1.0 We consider then that any recovery approach should, without exception, place the service user at the centre of their own personal service- planning, goal-setting and review processes.
However, it is essential to emphasise that this does not mean that service providers should utilise the recovery approach as a principal lever to cut costs, or as evidence that all people with mental health issues in their lives are capable of returning to a full-time work environment with any degree of strategic predictability.
1.1 We also consider it crucial that the language and practice of recovery retain the informal idioms and person-centred perspectives of service users themselves (as they of course developed and still claim the approach). Service users are concerned that the concept does not become, as many previous principles reflected in service user culture have, another impenetrable and organizationally-focused fortress of a traditional medical model that it was originally intended to challenge.
2.0 From a service user perspective, there are a number of pertinent reasons as to why the central issue of CPA must be addressed effectively before day services – or in fact any other service – will work effectively for them:
- v CPA is supposed to be the one place where service users can participate in negotiating their service, but few report that it works that way. There is no dignity without negotiation, and therefore no point.
- v If service agencies cannot design services to assist an individual’s recovery, why then expect service users to have faith in those agencies’ claims about their ostensibly genuine interest in ‘user involvement’?
- v If a service user does not feel known and appreciated for who they are, then a potentially unhealthy degree of reliance will be placed on their ability to articulate their needs at what they perceive to be a formal and so quite scary review, one populated largely by people they do not know.
- v If care co-ordinators are not enabled by the process to show an interest in an individual’s recovery journey, how can they then engender any real faith in or engagement with a service recommendation from the service user?
- v The ideal for most service users – however utopian it may first appear – is that “the person that knew them best”‘ should be their care co-ordinator; and that person would remain consistently in their lives for a reasonable period of time.
- v What we are attempting to describe is a class of relationship that demonstrates an organizational ability to demonstrate a degree of personal solidarity with a person in distress – rather than simply a professional expertise to promote a specific pre-planned service.
- v Anyone who is in receipt of CPA who does not know who their care co-ordinator is, or who meets them for the first time at a review meeting, considers this simply bad practice, and again such a performance shows no authentic interest in user engagement.
2.1 The committee feels that service user involvement in the further development of the local CPA process should be encouraged by the establishment of a service user CPA reference group.
2.2 That an advanced agreement system be incorporated into the CPA process.
2.3 That a means be developed to supply essential CPA-related information to the local strategic planning process.
2.4 We also consider it essential that service agencies begin to address the power imbalance engendered within the current system by incorporating, or at least supporting, the development of an arrangement similar to the Wellness Recovery Action Plan (WRAP) within CPA (see Appendix 4). We regard as critical to any future service user involvement in commissioning or strategic planning that CPA be overhauled and a person-centred process like WRAP be run alongside CPA or perhaps even be integrated within it.
3.0 We therefore stress to the PCT that before we agree, or perhaps even recommend, any substantial changes to local day services, we would benefit from a relationship with the principal service provider that is both more personal and increasingly flexible in its ability to respond to everyone’s recovery journey.
3.1 We think that recovery requires seeing people in the context of their surroundings and their relationships, and fitting health and social care support around this environment. People should not be ‘treated’ in isolation and without reference to their normal lives. It is the care co-ordinator’s role to ensure that this happens via developing meaningful personal relationships and ensuring that they maintain this commitment wherever possible for a significant length of time.
3.2 The care co-ordinator, then, should strive to have a relationship with everyone on their caseload, a relationship which reflects and complements our existing networks. In our view, the care co-ordinator ought to be given the following authorities and/or responsibilities:
- v To determine a ‘reasonable’ caseload that allows them time to develop a personal relationship with everyone they assist, mentor or help co-ordinate services and supports for
- v To respect and incorporate where possible individual WRAP plans
- v To be enabled to cost all personal plans and have routes to access necessary resources
- v To determine the degree of ‘discretionary’ spending within all individualised budgets
- v To co-ordinate the delivery as well as the planning of the care plan
- v To understand and appreciate the tangible benefits of services offered by those agencies other than their employer
- v To feed into strategic planning
- v To determine whether service users’ preferences for discretionary elements of their budgets are therapeutic on any level
- v That the advanced agreement process be included in the training provided to care co-ordinators
- v That ‘bridge-building’ be a required element of the care co-ordinator’s role
- v To be visible within the service user community
3.3 From a patient’s perspective, if a care co-ordinator is to ensure that the needs of the people they work with are met, then they have a duty to work in a ‘critical’ way. This involves being sensitive to and continually questioning:
- v Their own assumptions
- v People’s interpretation of an individual’s language and behaviour
- v The impact of discrimination on individuals
- v Where their role starts and ends
- v The role of others involved in the care
- v The communication of concerns, risk factors and changes to everyone involved
3.4 Service users believe that we should have a choice of care co-ordinator, and so it would be beneficial to us if a central registry of care co-ordinators were available. The registry should give a brief professional profile of the individual care co-ordinator, references, and an indication of how many CPAs they were currently co-ordinating.
3.5 We also recommend that local voluntary agencies be further educated into the centrality of CPA (and so also WRAP) for any service user’s recovery, and they should be obliged to consider their own role and obligations within it when designing and operating their services. This can be accomplished via inclusion of this responsibility in their own service specifications and their contract review process as well as the establishment of a user-monitoring process.
4.0 We feel strongly that, if the CPA (or WRAP-related) personal planning processes are to have any significant meaning for service users in terms of choice and empowerment, care co-ordinators should be able to cost individual plans and identify areas where discretionary spending could apply. We also consider that the Department of Health should contribute one of the income streams to the direct payments system.
4.1 It is clear that, should there be a significant take-up of the local authority direct payments system by mental health service users, this may well impact negatively on the provision of day services in the short term, so reducing the quality of available supports. We recommend that the PCT identify a sum of transitional money (minimum £300,000 per annum) to help promote and sustain a functional direct payments scheme and monitor its effects on individual support arrangements.
4.2 The committee also notes that one of the reasons that there has been scant take-up of direct payments (other than the artificially prohibitive acceptance criteria) is that the administrative burden for each successful applicant would be unacceptably complex. We consider that one way around this problem would be to provide a ‘back-office’ support system similar to that available to people with physical disabilities. This service could be provided within a user-run recovery centre.
5.0 In addition, our outlook will be that whatever sub-culture they may belong to, if people with mental health conditions are accused of a crime or any type of aggression, natural justice should be exercised, ending the current denial of basic rights like housing or employment because of an unsubstantiated claim (based on medical notes) of violence or aggression.
5.1 People should be genuinely innocent until proven guilty. Health and social services should also remove biased policies that signal greater priority to assaults on staff than to assaults on service users.
The centre will struggle to ensure that crime against people with mental health conditions will be treated with equal weight as all others; believing the evidence of people with mental health conditions; supporting them to give evidence; and taking action when they report crimes or seek to take a civil action.
5.2 The Centre will be divided into two parts:
Projects & training
- v Peer support/mentoring/coaching
- v Recovery training
- v How to offer hospitality – discovering people’s personal gifts and strengths
- v Advanced directives/crisis plans
- v Satellite group services
- v Research in service user development
- v Choice and control over one’s own support
- v Use of direct payments and individualised budgets, including ‘back-office’ support
- v Development of a spiritual space that a variety of religions could use
- v Service-monitoring
- v Mental health, equality and human rights
- v Self-advocacy
- v Strong links to a user-managed advocacy service designed to work differently and more effectively than traditional advocacy services
- v Group work
- v Develop a skills directory that will allow members to self-contract and exchange skills and services (similar to a LETS (Local Exchange and Trading System) scheme
- v Professional mental health development package
- v Diversity and community development projects
- v Women and Men-only projects
- v Health promotion
- v Tackling health inequalities
- v User involvement
- v Building stronger, safer communities
- v Listening and phone support service
Drop-in
- v Combine with a mental health support line?
- v Daily capacity 50+
- v Monitor unmet need
- v Subsidised food
- v Support for BME-only groups
- v Weekend support – move existing Sunday drop-in
- v Transport budget for those who justify it
- v Develop ‘alternatives’ for service users who ‘don’t fit’ other projects
- v Liaise with diversity groups
- v Liaise with Big Issue/ faith groups/crisis service, etc
- v Promote recovery
5.3 Location
- 1. The committee recommends that a purpose-built centre be designed and commissioned to open within 3 years.
- 2. In the meantime there are a number of options regarding location, but the most feasible and least disruptive option for the majority of current service users is the Allen Centre. Issues around the charges imposed by the local authority will hopefully be resolved quickly. The Sussex Partnership NHS Trust has agreed to assist in these negotiations.
- 3. This option would involve the closure of Aldrington House and the relocation of the Mind office. We are aware that Mind has been searching for alternative premises for some time and we would hope that the trust and the PCT could assist them with their goal. Meetings with the service users at Aldrington House have proved to be productive; many members support the work of the committee and look forward to assisting with the development of the new user-managed service.
- 4. Preston Park Day Centre would for the time being operate primarily as a time-limited structured day care centre to assist people who need more intensive support alternatives immediately after their hospital discharge. Committee members did meet with members of this service and also recommend that a) alternatives be found to the current day service charge and b) that the centre be redesigned to promote a more effective level of service user involvement in its administration.
- 5. Buckingham Road CMHC should remain as a drop-in service in central Brighton for the time being, but the staffing levels should be reviewed and, if possible, a trained staff member should be transferred to the Allen Centre or the Brighton Unemployed Centre, as required at the time of the review.
- 6. Satellite Services are highly valued and should also remain, although alternative community-based locations for various courses will be developed over time in order to facilitate further community inclusion. It is anticipated that the user-managed centre will be involved in the commissioning decisions and tendering process for new satellite groups.
- 7. The Allen Centre will be seen as a community resource centre with a café and internet services open to the public. A community cinema and a variety of community arts projects will also be hosted by the centre.
- 8. Capital funds will be required for re-badging, as well as for appropriate renovations and equipment. We consider that a minimum of £100,000 will be necessary for this purpose. Recent discussions with Sussex Partnership NHS Trust management have indicated that it would be feasible to raise this amount of capital money for the project.
- 9. Many people, of all racial and ethnic backgrounds, believe that religion and spirituality favourably impact upon their lives, and that well-being, good health, and religious commitment or faith are integrally intertwined. The centre will be sensitive to and embrace this aspect of mental health by supporting culturally-specific projects as they are identified.
- 10. It will also recognise family loyalty which means that, despite reported feelings of stigma and shame from some minority family cultures, families are often an important source of assistance in efforts to cope. Therefore minority and other family and social networks may expect to be involved in continuing support arrangements.
- 11. The Assertive Outreach Team will be prepared to receive a percentage of its crisis-related referrals from the centre.
Staffing
5.4
- 12. All staff will be hired by a service user panel
- 13. Staff will be supervised by the partner agency and a service user representative.
- 14. All staff will have six-monthly supervisory feedback from the collective membership.
- 15. Members on enhanced CPA will have a link worker to assist them and their care co-ordinator.
- 16. Minimally there will be a complement of:
- Ø A service co-ordinator with link responsibilities
- Ø 3 full-time staff during daytime hours
- Ø 2 full-time staff ‘out of hours’ (service to be operated until 9/10pm and later at weekends, 365 days per year
- Ø Part-time clerical staff
- Ø A kitchen ‘co-ordinator’ to train and assist with meal preparation
- Ø Care co-ordinators with bridge-building skills will be represented at the centre
- Ø A BME worker will also be based at the centre
- Ø A work and learning advisor
- Ø A family or carers representative
- Ø Volunteer hospitality co-ordinators
- Ø Volunteer phone monitors
- 17. A contract will be put out to tender for an organization to act as an arbitrator in the case of disagreements between the partners. This organization’s decision would normally be final.
6.0 Therefore we ask the PCT and the Sussex Partnership NHS Trust to assist the centre by ensuring that its activities are valued, its external links to the broader mental health system are functional, and its expertise is incorporated into a strategic feedback loop that encourages further individual empowerment, community development and person-centred change.
