Animate Consulting www.animateconsulting.co.uk
Community Renewal Moray Link Worker Evaluation
Contents Executive Summary.......................................................3 1 Introduction and background......................................6 2 Evaluation Methodology..............................................7 3 The Moray Mental Health Link Worker Service...........8 4 The Moray Mental Health Link Working Model............10 5 Evaluation Findings.......................................................14 6 Conclusions....................................................................36 Appendix........................................................................39
Community Renewal Moray Link Worker Evaluation 2
Executive Summary Community Renewal contracted Animate Consulting in August 2018 to undertake an evaluation of their Moray Mental Health Link Worker service, based in 13 GP practices across Moray. Community Renewal Trust is a social enterprise and registered Scottish charity that works to build community, improve quality of life and alleviate poverty by engaging individuals and families and supporting them to achieve sustainable employment, improved health and to become more involved in their community. The Mental Health Link Worker service it manages was commissioned and funded by Moray Health and Social Care Partnership through a sub-contract with Penumbra and the Moray Mental Health and Wellness Centre. It launched in April 2017 with 6 Mental Health Link Workers covering 13 GP practices. The development of the service followed on from two years of Modernising Primary Care pathfinding work which Community Renewal delivered for NHS Grampian and the Scottish Government including 2 Moray Practices, Elgin Community Surgery and Maryhill Health Centre. The Modernising Primary Care (MPC) work was based on the premise that the current context and paradigm of primary care runs into difficulties when people present with multiple life issues that are not easily “fixed” by a purely clinical intervention and require engagement with people in a different way. This work ties into the drive for public service reform and with policies and strategies including the Scottish Government’s 2020 Vision, the National Clinical Strategy, the Scottish Government’s interest in bridging the gap between GPs and local services, and with Realistic Medicine, the approach being promoted by the Chief Medical Officer to develop collaborative and de-medicalised approaches between medical staff and patients based on discussion and shared decision-making. Ultimately these developing strategies and actions all aim to position healthcare services better to cope with current characteristic challenges: depression, anxiety, dementia, obesity, drug use, alcohol dependency, diabetes, chronic illnesses and a wide range of mental health issues.
Using an holistic approach, the Modernising Primary Care and Mental Health Link Worker service, sought to test new ideas across two, interlinked, strands of activities: • Seeing the GP Practice as part of a wider community of health and building stronger connections to public health and third sector services. • Helping to disentangle patients’ medical and social problems using recovery-based techniques with a focus on finding the most appropriate support and activating latent potential for enhanced self-care. • Exploring alternatives to a fix-it paradigm for people for whom that paradigm isn’t working. • Consciously attempting to redress the power imbalance between healthcare workers and the people they support. Community Renewal recognizes that for most people Mental Health is impacted upon by life circumstances including family situations, work, stress, financial worries, housing, isolation, eroding resilience to deal with knocks and setbacks, etc. The process starts with taking time with the person to build a picture of what is going well for them and what is causing them concern or distress. The holistic process is a partnership between the MHLW and the person which starts by identifying areas in their life they would like to make progress on or change for the better. This results in an agreed prioritization where the person is encouraged to think about what changes they could make on their own, what changes could be supported by the MHLW and what changes could be supported by other support agencies. The process is a journey which puts the person in the driving seat and priorities are agreed on an ongoing basis. The purpose of the evaluation was to determine the satisfaction of those using the service and of GP Practice staff, to look for evidence of the progression of people using the Mental Health Link Worker service and evidence of the service being recovery-focused and to identify any areas for improvement. The evaluation focused on the impact of Community Renewal’s work on those using the service, and was therefore restricted in its scope. The evaluation methodology involved a review of project documents and reports, interviews with Community Renewal staff to determine the origins
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and ethos of the project, its operating context and model of working, 1 -1 interviews with diverse service users and with Mental Health Link Workers delivering the service, GPs and Practice Managers hosting the service, as well as with some of the agencies in the local community with some connection to the project. The evaluation found that the Moray Mental Health Link Worker service offers a highly effective form of primary care support. People who face challenges with predominantly social/psychosocial problems are able to take time to identify and take steps which can lead to them being able to make positive and long lasting changes in their lives. This is achieved via a very deliberate holistic model and is not linear. At the same time GPs have had access to an ‘in-the-practice’ referral route which not only offers their patients a better solution, but ensures that the time they spend with patients is more appropriately focused on medical issues. The evaluation found clear, and sometimes dramatic, examples of progression from service users’ starting points at referral, to significant changes in self-belief, positivity and confidence, a new stability in sometimes challenging situations and the prevention of deteriorating health conditions and personal circumstances thereby reducing the need for further GP practice support. Through the holistic process, service users better understand themselves, their situations and their capacity to make changes. In this way, the service was found to be more than a community connecting or signposting service, although these aspects were often present. Instead it offers a process of personal change, facilitated by the Mental Health Link Worker. The service was found to be highly recovery-focused as there were consistently clear examples of people feeling, and being, more in control of their lives, even if some of their symptoms persisted. The key components contributing to the project’s success are the time and safe space offered by the Mental Health Link Workers along with their empathic skills. These factors combine to offer service users a trusting relationship and options for small steps to make positive changes that encourage them to
consider new ways of living. Service users build emotional and mental strength through this process and emerge more empowered and better equipped to cope with current and future difficulties. The evaluation found overwhelmingly positive comments from practice managers and GPs on the value of the service to service users and to GP practices as a whole as they increased capacity to support people in a way which GPs are unable to do. Whilst the concept and operation of the Moray Mental Health Link Worker service is very well received, and the stakeholders we interviewed, are extremely keen that it remains in place, areas of improvement were also identified. Ensuring the future of the service was seen as the fundamental improvement needed to stabilise the service within its locality. Other areas for improvement were ensuring that Mental Health Link Workers are integrated as fully as possible as part of the staff teams within their respective GP practices (this happens more at some practices than others), and linked to this that practical issues around information sharing, internet access and the physical space required within GP practices do not hinder the service offered. Other improvements identified were the need to pay close attention to caseload sizes as high numbers can reduce the immediacy and level of support which service users receive from their Mental Health Link Worker. Furthermore, the need for the team of Mental Health Link Workers to have access to appropriate clinical supervision, given the often challenging personal and social issues which service users present with was highlighted. More widely, in terms of the service’s fit with the wider community, ensuring that Mental Health Link Workers have sufficient time to link fully with community fora and have access to a pool of community connectors, were seen as future ways of ensuring that the Mental Health Link Worker service is part of the most integrated and supportive environment which would best serve people’s healthcare needs. In conclusion the evaluation finds that Community Renewal’s Mental Health Link Worker service aligns strongly with national and local strategy and with current thinking around future healthcare systems because of the way that individuals become involved in decision-making around their own health with outcomes that lead to recovery and a more active role in determining their health and wellbeing.
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snapshot 1
Yvonne describes how self-employment ended overnight because of a lifethreatening medical emergency. She had had no hint of a health problem so everything was turned upside down without time to prepare. She went from working 16 hour days, to not working at all and soon experienced the knock-on effects of this sudden change; the loss of identity and focus affecting her mood, the loss of income creating money worries, the lack of contact with people through not working leading to her becoming isolated. She describes how her busy days narrowed to empty days to the point where she would watch neighbours going to work and see them coming home again at the end of the day, having done nothing herself in between. In fact she describes how she would sit on the couch, never getting beyond wearing her dressing gown and keeping the curtains closed. Yvonne describes it as “falling into a hole�. She knew that she needed help and made a GP appointment where she was told about the Mental Health Link Worker service and given a number she could phone. She didn’t do so immediately and in fact was at her lowest point when she chose to call. She talks of making that contact effectively being her last roll of the dice, without which Yvonne believes she would have chosen to end her life. However, even at her first meeting with a Mental Health Link Worker she immediately felt the benefit of the safe space offered, taking the chance to open up about what had been happening and how she felt. Looking back, she hugely appreciates the kindness she received from the start, and the chance to speak honestly, knowing that no-one else need hear what she said. Many months on, the result for Yvonne is that life now looks completely different. She feels better about herself, has joined some community-based activities and has re-engaged with some old interests which she had let slip. She is now confident enough to be out sharing this with others. She firmly believes her life was saved by the support she received.
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1 Introduction and background Bronze
In August 18, Community Renewal contracted Animate to conduct an evaluation of the Moray Mental Health Link Worker service, based in 13 GP practices across Moray.
In this model the emphasis is on light-touch signposting. The Link Workers operate within the existing paradigm of primary care and the main benefit of this model is reducing pressure on clinicians by sorting out single issues faced by patients such as housing, debt, benefits, etc. The bronze level of Link Worker can be carried out by people with no therapeutic training and can take on higher case loads.
Community Renewal Trust is a social enterprise and registered Scottish charity that works to build community, improve quality of life and alleviate poverty by engaging individuals and families and supporting them to achieve sustainable employment, improved health and to become more involved in their community. It was founded in 2003 with a desire to discover what it takes to lift neighbourhoods out of poverty. Since then they have been working in a wide range of deprived communities all across Scotland testing out holistic ways of empowering local residents to get involved in community activity and transform their communities. A key aspect of their work has been focusing on health outcomes as drivers for engagement and transformation. This has resulted in projects like Health Case Management, Peer Coaching and the Keep Well Outreach Service, in partnerships with other agencies including the NHS, Local Authorities, and Glasgow Association for Mental Health. Their commitment to transforming neighbourhoods includes partnership work with the Big Lottery Fund and The People’s Health Trust, through their Our Place and Local Conversations initiatives respectively, and bringing the WEL Programme (Wellness Enhancement Learning) into neighbourhoods and schools in partnership with The WEL Charity.
Silver This model focuses on a longer term more holistic journey co-designed by the Link Worker and the Patient. The emphasis is on significant and sustained change in life circumstances and wellbeing. Being more intensive, the case loads for this type of Link Working have to be smaller than the Bronze Model but the expectation is that this way of working will bring about lasting change where the person will eventually require less support from Primary Care. The Silver model requires Link Workers to be therapeutically trained in order to go deeper into hidden aspirations and barriers for the individual. In the 2013 evaluation by Dr Janine Thoulass of Community Renewal’s Edinburgh project cites the continuous therapeutic relationship as highlighted by most of the clients as being the key difference in supporting them achieve sustained improvement.1
Community Renewal describes itself as a learning organisation that focuses on what is required to deal with intractable problems and finds solutions that are scalable and sustainable. Its first iteration of the link worker role came in 2006 and it has spent the past 12 years developing an understanding of what works best for individuals as well as gaining an understanding of the levers of system change within Primary Care. To understand the different approaches to Link Working Community Renewal has developed a conceptual framework of three levels – Bronze, Silver and Gold.
Thoulass, J. Donnelly, U. Evaluation of Community Renewal’s Health Case Management Service in Craigmillar, Edinburgh 2013 1
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2 Evaluation Methodology
Gold The gold model of Link Worker takes a whole system approach as was highlighted in the Modernising Primary Care Work for NHS Grampian.2 This involves part of the Link Worker role mapping support services in a radius around the GP practice and the systematic relationship building between GP practice staff including front of house staff and these support agencies. The advantage of the gold model is that the whole practice begins to develop an alternative to the “fix-it” paradigm and the GP practice becomes part of a wider network of care. This model avoids the scenario where the more complex patients are dumped on the Link Worker, creating a bottle neck of capacity.
Our approach comprised: I. A review of project documents and interviews with key Community Renewal staff and others to learn about the origins and ethos of the project, the context and the operational model. II. Semi-structured 1 -1 interviews (face to face and telephone) with a range of people accessing the service in Moray. III. Semi-structured 1 -1 interviews (face to face and telephone) with Mental Health Link Workers delivering the service, GPs and Practice Managers hosting the service, and agencies to whom people were referred for support.
Community Renewal believes that it is unfortunate that large investment is unwittingly being made in the bronze model when for the same investment the silver or gold models are possible. The evaluation focuses on the impact of the Moray Mental Health Link Worker service - a “silver model”- on the patients accessing support, the workers delivering it, the GP practices and staff hosting the service and agencies to whom people were referred.
Modernising Primary Care: NHS Grampian and Community Renewal Report 2015-17
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3 The Moray Mental Health Link Worker Service The Mental Health Link Worker service was commissioned and funded by Moray Health and Social Care Partnership through Penumbra and the Moray Mental Health and Wellness Centre and launched in April 2017. It was initially expected to cover 6 GP practices but by the launch in April 2017 the 6 Mental Health Link Workers were active in 12 GP practices across Moray with the 13th and final practice in the area joining six months later.
Origins A range of Link Worker models have been promoted in different parts of Scotland and form part of Scottish Government’s Programme for Government. Work by Moray HSCP to refresh the mental health strategy through consultation and the development of a mental health hub proposal resulted in an identified a need for Mental Health Link Workers across the local authority to support under-pressure Primary Care services. The specific form of the Link Worker delivery model in Moray, and the enthusiasm for the implementation in Primary Care, came, in part, out of 2 years of Modernising Primary Care pathfinding work Community Renewal delivered for NHS Grampian, funded by the Scottish Government. The experimental project was called Deep Community Engagement.3
GPs who work at least eight sessions (i.e. 40 hours) per week – has fallen by 160, from 3,735 WTE GPs in 2013 to 3,575 in 2017. This figure represents a fall of over 4%. As a result, general practice services are over-stretched and this is having knock-on effects on patient care.4 The Christie Commission on the Future Delivery of Public Services5 established a clear direction for Public Service Reform in Scotland, leading to a fundamental shift in the relationship between people who are supported by Public Services and people who work within Public Services. Christie asserts that the best examples of Public Service Reform are where people, communities and front line staff are fully engaged in the designing and procuring of services; where there is a focus on the outcomes that matter to people, and on prevention and early intervention. A raft of polices and strategies are being pursued to address these issues, including: • T he Scottish Government’s 2020 Vision, which identifies an increased leadership role for GPs involving a range of community services and supports. • Health and Social Care integration, the new GP contract, the National Clinical Strategy - all with an emphasis on prevention, increased community based provision, person centred care and promoting selfmanagement. • The Scottish Government’s increasing support for Community Links Workers within primary care, bridging GPs and local services and supports in the community to address non-clinical needs (e.g. debt and employment) and connect patients to preventative support (e.g. healthy living activities). • Realistic Medicine, an approach being promoted by the Chief Medical Officer to address the issue of ‘over reach’ by doctors who ‘over treat’ their patients, preferring a collaborative and de-medicalised approach based on genuine discussion and shared decision-making with patients and learning how to implement this practically at a GP Practice level.
The project started from the premise that the current context and paradigm of primary care runs into difficulties when certain people present with multiple issues including psychosocial problems, as well as medical symptoms, and require us to engage people in a different way – looking at the root causes in their life that are impacting on their physical and mental health. The increasing numbers of older people who are living longer with more complex needs is placing a great strain on a primary care system which is facing significant workforce challenges. The GP work force is ageing and recruitment and retention is a major issue. Indeed, the Primary Care Workforce Survey, published in March 2018 by the Information Services Division of NHS Scotland (ISD), shows a fall in the number of whole time equivalent (WTE) GPs in Scotland. The number of estimated WTE GPs – those
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Modernising Primary Care: NHS Grampian and Community Renewal Report 2015-17
http://www.rcgp.org.uk/about-us/news/2018/march/primary-care-workforce-survey-highlights- need-for-strong-action-to-tackle-gp-workforce-shortage.aspx 4
https://beta.gov.scot/publications/commission-future-delivery-public-services
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Given this context, Community Renewal set out to explore a new way of working through the Deep Community Engagement initiative with 6 GP practices in Grampian, bringing with them their experience in asset based community development, community engagement and case management. Their search for new ways of engaging people has been heavily influenced by The Fifth Wave report6 and Nuka, the whole healthcare system developed by the South Central Foundation in Anchorage, Alaska and owned by the native Alaskan people. This highly relational system engages patients and the community, transforming primary care by shifting the power towards patients, redefining them as customer/owners and focusing on spiritual and emotional wellness alongside physical and mental health.
Implementing 3 core principles
1. Exploring alternatives to a “fix it” approach for these fifth wave epidemics. 2. Changing the balance of power between professionals and the people they serve. 3. Creating conditions for patients to shape their own health.
Testing new ideas across two, interlinked, strands of activities
• Seeing the GP Practice as part of a wider community of health and building stronger connections to public health and third sector services. • Helping to disentangle patients’ medical and social problems with a focus on finding the most appropriate support and activating self-care.
The Fifth Wave describes the British healthcare system over the past 200 years in terms of 4 waves of healthcare, each building on and succeeding the previous wave as it begins to exhibit diminishing returns. Thus (i) civic works and sanitation, (ii) emergence of medicine as a science, (iii) social change leading to the welfare state, and (iv) efforts to combat disease risk factors, are now ‘calling forth’ a 5th wave to tackle our modern epidemics: depression, anxiety, dementia, obesity, drug use, alcohol dependency, diabetes, chronic illnesses and a wide range of mental health issues.
Alternative to a fix-it model
They reasoned that if increasing numbers of people are living with more than one long term condition, their needs are inevitably more complex and less likely to be ‘fixed’ by the traditional three options offered by GPs – prescribe, refer, or do nothing. Through Deep Community Engagement they set out to explore through dialogue and conversation with staff and patients how community engagement could contribute to meeting the challenges facing primary care by:
GP practice becomes a hub in a wider community of care
6
Supporting patients take responsibility for own self-care
Lyon, A. The Fifth Wave. Edinburgh: Scottish Council Foundation, 2003
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The project involved: • Mapping the range of services, supports and networks in the wider community and building relationships between them and the GP practices. • Listening and talking to patients in waiting rooms, and in small groups, about their needs and ideas for getting the best out of GP services in collaboration with others. • Working with front of house staff to shift their focus from ‘gatekeeping’ to ‘community navigators’ sign posting people to effective support. • Developing a holistic assessment tool with GPs and other health professionals and training them to use it to support patients to develop their own self-care plans. • Nudging the culture away from the traditional ‘How can I help you?’ towards a ‘What would you like to get out of this session?’ approach. Key learning points included: • Mapping and connecting the GP practice to wider resources resulted in increased confidence in social prescribing. • Listening to patients enabled them to better understand the role and referral process between primary and secondary care and, for example, when to use community pharmacy services rather than the GP, and how the practice could be used as a learning and information/ exhibition space. • Front of house training in customer care and signposting helped practice staff to see how they could enable patients to get the right support inside and outwith the GP practice. • Clinicians having longer conversations with patients using the holistic assessment tool to learn more about their lives enhanced the quality of diagnosis. Having said this resistance to moving away from 10 minute appointments persists. • In the absence of a Community Link Worker role in a GP practice holistic assessments can be delivered by a range of clinical staff including GPs, Nurses and AHPs.
4 The Moray Mental Health Link Working Model Community Renewal have been testing and refining their link working and health case management model since 2006, and this project is the first time it has been used across a rural setting and with a focus on mental health.
Promoting recovery Community Renewal’s approach is predicated on a belief that consciously or subconsciously people know what they want and what will improve their quality of life. Sometimes they need help to disentangle the strands of medical and non-medical/social problems they are facing, which have caused them to become overwhelmed and that it is necessary to create a compassionate, safe, trust based relational space for that to happen. The approach the Mental Health Link Workers use to provide the service focuses on promoting recovery. It is based on compassionate listening and empowering people to undertake greater self-care and management. Improving the quality of life of those experiencing mental health problems through a strength based and recovery orientated approach to mental health services is a key strategic priority of the Moray HSCP mental health strategy, Good Mental Health for ALL in Moray 2016.7 The strategy describes recovery focused principles and practice as being at the heart of their mental health policy, and they want the approach to cross cut all other strategic priorities. Community Renewal believe that by focusing on creating an aspirational future, people can be supported to ‘reimagine themselves transformed’ and to move step by step and at their own pace towards making it a reality. It is generally agreed that there is no one definition of recovery and that essentially it means being able to live a good life, as defined by the person, with or without symptoms. The Moray Mental Health Link Worker role was delivered in line with Community Renewal’s 12 years’ experience of using a case management http://hscmoray.co.uk/our-strategies-and-plans.html Accessed 30.09.2018
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approach, where the Mental Health Link Worker supports patients to identify and set longer term wellbeing goals and then to begin their recovery journey, helping them to access services and supports as required.
• Conducting an holistic assessment conversation lasting at least one session using open and accessible questions, listening closely and taking brief notes.
GPs refer patients with mental health issues (including anxiety and low mood) to the Mental Health Link Worker service using a referral form. The Mental Health Link Worker then contacts the person by phone, email and/ or post to set up a first meeting.
• Building a picture with the person of their current circumstances in a systematic but open manner - covering family situation, social opportunities and networks, finance and debt, housing, jobs and ability to travel and get around. • Exploring their relationship to their own self-care, e.g. “Do you feel you get time to look after yourself ?”
The staff team of 6 Mental Health Link Workers recruited had previous experience of work in a range of different settings, including mental health, drugs and alcohol and Women’s Aid. All brought a high level of experience of 1:1 work and of the use of counselling skills. They were given additional training in the use of Community Renewal’s Holistic Assessment process, which includes:
• A forward looking, open ended discussion imagining the future e.g. ‘If your life had really improved in about 18 months’ time what would have changed?” The main issues and priorities that arise in the holistic assessment are scored and prioritized by the patients, who are then supported to disentangle medical and social issues and co-create an action plan that will help with their self-care. The process is illustrated below.
Referral by GP completed
Contacted
Met with mental health worker to discuss needs
Attended regular recovery-based support
Opted out
Moved on/ disengaged
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Kept in touch while ‘moving on’
snapshot 2
Eric talks of how an increasingly difficult and upsetting family situation led to him beginning to struggle. A close family member had received a serious health diagnosis but was living some distance away. Eric felt very cut off, unable to be there for the person in the way he wanted to, out of control of some key care decisions, and deeply saddened by unfolding events. As the situation developed beyond his reach, his mood lowered and he was signed off work for a short time. He talks of how everything became an effort and that looking back he is amazed that he can see that he even stopped taking care of himself in the midst of this, in a way that had never happened before. When he was signed off work, medication had been suggested and prescribed as an option but Eric felt uneasy about this solution, and he found the offer of the chance to talk and be supported through a Mental Health Link Worker to be more appealing. This proved to be the halting of a decline for Eric and turning point in how he coped with the situation which remained challenging. He valued the place where he could safely open up and talk through the upset and confusion he was experiencing. The first crucial intervention for him was a fresh insight and revelatory understanding of the emotions he felt from a book recommendation from the Mental Health Link Worker. This was followed by finding ways to express how he felt safely, both by writing them down as well as by speaking them out loud, finding, as suggested by the Mental Health Link Worker, the simple but effective technique that pets can be great listeners. Further supports included strategies of being able to remain private about personal matters, even when work colleagues asked, a way of creating a reminder to leave work on time and thereby regain some balance. Whilst the family situation remains distant and deteriorating, Eric feels better placed to cope and knows that he can return for further help from the Mental Health Link Worker to help keep him on track when things become tough.
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Flexible and open ended support The Fix-it Paradigm Community Renewal describe the fix it paradigm as the current status quo in medicine (and most other support services), where someone in need seeks the support of a professional who diagnoses the problem and seeks to mitigate or fix it for them. This relies on the professional providing the support themselves rather than empowering the individual. It also implies that problems are fixable – this has serious implications on expectations and wellbeing for the many people who are managing long-term/ chronic conditions or who have multiple issues that are more social or psychological. The case management approach used by the Mental Health Link Workers is in stark contrast to the fix-it paradigm.8 Community Renewal is hoping to share an alternative to the fix-it paradigm to be used as a more appropriate tool when the fix-it paradigm doesn’t work any longer. In the MPC programme Community Renewal trained 12 GPs, Nurses and AHPs in its holistic assessment as a way to become “unstuck” with patients where little or no progress was being made.9 The Mental Health Link Workers are well informed about the external support available in the community through public service and third sector services. They look to link people into these forms of community support, not simply by signposting but helping them to engage and make the most out of the support available.
The number of appointments varies, sometimes only one being needed. But for many people with more complex needs it can take time for them to express and understand them, and to choose to self-care differently. The Mental Health Link Workers provide ongoing case management support, meeting people for 1 hour face to face sessions as necessary (weekly, fortnightly, monthly). Progress is reviewed periodically, and people begin to ‘move on’ accessing the service less frequently, disengaging as they feel more able to self-care. Some disengage without saying why, with others a different agency takes the lead support role, while yet others chose to stay in touch rather than attend sessions. The door always remains open, and people can return should they feel the need. The Mental Health Link Workers have responsibility for case management in two or in one case three practice, given the practices vary greatly in size and location. The practices have different levels of additional primary care supports available to patients, for example in Lossiemouth there is access to a CPN and Psychologist delivering CBT, enabling the Mental Health Link Worker to be part of a ‘mini mental health team’. In smaller rural practices the Mental Health Link Worker is the only addition to the medical team beyond the psychological therapist and works in a more solitary capacity.
Modernising Primary Care op.cit., p19
8
9
Modernising Primary Care op.cit.
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5 Evaluation Findings
Summary
5.1 Quantitative data The data is extracted from the Annual Report 2017-18 and the 5th Quarter Report (April – June 2018) – see Appendix) The Moray Mental Health LW service headline numbers: 537 people seen
Quarters 1-5
4261 referrals to 377 external support services
The data shows a steady rise in the number of people being seen over the year, with a bit of drop off in the 5th quarter. This is reflected in the rising number of people receiving regular support (case management) and the corresponding increasing caseloads of the Mental Health Link Workers, rising from an average of 22 to 25 people receiving more intensive support in the 5th quarter. The number of people keeping in touch while moving on appears to be steady. It is interesting to note that the highest number of referrals are to other organisations and supports that also focus on mental health and wellbeing, with an emphasis on accessing peer support. The cancellation and DNA rates remain steady. To mitigate the impact of this, people cancelling appointments are offered another appointment and the cancelled slot is filled with another patient or is used by the Mental Health Link Workers to research information for patients, contact patients by phone or for general administration.
3538 appointments
5.2 Qualitative interviews in Moray:
Snapshot of Quarter 5
+ 25 people per MHLW receiving more intensive support
+ 154 people receiving regular support
91 people keeping in touch while moving on
• Patients – face to face interviews (20) and telephone interviews (2) and sight of Progress Reports (13). The patients represented 12 of the 13 practices served • Mental Health Link Workers – face to face interviews (6) • Practice Managers (4) • GPs (4) and 1 written statement • Other agencies (2) In total staff from 9 practices were engaged. We have used case studies (Snapshots) to present the impact of the service on the patients we interviewed. Names are changed and key details protected to ensure confidentiality.
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The evaluation looked at the factors which led to people being referred to the Mental Health Link Worker service. Service users described hugely varied personal stories which included employment difficulties (overworking, stressful workload or staffing issues), sudden changes in health, bereavement, caring responsibilities, isolation after relocating, financial concerns, relationship breakdown, or domestic violence amongst other factors. Mental Health Link Workers noted that some service users had presented with a long history of depression or anxiety, and subsequently revealed issues they had experienced many years previously, while others were encountering difficulties in coping for the first time.
“
I was like a tramp. I’d let myself go. I couldn’t speak without crying. I was ready to throw the towel in. I was in a right state. I wanted the ground to open up and swallow me. I found it hard to be who I’d become. My daughter said, “My mum’s broken.” I was in a dark place, constantly crying. Nothing got me to a good place. I was going about in a confused state. My way out was to get drunk. I was very isolated and becoming more of a recluse. I was a hermit in the house. I wasn’t going out. I wasn’t seeing anybody. I’d put my coat on and then think ‘I’m not going to do this’.”
A Practice Manager’s view of this was of the high percentage of GP consultations that involved “social aspects” which was unsustainable. GPs highlighted how the Mental Health Link Worker service had provided another option in this situation, describing the patients they referred as ones who were “a challenge in life that they are struggling to meet themselves” and people for whom making small changes or being goal-focused might “put them on a better track and lift their mood.”
My son said I was reduced to a shadow of my former self.
In the evaluation, service users described their lives at the point of referral as being seriously affected. This could result in people struggling to function at work, to maintain stable family situations, or in the most extreme situations service users described themselves withdrawing to the extent of not interacting with anyone or wishing to end their lives.
I was pretty much in a bad place with different things over a long period of time...I wasn’t coping, I couldn’t do it anymore. I admitted defeat and went to the doctor.
I was in a big hole and deeper and deeper depression, spiralling downwards. I was miserable, depressed, reclusive, spending all day in my dressing gown, curtains closed. I wouldn’t eat. I was minutes off suicide. I was signed off work. I didn’t bother with make-up or even putting my watch on. I was so incredibly low.
In summary, we found that at the point of referral, people described themselves experiencing low mood, a depressed state or feeling highly emotional. Many described how they were struggling to cope at home or work and noted that they had stopped taking care of themselves properly. Most were becoming increasingly isolated and felt out of control of their situation. They had lost hope and needed help.
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“
Starting points
snapshot 3
Robert was struggling. A bereavement, stress at work and a recent panic attack had left him feeling unable to cope. He knew that at best he was pretending he was ok particularly because of the public-facing and staffsupporting job role that he was in. He was struggling to cope and was signed off work, accepting the offer of support through a Mental Health Link Worker. He thought it might help to have a place where he could talk about work issues and get a different perspective. From the outset Robert found this a helpful environment, and describes how he has “never looked back” since. He feels that things were pointed out that were obvious but which he had become unable to see or process effectively. The result is that he feels he now has a completely different view of his job describing himself as being re-energised, to the point he is undertaking some career-related study with “a new passion”. Robert describes how he used the time with a Mental Health Link Worker as an “emotional check-in” but now that he is in a better place, he is able to do that more automatically himself. Some of the new understanding of his own emotional responses has been so helpful that he now views work situations differently, and feels better able to understand what the people he works are experiencing themselves in their own lives. As a result he therefore feels he has become a better manager, something he considers an important knock-on effect of him meeting with a Mental Health Link Worker. However, on a more fundamental level, Robert believes that were it not for the input of this service, he would be signed off work and be in need of additional medical support, a significant contrast to being a better manager who is actively taking steps to develop professionally in his chosen career.
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Referral and engagement
• New ways of looking at your situation are discussed. • New ideas of activities to try are offered as options. One patient said “it’s a safe haven to share worries. It’s filled with positive ideas for when life throws bumps.”
Some service users noted that they had been happy to be referred to the Mental Health Link Worker service because they knew they needed help and trusted the GP with the suggested action. Others were less sure about the idea of the Mental Health Link Worker service, sometimes because of a perceived stigma of engaging with a mental health support service, or because of more general uncertainty about what it might entail.
Mental Health Link Workers described that the common factor involved in support being effective was service users being willing to be open, and to want to make changes and move forward, however small each step might be. Mental Health Link Workers noted that not everyone referred to them is at this stage and that some people chose to engage with them some months after referral, or may not engage. “I wasn’t keen. The GP persuaded me.” “If I’d known what it was I probably wouldn’t have done it.” There was agreement from GPs, Practice Managers and Mental Health Link Workers that referrals had become more appropriate over the life of the project, as there had been a growing understanding of who was most likely to engage with and benefit from the service. Early on, the experience of Mental Health Link Workers had been of a more indiscriminate referral of people who simply were frequent users of the GP. Common themes expressed by service users of the experience of early meetings with Mental Health Link Workers were: • There was as much time as was needed. • It felt like a safe space. • You can be totally honest, in a way that is different from family or friends. • You are listened to. • There is kindness and compassion and someone who cares.
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Always positive, kind, gentle, so you relax and open your heart. [Mental Health Link Worker] changed my thinking. Even if you’re feeling down, there is something to make you feel uplifted. A gentle approach that makes you stop and appreciate. I said, “I’m frightened.” [Mental Health Link Worker] said “It’s ok to be frightened”. [Mental Health Link Worker] is very calming, reassuring. Let’s you take it at your own time. Practical support, appropriate, never patronising, my needs, empathetic, calming, non- judgemental, goes over and above, kind, compassionate, whatever problems there’s advice and they’ll say “When do you want to see me?” [Mental Health Link Worker] believed me. I trusted them because of this. [Mental Health Link Worker] came to the house on a few occasions. That was important to me at that time. Put me at ease straightaway…down to earth…nothing phases [Mental Health Link Worker] …so comfortable. Someone who can see in. You can’t see the wood for the trees. You’re all tangled up like spaghetti or wool - [Mental Health Link Worker] unravels it.
In summary, service users experienced empathy from meeting with a Mental Health Link Worker. They felt listened to, cared for, believed and understood in a kind yet constructive way.
Community Renewal Moray Link Worker Evaluation 17
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However, service users interviewed said their first impressions of the service once they met a Link Worker had been extremely positive as the staff involved were described as being approachable, interested, willing to listen, calming and kind.
The experience of meeting with or being listened to by the Mental Health Link Workers is described by service users in the following ways.
snapshot 4
Catriona described how she had suffered from depression for 20 years unable to “find a way out.” A repeat user of the GP practice, she was referred to the Mental Health Link Worker service after a change of medication had left her “going about in a confused state”. By this stage she said that she was extremely isolated and was “more of a recluse”. She wasn’t keen to meet with a Mental Health Link Worker but the GP persuaded her to do so. Initial help from the Mental Health Link Worker was practical and included form-filling linked to benefits; something which had caused difficulty for Catriona in the past and had been a trigger for more harmful behaviour - “I’d have been drinking out of frustration because nobody understood. I was unable to communicate”. Through further meetings with her Mental Health Link Worker, Catriona began to feel able to look at things in a different frame of mind. She was surprised to find mindfulness particularly helpful, initially learning techniques in groups she attended before beginning to use these independently – “I find myself doing it, taking a quiet time, looking for the good in things.” Her mental state is now completely different. She says that she has “remembered how to feel happy” whereas previously she notes that she would have overthought any problem and it would have “grown arms and legs”. Over the course of meeting with a Mental Health Link Worker Catriona says that she went from “not speaking to anyone” to “feeling part of society again.” She has been reunited with her son and granddaughter who she now sees most days. “It’s the best treatment I’ve had in 20 years” is how Catriona sums up the impact of the service on her life.
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The space offered by Mental Health Link Workers Service users’ positive experience of Mental Health Link Workers was largely built on being given time, a safe space, the chance to be listened to and a kind voice of reason. We found that the Mental Health Link Workers support service users to understand themselves better, see their overall situation in a new light and consider where change might be helpful. Whilst Mental Health Link Workers may also signpost people to activities or other forms of support, that is only one potential output of the process. We heard evidence from service users indicating that the following stages form the content of meeting with a Mental Health Link Worker: • I am asked some simple open questions about what has led me to this point and what my day or week looks and feels like. • I talk honestly and openly for as long as I want, crying if I need to. • I am listened to. I feel believed. I feel understood. • I trust the Mental Health Link Worker with all I have told them, often having never disclosed this information to anyone else. • I am encouraged to think about myself and how I might be kinder to myself. • I am encouraged to look at my situation in new ways, using simple techniques. • I am encouraged to think what small steps might be the first ways forward in my situation.
• I receive suggestions of options of activities and/or support in the local community to think about, most of which I was unaware of before. Some seem right, some don’t. It’s my decision whether I pursue them or not. The Mental Health Link Worker persists in looking for suitable options for me. • I may be offered the option to be accompanied to activities I would like to try but would find difficult on my own. • I am asked if it would help to meet again and how soon I would like to do that. • I am offered a future time to meet and subsequently find that the Mental Health Link Worker persists in offering me support if I do not immediately take it. • I hear a kind voice of reason throughout. In summary, service users described how the content of a meeting with a Mental Health Link Workers led them to experience a number of stages; being listened to and understood on a deeply personal level, reaching a new understanding of their current situation and feelings, and considering what changes might improve life and what goals might be set towards these. Many service users said that they felt very positive about the service after only their initial meeting with a Mental Health Link Worker, because they had experienced some of the stages above. Many described actions they had taken away immediately, with further meetings building on this.
Community Renewal Moray Link Worker Evaluation 19
snapshot 5
A serious degenerative back condition was the “start of a slippery slope” in Eve’s words. Pain, dizziness and an inability to drive meant that she could no longer continue her job. Eve says that she had always had a “negative voice” in her mind, but that “this came in when the door was open”. She notes the connection between chronic pain and mental ill health. Unable to work in the way she was familiar with, losing confidence and with an overwhelming sense of dread for the future, Eve became incapacitated. She would talk herself out of things before trying them, with the result that she was more and more isolated, affecting the family members she was living with. Eve says that after years of tolerating life in this way, she felt benefit “from the start” when she met a Mental Health Link Worker. The opportunity to talk about her situation in a safe space immediately took some weight off her shoulders, but she notes that it was two or three months down the line of meeting that she really started to “reap the benefits”. For Eve, writing things down in the form of pros and cons was a key technique. For her, this was a “light bulb moment” which has led to her being able to frame things in a different ways. The knock-on effect of this is that Eve finds herself able to “mute” the negative thoughts that she has, recognising that they are still there, but coping despite this. Feeling more willing to try things, Eve took on volunteering roles which then led to a part time work opportunity. 9 years on since she stopped working, Eve says that getting back to work “feels fantastic.”
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Between Mental Health Link Worker sessions Service users described how they felt and what they did as a result of time spent with Mental Health Link Workers. We found evidence of people reflecting on new ideas, seeing their situations in a different light and changing their behaviour. Service users told us about their feelings and responses to Mental Health Link Worker sessions, and based on this a summary of their typical thought processes between sessions is summarised below. We found that most service users experienced many of these stages repeatedly during the period of their support. • I think about the conversation I had with my Mental Health Link Worker. • Because of the nature of that conversation, I’ve continued to feel believed, understood and cared for, even after the session. It feels that someone cares about me and is looking out for me. • I’ve thought about some of the ideas we talked about for moving forward. • Some of the triggers or difficulties which have caused me problems before remain or reappear. They remain challenging, but I’m now more aware that there are ways in which I can begin to address them. • I can hear what the Mental Health Link Worker might say about the situations I’m experiencing or the feelings I’m having. It feels like I can tap into what they would say.*
• I try out some new tactics to address these difficulties. Some of these tactics work. That can make me feel better about myself, what I can do, and what more I might be able to do. • I feel new purpose in trying to move forward. • I feel a bit better about myself. I feel good about feeling a bit better. • I know I am going back to my Mental Health Link Worker talk about this further. That makes me feel more secure and less cut off from help. In summary, service users feel better equipped and more in control in various ways after meeting with a Mental Health Link Worker. They feel good about having been listened to, and they are buoyed by the empathetic experience and able to tap into this in their minds in between sessions. They are willing to try something new, even just a small technique, because of the trusted source of this. If these activities prove positive, they felt even better about themselves and encouraged to try more.
* Service users described this as having the Mental Health Link Worker “in my pocket”, “on my shoulder”, “in my ear” and “under my skin”. One service user said, “I think, ‘What would [Mental Health Link Worker] be saying to me now?’ I did that recently – it does work – I’m so glad.”
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snapshot 6
Bereavement led Clare to using the Mental Health Link Worker service. Her husband had died unexpectedly after a short illness. It was unforeseen and with little time to prepare. Soon after this Clare concluded that she wasn’t going to be able to get through the next stage on her own - “I felt I needed all the help I could get”. With a long wait to be able to access local bereavement support services, she sought help elsewhere and was referred to the Mental Health Link Worker service. For her, this was about a “need to get life back on track”. She soon found reassurance and understanding of her grief and as a result felt more in control of what she was going through. A further level of support from the Mental Health Link Worker offered suggestions of various local activities and groups which could provide social opportunities and interests. Clare said that she joined one of these “with reluctance” but sees it now as having been beneficial, getting her out, making her think about other people and getting some sense of achievement from completing the course she went on. On reflection, Clare doesn’t feel more confident necessarily but says that the gains for her are in strength and resilience. She feels that the support helped her concentrate on the issue she was facing and was very practical. She would describe it to others as getting support from “people who can help you get a grip.” She says that for her and for others this non-medical support helps people “move forward, get structure and not be a burden”. Given that her friends say that she has “come back to life” since getting support, she concludes “God knows where I’d be without it”. She now feels strongly enough about this form of support and signposting within the community to be so important as to begin to advocate about it
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We found high levels of evidence from service users of progress they believed they had made as a result of contact with, and ongoing case management support provided by, the Mental Health Link Workers. This ranged from people regaining confidence/independence, restarting former hobbies (from reading to model boat building), finding new interests, developing friendships, reducing or stopping medication, achieving better work/life balance, finding or maintaining employment, being involved in community activities, volunteering, feeling fitter and healthier, feeling more prepared to try or take up opportunities, feeling able to give to others and enjoying doing so, re-establishing relationships with family members, being more in control and being in a stronger position to cope with pre-existing or new difficulties. These quotes show that service users feel significantly better as a result of the case management support offered by Mental Health Link Workers; feeling more confident, more able to cope, more willing to integrate, able to look at life differently and in some cases no longer in need of medication. There is also evidence that people do not feel they are beyond having further difficulties, but they do feel better placed to deal with them. The scale of transformation is huge for some people. One service user who said they would be signed off work without Mental Health Link Worker support is now passionate about their job. Another service user who was completely isolated, confused and dependent on alcohol is now feeling good about himself, is regularly involved in community activities and is re-engaged with family. A further service user who had been forced out of work through ill health and had experienced serious isolation and extreme anxiety with no hope for the future, had just begun paid employment after a period of voluntary work. These are three of many examples. Others noted that whilst they continued to see their GP, this focused on medical matters, so they could see a clear distinction between the GP and Mental Health Link Worker roles in their lives.
percentages along with a summary of progress made and the activities and supports being accessed. Many of these show progress being made in terms of issues around personal and family relationships, financial and housing security and confidence and social isolation.
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I got myself in a better frame of mind. It helped me get tools to cope…ways of living so I can see light at the end of the tunnel… I’m smiling! I’m off anti-depressants now. [Mental Health Link Worker] saved my mental health; saved it from the brink. I was at -10 before [referring to mood]. Now I’m between 5 and 10. It’s helped me massively. I’m at a point where I can move on [from the service] and I’m in such a better place. Before I’d have thought ‘don’t bother’ [doing that activity]. You won’t be liked. You’ll be made fun of. You couldn’t do it. Now I think ‘I’m going to do it.’ [Mental Health Link Worker] really encouraged me to achieve my goals… to put myself out there. It changed my life around. I can deal with life a lot better. It’s the best treatment I’ve had in 20 years. I’m able to look at things in a different frame of mind. I’m a lot better than I was - a while ago I wouldn’t speak. I’m thinking more positive – cracking jokes. I’ll get there. I’ve got a recharge. The world’s not such a bad place. My wife says I’m a different person. It gave me the courage to approach my employers and drop my hours. I knew I was doing too many hours. It was nonsense. My confidence level is nearly back. I re-found old interests. It’s supported me to do my job. It’s impacted on me professionally and gives me a different outlook. I’m excited about my work. It’s unexpected to feel the way I feel about my job.
The Progress Reports, which we accessed during the field work in Moray, also presented clear evidence of progress. These set out goals from the holistic assessment, and latterly service users score themselves in a percentage on the level of the goal they have achieved. The Progress Reports show these growing Community Renewal Moray Link Worker Evaluation 23
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Progress through contact and ongoing case management support
snapshot 7
Patrick knew he was doing too many hours at work, but was struggling to do anything about it. The result was that he was feeling down and periodically anxious, in addition to being tired from overwork. A difficult family situation then compounded these issues and Patrick was coming close to handing in his notice as he felt he was not coping well. When he sought help, he wasn’t keen to take medication so he took the chance to meet with a Mental Health Link Worker.
The space offered by this helped Patrick to get some perspective on his situation. He began to see more clearly that most of his hours were spent working and that he was neglecting friends and had really lost any form of social life. In practical terms, sessions with the Mental Health Link Worker introduced some breathing exercises for relaxation, which Patrick still finds periodically useful when the need arises. Crucially, Patrick says the support he received gave him “the courage” to approach his employers to discuss reducing hours, which he was able to do. With extra time available, Patrick tried attending some groups where coping techniques were introduced and here he also found it helpful to see that his situation was not unique and that there were “other people in the same boat”. Patrick has now signed up for a wellbeing-focused course and is considering swimming as way of getting exercise and more routine in life now that he has more free hours. Patrick says he has moved a long way since he first met his Mental Health Link Worker; “Sometimes I would say nothing. I was down in the dumps – a bit negative”. But his experience was that the good humour and persistence of his Mental Health Link Worker helped him make important changes in life, building up his resilience to deal with future challenges, and giving a different outlook for the next stage of life.
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Service users described the elements that had helped them to move on. These included mindfulness techniques and relaxation, groups in the community, wellbeing courses, bereavement counselling, support to navigate financial or legal matters, re-engaging with hobbies or finding new ones, looking at life differently, or finding ways to express feelings in new ways amongst other things. The range described showed how Mental Health Link Workers make an effort to find what is right for each person and their individual situation. In many cases service users listed a number of varied activities and techniques suggested by the Mental Health Link Worker which they had found helpful in contributing to their progress. Each of these quotes show completely different techniques or supports which can prove meaningful for service users depending on their circumstances and which have emerged through the time given and suggestions offered as a result of the empathetic listening by a Mental Health Link Worker. In addition to the interviews undertaken the Progress Reports clearly show the range of steps being taken by service users, as the Case Wheels offer a visual of the communication and contact between service users and community activity or support, with or without the direct involvement of the Mental Health Link Workers as appropriate.
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Audible Books – I would never have done that. I wouldn’t have given it the time or wouldn’t have had the gumption. I wouldn’t have sat with my feet up before. I signed up for an evening art course. It’s give me extra confidence to find these things for myself. It’s helped me a little bit in every area of life. I had a lightbulb moment when I wrote stuff down…pros and cons…they got introduced early. It frames a situation in a different way. I signed up for emails about mindfulness – sets me up. Massively helps my mood. A diary of how I feel. I go to groups now – they take you out of yourself – someone said to me the other day “you’re really a barrel of laughs”. It was small steps of doing things. Like start by walking to the Post Office and being ready with ways to cope if I met someone from my family. Techniques, breathing exercises. I still use sometimes. I thought it would be a waste of time but it did help.
Community Renewal Moray Link Worker Evaluation 25
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What actually works
snapshot 8
A long term health condition had led to Elaine becoming isolated, depressed and anxious about new situations because she felt that people saw her as being different. Becoming increasingly cut off and lacking in confidence she felt that she had hit rock bottom and that she “wanted the ground to open up and swallow her up.” As she began home-based contact with a Mental Health Link Worker Elaine found that she started opening up, talking about the difficulties she was having, and found herself willing to listen to new perspectives and reach some acceptance of her health condition. Encouraged by the Mental Health Link Worker and accompanied outside for some initial visits, she began to ‘think forward’ more. As a result Elaine has now found the confidence and strength to go out a little more in public to the extent that she has started doing a volunteering placement each week. She loves this because she is able to help others as well as using skills that she has realised she can offer. She has also found this a good way to socialise with other people, some of whom share the types of difficulties she has. All of this marks a big step for Elaine as she had been struggling to leave the house. Whilst she still has days when she could feel that way she’s sees a big difference in herself, and family members have also commented on how much more she is willing to be outward looking.
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Given that service users reported that the Mental Health Link Worker service had supported them to make significant changes in their lives, we looked for further evidence of change by asking them where they believed they would now be, if they had not had access to the service. Service users believed that they would be more withdrawn, less engaged in community activities and generally be significantly less able, or completely unable to cope. More specifically, many commented on the difficulties they would have had in maintaining relationships, employment or in avoiding behaviour that harmed themselves or others. This included situations which would have seriously impacted on other people and potentially been costly in other care settings. The varied quotes suggest a common theme that service users believe they would be significantly more unwell, be less in control of their lives and be more dependent on other services, had it not been for the Mental Health Link Worker input they had experienced.
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I’d have been drinking out of frustration, unable to communicate. Sitting there depressed or I’d have packed my suitcase and gone away. Sectioned and an alcoholic. In all honesty…the place I was in when I was referred? I’d have ended up in hospital. I would be a burden on the NHS. I’d be less independent. I’d need more support. Six feet under. It had got to that stage. That’s what I wanted. If I wasn’t in control I’d be in jail. I wouldn’t be in work. I’d be signed off. I’d have struggled on. Then I would have crashed. Six feet under. I was minutes off suicide. I had everything set up.
Community Renewal Moray Link Worker Evaluation 27
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The alternative
snapshot 9
Linda describes herself as having been “bothered by bad depression and anxiety for years.” Whilst coping with that she was also caring for her father which took its toll emotionally and meant that she was more cut off from the outside world. When he died, Linda found that the final straw was emptying the family home and then selling it. This compounded her mental health issues and she “crumbled” becoming further cut off and “hiding away”.
She accepted the offer of support from a Mental Health Link Worker as she knew she wanted to get better, particularly for her role in looking after her son, and that somehow she had to find a way to help herself. She found these sessions both calming and reassuring and valued the fact that she could go at her own pace in them, without feeling that she was wasting anyone’s time. She felt able to follow some of the Mental Health Link Worker’s suggestions to get involved in local activities, and began to feel better about herself having reached a point where she “couldn’t understand why people like me.” Some months on she enjoys the company and support of a church-based group she has joined and does more around the house than she was managing before, feeling more purpose in life. She sees herself now as “thinking more positively” and is even back to “cracking jokes”, which she sees as a measure of how far she’s come. Whilst she notes that there are still days when she can feel overwhelmed, she can now “wait for it to pass” feeling more able to cope with down times. Her own hopeful summary of the future is, “I’ll get there.”
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Service users were asked about their ability to cope with future challenges and whether they believed themselves to be more in control of their situation than they had been before meeting with a Mental Health Link Worker. All of the evidence pointed to service users being better placed to deal with difficulties. The common theme in the quotes above is one of control; service users feeling that they have learned how to cope with the challenges they face, which had previously been overwhelming. Service users described how Mental Health Link Workers “persisted” in giving them options, acknowledging that they were never told what to do, but were more aware of techniques they could try, opportunities they could consider and action they could take to try to move forward at a time that suited them. One said, “There are suggestions which you can choose to try or not.” Progress Reports further endorse the evidence that service users have entered a process of recovery through the support of the Mental Health Link Worker service. These show what steps service users have taken, and feature examples and quotes which indicate how they are coping with life over the course of time.
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I’m more in control. I’m a lot better at saying ‘no’. Totally changed around. I can’t say I don’t have down days but I’m in a better place…more confidence in myself. I’m better equipped now. I would be doing half the things I’m doing. I’m more confident in organising things. [Link Worker] listened very carefully and we examined my options. [Link Worker] gave me control of what would happen to me. It put me in a position where I was in charge of my grieving process. It puts you in the right direction but leaves it up to you. Totally turned around the negative side of things. The dread is still there but it’s muted. I’m more able to deal with it…. The wheels were off but I’m sticking them back on. I now see that I have my emergency toolbox.* *Service user went on to describe various tools and techniques used to better understand grief, achieve work life balance, express feelings by writing them or speaking them out loud, and the voice of the Link Worker as an encouragement or rational viewpoint
Community Renewal Moray Link Worker Evaluation 29
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Looking ahead
snapshot 10
Hugh moved to the area encouraged by his family to do so, but a combination of housing difficulties, bereavements and the challenge of living in a new area left him struggling. Finding it difficult to cope, Hugh stopped looking after himself well to the extent of not eating properly. He reflects on this time saying that he became “unrecognisable” and was “like a tramp”. He was surprised to find himself in this position, having always been connected and supported by family or work in the past but now finding that he “couldn’t speak without crying”. Hugh accepted the offer of meeting with a Mental Health Link Worker and quickly found that he was able to open up in this environment and be understood in a way that was not proving possible with family. For him the value of this was having “somebody to pour your heart out to”. This support soon gave Hugh the encouragement to try to build a better life in his new location. Feeling able to take some first practical steps after sessions with a Mental Health Link Worker his comment is that “it’s snowballed from coming here”. He now enjoys taking part in social groups locally which provide a focus in his week. Attending these have then given him confidence as well as offering social contact with others which was sorely missing from life. Hugh says that the result of meeting with a Mental Health Link Worker is that he has “got out of the depression” and is now feeling more able to get up and do things. Somebody had recently commented “you’re really a barrel of laughs” which showed him that he had made a huge turnaround from his low point. Without the service Hugh thinks that he would either be sitting alone and depressed or would have “packed a suitcase and gone away.” As it is, he is increasingly integrated in his new home, feeling more connected and has started to make some plans for things he’ll do in the future.
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Evidence of satisfaction of people using the service That people are satisfied with the service is clearly evidenced throughout our report. Many of the service users expressed the fact that they wanted to take part in the evaluation because they felt so strongly about the transformation they had experienced and the importance of the service for others in the future who may face similar challenges. These sentiments are supported by testimonials in the annual report: “[Mental Health Link Worker] with her professionalism, knowledge, humour, practical suggestions and ideas (and limited time) has put me back on the rails, to a certain extent at least. [Mental Health Link Worker] has been coaxing me, successfully and unsuccessfully into things that I would not have considered as being right for me, for example, [Mental Health Link Worker] would suggest something, I would say no, but she always comes back with an alternative, I have learned that [Mental Health Link Worker] does not give up easily.”
Evidence of satisfaction of GP Practices and stakeholders GPs who have been referring to the Mental Health Link Worker service were also positive about what it was achieving for individuals. One noted, “Most [service users] have made good progress in whatever challenges they were facing”. Another talked of “a definite difference” in patients referred, some of them “taking care of themselves more” and others who they no longer saw or saw at a reduced frequency. A Practice Manager concurred highlighting the “impact on appointments made” for some people; “their regular contact with the surgery has diminished because they now have the right sort of help.” This service within the GP practice was seen as being of great benefit. One GP talked of the “real difference” made to their work and their patients, and said that having “been at this a fair while” they believe the current set up to be “the best experience of accessible primary care support in 20 years.” This statement referred to the combination of the Mental Health Link Worker service as well as in-practice access to other mental health services (CBT and CPN), but the GP noted the unique and complementary role of the Mental Health Link Worker service in this; “take away one strut of that then the others would be overwhelmed – if there is no holistic role then there would
be a knock-on effect on patients.” This “fully integrated holistic service” offered “a clear pathway if someone does need help and is ready to change” and was described as a “shining example of good practice.”
Further evidence of GP satisfaction is expressed in the Annual Report “[Mental Health Link Worker] is a very important link in empowering patients and build resilience and reduce reliance both on GPs and on medication. We just need more of her, it has been all positive. The project is excellent, and [Mental Health Link Worker] herself is a great addition to the team and I have had so much positive feedback about the help and support she has given to my patients, she is very valued by patients and by the practice. This model of working should be the way forward.” Practice Managers were also very positive about the Mental Health Link Worker service, one noting that it had been “a seamless addition to the service”. Another noted that it had “bedded in quickly – filling a gap that really needed to be filled” and that it was “clear what it does and who it’s for.” Another noted that they had experienced other pilots and initiatives coming and going over the years but that “this is one that has worked”.
Further evidence from a Practice Manager in the Annual Report “In a short period of time, our MH Link Worker quickly became a vital asset to both the Clinicians and the Patients of the Practice. She integrates with all members of our team playing a full part in our Practice meetings, audits etc. and her input is appreciated. Referring to her is easy and she quickly makes contact with the patients, many of whom are at crisis points in their lives, and supports and signposts them through this difficult period. As a practice we can clearly identify where her input has made a significant difference to the patients and helped avoid escalation of their mental health problems. Her skill set is unique and not available anywhere else in the locality.” The lack of an alternative without the Mental Health Link Worker service was also noted by GPs. The other options were described as being “quite criteria-led” and therefore restricted to patients who were “bad enough for secondary care.” Apart from that, GPs commented that their only other option was to “try anti-depressants and that’s it.” Therefore patients
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who didn’t become Mental Health Link Worker service users would have “muddled along as best they could until they scored higher” (i.e. until their condition had worsened). One Practice Manager said that without the Mental Health Link Worker service it would be “back to overload – these people attend frequently and don’t know where else to go.” Another said it would be “a huge step backwards if we lose it.” One noted why GPs can never fill this role saying “It’s difficult for GPs to be up to date about charities and financial organisations – this is always changing and there’s no one stop shop. It’s a big issue to keep up to date with that.”
There was widespread belief from service users that the Mental Health Link Workers offered something that GPs did not have time to do, or the local knowledge to assist with.
The Mental Health Link Worker service was not only popular in its current form, there was a commonly expressed view that it could be expanded. GPs all commented that additional time such as “another day a week” would be of great benefit. One Practice Manager said “If they wanted to give us another one [Mental Health Link Worker] that would be amazing – I’m sure we could create work.”
Two other agencies were interviewed as part of the evaluation. From their own direct experience of service users and of contact with GP practices and other health and social care agencies, they believed that the Mental Health Link Workers service provided a “vital contribution” to the resource available to support health and wellbeing. One commented, “When I’ve spoken to GPs they are very positive that this is working with the complexity of demand and are strongly in favour of it.”
The Mental Health Link Workers themselves all noted that their workload was sufficient that they could all spend more time in each of the practices they work in. Most commonly they said that they could be full time in a single practice, rather than part time in two.
Suggestions for improvements and opportunities for better integration with other local services The role of the service within GP practices: Most of the service users felt that the service fitted well within a GP service and were very appreciative of this form of support being available at their local practice. Some also noted that they were encouraged that their GP and the Mental Health Link Worker were in discussion behind the scenes with their permission to ensure the best care for them. There were some issues where service users had concerns about being visible as a ‘mental health service user’ because for example, other waiting patients could see them going to the Mental Health Link Worker’s room, although these comments were in the minority.
“GPs can’t take it all on.” “GPs are what they are – they’re not the ones who can deal with this.” Many noted that they continued to see their GP, but this was less frequent or there was a clearer line about medical matters.
Comments also reflected the fact that other agencies in the area showed that people were accessing services in the community because of the signposting role of the Mental Health Link Workers; “[Agencies] say people are coming through the door because of Link Workers.” There was also recognition that people linking with more community services had a direct improvement on their health; “It is helping people to connect into a more diverse range of services and support that helps them manage their conditions in different ways and stay well.” This is supported by feedback in the Annual Report: “tsiMORAY is …. really pleased to be aware that the link workers are proactively engaging with a range of third sector organisations, including Moray Wellbeing Hub and others, to connect people with peer support and opportunities to engage in a broader range of community activities, as well as helping signpost to essential services that provide advice on debt, housing, mental wellness, or drug and alcohol support.
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At Wednesday’s event ... [Mental Health Link Worker] chatted and networked with folk, helping everyone, including members of the public, community group representatives and the practice team feel comfortable to engage with each other. From the outset [Mental Health Link Worker] has taken an interest in what else is out there that might help the people that the practice team refer to him to work with. By taking part in the event [Mental Health Link Worker] demonstrated his willingness to continue building relationships with the community groups and the wider third sector, chatting with Keith’s Men’s Shed and helping the practice team consider how they could all help ensure that men who may be experiencing social isolation or loneliness for one reason or another are made aware of groups and activities that would be appealing, as well as friendly and welcoming to them.”
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snapshot 11
Pete was pretty happy, successfully achieving at a high level in work which along with family life kept him extremely busy. On reflection he says that he was “abnormally married to his job”. That meant that when some significant difficulties emerged at work eventually resulting in him leaving his post, he not only lost his main activity in life but what felt like his identity too. This proved to be a sudden and painful transition and despite having family around, Pete felt that no one close to him could really understand how deeply personal and difficult this change was. Pete felt lost and looking back can see that he was at risk of becoming dependent on alcohol as he sought comfort. Comments from family members on just how different they felt he had become, helped spur him on to take action. Pete met with a Mental Health Link Worker and found huge relief from the opportunity to relax in what he found to be a safe space. In this supportive environment he felt able to process and reassess this situation he was in and consider other opportunities for a fresh start, being helped to avoid his tendency to overthink things. He began to take more time for himself and in so doing learned to appreciate aspects of life which his focus on work had taken him away from. Overall he began to cope better with the change which had taken place and see a new way forward. Pete believes that without this help he could well have needed additional medical help as there was a danger of him deteriorating further. He now sees what had appeared to be a devastating loss for him as an “opportunity to break free”.
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Gary found that the fact that the Mental Health Link Worker didn’t know him was a good starting point. “They don’t know you, they don’t know your background or your family history” but he found that they “listen to what you say and suggest what to do” based on their knowledge and networking.
snapshot 12
A number of major life events combined over a few months to give Gary an extremely difficult time. Chronic pain, surgery, time off work, job loss, and a marriage split left him in a difficult place. “I’d lost myself,” he said, describing how that took him to a 10 minute GP appointment which became a 30 minute one instead. He emerged from this having been told he had stress, anxiety and depression for which he was prescribed medication and given an appointment with a Mental Health Link Worker.
Gary said that the sessions helped him to get himself in a better frame of mind in various ways. He got in touch with a chronic pain organisation which advised about some of his difficulties and he began attending wellbeing courses which provided him with techniques for better ways of living. The result of these was that Gary felt that he could “see light at the end of the tunnel” and on a practical level they helped him “get tools to cope.”
As Gary’s ability to cope improved and he was able to play a part in restoring some family relationships which had become difficult. He also felt inspired and confident enough to begin volunteering in a healthrelated role with his new found insight into his own condition. He now offers peer support to others facing some of the difficulties he himself has made significant progress in overcoming. “I became confident in talking about my medical problems with a smile on my face.”
Without his involvement with a Mental Health Link Worker, Gary says there is no way he would be contributing in this way and looking ahead to future opportunities, while he feels that home life and personal life would be much more difficult. Community Renewal Moray Link Worker Evaluation 35
6 Conclusions The Moray Mental Health Link Worker service offers a highly effective form of primary care support. It offers GPs a referral route for patients struggling with social problems, focusing GP time more clearly on medical issues, thereby reducing workload and offering those referred to become service users an opportunity for a transformative experience. The Mental Health Link Worker service encourages people referred to it, to identify and to take steps which can lead to positive changes in their lives, improving their ability to cope with the challenges they originally presented with, as well as leaving them more resilient for the future. Evidence of progression of people using the service There are clear examples of people progressing and making significant change in their lives, with potential for positive long term outcomes which can be directly attributed to the Mental Health Link Workers input, typically understanding and addressing the emotional and practical problems they faced and taking positive steps to move on. There are clear and sometimes dramatic differences between service users’ starting points at referral, to where they progress to, with evidence of people growing in self-belief, positivity and confidence, stabilising challenging situations, and increasing stability in a range of settings in their lives. A knock-on effect of this is that people who are more in control of their lives use their GP more appropriately for medical matters, so there is also progression in the sense of recognising that support can come from other services and other activities in the community. Furthermore, the Mental Health Link Worker service also succeeds in preventing people from being stuck in difficult situations or in these worsening with potentially serious knock-on effects. We conclude that the Mental Health Link Worker service reduces the amount of secondary care which would otherwise become necessary, and at the same time avoiding a potentially negative ripple effect on those in service users’ circle of relationships who themselves might have become in need of support.
Evidence that the model is recovery-focused It is abundantly clear that the Moray Mental Health Link Worker service successfully supports people to be more in control of their lives. This increase of control, of agency, is a key milestone on the road to recovery and perhaps the beginning of the self-belief necessary that will enable a person to live a good life with or without symptoms. Through a holistic process, service users understand themselves, their situations and their capacity to make changes for the better. The service is much more than connecting or signposting people to opportunities; it is a change process, facilitated by the Mental Health Link Worker. At the root of this is time, a safe space and the development of a trusting relationship that can encourage people to consider new ways of living. By introducing options for small steps to make positive changes, the Mental Health Link Worker service offers people choices along with the chance to be in control of these. Service users build emotional and mental strength through the process and emerge more empowered and better equipped to cope with current and future difficulties. Whilst they recognise that they may face future challenges, they also feel better placed to face these, and the Mental Health Link Worker service’s input assists in people being less fearful of life’s challenges because of a greater self-belief and renewed ability to cope. Evidence of support for the model from GPs and strategy development The principle of the project, the way that Mental Health Link Workers had fitted in with GP practice teams, and the content of their delivery were very positively regarded by GPs and Practice Managers and there was overwhelmingly positive comment on their impact on individuals and the practices’ accessible primary care options. Early teething problems on the suitability of referrals had been smoothed out as greater understanding of the service grew. Mental Health Link Workers have become valued members of staff teams within GP practices. GPs and Practice Managers not only see the benefits and feel the impacts of the Mental Health Link Worker service on workloads and on patients but believe that the service could be expanded. Any reduction of the service would be seen as a backward step that would impact negatively on patients and practices. The Mental Health Link Workers feel part of a team although the extent of this can
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vary from practice to practice, sometimes linked to size and the ease of communication and other times to the culture of the practice. Practicalities of difficulties accessing records, email and internet can lead to Mental Health Link Workers feeling more on the periphery, even if they know they are contributing to the overall work of the practice and to the benefit of the practice’s patients. In a wider context the Mental Health Link Worker service fits with the Scottish Government National Health and Wellbeing Outcomes (No.1 Healthier Living - People are able to look after and improve their own health and wellbeing, and live in good health for longer.) The local strategy (Strategic Plan 2016-2019 Moray Health and Social Care Partnership) presents a shared vision ‘to enable the people of Moray to lead independent, healthy and fulfilling lives in active and inclusive communities where everyone is valued, respected and supported to achieve their own goals.’ The project appears in keeping this and further in that plan there is a strong fit between the Mental Health Link Worker service and two of three quality ambitions: • ‘Beneficial partnerships between patients, families and those delivering care which respects individual needs and values, demonstrates compassion, continuity, clear communication and shared decision-making’ and • ‘The most appropriate treatments, interventions, support and services will be provided at the right time for everyone who will benefit and wasteful or harmful variations will be eradicated.’ It also evidences Realistic Medicine in practice by “ensuring decisions are made in partnership with people, helping them to make the choices about their treatment and care that are best for them as individuals. In terms of delivery, this evaluation finds the Mental Health Link Worker service fitting particularly closely with one of the Moray HSCP’s strategic outcomes: ‘to have supportive local communities which have the capacity to provide care and support with and for people. Growing community capacity that focuses on early intervention and a preventative approach will reduce
isolation and loneliness, enable participation, improve independence and wellbeing and delay escalation of dependency and need for more complex care and support. With the need to rethink how GP practices best serve their patients and with the potential changing nature of primary care support. The notion of ‘realistic medicine’, for example “ensuring decisions are made in partnership with people, helping them to make the choices about their treatment and care that are best for them as individuals” [Realistic Medicine Annual Report 2014-15 Scottish Government] is strongly evidenced by the stories told by service users taking part in this evaluation. They have taken control of their situations, and made choices which improve their health and their lives. Similarly the Mental Health Link Worker service provides evidence in support of the idea that “people presenting acutely unhappy to doctors are not best helped by anti-depressants... and an inappropriate prescription can cause problematic side effects and imply a diagnosis that is not accurate. The anti-depressant “treatment” may then prevent the patient seeking more effective solutions to their mood state such as exercise or socialisation.” The way in which the service is working can also can be considered to be a move away from the idea of going to the GP to be ‘fixed’. In the Mental Health Link Worker service we can see people coming to an understanding of the causal factors of their health difficulties, which they then find ways of addressing, with support and encouragement along the way. Further, the service being integrated into the GP practice invites a new understanding of discharge/disengagement/moving on. People are supported through holistic assessment, case management and signposting to shape the direction and decide the pace of their recovery. When they feel they are ready they move on from the support provided by the Mental Health Link Worker to other supports and opportunities, knowing they can come back at any time, as they would to the GP and other practice services.
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Improvements in the service Main comments from staff were to do with: • Caseload – whether the caseloads can be reduced even further. • Caseload – the need for increased (clinical) supervision due to the complexity of issues presented by service users. • Security of the service in the future – affecting morale – not affecting day to day delivery for service users, but in the mind of Mental Health Link Workers who believe in the service and want to be able to give out the right messages to service users about the future availability of the service. • The need to smooth out some practicalities relating to access to records, NHS email, internet access in order to avoid Mental Health Link Workers feeling on the periphery and having practical difficulties in doing some basic tasks for the benefit of the practice’s patients. It is worth noting that there have been significant challenges in negotiating aspects of the partnership working behind the scenes. Some of this has affected support structures for Mental Health Link Workers, such as available meeting space and training which was expected but not received. This had some negative effect on Mental Health Link Worker morale, however there is no evidence of this having affected the positive experience which service users have experienced or of Mental Health Link Workers’ perception or commitment to the service, which was found to be extremely high. All interviewees were asked about improvements which could be made to the Mental Health Link Worker Service. None of the comments made related to the concept or the content of what was being delivered. All of the responses given were around increasing the scale of the project so that GP practices had more Mental Health Link Worker hours, resolving practical issues around technology or staffing support to make the current service work more smoothly and safely, and increasing the time available for Mental Health Link Workers to disseminate experience and network locally. Specifically, comments included: • GPs, Practice Managers and Mental Health Link Workers themselves all noted that there was potential demand for practices to have
increased Mental Health Link Worker hours. Some suggested full time for each practice, others suggested that practices would benefit from an additional day a week. • In relation to the above point caseloads were felt by Mental Health Link Workers to be high and a challenge to manage. The weight of referrals meant that service users could sometimes wait longer to be seen than would be ideal. One Mental Health Link Worker noted that not meeting as frequently in early weeks could potentially lead to service users “regressing to previously learned behaviours”. • The complexity of issues presented by service users and the scale of difficulties they face, for example, one Mental Health Link Worker noted that half of the people they saw presented with a history of abuse. • The need to smooth out some practicalities relating to access to records, NHS email, internet access in order to avoid Mental Health Link Workers feeling on the periphery and having practical difficulties in doing some basic tasks for the benefit of the practice’s patients. • The value of Mental Health Link Workers who build up a high level of experience and local knowledge is sometimes lost from the wider social care community, as Mental Health Link Workers are busy with caseloads and unable to frequently attend local fora such as the Health and Wellbeing Forum. Increased participation here would build community capacity. • The need for more ‘community connector’ support to escort/ accompany people to services, freeing up time for the Mental Health Link Workers to focus on their therapeutic role. • The need to establish the security of the service in the future in order that Mental Health Link Workers’ morale is not affected and so that they can give out the right messages to service users about the future availability of the service. In conclusion the evaluation finds that the Mental Health Link Worker service aligns strongly with national and local strategy and with current thinking around future healthcare systems because of the way that individuals become involved in decision-making around their own health with outcomes that lead to recovery and a more active role in determining their health and wellbeing. It clearly evidences the value of support beyond signposting through a holistic therapeutic service which both stabilises lives and begins to impact on wider delivery of healthcare.
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Appendix Annual Returns (2107-18) Demographics of people using the service: Sex: Female: 58%, Male: 42% Over 60yrs Under 25yrs 14% 16%
• Among these people 98% undertook a full assessment with full three-monthly reviews. • 33% (158) of those who attended the service at least once kept in touch for some time as they were “moving on”. • 61% (291) of people using the service disengaged the service or completely “moved on” before 31 March 2018. • There was a total of 2907 appointments, meaning an average 6 per person using the service.
Caseload At the end March 2018, there were:
40 - 60yrs 34%
25 - 40yrs 36%
• 131 people receiving regular support (i.e. a caseload of 22 people more intensively supported per Mental Health Link Worker). • 98 people keeping in touch while they are “moving on” with less regular contact with Mental Health Link Worker.
Service level details Quarter Ethnicity: 100% of people using the service disclosing their ethnicity describe themselves as white
Over the full 12 months
• 667 people were referred to the service during 2017-18. • 99.9% (666) of these were contacted by a Mental Health Link Worker to try to set up an appointment. • 28% (189) of those referred opted out or did not respond the Mental Health Link Worker’s attempt to contact them. • 72% (478) of those referred met the Mental Health Link Worker face to face one to one at least once. • 11% (51) of people chose to have only one appointment. • 60% (402) of those referred received at least some regular support from the Mental Health Link Worker as part of their caseload.
1 2 3 4
No of appointments 428 835 855 789
No of cancellations and DNAs 108 213 222 172
Quarterly engagement figures Quarter 1 2 3 4
No of people seen 171 234 244 270
Community Renewal Moray Link Worker Evaluation 39
No of appointments 428 835 855 789
No of referrals and common referral destinations in 2017-18 In 2017-18 there were a total of 2907 appointments during which 1106 referrals were made to 160 external support services Organisation Penumbra Mental Health and Wellness Hub Penumbra POW WOW TSI Moray Services Breathing Space Citizens Advice Bureaux CRUSE Bereavement Services Steps for Stress Moray Council Income Maximisation JobCentre Plus or ESA Team Moray College Moray Council Housing Support Samaritans Moray Food Bank Moray Men’s Shed Advocacy Service Circles Library Services Moray Council Access Team Arrows North East Sensory Service
No of referrals 126 80 42 40 27 24 24 23 19 18 17 17 15 15 14 14 13 12 12
5th Quarter returns (to end June 2018)12 Demographics of people using the service Sex: Female: 68%, Male: 32% 18 - 29yrs 29%
70yrs and over 8%
50 - 69yrs 28%
29 - 49yrs 36%
Ethnicity: 100% of people using the service disclosing their ethnicity describe themselves as white
Number of people who in this quarter
• Attended their first session - 59 • Opted out of having a first session - 8 • Attended their first session then wanted regular sessions (joined caseload) - 56 • Were having regular sessions (part of caseload) - 154 • After a session opted to stop regular session and keep in touch instead (joined "moving on" caseload) - 13 • Were keeping in touch (part of moving on caseload) - 91 • After attending only a first session disengaged/moved on - 7 • After coming for regular sessions disengaged/moved on - 32 • After a period of keeping in touch ("moving on") disengaged/moved on -19
Community Renewal Moray Mental Health Link Workers Service – 5th Quarter Report
12
Community Renewal Moray Link Worker Evaluation 40
Caseload
Number of referrals and common destinations
At the end of the 5th quarter (end June 2018), the ongoing caseload size for the team of six mental health link workers was
In the 5th quarter there was a total of 631 appointments during which 670 referrals were made to 206 external support services
• 154 people receiving regular support i.e. a caseload of 25 people more intensively supported per Mental Health Link Worker). • 91 people keeping in touch while they are “moving on” with less regular contact with Mental Health Link Worker.
Service level details Quarter 5
No of appointments 631
No of cancellations and DNAs 191
Quarterly engagement figures Quarter 5
No of people seen 213
No of appointments 631
Organisation Penumbra Wellbeing/POW WOW/Peer Support Wellbeing Hub Recommended to patient self-referral at Penumbra 1-1 Breathing Space Samaritans TSI Moray Moray Council Income Maximisation Team Citizens Advice Bureaux Community Care NHS Online Prevent Suicide App
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No of referrals 63 55 37 19 14 12 11 10 10 10 10
If you would like to have a conversation with Community Renewal Trust with regard to Link Working please contact: Sheila Thomson, Link Work Service Manager at sheila.thomson@communityrenewal.org.uk or Paul McColgan, Community Renewal Trust CEO at paul@communityrenewal.org.uk www.communityrenewal.org.uk
Paul McColgan Community Renewal Trust CEO paul@communityrenewal.org.uk