparison to their overall life.

They said “I really appreciate you coming to see me, talking really does help”.

4.6 Specialist Areas of Interest

The Live Well model offers a range of interventions and types of support to people with a range of different conditions and life circumstances. It is simply not possible for every employee to hold every piece of information about community resources, conditions, approaches and population groups. It therefore works well to support link workers and health coaches to develop an area of special interest. This might draw on their life experience or their previous employment experience, their interests and hobbies or their cultural awareness. For example, an employee with experience of work in a sales and marketing job might take a lead on social media developments; an employee with interest or a qualification in teaching might lead the development of learning opportunities; another might take a lead on sustaining community developments, or working with younger/older people.

These areas of specialist interest need to have direct relevance and utility within the project, so they might not be apparent when the project starts, but can evolve over time. They ae yet another way of modelling Recovery focused practice: building on personal strengths and interests, developing individuals so that they can progress their career.

Within LLWiR, it became apparent that community groups developed by link workers needed additional attention to ensure that they become sustainable in the longer term with less input from the project. A link worker with previous experience of community development was given the lead on monitoring, sustaining and creating a consistent process for developing new community groups and resources. Another worker with an interest in IT and apps development took a lead on working with the University to develop a mobile phone application which listed details of local groups and resources already existing in the area, building on the resources listed on the Notts Help Yourself website. Once it became apparent that volunteers would be employed in the project, one of the link workers with experience of staff support and supervision took the lead on working with the Council of Voluntary Services to develop the volunteer pathway. Many other opportunities have been taken up by employees in line with both their own areas of interest and the evolution of the project.

In order to be successful, these roles need to be rewarding in themselves rather than exploitative. It is important to integrate the roles in personal development plans, support individuals to access relevant training and ensure that supervision covers these areas.

When carefully managed, this system of distributed leadership not only provides personal development opportunities for employees on the project, it also offers a framework for project development, a method of growing the sum of expertise within and available to the whole team, and an approach to working with coproduction group members in a rational and effective manner.

4.7 Developing a Library of Relevant Resources

Resource Library

As the project has worked with many people who face similar challenges, have similar goals and present similar dilemmas for workers, a huge amount of work has been undertaken by both employees in the service and the people they support to research appropriate coping strategies, supportive tools, services, groups, activities. Rather than individuals repeatedly undertaking the same research, all relevant material has been collected together, reviewed and develop into Live Well guides.

So, for example there are now toolkits, information booklets and lists of useful resources for many different long term condition and there is a growing compendium of local services, facilities, activities, groups and clubs available in the local area. These are formatted in such a way that people can insert them as pages into their Green Book.

As the team has developed, there have been a number of difficult situations which have fallen outside the experience and role of the team so the team has drawn on external expertise to develop clear pathways and guidance for managing these. For example, the team has developed Ten Top Tips for supporting someone expressing suicidal ideas and a pathway for accessing appropriate help.

At present these resources are all maintained on a team shared drive, but as the LLWiR mobile phone app is developed this ever expanding library of information will be available to all those using the service.

4.8 Volunteers

The Live Well model offers time limited support (up to 6 meetings with health coaches and/or up to 6 meetings with link workers). Inevitably there are people who would benefit from longer term support to enable them to continue to work towards their goals. Similarly, the goal for new groups and activities set up by Live Well is to become independent and sustained within and by their local community on a voluntary basis.

People who receive support from Live Well, and those who attend Live Well groups are often keen to continue their involvement as a volunteer but their role is limited if there is no process for them to gain DBS clearance and relevant training.

Once again, this situation was communicated to the coproduction group who shared their experience of managing similar challenges and offered their support in various ways. It was agreed that funding from the project would be provided to Rushcliffe Council of Voluntary Services to train and employ volunteers to work on Live Well initiatives.

A small working group was set up to develop appropriate recruitment procedures, training and ongoing supervision of volunteers. Rather than preparing volunteers for one specific role within Live Well, a Rushcliffe wide system was developed so that once recruited, checked and trained, volunteers are able to work with individuals as befrienders, or supporting groups and activities.

The first cohort of volunteer trainees included 22 ex-Live Well clients who wanted to ‘give something back’ and continue their involvement with the project.

Box 8. The core principles of peer support²⁴

1. Mutuality – The experience of peers who give and gain support is never identical. However, peer workers in mental health settings share some of the experiences of the people they work with. They have an understanding of common mental health challenges, the meaning of being defined as a ‘mental patient’ in our society and the confusion, loneliness, fear and hopelessness that can ensue.
2. 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.
3. Non-directive – Because of their claims to special knowledge, 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 help people 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.” (Recovery Innovations training materials. For details see www. recoveryinnovations.org)
4. Recovery-Focused – Peer support engages in recovery focused relationships by: inspiring HOPE: they are in a position to say ‘I know you can do it’ and to help generate personal belief, energy and commitment with the person they are supporting; supporting people to take back CONTROL of their personal challenges 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.
5. 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.
6. Inclusive – 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.
7. 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.
8. 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.

Box 9. Overview of training provided for Health Coaches and Link Workers

A 10-day training programme.

Most of the training was developed and delivered by the ImROC project team and includes some content from established recovery and peer support training programmes delivered by ImROC. Some was delivered by local and national experts.

A broad outline is included below:

Day 1 – Understanding personal care and support planning – delivered by NHSE

Day 2 – Getting underpinning principles of LLWiR: “lets be…”, project and roles, recovery principles, co production, exploring, negotiating working within our values and principles

Day 3 – Health coaching and using the PAM – delivered by NHSE

Day 4 – Essential Skills: Active Listening and Problem Solving, developing part one Green Book

Day 5 – Goal setting, goal attainment scaling and 5 ways to wellbeing, part two Green Book

Day 6 – Using lived and life experience safely, appropriately and effectively, lone working policy

Day 7 – Supervision and personal development, supervising staff / volunteers, developing a recovery focussed supervision protocol , developing your life passion at individual, practice and community level

Day 8 – LLWiR evaluation – what this means in practice – delivered by Clifford Stevens and team NTU

Day 9 – Co production reviewing content of Green Book, community development ABCD

Day 10 – Health Coaching part two – NHSE

Ongoing Training and Development

The team meets for one day every month to focus on shared issues that need further consideration. Thus, meetings include a catch up – sharing progress, achievements, challenges and questions, then goes on to provide training on a particular subject, often with an external trainer, for example:

• Supporting someone in crisis
• Problem-solving and setting personal goals
• Understanding the contribution of various community organisations and services
• Setting up a community group ….

In addition all members have monthly personal supervision, and can access support from the project manager or their health coach whenever they feel they need it.

5. Evaluating LLWiR

Evaluation of Let’s Live Well in Rushcliffe (for full report see Dr Moon Halder, Elizabeth Mair, Dr Juliet Wakefield, Dr Blerina Kellezi, Dr Niamh McNamara, Dr Mhairi Bowe, Dr Iain Wilson & Dr Clifford Stevenson (March 2019) Evaluation of the Let’s Live Well in Rushcliffe Initiative: Final Report FULL REPORT WITH TECHNICAL APPENDICES, Department of Psychology, Nottingham Trent University)

A full evaluation of the project was undertaken by Nottingham Trent university to assess impact on health and service use. This study reported significant improvements in patients’ physical and mental wellbeing after the initial four month period which were maintained after eight months. There was also an increase in community group membership at 4 months which reduced slightly by 8 months. There was a decrease in both primary and secondary care usage over the evaluation period. The economic evaluation of the programme attached savings to the improvements in health as well as the changes in health and social care usage. Projected over a year post-baseline assessment, this estimates a ROI of £1.00. In other words, if the patient benefits recorded for the first four months are continued for the rest of the year, the programme will recoup 100% of its costs by January 2020.

The Nottingham Trent University (NTU) evaluation set out to capture the degree to which the LLWiR pathway impacts upon the health and service use of its beneficiaries. Accordingly, it involved three studies: a patient survey study to establish the extent of the effects, a survey of GP and practice nurse perceptions and experiences of the pathway and an interview study with clients, providers and third sector organisations to understand how it works. Of the 1483 referrals received in the first 13 months of service provision, 1176 had received support by the end of February 2019 and 655 had agreed to participate in the evaluation and 630 provided usable responses at baseline. 178 at a four month follow-up and 63 at a final eight month follow-up.

There were significant improvements in patients’ physical and mental wellbeing after the initial four month period which were maintained after eight months. There was also an increase in community group membership at 4 months which remained stable after 8 months. There was a decrease in primary and secondary care usage over the evaluation period.

The economic evaluation of the programme attached savings to the improvements in health as well as the changes in health and social care usage. Projected over a year post-baseline assessment, this estimates a ROI of £1.00. In other words, if the patient benefits recorded for the first four months after initial assessment are continued for the rest of the year, the programme will recoup 100% of its costs by January 2020. This compares favourably with many other comparable programmes in this area.

Interviews with 7 GPs, 3 HCs, and 6 LWs indicated that they recognise both the increasing importance of addressing social factors in patient care and the need for person-centred care in addressing holistic needs. Their experiences of referring or delivering treatment on the pathway point to the importance of improving social connectedness among patients in the improvement of their health and wellbeing, even for those with a focus on specific health concerns. These findings were supported by the GP/practice nurse survey, which found substantial support for the programme and positive experiences of its performance.

Interviews with 19 beneficiaries evidence a range of physical and social benefits which patients had gained from their experience of engaging in the LLWiR programme. Of particular importance to patients were their relationships with LLWiR staff and their ability to connect effectively with activity groups, both of which contributed towards their confidence in meeting their set goals.

Interviews with 8 members of the co-production group, 8 group leads, and 3 volunteers pointed to the good work done by LLWiR in establishing supportive relationships across the voluntary sector, in setting up new groups to meet patients’ needs, and in drawing upon the skills of those with lived experience to develop the programme and support patients. Co-production members and group leads also highlighted the need to stimulate and maintain community engagement with groups whilst supporting their sustainability.

Key challenges for the programme include refining and promoting a clear message as to the purpose and focus of the pathway. Some GPs confessed to having only a basic grasp of the content of the pathway and lack of programme clarity was reported as the main reason for failing to refer to the programme. Lack of fit between expectations and service delivery was a key reason for negative experiences among beneficiaries, who occasionally reported that their groups were unfamiliar with their needs as LLWiR patients.

14. Recovery: the Business case

Mike Slade, David McDaid, Geoff Shepherd, Sue Williams and Julie Repper

Executive summary

This paper makes the Business Case for supporting recovery. We believe that this should be informed by three types of data: evaluative research (such as randomised controlled trials); the perceived benefits for service users – what might be termed ‘customer satisfaction’; and best evidence about value for money.

Some of the ImROC 10 key challenges have a very strong research base. For example, there is substantially more randomised controlled trial evidence supporting the value of peer support workers (challenge 8) than exists for any other mental health professional group, or service model.

Similarly, the scientific evidence for supporting self-management (challenge 1) is compelling. Other challenges have a strong evidence base indicating that they improve people’s experience of services. The positive experiences of students at Recovery Colleges (challenge 3) and the beneficial impact on experience of more involvement in safety planning (challenge 6) are clear.

Finally, the economic evidence is strong for some challenges. There is for example an established financial benefit from workplace mental health programmes (challenge 9), and a very strong value-for-money argument supporting the importance of access to decent housing, education and employment opportunities (challenge 10).

Of course, the Business Case is only one reason services should be attempting to support recovery. Some people would argue that it is a ‘rights’ issue. Those who use services simply deserve – by right – to be provided with the services that they appear to find most helpful. A third reason is political – mental health policy in many countries including the UK is clear that tax-payer funded services should focus on supporting recovery. A fourth reason is the pressure on Trusts to meet efficiency savings; a clear focus on supporting recovery can inform evidencebased resource allocation decisions. A final reason stems from the impact of political and economic pressures on the work of managers and practitioners in mental health. In countries throughout the developed world the demand for mental health services far exceeds the political will to dedicate adequate resources to it. This means that we may all have to think again about the nature of mental health services themselves – what should their priorities be? And, how should they be provided? Supporting recovery has some of the answers to these difficult questions. We believe there is now sufficient evidence to justify a focus on recovery as the ‘core business’ of the mental health and social care system.

1 Professor of Mental Health Recovery and Social Inclusion, School of Health Sciences, Institute of Mental Health, University of Nottingham
2 Associate Professorial Research Fellow, Personal Social Services Research Unit, London School of Economics and Political Science
3 Senior Consultant, ImROC
4 Senior Peer Trainer, CNWL Recovery and Wellbeing College
5 Director, ImROC

Introduction

This Briefing Paper presents the business case for offering recovery-focused services in health, social care, housing and other relevant sectors. It builds on existing work on investing in recovery which attempted to review some of the economic and social benefits of enabling people to achieve their own life goals, supporting them to manage their own condition, get a job, make friends, and maintain safe and secure housing of their choice¹. The paper is aimed at senior managers, chief executives and commissioners in health and social care and other related sectors, policy makers, clinicians, people who use services, their families and carers. In this Briefing Paper we use ‘mental health services’ as a shorthand for the full range of services across all sectors which support people’s recovery.

The concept of ‘recovery’ has become a dominant theme in mental health system policy internationally in the 21st century². Thus, the World Health Organization Mental Health Action Plan 2013-2020 identifies the need for ‘a recovery-based approach that puts the emphasis on supporting individuals with mental disorders and psychosocial disabilities to achieve their own aspirations and goals’³. The challenge for mental health services in each country is therefore not ‘whether to support recovery?’, but ‘how?’.

To do this, we must be clear what we are talking about when we use the word ‘recovery’. It is still a contested term and there remains considerable variation in how it is used by different commentators. In the ImROC programme we have consistently used it to describe the efforts of people with mental health problems to live meaningful and satisfying lives⁴. This is often referred to as ‘Personal Recovery’ to distinguish it from a process of symptom reduction (‘Clinical Recovery’)⁵. ImROC has also leant heavily on the early work by Repper and Perkins which highlighted the importance of ‘hope’, ‘control’ and ‘opportunity’ as key processes underlying these individual journeys⁶. Hope Control Opportunity.

These ideas have been confirmed in a systematic review of the literature which added two other key processes: ‘connectedness’ and ‘meaning’. This produces the ‘CHIME Framework’ 7 which consists of Connectedness (social support/ integration), Hope (optimism for the future), Identity (beyond that of a ‘patient’), having Meaning (in one’s life), and the importance of Empowerment (achieving some control over one’s mental state and adjustment). CHIME Connectedness Hope Identity Meaning Empowerment This framework has been widely used to identify the processes of personal recovery which need to be supported in mental health services.

Overall, recovery is consistent with an emerging new paradigm about the delivery of services, which places far greater emphasis on people’s strengths and possibilities than on their problems and deficits.

Supporting recovery therefore involves working differently. An international analysis of best practice in recovery support identified the need for transformation at four different levels⁸, shown in Box 1.

“The challenge for mental health services in each country is therefore not ‘whether to support recovery?’, but ‘how?’.”

“CHIME: Connectedness Hope Identity Meaning Empowerment”

Box 1: Best practice in supporting recovery

1. Supporting recovery – providing treatments and other supports as a resource for the person to use in their recovery journey, rather than doing things to the person
2. Working relationships – ‘how’ you work with the person matters, i.e. the relationship is more than the vehicle to provide treatment, it is the ‘treatment’ – which has implications for e.g. relationships in a care co-ordination context
3. Organisational commitment – the culture within services directly impacts on how our services work, e.g. a disempowering management culture creates a disempowering (and disempowered) work-force.
4. Promoting citizenship – recovery happens in ‘real life’, as individuals find a safe home to live in, make friends, engage in meaningful occupation, etc. – these are the things we all need for wellbeing.

So, supporting recovery involves using clinical expertise as a resource, engaging with people as partners in care, not simply recipients, ensuring top-to-bottom alignment with recovery values in our organisations, and focussing efforts beyond health and social care systems to create pathways to citizenship. The ImROC programme identified ‘10 Key Organisational Challenges’ to support these levels of transformation⁹, shown in Box 2.

Box 2: 10 key organisational challenges as published in 2010

1. Changing the nature of day-to-day interactions and the quality of experience
2. Delivering comprehensive, user-led education and training programmes
3. Establishing a ‘Recovery Education Unit’ to drive the programmes forward
4. Ensuring organisational commitment, creating the ‘culture’. The importance of leadership
5. Increasing ‘personalisation’ and choice
6. Changing the way we approach risk assessment and management
7. Redefining user involvement
8. Transforming the workforce
9. Supporting staff in their recovery journey
10. Increasing opportunities for building a life ‘beyond illness’

“Hope Control Opportunity”

Some of these key challenges have been updated in the light of experience, as will be discussed later. We also note that the journey of understanding about recovery is not finished, and anticipate the need to focus more in the future on for example experiences of family¹⁰, physical health (drawing on studies such as SHINE¹¹ and IMPARTS¹²), ethnicity¹³ and community partnerships.

In this paper, these 10 key challenges are used to organise the information for the business case. For each organisational challenge, three important types of evidence of effectiveness will be summarised:

• evaluative evidence from formal research studies. We now have credible scientific evidence for a number of effective approaches to supporting recovery, which we will describe later in this document.
• evidence from narrative accounts and experience of individuals regarding the impact of these ‘recovery-supporting services’ on them, their families and on workers in the services (organisational/ cultural changes). People using services have also talked about the transformative potential of recovery: Being supported in my recovery, rather than just having my symptoms of mental illness treated, meant that I got my life back, albeit a different one… I’d ended up with no hope, believing I was ‘untreatable’ and inadequate, but now I am back in the ‘driving seat’ of my life. I have friends, a job and an active role in my community because I was lucky enough to come into contact with people who could see the person behind the label and focus on me and my life, rather than just my symptoms.
• economic evidence where available on the cost and efficiency of these new services. We will argue that investing in effective actions to support recovery also makes economic sense; something that is vital when health and other public services are under enormous pressure. Recovery is associated with a lower need to make use of specialist health services, increased participation in paid and voluntary work, as well as in social activities, more stable accommodation, and positive impacts for family units.

These three forms of evidence (research, personal experience and economic) constitute the Business Case justifying a move towards more recovery-oriented services. This paper, like all ImROC Briefing Papers, is co-written between people with a range of professional and lived experience.

“Recovery is consistent with an emerging new paradigm about the delivery of services”

Key organisational challenge 1: Changing the nature of day-to-day interactions and the quality of experience

Key concepts: Narratives; Strengths-based; Coaching; Shared decision-making; Self-management; Joint crisis planning; Open Dialogue

Research studies

The first challenge – and the most fundamental one – is to change the nature of day-to-day interactions between staff and people who use mental health services so that they are continually perceived to be supporting personal recovery and improving the quality of care experienced. This is an ambitious aim, but it must be the ultimate objective of all the organisational changes to be discussed later. It is also needed –only 31% of people nationally report having a very good experience of care based on their contact with mental health services¹⁴.

Supporting personal recovery, whether inside or outside formal mental health services, is dependent on access to trusted and enduring relationships – what have been called recovery promoting relationships¹⁵. They are based on establishing shared values, demonstrating empathy, warmth, and respect for the individual, combined with a willingness to go the ‘extra mile’¹⁶. These qualities form the bedrock for all forms of mental health care¹⁷ and the evidence for the importance and effectiveness of these relationship skills is now well-established^{18 19}. All professions make some effort to include them in their basic training, but the extent to which they are central to accreditation varies across professional groups.

There is also now evidence regarding unhelpful characteristics of staff working with people with severe mental health problems. A systematic review of the literature concluded that conversations which are pessimistic, uncaring, paternalistic or disrespectful hindered the development of helpful relationships and contributed to instilling hopelessness and inhibiting personal growth²⁰. These detrimental effects were particularly damaging in the context of services characterised by discontinuity, coercion or insufficient time.

However, there are approaches which reflect recovery-supporting values, involve prorecovery working practices and have an emerging evidence base. These include:

Use of narrative accounts

In terms of recovery-oriented practices, the best starting point is listening to the persons own account of what has happened to them. Everyone has a story to tell and the process of telling your own version of your story in your own words is almost always experienced as positive and validating. Such narratives help people to make sense of their experiences, they provide a basis for formulating personal goals and monitoring progress. They also provide a source of information and explanation which is complementary to a conventional, ‘evidence-based medicine’ approach²¹. Approaches like Photovoice²² are emerging as ways of enabling people to find ways of presenting their own perspectives, experiences and feelings using different media.

“It [inpatient care] was a frightening and bewildering time for me. I felt completely lost and did not know what was happening to me or what the future might hold…(then) I met a nurse who proved, literally, to be my life-saver…She was a great inspiration. She told me that I would not always be in this state, although a lot of that would be up to me. With her support, I started to learn about myself…This wonderful woman gave me the strength to carry on, and not end my life as I had planned.”
Service user

“My experience of using services was mainly that the focus was always on what was wrong with me….. I was always on the receiving end of other people’s decisions about me, and I was not asked for my opinion. This just increased my own feelings of having nothing of any value to anyone…then one time my care co-ordinator asked what I thought about a decision … I remember feeling really surprised that he was asking me, but it actually started me thinking for the first time in a long time, about my own situation and what I could do about it.”
Service user

Building on strengths

A second important practice is the consistent use of a ‘strengths’ approach²³. This seeks to identify the person’s qualities, assets and competencies and their environmental resources (friends, neighbours, local opportunities) which might be used firstly as a basis for relationship building, secondly to confirm their personal value and achievements which they often struggle to identify, and thirdly as the foundations for building up skills and strategies to further their personal life goals²⁴. A review of strengthsbased interventions for people with severe mental illness identified benefits in relation to hospitalisation rates, employment/educational attainment, and intrapersonal outcomes such as self-efficacy and sense of hope²³.

Coaching

Another recovery-supporting practice, which has been developed in the last few years, is the ‘coaching’ model²⁵. This uses many of the same techniques as the strengths approach, e.g. an emphasis on the service user taking the lead, the importance of identifying personally-relevant goals²⁶, and a focus on strengths and natural supports. However, there is greater emphasis on the importance of staff behaviour as a ‘coach’, or learning partner (‘on tap, not on top’) and on the service user’s responsibilities to make a commitment to action. There is now emerging evidence for the effectiveness of coaching in relation to supporting recovery, both in²⁷ and beyond²⁸ the mental health system.

Shared decision-making

Systematic review evidence indicates that collaborative relationships which help individuals increase their sense of control over their lives are the best approach to supporting hope²⁹. This can be achieved by establishing a greater focus on shared decision-making³⁰, particularly in relation to medication management³¹. NICE Guidelines state that shared decision-making should be used with all people using mental health services (Quality Statement 3), including specifically those detained under the Mental Health Act (Quality Statement 11)³².

Joint crisis planning

This is an important application of shared decision-making in the context of discharge planning following inpatient admissions. The ‘Joint Crisis Plan’ (JCP) is formulated by the service user, together with peer support if available, and the key mental health staff involved in their care, including the treating psychiatrist. In an initial randomised controlled trial, people who were discharged with a JCP were shown to have significantly fewer compulsory admissions compared with controls over a 15 month follow-up period³³. Qualitative data also suggested that the JCP group felt more ‘in control’ of their mental health problems³⁴. A second study produced less impressive results, due to practical difficulties in ensuring that the joint planning meetings always occurred and were effectively facilitated³⁵. Implementation of JCPs also depends on successfully engaging clinicians and overcoming their prejudices regarding the validity of service users’ views and the feasibility of meeting them³⁶.

“The challenge for modern, recovery-oriented, mental health services is not just doing more of the same thing”

Self-management

Closely allied to shared-decision-making is the support of ‘self-management’. A comprehensive review of the evidence by the Health Foundation (550 systematic reviews, randomised controlled trials and large observational studies) concluded that “the totality of evidence suggests that supporting self-management can have benefits for people’s attitudes and behaviours, quality of life, clinical symptoms and use of healthcare resources” (p. v)³⁷. The review found robust evidence that effective self-management support leads to higher self-efficacy and subjective well-being. Lower-quality evidence linked more effective self-management with improved clinical outcomes and the potential to reduce visits to health services by as much 80%. Specifically, in relation to mental health, peer-led self-management programmes improve primary care contact and physical health-related quality of life³⁸. Approaches which include the full and active involvement of the person, rather than simply the passive provision of information, are most likely to be effective. Thus, the Health Foundation recommends, “a fundamental transformation of the patient-caregiver relationship into a collaborative partnership” (p.vi).

“I have noticed a gradual shift in the way the [memory service] team relate to people living with dementia since the peer support workers have been in post. They focus more on the existing skills and strengths of each person and how these can be built upon”
Project lead

Open Dialogue

A final approach which brings together a number of recovery- supporting practices is ‘Open Dialogue’³⁹. This was developed in a small rural community in western Lapland, but is now beginning to attract international attention. It places the service user and their immediate carers at the centre of a shared decision-making process and assumes that their key role is to listen and try to make sense together of the personal meaning of psychosis. Implementation of the approach is based on rigorous training and implies significant organisational change but much is currently being claimed for its effectiveness in helping people achieve long-term valued outcomes, particularly in relation to reducing dependence on medications. At the moment, the evaluative research requires replication in larger, more heterogeneous and urban populations.

To summarise, the challenge for modern, recovery-oriented, mental health services is not just doing more of the same thing – more staff, greater professional expertise, more ‘evidence-based’ treatments, etc. We need to change the fundamental characteristics of the interactions between those tasked with delivering the services and those receiving them. We need to provide high quality, basic human relationships which develop trust, based on a respect for individuality and personal experiences of developing resilience in managing their experiences (of ‘illness’). This will involve developing services which build on people’s strengths and resources to help them use professional expertise to move towards personally valued social goals (housing, integration, employment), not simply the reduction of symptoms.

Economic evidence

If better long term social functioning is achieved as a result of reshaping the nature of the relationship between staff and people who use mental health services then positive economic outcomes will be achieved. For instance we know that participation in employment is both empowering, associated with better health (and thus lower need for health care services) and reduces the need for social welfare benefit support. Specific economic evidence on the different approaches that we have described are however limited.

Evidence on the economic benefits of shared decision making (for any health condition) is mixed, but studies appear to focus solely on short term outcomes rather than longer term benefits of better social functioning⁴⁰. Separately there is also a literature on the value of peer support for decision making which is discussed later. Studies on shared decision making suggest that despite initial increase in staff contact time required for collaborative discussions, there are positive long term impacts on health service use. For instance several studies show that health coaching (particularly telephone coaching) for long term conditions can be cost effective. Analysis in the US of almost 10,000 people who received health coaching for conditions including depression and schizophrenia revealed consistent cost savings due to lower inpatient and outpatient contacts⁴¹. There is also some evidence in England that investing in coaching in community mental health teams, can be done without any immediate (one-year) significant impact on costs to the health system²⁷. A German study looking at telephone coaching for different patient groups including people with mental health needs also did not identify any significant impact on health outcomes or costs⁴². Another small English case study which looked at costs and benefits of providing training in health coaching for a wide range of health conditions, reported substantial cost savings due to reduced time needed to treat people which would more than cover the costs of training. It did however acknowledge the need for large scale quantitative evaluation of coaching to formally determine costs and benefits⁴³.

The economic evidence on approaches to self-management tends to focus on physical rather than mental health needs^{44 45}. This often suggests actions are cost effective. However little is known specifically about the economic case for self management in people with chronic mental health problems such as depression or anxiety disorders, although some economic analysis is underway⁴⁶.

There is evidence on the economic case for the joint crisis planning trials that we have discussed. The first of these studies found that there was almost an 80% probability of crisis planning being at least cost effective and often cost saving per additional 1% of hospital admissions averted compared to a standard information service, when taking into account use of health, social care and criminal justice system services over the subsequent 15 months⁴⁷. The second study reported a similar likelihood of being cost effective from a health system perspective; in addition crisis planning had a 44% chance of being cost saving, although there was no significant difference in costs compared to routine support, when the broader impacts of criminal activity and time out of employment were taken into account⁴⁸. A trial of joint crisis planning in the Netherlands found that it reduced future compulsory hospital admissions over the following 18 months, but there were no other significant impacts on health service use⁴⁹.

Key organisational challenge 2: Delivering comprehensive, co-produced learning opportunities

This key challenge has been updated in the light of experience.

Key organisational challenge 2: Coproduced Recovery focused learning and development opportunities are available for all staff working in services

Key concepts: Adult education; Self-directed learning; Problem-centred learning

Research studies

Adult learning is inextricably intertwined with recovery⁵⁰. In general terms, adult learning in younger adults has been empirically shown to be an effective approach to reducing health inequalities^51-53. There is also evidence from across the age range that participating in learning events can have positive effects on life satisfaction, health and wellbeing^{54 55}. For mental health service users, adult learning can also enhance resilience and help build social capital⁵⁶; it can also reduce symptomatology and enhance wellbeing⁵⁷. Overall, adult learning is therefore likely to impact beneficially on health and well-being and may increase community participation⁵⁸.

Specifically in relation to supporting recovery, adult learning is at the heart of developments like Recovery Colleges (key challenge 3) and peer support (key challenge 8) and it is through staff learning that changes in attitudes occur – especially among those in senior positions – and these lead to changes in organisational culture (key challenges 4 and 9). However, how these educational processes are organised is critically important.

Learning is not the same as being taught. Both teaching and learning are important. Some individuals prefer one method to another and some topics lend themselves more easily to one approach over the other. Nevertheless, ‘perhaps the most critical shift in education in the past 20 years has been a move away from a conception of “learner as sponge” toward an image of “learner as active constructor of meaning” ’⁵⁹. The key differences between ‘teaching’ and ‘learning’ (adapted from Wilson and Peterson⁵⁹) are summarised in Box 3.

“Achieving authenticity and integrity…that’s the challenge! I think genuine transformational leadership can be achieved by creating increased opportunities for dialogue between service users, carers and practitioners which is unfettered by the institutional restraints of the organisation. This is not “a quick fix” but a complex, slow process which requires a lot of hard work. If this process is endorsed corporately, it enables an on-going conversation at all levels of the organisation which facilitates the development of common values, aims and more open, genuine co-productive relationships between all the participants.”
Recovery Programme Lead

“I think a recovery focused leader needs all the usual qualities of transformational leadership but they also need to really ‘get recovery’ and to be able to communicate it in a way that inspires others. They don’t give up and they keep going even when the odds are stacked against them. They are prepared to take a leap of faith and although they know the direction of travel, they don’t think they have all the answers.”
Clinical Director

An approach to learning that ImROC uses with whole teams (including staff from all professions and people using the service) is the Team Recovery Implementation Planning Process (TRIP)⁶⁰. This process is a collaborative learning experience founded on co-production, in which the service becomes a catalyst for change rather than a creator of change by (a) enabling people to lead their own recovery and (b) supporting the development of recovery-oriented services and empowering people to develop resources in peer networks and communities. Early evaluation of the impact of TRIP is promising⁶¹.

To summarise, changing staff (and thus organisations) to become more supportive of recovery involves using modern educational ideas which assume that people come to training with an active interest in learning, but also with their own pre-existing beliefs. Learning is about providing opportunities where these beliefs can be made explicit and can be discussed and, if appropriate, challenged. This is often best done in a group setting where everyone – not just the teacher – is encouraged to contribute. Approaches such as Schwartz Rounds⁶² and engaging leadership⁶³ address the dynamic, relational and distributed nature of leadership.

“In order for staff to be able to work effectively within the recovery approach, they must feel empowered by their managers. Giving recovery targets or instructions to deliver recovery just won’t work. Recovery focused leadership looks for the strengths of individual staff members and teams and brings them out, by giving support and encouragement. This does not mean that managers overlook problems or ignore bad practice, but looking for problems is not their starting point.”
Service Director

Economic evidence

It is important to assess the economic impacts on staff of co-produced learning and development opportunities, as well as understand whether there are any financial and/or organisational barriers to participation in such learning opportunities. However much of the existing literature on co-production does not appear to devote much attention to outcomes and impacts on staff, other than changes in attitudes, as seen in the REFOCUS study. Improved understanding and insights for staff as a result of this type of learning, may be beneficial in terms of their own mental and physical health and perhaps also in terms of staff turnover – something that has been seen with the implementation of co-produced approaches to safety planning that are discussed in key challenge 6. This however needs to be assessed in future studies that look more at the impacts on the workforce and not just at changes in attitudes or knowledge.

Key organisational challenge 3: Establishing a ‘Recovery Education Unit’ to drive the programmes forward

This key challenge has been updated in the light of experience.

Key organisational challenge 3: Coproduced, Recovery focused learning opportunities are available for everyone using the service where people with mental health conditions, the staff and families who support them and others in local communities can share expertise and learn together

Key concepts: Recovery Colleges, Educational Approach, Co-production, Adult learning

“The recovery and social inclusion course felt amazing for me .… I have owned and worn a coat of stigma for most of my life. It was made to measure. Nowadays though, whenever I feel its weight upon my shoulders, I take it off and hang it on the nearest hook. It has become outworn, unnecessary and for the first time in my life, I feel confident enough to say that my own business with it is finished.”

Coming to the college was an important first step in regaining confidence and motivation to do more with my life.”

Research studies

Recovery Colleges are one of the key developments for promoting co-produced learning⁶⁴ and are probably the most visible change in mental health services which are attempting to engage with the recovery agenda. Currently there are nearly 70 Recovery Colleges in England⁶⁵ and they are being developed in several different European countries, and in Australia, Japan and Hong Kong⁶⁶. The theoretical foundations for Recovery Colleges include: shared decision-making and self-management (key challenge 1), adult learning (key challenge 2), coproduction (key challenge 7) and community participation (key challenge 10). They therefore embody a number of the central principles for supporting recovery. However, while the theoretical foundations are strong, the empirical evaluations are still weak.

Overall the available empirical evidence is consistently positive. Recovery Colleges are popular with service users, they engage people who often find traditional day services unattractive and attendance rates are consistently high⁶⁵. There is also some evidence that they are associated with improved outcomes, both subjectively (higher hopefulness, more goal-directed behaviour) and reduced use of community mental health services, particularly among those who attend at the majority of scheduled sessions. Care co-ordinators with clients who attend RCs are also more likely to value and support selfmanagement⁶⁷.

“The ‘telling your story’ course gave me a different perspective on what I was feeling. I realised I still had some work to do, but was helped to see how to do it. Meeting other people who told their stories in different ways helped too.”

There is also evidence of benefits for the organisation as a whole in terms of improved staff expectations and attitudes⁶⁸. There is patchy evidence that they can help with restarting education, voluntary work or employment⁶⁹ with one study finding 70% of students going on to be mainstream students or to paid or volunteer work⁷⁰. This led an independent think-tank report to state that Recovery Colleges have ‘significant potential for impact on improving employment outcomes’⁷¹.

However, the methodologies used to investigate these outcomes consist primarily of single case, prospective, follow-up studies using cross-sectional interviews or observational approaches^{72 73 69 74 75}. There is little agreement on standardised outcome measures⁷⁶. There is also a need to conduct further research to clarify the key elements of the ‘independent variable’ (i.e. attendance at the college). At the moment it is not known exactly what characteristics are critical⁷⁷. These issues are being addressed in a NIHRfunded study called RECOLLECT (www.researchintorecovery.com/recollect).

“I have found the course to be a source of inspiration – I feel it breathed new life into my practise. It gave me a new approach to my patients, not seeing his/ her problems, but their strength”

“It was helpful hearing people describe problems similar to those of my son.”

“Recovery Colleges are one of the key developments for promoting co-produced learning”

Economic evidence

There is positive albeit limited evidence on the economic impact of recovery colleges. In England in-house evaluations of recovery colleges do suggest that there is a justified business case. The most methodologically robust evaluation compared the use of mental health services by students in the 18 months prior to and post enrolment in a recovery college. Overall there was a reduction in inpatient stays, admissions under the Mental Health Act and in community contacts while mental health outcomes also improved. Reductions were greater for students who completed a course compared with a retrospectively identified population that did not. It was estimated that overall there was a significant reduction in NHS Trust resource demands of £1,200 per student per year, even after taking into account the additional costs of delivering the Recovery College⁷⁸. Costs averted increased to £1,760 for students who successfully completed a course.

An in-house evaluation of another Recovery College also identified a significant reduction in the use of health services by students (costs averted of more than £845 per year for those the completed a course) twelve months after attending courses⁷⁹, but students may have not have been comparable to those who did not use the college⁷⁸. Overall, the evidence is encouraging, and potentially conservative. Some of the other benefits of using Recovery Colleges that may be realised, such as more confidence in seeking employment, will likely make the economic case more powerful. They also need to take account of the value of volunteer / co produced time and discretionary unpaid additional inputs from staff⁸⁰. Going forward it will be important to compare investment in Recovery Colleges with appropriate alternative options to support recovery, using methods including controlled trials.

Key organisational challenge 4: Ensuring organisational commitment, creating the ‘culture’. The importance of leadership at every level

This key challenge has been updated in the light of experience.

Key organisational challenge 4: Recovery focused leadership at every level and a culture of Recovery

Key concepts: Organisational commitment; Recovery as a priority; Empowering management; REFOCUS; Illness Management and Recovery (IMR); Team Recovery Implementation Plan (TRIP)

“We must think beyond simply ‘training’ staff to behave in different ways.”

Research studies

Helping mental health services better support recovery means addressing some of the organisational changes necessary to establish a unique and distinctive culture. Of course, the quality of support for individuals will ultimately depend on the quality of care provided by individual staff in their everyday interactions (key challenge 1) but, in order for this to happen consistently across the organisation, we must think beyond simply ‘training’ staff to behave in different ways. This is illustrated in a study examining the implementation of ‘Illness Management and Recovery Programmes’ across 12 community settings in the USA⁸¹. Training was found to be important, but it only had a lasting effect if issues of supervision and leadership were also addressed. A ‘culture of innovation’ was also found to be important, i.e. organisations being open to considering changes in existing practices. This aspect of organisational readiness has also been found important in England⁸². If all these factors were present then they acted synergistically, but no one element was sufficient on its own. So, how can we ensure that the shared values of recovery permeate the whole culture of the organisation and are reinforced by leaders at all levels?

This is particularly difficult at a time when there are ‘unclear goals, overlapping priorities that distract attention, and compliance-oriented bureaucratised management’⁸³. These directly impact on how the organisation performs and, across the NHS at the moment, staff and managers feel overloaded, disempowered and are failing to deliver the high quality care that they seek to achieve. These three elements of organisational culture – goal clarity, clear priorities and an empowering management style – all therefore need to be addressed.

1. Goal clarity – Implementation of the REFOCUS intervention¹⁵ in England was directly related to staff perceptions about organisational commitment⁸², i.e. did the Trust really want to change? The commitment of the organisation was judged by staff on the basis of resource allocation (e.g. what training is compulsory and back-filled?) and the choice of Key Performance Indicators and outcome measures currently used by the Trust. Put simply, the dimensions an organisation chooses to notice (and then either celebrate or punish) send a powerful message about its core business – what it is really here to do. If these don’t reflect recovery concepts and values⁷⁶ then staff will not think that the organisation is really committed to delivering a more recovery-oriented service. One approach is to collect and publish recovery-related outcome data⁷⁶, such as the proportion of people on the caseload meeting normal citizenship expectations (e.g. meaningful occupation, decent housing, at least one close relationship, enough money to live on) and personally valued life goals⁸⁴.
2. Clear and recovery-focused priorities – A grounded theory study (n=97) across England showed that staff experience conflicting organisational demands and priorities⁸⁵. This was confirmed in a systematic review which found that organisational priorities influenced staff understanding of recovery support⁸⁶. However, simply having a clear priority does not guarantee that recovery is being supported, especially when there are multiple meanings of the word. Thus, there is currently a rather cynical conceptualisation of ‘recovery’ which sees it as simply subservient to the financial needs of the organisation, using success indicators such as cost reduction, throughput, discharge, and setting limits on service provision. Although this co-opting of the word ‘recovery’ to meet organisational goals has been criticised by both the people who work in services² and those who use them⁸⁷, nevertheless it persists. It highlights the need not just to set recoveryoriented priorities but to be clear about what this means. This involves addressing questions such as how the Trust Board will know that people recover, and from a wider sociopolitical perspective how Trust activities relate to the public health agenda, support community resilience, address health inequalities and improve overall population health.
3. Empowering management style – There is a close link between empowerment and wellbeing in the workplace⁸⁸ and there is also good evidence that improving staff wellbeing improves the experience of care⁸⁹. We should therefore be thinking about ways to increase feelings of empowerment among frontline staff (and users). One way that we have found very useful in achieving this in the ImROC programme has been the use of a team-based, practice development instrument, the Team Recovery Implementation Plan (TRIP) as described in Challenge 2⁶⁰. The TRIP operates at the first level of leadership in the organisation (frontline staff and people who use services) but, of course, leadership is to be found at all levels and in all disciplines. Furthermore, organisations don’t change from the ‘top down’, or the ‘bottom up’: they change when leadership at all levels of the organisation are giving consistent messages. ‘The most important determinant of the development and maintenance of an organisation’s culture is current and future leadership’⁹⁰. This is why any attempt to help services become more recovery-oriented in their practice must grapple with the organisational context (for example by engaging in compassionate leadership⁹¹), not simply the behaviour of individual staff members or groups. Addressing organisational inhibitors (e.g. bureaucracy, paperwork, caseload size, Serious Untoward Incident processes, safety policies, risk averse cultures) has been one of the most important lessons of ImROC.

“My experience of recovery focused management is having a manager who can have a conversation with you that leaves you feeling supported and like they are getting to know you as a person. Someone who has got to know your particular skills, interests and expertise, and has the confidence in you to take responsibility in those areas for the benefit of the team as well as for me as an individual.”
Physical health and wellbeing lead

Economic evidence

There is little economic evidence specifically on the notion of recovery focused leadership and a culture of recovery, but this Briefing Paper has highlighted the value of other aspects of meeting the key challenges of recovery. Effective recovery focused leadership potentially should improve the working environment. A management style that empowers frontline workers and service users to make co-produced decisions is consistent with the principles of a healthy workplace environment. Following the implementation of TRIP in one ward in a London Trust the level of staff sickness absence and assaults on staff over the following year decreased, but a comparative evaluation is required in order to determine whether this reduction is due to TRIP⁶⁰. More broadly the economic benefits of a healthy workplace environment that may arise in part due to a recovery-focused orientation, such as improved productivity, innovation and creativity, as well as reduced absenteeism and staff turnover are set out in response to key challenge 9. The economic benefits of a co-produced and recovery focused approach to safety management are set out in key challenge 6.

Key organisational challenge 5: Increasing personalisation and choice

Key concepts: Personal budgets; WRAP; Advocacy

This relates to both personal budgets (addressed in key challenge 10) and approaches to supporting self-management and personal control (addressed in key challenge 1). The focus here is on the translation of these challenges through care planning and advocacy processes.

“For me my Health and Wellbeing plan is a way I can manage my life. It constantly changes but it makes me reflect on the things I can do for myself and what I need to do to keep balanced. This has helped me inform my careplan, but that is always something I have felt more imposed on me. It’s my Drs opinion of what they need to do, it never really helped me know myself. As you know. It gave me a context to hang the strategies I already had and used, I just hadn’t seen them that way before.”
Peer trainer

Research studies

As different people’s recovery journeys are different, a central task for mental health services is to ensure that individual care is genuinely personalised and maximises involvement and choice. This is not easy. Despite repeated exhortations, in various Department of Health policy documents over many years, a cross-sectional study of care planning in England and Wales found that care planning remains very bureaucratic, often with little evidence of user involvement or shared decision-making, and lacking in clarity regarding support for personal recovery⁹².

One way around this is for services to use specific tools aimed at documenting personal recovery plans. The Wellness Recovery Action Planning (WRAP) provides such a framework and covers developing a personal plan, coping with distressing symptoms, managing crises, and staying ‘well’. It was designed by a service user for service users and has been widely used around the world⁹³. WRAP guides the individual or group to reflect on what has assisted them to stay well in the past and to examine strategies that have assisted others with their recovery. The focus is on approach motivation (defining wellness and supporting goal striving) rather than avoidance motivation (e.g. symptomatic relief), in line with the insight from positive psychology that positive (‘approach’) goals are more likely to be sustainably attained than negative (‘avoidance’) goals⁹⁴. The process also relies on peer facilitation to activate the hope-inducing benefits of authentic role models⁹⁵. A large randomised controlled trial involving people using community mental health services in the USA showed positive results for WRAP in terms of reduced symptomatology, increased hope and quality of life compared with standard care⁹⁶.

Whatever their derivation, Personal Recovery Plans should contain an identification of the person’s internal and external resources and a plan for how they can use these to achieve their chosen goals. It is also desirable that they are clear and as short as possible. The person should not necessarily have to share their recovery plan with staff: it belongs to them. This creates new expectations about role expectations and the balance of power. So recovery plans are not the same as care plans, although there should be as much overlap as possible between the two. Learning from maternity services in which the mother owns her plan may be relevant.

“Recovery plans are not the same as care plans”

“It [Health & Wellbeing Plan] makes me more reassured and less stressed to know that we have a way to communicate easily and effectively with others involved in his [my son’s] life.”
Carer

Economic evidence

There is limited evidence on the resource impacts of individual care planning. Some approaches in England to care planning have been criticised for excessive paperwork and bureaucracy, whilst reforms in the way in which mental health services are paid for may act as a disincentive towards genuinely individualised care plans⁹². The business case needs to be strengthened for mechanisms to promote increased personalisation and choice. WRAP has been the subject of some economic assessment. A randomised trial in the US found that compared to individuals who received non-peer delivered nutrition or wellness education, individuals who received WRAP subsequently made use of fewer mental health services over an eight month follow up period, which implies a reduction in health care costs. Their perceived need for services also reduced, while both groups had positive recovery-related outcomes⁹⁷. In a small qualitative study in Ireland some service users cited how WRAP had helped them avoid hospitalisation⁹⁸.

“I meet with people and we try to identify what they would like to do and how best they can achieve their goals supporting them on their road to recovery…..I support people to complete the Self Directed Support (SDS) questionnaire….For me the most important part of this is encouraging and enabling the individual to rediscover passions and hobbies that they may have forgotten about/or think is no longer possible because of their mental health and I also encourage and support them to try something new.”
Peer support worker

Key organisational challenge 6: Changing the way we approach risk assessment and management

This key challenge has been updated in the light of experience.

Key organisational challenge 6: Reducing restrictive practice; changing conceptions of risk as something to be avoided towards working together to improve safety

Key concepts: Safety planning; Seclusion and restraint, No Force First

“Professionals and people using services need to work together to agree the right balance of risk and choice.”

Research studies

Accurately predicting the risk of violence or self-harm in a given individual is extremely difficult⁹⁹. However, notwithstanding the lack of evidence that it is possible, mental health services have become increasingly preoccupied with procedures for the assessment and management of risk and this has sometimes become a barrier to personal recovery¹⁰⁰. Many staff have become so risk averse that they are no longer prepared to engage in what might have previously been seen as positive risk-taking, i.e. working with the service user to help them manage those risks which are necessary for them to pursue reasonable and realistic life goals¹⁰¹. This has happened despite clear government and professional guidance to the contrary¹⁰². A 2016 article in the British Journal of Psychiatry concluded that risk prediction is not only ‘futile’, it is ‘potentially harmful, confusing clinical thinking’¹⁰³. Instead the authors argued ‘for a shift in focus towards real engagement with the individual patient, their specific problems and circumstances’ (p.271).

Real engagement with the individual in the context of risk management is exemplified in the work done on safety planning¹⁰⁴. Safety planning is not casual or reckless, but it promotes a way of working with risk that enables practitioners to support people in taking risks as a route to positive outcomes.

The change in language from ‘risk’ to ‘safety’ also recognises that risk is an inevitable part of life and should be an integral part of informed (and shared) decision-making regarding a person’s life goals. Professionals and people using services need to work together to agree the right balance of risk and choice. For people using services, it is important to be an active participant in conversations and subsequent decisions about keeping themselves safe. This way they contribute to, and see the relevance of certain decisions, and are more likely to feel able to take responsibility for letting staff know what can be done to help them feel safe; what their ‘triggers’ are; what can be done to avoid or minimise these situations. Thus they are able to take more responsibility for their actions and to learn how to increase their confidence in managing their own risk. This process of ‘co-producing’ (see key challenge 7) their safety and wellbeing plans at every stage in the process has not been empirically investigated.

One area where the management of risk is based on much greater involvement of service users is regarding the reduction of serious and violent incidents in hospital, particularly those which result in the use of physical restraints, seclusion or forcible medication. Research in the U.S. identified ‘6 core strategies’ for reducing seclusion and restraint in hospital^{105 106}. These are shown in Box 4.

Box 4: Core strategies for reducing seclusion and restraint

1. Ensuring leadership to support organizational change, involving the senior management team
2. Developing the workforce (training in de-escalation techniques, ‘trauma induced care, modifying the environment, etc.)
3. Planning ahead to prevent incidents occurring
4. Developing the roles of service users as staff trainers, advocates and peer workers
5. Using debriefing techniques to promote learning.
6. Using data to inform practice

“It goes without saying that it can at times be quite emotive seeing people suffer from their mental illness or from the effects of being sectioned, particularly having been there myself and being able to identify with their pain and frustrations. It was initially quite hard to see the use of physical interventions but going on the training helped to ease my discomfort and gave me an opportunity to provide valuable feedback so that the training can be developed to be more recovery focused.”
Peer support worker on acute inpatient ward involved in co-producing de-escalation training

A training curriculum based on these strategies has been developed and evaluated across 43 facilities in 7 States over a fouryear period^{107 108}. Two-thirds (n=28) were able to achieve stable implementation, and on these sites 54% were able to reduce restraint hours by an average of 55% and the percentage of people restrained by an average of 30%. Reductions in seclusion and restraint were less impressive where full implementation was not achieved. There were also increases in both user and staff satisfaction, significant reductions in staff turnover and related costs. These results have also been replicated in Canada and a similar study is currently being conducted in England by Professor Joy Duxbury.

A second example of reducing seclusion and restraint which is based directly on the implementation of recovery principles has been reported by Ashcraft and colleagues¹⁰⁹. They called their approach No Force First, and used similar strategies to the six described above with an emphasis on leadership, staff training, consumer debriefing and regular feedback. However, they placed the contribution of service users as trainers, alongside staff, at the centre of the initiative. With constant support they were able to eliminate seclusions and restraints in two crisis centres over a period of two-and-a- half years. Later revisits found no replacement with chemical restraints. The No Force First approach has been replicated in this country, particularly by Mersey Care NHS Foundation Trust. It explicitly uses a process of coproduction, with professionals and service users working together to design, implement and evaluate the programme. Early data from two pilot wards assessed over two years indicated 60% reduction in physical and medication-led restraint, 46% reduction in staff assaults, staff sickness reduced by 25%, improved staff morale and satisfaction, and a positive improvement in service user experience^{110 111}. As a result, the Care Quality Commission positively acknowledged No Force First as a restraint-reduction strategy. More generally, there is evidence that coproduced approaches to reducing violence on wards are effective, from trials in Finland¹¹² and Spain¹¹³.

Economic evidence

There are substantial costs associated with seclusion and restraint, some of which may be averted through the adoption of a coproduced approach to safety management. A number of studies have highlighted costs for service users and staff related to adverse health impacts, such as injuries, falls and deaths¹¹⁴. Agitation and distress, which can be inevitable consequences of restraint, have themselves in a review been associated with longer inpatient stays¹¹⁵. Analysis in Spain also suggests that the costs of managing agitation in service users using seclusion and restraint are roughly three times the costs of verbal or psychological actions alone¹¹⁶.

There are substantial costs associated with the intensive levels of staff time that are needed for the management and implementation of traditional seclusion and restraint policies. One costing study in England estimated the costs of managing conflict and the use of restraint on adult inpatient psychiatric wards in 2005¹¹⁷. It estimated that around 50% of all nursing resources were taken up in the management of conflict and use of containment strategies. Costs of manual restraint per year per ward were reported to be £14,084 while costs of seclusion were a further £5,007.

There will also be legal and other costs associated with adverse events arising from the use of restraints. Although not well studied, violence and injuries are likely to have an adverse impact on workplace staff sickness rates and staff turnover, implying further costs to mental health care systems¹¹⁸. The mean costs per violent incident were estimated to be £3,212 in six inpatient wards in East London, of which 54% was for staff sickness absence, and replacement staff costs, with the remainder attributed to response team costs, legal costs and medication¹¹⁹.

Few studies outside of the US have evaluated the economic impacts of introducing measures to reduce the use of restraints¹¹⁸. For instance one US study looked at the impact of a policy to reduce the use if restraints at one inpatient facility for young people aged 13-18¹²⁰. The costs of staff time and medication related to restraint reduced by 91% in the year following the introduction of the policy – 3,991 restraint events fell to 373 events. Costs for managing restraint were then just 8% of what they had been prior to the policy change.

More potential benefits can also be seen in a randomised trial in Finland of a co-produced approach, which found that staff time for seclusion and restraint could be significantly reduced without any increase in violence, although impacts on staff sick leave were equivocal¹²¹; it did not however report actual changes in costs. The No Force First pilot study in Merseyside did realise estimated savings of £0.25 million per annum in secure awards alone due to reduced staff sickness and absence related to assaults and injuries, according to an independent assessment¹¹⁰. This assessment also concluded that scaling up implementation to all wards potentially might avoid costs of £1.2 million per annum.

“Another area where peer support has helped, I believe, is in the use of physical interventions. I think those who have been there have an awareness of how apparently trivial issues, like not being allowed to go out for a cigarette for example, can become magnified when you’re an in-patient, and how quickly such situations can escalate and result in physical restraint. Working on a very busy in-patient ward, I think my particular focus has been on trying to identify and respond quickly to the day to day individual issues that arise for service users in a way that prevents any escalation. I’ve found it be very helpful just talking quietly to the person, acknowledging (with the benefit of lived experience) just how difficult and frustrating their current situation is, and trying to figure out solutions together.”
Peer support worker

“I completed my health & wellbeing plan and asked for the advanced statement part of it to be scanned onto my notes. Many months later, I experienced a ‘blip’ and ended up in A&E. The doctor got a copy of my plan and reminded me of what I had said would be helpful in a crisis. Just being able to share this information in this way made a massive difference and I was in a position to return home much sooner than had ever happened before.”
Peer trainer

Key organisational challenge 7: Redefining user involvement

This key challenge has been updated in the light of experience.

Key organisational challenge 7: User involvement is replaced by fully resourced coproduction so that the views, experiences and aspirations of people using services and their family members are accorded the same value as the views of staff in the organisation

Key concepts: Co-production; Power

Research studies

The importance of user and carer involvement in mental health services has been emphasised for many years. However, making it a reality is difficult and timeconsuming, and many services are still essentially staff-led, with users and carers being consulted at the end of the process when most of the important decisions have already been taken. For this reason when we have been promoting services to support recovery through ImROC we have continually come back to the concept of co-production.

Co-production represents a new way of thinking about the delivery of health services. The ideas came from an analysis of the difficulties faced by public bodies in delivering effective and relevant services in times of economic austerity. They have been popularised in England through the work of independent think-tanks such as the New Economics Foundation (nef) and Nesta. In a seminal publication they defined coproduction as, ‘delivering public services in an equal and reciprocal relationship between professionals, people using services, their families and their neighbours. Where activities are co-produced in this way, both services and neighbourhoods become effective agents of change’ (p.11)¹²².

According to the New Economics Foundation, Nesta and the Innovation Unit¹²³ the main features of co-production are shown in Box 5.

“It [co-production] feels democratic and about mutual respect, rather than pity. It’s about everyone learning together. It feels exciting. It just feels so much better.”
Mental health worker

Box 5: Key features of co-production

• Recognising people as assets – transforming the perceptions of people as passive recipients of care and ‘burdens’ on the system, to equal partners in designing and delivering services.
• Building on people’s existing capabilities – actively supporting people to recognise and use their strengths, rather than conforming to a deficit model.
• Reciprocity and mutuality – offering people who use services opportunities to develop reciprocal relationships with professionals (and with each other) and enter into mutual responsibilities and expectations.
• Peer support networks – enhancing knowledge generation and transfer through engaging personal and peer networks alongside those of professionals.
• Breaking down barriers – blurring the distinctions between professionals and producers and consumers of services. Reconfiguring the power relations and the way services are developed and provided.
• Facilitating rather than delivering – enabling professional staff to become catalysts of change, instead of sole providers of services.

“Co-production represents a new way of thinking.”

Co-production is about doing things with people, rather than for or to them. It assumes that the people who use mental health services and their carers have specific knowledge and expertise that traditional professionals don’t have (or at least not in the depth that service users and carers have it). It further assumes that both professional expertise and personal experience are important, so the most effective services arise from both parties being fully involved in their design, delivery and evaluation.

Co-production is not the same as the ‘big society’. It is not simply using service users and carers to do the traditional things that professionals do without training or paying them appropriately. Co-production is about service users and carers working together with professionals in different ways, bringing their experience and expertise to produce different solutions, and then integrating these – wherever possible – with professional approaches, e.g. in Recovery Colleges (key challenge 3) or Peer Support (key challenge 8). Co-production is therefore explicitly about a change in the power relationship between professionals and people who use services¹²⁴. This is probably the most controversial and challenging implication of trying to work in this way.

Nevertheless, the value of co-production for public services is now widely acknowledged. It underpins policy initiatives in England (e.g. People Powered Health programme¹²³, Cocreating Health^{125 126}), Wales¹²⁷ and Scotland¹²⁸. For people using services it means improved outcomes and quality of life and better, more realistic and sustainable, public services. For frontline staff it means shared responsibility and increased job satisfaction from working with more satisfied service users. For managers it means more positive ways of limiting demands on services, making them more efficient. For all citizens it means increasing social capital, social cohesion, and reassurance about the availability and quality of services in the future. True co-production must therefore lie at the heart of mental health services which aim to support recovery¹²⁹.

“I know first-hand, just how transformative being involved in co-production can be. I have moved from feeling I was just a burden on services to now being full involved in helping to develop them… At one time the only adults in my life were mental health professionals, now I have work colleagues and a network of friends!”
Peer trainer

Economic evidence

In many cases evaluations that have looked at co-production have not put an economic value on the benefits of this approach. In order to calculate the return on investment it is important to know about the financial costs of supporting co-production. Little information has been published on these costs, but it is likely that value of the time and other inputs of people with lived experience into co-production will more than outweigh additional formal resources that are required. Co-production in effect should provide net additional resources and capacity to mental health services. This hypothesis needs though to be formally tested.

It is also important to know what the economic consequences of co-production are. A review of evidence on co-production in mental health identified a number of studies (both small scale evaluations and trials) that reported an association with reduced health care costs, e.g. for medications and specialist mental health services. The review also identified benefits from improved social functioning outcome, e.g. employment and reduced dependency on public services¹²⁴.

Recently a significant trend in reduced costs in contacts with health and social care services six months and nine months after beginning to participate in peer support groups was observed in England. This uncontrolled analysis combined the experiences from people involved in one or more peer support activities, including online peer support. Overall, including impacts on employment, education and volunteering, costs were 28% lower than baseline at 6 months and 53% lower at nine month follow up¹³⁰.

This finding reinforces an earlier review which suggested that “an approach which may also in time offer the biggest scope for cost savings in mental health care is to promote and expand co-production, drawing on the resources of people who are currently using mental health services, for example in peer support roles”¹ (p.6).

“Co-production is about doing things with people, rather than for or to them.”

“As a service-user, I’ve been asked a quite a lot about my opinions on the professional’s ideas in mental health services, but now through co-production, I am able to also share my ideas and hear the professional’s opinions on these. That is really empowering!”
Service user

Key organisational challenge 8: Transforming the workforce

Key concepts: Peer support workers; Peer trainers; Stigma; Staff attitudes

“Working as a Senior Peer Support Worker is an opportunity that is beyond any expectations that I had when I was unwell. During my time in hospital I thought a lot about wanting to use my experience as a way of supporting others in future, in order to help them feel understood and less alone. At the time I never thought this role would exist and I feel privileged to be part of an initiative that I believe has and will continue to have an invaluable impact on mental health services. Doing this work gives me a sense of purpose, and has given meaning to the difficulties that I went through in the past. I believe that my role keeps me motivated to keep well and look after myself, in order to support others in doing the same and this responsibility has added huge value to my daily life and future aspirations.”
Peer support worker

Research studies

In addition to Recovery Colleges, the other most visible sign of services moving explicitly towards supporting recovery is the inclusion of peer workers. These are individuals with mental illness who use their lived experience to support others to recover¹³¹. The value of peer support has long been recognised in mental health services¹³² but only recently have peer workers begun to be taken seriously as an effective addition to the workforce. A Cochrane review conducted in 2013 identified eleven randomised trials involving 2,796 people, showing equivalent outcomes from peer support workers compared with professionals employed in similar roles¹³³. Wider reviews using a greater range of studies have shown more positive effects^{134 135 136}. These are summarised below.

• 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.
• In a number of studies when patients are in frequent contact with peer support workers, their stability in employment, education and training has also been shown to increase.

Some of these findings are not replicated across all studies depending on the methods used and the quality of the evidence (which is quite variable). Nevertheless, the overall evidence shows that having contact with a peer support worker leads to an increased sense of empowerment and positive benefits in terms of social inclusion. The next frontier is therefore implementation, and both ImROC^{137 138} and others^{139 140} have developed guidance to assist in this process.

“One of the main benefits to working with a peer support worker is that of positivity; seeing someone who has experienced mental health problems but has moved forward and is now working. I believe the PSW is good at validating service users’ experiences whilst also seeing the potential in people and being able to identify people’s strengths rather than looking at all the negatives.”
Mental health worker

If individuals are to be supported in their personal recovery by traditional staff or peers then staff have to believe that it is possible. There is evidence that some mental health professionals still hold stigmatising views about people using services¹⁴¹. This ‘othering’ behaviour – emphasising differences rather than commonalities – can foster low expectations and negative attitudes to the possibility of change hindering the development of ‘non-patient’ identities and getting in the way of recovery. This needs to change and we therefore need to think about how to change staff attitudes so as to make them more generally supportive of recovery.

The most effective approaches to reducing stigma in the general population are those that include direct contact between persons from the stigmatised group and those that hold the stigmatising attitudes¹⁴². If managed correctly, this contact should allow both groups to identify and share their common humanity, which then breaks down stereotyped attitudes. An early peer support service in assertive outreach found that peer workers “created a more positive attitude toward persons with mental illness”¹⁴³. A comprehensive review concluded that antimental health stigma programmes aimed at staff should contain personal testimony from a trained and enthusiastic speaker who has lived experience and who shows that recovery is both real and possible, demonstrating by their example competence and a successful way of living¹⁴⁴. This is what peers do, and so the inclusion of peer workers in the workforce should be a powerful way of addressing negative staff attitudes. Where peer workers are well-established there is good anecdotal evidence that this is indeed the case. Thus, the inclusion of peer workers not only has direct benefits for people receiving this service (and for those delivering it) it also contributes to changing the organisational culture so as to make support for recovery more generally acceptable.

“Having contact with a peer support worker leads to an increased sense of empowerment and positive benefits in terms of social inclusion.”

Economic evidence

It can be difficult to distinguish between studies focused on the economic benefits of peer worker interventions and other types of peer support interventions. Evidence on the broader benefits of peer support interventions was discussed in challenge 7. Here we focus on the economic case for peers who are salaried members of the workforce, though studies on volunteer peer workers have also been conducted.

One review looked at the impact of paid peer workers on the use of psychiatric hospital beds, where peer workers provided additional services such as befriending, mentoring or advocacy in community mental health teams or in the community¹⁴⁵. Six studies (one from Australia and five from the US) were identified, four of which generated a positive return on investment, with a weighted average return on investment of almost 5:1. While this is a limited evidence base, the economic benefits may be understated as the analysis does not take account of any positive impact on quality of life and other outcomes.

Findings from one of the US studies in this review were used to help model potential cost savings to the mental health system in England through peer mentoring, although the precise value of mental health specific savings was not reported¹⁴⁶. This analysis may be limited by its assumption that changes in the future use of psychiatric services in one hospital in Connecticut through the use of peer mentoring would apply to the English context¹⁴⁷.

A pilot randomised trial in the UK looked at 4 weeks support provided by peer support workers to people who had recently been discharged from inpatient mental health care¹⁴⁸. The study was too small to identify any statistical differences in costs or outcomes, but did suggest that a larger study might be able to confirm the observed good probability of being cost effective. Another US study looking at the use of peer mentors in homeless veterans found no difference in the costs or use of health services¹⁴⁹.

“There is no sense of ‘us and them’ in our team, and I feel that the unique perspective that I have brought having been a service user on the ward, who understood first-hand how it can feel, was genuinely appreciated. I saw how perceptions and stereotypes relating to mental health could be transformed by having someone that used to be a patient on the ward working there. More than one colleague and a number of service users have said things along the lines of “I can’t believe you were ever on the ward!” Many said in different ways, that they were inspired by seeing such a thing was possible – I know because two years ago I’d have agreed with them!”
Peer support worker

“I would like to think that my practice very much embraces the concept of recovery, yet (the peer support worker) has arrived and made me pause and rethink, not in a critical way but in a gentle questioning way.”
Consultant psychiatrist

Key organisational challenge 9: Supporting staff in their recovery journey

This key challenge has been updated in the light of experience.

Key organisational challenge 9: Supporting staff to cope effectively with the stressors that are inevitable in working in mental health services

Key concepts: Lived experience in the workforce; Reducing absenteeism and presenteeism; Expertise in wellbeing

“Supporting staff makes sense every way you look at it.”

Research studies

Supporting staff makes sense every way you look at it. Stressed, demotivated and demoralised staff either go off sick or are vulnerable to ‘presenteeism’ (consistently under-performing at work) – both of which reduce organisational effectiveness. However, there are further recovery-specific reasons to attend to staff wellbeing.

First, to harness the un-tapped resource of lived experience in the non-peer workforce. A national survey found approximately 2 in 5 of the NHS mental health workforce have personal experience of mental ill-health, and over three-quarters have supported a family member or friend with mental health problems¹⁵⁰. However, less than half had fully disclosed their lived experience to colleagues. Initiatives around ‘valuing the life, lived and professional skills and experiences of staff’¹⁵¹ will involve organisational leadership with engaged support from human resources.

Second, there is evidence that staff hold different views about sources of wellbeing for themselves compared with people using their services. Mental health staff in England hold a more deficit-based perspective on wellbeing for service users and a more strengths-based view for themselves (i.e. ‘they’ need fixing but ‘we’ need a meaningful and enjoyable life)¹⁵². Developing expertise in sources of resilience and wellbeing as a core part of professional experience has the potential to positively impact on this anti-recovery attitude.

Third, developing expertise about wellbeing makes ideas about recovery easier to understand. For example, the CHIME framework aligns very closely with the Foresight work on mental capital¹⁵³, summarised by the New Economics Foundation as five-a-day for wellbeing: Connect, Be active, Take notice, Keep learning, Give¹⁵⁴. Supporting the development of worker expertise in wellbeing will increase their skills in support recovery, because in many senses wellbeing is recovery¹⁵⁵.

Finally, as noted in key challenge 4, improving staff wellbeing is a pathway to improve the experience of using services: ‘Individual staff wellbeing is best seen as an antecedent rather than as a consequence of patient care performance; seeking systematically to enhance staff wellbeing is not only important in its own right but also for the quality of patient experience’⁸⁹.

Specifically in relation to wellbeing in the workforce, evidence-informed strategies are now possible. A systematic review of workplace interventions for common mental disorders such as depression or anxiety synthesised 140 reviews including 20 of moderate or high quality, incorporating findings from 481 studies¹⁵⁶. The review identified empirically-supported approaches to primary prevention to reduce onset (enhancing employee control, promoting physical activity), secondary prevention to mitigate effects (cognitive-behavioural therapy-based stress management), and tertiary prevention to support symptom reduction and return to work (exposure therapy, CBT-based and problem-focused return-to-work programmes).

“He (the nurse) just seem really tired and stressed and like he just did not have the energy to bother with me at all, let alone care about me.”
Experience of being treated by stressed, demotivated and demoralised staff

“She (the doctor) looked at me, but there was no eye contact and she rushed me away. It made me wonder what she’d been on. She seemed in a worse place than me.”
Experience of being treated by stressed, demotivated and demoralised staff

“A long time ago, I saw a doctor after I’d attempted to take my own life. I remember that he asked me what it proved? I replied ‘a lot.’ I never saw him again and I heard that he took his own life. I’ve often wondered if my comment had an effect on him.”
Experience of being treated by stressed, demotivated and demoralised staff

Economic evidence

It has been argued that an extension of the recovery based approach to the health and wellbeing of staff working in mental health services may help the NHS to have a healthier workforce and reduce levels of absenteeism¹⁵¹. In fact many of these principles, e.g. empowering staff to have more control over the way that they work, focusing on workplace environmental factors that can be conducive to occupational stress and poor mental health, flexible working arrangements, increasing the value that line managers place on their staff and the importance of maintaining contact with staff when they are on sick leave are entirely consistent with what are now regarded as key approaches to promoting mental health and wellbeing in the workplace^157-159.

Moreover there is a strong business case for adopting these principles for workplace mental health promotion programmes. While most of the evidence tends to focus on specific interventions, such as the introduction of workplace wellbeing programmes or brief psychological support for staff experiencing stress, there is also a recognition that broader workplace measures such as training for line managers to recognise stress and workplace environmental assessments, including measures to establish a healthy working culture, can generate positive returns on investment to workplaces, including health services¹⁶⁰. Positive benefits include a reduction in sickness absence, presenteeism, staff turnover and early retirement. There is a very broad literature on the level of return on investment from these types of workplace health promotion activities. While caution must be exercised on how the results of these studies are interpreted as many different methodologies are used in different country contexts, in broad terms there tends to be at least a 2:1 return on investment to the workplace of evidence-based actions to address common mental disorders and an even greater level of return on investment for some workplace (mental and physical) health promotion actions¹⁶⁰.

Key organisational challenge 10: Increasing opportunities for building a life ‘beyond illness’

This key challenge has been updated in the light of experience.

Key organisational challenge 10: Prioritisation of life goals (full citizenship and community integration) in all care planning processes

Key concepts: Housing First; Personal budgets; Individual Placement and Support (IPS); Community participation

“Leaving home at 16 was the start of a long personal journey into homelessness, and a 20 year battle with complex mental and physical health difficulties. After several intensive hospital admissions, time spent sofa surfing, in hostels, and insecurely housed, I became what is often termed a ‘revolving door patient’, with little hope of finding the way out. I now have a place that I can call home, a place that feels safe and warm and where I have the choice to stay for as long as it suits me.. .. I have skills and strengths that health care and social workers helped me to find and to build upon…The things that helped me to find a way to stop the door revolving, to find a door to a home, were being seen and respected as an individual, not being defined by my problems or my label of ‘damaged’ or ‘vulnerable’ or ‘homeless’ …Respect, compassion, empathy, being seen and heard and valued… Life being homeless is hard. People usually don’t end up homeless because they have had easy lives up to that point. Having no security, no stability, no support system, alongside the demoralising and damaging effect that homelessness can have on mental and physical health, where just surviving feels like a battle”
Peer researcher working with people experiencing homelessness

Research studies

If supporting recovery is about one thing, it is about placing the achievement of personal life goals (full citizenship and community integration) alongside symptom reduction as the major objective of mental health services⁸. This is reflected in a focus on housing, money, employment and social integration. There is now a robust evidence base for the effectiveness of a range of approaches to achieving these objectives and these now need to be (re)incorporated into service design.

Housing

Good housing is more than just shelter¹⁶¹: it is the bedrock of successful community living. Notwithstanding this simple fact, the topic of housing has received little attention over the years from mental health professionals. An exception to this rule is the Housing First initiative. This was developed in the U.S.A. to meet the needs of homeless people with complex mental health and substance misuse problems. It prioritises the identification of suitable housing, based on personal preference, and then delivers other supportive services to the person once they are housed, without a pre-requisite that their substance misuse must cease first. The use of permanent housing options and the commitment to floating support means that the resident does not have to make continual moves between different types of accommodation as their support needs change.

A definitive randomised controlled trial across Canada showed that homeless people living with mental illness (n=1,198) who received the Housing First intervention had increased housing stability over 24 months compared to those not receiving the intervention¹⁶². A qualitative study with a sub-group of participants (n=60) also found positive impacts on hope and recovery goals¹⁶³. In this study, despite there being no requirement for the Housing First group to abstain from substance misuse, there was actually no significant difference between the two groups regarding their levels of drug and alcohol use. The annual per capita costs of the Housing First programme were also around half those of ‘treatment first’ programme. This approach has been tried in England¹⁶⁴ but is not widespread.

Employment

The Individual Placement and Support (IPS) approach is now the best researched approach to supporting people with mental health problems to access and retain mainstream employment. It has a number of similarities with the Housing First approach in that it is also based on placing the person in a work position of their choice as quickly as possible and then providing them and with an integrated package of vocational and clinical support in situ. A 2013 Cochrane review (14 trials, 2,265 people) concluded that IPS ‘is effective in improving a number of vocational outcomes relevant to people with severe mental illness’¹⁶⁵. IPS consistently achieves employment rates 2-3 times better than traditional alternatives such as pre-vocational training and sheltered workshops. This holds true in high and low income settings, across different countries, irrespective of the underlying employment rate. Longer term follow-up studies of people placed through IPS suggest that the higher rates of employment are maintained and have positive impact on non-vocational outcomes such as improved confidence and wellbeing, and reduced sense of stigma. The one study where IPS failed to produce such impressive results was where it was not implemented with good fidelity to the research model^{166 167}. A more recent review and meta-analysis of 19 international studies also found that IPS was more than twice as likely to lead to competitive employment compared to vocational support even where economic growth was low¹⁶⁸.

In contrast to supported employment, much less attention has been focused on assessing the cost effectiveness of supported education services to help young people remain in and complete their education, which in turn will increase career opportunities and earning potential. There is emerging evidence on adapting IPS to deliver supported education, for instance in Australia¹⁶⁹.

Money

For people with serious mental health problems – as for the rest of the community – not having enough money clearly reduces both the meaning and enjoyment of life¹⁷⁰. Since people with serious mental health problems are more likely than the rest of the community to experience poverty, it is specially important to ensure that they have access to financial advice in various forms¹. The topic of material support is only recently receiving attention from mental health professions^{171 172}.

An approach which aims to give the person direct control over a substantial proportion of their financial support is known as Personal budgets (or self-directed care). This has been tried both in the U.S.A.¹⁷³ and in England¹⁷⁴, and aims to provide the person with the resources that would otherwise be spent on services to allow them to spend them on whatever they think will be most helpful. This sounds like it must be a good idea, but there are considerable practical problems in its implementation, both bureaucratic and in ensuring that resources are effectively targeted on those in greatest need. The effectiveness of personal budgets also depends very much on the quality and continuity of the supportive relationships¹⁷⁵. It therefore remains to be seen whether it will be possible to get personal budgets to work effectively and if they can be rolled out on a large scale in statutory services. (The best examples of effective use of personal budgets are currently still in the voluntary sector). If these problems of implementation could be successfully addressed then personal budgets could undoubtedly make a significant contribution to supporting community integration and social inclusion.

Social integration

Personal networks are important for recovery at an individual and a group level. Each one of us, whether living with mental health problems or not, can probably name a few key individuals who have helped us keep on going when times are tough. Close, personal, social supports help reassure, they shape identity, provide meaning to life, give a sense of belonging and access to new resources¹⁷⁶. There is specific evidence that positive relationships can be the tipping point that starts a person’s recovery journey^{177 178}. Similarly, feeling a part of the community, not just physically located within it, is a fundamental human need. However, despite the obvious importance of social support, interventions to support social network development have not been much researched in the mental health literature. Approaches like wellbeing networks and asset mapping¹⁷⁹ therefore need to be given more attention and evaluated in terms of their practical value.

“People with serious mental health problems are more likely than the rest of the community to experience poverty.”

“I know only too well the barriers to getting (and using) treatment that come with the label of ‘homeless’. Not having support or the hope that things can be different… Lacking the confidence and understanding of unfamiliar health systems…Feeling undeserving, worthless… These things can make it impossible to even identify the help you so desperately need, never mind where to get it.”
CNWL Recovery Stories, 2014

“Positive relationships can be the tipping point that starts a person’s recovery journey.”

Economic evidence

There is a strong evidence base on the benefits of facilitating recovery and preventing relapse through actions that support education, housing and employment, and other aspects of social functioning¹. In this Briefing Paper we can only provide a brief flavour of this evidence base. A key challenge though is to work effectively not only within the health sectors, but across sectors, such as with the private sector, financial services and banking sectors to reduce the risks of unmanageable debt, with employers, and not least with the non-government sector such as housing associations to both fund and implement evidence based actions.

It is vital to measure and highlight the personal, social and economic outcomes such impacts on the rate of employment, the completion of education and training, and securing stable housing, in addition to more narrow mental health specific measures of recovery. Achieving secure employment will benefit society through a reduced need for welfare support while better educational outcomes increase the likelihood of securing good employment. Employment in turn can promote independence. A lack of access to secure housing and employment, as well as unmanageable debt and poverty are also associated with an increased risk of future poor physical and mental health.

Housing

As well as being a key component of a recovery strategy, there are substantial economic opportunities along the care pathway to improve outcomes and reduce costs for mental health service providers through use of appropriate housing services, rather than more expensive mental health services. These housing options are heavily dependent on the level of housing stock available in any local area; clearly this is challenging in England.

Recovery may be aided by better access to long term (albeit still transitional) housing support as well as long term independent housing. Housing associations can play a very important role. For instance the ‘One Housing Group’ and an NHS Trust in London have developed a Care Support Plus model which initially provided 15 high quality self contained supported housing units, helping service users prepare for the transition to other forms of accommodation. The service has reduced hospital stays and costs to the health services by more than £440,000 per annum with a reduction in hospital admissions from a total of 408 weeks in the two years prior to the scheme compared with 57.7 in the subsequent two years, with a further 12 flats built¹⁸⁰.

Looking at longer term support, a review of economic studies on Housing First in Canada, the US and Australia suggests that they ‘can lead to significant cost offsets. When considering improvements in housing stability, health, and quality of life, Housing First may be a very cost-effective intervention for chronically homeless populations’¹⁸¹. However the follow up time periods for most of these studies are quite short so less is known on long term impacts. Furthermore Housing First has had to operate in a climate with a severe shortage of social housing and affordable private-market housing in many Canadian communities. This can impact on the potential benefits of the programme.

“Around two-thirds of all of the costs of poor mental health are due to lost opportunities to participate in employment.”

The City of Toronto’s 2007 examination of the Streets to Homes programme found that the low supply of affordable housing resulted in a reliance on shared accommodation, which was less desirable to participants and generally led to worse outcomes, when compared to individuals housed in private apartments¹⁸². This is pertinent given the housing shortage in England.

An observational study of the Housing First approach in England reported decreased repeated homelessness for people who on average had previously experienced 14 years of homelessness. Potential cost-savings were estimated to be £15,246 per person per year, assuming potential savings between £4,873 and £3,098 per person in support costs, as well as from reductions in A&E visits and fewer contacts with the criminal justice system. While promising, sustainable funding will be an important factor for the continued success in the provision of this type of open-ended support¹⁸³. This may also be dependent on rules governing entitlements in respect of housing benefit.

A national survey of 619 people from 22 residential care, 35 supported housing and 30 floating outreach services across England also looked at the costs of mental health supported accommodation services. It estimated mean costs of £371,445 for supported housing compared to £474,339 for residential care¹⁸⁴. After adjusting for differences in need, quality of life was similar in supported housing to residential care, but with greater levels of social inclusion and a higher risk of experiencing crime. Floating support was much less expensive but associated with poorer quality of life outcomes and higher risk of crime.

Employment

Around two-thirds of all of the costs of poor mental health are due to lost opportunities to participate in employment. Most evaluations suggest that IPS is more effective than vocational rehabilitation in helping people return to competitive employment¹⁶⁸. There is evidence particularly from the US on long term sustainability of benefits, although these have been hampered by funding structures¹⁸⁵.

In Europe evidence from Switzerland indicates that higher rates of competitive employment can be sustained over at least five years: 43% employed for at least 130 weeks versus 11% in the vocational rehabilitation groups. In this analysis there were no significant differences in overall costs of the two programmes – the higher costs of the supported employment programme were offset by reduced in patient admissions and lengths of stay. However mean incomes from employment in the supported employment group in the study were also almost double those in the vocational rehabilitation group¹⁸⁶.

A review of economic studies drew the conclusion that in the English context IPS would pay for itself within a year – with then annual costs per individual of £2,700 being offset by reductions in the use of mental health services of more than £3,000 per annum¹⁸⁷. In an earlier multi-country trial, including supported employed in London, IPS was found to be less costly than vocational rehabilitation, with an overall mean net benefit to society, taking account of additional productivity through employment, of £22,615 per client compared to vocational rehabilitation services¹⁸⁸.

“So it’s the day after my release…I’m on my way to sort out my script and prevent myself from going in to withdrawals and using. The first key worker I saw there was brilliant! Not only did she ensure my script…she also spoke about actually where to go from here….the ambition I had from before drugs was slowly coming back but I didn’t honestly know how to get back into society and work etc.”
CNWL Recovery Stories, 2014

“Good housing is more than just shelter.”

These findings can be replicated even in very different country contexts: a recent evaluation of IPS plus psychological therapy was compared with traditional vocational support in Japan. At one year follow up while there were no overall differences in costs between the two groups, rates of employment were higher and clinical outcomes better in the supported employment group¹⁸⁹. In contrast to employment, insufficient attention has been given to the assessing the economic case for comparable supported education services; a gap in the evidence that should be addressed.

Money

Evidence on the cost effectiveness of personal budgets is modest, in part because evaluations have tended to focus on different client groups rather than people with mental health needs. A systematic review on personal budgets for people with mental health problems only identified cost effectiveness evidence in two of 15 studies assessed¹⁹⁰. The more recent of these English studies concluded that the additional cost of delivering personal budgets was a cost effective use of resources given the improvements in quality of life and neutral impact on costs¹⁹¹.

However, there remain many logistical and administrative challenges in expanding the use of personal budgets; the flip side of more individual choice is that the sustainability of existing services and supports is also weakened. Some of these issues may be explored further in ongoing evaluation of the relatively new Integrated Personal Commissioning areas that are being rolled out in England. These IPCs can include personal budgets as one element of an approach that in theory should be co-produced with service users¹⁹².

People with some mental health needs may also be particularly vulnerable to falling into debt. Financial difficulties reduce the likelihood that people will recover from mental health difficulties. Investing in services that provide specialist welfare advice to people with mental health needs is likely to be a cost saving intervention even if only a small number of clients then have a reduced risk of using inpatient mental health services¹⁹³. A recent economic modelling analysis suggests that the provision of face to face debt advice would aid recovery rates from depression, with costs of service provision being more than outweighed by a small reduction in costs to the NHS and a much greater impact on the wider economy by decreasing barriers to work¹⁹⁴. Other new modelling work also suggests that there is a return on investment to face to face debt advice services of almost £3 for every £1 invested due to the avoidance in the general population of depression and anxiety problems associated with problematic debt¹⁹⁵.

“There is a strong evidence base on the benefits of facilitating recovery and preventing relapse through actions that support education, housing and employment.”

Conclusion

We have considered a broad sweep of evidence and across a wide range of subject areas. That is inevitable with a topic like supporting recovery since it is as much about a set of underlying ideas, principles and values which can be applied to almost any intervention, as it is about the effectiveness of specific approaches. However, we believe it may be helpful for commissioners, health and social care leaders, and other stake-holders to be aware that there is a defensible and growing business case for the ten key organisational challenges.

Where the business case can be made specific, the traditional outcome evidence is – unsurprisingly – patchy. The scientific evidence supporting self-management (Challenge 1) is compelling and the emphasis on ‘learning’ – particularly joint learning (‘coproduction’) is highly consistent with modern educational thinking (Challenges 2 & 7). The evidence regarding the effectiveness of Recovery Colleges is promising (Challenge 3), but, at present, it is methodologically weak. A recovery-oriented approach to leadership and management (Challenge 4) is also very much supported by a substantial literature on organisational change, and a highly individualised approach to the planning and delivering of care (Challenge 5) is globally accepted as the bedrock of good practice in mental health services. Staff are also commonly overworked and undervalued, so the evidence that practising in a way that supports recovery is helpful to their morale and well-being (Challenge 9) is therefore potentially very important. There is good randomised controlled trial evidence supporting the value of peer support workers (Challenge 8), and the evidence in favour of the benefits of helping people pursue common personal recovery goals – stable housing, employment, financial support, social integration (Challenge 10) – is well established. Thus, the overall picture is of general support for a recovery-oriented approach, with more evaluative evidence needed, but strong evidence for high service user satisfaction and promising evidence for cost-effectiveness in certain key areas. It is this general picture which led the World Health Organisation to make supporting recovery one of its central organising principles for mental health services across the globe³.

In terms of the strength of the evaluative evidence it is not surprising that randomised controlled trials are relatively rare. This is generally a new approach and it will take time for researchers (and funders) to catch up with the promising nature of these new developments and give it rigorous attention. However, this is balanced by the very strong evidence for increased satisfaction from people who use recovery-supporting services. In our view it is unusual for service developments to have generated such consistently high support from the people who use them – and from most of the people who deliver them. This leads us to believe that supporting recovery is a process which taps into some of the basic reasons why people approach mental health services for help and the essential motivation of staff to try to help them. This has to be a powerful combination.

Finally, we believe that supporting recovery may be a part of the solution to the global crisis of apparently almost limitless demand for care in the face of increasingly constricted resources. If these two pressures are to be reconciled we believe it will require a fundamental rethink of not only what is delivered by mental health services, but also how it is delivered. As part of this reevaluation we believe that governments, managers and practitioners will have to redefine their goals and re-examine their workforce. Our speculation is that this transformation will involve changes in skills (such as a far greater emphasis on coaching to support self-management), structures (e.g. more partnerships with, and working through, community resources) and workforce, with the involvement of many more peer workers alongside traditional professionals. This transformation is perhaps the most daunting – but exciting – challenge.

Acknowledgements

We would like to thank the people using Central and North West London NHS Foundation Trust (CNWL) services who gave quotes and shared their invaluable insights, including the staff and students of CNWL Recovery & Wellbeing College, CNWL peer support workers, peer researchers, carers, service leads and practitioners. We thank Jane Rennison and Steve Trenchard for their comments.

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