East Renfrewshire Health and Social Care Partnership (HSCP) is committed to embedding peer support for recovery within statutory services - for individuals with harmful alcohol and / or drug use, and individuals with mental health issues. The HSCP wishes to achieve positive outcomes for people in recovery by exploring the extent and potential for people with lived experience to work alongside people in recovery and those with clinical experience.
The HSCP commissioned Penumbra to develop and deliver the Peer Support Service in East Renfrewshire. This was the first service in East Renfrewshire operating jointly across alcohol and drugs and mental health, recognising that peer support for recovery has the potential to be effective in both settings.
The East Renfrewshire Peer Service was launched in September 2020 and is delivered by a recovery team that includes an area manager, a support manager, and two whole time equivalent peer workers who work with mental health and addiction teams.
In 2020, East Renfrewshire HSCP commissioned Matter of Focus to act as evaluation partners for the programme. Matter of Focus has reviewed the evidence reflected here and authored this report. The aims of this evaluation partnership were as follows:
This summary report describes the findings of this evaluation in brief. As such, it presents data at a summary level for each heading in the outcome map. To examine findings at a more detailed stepping stone level please access the full report. The full report also includes additional information on our review of wider evidence, the context for this work, the methods we applied, the evidence sources included and how we assessed them.
What can we learn from the evidence base on peer support working?
A recovery-oriented practice is one that is holistic and assumes the position that an individual’s recovery is a journey or process rather than a clinical outcome. Employing people with lived experiences of recovery to work as peer support workers in support of other people in receipt of services has long been recognised as being a preferred means of realising recovery principles.
Peer support can be part of a range of recovery-oriented supports to "provide a multi-faceted support at all points; before, during, after and, where appropriate, instead of formal treatment and care services." As such, peer workers have been described as occupying a liminal space, somewhere between formal services and the people who use them.
 Bradstreet, S. (2006) ‘Harnessing the "Lived Experience": Formalising Peer Support Approaches to Promote Recovery’, Mental Health Review Journal, 11(2), pp. 33–37. doi: 10.1108/13619322200600019.
 Rome, A. (2019) Independent Review of the Glasgow Recovery Communities. Available at: https://www.glasgow.gov.uk/CHttpHandler.ashx?id=46671&p=0.
 Gillard, S. (2019) ‘Peer support in mental health services: where is the research taking us, and do we want to go there?’, Journal of Mental Health, 28(4), pp. 341–344. doi: 10.1080/09638237.2019.1608935.
The work shown in this report has been carried out using the Matter of Focus approach, a theory-based approach to outcome monitoring and evaluation, learning, and improvement that builds on contribution analysis. Steps included developing a theory of change for the project and an associated outcome map and then developing a plan to gather data to understand progress towards intended outcomes. Having reviewed what information was available we gathered additional data to allow us to complete an analysis against the agreed outcome map and its stepping stones. Our approach is described in more detail in the main report.
 Mayne, J. (2008) ‘Contribution analysis: an approach to exploring cause and effect’, Institutional Learning and Change Brief, pp. 1–4. Available at: https://www.betterevaluation.org/en/resources/guides/contribution_analysis/ilac_brief
This image shows a high-level summary of how well the project is progressing and how confident the team is in the evidence. The key shows how the colour coding works.
See the standards against which progress and evidence have been assessed.
The Peer Support Test of Change started in February 2020, when East Renfrewshire HSCP funded Penumbra to work with them to develop and deliver the service. The HSCP and Penumbra worked together to develop the service with support from Matter of Focus, funded as evaluation partner to the test of change. Involving stakeholders including a small number of people using mental health services in early conversation was an important part of the service design process and led, critically, to building a network of champions to raise awareness of the service and support referrals.
The service was launched in September 2020 and was immediately positively received, considered at full capacity by December 2020 with 25 people using the service. As the following graph shows 36 people had been referred to the service by February 2021 and 42 by June 2021, with a waiting list in operation from December. We reflect on the possible tensions between increasing referrals and referral routes into the project and the project's capacity later in this report and one consequence of the level of demand for the service has been an increase in waiting times.
Due to Covid-19 restrictions the service has primarily been delivered one-to-one to people over the phone, meaning the groupwork element was not developed as intended. The use of well developed and tested recovery tools such as the HOPE model supports meaningful conversations about people's needs, wellbeing and recovery. The decision to work with an expert, outside organisation to deliver the service is a key contextual factor and a key decision to understanding this work and forms a thread in our analysis.
Between September and February 2021 the two peer workers had delivered 196 appointments to 25 people. On average people have attended 12 appointments, with four people exiting the service. The peer workers have also run one group session on zoom focused on sleep, and plan to run more over time.
We saw evidence that peer workers work with people to:
It is clear from the evidence that the Peer Support Service provides a different kind of space for people to come and get support, compared with support from formal or statutory services, as the following excerpts from peer worker reflective logs show. The special qualities of this relationship form a narrative thread that runs across this pathway to impact.
The Peer Support Service is delivered by two peer workers. The first started taking referrals in September 2020 and the second in December 2020. Both peer workers have lived experience of mental health issues and recovery, which they bring to their professional role as peers supporting others in the recovery journey and see as critical to their role. The peer workers have played a vital role in developing, delivering and evaluating the service to date.
To date, 32 people have benefitted from the service, with a further 10 people on the waiting list. There is a strong gender bias in favour of women in those accessing the service that requires further exploration. Additional recruitment provides a chance to review whether there is a benefit of recruiting according to specific experiences or identities. Analysis of the referral information shows that social isolation is the most common issue that people are referred to the service for help with, followed by anxiety, depression and low mood and mental ill health. This is summarised in the graph below.
The service has benefitted from strong engagement with the HSCP staff and partners, evidenced by the wide range of referrals to the service from Adult Mental Health Teams, Community Addictions Teams as well as from voluntary sector partners RCA Trust and RAMH. In particular the service has had strong support from psychiatrists with more than half of referrals coming from the Adult Mental Health Teams coming from that source.
Several staff from the HSCP's Community Addictions Service, Adult Mental Health Teams, RCA Trust and RAMH acted as service 'champions' for the Peer Support Service. These champions shared information about the service, attended workshops to support its design and development and were on hand to answer questions from their teams about peer support.
There is strong evidence that the Peer Support Service has been well-received by people accessing support. There is consistent evidence that people accessing support value the nature of the relationship and the open approach to conversation which can focus on a range of topics - not just mental health or harmful alcohol and/or drug use issues. This creates opportunities for connection of all kinds, for example a shared love of the outdoors or of cats. In some instances, these different types of conversation seemed to encourage remarkable shifts in perspective. Whilst building trust with the service takes time, evidence from the peer workers shows that this has been realised in many cases, as the following excerpts from the peer worker case note reviews show. Contributions from people using the service suggest the importance of a neutral or non-judgmental approach and how also how reassuring they have found the conversations to be.
Through their work with the peer workers, people using the service have gained a deeper understanding of what matters to them, from building relationships to family members to having someone to talk to about their personal life, without judgement. Peer workers reflected that the peer support allowed people to explore their hopes and goals in a relaxed setting and often quickly identify areas to progress. This in turn helped people build confidence, self belief and hope for the future, seen both in modest improvements in I.ROC scores in these domains and in feedback from people supported by the service.
In turn, peer workers have been able to identify a number of areas for improvement in the service, most crucially, the move to face to face engagement as Covid-19 restrictions allow. One peer worker notes the learning they have gained about their own recovery: "An awareness of how far I’ve come in my own recovery/self-actualisation that I’m in a position where I can do this work." Another entry described how the role had helped them: "become more confident as my relationships with people grow" and be more confident in, "the limits of my influence/responsibility (i.e. you can’t help someone with everything)" (Reflective Impact Log - Peer Worker 1).
The test of change has enabled HSCP staff to understand the specific contribution that the Peer Support Service brings to their wider offering in helping people to 'open up'. Their trust in the quality of the service is an important thread through our analysis.
There is considerable evidence that people engaged with the service are making changes in their lives as a result of the tools, knowledge and support. Examples include people being supported to stay sober, join a gym for the first time, feel safe in their own garden, better understand diagnoses, rebuild close family relationships, travel alone, reframe previous negative experiences and seek therapy for the first time. People were also supported to access new services and assert their rights within existing service relationships. Powerful case examples of being more able to process experiences and move towards positive change include a person challenging a service for better care, and another getting support around a personal experience of trauma while drawing from this experience to make a positive contribution to their community on safety issues. Some people using the service were linked into wider or more specialist supports. Being able to speak to someone was key to making these changes and I.ROC was identified as a helpful tool to support this, as the following quotation shows.
Elsewhere, such realisations were described as an "eye opener. [The peer worker] helps me break it down, my thoughts, my feelings, my emotions. Rather than keeping these deep, it's about speaking about them. It’s a much better, much healthier way".
In tandem the HSCP has taken the learning from this test of change and taken action to embed peer support as part of formal services. Crucially, in June 2021 the HSCP agreed to fund the service for the next three years and to extend the service, recruiting an additional peer support worker. Alongside this staff are continuing to support, discuss and refer people to the service, as one practitioner reflected.
The evidence brought together in this report from people using the service, the peer workers and practitioners shows that some people have moved forward in their recovery and have improved quality of life as a result of their interactions with peer supporters. These have been described throughout this report and have included people becoming more financially independent, building and rebuilding social networks, becoming sober, taking up exercise and addressing long-standing and deeply complex challenges for the first time in their lives. We have also seen that it is possible to link many of these shifts in wellbeing and quality of life to the peer relationships, characterised by informality, trust and shared learning.
Recovery is a long process that involves ups and downs and therefore it is not necessarily to be expected that people will gain measurable improvements over a relatively short timeframe. Analysis of I.ROC data for ten people who completed the tool on assessment and then review shows modest improvements in some domains, with small steps back in others. This contrasts with, but to some extent balances the overwhelmingly positive qualitative feedback.
By implementing the Peer Support Service there is clear evidence that the HSCP have provided a complementary service to people using mental health and addictions services. Critically the Peer Support Service offers people someone to talk to about anything in life in a way that is completely non-judgemental and is able to draw on lived experience of how different kinds of service and supports helped with their recovery journey. There is extensive evidence that people using the service very much value this complementary support as the following quote shows.
The Peer Support Service in East Renfrewshire was conceived of as a 'test of change', which would run for 12 months in order to:
From the evidence we have reviewed we conclude that these objectives have been well met. We also conclude the following.
Strengths of this test of change project include how quickly it reached capacity and to the way in which people using the service chose to sustain their engagement. We also saw high engagement of partners in the collaborative development of the service and in ensuring productive and wide-ranging referral routes.
A number of 'golden threads' run though our analysis and help to explain the progress that this test of change project made. One relates to the qualities in the relationships and communication between peer workers and people using the service, including the informal or everyday conversations which took place and the particular personal skills and qualities that the peer workers brought to their role. This reaches out to the point raised in our initial literature scan; that peer support sits in a liminal space between formal support and people using the service, and to the value of connection and mutuality. We saw powerful testimonies of people using the service showing the personal impacts of those open conversations with peer support workers and how they led to greater self-knowledge and an openness to exploring new opportunities and approaches.
The decision to contract an external organisation with expertise in providing the infrastructure for supporting peer-based services was shown to be important to providing informed support for the peer workers, and also to the trust shown in the service by wider stakeholders including clinical staff. Again, this mirrors points in the evidence base related to the importance of role clarity, training and supervision. This trust, alongside the role of service champion and the collaborative approach taken in developing the service, helps to explain why the service was able to reach capacity in such a short period of time. The particular skills and attributes of the peer workers have also been critical as well as their expansive role, and their effect can be felt across the pathway. Together these elements suggest points of good practice that may inform efforts to develop effective peer support in other settings.
This evaluation offers a good news story for East Renfrewshire HSCP, its partners and most importantly for the people who could potentially benefit from this new approach. Developing any new service is hard. Developing new services which integrate and value lived experience in delivery adds complexity. That such obvious progress has been made in a relatively short space of time is all the more remarkable given it also happened during a global pandemic with all the additional problems this has brought.
The HSCP, Penumbra and partners are therefore to be congratulated for their efforts and commitment. It is also important to recognise the dedication and hard work of the two peer workers who have enthusiastically and intelligently contributed to this evaluation despite the pressure of operating the service at full capacity. We at Matter of Focus are delighted to have had the opportunity to accompany HSCP, Penumbra and partners on their learning journey and would also like to extend our particular thanks to people using the service, stakeholders and practitioners who offered their time and experiences to build our understanding of this work.