What people want from rehabilitation services

1
What people want from rehabilitation services

• Paul Wolfson
• Debbie Mountain
• Imperial College
• 04.07.08

2
Which people?

• Service users
• Carers
• Professionals (including managers)

3
The background

• What do mental health services do and what are
  they for, Killaspy H et al (2005)
• The Forgotten need for Rehabilitation in Mental
  Health Services, Holloway F (2005)
• Rehabilitation services in the UK and Ireland,
  current status and future need, Mountain D,
  Killaspy H, Holloway F(2007)

4
Why ask the question?

• Rehabilitation services
• 40 of Mental Health spend
• Excluded from the NSF
• Evidence from surveys of uneven provision
• Piecemeal development
• Fair deal campaign
• No national strategy
• A good thing to do

5
How was it done?

• 11 Workshops lasting a little over an hour each
• service users only, carers only, managers only,
  mental health workers only, everybody together
• Avon, Edinburgh, Hampshire, SE London, North
  London
• Low secure, residential, day centre and community

6
What were they asked about rehabilitation
services?

• Purpose
• Values
• Functions
• Clients
• Facilities inpatient and community
• Skills

7
What did they say

• They could only speak from personal experience a
  strength and a limitation

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1. Purpose - service users

• Getting better
• Taking care of people
• A safe space
• Learning life skills
• Building on what people can do
• Moving on
• Get me out of here

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Purpose - carers

• Prepare for independent living
• Relearn skills
• A more peaceful setting than the acute wards
• Time to develop relationships

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Purpose - professionals

• Supporting people who have not been helped by
  mainstream services
• Preventing fragmentation of service delivery
• Developing long term strategies
• Improving health and life expectancy
• Reducing out of area placements
• Providing consistency and non abusive
  relationships

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2. Values and philosophy service users

• Happiness
• Peace of mind
• Communication
• Healing
• Safety
• Learning from other peoples experience
• Valuing people who provide hands on help

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Values and Philosophy Carers

• Integrity
• Respect for others
• Especially younger and older people
• And people with different needs or from different
  cultures
• Valuing carers and valuing communication with
  carers
• never giving up on people

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Values and philosophy - professionals

• Valuing clients experience of life
• Hope
• Therapeutic optimism rather than hope
• Openness to change
• Engagement and communication
• Valuing outcomes
• Valuing individuality
• Valuing participation in care
• Building on strengths
• Attunement sensitivity to what a client is
  ready for

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3. Client group who are we here for?

• People with complex needs, long histories aiming
  for long term changes
• Need for additional resource to make use of
  recovery approach
• - unable to use mainstream services
• - unable to leave acute wards
• - require more support in less secure settings
• Exclusion criteria?- unable to predict who would
  benefit

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Client group users views

• other services not worked
• for someone to get well
• getting on your feet again
• hygiene
• should have more say about coming to
  rehabilitation
• long term hopeless case ward

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Client group carers views

• Learning life skills
• Develop relationships and make social adjustments
• Role models of others who are improving

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4. What services should be provided?

• A. Direct services
• Long term planning
• - long term coping strategies including relapse
  prevention
• Wide range of therapeutic activities
• Wide range of settings/teams
• - Early Intervention Service, links with CMHT,
  community rehab team
• - secure provision- step down, safe place to
  take risks
• Good discharge planning
• - robust support
• - access to range of accommodation,
• - access to short term relapse facility

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• B. Consultation liaison role
• - overview of needs of those who have severe
  mental illnesses across the service
• - role in placement panel
• - links with housing, education, employment,
  training, volunteering

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What services should be provided? users views

• safe place
• sleep well
• get better
• general health, physical health
• individualise understanding
• aims can take many years, scared of future
• not to have a lot of challenges
• carry on as normal citizens as best as we can
• not feel excluded get served in local pub

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What services should be provided? carers view

• Range of activities
• Relieve distress, challenge but not overwhelm,
  listen, care and inspire
• Educate public to reduce stigma

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5. Facilities

• Good range of inpatient facilities
• -gender sensitive and specific
• -good links with community and contact with own
  community
• -domestic design, outside space
• -flexible to personalise, constraints of
  institutional operation to minimum
• Good range of community facilities

22
Facilities- users views

• Clean, should be nice
• Outings
• Medical facilities
• Access to internet
• Cooking facilities
• Leisure/work/learning opportunities

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Facilities carers views

• Safety of site
• Safety of relatives
• Visitors room
• Cooking for residents
• Social events
• Access to range of activities, art, music, gym
• groups

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6. Skills

• Multiprofessional team
• - core clinical team
• -range of skills including range of
  psychological approaches and therapies
• -range of therapies (music, art, drama)
• -recovery awareness of values, WRAP,
  narrative base, person centered
• Team work
• -learn from each other, including differing
  perspectives, reflective practice
• -share anxieties, acknowledge limitations
• -expect success but also able to tolerate slow
  progress, uncertainty

25
Skills- users views

• medical understanding, not causing unnecessary
  pain, kindness
• being able to talk
• good nursing staff

26
Skills carers views

• staff aware of where people are
• continuity of care
• not talking down to people
• knowing what a Klingon is

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Elements of a Comprehensive Rehabilitation
Service?

• The focus of the Rehabilitation Service will be
  individuals with severe mental illness and
  complex needs. The Rehabilitation Service will in
  particular provide treatment and care for people
  who are or might otherwise be high users of
  inpatient resources
• The Rehabilitation Service will comprise a
  managed functional network across the whole
  spectrum of care the network will consist of a
  wide range of resources that are used by the
  client group

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• Much of this service provision will be from the
  independent sector and shared with similar but
  less needy patient populations
• This will include
• - A SPECTRUM OF ACCOMMODATION OPTIONS -
  including supported housing and arrangements for
  intensive housing support
• - OPTIONS FOR VOCATIONAL TRAINING AND
• OCCUPATION
• - OPPORTUNITIES FOR SOCIAL INCLUSION
  including access to generic facilities and
  user-led services
• - ACCESS TO ADVOCACY AND PEER SUPPORT

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Elements of a Comprehensive Rehabilitation
Service?

• Specific Rehabilitation provision will include
• INPATIENT BEDS
• Open/Locked
• Short term/Long term
• Hospital based/Community based
• Specialist/Highly specialist
• NHS provided/Independently provided
• Local/Out-of-Area
• Forensic/Non-Forensic
• needs will vary markedly depending on local
  demography

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Elements of a Comprehensive Rehabilitation
Service?

• Specific Rehabilitation Provision will include
• COMMUNITY SERVICES
• A Community Rehabilitation Team to provide
• intensive community support to people with
  complex needs
• clinical management people in local placements
• an overview of all placed patients including
  direct work with providers on issues of service
  quality and move-on
• Early Intervention in Psychosis Team
• Assertive Outreach Team
• needs will vary markedly depending on local
  demography

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Acknowledgements

• Dr Jane Mounty
• Dr Helen Killaspy
• Dr Moira Ledger
• Dr Mike Metcalfe