A key aim of this proposal is to achieve better health outcomes and an improved quality of life for people with long term conditions through improved self-management and motivation. Peer coaches have a unique value as they serve as a testimony to recovery or self-management from those with lived experiences. This can provide inspiration and motivation that is hard to achieve through the usual method of patients repeatedly being ‘told’ it is possible. The team has been set up to provide coaching conversations with people with complex health issues in order to facilitate personalised care planning that informs the development of personal health budgets (PBHs) and new strategies for that person to lead a meaningful life.
Please briefly describe your project, group, team or service, outlining what you do and why it makes a difference.
A key aim of this proposal is to achieve better health outcomes and an improved quality of life for people with long term conditions through improved self-management and motivation. Peer coaches have a unique value as they serve as a testimony to recovery or self-management from those with lived experiences. This can provide inspiration and motivation that is hard to achieve through the usual method of patients repeatedly being ‘told’ it is possible. The team has been set up to provide coaching conversations with people with complex health issues in order to facilitate personalised care planning that informs the development of personal health budgets (PBHs) and new strategies for that person to lead a meaningful life. The team is roughly halfway through a year-long pilot that is due to finish in November 2018. The pilot followed a shorter trial period funded by HEE to show proof of concept. The team have 17 Peer Coaches in active service with over 100 clients active currently. Overall there have been 136 clients referred to the service at the time of this application. Peer Coaches were trained locally using a combination of training approaches trialled in the UK and Africa, coaching communication skills and key local priorities such as safeguarding and personalisation. They offer up to 10 one hour sessions, mostly in people’s homes.
The approach to development has been through coproduction at all points. The original idea stemmed from feedback provided in consultation with local service users in 2015, was further supported by service users assisting the management of the pilot and now include a coproduction reference group that provides liaison and advice. Service user leaders were involved in the set-up of the programme, attending meetings related to practical and operational considerations. The Snapshot personalised care plan that is used was coproduced by service users and GPs and gives equal weight to physical and mental health issues and the relationship between the two. They utilise a strength based approach. The key professionals involved work across Local Authority (LA) and NHS silos providing advice and support to the Peer Coaches. Clients to the service are referred from a variety of sources including GP’s, primary care mental health services, pharmacists, social workers and others. Once received by the CCG managing the overall Choice and Control programme, clients considering Peer Coaching input are passed onto the Peer Coaching service who then match them with a Peer Coach. Peer Coaches assist the person to develop a personalised care plan that provides a blueprint for a future personal health budget. They link the person with Age UK and facilitate the client accessing other services. They do this within a context of using their own lived experience to illustrate options and demonstrate understanding. Peer Coaches receive group supervision from two facilitators with lived experience as well as managerial supervision from the project leads. The expertise of peer coaches is sought as part of the supervision process and is fed into the programme.
What makes your service stand out from others?
Flexibility – whilst Peer Coaches have a remit to ensure that people utilise the Personal Health Budget on offer, they regularly provide support to ensure that people’s priority needs (as determined by the person) is attended to. Examples include identifying one client who experiences depression and anxiety but has a passion for cars. The work of the Peer Coach has been identifying courses related to car maintenance and car clubs that he will be able to access via his PHB. Ease of access – Peer Coaches go to the places that people feel most comfortable. Many of the clients rarely leave home so Peer Coaches will visit people at home. They will also rendezvous at neighbourhood centres, parks and cafes to mention a few. One example is a person who was struggling to have contact with any workers and the Peer Coach maintained phone contact and managed to build much trust over 5 phone sessions. Eventually, the client allowed the Peer Coach to assist her to organise a clear out of her aged mother’s home. Sees the person and their strengths – The whole process is devoted to identifying what is meaningful for the client and what may be possible. The relationship with the Peer Coach is considered primary rather than forms or other bureaucracy. One man, who suffered Parkinson’s disease and depression, who didn’t like the idea of care planning preferred to spend his Peer Coach time walking and talking. These conversations became key in identifying how the client wished to spend his personal health budget and fully understanding the limitations and challenges that his condition created. Trust the expertise of lived experience – As peer coaches are empowered to be flexible in their approach, they communicate with clients with a deep empathy, authenticity and directness that is often lacking from services. They are highly encouraging of small acts to help people take action. One Peer Coach recently accompanied his client to a hairdressing service locally. Peer Coaches see the value of just being alongside someone as they take these important steps and spend the time listening to ensure they know what is a priority for a client.
Physical health – Peer coaches talk about the relationship between physical and mental health. They recognise that the two are not separate but connecting and dynamic. They find out more about what helps and doesn’t help and the advantage of the Personal Health Budget is that they can often facilitate the person self-defining what can help and getting that help. An example is a client who had the opportunity to talk about the impact of having a long term health condition, who identified how the physical and mental health affects each other. This has led to further conversations about how to keep balanced in regard to these. Equality – Clients report that there is a positive message of equality and parity of esteem. Peer coaches and clients share similar experiences and understanding is reciprocal.
How do you ensure an effective, safe, compassionate and sustainable workforce?
The 17 peer coaches received a training package that included:- The Tree of Life – derived from Narrative therapy methods and first used in Zimbabwe, this approach uses the metaphor of a tree to increase a person’s sense of their own strength, values, heroes and aspirations and the connection with their history and each other. They also receive training in coaching skills and personalised care. Alongside this, they received further training in responding to aggression and violence plus spotting and responding to safeguarding concerns. All Peer coaches have three weekly group supervision facilitated by a peer trainer. It has a reflective approach and a set of principles that inform the way of operating. Fortnightly individual supervision runs alongside this where training needs and opportunities and continued professional development are discussed. Plans are also underway to explore more using theatre approaches, the nature of coproduction for the involved organisations in order to look at how to better provide a consistent and supportive environment for people with lived experience within the organisation. During the recruitment process there was close liaison with HR on process and service users were involved in developing the recruitment process chosen including a group meeting and activity. The LA representative connected people on benefits to the Income Maximisation team that could assist them to choose what impact a sessional contract would have on their benefits status.
Who is in your team?
Nurse Consultant 8b 1 x 0.5 Project Officer PO3 1 x 0.6 Peer Coach Band 4 x17 Sessional workers
How do you work with the wider system?
The team are located within mental health services and as such have regular contact with mental health services that are providing for clients. There are plans to further embed coaches within the Practice Based Mental Health Team locally. The project is co-managed by the local authority and as such have assistance linking with local authority services. They regularly refer to employment services and support people to access those services directly. Peer Coaches will regularly go with clients to seek out opportunities and take steps towards goals. Peer Coaches make referrals to a host of services and in particularly work with partner agency, Age UK Islington navigation team to identify suitable services locally and then accessing them. Peer Coaches assist other services to link with clients. They look with clients at how services can better serve them and then assist those services to do so. Age UK Islington also work jointly with the peer coaches to set up clients’ personal health budgets through support planning and guiding people through the direct payment process. As well as joint appointments with Age UK as part of the process of developing PHB plans Peer Coaches will regularly accompany clients to appointments with different services and agencies. They assist clients to identify gaps in knowledge, to seek assistance and to raise their agenda with providers. The programme also looking to promote peer working in the mental health trust more generally and as such has facilitated the use of peer coaches for the collection of physical health based data with an Integrated Practice Unit and been involved in working with Islington Council to promote more joined up thinking amongst organisations utilising Peer Workers.
Do you use co-production approaches?
The programme was coproduced. The original three month pilot was co-managed between two service users and the Nurse Consultant. The style of working, training programme and supervision approach is heavily influenced by this three month period. There is a constant feedback loop between reflection and the development of the programme. An example is at the recent Peer working forum attended by 30 people with a local interest in Peer Work and many Peer coaches within that. The Peer Coaches identified an aspiration to connect clients with similar experiences or interests with each other. We are now looking at whether we can have smaller events at neighbourhood centres to foster this effort. The midpoint evaluation is being partly carried out by people with lived experience and the final evaluation will be led by the McPin Foundation and inclusive of direct evaluation and comment by Peer Coaches and their clients.
The McPin Foundation researcher also has lived experience of using services for both physical and mental health and has been able to bring this to the project evaluation design. The group are highly motivated and strongly committed to the value of the work they are doing. They bring a natural empathy that has been very powerful for clients. The service has been highly valued by clients who have commented that they feel heard and respected. They have been shocked at times by the responsiveness of the service and our willingness to be flexible in the service of encouraging their action. The coproduction ethos has also led to the Peer Coaches being an empowered group who recognise their own leadership and specialness within this context. They are quick to make suggestions and do so with an expectation that we can learn and act upon this learning.
Do you share your work with others?
The peer coaching service is a core component of Islington’s work that is part of NHS England’s Personalised Care Programme. As a demonstrator site Islington CCG shares learning about successes and challenges with NHS England and other areas that are part of this programme. The Peer Coaching programme is a fairly new entity so our reach is somewhat limited. Locally, the Nurse Consultant has spoken at nursing forums about the opportunities of Peer working and coproduction. We have also attended meetings of community groups to encourage participation. As mentioned earlier we have been a key partner in a Peer Working forum that is being created with the LA that will include other organisations that employ Peer workers. This is to promote a shared language and some sharing of expertise and knowledge on Peer Working. The Choice & Control programme has been shared with Adult Social Care Senior Management and the Qualitative Research and Involvement Network in Islington.
What outcome measures are collected, how do you use them and how do they demonstrate improvement?
A stakeholder meeting of staff, Peer Coaches and evaluators highlighted the following outcomes as important to collect for evaluation purposes: Time-frame > Detail > For whom Short term >Clients have better knowledge of how to access services>Clients Medium term> Clients more engaged with services, resources and networks (as appropriate) >Clients Medium term >Clients build resilience to deal with setbacks > Clients Medium term >Clients have improved confidence and skills to self-manage > Clients Long term> Clients leading lives which are as ‘active’, healthy and fulfilling as possible> Clients Medium term >Peer coaches gain improved skills and confidence> Peer coaches Medium term > Peer coaches gain role satisfaction in using ‘peer identity >Peer coaches Long term >Gain meaningful employment and vocational activity > Peer coaches Short term > Clinicians able to see personalisation in practice>Clinicians Medium term >Clinicians more persuaded by client’s input into care planning process >Clinicians Client data is being collected as part of a national evaluation for Choice and Control sites (led by the University of York). This is being collected by the Choice and Control team locally. Clients are asked to complete the following validated scales at baseline and follow-up: • Warwick-Edinburgh Mental Well-being Scale (WEMWBS 14) • EQ-5D-5L • ASCOT SCT4 • Patient Activation Measure Additionally, the McPin Foundation has been commissioned to evaluate the success of the ‘peer coaching’ elements of this service, specifically to address the following questions: • How effective is peer coaching at: o Helping clients meet health and social care needs o Improving health and wellbeing o Improving engagement with health and care services (e.g., engaging in positive health-related behaviours) • What are clients’ experiences of peer coaching? • What are the potential benefits for peer coaches? (e.g., life skills, employment skills, role satisfaction) • What is the influence of other stakeholders? (e.g., GPs, health navigators) Measures were developed with input from peer coaches and service users, as well as members of the staff team at C&I and Islington Choice and Control. Data collection is ongoing until September 2018. McPin is also gathering data about the experience of being a Peer Coach.
A baseline questionnaire has been completed by eleven newly trained Peer Coaches and this will be repeated at six months post-training. Both the Peer Coach and Client evaluation take a mixed methods approach and use a combination of validated (such as WEMWBS) and tailored scales as well as open-ended response options. Peer Coaches suggested that there was a differentiation between the personal and professional qualities or competencies of the role, as well as the need to avoid jargon. With this in mind we chose to include a number of confidence-related questions based on skills that are required for the role, or on suggested skills and abilities from the Peer Coaches that we consulted when designing the evaluation. The final aspect of the evaluation will look at the effects of the programme on other stakeholders, for example GP’s and Age UK Navigators. This will be 6-8 interviews carried out by the McPin researcher; questions may include: how they think the peer coaching has affected clients, whether it helps clients meet healthcare needs and improve health behaviours. An interim report will be delivered by July 2018. This will outline the evaluation methodology and provide summary findings of baseline client data, peer coaching casework, and any follow-up surveys collected at this point. It will also include baseline data from peer coaches. A full report containing an analysis of the remaining data (including all follow-up data collected up until that point in the programme) will be submitted by October 2018.
Has your service been evaluated (by peer or academic review)?
As mentioned above, the McPin Foundation has been commissioned to evaluate this programme in a rigorous manner and utilising qualitative and quantitative data from patients, Peer Coaches and those that work alongside the team.
How will you ensure that your service continues to deliver good mental health care?
The Programme sits partly within Islington CCG, therefore relationships with commissioners is strong and the planned economic evaluation will be vital for ensuring the service continues in its current form, as funding will be made available if pressure on other parts of the system reduces as a result of the peer coaching intervention. The midpoint evaluation is being undertaken to promote an extension to the programme for a further 5 months. Peer Coaches are also being embedded into the Practice Based Mental Health Team locally to develop further understanding of how the service could work within existing structures. Further project funding will be sought to develop innovative elements of the overall programme. The Trust is also exploring mechanisms by which to increase the Peer Working cadre within the Trust e.g filling vacancies with Peer Workers, therefore new opportunities are likely to arise.
What aspects of your service would you share with people who want to learn from you?
Firstly, our service has demonstrated that well supported, well trained, Peer Coaches have the ability to successfully reach out and inspire people with complex health and social care needs. Again and again, new clients of the service found the sheer fact of their worker having a lived experience to be of importance in working well together. The client group is known for not engaging in treatment regimes. The programme seeks to prioritise the personalisation of care, therefore discovering what the person values and where their commitment lies to enhance their activity. Peer Coaches have flexibility of where they see people and how long they spend. Initial sessions are often two hours rather than one but can also be shorter to enable people to engage on their own terms. The relationship is considered primary and the bureaucracy secondary. The programme works across local authority, NHS Trust and third sector and the process of shared working has been challenging. The inconsistencies of systems, the use of jargon, the unhelpful bureaucracy, are all highlighted as we worked together. The opportunity of this work is not only to highlight what is unhelpful within these systems but also to challenge them to improve.
For example Human Resources systems are designed to provide accountability however they can be perceived negatively by people with a lived experience of mental or physical health problems. Comparing HR systems across partners and service users being key in influencing how HR requirements are communicated and delivered has led to innovative interview methods and closer working between the programme and the HR team. Working across organisations, CIFT and the LA, in an integrated and collaborative way. Public sector Human Resources departments are not well equipped to work in different ways e.g sessional contracts and service users who may not have worked in a large organisation before. We worked with the Peer coaches to help them understand these difficulties and supported them through the process. For genuine co-production to be part of the development, an adequate budget for this purpose should be factored into the programme from the beginning. The programme is a new one that has effectively created a new role with 17 new employees. There is a constant feedback loop that takes the learning and uses it to mold the programme. Peer Coaches are empowered to communicate ways of working they think will serve the overall purpose. Within the resource constraints, we will endeavour to be creative in order to successfully link with and empower our clients. Communication with clients and partners is key. Perceptions of the role of peer coaches varies from organisation to organisation and along with this agreement on what tasks are appropriate.
We have retained a transparency of communication that means our understandings have become more aligned as we have progressed but also retained a flexibility that new ways of working will continue to arise. Peer Coaches do not generally come from a professional background that has thoroughly codified the nature of their relationship with clients, and as such, they often come with a deeply personal connection to their clients. Mental health professionals often carry a suspicion of need, for fear it will create dependency. There has been an ongoing challenge to ensure that the sense of direct assistance that Peer Coaches offer is not lost whilst also respecting the importance of creating sustainable solutions for their clients and their limitations. The coaching focus helps to promote an empowering stance whilst the willingness of the service to be ‘alongside’ people as they take a variety of action helps to ensure the response to need is also felt in direct ways. The provision of a reflective supervision space for Peer Coaches also helps to deepen the understanding of the role and limitations.
How many people do you see?
Since the inception of the programme in January 2018 until 10th June 2018, we have had 141 clients referred into the Choice and Control programme. 116 have agreed to the Peer Coaching service. Of the 108 currently allocated there have been 282 visits by Peer Coaches. 65 clients have gone onto Age UK Islington for the creation of a Personal Health Budget
How do people access the service?
Main referrers are GP’s (35%), Navigators (19%) followed by Social workers, physical and mental health Nurses and Psychiatrists. We have had a few referrals from health coaches, pharmacists, support workers and psychologists. We publicise directly with GP’s and via integrated health networks where various health professionals meet and discuss complex clients. We have also made special arrangements to reach out to clients who have been invited for health planning sessions to consider our input. New referrals are logged within the CCG project team before being sent to CIFT and Age UK Islington. Clients are contacted within three weeks to discuss the choice and control programme and the peer coaching service. Triage is based on the preferences they express and referral information.
How do you ensure you provide timely access?
Referrals can contain information that influence how access should be offered to ensure success. Referrals are screened to ensure they meet the criteria. Information is provided almost immediately to the Peer Coaching service and contact is then sought within 3 weeks of receipt. Clients themselves will influence prioritisation by indicating any preferences for contact e.g one client was completing a self-management course so wanted to wait until had completed. Peer Coaches vary in the amount of sessional work they wish to undertake however they have capacity to meet the expected referrals. Modelling of capacity happened during the early part of the programme to ensure this was the case.
What is your service doing to identify mental health inequalities that exist in your local area?
We are collecting data on the individuals we are seeing and their challenges. We are recording what goals they identify and what they spend their personal health budgets on.
What inequalities have you identified regarding access to, and receipt and experience of, mental health care?
The service has noticed that many people with serious physical health issues have comorbid mental health issues that do not meet the threshold for secondary care services. Problems are compounded as a result. Peer Coaches provide mental health promotion by offering a recovery oriented care planning service that is also willing to walk alongside people who wish to take action to improve their lives. The Personal Health Budget Scheme further enhances this opportunity.
What is your service doing to address and advance equality?
Our service reduces stigma by way of people with a lived experience bringing that perspective to professional conversations about and with clients. Their presence increases the credibility of the client perspective and assists service providers to consider recovery not only from a symptom reduction perspective. Our Peer Coaches reduce stigma by bringing themselves into a professional role with other clinicians thereby demonstrating the capacity of people with complex health issues to be supporting others. They have a special role in increasing the uptake of people with mental health problems with their physical health. Helping people with anxiety, depression, and psychosis to link with resources is an offer of this service.
How do you identify the needs of a person using the service (such as their physical, psychological and social needs)?
Generally health professionals working with the client will list the conditions the person is experiencing. We use a personalised care planning template called ‘The Snapshot’ to identify the person’s needs and aspirations. It was coproduced between GP’s and service users in 2017. The tool looks at client knowledge and experience of physical and mental health needs as well as the relationship between the two. It also identifies strengths and goals.
How do you meet the needs of people using the service and how could you improve on this?
We offer emotional and practical support that is recovery oriented and hopeful. Peer Coaches not only connect people to recovery as a process but also to resources that can bring their goals to fruition. Peer Coaches are well placed to assist clients to assess their next steps and access specialist services as needed. The offer is effective because it is focused on the client experience whilst retaining a realistic prospect of change.
What support do you offer families and carers? (where family/carers are not the service users)
Carers are provided with links with the Carers Hub that AgeUK Islington manage. Several of the peer coaches are carers and as such also provide that perspective within their support role. Quite a few of our clients with complex health needs are also carers.
Hours the service operates *
Brief description of population (e.g. urban, age, socioeconomic status):
Brief description of population (e.g. urban, age, socioeconomic status): People living in Islington with a long term physical health problem, a mental health issue and a social care need. It’s an urban setting and tends to work with people who are receiving disability and other benefits.
Size of population and localities covered:
Islington’s population is around 220,000 people. Anyone registered with an Islington GP who meets the eligibility criteria (long term physical health condition, a mental health issue and a social care need) can access this service. Approximately 30,000 adults in Islington have depression, anxiety or both, and 50% of people diagnosed with depression also have one or more long term physical health conditions. Approximately 15,000 people could be eligible for this service. Islington is the most densely populated local authority area in England and Wales, with 15, 517 people per square km. This is almost triple the London average and more than 36 times the national average. Only 13% of the borough’s land is green space, the second lowest proportion of any local authority in the country. Older people make up a significant proportion of Islington’s social housing households and pensioner households also have a considerably lower income than the rest of the borough. There are also high numbers of affluent older adults in Islington, many of whom choose to self-fund their social care needs. Under half 48% of Islington residents described themselves as ‘White British’ in 2011, compared to 45% in London and 80% nationally.17 52% of residents were in Black and Minority Ethnic (BAME) groups, compared to 43% in 2001. Overall, Islington is the 24th most deprived local authority in England.57 However, Islington ranks third nationally on the income deprivation indicator for children, and fourth for income deprivation affecting older people. Every ward in Islington has at least one area that is among the 20% most deprived areas of England.
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
Provided by (e.g. name of NHS trust) or your organisation: *
Camden and Islington NHS Foundation Trust