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Evaluation of a Peer Support Test of Change: Summary Findings

East Renfrewshire Health and Social Care Partnership

Date produced • 03/11/2021
Date expires • 01/02/2023

This report was generated by OutNav using the theory-based approach to evaluation pioneered by Matter of Focus.

Content

Evaluation of a Peer Support Test of Change: Summary Findings

1. Background

About this test of change project

Overview

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. 

About this evaluation

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:

  1. To support the collaborative development of the Peer Support Service in East Renfrewshire
  2. To review the background literature to strengthen the rationale for the Peer Support Service
  3. To provide contextual analysis of any barriers and enablers for a Peer Support Service
  4. To design and deliver an evaluation which would show the emerging impacts of the Peer Support Service, for individuals and for the wider service environment
  5. To support the embedding of outcome-based reporting through OutNav in Penumbra and the East Renfrewshire HSCP
  6. To share learning and support ongoing development of the Peer Support Service.

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.

How current thinking/context shape this work

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.[1]

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."[2] As such, peer workers have been described as occupying a liminal space, somewhere between formal services and the people who use them.[3]


[1] 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.

[2] Rome, A. (2019) Independent Review of the Glasgow Recovery Communities. Available at: https://www.glasgow.gov.uk/CHttpHandler.ashx?id=46671&p=0.

[3] 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.

How we approached this evaluation

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.[1] 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.


[1] 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

Evaluation of a Peer Support Test of Change: Summary Findings

2. Our pathways

Evaluation of a Peer Support Test of Change: Summary Findings

3. Our risks and assumptions

Risks
  • People being referred, or those making referrals, don't know what peer support is or what it can offer.
  • The Covid-19 pandemic exacerbates problems and health issues for people accessing support increasing complexity.
  • Supporting people over the phone (due to Covid-19 restrictions) does not meet people's needs.
  • Communication between the HSCP and Penumbra does not meet information needs of one or both parties.
  • Tools and resources that were designed for face to face working are harder to use because of Covid-19 restrictions.
  • There is an over reliance upon champions for referrals.
Assumptions
  • Peer workers are supported by Penumbra and the HSCP.
  • People with lived experience will be involved in decision making around their own care and support.
  • Peer support models meaningful relationships and supports people to work on strengthening and expanding their own relationships.
  • People get the right support at the right time in their recovery journey.
  • Important and necessary perspectives are included in the development of peer support service.
  • East Renfrewshire is recovery focused and working to reduce stigma around mental health and harmful alcohol and or drug use.
  • When ready, the HSCP and service support people to plan a positive exit from formal supports.
  • People are open to recovery, which is understood as the realisation of a meaningful life in the presence or absence of symptoms.
  • People who can benefit from peer support get access to the service.

Evaluation of a Peer Support Test of Change: Summary Findings

4. Developing and piloting a peer support model Pathway progress

Pathway legend Close

Great
Progress
Some
Progress
No
Progress
High Confidence
Some Confidence
Low Confidence

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.

Who with
Progress: Great
Confidence: Some
Progress: Great
Confidence: High
Progress: Great
Confidence: High
How they feel
Progress: Great
Confidence: High
What they do differently
Progress: Great
Confidence: High
What difference does this make?

Evaluation of a Peer Support Test of Change: Summary Findings

5. Developing and piloting a peer support model Summary findings

What we do
Who with
How they feel
What they learn and gain
What they do differently
What difference does this make?

Highlight findings

  • In a six-month period, the peer workers delivered 196 appointments to 25 people. The average number of appointments was 12, showing that once engaged, people tended to sustain their engagement.
  • The decision to work with Penumbra, as experts in supporting recovery and peer-based approaches, was a key decision in understanding trust in the project and how the peer workers were equipped and supported.
  • We saw evidence of strong relationship between people in receipt of the service and peer workers. Relationships were often built upon lighter touch and informal conversations, which set the conditions for a high degree of trust and mutuality which in turn supported change. This relational practice emerged as a 'golden thread' across our analysis, helping to explain why this way of working was experienced so positively by those using the service.
  • Collaboration in service design and the network of service champions were important features of this work.

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.

Figure 1. Flow of people into and out of the service

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:

  • create a peer relationship built on mutual respect and empowerment
  • provide support, a safe space, motivation and structure for people
  • promote recovery and a focus on people's strengths
  • use tools such as I.ROC and the HOPE toolkit to help people to evaluate their lives and create positive changes for themselves

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.


What we do
Who with
How they feel
What they learn and gain
What they do differently
What difference does this make?

Highlight findings

  • The Peer Support Service was delivered by two peer workers with experience of mental health issues and recovery; their role has been pivotal to design, delivery and evaluation of the service.
  • People are typically referred to the service because of isolation, mental ill-health, anxiety, depression and low mood.
  • The service has received referrals from a range of sources such as Adult Mental Health Teams (including psychiatrists), Community Addictions Teams and voluntary sector partners. 

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.

What we do
Who with
How they feel
What they learn and gain
What they do differently
What difference does this make?

Highlight findings

  • People using the service valued the nature of the relationship and the holistic approach taken.
  • People valued working with someone with lived experience because it helped them develop a sense of clarity and reflection on their own experiences. In this way of working connections can extend beyond the experience of mental ill-health or substance use to other experiences or passions.

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.


What we do
Who with
How they feel
What they learn and gain
What they do differently
What difference does this make?

Highlight findings

  • There has been significant learning from this peer support test of change for the people using the service, the peer workers and the HSCP.
  • A common thread across the experiences of those using the service was that it supported greater self-awareness and knowledge, and therefore aided their own personal goals. In this evaluation we heard powerful testimonies of people using the service, sitting alongside more modest gains in quantitative indicators.

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.


What we do
Who with
How they feel
What they learn and gain
What they do differently
What difference does this make?

Highlight findings

  • There was evidence from our review of case notes that people who engaged with the service used the space for open dialogue to understand what was important to them and to take positive steps forward.
  • Awareness of peer support appeared to be growing in the area, with more practitioners becoming aware of the benefits and considering referrals.

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. 


What we do
Who with
How they feel
What they learn and gain
What they do differently
What difference does this make?

Highlight findings

  • The Peer Support Service has provided a complementary service to people using mainstream addictions and mental health services, providing opportunities for informal conversation and connections of different kinds.
  • There is evidence in this evaluation that people using the service have maintained or moved forward in their recovery, being mindful that recovery can be a long process for many people and one subject to many influences.

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. 


Evaluation of a Peer Support Test of Change: Summary Findings

6. Conclusions & learning

The Peer Support Service in East Renfrewshire was conceived of as a 'test of change', which would run for 12 months in order to:

  1. Develop a peer support service that works locally and embed a peer support service within the formal service landscape of the HSCP.
  2. Deliver a recovery-oriented service which emphasises the value of lived experience for helping others to progress towards their own recovery goals and personal outcomes.

From the evidence we have reviewed we conclude that these objectives have been well met. We also conclude the following.

  1. There is clear evidence that the service has been carefully developed with good involvement from wider stakeholders.
  2. We saw evidence that the service was complementary to wider services in the area and that people referring to the service were satisfied by the experience and relatively well informed about what it had to offer.
  3. The service was experienced as different by people using it. There was clear evidence that the peer approach and the sharing of lived experience encouraged different types of conversation and that these could be a gateway to improved wellbeing.
  4. The service has engaged peer workers who are confident in the delivery of the service, learning and adapting as they go. Additionally, in contracting Penumbra to run the service the HSCP benefited from their experience in, and infrastructure for, the delivery of peer-based and recovery-focused services.
  5. The service champion role played an important part in establishing the credibility and wider awareness of the service.
  6. Problems with communication were rightly identified as a risk in the outcome mapping process. Early issues, such as feedback to key workers on the progress of referrals they had made, were promptly rectified as a result of well-developed and trusting partnership working. Work will be required to maintain this positive start.

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.

Recommendations:

  1. A large proportion of referrals to date have come from the peer support service champions in each team as well as some key senior clinicians (e.g. a consultant psychiatrist in Adult Mental Health Team) and continuing efforts to raise awareness of the service more widely should encourage more referrals from other practitioners and support longer term sustainability. Efforts should also continue to ensure that all referring services consider peer support so that as many people as possible can benefit. This includes the need to increase referrals from the Community Addictions Team and third sector partners in the HSCP.
  2. The success and wider acceptance of the service has meant it was at full capacity quickly and has remained so. It will be important to carefully manage demand and to ideally ensure additional peer worker capacity. The service should also consider whether service demand could be managed in other ways. These could include increased group working. Given the risk of increasing waiting times thought may need to be given to time limiting the service, albeit this is a complex issue for a service founded on relationships.
  3. Covid-19 has had a profound effect on the development and delivery of the service. As restrictions are reduced there will be new opportunities to alter practices to better support service user needs and preferences, including opportunities to support community integration and inclusion. Reduced restrictions could also have an impact on service capacity and planning. For example, shifting to face to face meetings may reduce the number of people that it is possible to see in a day, when compared with phone support. Such considerations should be factored into service planning.
  4. Work should be undertaken to better understand the gender imbalance in people using the service. This could allow for improved targeting of potential male services users increasing access to the service. 
  5. There is much to learn from this evaluation both for the HSCP but also for the wider movement of people with a role in developing recovery-focused and peer-involved services. We encourage the dissemination of these findings both locally to raise awareness but also more widely to the community of people seeking to develop peer-based approaches.
  6. We encourage the continued culture of evidence and evaluation in the service and recommend that the service continues to use the well-developed evaluation framework which now exists to facilitate the process. However, high quality monitoring and evaluation takes time and this must be recognised and factored into the time of the peer workers.

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.

Evaluation of a Peer Support Test of Change: Summary Findings

Evaluation of a Peer Support Test of Change: Summary Findings

This report has been created using OutNavTM
developed by Matter of Focus.

OutNav is an innovative online platform that takes teams on a logical,
user-friendly journey to develop and manage a meaningful approach to
outcome-focused monitoring and evaluation.

Date produced: 03/11/2021
Date expires: 01/02/2023

OutNav Logo

This report was generated by OutNav using the theory-based approach to evaluation pioneered by Matter of Focus.