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From segregation to inclusion:

Commissioning guidance on day services for people with mental health problems


ROCR ref Gateway ref: 5658


Title From segregation to inclusion: Commissioning


Author National Inclusion Programme,


NIMHE, CSIP


Description Commissioning guidance on day services for adults with mental health problems


Health and social care services have a key role in tackling the social exclusion that people with mental health problems experience. In 2004, Lord Rooker and I launched the Social Exclusion Unit’s report on Mental Health and Social Exclusion. The report set out the Government’s action plan to improve the health and wellbeing of people with mental health problems through improving access to mainstream community activities and enabling people with mental health problems to gain and retain employment. Being able to access and use mainstream community services like colleges, or arts and sports activities can improve confidence and self-esteem. The opportunity to meet new people and create a network of friends plays a critical role in promoting well-being. We need to ensure that modern day services provide an individualised and flexible service to meet the aspirations of people with mental health problems and, crucially, to provide the support to enable people to achieve these aspirations. A key aim for day services is to promote and facilitate social inclusion. This guidance provides commissioners with a framework to commission day services that promote social inclusion through improved access to mainstream opportunities for people with mental health problems. We will only be able to achieve this if we work in much closer partnership with other agencies and organisations including the voluntary and community sector.


Rosie Winterton, MP


Minister of State for Health Services


Foreword


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


1. This guidance is designed to assist commissioners of mental health services in the refocusing of day services for working-age adults with mental health problems into community resources that promote social inclusion and promote the role of work and gaining skills in line with current policy and legislation, including:


• National Service Framework for Mental Health (Department of Health, 1999);


• Mental Health and Social Exclusion (Office of the Deputy Prime Minister, 2004);


• Choosing Health, Public Health White Paper (DH, 2004);


• National Standards: Local Action (DH, 2004);


• Delivering Race Equality in Mental Health Care: An Action Plan for Reform Inside and Outside Services (DH, 2005);


• Independence, Well-being and Choice, Adult Social Care Green Paper (DH, 2005);


• Life Chances for Disabled People (Prime Minister’s Strategy Unit, 2005);


• Health, Work and Well-being Strategy – Caring for Our Future (Department for Work and Pensions, DH, Health and Safety Executive, 2005);


• Disability Discrimination Act 2005;


• Gender Equality Public Sector Duty (Department of Trade and Industry, 2004).


2. This is good practice guidance for commissioners and it progresses the implementation of the developmental standards as set out in National Standards: Local Action (DH, 2004).


3. The guidance relates to the commissioning of day services. It does not address acute day hospitals, crisis services or vocational services. The development of crisis services is addressed in the National Service Framework for Mental Health Policy Implementation Guide (DH, 2001). The development of vocational services is addressed in the Vocational services for people with severe mental health problems: Commissioning guidance (DH, 2006). In commissioning day services, it is vital that consideration is given to the diverse range of needs and experiences of people requiring support, in particular women, people from minority ethnic communities, younger people and older people, and that the services provided are sensitive to religion, sexuality and disability. Supporting Women into the Mainstream (DH/NIMHE, 2006) provides detail on commissioning day services for women. Both sets of guidance therefore need to be considered in implementing changes to day services.


Aim of this guidance


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


4. Many services have developed innovative and inclusive practice in day service provision. Examples are not provided in this guidance but they are available in many other documents and resources, for example:


• Mental Health and Social Exclusion (ODPM, 2004);


• NIMHE Knowledge Community (http://kc.nimhe.org.uk/);


• Redesigning Day Services. A Modernisation Toolkit for London (NIMHE London, 2005);


• Supporting Women into the Mainstream. Implementing women-only day support (DH/NIMHE, 2006).

The policy context


‘Though a simple aspiration for most people socially isolated by mental illness, the sense of belonging to a community with all that this can imply for mutuality and participation remains stubbornly elusive in spite of community care.’ (Morris, 20011).


5. The development of community-based services to replace the remote institutions of former years has meant that the vast majority of people with more serious mental health problems now live within their own communities. Although they may now be physically located within these communities, too often they remain apart from them: living, working and spending their leisure time in a range of specialist mental health provision. Such segregation limits both the opportunities available to people who experience mental health problems and the wider community’s understanding of and ability to accommodate them. Until people with mental health problems can participate fully, as equal citizens, with access to the same opportunities that most people take for granted, understanding and opportunity will remain limited, with all that this implies both for individuals and for the wider community.


6. For the benefit both of individuals with mental health problems and the communities to which they belong, current policy and guidance requires that resources be directed towards promoting inclusion rather than maintaining exclusion. Enabling people with mental health problems to use and develop their skills ensures that their talents are not wasted and that communities can benefit from the social and economic contribution that they can make.


7. While some people may require support for time-limited periods, the continuing participation of those who are more disabled can only be achieved with ongoing, time-unlimited, support. However, it is only when those with mental health problems and those without such difficulties can live, work and spend their leisure time


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Together, participating on equal terms, that the prejudice and discrimination born of ignorance can be eroded.


The need to refocus day services


8. £140 million was spent on day and employment services for adults with serious mental health problems in England in 2002/03,2 yet many people with such problems remain socially isolated and excluded from the communities in which they live. Such isolation has been identified as one of the factors that needs to be addressed in order to achieve the target of reducing death by suicide.3


9. Traditionally, day services have focused on the provision of specialist support solely for those with mental health problems, typically providing a ‘package deal’ of activities within the centre that includes a place to go during the day to meet other people through a range of group social/leisure activities, group therapeutic opportunities, and various forms of help and advice.4


10. While recent years have seen some services move towards a greater focus on community integration, and some innovative ways of assisting people to access mainstream opportunities, many retain a more traditional focus, for example:


• Day services often remain largely building-based. Most activities occur within a centre: contact with the local community is often restricted to inviting community organisations, for example local colleges, to sessions in the centre and a limited number of group outings to community facilities (for example cinemas, sports centres). If day services are to promote inclusion and participation the focus needs to change to supporting people to access opportunities within their communities alongside other members of the community.


• Those who do not wish to adopt the identity of ‘mental patient’, especially younger people and those who have more recently developed mental health problems, reject the idea of attending a segregated day facility. ‘I want a way forward, not just sitting there, just drinking tea and talking about the side effects of various medication.’ 5


• With some notable exceptions, day services often fail to meet the needs of the diverse populations that they serve. In particular, they may fail to meet the needs of, and be under-used by, people from minority ethnic communities, women, younger people and older people, and they may not provide services that are sensitive to religion, sexuality and disability.


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Key principles for refocusing day services


11. Current policy and guidance includes a number of common principles that commissioners should observe in the refocusing of day services:


• Promote recovery: enable people with mental health problems to maintain and/or rebuild meaningful, valued and satisfying lives even in the face of ongoing mental health problems.


• Focus on community participation: support people to access existing opportunities in their local community rather than creating segregated activities, and increase the capacity of communities to accommodate those with mental health problems.


• Reduce social isolation: provide people with opportunities to extend their social networks and form relationships not only with other people with mental health problems and staff, but also with people outside the mental health system.


• Offer opportunities for people with mental health problems to provide support to each other and to run their own services: increase the extent to which services are led and run by people who have mental health problems themselves:6 people with such difficulties who have successfully rebuilt their lives are often in the best position to help others to achieve the same.


• Maximise choice and self-determination: enable people with mental health problems to determine what is provided via user-led services. This enables individuals to make choices about the things that they wish to achieve and the type of support that they require to achieve them and will help to facilitate inter-dependence.


• Meet the needs of diverse groups: address the diverse needs of different groups within the population, especially those who have historically been poorly served, being mindful of the need to provide services that are sensitive to age, gender, ethnicity, religion, sexuality and disability and explicitly meeting those needs in their design. See Supporting Women into the Mainstream (DH/NIMHE, 2006) for specific guidance on commissioning day services for women.


• Ensure that services are accessible to people who are more seriously disabled by their mental health problems: meet the needs of people with a range of problems including those with more severe and enduring difficulties who may require a relatively high level of support on an ongoing basis.


• Involve users and carers: maximise use of the expertise of those with personal experience of mental health problems in designing and developing services, including those who may not be using existing day services because they find them inaccessible or unacceptable.


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


• Increase diversity of provision: maximise the contribution of the voluntary and independent sector in service provision, supported by statutory services.


• Improve cross-sector working: ensure integrated, participative working, not only across statutory and voluntary providers of mental health and social care but also with and between providers outside the mental health system.


These could include:


• faith groups;


• minority ethnic community organisations;


• libraries;


• employers and employment organisations;


• colleges;


• the full range of providers of sports and leisure activities.


Key functions of day services


12. There needs to be a comprehensive range of day service provision designed to promote recovery, social inclusion and self-determination and to decrease social isolation. This should fulfil four key functions:


a) Provide opportunities for social contact and support Research among those who use day services suggests that having somewhere to go during the day and the opportunity for social contact and peer support on a drop-in basis are the most highly valued elements of current day care ‘packages’.7


b) Support people to retain existing social roles, relationships and existing social/leisure activities that they value When people develop mental health problems, or experience an acute episode and/or hospitalisation, their social roles, relationships and activities are placed at risk. Too often they lose their job or place in education; many friendships are lost and social activities may never be resumed. Retaining existing roles is both easier and less damaging than regaining them once they have been lost and is an important secondary prevention role within both primary and secondary mental health services.


c) Support people to access new roles, relationships and mainstream social/leisure opportunities of their choosing Many people who currently use day services have already lost contact with friends, spending much of their time alone with few activities to fill their time.9 Day services should play a critical role in promoting valued social roles, relationships and activities in mainstream community facilities and organisations.

From segregation to inclusion: Commissioning guidance on day services for people with mental health problems

This not only improves the quality of life for the individual but it serves gradually to increase the capacity of the community to accommodate people with mental health problems. Knowing people with mental health problems – living, working and pursuing leisure activities alongside them – is key to reducing fear, ignorance and discrimination.


d) Provide opportunities for people with mental health problems to run their own services People who have themselves used mental health services bring the expertise of experience to the provision of day services. Many service users particularly value help from others who are, or have been, in a similar situation; this can inspire hope, self-belief and confidence.10 User-run services can provide valuable ongoing social support to avert crises and to access mainstream opportunities.


Commissioning framework


13. The key functions, principles, providers and performance indicators of day services are summarised in Table 1. This constitutes a framework to guide commissioners, specifying the features of effective day services. It is recognised that there needs to be a range of services available to meet the needs and preferences of all individuals. Commissioners must consider whether there are people with mental health problems who may not wish to participate in mainstream community activities. One approach will not fit all.


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support one another


Key functions


Table 1: Framework for commissioning day services


Key features


Increase access to confiding and hope-inspiring relationships Support tailored to individual needs and preferences Help provided to people to:


• identify existing roles, relationships and activities that they value


• maintain their confidence that they will be able to continue these despite their problems


• identify the support they will need to do this Support tailored to individual needs and preferences

Help provided to people to:


• identify individual aspirations and interests


• inspire hope and raise expectations


• increase self-belief and self-worth Support tailored to individual needs and preferences Empower those service users/ex-users who would like to take control of their own services or aspects of a service run by another provider Provide training and support to users/user organisations to develop the skills to run their own services Work with existing providers to increase their confidence that people with mental health problems are capable of running services Users/ex-users provide training to mental health professionals working in these services Support tailored to individual needs and preferences


Promote recovery


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support one another


Key functions


Service provided in community locations that are as non-stigmatising as possible Provide opportunities for people:


• to meet in mainstream settings

• to extend their social networks to include people outside the mental health system Measures to ensure that workers in primary and secondary care are aware of the importance of maintaining existing roles, relationships and activities In-reach to acute inpatient wards and crisis services Flexible support within both primary and secondary care to maintain existing:

• friendships

• family relationships

• social and leisure activities

• accommodation (and work/education in conjunction with vocational services) Help people to resume existing roles, relationships and activities after a period of hospitalisation/acute illness Enable people to use mainstream support services wherever possible A focus on enabling people to use mainstream community activities and facilities in line with their interests and aspirations Where segregated groups are provided these:

• are located in mainstream settings (colleges, sports centres, etc)

• focus on supporting people to engage in mainstream activities wherever possible Flexible support provided at times appropriate to the activity in which the person is engaged – including at weekends and in the evening Use of other people without mental health problems engaged in the activity as ‘mentors’ to support those with mental health problems Users/ex-users receive support and practical help in management of the service (support may come from outside mental health services) Users/ex-users run groups within mainstream facilities for people with mental health problems Users/ex-users run services to support people to access mainstream activities and facilities Users/ex-users provide practical support to help people maintain their community tenure (shopping, cooking, cleaning, management of finances, etc)


Focus on community participation


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support one another


Key functions


‘Buddy’ systems (one service user befriending another) Users/ex-users run social groups, social activities and services Promote contact with, and support from, people with mental health problems who have successfully resumed their previous roles, relationships and activities, eg via mentorship systems, self-help groups or peer support Users/ex-users run services Identify people with common interests/aspirations and enable them to come together and support each other in their chosen activities ‘Buddy’ systems within which one service user helps another to access activities and facilities of their choice Users/ex-users run services Users/ex-users run networks/services to provide: • ongoing peer support • peer support to avert and contain crises


Maximise opportunities for peer support


Available during evenings and weekends Provide opportunities to meet and form relationships with others and increase size of social network In-reach into inpatient wards and sheltered accommodation Offer support to:


• the individual to resume contact with relatives and friends


• family and friends to understand what has happened and how to accommodate any ongoing problems the person might have Pay attention to enabling people to integrate into, and form relationships with others in, mainstream settings Users/ex-users provide ongoing individual peer support/buddy systems Users/ex-users provide services where people with mental health problems can meet for company and mutual support Users/ex-users provide support to access mainstream opportunities


Reduce social isolation


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities


Opportunities for service users to run their own services and support one another

Key functions


Services:


• are located and provided in ways that make them accessible and sensitive to age, gender, ethnicity (including BME communities), religion, sexuality and disability

• provide support and access to opportunities tailored to the specific needs of BME communities, women, younger people, older people, disabled people, religious groups and sensitive to sexuality

• ensure that the voice of service users who experience multiple discrimination on the basis of ethnicity, age, religion, sexuality, gender or disability is heard and heeded in the planning and delivery of services


Meet the needs of diverse groups


Users/ex-users responsible for management of the service and its financial resources Users/user groups make decisions about operation of the service: where, what, when and how Users/ex-users of the service supported to make the transition to providers of the service Users/ex-users provided with training and support to enable them to lead and manage services Users/ex-users run advocacy services


Enable people to:


• determine for themselves which existing roles, relationships and activities they value and wish to retain/resume

• decide what sort of help/support they need and would find most acceptable

• access direct payments where appropriate

• facilitate inter-dependence


Support self-management of continuing cognitive and emotional problems and treatment to minimise the negative impact that these have on valued activities User/ex-user-led service


Provide:


• open access, drop-in and self-referral opportunities

• opportunities to access relationships with people and communities of their own choosing in a range of settings

• a choice of different forms of support and help User/ex-user-led service


Maximise choice and self-determination


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support one another


Key functions


Target those who are most socially isolated in the context of promoting independence

Provide:


• opportunities for social contact within clients’ own homes (someone to visit people who find it difficult to go out)

• support to travel to and engage in social settings

• an environment that is tolerant of people who may behave in unusual ways

• meals/help with day-today activities

• help to develop the skills and competences necessary to form relationships with others

• support available without time limit


Targeted to the needs of all groups of people. For example people with first episode psychosis so that they receive help to maintain/resume existing roles, relationships and activities All care plans include assessment of existing roles, relationships and mainstream activities and actions to maintain these In-reach into inpatient wards, rehabilitation units, and sheltered/supported accommodation Support available to both the individual and community providers of mainstream occupational activity and community organisations for as long as necessary (no time limit) Support for community providers to enable them to understand and make any adjustments to accommodate people with more serious problems Practical help and support to engage in chosen activities Targeted to the needs of people on enhanced care plans to ensure that care plans include assessment of social and leisure needs and actions to maintain these In-reach into inpatient wards, rehabilitation units, and sheltered/supported accommodation Support for community providers to enable them to understand and make any adjustments to accommodate people with more serious problems Support available without time limit to both the individual and community providers Practical help to engage in chosen activities Support should be provided to people who are more disabled by their mental health problems to enable them to take a greater role in running their own services (similar to the personal assistants who can assist people with physical impairments) Arrangements in place to accommodate periods when a person may not be able to contribute to the running of services (eg job share/cover arrangements)


Ensure that services are accessible to people who are more seriously disabled by their mental health problems


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support one another


Key functions


Existing user/carer groups Existing user-run businesses User-run businesses established for the purpose of running the service Voluntary organisations and organisations outside the mental health arena supporting users to establish a service User and carer groups Organisations outside the mental health and social care system – churches, community groups, etc Voluntary sector mental health providers Clinical support and advice from statutory mental health services


Providers


Users help to define and determine what social opportunities are provided:

what, where, when and how Support relatives and friends in maintaining contact with service user Support relationships between the service user and their family Users help to define and determine the range of services to be provided:

what, when, where and how Relatives and friends are involved in supporting the person to maintain mainstream activities and provided with the support they need to do this Users define and determine the range of services to be provided:

what, when, where and how Relatives and friends are involved in supporting the person to access mainstream activities and provided with the support they need to do this Users/ex-users run services that enable those who use them to be involved in decisions about their development and operation Users/ex-users run services that are provided on a cooperative basis by those who use them


Involve users and carers


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Opportunities for social contact and support


Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support oneanother


Key functions


Available within every PCT area at a level determined by local need Available within every PCT area at a level determined by local need Available within every PCT area at a level determined by local need Available within every PCT area at a level determined by local need


Level of provision


Links with:

• primary care

• community mental health services

• inpatient mental health services

• supported accommodation providers

• vocational services

• voluntary sector mental health providers

• user and carer groups/organisations

• community groups and services outside the mental health system in the statutory, voluntary and independent sectors


Improve crosssector working


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems

Opportunities for social contact and support Support to retain existing roles, relationships and social/leisure activities Support to access new roles, relationships and mainstream social/leisure opportunities Opportunities for service users to run their own services and support one another


Key functions Performance indicators


Extended social network: size and composition to include people outside mental health services Improved quality of life Improved satisfaction with social life Decreased social isolation Maintenance of size and composition of social network to include people outside mental health services Maintenance of engagement in mainstream activities and roles Increased empowerment Increased frequency of engagement in mainstream social and leisure activities Increased amount of time spent in mainstream settings A majority of activities/opportunities provided by the service are based in mainstream integrated settings


Specific


The chair and the majority of the governing body are users/ex-users The chief executive/director and the majority of the senior management team are service users/ex-users The majority of those employed within the organisation are mental health service users/ex-users Initial assessments in primary and secondary care include social roles, relationships and activities Care plans include local targets relating to the maintenance of existing roles, relationships and activities Equality in service provision and outcomes for people who experience multiple discrimination on the basis of ethnicity, gender, age, religion, sexuality and disability and those with more serious mental health problems People using services are involved in monitoring the implementation and effectiveness of the service


General Restructuring


Restructuring provision


14. The move from day services that maintain segregation to ones that promote social

inclusion and recovery and reduce social isolation involves fundamental change in:

• structure;

• location;

• providers;

• skill mix;

• range of services.

15. It is important to emphasise that this guidance is concerned not with reducing resources but with using existing resources in more innovative and creative ways.

These could include:

• increasing the range of providers so that different providers are using their expertise to greatest effect;

• increasing services run by users/ex-users;

• exploring additional funding sources to support service development, for example: Section 64 funding; Learning and Skills Council; regeneration monies;

European Social Fund; Phoenix Fund; and supported capital (revenue) expenditure;

• changing the balance between services that are directed towards enabling social/ leisure pursuits and those directed at vocational pursuits; historically relatively little support has been provided to enable people to access mainstream work/education (see commissioning guidance on vocational services for people with severe mental health problems);

• considering whether it might be useful to conduct a cost-benefit analysis on buildings used to establish if there is a case for disinvesting in potentially costly buildings to provide more outreach support and support in mainstream settings.


Transforming existing services


From segregation to inclusion: Commissioning guidance on day services for people with mental health problems


Beyond buildings


16. A day service does not necessarily require a dedicated building or centre. It is the function of day services in maintaining and extending social networks and access to mainstream roles and activities that is critical and there is a need to move from group-based to individualised support.


17. This function may be achieved in a number of ways, via outreach support, support in mainstream settings and separate services in mainstream settings. Opportunities for social contact and support may be provided through people getting together in, for example, cafes, community centres, arts facilities, pool halls, faith centres, or through people with similar interests pursuing these together in mainstream settings (eg going fishing, bowling, rambling, to the cinema).


18. Some people, often those who are the most severely disabled, find it difficult to get to a designated ‘centre’, therefore outreach work is likely to be necessary; for example a mental health worker, or preferably perhaps another service user, going to the person’s home and helping them to get out and about and achieve their hopes and goals for participation.


19. A designated ‘centre’ may be of value as a meeting point or for providing a flexible ‘drop-in’ for people at times of their choosing. However, many people decline to use the traditional day centre because of the stigma associated with doing so. In order to reduce this effect, it might be preferable to:


• take the form of an ordinary facility – perhaps a café, and preferably one that can be used by anyone, regardless of 

whether or not they have mental health problems (integration can be fostered by non-disabled citizens using mental health facilities as well as disabled citizens using mainstream facilities);


• locate the facility in a mainstream setting, for example a college of further education or community centre.


Making the changes


20. The fundamental changes required to refocus services cannot be achieved immediately. They are likely to require a more gradual (although time-limited) period of modernisation resulting in the ultimate transformation or transfer of provision.


This might involve, for example:


• the engagement and involvement of existing service users, and those people with mental health problems who do not use existing services, but who are socially isolated and socially excluded;

• agreement on the role of day services with all stakeholders (including statutory and voluntary sector agencies): local agreement on the four key functions, what is to be achieved and what this means in the local context;

• agreeing with service users, relatives and staff the potential transformation from building-based services to services that maintain and extend social networks and access to mainstream roles and activities;

• mapping existing provision in terms of the four key functions;

• identifying gaps and areas for development in line with the identified key functions and features of day services;

• identifying potential local partners and alternative providers (including mainstream community facilities, voluntary and independent sector providers) to develop opportunities both within and outside existing provision and fill identified gaps;

• increasing use of direct payments to provide individualised, flexible support to access mainstream activities.12, 13 For further information see Direct Payments for People with Mental Health Problems: A Guide to Action (DH, 2006);

• negotiating inclusion outcomes as part of local development plans and key performance indicators;

• reviewing and progressively changing existing service specifications, service-level agreements and outcome indicators;

• identifying possibilities for reducing those aspects of services that do not promote inclusion and redirecting resource to activities that do in order to achieve transition. For example groups run within day centres can first be changed to those run in mainstream settings and later transformed to the provision of support for access mainstream activities.


Workforce issues


21. The ten essential shared capabilities for mental health practice14 illustrate that social inclusion is not the responsibility of a single profession. All mental health professionals have a role to play in helping people with mental health problems remain or become socially included. However, promoting social inclusion and reducing social isolation requires that we move beyond the skills of traditional mental health professions. While mental health professionals may have an important consultancy and support role for day services, in developing a workforce that can deliver inclusive day services, existing staff may require training in new skills such as:

• fostering hope and promoting recovery;


18


• assessing the needs of diverse groups enabling them to deliver services that promote race and gender equality;

• understanding the ways in which ongoing mental health problems may impede a person’s ability to do what they wish to do and the ways in which the negative impact of these problems can be minimised in different situations;

• appreciating the importance of raising expectations of what people with mental health problems can achieve;

• helping people to access the mainstream opportunities that they seek;

• gaining a comprehensive picture of what is available in the local area;

• approaches and techniques for working with, and supporting, community organisations and providers outside the mental health system (eg colleges, leisure facilities, community groups) in providing information and advice, helping them to make adjustments/accommodate people with mental health problems.


22. It may also be useful to review the skill mix that is required and employ/engage people with experience outside the traditional mental health system who have specific expertise and experience, for example:


• fitness trainers, teachers, welfare rights experts and people with a range of ordinary experiences who are thoroughly acquainted with the local area;

• people who have themselves experienced mental health problems who are likely to be in a better position to respond sensitively to the needs of people who experience similar difficulties and provide positive role models;

• people with expert knowledge of different communities: people from different sectors of the local population, for example people from minority ethnic groups and different religious backgrounds who can form effective relationships with different community organisations and understand the needs and expectations of clients from these communities.


23. STaR workers, primary care graduate mental health workers and community development workers15 – with many of the skills and competences listed above – may be a useful addition to the day services workforce and have already been used to good effect in a number of services.


24. Effective leadership of services is key to the successful implementation of change, particularly in fostering a sense of optimism and possibility in staff: a focus on possibilities and solutions to problems rather than deficits and dysfunctions.


Monitoring and evaluation of services


25. Ongoing monitoring and review of developing services can ensure the achievement of objectives, measure the effectiveness of services and inform future service development.


26. Such monitoring should cover all four functions of day services (see Performance indicators on Commissioning framework, page 15):


• People using services provide an important perspective in assessing whether services are meeting the needs and preferences of those using them.

• Monitoring should take place at different levels of the service and include indices of community participation (such as number of groups running in mainstream settings, number of people using mainstream sports facilities/clubs) as well as measures of individual’s inclusion (such as increase in social network size, improvement in quality of life).

• Monitoring forms part of an ongoing process of review in the development of inclusive day services.


1 Morris, D (2001) Citizenship and community, Mental Health Review, 6.


2 See Social Exclusion Unit Report Mental Health and Social Exclusion (Office of the Deputy Prime Minister, 2004).


3 See National Standards: Local Action (Department of Health, 2004).


4 See Social Exclusion Unit Report Mental Health and Social Exclusion (ODPM, 2004).


5 See Social Exclusion Unit Report Mental Health and Social Exclusion (ODPM, 2004).


6 A distinction has been drawn here between a ‘user-led’ service – in which service users make decisions about what should be provided and how, but the service may actually be provided by non-users – and a ‘user-run’ service – in which service users provide the service.


7 Caan, W, et al (1996) Auditing psychiatric day hospitals. The users’ views in an inner city setting, Journal of Mental Health, 5, pp 173–82; Holloway, F (1989) Psychiatric day care: The user’s perspective, International Journal of Social Psychiatry, 35, pp 252–64; Malpas, G and Weekes, J (2002) An investigation into drop-ins: Exploring the impact of peer support, Mental Health Foundation (Strategies for Living Programme), London.


8 Buchanon, J (1995) Social support and schizophrenia: A review of the literature, Archives of Psychiatric Nursing, 2, pp 68–76; Holmes-Eber and Riger (1990) Hospitalisation and the composition of patients’ social networks, Schizophrenia Bulletin, 16, p 157.


9 See Social Exclusion Unit Report Mental Health and Social Exclusion (ODPM, 2004).


10 Young, SL and Ensing, DS (1999) Exploring recovery from the perspective of people with psychiatric disabilities, Psychiatric Rehabilitation Journal, 19, pp 55–62.


11 For more funding information see www.funderfinder.org.uk.


12 National Institute for Mental Health for England Direct Payments Practice Exchange Network (NIMHE East), http://kc.nimhe.org.uk.


13 Community Care (Direct Payments) Act (DH, 2003).


14 Ten Essential Shared Capabilities (Mental Health Workforce Commission, NIMHE, 2004).


15 See National Mental Health Workforce Strategy (NIMHE, DH, 2004).


References


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