WRC Action Group

 

Wallington Resource Centre

77 Woodcote Road, Wallington, SM6 0AU

email: wrcactiongroup@hotmail.co.uk

Model of Day Services

Developed by WRC Action Group February 2007

Summary

A model of day services created by clients at Wallington Resource Centre which we feel best meets our needs and the needs of the local area and provides good value for money.

Our proposed model represents different types of individual needs as suggested by a major independent body, the National Development Team, and shows how these can be provided for whilst retaining the advantages of a building based service, placing the emphasis on flexibility and social inclusion. It suggests how the vital and unique role within the borough of the Children's nursery can be built upon.

The model focuses on the importance of having varied and inter-linked services working together, but argues that this should not be at the expense of statutory providers such as Wallington Resource Centre. Our model points out improvements needed to the existing crisis service, as well as other issues needing attention.

This document goes into detail about the complex body of evidence, points of view and influencing factors upon which we have based our conclusion, we outline our own interest and reasons for undertaking this work.

Finally, a comparison between what is provided by Wallington Resource Centre (WRC) and the government blueprints set out in the form of the National Service Framework (1999) shows that WRC meets these requirements. Where there are omissions, these could be rectified by unfreezing and re-building staffing levels and a return to an open referral system.

WRC Action Group, February 2007

Principles of Future Model of Day Services

Day services to include the Resource Centres provided at Wallington in Wallington Resource Centre (WRC) building and at Cheam in Cheam Resource Centre (CRC) building (and Sutton Drop-In although this is a separate service).

See Appendix 2 for supporting evidence of this model

The Resource Centres

The structure of the model aims to be mindful of the National Development Team[1] Inclusion Traffic Lights system in that the model reflects the benefits of having different levels of support and inclusion but is not a level system where a client moves between different levels but a service which provides access to a mixture of these levels in a kind of 'mix and match' system. For example, people may be able to attend SCOLA classes (green) but only with day service support (red) at other times during the week. The general objective would be that people would need less intensive support (red) as they recover or in periods of good health but that each person's needs would be considered on an individual basis.

 

We would retain a building based service which continues to:

• be run by professional and trained staff
• have easily accessible staff in times of crisis
• provide the nursery facility (see below),
• provide the lounge culture
• be a non clinical, out of public eye, safe place,
• be a place with peers and staff
• be a normal environment
• be a non judgement environment where distress is accepted,
• be an environment that creates a balance between non pressure to pretend to be ok, where you are accepted for who you are and how you feel, but,
• that does not allow individuals to vegetate during their time at centre
• Which provides a variety of leisure activities with therapeutic value

 

The future model will therefore continue to include a service where:

-      The individual will be the priority factor within a community ethos which provides

o      Flexible programmes which meets the needs of individuals

o      To support people in as conditions improve, fluctuate, worsen or stabilise.

o      To continue to cater for people who have long term conditions and acute phases.

-      To continue to place an importance on social inclusion, through links with wider community education/employment/voluntary organisations and activities in the community

-      To continue to acknowledge that the treatment of psychiatric conditions is complex and requires professional support by mental health clinically trained staff though.

o      continuing to serve a wide range of mental health problems without being too clinical and focusing on conditions themselves more than necessary

o      intensive therapeutic and psychological treatment

o       Psychological intervention groups eg anxiety management

o       One to ones with caseworker/professionally trained staff

o      help with social integration

o       through groups and activities in the community settings (amber), or from external providers at the centre (amber) ie SCOLA or with encouragement and links with mainstream services for clients to access themselves (green)

o      help with regaining interest through activities which have an exercise or leisure therapeutic benefit at the centre and in the community

o       Leisure groups ie games/gardening

o       Sport/exercise groups

o       Creative groups ie art and crafts

o      Assistance with life skills

o       Healthy living groups

o       Cookery groups

o       Budgeting and money management groups

o      To develop further links and resources for those who want to return to work or explore employment and education activities.

o      To consider some women-only sessions to address gender and cultural needs as recommended by the Department of Health[2]

See Appendix 2 for supporting evidence of this model

 

Nursery

In September 2005 the Care Services Improvement Partnership which is funded by the Department of Health and works in association with the Mental Health Foundation, produced a toolkit for redesigning and modernising day services - Redesigning Mental Health Day Services: A Modernisation Toolkit for London. Page 13 says redesigned day services should be responsive to the wide range of women's needs and take account of their caring responsibilities..services should recognise their responsibilities to by providing flexible provision to women and men with caring responsibilities through provision of creche workersgroups in nurseries, liaison with social services to provide day placements and close working with services such as Sure Start. The Department of Health Women's Mental Health: Into the Mainstream also recommends that services design principals take into account women's parenting responsibility and consider the need for child care facilities[3]. 50% of clients at WRC are women and the centre has a nursery.

 

Clients want to see any future model to continue to provide the well respected nursery at WRC: with the unique aspect of being licensed to take new born babies, which makes the service easily accessible for mothers who become postnatally depressed; where babies and mothers are in the same building; where nursery and resource centre staff work together and the child and parent's needs and health are monitored.

The PCT have said that current day services do not meet the needs of people with young . Since the open referral system was stopped and clients can only be referred to WRC from the community mental health teams there has been a drop in use; many families will avoid contact with psychiatric and social services out of fear of losing their . An open referral system would allow health visitors and Sure Start to make referrals reducing the possibility of parents and especially women being excluded from day services, Sure Start is incidentally based in the north of the borough. Before the staff team was so depleted there were good links with Sure Start and an investment in staff would allow these to redevelop.

 

Many of the issues said by the PCT to demonstrate that day services are not working well, such as the accessibility of the services for Black & Minority Ethnic Groups and young mothers could be addressed by an open referral system where GPs and health visitors make referrals instead of only the Community Mental Health Teams. Unfortunately the government criteria for funding of day services is for people experiencing severe and enduring mental health problems and Trust's need to be able to reflect this in their stats, it seems that the PCT's interpretation of this is to only allow access to day services to those who are under an enhanced CPA, it is necessary for the client to be under a CMHT to have this and these people would have enduring and severe mental health issues. A catch-22 situation has been created and this needs to be addressed nationally and locally.
Services to run along side and to compliment resource centre:

 

Sutton Drop-In

 

No Panic -User led anxiety group which meets fortnightly.

Soundmind - a voluntary organisation working with people using music, poetry, performance etc. based in Clapham phone www.soundmind.co.uk 

Befriending scheme (volunteers) as mentioned in PCT document (pg 5; 6.3) for isolated, anxious socially phobic people who may need a visitor, someone to accompany them to shops, to a mainstream group or travel on the bus to a day service and return with them. It should be clear that befriending is not about providing advice or counselling as they will not have sufficient training to do this and should not be offered in place of existing day services. (amber or green).

 

Education - PCT document[4] refers to a Good Practice Worker & Client Development Worker, who could make links with SCOLA to educate and increase accessibility to mainstream SCOLA courses and work with SCOLA ensure they meet the Disability Discrimination Act (DDA) in terms of accessibility ie by providing a mentor for those who may need support in class (to others in the class it may be necessary that they appear as if friends doing the course together); to meet at a central point to support them getting into the class; someone to contact if not ok during time in college even arrangement to have a quiet room to sit in; a telephone call to encourage them to attend before class (green).

Also to continue with and expand on SCOLA literacy/numeracy and yoga classes in day service itself (red), and in SCOLA venues around borough but specifically for people with mental health problems (amber).

 

Employment - Drop In or resource centre to have monthly or bi-monthly Job Club (run by voluntary sector ie SCVS) with help developing CVs, writing job applications, interview preparation as recommended by Toolkit[5]. (amber)

 

PCT's document[6] refers to the Sutton Advocacy Project (green), and the Sutton Mental Health Foundation Recovery training and Hearing Voices and user led groups (amber), Vine (amber) and SUN projects (amber), we recognise the value of these and hope they continue alongside resource centre services to provide training, user led support and access to voluntary employment. However the long term funding of the Vine and SUN projects is not secure.

 

Toolkit document[7] recommends that staff explore discounts to leisure and sport facilities. If extra staff resources were available they could explore the possibilities of taster sessions of courses at SCOLA and discount at leisure centres and ensure that staff and clients know about the cinema discount card called Cinema Exhibitor's Association Card[8] for those in receipt of certain benefits.

Crisis line

PCT document[9] suggests that crisis support could be provided by ex users based on the SUN model. Clients do not feel it is appropriate to run this service by volunteers or current or ex service users mainly because:

• they want to talk to a professional
• of the stress it places on those running the service
• the level of training and support that would be needed
• the difficulties the SUN group has experienced in getting their out of hours support off the ground.
• SUN project also states that people should not use their service if in severe crisis, instead to contact the Crisis line.

 

We feel the current Crisis line service could be a workable service for out of hours time if it was improved; currently it is impersonal and clinical and a typical response maybe have you taken your medication? Take a tranquilliser, which maybe necessary but not always good as the sole response, or unhelpful advice such as you're still young, you shouldn't be depressed. Crisis Line should be manned by appropriate staff who are dedicated to that task for the duration of their shift on the line. Urgent need for training on

• Distress
• crisis management and intervention
• interpersonal skills, talking skills
• distraction techniques
• counselling skills
• understanding of issues which affect users and how responses from crisis line can be perceived
• self harm and suicide

There should be a protocol for follow up when the line has been used by a client ie contact to their team. Staff who man crisis line should be obliged to visit the wards and day services regularly to meet clients and liase with staff to over come the impersonality. This would fit with the whole systems approach of effective working partnerships of working closely together recommended in the Toolkit[10] .

 

A promotion of any improvement needs to be carried out to encourage use of this service.

 

View of the Model using the inclusion traffic light system:

RESOURCE CENTRE To cover both Wallington Resource Centre building and Cheam Resource Centre building Based on model described on pages 3-4, in brief: Service based on individual need Run by trained staff Clients have a named casemanager Open referral system Clients have one to ones based on individual need Groups: Creative ie art and craft Leisure ie gardening, table tennis, relaxation, yoga Psychological interventions - ie anxiety management, Life skills - cookery, money management, literacy/numeracy, healthy living Social book club, social affairs Nursery Lounge Garden Links with: Sure Start; SCOLA; employment and voluntary organisations and sources of advice inc SCILL; SCVS
Community based activities and groups (inc staff facilitator):
Tennis Wallington Tennis Club	Walking Group - various venues over borough	Badminton Westcroft Leisure Centre	Pool group - The Waddon Pub	Book club -Wallington Library	Yoga -Sutton SCOLA site
Clients personal networks and support structures set up through socialising and friendships

 

View of the model in conjunction with other services using the inclusion traffic light system:

RESOURCE CENTRES In house service at Wallington Resource Centre and Cheam Resource Centre   Community based activities and groups inc staff facilitator			SUTTON DROP- IN
			Assertive Outreach
			Community Mental Health Teams
			Early Intervention Team
Sutton Mental Health Foundation Recovery training	Vine Project	SUN project	Home Treatment Team
			Crisis Line
No Panic	Befriending	SCOLA	Sure Start
Hearing Voices groups	Citizens Advice Bureau	Bananas Art		Art Aloud
Soundmind	Women's Centre	Leisure centres			SCVS

Suggestions, Issues of concern and for further exploration

Clients suggest exploring the following:

-      renting out nursery in afternoons

o      to Family Focus or Sure Start or Child & Adolescent Mental Health Services or local authority and Families department to

o       generate revenue

o       create good working links

o       maximise the use of this space

o       increase accessibility if a small proportion of places were offered to of clients who cannot access the morning nursery

-      renting out buildings or rooms at other times to voluntary sector or for weekend use ie for workshops, to

o      generate revenue,

o      maximise the use of this space

o      links like this would also help address issues of stigma if other groups use building

o      PCT to encourage local businesses and organisations to run 'managing stress at work' workshops or 'mental health awareness in the workplace' away days based at Cheam Resource Centre (CRC) and WRC. The resource centres would rent out rooms to create revenue, financed by workplaces and facilitated externally.

o      There is duplication of roles ie Client Development Worker, Good Practice Worker and we have been told that the PCT funds community bridge builders who liase with public sector and distribute leaflets to the public, if savings can be made then reinvested in staff for resource centre.

-      Mainstream/Imagine: currently receives £98, 000 from LBS[11] is spearheaded by Joint Commissioner for Mental Health Services. Clients say that Mainstream staff are not trained to understand mental health issues and have reported that Mainstream have given them an inefficient service and we are aware that at least one formal complaint has been made.

-      Clients wonder why Imagine duplicates other initiatives such as John Land and the role of SCVS and SCILL. We are not clear what the £98k from PCT funds what service should be being provided by Imagine and what is actually being provided, whether Imagine is good value for money.

-      Seek funding from government initiatives which could relate to day services.

-      Address referral system to day services

Ways PCT can invest more staff in day service:

The NSF says that new investment and reinvestment of existing resources will need to be prioritised, recognising that mental health services are whole systems which work effectively only when the component parts are all in place and in balance[12].

-      PCT should look at the staffing in new CMHTs and the need for increased staffing in day services.

-      Funding at WRC and CRC a type of part time work experience placement for people on OT or social work course to work with and be supervised by day service staff. This person would be cheap and links with local universities should generate people interested as work experience is needed but hard to find. They could support outside groups, assessments and do specific work with individuals ie travel training.

-      Funding STAR workers who would be untrained therefore cheaper, but supervised by day service staff to work alongside staff and assist with travel training, supporting to access day services and mainstream services.

Appendix 1

 

Background to our Principles of Future Model of Day Services

 

Planning

Planning requires a number of elements to come together

o      Involvement with organizations

o      Requesting and gathering statistical data

o      Supporting individuals and groups to develop the model

o      Gathering together, processing and presenting information in a simple, easy to understand, but well referenced form

o      Disseminating information and obtaining feedback from all involved at each stage in production of the model

 

Limitations and Complexities

Any model will be limited, and we must recognize these limits

o      Time / effort of those working on it is finite

o      Money - PCT intends to cut £45K from the 2007/8 resource centre budgets - part of the one million pound cut to mental health services

o      We have not been able to obtain a clear budget for WRC as the mental health trust does not have full figures. The mental health trust and PCT need to have comprehensive budgets for day services before making decisions.

o      less resources to meet more people and more needs without ruining current examples of good practice in borough.

o      Willingness / ability of external organizations to respond to requests for help and information in making the model is limited

o      No model can be entirely bias free, as it depends on the situation of those involved in its production, so potential sources of bias should be stated

 

The Toolkit[13] recommends that there is a need to articulate the role of day care within a whole systems approach clearly our ability to do this as a non statutory organisation will be somewhat limited.

 

Statistics and lack of detail:

One difficulty we faced in drafting a model is that PCT's document[14] states that the number of people using mental health services within the Mental Health Trust from Sutton amounts to approximately 1200. Attendance figures indicate that less than half of those clients use day services. We feel this is misleading as the PCT does not say whether those not using day services want or need to use day services. The PCT does not state whether:

• They work but are under a psychiatrist
• They receive adequate support from family, friends
• They have chosen to seek private therapy
• They use other services ie drug and alcohol services/ out of borough services ie personality disorder services at Clare House/learning disability services
• They have physical disabilities/ill health which prevents them from getting to services or are in services which care for these physical disabilities
• Are wheelchair bound
• Are under an enhanced CPA

All these factors will impact on the service needed.

 

The PCT's document[15] states it pays £197,891 to the voluntary sector but does not break this down between services. We have been told that this figure is not correct.

 

PCT document[16] states St Helier, Wandle Valley and Beddington South are more deprived areas and it has been said that people from these areas are less likely to use day services, although no figures have been produced. In 2002/3 the PCT and LBS explored plans for a hospital hostel for people with mental health problems at the Middleton Circle site to coincide with the development of the community health centre. This proposal was abandoned out of concerns for the safety of those who would use the hostel following a public meeting, at which the level of hostility from local residents was extreme. Any mental health groups set up in the north of the borough needs to be able to ensure the safety of those attending and to instil confidence in clients of this.

 

The PCT document does not state how many people who use mental health services within the Mental Health Trust from Sutton regardless of whether they currently access day services who are already involved in mainstream, socially inclusive services which has been arranged by themselves such as regular adult education, clubs, voluntary or paid work.

 

Other influencing factors

The reconfiguration of Community Mental Health Teams (CMHT), Assertive Out Reach Team (AORT), Home Treatment Team and Early Intervention Team will have an unknown impact. It complicates matters that these are currently being looked at as separate issues with separate consultations (although the HSC have challenged this fact on 11^th January 2007). Any reconfiguration of CMHTs could impact on Cheam Resource Centre as one of the teams is currently based there and we are not clear whether this will continue.

 

PCT has suggested[17] renaming day services Community Support Services, we have continued to call them day services in this document regardless of whether these are provided in the evenings and at weekends, based on the fact that these are not overnight services, and to ensure that we all know exactly what service is being talked about and to avoid confusion with the Community Mental Health Teams and Community Services department at LBS. Our understanding regardless of the term is that the purpose of day services broadly covers prevention of admission, promotion of independence and on going support.[18]

 

What is Wallington Resource Centre? We see it as a modern, forward thinking day service which meets the complex needs of people with acute and severe and enduring mental health needs through a variety of therapies and activities. It certainly is not day hospital or a traditional day centre which the Toolkit damns, and is non medical in that no medical or psychiatrists are on site, but it does value its mental health trained staff. What is clear is that WRC cannot be judged without exploring the service fully and we feel this has been missing from the review of day services to date.

 

Gathering Clients Views

We collected views from WRC clients by holding group meetings and making notes of brain storming, we provided opportunities for clients to write down in their own time what they value from current day services and what they want from future day services.

 

Ideology

 

To meet the Toolkit[19] goal that modernised day services provide support and help with functioning and to facilitate access to employment and other meaningful daytime activity, with social functioning and social inclusion the key aim. At the same time being mindful that the model should be based on individual choice as well as collective needs

o      Not everyone wants to work

o      Not everyone wants to meet lots of new people

o      Not everyone wants to spend all their energy on 'getting better'

 

The model belongs to those it effects

o      The effected individuals & services will be the first to be involved

o      These people's opinions are more important than professional ideas of best practice

o      'Consultation' after the fact is not good enough those affected must be supported to develop the model for themselves

o      Experts/professionals are there to support, not to decide

 

Toolkit[20] says that Mental Health and Social Exclusion report (2004) observed that both users and carers valued day services.

 

Social Inclusion Unit report Mental Health and Social Exclusion, June 2004[21], set out 6 key objectives that day services were to achieve:

1. Offer access to supported opportunities
2. Provide person centred provision; to cater for needs of all individuals , including those with mental health problems
3. Develop strong links and referral arrangements with community service and local partners
4. Provide befriending, advocacy, and support to enable people to access local services
5. Involve people with mental health problems in service design and operation
6. Focus on social inclusion and employment outcomes

We feel WRC meets many of these needs and therefore our model will also, but there is a contradiction in these 6 key objectives as a service cannot be person centred catering for the needs of all individuals and focused on social inclusion and employment outcomes as clients tell us this is not the wish of everyone. Many will have caring responsibilities, , be over the age of retirement, not want to be more socially inclusive and services need to reflect this also, so a balance is needed.

 

The toolkit argues that the guiding principles for mental health should revolve around social inclusion and recovery; that day services should facilitate the recovery of a meaningful life andenable people to do the things they want to do and that recovery is seeing people beyond their problems, both recognising and fostering opportunities to enable them [to] realise their abilities, interests and dreams, and thereby recovering the social relationships that give life value and meaning[22]. Clients Perspective booklet and presentation to HSC demonstrates how WRC service fulfils this and our model will continue to do so.

 

The Toolkit recommends a recovery model[23]:

1. Does not necessarily mean getting back on track to where you were before
2. Happens in 'fits and starts' and like life has many ups and down
3. Is a journey rather than destination

The above take into account the need for services that can meet the varied and complex and long term needs of individuals we feel WRC meets these criteria[24] and our model will continue to do so.

4. Calls for optimism and commitment from all concerned

This is a confusing statement, a service and staff can be optimistic and committed (we find staff and atmosphere generally at WRC to be both these[25]). However the reality is that clients may not always be optimistic or committed and neither will the atmosphere of a service always be positive as events and situations occur.

5. Is profoundly influenced by people's expectations and attitudes

People's attitudes and expectation are individual and fluctuate and services need to be flexible as WRC already does[26] and our model will continue to do so. Often, when unwell, people do not have any sense of the future of expectations and their attitudes can be coloured by their state of mind. It is realistic to acknowledge this.

6. Requires services to embrace new and innovative ways

We feel WRC is a unique and modern service[27] and our model will continue to be so. However embracing many new and innovative ways is often reliant on funding.

 

Toolkit recommends Befriending schemes, weekend services and social clubs and drop-ins[28]. It should be noted that in 1990s WRC offered a client run weekend drop in facility which stopped after two years due to lack of demand.

 

Toolkit says say services need to be more culturally and gender sensitive[29].

• 50 % of those attending WRC are women
• the fact that men and women engage equally in the centre makes it unique.

 

The client group at WRC reflects the demographics of the area. It has been said that there is a higher proportion of people from Black & Minority Ethnic (BME) groups on the wards than the local demographics. Anyone on the wards at Sutton will be linked with a Community Mental Health Team (CMHT) all CMHTs can refer clients to WRC and CRC, so we wonder if the CMHTs are not referring clients to day services or if people do not want to use day services. It would be useful to know how many people want day services who are not receiving them and how many want assistance in improving their life and future who are not receiving help. For those people who are only seen in primary care settings ensuring GP have a knowledge of the services available would be helpful.

 

While the needs of people who may require a service and are not receiving one concerns us, we would also suggest that losing a service which serves many well to provide an alternative for others is not a useful solution. We would like to caution the PCT against decisions made under the guise of equality and diversity which result in restrictions for everyone.

 

WRC has a good balance of ages:

• ten clients between the ages of 18-30,
• twenty between 30-40, nineteen between 40-50,
• nineteen between 50-60 and six clients who are 60+.
• In 2006 nine 18-30 year olds were referred to the centre and six were offered an assessment, these statistics show that WRC does cater for all ages.

 

 

Objectives

 

This model is being created by Wallington Resource Centre Action Group which is run by clients for clients and aims to represent the views of those who attend the centre. Wallington Resource Centre (WRC) is a day service for people with chronic and acute mental health problems. As we value the service provided by WRC we want to retain the essence of it in future plans for our borough while bearing in mind the need to address the need for increased accessibility. We feel that WRC is good practice and that there is evidence from clients[30] and outside organisations (ie Rethink) which demonstrate evidence that WRC is an example of good practice day services. Rethink[31] say that in Sutton the average stay on an acute ward is now reduced to 11-17 days and our borough has the lowest rate of re-admission within 90 days of discharge of all the Trust's 5 boroughs: Rethink attribute these positive statistics to current good day services.

 

While the Government has said that day services should move away from building based services and become more person centred, clients at WRC value a building based service, not necessarily the building itself but a service which has a base. If a client is in a crisis their care can continue to be managed within their programme at the centre by familiar staff, perhaps with extra support or increased attendance reducing the need for hospital admission. It would be difficult to provide this without a building based service. This continuity of care is important and minimises the sense of crisis for the individual and the cost for stakeholders[32].

 

The lounge is a central part of the resource centre; people use the lounge before and after groups. The lounge culture is provides social therapy, through interaction with and acceptance from peers and staff. It is unique to the resource centre service, is valued by clients and renews self respect and confidence[33].

 

The use of structured timetables and organised activities comes in for criticism from external agencies ie government as it is sometimes said that clients have to fit in around something external to themselves and it is not individual enough, to meet everyone's specific want and needs would be impossible but a varied programme would address the concern that people were not able to find activities which suit them. Whether we like it or not for most people life is structured and in that sense it is good preparation for those wanting to return to 'mainstream' lives. For those who exist in chaos or lack motivation, a non rigid structure has many benefits and can be a good learning tool for self management. Bryant et al reports that the therapeutic value of engagement in a meaningful occupation suggests that activities should be a key part of day services.

 

WRC works within a timetabled structure but this has flexibility to take into account individual needs and fluctuations in wellness. Clients' view that this works well for them is supported by the findings of Yurkovitch, Smyer and Dean in 1999 which showed that when staff supported and facilitated clients to build on tactics for self management, creating individualised networks of support, the day service was more effective[34].

 

At WRC the structure, regular reviews, the knowledge that everyone is discharged at some point and being individually focused provides boundaries and a balance between dependence and independence.

 

Appendix 2

 

Research

Expressions such as evidence based practice and clinical effectiveness are buzz phrases in the NHS today; however effectiveness and the measuring of value means different things to different people. Outcome based assessment of effectiveness is popular but not necessarily the best way to evaluate a facility which provides day services to people with complex needs who have a diverse aspirations.

 

Evidence does not have to be research based and there is a wide variety of different sources of evidence available ie research projects, users' views, staff views. When looking at whether or not a type of service is effective a truly inclusive method would be to use all the evidence available to service providers.

 

Those involved in the review of day services in Sutton should be aware that mental health day services are jointly run by S&M PCT and London Borough of Sutton Council, and this immediately poses a conflict in the current review of day services: typically the NHS and social services have different approaches to research and evidence and different ways of evaluating its quality and robustness:

 

NHS	Social Care
Hierarchy of strength of evidence involving in depth analysis of method and results of study: -      Randomised Controlled Trials (RCTs) are the strongest evidence and are referred to as gold standard[35] -      Quantative (numbers) studies as opposed to qualitative (words) -      respected opinion, expert discussion[36] is considered the weakest evidence	Acknowledges all sources of evidence: user, research, practitioner, policy knowledge in non - hierarchical assessment of evidence uses 7 quality standards: 1.     Transparency 2.     Accuracy 3.     Purposivity 4.     Utility 5.     Propriety 6.     Accessibility 7.     Specificity source

 

The NHS often makes use of Cochrane systematic reviews which carry out retrospective reviews on Randomised Controlled Trials (RCTs), some are almost 20 years out of date and RCTs use numbers rather than words which may not be the best way to measure people, especially those with complex needs.

 

The conclusion of the Cochrane systematic review carried out by Marshall, Crowther, Almaraz-Serrano and Tyrer in 2002 into Day Care V Out Patient Care for Psychiatric Patients, was that there was not much evidence of the effectiveness of day services and therefore no evidence to justify the provision of day services[37]. In another Cochrane systematic review carried out by Catty, Burns and Coma in 2002 which evaluated the effectiveness of non-medical day centres, the conclusion again was that there was insufficient evidence. However lack of evidence does not mean the services are ineffective [38]. It is important to bear in mind that the first review was only based on eight studies, the second reviewed nine and three of these were from the 1960's and 1970s and do not seem relevant to today, both only used randomised controlled trials and no qualitative studies[39]. These Cochrane reviews have been cited as evidence against the effectiveness of day services and as reasons not to fund this provision, however there is much qualitative research which supports the effectiveness of day services, as well as the experiences of clients attending WRC which have been presented in Clients' Perspective, via the WRC Action Group and individually to the PCT and in the report by Rethink.

 

Small scale studies which take into account user views contrast the Cochrane reviews and suggest that day services are beneficial. Studies such as Allen's 2000 report of a review of day services in Cambridgeshire show the effectiveness of day services; users consider day services prevent relapse and promote independence, with low key activities as therapeutic and beneficial for clients[40]. To include the observation of these smaller scale reports would be an inclusive method of using the evidence available to service providers when reviewing day services.

 

Evidence to support effectiveness of service provided by WRC:

Mental illness interrupts lives and pushes ambitions into the background, often forcing people to re-evaluate their direction once they are in a position of thinking about directions again[41]. It needs to be remembered that for many returning to financially sustainable employment would be too much pressure and trigger a relapse.

 

For many, the management of their own lives and their health is as much a full time job as any employment. Many people will be considered to be 'well' but their good state of health is dependent on their choice of lifestyle whatever that may consist of. Nagle, Valiant Cook and Poatajko say of the informants in their study that while they were not working for money, ie paid employment, they were working in that they devoted a significant amount of energy to do the things that allowed them to remain well and socially connected. They provide valued instrumental and emotional support to others in their social network and work hard to meet their own needs[42]. Others function well enough to prevent serious relapse but could not be said to be 'well' and they contain themselves and their health with direct and indirect support from community day services, the psychiatrist, voluntary organisations, family and friends, part time or voluntary employment, therapy, educational and leisure activities.

 

Husted and Wentler concluded in their paper on The effectiveness of day treatment with persistently mentally ill in rural areas that in urban areas day services are cost effective because of the benefits of structure within a community setting are effective in preventing relapse[43]. Rethink say that in Sutton the average stay on an acute ward is now reduced to 11-17 days and our borough has the lowest rate of re-admission within 90 days of discharge of all the Trust's 5 boroughs[44]. Estimates from South West London and St George's NHS Trust based on the amount paid by the PCT; it costs approximately £41 per client per session at WRC. As the PCT pays a set amount the service becomes more cost effective the more clients attending. It is difficult for clients to gain a good understanding of the costs of WRC as the budgets are complicated by the LBS/PCT input and not all the figures are available.

 

Studies suggest that patients receiving community-based care have a lower use of psychiatric beds in the follow up period that those receiving more traditional services (Stein & Test 1980, Hoult et al. 1984)[45].

 

Leisure, creative and social activities:

-      a lack of structure to the day exacerbates the symptoms of mental ill health[46]

-      people with severe and enduring mental health problems can be motivated and empowered through involvement in a meaningful purpose or activity (ie woodwork in this study and a drop-in environment) which has a social aspect in a non pressured where the individual has control over their attendance (unlike employment in general)[47].

-      creative pursuits helped people manage their symptoms[48].

-      clients find art and creative activities build self worth and self esteem, is absorbing and distracting[49]

-      art can be cathartic even without awareness of trying to express feelings through art

-      art can encourage spontaneity and enrich everyday awareness as ordinary objects and scenes are viewed through an aesthetic awareness[50].

-      it is possible that many similar life affirming experiences [psychosocial benefits] may be gained via many quite different forms of personally valued activities and projects (eg gardening)[51]

-      The garden offers an environment which can play a significant role in recovery from mental fatigue and promote spiritual expression[52].

 

Exercise focused activities:

-      NICE guidelines recommend structured and supervised exercise for people with depression[53]

-      regular exercise helps to reduce the symptoms of depression[54].

 

Life Skills:

-      living skills training are effective at improving independence for adults with persistent schizophrenia (ie cooking money management)[55].

Social networks:

-      Adequate networks of support will reduce the likelihood of hospital admission

-      people using day care are more not restricted in their social networks and likely to build larger social networks than people using hospitals settings[56].

 

Anxiety Management:

Studies comparing people on a short term anxiety management course with people in a control group show that anxiety management courses are effective in significantly reducing the symptoms of anxiety and depression compared to those in the control group[57]. When the control group went on to receive the course they also benefited and this pattern of success was repeated and off set against the new control group.

 

Staff

WRC clients repeatedly stress the importance of having trained staff as the core staff team in day services with their experience, knowledge of mental health illnesses and the mental health system, legislation, medication, links with the CMHTs and social services. Clients value the one to one support and the presence of staff in groups. Concerns have been expressed by clients that non trained staff will not be experienced enough to provide adequate support, counselling to people and will not be containing in an acute episode. There is an issue of respect from other clinicians which needs to be born in mind; clients are aware that untrained staff in other projects are not taken as seriously by hospital staff when they express concern over a client, whereas WRC staff who are trained and known and respected are taken seriously. Bryant et al recognise this as a difficulty and records that untrained staff are frustrated with the lack of medical support and the dismissiveness of their opinions[58].

 

Faulkner and Layzell found in their user led research of user views on strategies for living with mental health that people want professional support to help them retain and to attain their chosen style of living[59].

 

It is not a coincidence that WRC has a feeling of safety, this is because staff are trained and provide containment and people feel in charge of their lives.

 

NICE guidelines recommend that people with bipolar should have continuity of care and for an improved long-term outcome see the same healthcare professionals regularly[60]. NICE guidelines say that psychological and psychosocial interventions have an important part to play in the treatment of bipolar and that people need support to return to or engage with education or other structured, purposeful activities[61]; long-term treatment and support are required to minimise the risk of recurrence and optimise quality of life, and social and personal functioning[62]

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard one Health and social services should: 1. promote mental health for all, working with individuals and communities               2. combat discrimination against individuals and groups with mental health problems, and promote their social inclusion. (Page 14 NSF)	Exercise, relaxation and stress management have a beneficial effect on mental health.   Teaching interpersonal awareness reduces emotional exhaustion and depression Tailoring individual programmes to individual circumstances (page 16 NSF)		Groups at WRC include 5 different exercise related activities, 2 specific relaxation and an anxiety management group Interpersonal awareness through interaction with others and staff in lounge, in groups, psychological groups Individual programmes are already tailored to individual circumstances   Social inclusion: groups and activities in community settings, from external providers at the centre ie SCOLA, encouragement and links with mainstream services for clients to access themselves

Appendix 3- NSF Guidelines

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Mental ill health higher among groups which experience social exclusion: BME, unemployed, people in poverty, women, domestic violence, homeless, drug and alcohol, physical illness	All services should be sensitive to cultural needs, including the needs of people from black & minority ethnic communities. (Pg 29 NSF) Use of an interpreter. Recruitment of staff from, and representative of, local communities is the most effective longer term strategy to build cultural competence. (pg 44 NSF)		WRC clients reflect the demographics of Sutton. PCT says day services do not meet needs of BME in area.16.4% of Sutton population are from BME groups. WRC/CRC are only referred people who are linked with a CMHT.   WRC uses interpreters where necessary.	Open referral system   Free frozen staff places and fund further staffing to engage more staff greater possibility of recruiting staff from BME and local communities
	Women and : The emotional and cognitive development of socially deprived of a depressed mother is especially affected, with boys more vulnerable than girls 63,64 (II, I).page 32 Professionals in adult mental health services should be familiar with local child protection procedures. (Page 45 NSF)		WRC Nursery: links between nursery staff and WRC staff ensure good monitoring of the child and parent, awareness of issues affecting family for nursery staff with support from mental health professionals. Previous social workers have been trained in child protection issues and had good links with Sure Start social worker post frozen	Investment of funding in social work post
NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Health visitors, with training, can use their routine contacts with new mothers to identify postnatal depression, and treat its milder forms.pg29			Nursery	Many families may resist contact with psychiatrists and social workers for fear of being taken into care. Once trust has been established at WRC many are happier to consider other sources of help. Open referral system women in difficulties can be referred by GPs, health visitors and Sure Start, reducing need for psychiatrist only referrals
NSF most people with mental health problems are cared for by their GP and primary care team (page 3)		People only under there GP would not currently be referred to day services as without a CMHT they would not be under an enhanced CPA and therefore they do not fit the criteria for receiving day services. (See page 5). An issue which needs to be addressed.		Open referral system to day services not just through psychiatrist and Community Mental Health Team. However the Government will only fund people for people who have severe and enduring mental illness. Adequate staffing levels to meet extra demand this would place on service

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard two Any service user who contacts their primary health care team with a common mental health problem should: - have their mental health needs identified and assessed - be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it. (page 28 NSF)	Mostly Standard 2 is more relevant to GP and primary care services not day services. Individuals in need should be able to access services which are responsive, timely and effective.		When adequately staffed WRC does not have a waiting list and clients referred to the centre are assessed and offered a place if appropriate. Currently due to low staffing level WRC not taking on new clients unless there is a need for the nursery	Open referral system   Free frozen staff places and fund further staffing to engage more staff greater possibility of recruiting people from BME groups

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard three Any individual with a common mental health problem should: - be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care - be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines or to local services. (pg 28 NSF)		A&E, Crisis Line, Day services, 9-5 CMHTs, Drop In with weekend and evening drop in service		Crisis Line: appropriate staffing and increase in training see page 7
The majority of mental health care will remain within primary care as at present. The protocols will ensure that more complex cases receive ready access to skilled specialist assessment and treatment, including psychological therapies, and continuing care. Page 35			WRC staff are fully trained mental health professionals whose expertises a vital. The services functions at its best with a fully staffed multidisciplinary team	Free frozen staff posts and increase funding for staffing         Open referral system people difficulties can be referred to day services by GPs if they are resistant to idea of CMHTs.
NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard four All mental health service users on CPA should: - receive care which optimises engagement, anticipates or prevents a crisis, and reduces risk - have a copy of a written care plan which: - includes the action to be taken in a crisis by the service user, their carer, and their care co-ordinator - advises their GP how they should respond if the service user needs additional help - is regularly reviewed by their care co-ordinator - be able to access services 24 hours a day, 365 days a year.page41	People with recurrent or severe and enduring mental illness, have complex needs which may require the continuing care of specialist mental health services working effectively with other agencies. A range of services are needed in addition to primary care - specialist mental health services, employment, education and training, housing and social support. Needs will fluctuate over time, and services must be able to anticipate and respond to crisis. (page 43 NSF) For people with severe and enduring mental illness, the care package may need to include help with social skills and social networks to address the social isolation of individuals with severe mental illness. (page 45 NSF) Service users are more likely to stay in contact with community rather than hospital-based services. Studies suggest that these services, help to reduce suicide rates 126,127,164,165 (III, IV, I, I). (page 47 NSF). Community mental health teams may work with other specialist teams covering early intervention; assertive outreach; home treatment; the needs of those with co-morbidity; black and minority ethnic communities; homeless people; or mentally disordered offenders. (page 47 NSF) The written care plan for individuals on an enhanced CPA should include: - arrangements to promote independence and sustain social contact, including therapeutic leisure activity (page 53 NSF). To ensure that each person with severe mental illness receives the range of mental health services they need; that crises are anticipated or prevented where possible; to ensure prompt and effective help if a crisis does occur; and timely access to an appropriate and safe mental health place or hospital bed, including a secure bed, as close to home as possible.	The phrase people with severe and enduring mental illness is interpreted locally as those under and enhanced CPA which leads to referral difficulties see page 5 and a catch-22 where only those who have a CMHT and who are under a CPA can be referred to day services.                                                                                                     Day services ie WRC and CRC, Early Intervention Team, Assertive Outreach Team, Home Treatment Team	WRC clients have enduring and severe mental health problems, which fluctuate and have acute phases: 33 people have schizophrenia, 23 have personality disorders, 17 depression and 10 bipolar affective disorder.   WRC has links with employment, education organisations         WRC manages crisis reducing need for hospital admission by increased support and attendance and links with CMHTs Lounge culture and groups at WRC increase social skills and networks                                                             Lounge culture and groups at WRC increase social skills and social networks. WRC encourages independence + maintaining good mental health through counselling, psychological interventions, distraction techniques, stimulating interest through leisure activities ie sport, art and craft, gardening. WRC, the staff, structure, support and contact provides containment and can act as a prevention of relapse. Staff see clients regularly in the groups, lounge + in one to ones so their condition is monitored unobtrusively but effectively. Staff can be accessed in times of crisis. WRC manages crisis reducing need for hospital admission. WRC staffs links with psychiatric teams mean that if an admission is necessary or a client needs to see a doctor it can be organised swiftly.	Increase in staff levels would increase ability to develop links with other organisations

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard five Each service user who is assessed as requiring a period of care away from their home should have: - timely access to an appropriate hospital bed or alternative bed or place, which is: - in the least restrictive environment consistent with the need to protect them and the public - as close to home as possible - a copy of a written after care plan agreed on discharge which sets out the care and rehabilitation to be provided, identifies the care co-ordinator, and specifies the action to be taken in a crisis.	N/A to day services	N/A to day services	N/A to day services	N/A to day services

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard six All individuals who provide regular and substantial care for a person on CPA should: - have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis - have their own written care plan which is given to them and implemented in discussion with them. (Page 69 NSF)		Sutton Carers Association and Sutton Carers Action Group     3 workshops which have involved service providers, carers and users. Limited chance for feedback	Staff liase with and provide intervention for carers of users, separately to users when necessary	Greater respect for carer opinions and greater involvement of carers in service planning

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Standard seven Local health and social care communities should prevent suicides by: - promoting mental health for all, working with individuals and communities (Standard one) - delivering high quality primary mental health care (Standard two) - ensuring that anyone with a mental health problem can contact local services via the primary care team, a helpline or an A&E department (Standard three) - ensuring that individuals with severe and enduring mental illness have a care plan which meets their specific needs, including access to services round the clock (Standard four) - providing safe hospital accommodation for individuals who need it (Standard five)             - enabling individuals caring for someone with severe mental illness to receive the support which they need to continue to care (Standard six). and in addition: - support local prison staff in preventing suicides among prisoners - ensure that staff are competent to assess the risk of suicide among individuals at greatest risk - develop local systems for suicide audit to learn lessons and take any necessary action.			WRC clients say that attending WRC reduced incidents of self harm, suicide and admission to hospital[63].

 

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
	Involve service users and their carers in planning and delivery of care	3 workshops which have involved service providers, carers and users but little chance for feed back. Limited access to sub group	WRC Action Group set up. To date clients at WRC do not feel the PCT has responded to the views given by WRC Action Group in contrast to HSC. Continued difficulties in making arrangements for PCT meet WRC clients	PCT to fully involve users
	deliver high quality treatment and care which is known to be effective and acceptable		Rethink say that in Sutton the average stay on an acute ward is now reduced to 11-17 days and has lowest rate of re-admission within 90 days of discharge of all the Trust's 5 boroughs: Rethink attribute this to current good day services. [64]
	be well suited to those who use them and non-discriminatory
	be accessible so that help can be obtained when and where it is needed		A client in crisis can be managed within their programme at the centre with extra support or increased attendance reducing the need for hospital admission.
	offer choices which promote independence		Varied programme of activities and options to access other organisations, links with voluntary, educational and employment services
	be well co-ordinated between all staff and agencies		Clients feel there is good coordination between WRC & CMHTs	Higher level of staff would ensure greater co-ordination and links with other agencies as staff resources would be less stretched
	deliver continuity of care for as long as this is needed		Each person's treatment at WRC is individual and discharge is jointly considered

 

NSF Guidelines A National Service Framework for Mental Health	NSF Recommendations	Local Interpretations	How Wallington Resource Centre Meets This Standard	Changes Needed to Meet Standard
Staff Work can cause both mental and physical ill health. Work overload, monotony, and pressure of work are key factors, as are lack of control over work and exclusion from decision making. (Page 16 NSF)	Participation in problem solving and decision making can improve mental health (page 16 NSF) All staff should be engaged in shaping services and in planning and delivering change. Staff can expect to have the reasons for change and benefits for service users clearly demonstrated and explained, drawing on the evidence-base of the National Service Framework. (Page 83 NSF)	3 workshops which have involved service providers, carers and users. Limited chance for feedback	We understand that staff team are being supported among themselves. Clients are concerned about the lack of consultation they see from PCT to staff and lack of involvement of staff in future plans. We are concerned that the PCT is not promoting a good example of a healthy workplace for its staff.	Greater respect for staff opinions and greater involvement of staff in service planning
The National Service Framework's programme of change cannot be implemented in a matter of months. (Page 7 NSF)	Additional facilities, extra staff and more training will be required in some areas to achieve some of the standards.			Free frozen staff places and fund further staffing to engage more staff

 

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