Alternatives to institutional care for people with mental health problems

‘Every Institution not only carries within it the seeds of its own dissolution, but prepares the way for its most hated rival’. William Inge 1922
Historical context The transition from the hospital dominated system of treatment of mental illness to a more holistic, community based model has been a fractious evolution requiring not only a review of simple bricks and mortar, but a revolution in attitudes and theory for all involved in the process. It would be heartening to suppose that the move to community care was a decision born from embracing sound humanitarian principles. However, in reality the birth of the British model had firmer roots in economic policy than in an acceptance of holistic principles. The hospital closure programme, which rolled with indecent haste during the 1980s and 90s, grew more from the desire to save money on in-patient treatment and this was reflected in the deeply flawed community infrastructure that grew from the ashes. Little attention was paid to the successes and failures of other established models in the US and Italy. The British system frequently replaced or relocated dependency inducing mental health systems previously found in the long stay hospitals with identical models situated in the wider community. Hospital staff, more often than not inexperienced in person centred approaches and often institutionalised themselves, were re-employed in new community services. This re-deployment of staff, without the necessary re-education often led to a simple replication of an outmoded system that reinforced the service user’s role as a dependent ‘patient. To the dismay of mental health ‘activists’ the ‘new’ system was neither revolutionary nor client centred. To compound an already unacceptable series of mistakes, no effort had been made to accompany this change with a parallel process of education for the public. Socialised to believe that people suffering from mental health problems constituted a danger to the community, the general public and the media mounted a campaign that broadly vilified those entering the community from the hospitals.

With no government defined template for the development of community based services, what replaced the old system was often ill conceived and more often than not merely replicated attitudes of old but with a lower budget. The British community care system, grew on an ad hoc basis, with little idea of progression or development for users of the service. Isolated ‘Islands of Service’ were developed in indecent haste to speed up the de-institutionalisation process. Drop-ins and statutory day centres became the ‘cutting edge’ of community development, delivered rather than constructed in partnership with service users. It came as no surprise that many patients who had been decanted from the old asylums actively demanded to return to them. The old asylums had fallen into disrepute over a period of years, being seen as old fashioned, outmoded and costly. However their closure and fundamental rejection had witnessed ‘a throwing out of the baby with the bath water’. Many ex-patients felt isolated, unsupported and unwelcome in the community and hankered for the perceived security and continuity of the old regime. The old institutions often provided a meaningful existence in terms of occupation. Farms, workshops, bakeries and organised groups, regularly a feature of the asylum had disappeared when the bulldozers arrived, to be replaced when community services were erected by a dearth of constructive activity. The new services offered little in the way of occupationservice users were frequently left to their own devices. Day centre activities were frequently focused on the existence of a pool table or a television set. The ethos of ‘containment’ remained intact. Community services targeted exclusively on the needs of the chronically ill, and outcome measures were unclear. Over the 1990s specific events changed attitudes and service delivery perceptively. During 1993 at least two high profile cases were highlighted by the media to further their anti community care campaign. The murder of Jonathan Zito by schizophrenic Christopher Clunis on the London Underground followed by the drama of Ben Silcock, another schizophrenic, throwing himself into the lion’s cage at London Zoo brought the issue of mental illness in the community into the public arena in a way that had not been seen before. Guided by Fleet Street, the debate was promoted to the front pages of the tabloid newspapers and television. Although the fundamental issue

was ‘safety’ from the ‘psycho-killers’ that the public were at risk from, the anti community care campaign had a positive side effect for the world of mental health. The lack of community based resources for mental health became public knowledge really for the first time. During the early to mid nineties, public enquiry after public enquiry raised the issue of insufficient community resources. It became increasingly apparent to all that could look that the UK did not possess a strategic plan for community care. No template existed for effective and proven service development. In reality there were some individual local providers who provided high quality services but there was no even distribution across the country. Service development since the hospital closure programme had not only been ad hoc but had also been illserved by negative territorial disputes between Health agencies, Social Services and the voluntary sector. In short, the three main sectors for service delivery were unable to recognise each other’s importance in terms of strategic planning or co-operation. Health and Social Services departments, coming from different ideological backgrounds had very different views on exactly how mental illness could be effectively treated. The two views, one dominated by medication and the other by social work process failed to work together. No identifiable joint agency strategy existed as a result of this ‘sectarianism’. Health developed its own system of community care while social services developed another. Unnecessary duplication of processes, assessments and poor services was the inevitable result. The voluntary sector at this time represented the most dynamic sector perhaps benefiting in some way from being stuck between the two warring factions, but totally dependent on the financial crusts that fell from the statutory table. Communication was poor or non existent, there was no strategic agreement as to how services should be best developed (either locally or nationally), the main service providers could not work effectively together, the public had high levels of concern over safety and community care, the media portrayed mental illness as a stigma, there were insufficient services and service users remained isolated and impotent in society. In essence community care was not working.

A step in the right direction. As the 1990s drew to a close it became apparent that mental health services were not going to change without governmental intervention and coercion. The main protagonists had largely ignored Ten years of recommendations for positive change by the Department of Health and independent agencies. The National Service Framework, finally produced by the labour government at the close of the century for the first time demanded co-operation between agencies. More importantly for the first time lay down some basic values as to what mental health services should be seeking to achieve in terms of user involvement, strategic services, assessment and the ‘image’ of mental health. The NSF demanded accountability, the existence of multi-agency implementation teams and the establishment of key standards of care for mental health and as such it represented a move in the right direction, however late. It may be that over the next three to five years a ‘system’ of mental health in the community may be developed on a national scale that effectively meets identified needs. Cynics will point to a lack of resources to implement the NSF, low levels of public education and internal chaos in the statutory sector to suggest otherwise. This general historical over view of the slowly developing British model represents a pertinent lesson in how NOT to achieve positive change. The UK Community Care system has grown on an ad hoc basis, without the essential education and philosophy that should accompany fundamental shifts in policy. Lessons can and should be learned from the UK experience when societies look for alternatives to institutional treatment of mental illness. The following pages seek to look at some of the essential components of effective community approaches to mental health from philosophy to practical applications. No single discipline represents the ‘cure’. All aspects are pieces of a jigsaw of ‘treatment’ that cannot produce a clear picture without all of the pieces being present.

The Conceptual Foundation. “You can tell a civilised society by the way it treats its most vulnerable members”

If we accept that the vast majority of adults suffering from mental illness do not need the safety of an institution for their treatment then we should seek to examine what is the purpose of community based mental health services. The old system of hospital based treatment produced a philosophy based on containment and dependency. A regime that delivered ‘to’ rather than involve the service user in treatment. A system that perhaps had little or no identified outcomes apart from life long membership of a minority group with few opportunities or little expectation in wider society. Modern systems should seek to include individuals in society rather than isolate them. This fundamental concept has to be addressed proactively by mental health agencies. Social inclusion is not as simple as merely closing hospitals and releasing patients into society. Inclusion needs a considered strategic approach and should be the most basic aim of all services. Over the following pages I will look at several pieces of the jig saw that are essential if a realistic alternative to hospital treatment can be established. • • • • User Involvement and self advocacy Community Care Planning ,Risk Assessment and Management Community Services Housing

Not all of the components are service delivery based; some may be attitudes and ways of working rather than processes or systemic. Equally not all of the service ‘pieces’ may be exclusively mental health based. It should be said that this short list should not be considered to be exhaustive. There are several other ‘key’ pieces of

community ‘hardware’ such as Community Mental Health Teams, Assertive Outreach Teams and Community Psychiatric Nursing that could have been included. The four chosen ones represent the basics of a workable; user focused system that embraces cooperation between both statutory and voluntary agencies. What is essential however is the existence of a strategy of clear progressive pathways that both professionals and service users can easily identify and understand. In essence a simple two-tiered pathway can be used to underpin almost all mental health and mainstream services . There should exist a clear pathway from the hospital through the community towards disengagement from mental health services for those adults with mental health problems who are able to achieve social inclusion and integration. The experiences along this pathway should be empowering and break any dependency that is associated with either treatment regimes or the mental health condition itself. The pathway should be constantly monitored and reviewed by both service users and staff to ensure that individual aims are achieved. Equally, there should exist support systems and services that seek to engage adults with mental health problems who, by virtue of their age or mental health condition are unlikely to ever progress very far down the yellow brick road towards total social inclusion and employment. It should also be acknowledged that other specialist services for mental health groups with specific needs should also be in existence. Individuals with substance abuse difficulties, dual diagnosis with learning disabilities or physical disabilities or victims of abuse should have access to specialist support. Once again, it is the ethos of empowerment and social inclusion that should pervade rather than the anachronistic dependency inducing philosophy of old. This different way of thinking that underpins modern mental health services involves a fundamental shift in attitudes and can be illustrated by the following diagram which highlights some of the philosophical ‘shifts’ essential for positive progress.

A Different Way of Thinking Moving Away From FOCUS ON SERVICES • • • • • Fitting people into a service. Focusing on what it is Professional Control Building Programmes Responding to control from the top Moving Towards FOCUS ON INDIVIDUALS Listening to People Focusing on what it could be. Empowering People Building Community Changing structures that limit

This different way of approaching working with mental health needs to underpin all aspects of service development and delivery. The old ideology led inexorably to ‘clienthood’ whilst modern services should lead to ‘citizenship’.

User Involvement and Self Advocacy ‘The things that stand out about the workers we identify as empowering are such things as being treated as individuals and real people. They engage us as equals rather than distancing themselves and seeing us as dependent clients. Part of this is recognising the expertise that we have gained from our lives by living as a user’. Service User It is often asked by workers form other disciplines, ‘Why Involve Service Users at all?’ In mental health work there are several compelling reasons to do so, such as • The essence of user involvement is to promote psychological rehabilitation and recovery, their involvement and participation as a partner in the process breaks dependency and leads to empowerment and self-esteem. • Like any consumer of services, mental health service users should have the resources and authority to hold service providers accountable for the quality of services they receive. • • User Involvement changes staff / client relationships and build trust. Service content needs to reflect user concerns and priorities. Working together with users develops ‘ownership’ and helps break the dependency culture and develops equality. Effective User involvement is a developmental pathway in itself, the theme of identifiable pathways runs though all progressive aspects of mental health work. User Involvement has three stages of development, starting with the basics of advocacy leading to local service level involvement and ending up at the level of strategic involvement. It has been a common mistake in developing user involvement to try to involve service users at a strategic level of service planning in isolation, without the foundations of advocacy and service level involvement. Inevitably, to ignore

progression will lead to failure. User Involvement is developmental and should be part of a ‘pathway’ towards independence wherever possible. If services induce dependency then involvement will be ineffective and unattainable. Stage 1 - Advocacy and self care in Mental Health Advocacy can be defined as: Supporting an individual to speak for themselves, or acting as a voice for another. “The benefits detained patients can derive from an advocate have become more and more apparent in recent years. An advocate is someone who can represent and defend the views, needs, wishes worries and rights of patients who do not feel able to do this themselves. Advocacy can also help patients participate and make decisions. Advocates are wholly independent, they represent their patients without taking a view on their “best interests”. Many service users feel dis-empowered, those in hospital more so. They may be detained against their will and experience loss of liberty or choice. Often people say that they are not believed or listened to by hospital staff with respect. Add to this the symptoms of the illness, side effects of medication, which can affect the person’s thinking or their ability express themselves clearly, then the person can feel very frustrated and unable to express their views and wishes clearly. Many people do of course, have family and friends to support them, but this is not always ideal. The family member might believe they are speaking up for the person and acting in their best interest, but in reality there may be conflicts. What the family member or friend thinks is the best course of action, may not be what the service user really wants. This is where independent Advocacy can help. Most Advocates are independent, and clearly this is the best model. In many cases advocacy services are funded by local health authorities or by social services. However the projects are usually managed independently by local mental health charities, and non- profit making organisations. It is vital that the Advocate can work independently of the hospital or community where they are based. At times the

Advocate may have to challenge senior members of staff on behalf of the service user, and this can only really be effective if the advocate does not have a professional conflict of interest. The Advocate can help the service user in many ways, e.g.: • • • • • • • • Support at meetings, case conferences, and reviews Help in understanding human rights Information about medication Assistance in accessing health records Help in making a complaint Help in securing leave or discharge from hospital Advice about community resources Referral to appropriate agency on Welfare Issues

The Advocate will always act on the instruction of the service user, and will not set the agenda – the client always decides. It is important that the service user and the advocate agree on the most appropriate and correct level of advocacy for the particular situation. In an ideal world, everybody should be able to speak for themselves – Self Advocacy. However it is not an ideal world, and in most cases the service user will initially ask the advocate to offer supportive advocacy or full advocacy. As time passes, and confidence is restored the service user is often able to self-advocate.

The Royal College of Psychiatrists’ Report on Patient Advocacy dated February 1999 generally supports advocacy and states;

“Advocacy allows people to communicate what they need and want to say and to argue for a better service from health care professionals, the assumption can be made that without advocacy these aims would be less likely to be achieved. Psychiatrists are encouraged to work with advocacy schemes, to encourage their development and to promote availability of adequate funding”. Stage 2 – Service Level and Local User Involvement There has to be a need for users to become involved in their own recovery. Once the fundamental principles of user involvement have been established through hospital and community advocacy then the process can be developed within local services. Service level user involvement cannot be achieved overnight. It is a long process that starts with raising the confidence of individuals who may not have any to start with. User involvement & communication can be a mixture of formal and informal processes within a locality. User training is essential as is the training of staff to understand fundamental principles There are several potential areas of practical application including. • • • • • • • • Development of self help groups User operated services User involvement in service policy making User involvement in service design User involvement in service delivery User involvement in staffing and recruitment. User involvement in evaluation. User involvement in training

Stage 3 – Strategic Level- User Involvement The UK model now promotes the involvement of service users at a strategic level up to and including national policy planning. It can be argued that it is only after the experience of locally based empowerment that this strategic involvement can be achieved. Service users should be involved in longer term planning committees and development groups to provide a service user respective to important issues. The success of developing effective service user involvement depends heavily on the attitudes of professional staff and their willingness to progressively disengage from the active role. It has to be recognised that at the more acute end of the treatment spectrum i.e. At the hospital, levels of user involvement in their own treatment may well be low, whilst the interventionist role of staff may be high. However, as patients are discharged to the community, the role of staff should be reduced in treatment whilst simultaneously the part played by service users in their own treatment should be raised. The involvement of service users in treatment can be best illustrated in the user focused Care Programme Approach, a system of assessment and review of the progress and treatment of mental health sufferers in the community.

The Care Programme Approach CPA was introduced into England and Wales in 1991 to provide an effective framework for mental health work in the community. Its four main elements are; • Systematic arrangements for assessing the mental health and social needs of people accepted in specialist mental health services. • The formation of a care plan that identifies the health and social care requirements from a variety of providers • The appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care. • Regular reviews and where necessary, agrees changes to service user and other professionals. care plan with the

All mental health service users have a range of needs which no one treatment, service or agency can meet. Having a system that allows a service user access to the most relevant response is essential. The principle is getting people to the right place for the right intervention at the right time. This principle is, of course, particularly important in the case of individuals who need the support of a number of agencies and services and there are some who, as well as their mental health needs will have a learning disability or a drug / alcohol problem. In all these cases a co-ordinated approach from the relevant agencies is essential to efficient and effective care delivery. No one service or agency is central to such a position. Service users themselves provide the focal point for care planing and delivery.

Effective care co-ordination should facilitate access for individual service users to the full range of community supports they need in order to promote their recovery and integration. It is particularly important to provide assistance with: • • • • Education Housing Employment Leisure

and to establish appropriate links with the criminal justice system and any benefits / information / advice agencies. Establishing ‘Need’ Through a CPA System (Assessment) For the sake of consistency and clarity over levels of user need, and therefore the expected response, definitions should be centrally defined. In the UK there are two levels of identified need in the CPA system. 1) 2) Standard CPA Enhanced CPA

If an individual does not fit the criteria for these two categories they will not be considered for specialist community mental health interventions. The characteristics: Standard CPA • They require the support or intervention of one agency or discipline or they require only low key support from more than one agency or discipline. • They are more able to manage their mental health problems

• • •

They have an active informal support network They pose little danger to themselves or others They are more likely to maintain appropriate contact with services.

Enhanced CPA People on Enhanced CPA are likely to have the following characteristics. • • • They are only willing to co-operate with one professional or agency but they have multiple care needs. • • They may be in contact with a number of agencies (including criminal justice) They are more likely to require frequent and intensive interventions perhaps with medication management. • They are more likely to have mental health problems co-existing with other problems such as substance misuse. • • They are more likely to be at risk of harming themselves or others. They are more likely to disengage from community services. They have multiple care needs, including housing, employment etc. requiring inter-agency co-ordination.

Once a service user has been assessed by social workers and medics for their health and social care needs then the CPA care plan is created as a response. The care plan should be user focused and include their personal aims and aspirations. The six monthly review processes, where the service user meets in the community with all people involved in his care and treatment is used to evaluate the effectiveness of all

interventions and proactively plan for the next six-month period. The needs and wishes of the service user is the focal point of CPA. The emphasis of effective CPA planning is not on the organisational needs of professionals but on the individual needs of the service user. Part of effective CPA processes is the role played by risk assessment and management. Risk assessment is inextricably linked to Care Planning as it involves identifying and controlling risks to the individual. The whole concept of risk assessment is a controversial subject for many. If risk assessment and management are to have any meaning they should be focused on the needs of the service user and not on the ‘demands’ of wider society. Other key groups and individuals have a ‘negative’ interest in risk assessment, such as; • The government – needing to be responsive to media representation and its influences on public perceptions. • The public – fearful of the incidents which are reported and the linking of these to the policy of community care. • The employer – mindful to fulfil obligations set out in national guidance and legislation. • The multi-disciplinary team - needing to put into operation the policies of the organisation and wishing to avoid scrutiny of the serious incident inquiry. • The mental health professional – issues of self-preservation are perfectly legitimate influences on individual practice. The unfortunate side effect of risk assessment is that a fear of risk and the need to counter its perceived threat can often be at the expense of the service user. It is the right of the service user to take risks; it is part of the recovery process.

Risk assessment in the UK system is broken down into five main categories; • • • • • Aggression & Violence Severe Self Neglect Suicide & Self Harm Exploitation Other

It is perhaps only the first category that fulfils the public’s misconception of mental illness sufferers as being a danger to society. The vast majority of people with severe and enduring mental health problems are no more dangerous than the general population. Only 17 % of people convicted of homicide had symptoms of mental illness at the time of offence. (1997 –Appleby Report). However, this perception remains relatively unaltered in the minds of the public.

Risk Assessment has become an essential element of good mental health practice. Risk Assessment is not, however, a simple mechanical process of completing proforma. Risk assessment is an ongoing and essential part of the CPA process. All members of the team, when in contact with service users, have a responsibility to consider risk assessment and risk management as a vital part of their involvement, and to record their consideration. Risk cannot simply be considered an assessment of the danger an individual service user poses to themselves or others. Considerations also needs to be given to the user’s social, family and welfare circumstances as well as the need for positive risk taking. The outcome of such consideration will be one of the determinants of the level of multi agency involvement.

Risk assessment and risk management is at the heart of effective mental health practice and needs to be central to any training developed around the CPA. Staff must also consider the extent to which they might need support from colleagues, other services or agencies, especially when someone’s circumstances change unexpectedly. When the documents have been completed, the information gathered needs to be organised to facilitate the process of writing a treatment plan. In line with CPA documentation, the person’s problems should be identified and prioritised. The second aim is to establish the aims of the treatment. Once the problem(s) to be solved have been identified, the aims of the treatment should follow logically from them. Such as; Problem. Aim of Treatment ‘Past history of self harm through taking multiple overdoses.’ ‘To reduce the risk of harm to self.’

The Action Plan should describe in detail the action taken to meet the aims of the treatment. The action outlined should be practical and specific. The detail should show how, where, when and by whom this is to be done. As with all care plans the management plan needs to be regularly reviewed and the date of this should be documented on the form. Equally as with all care plans it is essential to include the service user in the risk management process. It is good practice to have a service user decide what actions he or she would expect from professionals if a situation of risk were to arrive in the community. It is common practice in the UK for service users to carry a ‘crisis card’ with them at all times that describes what actions should be taken should relapse occur. Having been assessed for needs and risks, and having received a care ‘package’ that is aimed at maintaining, supporting and ‘treating’ the service user in the community, the individual’s potential success is pivotal around the availability and suitability of meaningful community services.

Community Services It is in the area of community service development that the concepts of ‘pathways’, social inclusion, progression and user focused involvement can be put most effectively into practice. Historically the community service in the UK developed in the absence of a cohesive strategy, as mentioned earlier. The effect of a lack of planning was the development of unrelated islands of service with poor levels of communication and little or no meaningful interaction. The individual service user fairs badly in this scenario, and services developed in such haphazard ways often find themselves blocked with service users with no obvious route for development. Services need to be locally planned with service users to provide a spectrum of responses to identified needs. There should be clear lines of referral that allow for movement and clear objectives for individual services with measurable outcomes. In essence a service user should know why he or she is there and what they expect to achieve from attending mental health day services. At the acute end of the spectrum, community based injection clinics and community based occupational therapy should be available for those with acute needs. Services such as these are characterized by high levels of medical professional input and lower levels of service user involvement. Assessment procedures and short term focused interventions are usually carried out by statutory service staff. During the early post in-patient stage of recovery there should be community based provisions with support structures built into them such as Drop-ins, weekend and evening activities, advice and information projects and counselling services. There should exist active links to the mainstream (non-mental health) leisure and education facilities in the locality. At this point in the pathway there should also be preparation for work projects, training and long-term employment projects for those unlikely to return to the open employment market. It is at this level that user involvement in decision making at service and local level should become firmly established.

For those able to progress away from mental health services, the pinnacle of service development should be the existence of user run services and employment services. At all points from the hospital onwards the service user should be fully aware of what is being made available to them by service providers and what he or she can expect from them. This understanding and clarity should e the function of established planning procedures manifested in the CPA process. The issue of work and the existence of employment for those suffering from mental illness remains high on most agendas. There are a number of benefits excluding the provision of income. Including: • • • • • • • Social contact Support Social Status & Identity Time structuring and occupation Activity & Involvement Personal achievement Potential source of recovery from Mental Illness

For these reasons and many more employment in mental health remains of paramount importance, not least for the service users who often measure their own ‘wellness’ by their ability to be employed. Historically people with mental health problems have been excluded form the employment market. It has been suggested that there exists an 85% unemployment rate amongst people with a mental health diagnosis. A MIND survey (1997) showed that most employers discriminate against people with mental health problems. An earlier study in 1995 by the Royal College of Psychiatrists study showed that 30% of 120 companies studies would NEVER employ people with a mental health diagnosis. There exists a clear need to create a system of mental health employment in most localities. It should be emphasised that it should be a ‘system’ that involves

movement and progression. To often a single employment project becomes blocked through the absence of opportunities for service users to move on and develop. The 1992 research by the National Institute of Disability and Rehabilitation showed that neither diagnosis nor symptoms had much to do with employability. Instead it depended on employment history, work readiness, inter-personal skills and the desire to work. The are measurable benefits of having effective employment services; • The 1994 (Conning and Ekdawi) study shows that between 15% - 40% are people with psychiatric history are capable of full time employment within three years of their illness. • People with MH problems are particularly vulnerable to the negative effects of unemployment. • Clinical deterioration in chronic schizophrenic patients was associated with lack of occupation. This was the only distinguishing feature of those who improved with those who didn’t (8 year study, 3 large hospitals, Wing & Brown 1970) • In the community, those who are working are more likely to stay out of hospital and for longer. Values and principles in Employment Models Whatever the employment model there are certain values and principles that must underpin the project. It is very important that projects do not pursue some values to the exclusion of others. For example a project that seeks to empower must not neglect the need to offer support. Similarly a project that seeks to offer a comfortable and supportive

workplace must not neglect the opportunity for progression for those that could benefit from ‘movement’. Service users should be involved in all aspects of the design of services and the defining of values. Ownership is a key ingredient of successful employment projects. The following represent the further basic principles that should underpin any employment project. NEEDS BASED Services should be designed and operated around the clearly identified needs of individuals with mental health problems. They therefore should be ‘needs’ rather than funding, or programme model led. ACCESSIBILITY Services should be equally accessible to all groups in the community, particularly those that are under-represented. These may include; ♦ ♦ ♦ ♦ ♦ ♦ ORIENTATION TO THE LOCAL MARKET Services should be designed and operated in ways that reflect the characteristics of the local economy and labour market. Production of goods and services should mirror demand within the local economy and employment services should carefully address employer requirements. USER DRIVEN Services should be organised in a way that meets each user’s individual requirements. Users should have as much control as Women People with physical, sensory and learning disabilities Ethnic minorities Those with responsibility for children and others Alcohol / drug users Those with criminal records

possible over the timing, pace and intensity of the services they receive. They should be supported to participate in service design, operation and evaluation. CHOICE Services should offer as much choice as possible in terms of programmes, settings, skill levels and skill areas. SUPPORT Services should offer suitable and sufficient support for individuals to find and keep jobs or meaningful occupation, and / or participate in local education and training programmes. Support should be individually tailored and available on a longterm basis. SECURITY Services should provide a supportive environment for service users. CONTINUITY Services should be available on a long-term basis. Service users should be able to re-access services after an episode of illness. PROGRESSION Service users should have opportunities to progress or develop if they so wish (for example, build confidence, develop work skills, acquire qualifications, find employment etc.). Conversely they should have the opportunity to remain at a particular level, or in a specific project, if this is what they want. FLEXIBILITY Should provide a range of possible outcomes i.e.. paid, unpaid work, education, training etc. EMPOWERMENT Services should focus and build upon service user abilities and strengths and involve uses directly in service planning, operation and evaluation.

INTEGRATION

Services should be sited in an ordinary community setting. They should support the usage of community facilities and the development of wide relationships in that community.

QUALITY

Services should offer interest, variety and satisfaction. They should seek to enhance self esteem and social status by producing valuable outcomes.

COST EFFECTIVENESS Services should meet needs effectively and efficiently.

There are several distinct models of employment. In every area there is a diversity of needs: Therefore it is crucially important that a range of services is needed to provide an employment continuum’ the key components of which are:

♦ ♦ ♦ ♦

Sheltered work opportunities. Vocational Rehabilitation Support into open employment Education and Training

These components have to be complementary and interdependent. Unless there is movement or progression, and unless there is access to open employment then individual projects will either get blocked or when users are ready for employment there is nowhere for them to go. Models are NOT set in stone. They should be adapted to meet local need and availability. They should evolve and change over time, with users involved in change. There are numerous models of employment available in the UK that have proved effective when working with both people with long term mental health problems and with those who may reintegrate into the open employment market. The following represent thumbnail sketches of some of the main UK models

Sheltered Work The provision of unwaged work opportunities within protected and supportive settings. (E.g.. Industrial therapy units in day hospitals or day centres) Work Rehabilitation The provision of unwaged work opportunities within supportive settings but with an emphasis on the development of work skills, building confidence and progression to paid employment for some (e.g. Voluntary sector work projects, work rehab services) Sheltered Employment The provision of paid employment within protective and supportive environments of medium to large commercial enterprises. (E.g.. Sheltered workshops, Remploy factories) Social Firms and Co-operatives. The provision of paid employment opportunities within smaller community based commercial enterprises which aim to pay market level wages and have integrated workforces. Consumer run enterprises Business enterprises in which individuals with mental health problems have full control over the important commercial decisions. Clubhouses Member run facilities where individuals can regain confidence, develop, personal and work skills and can undertake work experience through Transitional Employment Programmes. ( a series of time limited, part time, entry level posts within ordinary employment).

Supported Education & Training The provision of intensive support for individuals to participate in education and training programmes both targeted and mainstream. Employment Services Agencies providing a range of help in gaining paid employment, including vocational guidance, work preparation courses, volunteering, wage subsidy etc. Supported Employment The provision of intensive support for individuals to identify, secure and sustain paid work of their choice in open market. Job coaches in or around the workplace. Local Exchange Trading Systems A system whereby people in a locality can exchange goods or services without using money. Members buy and sell goods or services through a notional currency system. Further information about working examples of these models are generally available from the Department of Health website. Housing The closure of the large psychiatric hospitals in the UK necessitated the resettlement of those with a long-term mental illness into the community. With the benefit of hindsight it would appear that that the closure programme failed to look at future mental health accommodation needs and produced a ‘system’ that perhaps to a large extent merely recreated new institutions in the community centred around a philosophy of ‘homes for life’. The philosophy of progression is core to successful mental health housing. A culture that looks beyond containment and seeks to promote independence and movement for those who are able and security for those who are not.

It is essential that for those who do not need a home for life the ‘idea’ that they are being placed for a tangible reason should be introduced and reinforced through CPA review procedures. However if movement is promoted, then a system has to be in place that enables the philosophy to continue. The exercise has to be continuous and therefore continually monitored. Mental health housing should have a range of different services responding to a spectrum of need. Long term residential units with 24-hour support are the broad base of provision for those with long term conditions and perhaps should be considered as being almost separate from the facilities that should be available for the population with more recent mental health problems. Supported housing with clearly defined outcomes should provide the movement required if housing systems are not to become blocked. Housing needs are an essential part of CPA review processes and a system that promotes reducing support a necessary part of recovery and movement towards independence. Most UK based Housing Associations accept that the system of Floating Support could be adapted for use with clients with higher levels of identified need if augmented levels of support were forthcoming from other agencies such as community rehabilitation and domicilary support from the statutory agencies. ‘Supporting People’ is a new initiative in England and Wales that develops the idea of floating support and promotes inter-agency co-operation in mental health housing. The Supporting People programme offers vulnerable people the opportunity to improve their quality of life through greater independence. It promotes housingrelated services which are cost-effective and reliable, and which complement existing care services. Supporting People is a working partnership of local government, service users and support agencies. The new system promotes housing related support services, which are both cost effective and planned using a co-ordinated approach and budget. Supporting People depends on a working partnership of Local Government, the NHS, the National Probation Service, the Voluntary sector, service users and support agencies.

The new system is aimed at (for example) • support to older people in sheltered housing, or support to those who wish to

continue living in their own homes but need some help to do so. • supported housing for people with learning difficulties who can move out of

institutional care and into the community if they are helped to do so • housing for people with long term mental health problems, who can move out of

hospital if regular support is provided to help them cope with living independently; The Supporting People programme aims to provide the means of enabling them to settle in a new home, and learn basic life skills that other people take for granted like how to pay rent, shop for food, organise going to regular training and so on. Stable housing tenancies enables them to take the necessary steps forward towards independence and stability.

People with learning difficulties or mental health problems can often find themselves living in institutional care such as hospitals, which are not only unsuited to their needs but are also an expensive form of housing provision. Their quality of life can be immeasurably enhanced by being enabled to live in the community, perhaps in a shared house or other supported accommodation, and sometimes eventually in independent housing with support. Again Supporting People services enable such individuals to gain the life skills and provide the basic support which can sustain them in the community, and promote their growth and development to be a part of the local community rather than confined to an institution. They also provide them with the necessary support to enable them to take part in programmes of education and employment training. Supporting People and new mental health housing initiatives have the essence of user empowerment, recovery, social integration and independence and the cornerstones of their philosophy.

Modern Mental Health Services Conclusion A system based on ‘Recovery’

The last forty years has seen the move from the Institutions to the Community. This has led to a shift in emphasis from containment, medical treatment (only) and protection for the individual and society. The new system places importance on the idea of recovery and support. No longer the permanent patient. The UK experience of community care should be examined if not for any other reason than learning to avoid making the same mistakes. The role of education in the entire process of de-institutionalisation cannot be overestimated. One of the major shortfalls in the UK process was the overlooking of the education process. It is essential that several key groups are fully aware of the facts around mental illness and not left to rely on the stereotypes that societies have repeatedly fed them for generations. The general public needs to be prepared in advance for alternatives to institutional treatment; they need to understand the safety aspect and their risk to violence. Equally important professional workers in all agencies should be prepared for the fundamental shift in emphasis that is required if treatment is focused in the community rather than in the hospital setting. It comes as no great surprise to many that staff ‘educated’ in the institutions remain as institutionalised as many of the patients and without support are unable to make the necessary conceptual shifts. Communication and cooperation between agencies is fundamental to a successful community based system. In the early days of community care, many public enquiries into serious incidents led investigators to lay blame at the lack of effective communication. Health, Social Services and voluntary sector agencies all have

crucial parts to play at different stages of the recovery process. Assessments should be multi-disciplined and CPA processes should involve all agencies. Modern community mental health systems have certain immovable foundations that cannot be ignored if the move from institutional treatment is to be successful: • Modern systems are “User Directed”. The user is the centre of the system. This necessitates the gradual reduction in the role of the ‘expert’ for those working in mental health. The progressive style is one of facilitation and partnership. Any system must use 1. User consultation as part of evaluation and monitoring 2. User groups as a forum for change 3. User led and run services as part of the recovery continuum 4. CPA, assessment and reviews systems to ensure personal development. • Modern systems are “family supporting”.

Support must be given to the families of service users; they are often an important part of the recovery process. Family members should receive Education and information about mental illness if they are to succeed in a supportive role. • Modern systems are oriented to “outcomes and recovery”. Unlike the old system, community care has the right to take part in society as the fulcrum of its existence. The service user has a responsibility in the own recovery. Key outcomes affecting quality of life of the user are crucial and emphasis should be placed not only on the illness but also on issues such as, housing, education, employment and leisure.
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Modern systems are characterised by “Best Practices”

Attention should be paid to gender and ethnicity of those with mental health problems and reasonable adjustments should be made to include these issues in treatment. Modern systems should be ‘whole systems’, not exclusively mental health. New systems look at the whole person and all the influences that determine the success of the social process. Although this paper has looked at certain key areas of successful community work, a whole system should have: • Individual tailored personal development plans. Including 1. health, 2. social, 3. employment, 4. housing 5. education. • Community mental health teams that are multi-disciplined and offer ongoing support and routine medical support. • • • Crisis support systems that can respond appropriately to prevent hospital Assistance with benefits and finance through advocacy and advice centres. The capacity to respond to special issues such as substance abuse, homelessness, criminal behaviour, suicide prevention etc. • Support for ‘wellness’ i.e. counselling, psychotherapy and good quality healthcare. • Developed social networks and peer support systems