Our service was originally established in 2014 as an 'alternatives to admission' programme using assertive engagement and stabilisation methods, for people who had spent considerable periods in psychiatric hospital and were not much helped by the mainstream mental health services. The people joining our programme have severe and enduring mental health conditions, who have usually been hospitalised for their high risk of suicide, or other acute-on-chronic problems. Although we concentrate on formulation rather than diagnosis, most could be diagnosed with ‘personality disorder’; our only firm exclusion is active, persistent and severe psychosis. Over the last five years, the council and NHS have been developing an innovative and comprehensive pathway for the population of Slough, by creating an ‘Enabling Town’ which aspires to meet the needs of all those requiring mental health services.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
Our service was originally established in 2014 as an ‘alternatives to admission’ programme using assertive engagement and stabilisation methods, for people who had spent considerable periods in psychiatric hospital and were not much helped by the mainstream mental health services. The people joining our programme have severe and enduring mental health conditions, who have usually been hospitalised for their high risk of suicide, or other acute-on-chronic problems. Although we concentrate on formulation rather than diagnosis, most could be diagnosed with ‘personality disorder’; our only firm exclusion is active, persistent and severe psychosis. Over the last five years, the council and NHS have been developing an innovative and comprehensive pathway for the population of Slough, by creating an ‘Enabling Town’ which aspires to meet the needs of all those requiring mental health services. The pathway relies on co-produced interventions jointly delivered by peer-mentors in different settings across the town: in health, social care and the voluntary sector. This is our ‘whole-town’ approach, for which the ASSiST and EMBRACE programmes provide its main therapeutic hub. Using an asset-based community development approach alongside evidence-based psychotherapeutic and psychosocial approaches we ensure that requirements of the different sectors are both met.
The key to our work is co-production and relational practice, with which was wholly developed – across health, social care, the voluntary sector, and supported living provides. This creates a synergy between all parts of the system and of itself creates opportunity for people in services, which support independence and personal agency, to build preventative approaches to build social cohesion, resilience and well-being. The members of the groups maintain a YouTube video channel which includes psychoeducational and mindfulness exercises, and expressions of artistic creativity used in teaching materials. Recently, it has been so successful that the graduate ‘peer mentors’ are now gaining employment within the system as social prescribers. The approach we have developed challenges the health deficit model and utilises a positive community asset-based methodology. This normalises people’s troubled experience, and is not specific to any particular population of mental health service users.
What makes your service stand out from others? Please provide an example of this.
We are not a fixed service, delivering interventions to a prearranged plan or manual. The ability to be continually responsive to people’s changing uses our embedded principles of co-production, and structures to ensure this is continuous and never static. This involves the ability to make decisions flexibly at clinical, organisational and town levels – through building and maintaining reflective and creative relationships in all three levels. The clinical approach we have developed challenges the health deficit model and utilises a positive community asset-based methodology. This normalises people’s troubled experience, and is not specific to any particular population of mental health service users. Recently, it has been so successful that the graduate ‘peer mentors’ are now gaining employment within the system as social prescribers.
How do you ensure an effective, safe, compassionate and sustainable workforce?
Our service ethos, of openness, relational practice and true involvement of all professions and stakeholders, makes us recognised as an innovative service that constantly attracts a high number of visitors from our own organisations as well as from across the UK and overseas. Through supervision and support structures, nobody is left with sole responsibility for ‘holding the risk’ in a way that reduces the sense of threat, and possibility of vicarious traumatisation. This includes co-working, regular indivual and group supervision and periodic relational space sessions. Peer mentors are part of the clinical team, after they have completed the therapeutic programme and have undergone specific training through Hope College (the local Recovery College). The service has now reached a stage where they are being employed in substantive posts. The overall culture of relational practice is developed, maintained and quality assured through the Enabling Environments initiative at the Royal College of Psychiatrists Centre for Quality Improvement.
Who is in your team?
Team lead – 1wte psychology – band 8B Senior MH practitioners – 2wte band 6 Psychology assistant – 1wte band 4 + 0.4wte band 4 Adult psychotherapist – 0.2wte band 7 Administrator – 1wte band 3 Medical psychotherapist – 0.3wte consultant Psychologist – 0.2wte band 8a Representative from Hope College – 1x individual, <0.1wte Head of MH Services, SBC and BHFT – 1x individual, <0.1wte Volunteers Peer mentors – 4x 0.4wte Hon assistant psychologists – 2x 0.4wte Research lead – 0.1wte post-doctoral research psychologist Representatives from local charities – 4x individuals <0.1wte each
How do you work with the wider system?
The model we have developed is based on ‘relational practice’, which is a primarily clinical approach focusing on the engagement, and establishment of a good therapeutic relationship. Rather than seeing people as ‘individual faulty machines’, we emphasise how change and transformation can be brought about through building relationships, and networks of relationships. We have extended the concept to include wider links to the whole community and its services: a whole-system approach. In this way, relationships between organisations and teams are vital to the project, in a similar way to how the quality of relationships is vital at a clinical level. We have successfully integrated ‘relational practice’ in this way. An example is the joint commissioning (Local Authority and Health) of Hope Recovery College, Hope House and Doddsfield Road (16-bedded supported living unit), by developing a pathway for peer mentors to become key workers for the residents. The links we have formed with the voluntary sector include expanding social prescribing into primary care.
We are also developing an Enabling Environment strategy14 with all our voluntary sector supported living providers – again to develop a ‘whole-town ethos’ which is owned by all. This includes Independent Placement Support (IPS) return-to-work initiatives which have enabled 53 people to return to work, and 85 to access training, education and voluntary work. The success of the model has been recognised by the third sector consortium, which awarded Slough MH Services with an award for partnership working. Part of our success in spreading these ideas is through the work of our Mental Health Partnership Board, and our Mental Health Providers Forum. These have been designed to allow and enable co-production and close working relationships. Further evidence of the success of this work is the ‘Partnership Toolkit’ which has been developed by collaborative working and it is now to be used across the whole town15. Another example of third sector partnership is the engagement with ‘greencare’ (a co-produced ecotherapy programme which won the Royal College of Psychiatrists 2014 Sustainability Award, run by Growing Better Lives CIC). This has recently been transferred to the Hope Recovery College steering group, and will be run by service users for the wider good of the whole community. The growing evidence base for nature-based therapy applies to the well-being of the whole populations, and is recognised as an effective preventative measure.
Do you use co-production approaches?
Our central tenet of co-design and co-production, across the system, necessarily challenges inequality in the health system by creating opportunities for all by minimising ‘us and them’ dynamics, and transcending any diagnostic categorisations. An example of our work is ‘Ward Embrace’, where senior peer mentors of the Embrace group saw the need for relational engagement while people were still on the ward, to help the transition from ward to community. Several members of the group, together with staff, now travel 25 miles to the hospital to co-facilitate a weekly group to engage new members of the ASSiST service. They are currently planning other more informal activities on the wards to recruit those who feel unable to attend the groups. This is now embedded in the culture of the inpatient unit, and part of the pathways development programme. At the borough level, we regularly hold an open dialogue group process called ‘The Circle Works’ in different venues across the town. These meetings include service users, family and friends, carers, local authority commissioners, voluntary sector providers and NHS staff in co-creating future pathways. All have an equal voice.
Do you share your work with others? If so, please tell us how.
We are active members of several organisations and networks; we present our work at their meetings and discuss and develop it with colleagues (including those with lived experience who participate in them all). These include: • The ‘Community of Practice’ of the British and Irish Group for the Study of Personality Disorder (BIGSPD) • The research group of the Consortium of Therapeutic Communities (TCTC) • The International Network of Democratic Therapeutic Communities (INDTC) • The Group Analytic Society International (GASI) • The ‘Community of Communities’ quality improvement programme at CCQI • The ‘Enabling Environments’ initiative at CCQI • The ‘Social Futures’ research centre at Nottingham University’s Institute of Mental Health. With our peer mentors, we have ongoing teaching and training commitments with other services, and some regional and national training courses. We attend national and international conferences to present various aspects of our work. We also publish in professional journals, and are sometimes invited to contribute book chapters on aspects of the work. Each voluntary assistant psychologist who has a placement with us is encouraged to undertake a small research project, usually qualitative, and write it up as an oral presentation or poster for a conference, and for publication if possible.
One of our main ways of sharing our work with others has been through welcoming visitors (maximum two each week) to our Tuesday ‘EMBRACE’ hub group, and shared lunch. Clinical professionals can also attend the preceding team meeting. This gives us the opportunity to explain what we are doing, involve the group members and peer mentors, and convey a sense of pride in the work. When we attend conferences and seminars elsewhere, we offer this opportunity – and find it very valuable on both sides. We are also a site for ‘experiential visits’ recognised by some national training courses and institutes. We have started to build a YouTube channel for short videos which we use for training purposes – which are co-produced with our peer mentors. In the local community, we always hold annual events on 10 October (World Mental Health Day) which are open to the whole town. These aim to challenge inequality and stigma by bringing the population together – and celebrating who we all are – in our diverse community.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
We undertake various routine ‘practice-based evidence’ as part of our standard operating procedure. We prefer to use PROMS and PREMS and to do so in ways that the data is openly shared and discussed with our service users. We routinely collect standard NHS measures such as HoNOS, but find modern standardised measures more appropriate for our work, and the population we serve: ReQoL-20 (with its coproduced and recovery focus on measuring what matters to service users); WEBWMS (with its emphasis on wellbeing); and other specific measures when indicated (such as ASD or severity scales). These are always measured at admission and discharge, and also after 3 months then 6 monthly intervals. We analyse them and feed the results back to service users, and (when anonymised and collated) to commissioners. We use an online system called POD (Patient Owned Database) run from the Anna Freud Centre in London. With this, questionnaires are administered online (mobile phone or tablet), and can be seen by, and discussed with, the members of our groups. We also collect economic data for all the participants of our programme – including pre and post bed days, crisis team use, CMHT appointments and A&E attendances. These figures are required by our commissioners to demonstrate the founding principle of our service (‘alternatives to admission’) and to show that this continues as the project develops. Here are some of our figures, for the 12 months before and after participation in the ASSiST/EMBRACE programme: • Bed days: 4786 (pre) to 312 (post). Cost of these £1.6m (pre) to £101K (post) – reduction to 6.4% of previous level. • Crisis and A&E: 4451 (pre) to 1235 (post) – reduction to 27% of previous level. Another example of specific savings identified is Hope House, which is an innovative supported living facility. It has significantly reduced the cost per bed for each resident, and improved the quality of care for the individual.
This has proved to be successful with cost avoidance of expensive out-of-area (OAPs) placements, and cost savings by repatriating users of long-term private residential units. The development of this whole-system approach has proved to be successful in times of austerity and is in line with the forthcoming Accountable Care Systems. The model has allowed us to improve quality and achieve cost savings for the local authority and NHS. This success has demonstrated sufficient cost savings to the local authority that further investment was agreed for 2018-19. This will support further growth and the development of the model, across the system. After each clinical session, short open text questionnaire feedback forms are used, which are collated and used for clinical reflection and co-produced changes to the service. All these elements are part of an established and systematically used research and evaluation strategy, which is regularly reviewed by the senior clinicians and our research lead.
Has your service been evaluated (by peer or academic review)?
CCQI: we are part of two CCQI quality initiatives. These are the Community of Communities accreditation scheme and the Enabling Environments quality award. We are in our third year of CofC membership, and our service has undergone 2 full peer reviews. As a mixed staff/service user team, we have also participated in a number of peer reviews of other services. Several of our peer mentors have also undergone the training to become peer reviewers in the project. Our peer mentors have also led presentations of our work to the Annual Forum of the CofC project (2016). The Enabling Environments Award is less clinical in its focus, and is seen as a guiding principle in our work across the town (see references to ‘Enabling Town Slough’, above). Specifically, membership of the programme – with intention to achieve and maintain the award – has now become a commissioning requirement for all MH housing providers in the statutory sector within the borough. The BHFT staff awards was in 2016 and ASSiST won ‘the Best Patient Initiative and Practice’ first prize for the development of the co-produced EMBRACE Therapeutic Programme During the 2017 CQC inspection, ASSiST’s EMBRACE group was observed; patients and carers were individually interviewed.
In the CQC report on the BHFT performance ASSiST was quoted four times as an example of good practice. Inspectors commented on the inherent value of patient’s voice in the ASSiST service: We observed and had excellent feedback about an ‘embrace’ group offered by Assist and the Hope Recovery College for training and for peer mentoring for patients. Assist is a service commissioned to provide 12 weeks intensive work which involved assertive engagement and psychological intervention to achieve stabilisation and reduce vulnerability to hospital admission. We observed an EMBRACE group in progress and saw the compassionate attitude of the staff while patients themselves highlighted to us the level of empathy and commitment they felt from the staff. We saw that staff provided an individually tailored response to patients and were flexible in their approach. People spoke about the skills they had acquired and the value of peer support. Patents described having their lives transformed and consistently described that the group had engendered hope, helped then to overcome suicidal urges and helped keep them out of hospital. All of the patients we spoke to echoed their own beliefs that this has been of vital importance for them.
One patient told us they had the opportunity to chair the embrace group and take minutes. A carer also present said they had opportunity to come into sessions and told us that they believed it to be essential. The ASSiST/EMBRACE programme was named as an example of excellent patient experience in a report compiled following a visit by six local Berkshire Healthwatch associations in October 2017, researching the experiences of people admitted to Berkshire’s psychiatric wards at Prospect Park Hospital in Reading. Healthwatch stated: “We heard about the ASSiST/Embrace initiative, where former inpatients now living in Slough, are trained as peer mentors, to go to psychiatric wards to visit small groups of inpatients to discuss hope, recovery and living with mental health needs once they leave the hospital and the type of ongoing practical and peer support they can access in the community.”
How will you ensure that your service continues to deliver good mental health care?
At the onset of the programme, the explicit requirement for detailed quarterly reporting, particularly on reduction in bed use, was set. We have seen it as important to continue and develop this relationship with commissioners. We also collaborate closely with clinical colleagues in the local NHS, other sectors such as drugs and alcohol services, housing/homeless projects and voluntary organisations such as the Samaritans. Our service users and peer mentors are also closely involved in maintaining these links, as well as family and friends/carers. The strength of our cost-saving evidence for reduction of bed days, and several other economic parameters, appears to have had an impact on ensuring the continuation of funding support for the programme. This, of course, is in addition to the clinical and ethical benefits of helping people without the need for detention or coercive treatments. Across the county (which comprises five localities apart from Slough) we, and our peer mentors, have been involved in contributing to the development of ‘Cluster 8 Pathways’, the trust’s ‘zero suicide’ initiative, and the county’s public health suicide prevention strategy. On a wider scale, members of our staff and some of the peer mentors are involved in consultative and policy work at the Royal College of Psychiatrists, NHS England and other national professional and service user organisations.
What aspects of your service would you share with people who want to learn from you?
Our challenges have mostly been concerned with instituting a different model of care, and therapeutic philosophy, within a large organisation where many staff and managers do not understand what we are doing, or why. Our approach – using asset-based community development and relational practice – does not always sit comfortably with current areas of concern such as risk management, detailed operational compliance monitoring and documentation requirements. However, we make strenuous efforts to meet these NHS administrative demands – and, where possible, co-produce better ways to meet the requirements by finding user-friendly solutions with our service users and peer mentors.
How many people do you see?
50 referrals pa to ASSiST • Approx 700 x 1:1 or 2:1 individual community-based ASSiST engagement sessions pa • Weekly EMBRACE group up to 20 plus peer mentors and staff • 23 peer mentors trained and occupied since the start of the programme • Weekly workshops with Hope College workshops attended by 80 different people pa
How do people access the service?
Referrals to the ASSiST service must all come from secondary MH professionals, although they are sometimes encouraged/initiated by service users themselves, family and friends, or through other agencies. Suitability for referral is also often prompted by our clinicians examining clinical records on wards (eg for lengthy or repeated admissions for non-psychotic conditions) Referral can also be suggested by discussions between our peer mentors, ward patients, and ward staff following discussions in their ward groups. There is no referral form – colleagues need to discuss cases by email/phone/meeting, and email us with the details. All cases with high bed use, and presentations which do not show severe and active or chronic and persistent psychosis, are accepted, with email confirmation, and then met for 1:1 or 2:1 engagement session(s). We offer 12 sessions to build a therapeutic relationship, and plan what further interventions might be helpful. This usually, but not always, involves moving into the EMBRACE programme.
How long do people wait to start receiving care?
We usually first meet people while they are still resident on the acute wards. Referrals rarely wait for more than two weeks before being seen by us, unless for administrative reasons.
How do you ensure you provide timely access?
We always have 2 clinical referral meetings per week, and one where we discuss the whole caseload in detail. As much as possible, we share care with staff who are already involved. In order to avoid undue dependence on a single clinician, everybody meets several members of the team in the course of their time with us, although a designated clinician usually does the majority of the 12 relationship-building sessions.
What is your service doing to identify mental health inequalities that exist in your local area?
As part of the wider system across the town (ie not specifically the ASSiST/EMBRACE programme) we attend relevant public events and have a regular presence in public locations (such as the new library, and some sports centres, and a friendly coffee shop – to reach out to the local population. Also, We deliberately approach minority groups where we know there is a probable need. eg Somalian refugees; FGM voluntary organisations; domestic violence, retirement age Asian men – and collaborate with council initiatives.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
There are important cultural issues which determine who feels able to seek help from statutory services. Language barriers often prevent people from seeking MH services in our area.
What is your service doing to address and advance equality?
Through wider public events, such as our regular large group Circle Works at the library, we can be responsive to current and changing needs in a diverse and mobile population. Our peer mentors are very active in this, and often co-produce workshops, sessions or short-term groups for specific issues – such as young people, Asian women and others.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Routine use: HoNOS ReQoL WEBWMS …using the POD (Patient Owned Database) online system. See above. Other specific standardised instruments as required. Of more clinical relevance, we prepare a detailed biopsychosocial formulation in collaboration with those referred to us, during the 12 weeks therapeutic engagement phase. This normally involves drawing an annotated genogram to understand the family dynamics, and a chronology as a timeline to understand the relevance of all major life events. Once completed, this is discussed in the multidisciplinary team meeting and the resultant formulation reflected upon with the service user.
How do you meet the needs of people using the service and how could you improve on this?
Our work is based on psychotherapeutic principles of relational practice – and the crucial importance of establishing a trusting relationship and experience of emotional safety (as much as possible) as a basis for engagement, before any specific or definitive therapeutic techniques or approaches can be used. We believe that solely ‘administrative’ approaches – based on standardised delivery of manualised protocols – often fail because pressure on staff and services fail to allow sufficient time and flexibility for the development of the necessary therapeutic relationship.
What support do you offer families and carers?
We hold monthly ‘Friends and Family’ workshops, which are co-produced with our service users and peer mentors. They are psychoeducational in nature, and usually focus on issues of communication. Several short videos have been recorded to illustrate how problems can arise, and to stimulate discussion in the sessions. These are available on our YouTube channel. When required, usually during the 12 weeks of the ASSiST engagement, other family meetings and interventions are arranged. Depending on need, these can take the form of whole family sessions, meetings with spouses or important others.
One of the main architects of the services across the town is Slough’s head of mental health, Geoff Dennis. He works closely with the two clinicians who have completed this form (RH & NB), and if you want to follow this up, he might be helpful with the strategic and cross-agency aspects: firstname.lastname@example.org
Size of population and localities covered:
Core service Slough (140,000) with extension of some NHS aspects to East Berkshire (440,000) including Bracknell, Maidenhead, Ascot and Windsor.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): East Berkshire CCG and Slough Borough Council
Provided by (e.g. name of NHS trust) or your organisation:
Slough Borough Council, Berkshire Healthcare NHS Foundation Trust, Local housing providers (Look Ahead Housing Association, Comfort Care, Coughlan Lodge, Advance Housing, Enriched Care, Collaborative Care) Local voluntary and third sector organisations (Slough Council for Voluntary Service, Growing Better Lives CIC, Art Beyond Belief, P3 Floating Support) Royal College of Psychiatrists (Centre for Quality Improvement) Nottingham University (research link)
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