Bath and North East Somerset Community Health and Care Services:

Community BasedMental Health Pathway

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1. Introduction

Mental health issues affect a large proportion of society: approximately 1 in 4 people seek help for poor mental health at some point in their lives and may experience this as a long term condition. Yet most resources are allocated to the small percentage of the population requiring intervention from specialist psychiatric services, with around 90% of funds being dedicated to the treatment of a comparatively small group. Moreover, a narrow focus on the medical outcomes of diagnosis and treatment fails to harness the knowledge and expertise of other service users or make best use of solutions with community based support networks and services, which are key factors to sustaining recovery and preventing crisis.

It is proposed to build on new and existing provision to develop a community based mental health pathway offering one-to-one, peer and group support to include a wide range of creative, social, cultural, educational and productive activities as well as high levels of practical, social, therapeutic and emotional input aimed at maximising independent living skills.

This pathway will focus on the needs of the individual and will be fully integrated, with a shared philosophy and way of working, taking a holistic approach to a person’s needs, and working closely with the Wellness Service, CAMHS (child and adolescent mental health services) and other Mental Health statutory provision and 3rd sector providers. Throughout the pathway, clients will be supported to develop and improve social skills, a healthy lifestyle, independent living and preparation for work or work related skills.

The development and design of the proposed model has been informed by the Your Care Your Way consultation with service users and stakeholders, and the key principles will be central throughout any further development and implementation of the model:

Choice / Personalisation, with the person at the centre of the support, rather than a service based system

Needs led, taking a holistic view of a person’s needs and interests A joined up approach, on the principle of ‘only telling your story once’, with shared

Information and appropriate governance protocols, throughout the pathway Shared Goals for multiple Providers working in partnership Outcome focused Cost Effective and demonstrating a sharing of resources High Quality Diversity Transparent

There will also be fluidity of movement between Services / Interventions and with other pathways, such as the Wellness Service

Social action underpins this approach to managing Long Term Conditions, its social value including growing a new peer workforce, patients moving from passivity to becoming contributing citizens, and reduced demand on high cost care services generating investment in growing community capacity and circles of support.

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2. Purpose

2.1 Aims and Objectives

Aim:

“I can plan my care with people who work together to understand me and my carer(s), allowing me control, and bringing together services to achieve the outcomes important to me.”

People will have the capacity to live healthy lives and regain or maintain their independence by addressing the lifestyle, social and risk factors that influence their mental and physical health and wellbeing, and have access to both mainstream services and community resources to support and improve their mental health and quality of life.

Objectives

The encompassing integrated Community Based Mental Health pathway objectives, are-

• To use personalised approaches to reduce demand for more formal health and social care services

• To enable people who are experiencing the effects of serious mental illness and who may have complex needs, who live in non-residential care accommodation, access to the necessary recovery focused support to enable them to live independently within the community and increase their independence

• To reduce the number of people with mental health needs and / or long term conditions requiring emergency hospital admission, attendance at A&E departments, psychiatric, in-patient or residential care

• To support the continuous improvement in the safety and effectiveness of community based support resulting in a positive experience for service users

• To help people live healthily and independently and improve their quality of life in the community

• To ensure, whenever possible and desirable, that people who access secondary care are enabled to recover both a quality of life and achieve independence of health and social care services

These objectives will be achieved through the following-

• To make good and effective use of a supportive holistic signposting and assessment service (social prescribing), drawing on peer and community networks where appropriate to reduce demand on clinical services

To enable people to self-access directories of opportunities that meet their needs and interests

• To take a preventative approach and deliver effective community based pre-crisis support to help prevent people’s needs escalating and requiring higher level care

• To enable service users to develop skills to sustain or regain their own accommodation

• To take a holistic and flexible approach with a strong focus on clients’ abilities and strengths that promote recovery and rehabilitation.

• To tailor the support to individuals to facilitate improvements in self-esteem and confidence, focussing on practical, social, therapeutic and emotional issues, working alongside assets within the local community.

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• To have for all GPs and health professionals a clear pathway for patients to access appropriate social support, including pre-crisis services

• To support professionals and community opportunities to work together as an integrated social care team with a focus on the individual rather than the condition

• To explore and develop an Alliance Contracting approach within the mental health pathway, to ensure services collaborate and support each other in delivering bespoke services

• To develop and make use of clear and close links with Talking Therapies, the Wellness Service (for example Social Prescribing, Volunteer Hub, Employment Development and Wellbeing College), and other clinical and social care pathways as relevant

• To deliver a community development function to help build community capacity, resilience and strength, supporting the ‘Give’ element of 5 Ways to Wellbeing, and enabling people to support each other

• To ensure that through integrated working and governance protocols, people only have to ‘tell their story once’ throughout the pathway. Develop integrated working with other pathways to extend this principle.

• To continue to harness the potential of new technology to help make health and social care and support more personalised and integrated.

• To ensure that carers are recognised as part of the peer network, and offered appropriate support & training where required

• To uphold and promote the rights and expectations detailed in the Mental Health and Wellbeing Charter (appendix 3a) and the Carers Charter (appendix 3b), throughout the Pathway

3. National / local context and Evidence base

Our health, our care, our say (DH White Paper 2006), states that service users and carers want services / care closer to home. It also stated that health and social care services: need to support people to stay healthy and well; empower them to live independently; should tackle inequalities; offer safe and effective services and support people to exercise maximum control over their own life. This direction of travel for the delivery of services is further set out in Putting People First (DH 2007) and Transformation of Adult Care Services (DH LAC 2008) and New Horizons (2009)

A report on mental health and social exclusion (ODPM 2004) identified that one of the causes of social exclusion experienced by many adults with mental health problems is the actual fear of, or rejection from, the community leading to people wanting to stay in the safety of mental health services rather than engaging in the mainstream. The Social Prescribing element and principles of this Mental Health Pathway will support people to take up and be part of mainstream opportunities.

Rapp & Gosha (2006), propose six recovery principles, these being:- People with psychiatric disabilities can recover, reclaim, and transform their lives The focus is on individual strengths rather than deficits The community is viewed as an oasis of resources The client is the director of the helping process The case manager-client relationship is primary and essential The primary setting for the work is the community

‘The goal for modernised day services is to 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’. Dr Andrew McCulloch (The Mental Health Foundation)

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The action plan of the Social Exclusion Unit report Mental Health and Social Exclusion report (2004), advocated the need to: ‘Transform day services into community resources that promote social inclusion through improved access to mainstream opportunities’.

The Strategic Framework for Improving Health in the South West1

Engage with local community groupings so that these communities are empowered to address relevant health needs;

Creating an enabling and accountable state Appleby et al – benefits of non-pharmacological support based approach can be as

effective as prescribed antidepressants (Appleby at al, BMJ 314 1997) Mental Health Foundation – showed that people who experienced MH problems

identified the ability to make own choices and take control a major factor in maintenance of mental health (Strategies for Living, Mental Health Foundation, 1997, revised 2000)

The key strategies that assist in designing and delivering mental health services include: • The National Service Framework for Mental Health (1999) – a 10 year national

strategy to improve adult mental health services for people measured against seven standards2

• The NSF Five Years On (2005) re-emphasises the priorities for the years 2005 -2010 e.g. social inclusion, long-term conditions, primary care and dual diagnosis3

• Mental Health and Social Exclusion Report (2004) - A 27 point action plan to address social exclusion that sits with the Director of Social Services4

A report presented to the Foresight Challenge Project on communicating the evidence base for improving people’s well-being, stated -‘The concept of well-being comprises two main elements: feeling good and functioning well. Feelings of happiness, contentment, enjoyment, curiosity and engagement are characteristic of someone who has a positive experience of their life. Equally important for well-being is our functioning in the world. Experiencing positive relationships, having some control over one’s life and having a sense of purpose are all important attributes of wellbeing’.

The evidence emerging from the Foresight Challenge Reports indicates that social relationships are critical for promoting well-being and for acting as a buffer against mental ill health.

Regular physical activity is associated with a greater sense of well-being and lower rates of depression and anxiety across all age groups. For example, engagement in physical activity is thought to be beneficial to wellbeing by providing increases in perceived self-efficacy, a sense of mastery and a perceived ability to cope. It also detracts from negative thoughts.

1 The Strategic Framework for Improving Health in the South West http://www.southwest.nhs.uk/pdf/Strategic%20Framework%20FINAL%20FOR%20PRINTING.pdf p522 Department of Health, England; London, 1999. NSF for Mental Health.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_40095983 Professor Louis Appleby, National Director for Mental Health. The NSF Five Years On. London, Department of Health, England, 20 December 2004. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4099120 4 Social Exclusion Unit. Mental Health and Social Exclusion – 2004. London; ODPM, 2004.

http://www.cabinetoffice.gov.uk/upload/assets/www.cabinetoffice.gov.uk/social_exclusion_task_force/

publications_1997_to_2006/mh_summa ry.pdf

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The continuation of learning through life has the benefits of enhancing an individual’s self-esteem, encouraging social interaction and a more active life. Fieldwork studies indicate that participation in lifelong learning serves to positively impact on an individual’s well-being and resilience. These effects are mediated by self-esteem, self efficacy, a sense of purpose and hope, competences and social integration.

The Foresight definition of mental well-being says that it is enhanced when an individual is able to achieve a sense of purpose in society and, thus, contribute to their community. So, helping, sharing, giving and team-oriented behaviours are likely to be associated with an increased sense of self-worth and positive feelings.(Report to the Foresight Project on communicating the evidence base for improving people’s wellbeing. Written by: Jody Aked, Nic Marks, Corrina Cordon, Sam Thompson from the Centre for Wellbeing.

Mental health prevalence across B&NES

Condition Estimated Prevalence rates– all ages

Generalised anxiety disorder 5,465Depressive episode 3,249Mixed anxiety and depression 11,097All phobias 2,194Obsessive Compulsive Disorder 1,459Panic disorder 888All neurotic disorders 20,717

Bridging the Gap – Peer Research carried out by New Hope and St Mungos – see appendix 1

See also Appendix 2.

4. The policy context

Clinical Commissioning Group (CCG) Five year forward view Sustainability and transformation plans B&NES Mental Health Strategy 2016-20

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5. Service Delivery

5.1 Service Development

Principles

Overarching Principles

A social care system that mobilises people and recognises their assets, strengths and abilities, not just their needsAn ability to live well with long-term conditions powered by a partnership between individuals, peers, carers, community opportunities and frontline professionalsA system that organises care around the individual in ways that blur the boundaries between health, public health, social care, and community and voluntary organisations

Pathway specific principles

To develop for all referring agencies and self referral a clear pathway for people to access appropriate support, including pre-crisis services

People referred have access to a personalised and holistic response including supported signposting, assessment and social as well as pre-crisis services, drawing on peer and support networks where appropriate, to reduce demand on clinical services, and more formal health and social care services

To explore and develop an Alliance Contracting / Partnering approach to ensure services collaborate and support each other in delivering bespoke services to individuals

Close and effective working with the Wellness Service and Talking Therapies in addressing people’s holistic needs and issues

Issues and Opportunities

The following issues and opportunities for service development have been identified:

Issues

There is a need to increase the self-care offer and access to health literacy. There is a need to separate accommodation from support for people with moderate

to high mental health problems, and for the support to be delivered as far as possible in their own homes. This would aim to avoid people having to be rehoused as their mental health improves, and associated difficulties over finding suitable and available accommodation, and moving into new communities

Following on from the point above, there is an increasing risk averseness amongst landlords, including housing associations, in providing tenancies directly to people with mental health issues

There is a need to develop more support for people with personality disorders There needs to be high quality training on specific issues provided for staff in pre-

crisis provision so they are suitably qualified to deal with issues such as personality disorders, and so they hold the same boundaries as Community Mental Health Team (CMHT).

There is a gap in longer term support which is outside of meeting Local Authority (LA) criteria, and of people having complex issues which prevent them taking up community opportunities

There need to be community opportunities available which are affordable for people on low income or benefits to take up. Likewise, the ongoing cost of support and / or

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tutors in community opportunities needs to be addressed if they are to be successful, and the provision of taster sessions, for example, under a community development role.

Transport and accessibility issues need to be addressed across B&NES There is a need for more emphasis on helping people to find ways to support

themselves in the community over the long term, which doesn’t reflect an institutional, hand holding approach

There is a need to improve the pre-crisis support available in the community Need to reduce the stigma associated with mental health conditions in the community Need to maximise the role of Primary Care and other organisations and services that

come into contact with those that would benefit from prevention and wellbeing services.

Risk assessments, while important, can be a barrier in taking up community opportunities

An increase in sheltered housing with low levels of ongoing support People should have easy and consistent access to the same breadth and scope and

quality of wellbeing and health information, which is not dependent on the service approached

Opportunities

There is an opportunity through true partnership working to develop a clear and consistent approach across the pathway and into the community, which improves peoples’ flow through the pathway, and flexibly meets peoples’ needs and interests to improve their mental and physical wellbeing.

There is an opportunity to move beyond focussing on single issues and take a more holistic and person centred approach addressing the psychosocial determinants of behaviour, and making full use of community strengths and resources – linking with the social prescribing element of the Wellness Service.

Services could make greater use of community engagement approaches with more involvement of communities in the design and delivery of services. The community could be enabled to develop its own solutions through a Community Wellness Fund and a responsive Wellbeing College via close links to the Wellness Service.

There is an opportunity through the Wellness Service to jointly develop affordable community opportunities which support people’s mental wellbeing

Through close links with the Wellness Service, the model could make enhanced use of volunteers / peer mentors in the community to support people and opportunities, promote lifestyle change, and signpost to local services.

There is an opportunity to work more closely with CAMHS to develop excellent transition services

There is the potential to combine referral, assessment, information systems and data bases with other referral, assessment and information systems to deliver on ‘telling my story once’ approach. Shared risk assessments could reduce barriers to taking up community opportunities while maintaining safe environments

There is an opportunity to move towards separating accommodation from support with supported living and floating support services working together in the community

Through the development of Safe Havens and a Wellbeing / respite House, there is an opportunity to improve pre-crisis support for people in the community

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5.2 Service Model

Values and Principles of the ServicePlease see the outcomes framework detailed on page 17.

The Pathway will incorporate, as a minimum, the following values and principles into the pathway’s work with people with mental health problems across the community:

o Working to clients’ qualities, strengths and abilities, and not defining them only in terms of their illness.

o Recognising that people with mental health problems have the right to live independently with support if required.

o Demonstrating a commitment to working in partnership with other agencies to ensure a significant contribution to community and social inclusion agendas.

o Ensuring that people with mental health problems participate voluntarily with the support and the service allows them choice and control over decisions affecting them.

o Demonstrating a commitment to clients’ participation in the development and delivery of the service.

o Working to ensure the safety and well being of service users.o Working to promote access to mainstream serviceso Offering an anti-discriminatory service that contributes to redressing the

inequalities experienced by people with mental health problems regardless of their age, gender, sexual orientation, disability, religion or faith belief

o Having skills and processes to evaluate the effectiveness of the service.o Ensuring that clients from a diverse range of communities, including clients from

non-established and / or under represented communities, socially isolated and disabled service users are aware of the service, able to access it and have their needs met appropriately; including the use of appropriate communication methods, literature and documentation in appropriate languages and styles

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Service Model

National and local research indicates that those most affected by health and social inequalities are likely to have multiple risk factors, mental health issues, unhealthy lifestyle and social behaviours. Therefore, these behaviours should be dealt with in an integrated manner to offer a more personalised approach. The model comprises of components which separately and in combination aim to deliver an integrated mental health pathway:

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Support for wellbeing Community based Wellbeing opportunities

Wellbeing college

Steering Group

Consisting of representatives from

Mental Health Pathway

Primary Care Liaison Service

Wellness Service

Mental Health Pathway

To include functions of –

Supported Living

Floating Support

Wellbeing House (respite)

Mental Health Reablement

Evening cafes / Safe Havens

Housing related support

Supported Community Opportunities

Transition work (CAMHS)

Working closely with

Talking Therapies(social)

Social Prescribing via Wellness Service + ROVa

Specialist Care and Support

Self help guidance

Wellbeing Options Websites Directories Leaflets etc ROVA App for self access

social prescriptions

Wellness Service

Integrated working with

Social prescribing

Volunteer Hub

Employment Devt

Wellbeing College

Community Fund

Healthy Lifestyles

Managed byIntegrated working

Model componentsThe pathway will deliver a shared philosophy and way of working, shared care planning and risk assessments, and ease of transition on the pathway. There should be close working with CAMHS and other Mental Health provision, talking therapies, schools and colleges, and other 3rd sector organisations, including the Wellness Service, to ensure person centred and community based support and planning.

It is anticipated that the elements making up the pathway will comprise of –

a) Steering GroupIt is anticipated that this will comprise a membership consisting of representatives from the Mental Health Pathway, the PCLS, the Wellness Service, and other providers as appropriate.This group will oversee the delivery and development of the Pathway in response to expressed need from its own clients and other pathways. It will collect data and report on the whole system, identifying unmet need and co-developing community based solutions.

Outcomes Creating effective and meaningful links between the Pathway and the range of

health, support and community services and opportunities Ensuring approaches are joined up, complementary and reciprocal with cross

referring taking place easily and transparently (between eg the Carers Centre, Housing Support and the Employment Development etc)

Maximising the use of technology and social media to publicise the pathway and opportunities, and responding to collated information

Continual improved response to expressed need Reduced barriers to access Improved information sharing to benefit the clients Improved quality assurance across the pathway Improved sharing of resources across the pathway. Improved integration with health and statutory services

b) Mental Health Supported Living and Floating SupportThis will be largely accommodation based, due partly to a shortage of affordable and suitable accommodation in Bath, and risk averseness on the part of landlords in offering direct tenancies to clients with mental health issues. It is intended to work towards separating accommodation from the support element. This would infer a transition towards an increase in the scope and size of floating support services, delivering support flexibly in a clients’ home, where the support is directly related to need, which may fluctuate over time.It is likely that there will always be a cohort of clients whose needs are high or complex, and for whom supported living is the most appropriate provision, but providers should still work towards moving these clients on into their own accommodation in the longer term with floating support to meet their needs.This element is likely to be commissioned as a mixture of block contract and preferred providers, funded by spot purchase / Personal Budgets, due to the fluctuating numbers of clients requiring a service at any one time, and the proposed shift towards floating support. There are currently 66 clients receiving supported living and mental health floating support services, plus 13 clients under a block contract in supported living. It is anticipated that the current level of block purchase at Mulberry House premises will remain the same.

The aim of these services is to support clients to recognise and develop their own resources to manage their Mental Health, and to develop resources to live independently:-

o To reduce the need for people with mental health problems to live in supported living, or residential accommodation

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o To support clients to acquire the skills and confidence to move away from one to one support and towards independent living

o To improve clients’ opportunities to engage in employment, or work related activities and social activity

o To reduce the risk of the person being victimised or becoming vulnerable to abuseo To help the person to take an active part in peer support to enable them to maintain

independent living both within and moving on from supported livingo To support clients’ re-integration into the wider community, and making full use of local

community resources or facilities.

c) Housing Related SupportSuitable and settled housing is an important element of a person’s wellbeing, and support to find or retain accommodation is vital and should be available flexibly throughout the pathway responding directly to peoples’ needs. This element should also link in to people based in other mental health services, such as residential and hospital care, as appropriate.

d) Mental Health Reablement Beds (Wellbeing House); This will be a pre-crisis, therapeutic sanctuary and respite facility, where paid and peer support is available to support people with the self-management of their mental health problems and deliver a form of social prescribing for future support, and to reconnect people with support in the community. It will meet the needs of adults of working age experiencing emotional distress associated with a mental health problem. It will provide a place of retreat, which is safe, welcoming and comfortable for people in emotional distress and for those seeking to prevent the onset of a crisis. It will be confidential, person centred, non-diagnostic, with no charge to the service user, be user led, with peer support from staff and guests, and with paid staff support always there; it will be non-judgemental, and non-medical. Time in the beds will always be planned so there will be no emergency / crisis “admissions” (these are to be managed in National Health Service (NHS) beds). It is currently available for up to 4 nights at one time, and up to 4 times a year, with 3 beds available per week. It aims to prevent hospital admissions or the need for crisis beds. It will deliver training to support staff so that they are sufficiently qualified to deal with a range of issues, such as personality disorder, and will hold the same boundaries as CMHT.

It will aim to Effectively support people through emotional distress and prevent the onset of a

crisis Support individuals to recognise and develop their own strategies for crisis

prevention and management Reduce admission / readmission rates to Avon & Wiltshire Partnership (AWP) beds Reduce the use of AWP intensive / crisis team through planned use of these beds

within the community facility Achieve a reduction in escalation of need as expressed through the LA’s Fair Access

to Care’s (FAC) criteria and therefore generate savings in local authority spend as part of the integrated pathway

e) Mental Health Reablement Service; This will provide free, intense and focused support for a maximum of 10 weeks to support people through issues which could, if not addressed, lead to deterioration in their mental wellbeing. The model is one of short term, floating support, with targeted interventions to address social crisis and increase coping strategies. Interventions will be intensive but brief and will link people into existing and developing support services. It aims to prevent hospital admissions or the need for clinical / crisis support. It will deliver a form of social prescribing for future support, so that clients leave the service with a jointly agreed recovery and action plan.

It will -

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- Contribute to the prevention of unnecessary psychiatric hospital admissions- Contribute to the timely discharge from psychiatric or general hospital- Assist people to manage a short term crisis in their mental health- Enable people to remain within their existing home environment and community- Assist in the care pathway for people leaving residential care- Help people to be as independent as possible and regain and maintain daily living

skills- Contribute to an overall assessment of a service users needs and to broker access to

other relevant services- Promote socially inclusive and recovery focused activities.- Bridge the interface between primary, secondary and adult care services

f) Evening Cafes / Safe Havens (pre-crisis support); This is currently under development. This will deliver community based support, operating as an out of hours service, to help prevent people going into crisis. It will act as a safe haven, with some clinical as well as social care and peer support available, within a safe, comfortable and sociable environment, which encourages informal buddying and peer support, and with an emphasis on social prescribing or signposting. It will not be therapeutic in nature. It will aim to reduce emotional and psychological distress and offer an alternative to attending Accident & Emergency (A&E) when people are experiencing or at risk of escalating to a mental health crisis. It will be staffed with skill-mixed, appropriately trained mental health professionals with capacity to work with people in emotional / mental health distress.

The aim of this element is that through early intervention in people’s social crisis or pre-crisis, and support people through emotional distress. People will be empowered to regain control and minimise the impact of a crisis on their functioning, quality of life and that of their families and friends.

g) Navigation & Practical Support; People throughout the Pathway will be offered signposting, advice and support, appropriately tailored to their needs. It is envisaged that this will be delivered through the social prescribing function of the Wellness Service, although the principle of social prescribing will be built in to all areas of the mental health pathway, and the use of ROVa (a health and social prescribing app developed by a local partnership) as a self-management tool demonstrated and encouraged. Peer / volunteer support will be encouraged and facilitated.

This will offer – Positive, expert support to manage health or social issues Lifestyle assessments and motivational coaching Guided self-help and learning Help to find other services, groups and support networks in the local area which can

improve physical and mental health Help to get involved with activities and groups

The aims will be that - Individuals will be supported to manage their mental health issues and long term

conditions, & offered support to maximise their independence & wellbeing People will have the opportunity to be linked to other opportunities for peer

mentoring, etc. in accordance with their individual needs Reduced use and improved targeting / productivity of clinical services

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h) Supported community groups and activities This element will have a community development rather than a service orientated approach. It will work closely with the Social Prescribing and Community Wellness Fund functions of the Wellness Service to bring people together in a targeted way, meet their identified needs and interests, and enable suitable opportunities to be developed. The opportunities will provide a person-centred process of engagement and progression which supports people with mental health needs to take up opportunities in the community, based around the life domains of arts and culture, employment, education, training, and vocational activities, and which support their transition from using mental health services to community based activities. These could take the forms of creative activities; music therapy; day services; support groups, social groups, etc.There will be close cooperation and partnership with a number of other community based services, including Museums and Art Galleries, as well as statutory provision such as Hillview Lodge, to deliver further opportunities and events.The opportunities should have a strong element of peer support, and the majority of opportunities should aim to become peer led. The aim is to build up community strength and resilience, and provide an outlet for social prescribing.In recognition of the need to maintain people’s mental health, and its potential impact on the stability of a group, there will be paid or volunteer / peer support providing a low level of support. This support, however, will have an emphasis on encouraging and enabling people in better manage their conditions, and any direct 1:1 support will be kept to a minimum. There may be exceptions, such as HeyHill, where people require a higher level of support to maintain their wellbeing, and who may be under the care programme approach, but the aim should still be to work towards the above.It is likely that there will be ‘taster sessions’, following which participants are enabled to decide their future direction. It is anticipated that, following taster sessions, people will fund the activities themselves. Part of the aim will be to address issues of affordability while ensuring quality and responding flexibly to the needs and interests of the group. The community development and specialist support functions are to be funded. They will be responsive to the mental health social and lifestyle needs of people living within Bath & NE Somerset and will build on the inherent strengths of the community. They will promote prevention, social inclusion, community networks, and the development of peer support and self-management, so that people are enabled to live personally meaningful lives.It is likely that many activities will have a ‘natural life’ and it is important in that event that they end well, with personal progression and development addressed.

This function will work within a recovery model to:• encourage greater social inclusion and community integration• improve service user’s confidence, self esteem, communication and social skills

to enable and empower service users to achieve their recovery goals• encourage and enable service users to develop skills and interests based on the

life domains • promote independence and choice

i) CAMHSThere will be integration with transition work via CAMHS, but this is currently under negotiation.

There will also be strong links to a Talking Therapies Service in addressing mental health needs for people in the community with a social care focus, and which will be integrated with a Primary Care Talking Therapies Service.

The pathway will adhere to and uphold the principles laid out in the Mental Health and Wellbeing Charter and the Carers Charter (appx 3a & 3b).

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5.3 Who the service is for:

The Pathway is for residents, or people who are registered with a GP, within the boundaries of Bath & North East Somerset (B&NES), who are experiencing the effects of serious mental illness, and who live in non-residential care accommodation

Exclusion criteria People who do not have a recognised mental health condition People with an organic mental illness (these services are already in place). People who have a primary diagnosis of alcohol and drug dependency People who have a primary diagnosis of learning disability. People who essentially require a home care or personal care service People under the age of 18, although there will be transition work in conjunction with

CAMHS (to be determined)

There are no exclusions to the service on the basis of: Age (18+ ) Disability Gender re-assignment Marriage and Civil Partnership Pregnancy and Maternity Race Religion and Belief Sex Sexual Orientation

The Provider will ensure the above are positively engaged.

6. Whole system relationships

The integrated Community Based Mental Health Pathway model will aim to provide simple, flexible and equitable access to all its functions.

People who experience mental ill health will invariably have a range of social care needs which can affect their mental health. The service will work within a multi-agency context to deliver joined up care and support.Key partnerships will include: the specialist mental health trust (Avon and Wiltshire Mental Health Partnership Trust) in-patient and integrated community teams; other health and social care practitioners and agencies e.g. Integrated Access Team; Housing Services; Rethink; Bath MIND; Wellness Service (eg Employment Development, Social Prescribing, Volunteer Hub etc); Talking Therapies, CAMHS and AMHP Service etc.

7. Interdependencies and other services

The Pathway will work with GPs, health professionals, other Providers and stakeholders as necessary to support mental wellbeing outcomes, eg Health & Social Care Practitioners - Avon & Wiltshire Mental Health Trust, Talking Therapies, Adult Reablement & Intermediate Care TeamIt will also work with

Referring organisations: providers of Universal opportunities, Providers of targeted lifestyle and wellbeing Providers of physical activity interventions.

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providers of further opportunities which may include, Substance misuse services, Sexual health services; Mental wellness services etc

The Pathway will also engage in local partnerships as appropriate.

8. Reporting and Review

The Pathway, through the Steering Group, will:

Compile quarterly reports of activity, detailing (list is not exhaustive): Performance measures of effectiveness ( outputs, quality and client outcomes –

see tables below) Analysis of measures taken to reduce barriers to interventions Evidence of delivery across B&NES in response to need, and against equalities

measures Ensure that these quarterly reports are provided to the local Prime Provider and

Commissioners.

Format and content of the reports to be agreed between the Provider(s) and the Council / CCG.

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Outcomes Framework for the Community Based Mental Health Pathway

The Service will work to achieve the following benefits for clients who engage -

improved mental and physical health improved wellbeing improved social networks and support mechanisms, and reduced social exclusion improved self-management of their conditions new skills and interests improved confidence and self-worth engagement with their community (e.g. volunteering) improved employment opportunities healthier lifestyle reduction in GP Practice and clinical services attendance, and residential and

hospital care

Providers will work together to achieve the following –

Peop

le s

ay th

at …

Identity and respect

I am treated as a whole person and care is tailored to me as an individual

I am treated respectfully by all

Optimism and resilience

All those involved in my care had a positive approach that encourages and motivates me

I am supported to help me deal with the effects of other agencies, such as Department of Work and Pensions

TimelinessI am able to access the advice, support or treatment I need when I need it

If things are not going well again, I know what to do and am able to access the support needed quickly

Information, choice and control

I was well informed about the choices of treatment and support available to me when I first asked for help

I feel in control of the choices I make

I have the information I need and am able to make choices about:

- professional and peer workers I can access- medication and side effects- wider networks and other opportunities and support available to me

Service co-ordination

I feel supported while moving between services and that my aims and goals are known to all those I am in contact with

Care qualityI have confidence in all the services I have been in contact with

I feel safe and supported

I feel able and am encouraged to give feedback on the services I am in contact with

Car

ers Carer

involvement and support

My carers feel informed and involved throughout

My carers have access to support and training as appropriate

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Soci

al O

utco

mes

Meaningful activities

I participate in activities that have meaning to me

- Community participation and leisure- Social networks- Education and training- Volunteering- Employment

Finance and housing

My income / debt becomes manageable

On leaving services, I am able to live independently

Hea

lth o

utco

mes

Mental health I have sustained improvement in mental wellbeing and mental health functioning’

Physical health

In B&NES community

- life expectancy for those with mental health problems matches that of the general population

- those with mental health problems have increased number of years in good physical health

- markers of good health in those with mental health problems matches that of the general population: includes smoking levels, obesity, cholesterol, blood glucose levels

Service utilisation

In B&NES community, those with mental health problems have

- reduced hospital admissions (and re-admissions) and length of stay- reduced referrals (and re-referrals) to secondary care community services

Mortality and health inequalities

In B&NES community , there is

- reduced variation in outcomes in relation to ethnicity, disability, age, gender or faith- reduced mortality from self harm / suicide

The outcomes for the Service link to:- Social Care Domain 1: Enhancing Quality of Life for People with Care and Support

Needs. Social Care Domain 2: Delaying and Reducing the Need for Care and Support. Social Care Domain 3: Ensuring People have a Positive Experience of Care and

Support. Social Care Domain 4: Safeguarding People whose Circumstances make them

Vulnerable and Protecting Them from Avoidable Harm

NHS Outcomes FrameworkDomain 2: enhancing quality of life for people with long term conditions

Guidance for Commissioning Public Mental Health ServicesObjective 1: More people will have good mental healthObjective 3: More people with mental health problems will have good physical health

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Exemplar Service Performance measures

Activity - How much did we do

Quality - How well did we do it

Client outcomes – Is anyone better off

1) Steering GroupMarketing and communicationNumber and range of awareness raising activities delivered in support of implementation of Integrated Model

Materials and communications are culturally relevant

Assurance that details of both commissioned and non-commissioned opportunities are kept up-to-date and all materials used (electronic or paper based) are maintained effectively.

Improved awareness amongst professionals and referring organisations

Improved awareness of community based opportunities in the target community

Increased wellbeing literacy

Capacity buildingNumber of training courses and number attended

Number and scope of co-developed community based solutions which work in an integrated way

High level of participant satisfaction levels with training opportunities

High level of participant satisfaction with community opportunities which meet their needs

Staff and volunteers self report of increased knowledge and skills following training

Improved quality assurance across the Pathway

Improved numbers and range of community based opportunities which enable people to –- Self manage their conditions- Improve their mental wellbeing- Improve their physical wellbeing- Live independently in the community

Improved information sharing to benefit clients

Improved sharing of resources across the pathway

ReferralsCollated numbers and sources of referrals

Response times from referral and waiting times to access opportunities & services

Drop-out rate & number of inappropriate referrals

Service user satisfaction is maintained >80%

Improved take-up of community based opportunities and services

Implementation of a common Outcomes Framework across all providers evidencing recovery outcomes

Improved wellbeing opportunities

More people with long term conditions will feel that their support is well co-ordinated & based on their personal needs & preferences, and that they are supported to manage their own

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Activity - How much did we do

Quality - How well did we do it

Client outcomes – Is anyone better off

Collated progression routes

Support demonstrates a good collaborative approach

health and social care in the community where appropriate

Improved self management and wellbeing

2) Supported Living & Floating SupportNumber of clients starting support, showing referral route

Number of clients leaving the support, showing progression routes

Number of safeguarding alerts

Number and % of clients reporting improved self-management, self-confidence and self esteem

Number and % of clients having their needs met, achieving rehabilitation, able to meet their independent living needs / obtaining their own housing

Number and % of people using a Recovery / Outcomes Star or similar tool, and setting a recovery and action plan

Number and % of clients where the placemnent was unsuitable, showing rationale and onward route

Improved client wellbeing measures

Improved numbers of people with mental health issues are able to live independently in the community

Improved service user and carer experience

Improved flow through mental health services for service users and with better and communication

Improved service user involvement in service delivery

Improved numbers of clients having their needs met

3) Mental Health Reablement Beds (Wellbeing House)Number of referrals with details of referring agency

Geographic location of referrals

Number of clients who leave the service early

Number of repeat referrals

Client satisfaction is maintained >80%

Satisfaction of referring agency is maintained >80% (ie has it made a difference)

Numbers and range of activities taking place

Reduced numbers of people in emotional distress being held in a place of safety

Reduced numbers of people in emotional distress with no physical health needs being seen in A&E

Reduced entry into crisis beds or hospital

Clients have improved take up of community based opportunities

Clients are better able to self-manage their

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Activity - How much did we do

Quality - How well did we do it

Client outcomes – Is anyone better off

Progression routes identified

Client satisfaction feedback on activities

Numbers and % of clients who, as a result of the service, are assumed to have avoided hospital, A&E, or crisis support

mental health problems and able to live independently in the community

4) Mental Health ReablementNumber of referrals with details of referring agency

Number of referrals for people being discharged from an in-patient unit or residential care

Number of people having a repeat referral over a period of one year

Number of clients leaving the service before their identified needs are met, with reasons identified

Progression and onward routes identified

Number and % of clients reporting improved self-management, self-confidence and self esteem

Number and % of clients having their needs met, achieving rehabilitation and able to meet their independent living needs

Number and % of people using a Recovery / Outcomes Star or similar tool, and setting a recovery and action plan

Numbers and % of people supportedto live independently who might otherwise have been admitted tohospital.

Client satisfaction is maintained >80%

Increase in the number of people enabled to remain living at home and meeting their independent living needs

Improved support to enable people to leave hospital care

Increased opportunities for people to access a range of mainstream services

Reduced number of people entering secondary mental health care.

Reduced number of admissions to hospital or crisis support

Increased proportion of service users expressing that the service made a positive contribution to their situation.

5) Evening Cafes / Safe Havens (to be developed)Number of referrals with details of referring agency

Geographic location of referrals

Client satisfaction is maintained >80%

Satisfaction of referring agency is maintained >80% (ie has it made a

Reduced numbers of people in emotional distress being held in a place of safety

Reduced numbers of people in emotional distress with no physical health needs being seen in A&E

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Activity - How much did we do

Quality - How well did we do it

Client outcomes – Is anyone better off

Number of repeat referrals

Progression routes identified

difference)

Range of training delivered to staff and volunteers

Numbers and range of opportunities and services referred to

Client satisfaction feedback on signposted opportunities

Numbers and % of clients who, as a result of the service, are assumed to have avoided hospital, A&E, or crisis support

Reduced entry into crisis beds or hospital

Clients have improved take up of community based opportunities or services

Clients are better able to self-manage their mental health problems and able to live independently in the community

6) Supported Community OpportunitiesNumber & type of community groups supported. inc geographical area

Number & range of community activities started, and closed, inc area

Number of people attending supported community oppsDrop out rate of people attending opportunities

Number and range of peer led opportunities

Number of volunteers and peers recruited and trained, linked to type of opportunity

Number of volunteer hours

The number of participants who access education, training, employment and volunteering opportunities

The number of people receive appropriate training and progress to leading community groups

The number of groups who successfully apply to the Community wellness Fund

The number & % of people who successfully engage with the opportunity

Client satisfaction is maintained >80%

Satisfaction of referring agency is

More people are enabled to develop their creative ideas, enhance their self-esteem, and improve their health and well-being through engagement with socially inclusive creative activity.

More people are encouraged and provided with opportunities to support each other through spending meaningful time together in creative activities, and gaining a sense of purpose.

More activities are developed in response to needs expressed by regular monitoring of participantsAn increase in the peer and volunteer workforce supporting people in the target cohort to have improved mental wellbeing

More community and social groups are established in response to need and interests, offering opportunities for people to connect

A self reported increase in self esteem and self confidence among people attending activitiesWith more people reporting improved Personal development - life skills, employment, education attainment

A reduction of use in Community Mental Health

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Activity - How much did we do

Quality - How well did we do it

Client outcomes – Is anyone better off

supporting wellbeing or lifestyle interventions

Unmet demand

Number of 1:1 sessions held with rationale and issues dealt with.

Number of people meeting assessment criteria for PBs

maintained >80% (ie has it made a difference)

Numbers & % of people who report that they are better able to self-manage their mental health and wellbeing needs as a result of the opportunities.

Provider assurance that outreach work is carried out safely, in appropriate venues and in compliance with relevant lone working guidance

Services

An increase in the development of networks of social support, where people with lived experience of mental health problems become experts in self-care and provide peer support.

Improved collaborative working and shared plans and risk assessments

Transition Work –To be determined

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APPENDIX 1

Bridging the Gap Peer research on people with mental health issues accessing community activities and groups in Bath and NE Somerset Research and report prepared by peer researchers, Helen Bilton and Robyn Williams Executive Summary | November 2012

This report examines what helps and what hinders people affected by mental health issues when accessing groups and support which would improve their overall wellbeing. The research was carried out in Bath and NE Somerset by peer researchers who are clients and carers affected by mental health issues themselves and trained by St Mungo’s Bridges to Wellbeing project to do the research. These researchers were particularly keen to research access to peer support groups and statutory mental health services. However the findings and recommendations can be applied to any form of group or service.

Five New Hope peer researchers conducted 42 interviews for this project and we used the data from the interviews to come up with suggested solutions based around six ‘gaps’ where there was clear room for improvement and we could recommend bridges to better wellbeing.

1. Improving wellbeing in generalPeer researchers came up with a definition of wellbeing, which has been used throughout this research:Someone who has good wellbeing has a clear mind and feels safe, self-confident and happy. They have a sense of purpose and positive connections with other people and the community around them.The research showed that the wellbeing of the people interviewed fluctuated over time, and that different components of the definition changed for them, especially ‘confidence’ and connections with people in the community. We found that good wellbeing is possible to achieve for those living with mental health issues, however it is important to provide flexibility and continuity within groups and services in order to meet the needs of those with variable mental health.

Recommendations for bridging the wellbeing ‘gap’• Build your service on a base assumption that improving wellbeing for people living with

mental health issues and their supporters is both possible and worthwhile• Flexibility and continuity are the key to meeting the needs and aspirations of people who

have variable mental health. This is particularly important for people rejecting support because of their low mental health (see ‘Motivation’).

2. Connections between peoplePeople need connections. Our research shows that loneliness, isolation and disconnection exacerbate (even cause) mental health problems and impede wellbeing. We found that the people in our study highly valued their social networks and most had good support from either family or friends. The top answer to ‘What helps the most’ was basically ‘connections with other people’.Groups and activities providing a sense of purpose, encouraging positive connections, and encouraging service user involvement have many benefits both for the success of the group and individual wellbeing. Groups which allow people with similar mental health experiences to spend time together were considered valuable. Additionally, group members need to be in a friendly welcoming environment for a group to be successful.

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Recommendations on how to build connections between people• Create accessible group and activity opportunities for people that provide a sense of purpose, build confidence and reduce isolation• Develop opportunities for people with similar health or caring issues to spend meaningful time together and create peer support opportunities• Maximise client involvement, including in service design, review and implementation• Train staff and volunteers to model friendly, welcoming behaviour from the top-down. Even the tiniest of gestures can make a big difference to someone struggling with low wellbeing.

3. Statutory servicesWe looked at the support received from professionals because this was seen by our peer researchers and interviewees as a key factor in underpinning improved wellbeing. Respondents showed that if statutory services are not providing appropriate support, people feel ‘stuck’ and unable to improve their wellbeing. Our respondents said they needed the bedrock of professional mental health support to rely on and reported that they often found it was not as reliable as they would like. Our respondents were keen to get involved with influencing the development of statutory services. People’s support networks consist of a mix of statutory and informal support networks (family and friends). It is important for statutory services and other support networks to work together to optimise support for the individual.Discharge was highlighted as a particularly crucial point, as was crisis support. We suggest that there is further research to be done in investigating the issues around how much and what type of support people need compared to what they may perceive themselves to need.

Recommendations for statutory services• Develop closer working relationships between statutory mental health services and community organisations • People’s individual support networks consist of a mix of statutory and informal. Statutory services need to work as closely as possible with the individual’s friends and family as they will be there when statutory services are not• Statutory services need to request and utilise feedback from current and former services users via voluntary organisations • Discharge is a particularly critical point where support is needed and statutory services need to ensure people don’t feel ‘abandoned’. Peer support could be especially valuable here• Promote positive stories/outcomes you’ve had.

For all services, (especially) including informal groups• Pay attention to exit strategies and don’t allow people to end up feeling abandoned. Understanding and information will go a long way.

4. MotivationThere is a known link between mental health issues and low motivation. There is also a body of evidence to lead us to the key conclusion that ‘doing’ is important and motivation can be raised as a result of ‘doing’ rather than the other way around. Therefore making services and groups attractive and simple to access will help to improve motivation.Groups and services should be flexible and consistent, allowing for fluctuating wellbeing and should offer a sense of purpose that complements people’s interests. Respondents reported a desire to ‘give something back’ so offering voluntary opportunities and chances to get involved which are mindful of members’ needs could help to improve the success of a group or service as well as helping to improve the wellbeing of the person involved.

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Recommendations to do with motivation, for service providers• Flexible services, as recommended under the ‘wellbeing’ heading will accommodate people’s fluctuating motivation• Design services to overcome low motivation – attractive, based around people’s aspirations, easy to use. People will be attracted above all by the ‘purpose’ of the group but may be put off by barriers – use the recommendations of the next two sections to ensure your services are easy to use and known about• Develop involvement and volunteering opportunities for and with people affected by mental health issues. People want to get involved, so ensure your offer is as good as it can be.

5. Accessing servicesPeople interviewed were interested in a wide range of groups and activities, and most had some kind of activity that they wanted to do more of but felt that there were things stopping them. What is interesting here is that the top factors are not psychological but highly practical – cost and transport. However, confidence is also a key barrier and we discovered that the number one piece of support that people needed to attend a new group was someone to go with them.

Recommendations for service providers on breaking down the barriers to their services

• Cost. Think about ways you can reduce, offset or subsidise the cost of your activities to make it more manageable for people on low incomes. Look for any grants that may be available or offer income-based charging scales. Consider ways in which you could get people to connect with each other and share the costs, or let people pay ‘in kind’, by contributing in some other way• Transport. Consider how people will get to your group or activity, ensure there is access to good public transport, look into transport schemes in your area1 or organise lift sharing, this has the added benefit of putting people in contact with each other• Someone to go with. Half of our respondents said they’d like someone to accompany them the first time they attend a group. Where appropriate, allow people to bring a friend to the first session, or support them to find someone who can accompany them. Befriending schemes are useful in matching up people in need of support with someone who can help • Be welcoming. Train your staff and volunteers to be welcoming, friendly and non-judgemental and encourage them to explain the group clearly to newcomers

6. Finding out about servicesPeople found out about groups and activities in a number of different ways, with quite a large number of people who said they wouldn’t know where to look at all. Only a quarter of people used the Internet to find groups, and most people relied on getting information through word of mouth (from professional, groups, friends and family).Ensuring that information is available in a variety of different ways and places is important to increase the likelihood of it being found. Be aware that people with mental health issues may not proactively seek information, and be sure to include carers and professionals when promoting group/activity information.

Recommendations for informing people about services• People find out about groups and activities from other people. Ensure that information

about your service is available. Encourage word of mouth, perhaps by encouraging existing members to talk about their experiences at different places

• Do not rely exclusively on any one format, and particularly not the internet. Leaflets, noticeboards and local press are definitely useful but limited in their reach

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• People very frequently find out about groups and activities at the places they already attend, and from professionals involved in their support – target these

• Remember that people with mental health issues may not proactively seek out information at all, they may only react to information provided to them. Don’t always expect people to look for information about your service/group, get out there and deliver it to them

• Make sure your information reaches carers too.

ConclusionWe organised our findings into six ‘gaps’ and suggested ways to build bridges. But what we also found is that the gaps are all intertwined with each other. In particular, a strong theme which came out of the data is that overarching everything is the need to improve connections between people. There are many, many things we can and should be doing towards improving wellbeing for those affected by mental health issues in B&NES but building social relationships, networks and ties underpins anything else we might do.We found that people are motivated by interest, by enjoying something and by getting something out of it (including a very strong desire to ‘put something back’ into society). Offering opportunities for people to do things they are interested in, and building ways for as many people as possible to access them, is working towards improving wellbeing. In conclusion, we say that our study found sub-optimum wellbeing amongst our study population and identified many areas where changes could be made to achieve better wellbeing. We found that there is no magic silver bullet which will instantly transform people’s lives; instead a wide and deep ranging approach is needed, reaching across ‘service’ boundaries and being prepared to delve into profound topics such as loneliness, friendships, community, motivation, client involvement, what really works and what wellbeing actually means. Our evidence suggests that the benefits of making these changes and building the bridges to wellbeing would be immense.

St Mungo’s Bridges to Wellbeing works with people affected by mental health issues in Bath &NE Somerset. It enables people to have more independent and fulfilling lives by developing peer support networks and groups with volunteers. It also supports and collaborates with: –

New Hope a forum for those who have been affected by mental health issues (inclusive of clients, carers and supporters) who are involved in improving and setting up local groups and services, and reducing stigma surrounding mental health.

For more information please contact:St Mungo’s, Griffin House, 161 Hammersmith Road, London W6 8BSTel: 020 8762 5500 Fax: 020 8762 5501 Email: info@mungos.org www.mungos.orgRegistered Charity No. 1149085Company No. 8225808Housing Association No. LH0279

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Appendix 2Local and national evidence base (cont).

B&NES (Bath and North East Somerset) Mental Health ServicesMental health services in B&NES5 support disorders that are classified as psychotic, neurotic, or other, with each made up of a more refined sub-categorisation. Severe mental illness is defined as having a mental disorder diagnosed by a mental health professional with either very severe symptoms or recent psychiatric service use. The aims of the B&NES mental health services is to support and enable people who experience mental health problems to recover and lead personally satisfying, physically safe and socially meaningful lives as valued members of local communities.Stakeholder views of needs

Mental health services should:- Be socially inclusive helping people to remain at home, in work, in contact with

friends and family and taking part in personally meaningful activities - Provide clear and concise information about what is available - Be easily accessed

Cost-benefit evaluation of Artlift 2009-2012: summaryThe number of times a patient visits a GP after taking part in an arts intervention was observed to fall. The overall NHS health spend on patients was observed to reduce. Whilst no firm conclusion about the effects of art can be implied from this study, the results suggest that using an artist in primary care may well at least pay for itself. These effects are closely linked to proven improvements in wellbeing scores described by UoG evaluation (Dr Simon Opher GP, 9/12/2011)

Arts on Prescriptionwww.city-arts.org.ukIncreasingly, services aim to go beyond traditional clinical care and support individuals back into mainstream society. Recovery needs to be re-defined, encompassing a good quality of life such as an occupation, a decent place to live, friends and a social life. It is therefore even more important that the most vulnerable people in our society are supported and offered the tools to become more resilient and independent in order to seek out new opportunities for 'their future'.City Arts NottinghamUniversity of NottinghamJanuary 2011

5 B&NES PCT and B&NES Council, Draft mental health needs assessment. Publication Date: June 2008 Review Date: June 2009 http://www.banes.nhs.uk/SiteCollectionDocuments/About%20Us/Strategies%20and%20Plans/JSNA%202.Mental%20Health%200308.pdf

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A Survey of Arts and Wellbeing Practice within Bath & NE Somerset (September 2012)

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