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Moves are afoot to improve the status and professionalism of community mental health support workers. But could those moves undermine their relationship with clients, asks Simon Lawton Smith of mental health charity Maca.

Community mental health support workers do not get into the headlines much. They lack the clout of psychiatrists and psychologists, and the professional status of community psychiatric nurses and social workers. But ask mental health service users who they value most, and the odds are they would plump for their humble support worker every time.

Back in March 2001 national mental health charity Maca commissioned the late David Brandon and Lana Morris of TAO Research to look at the role of community mental health support workers. The focus fell on east Suffolk, where support workers are employed variously by Suffolk social services, East Suffolk Mind and Maca itself. The aim was to discover the usefulness and effectiveness of support workers, and in particular to look at whether support improved service users' lives. Their findings are now about to be published, under the title Changing Light Bulbs?¹

Encouragingly, the researchers were positive about the overall service, going so far as to say that "our hearts were nourished and minds stimulated by almost all of what we heard and saw".

More specifically, they found that support workers were perceived by other mental health workers and their employers as mainly action people, doers rather than discussers. They have a unique role in supporting people with mental health problems as they are more attuned to everyday needs - daily living skills, management of finances and benefit applications, and coping with physical problems. The continuity of such holistic relationships was central to good outcomes for service users.

There were, however, questions raised over the support worker role and in particular the confusion due to overlaps with other professionals such as community psychiatric nurses, care managers and keyworkers. This was compounded by the view that some prejudice still exists within statutory services about working with the voluntary sector. At the same time, many support workers were uncertain about their role, finding the boundary between professional support and personal friendship blurred.

In addition, support workers themselves felt a lack of ongoing professional development that perpetuated a feeling of being devalued and of having less status. This was particularly worrying as the research made clear that support workers were seeing an increasing number of people with more complex mental health needs including personality disorders, a history of self-harm, or drug and alcohol abuse.

The research may have been local to Suffolk, but the findings could hardly come at a better time to contribute to the national debate about the future role of support workers. Much of this centres around the recommendation from the Mental Health Workforce Action Team² to create a support, time and recovery (STR) worker. This is someone who would, as part of a care team, "give direct support to users by spending time with individuals" and "promote independent living, provide companionship, friendship, regular and practical support". Suggesting the need to recruit 10,000 STR workers in England, the workforce action team envisages existing support workers converting to STRs.

Maca's findings about the effectiveness of support workers echo the Sainsbury Centre for Mental Health's report More Than A Friend.³ This reported that as far as service users were concerned, support workers were more "in tune" with patients and with their priorities and equally - if not more - open, honest and easy to trust, compared with professional key workers.

Andrew McCulloch, director of policy at the Sainsbury Centre, says this remains just as true today. "The use of support workers has moved up the agenda in a major way since 1997, with the publication of the Workforce Action Team Report² and the deteriorating labour market. But the message remains the same - support workers have a key role to play which is highly valued by service users".

This may all look pretty good on paper, but there are two areas where concerns have been voiced. The first is around the practicality of recruiting and retaining such a workforce. Many areas of the country, and in particular the South East, already have enormous difficulty recruiting staff. Outside the existing workforce, where are the new STRs going to come from?

The Maca research found, in addition, very low rates of pay by all three service providers surveyed, and relatively little career development. These disincentives could be corrected, but at a cost. Linked to this is the question of who pays. According to Maca chief executive Gil Hitchon: "We calculate, conservatively, that 10,000 STRs means £145m for recruitment, training and pay. Is this going to be added to the £329m already promised through the NHS Plan for better services and more staff?"

The second concern arises from a potential tension between making the support worker workforce better trained and more professional, and losing the vital quality of human involvement that service users so value.

It is difficult to argue against a better qualified mental health workforce at all levels. Ongoing professional development is one way of tackling problems that support workers have in terms of feeling valued and having recognition - and being seen as complementary to other mental health workers, rather than subordinate. The draft code of conduct for social care workers, developed by the General Social Care Council, will aid this. So also will the continuing thrust towards NVQ qualifications, the introduction of the new certificate in community mental health care, and the development of national occupational standards.

But Maca's research also suggested that the danger of a drive towards standardisation is that it erodes what users value most - ordinary humanity. As Changing Light Bulbs? puts it, "support workers have time to chat, to drink coffee, to share stories about their family and dogs in a way that other professionals do not".

This concern isn't new. The Sainsbury Centre's Down Your Street report stated that "In some cases there may be a positive disadvantage to having professionally qualified workers, as this could detract from the ethos of providing a service untainted by institutional attitudes."⁴ So are the excellent outcomes demonstrated in the Suffolk work being endangered by the desire to professionalise the workforce?

This is certainly a concern for researcher Lana Morris. "We have always known anecdotally that when someone becomes 'qualified' in our profession, they are no longer allowed to change a light bulb, either because of insurance, health and safety or procedure from the agency. What we were trying to show was the less 'professional' intervention there is, the more likely you would do things like change a light bulb, get someone's shopping, or put the bins out. Therein lies the complexity of the relationship - the struggle between being human and informally providing support and at the same time being able to provide a professional and caring service recognised by the so-called professionals".

Gil Hitchon is equally concerned about where commissioners of services look for the support worker of the future. "If STRs and other support workers are employed by the statutory sector they could simply become subsumed into community mental health teams as 'assistants' to other professions. This would result in a much narrower focus to their work, to the detriment of the service user. Our research shows that what service users particularly value is the 'whole person, whole life' approach that they get from workers who are allowed to be flexible in their approach. We believe the voluntary sector is both most experienced and best placed to achieve this".

The final word might go to the "significant other" of one of the service users in Suffolk. "His recovery is due mainly to the wonderful support from the various services, especially that of the young support worker. They have a good relationship based on a sort of friendship." Those responsible for the development of the future mental health workforce would do well to keep those words in mind.

- An executive summary of Changing Light Bulbs? is available, free of charge, from Maca at 25 Bedford Square, London WC1B 3HW, telephone: 020 7436 6194.

Simon Lawton Smith is head of public affairs at national mental health charity Maca.

References

¹ D Brandon and L Morris, Changing Light Bulbs?, Maca, 2002

² Mental Health Workforce Action Team Final Report, August 2001

³ A Murray et al, More Than A Friend, Sainsbury Centre for Mental Health, 1997

⁴ L Warner, R Ford, S Bagnall, S Morgan, C McDaid, S Mawhinney, Down Your Street - Models of Extended Community Support Services for People with Mental Health Problems, Sainsbury Centre for Mental Health, 1998

Websites

See Sainsbury Centre for Mental Health web site at www.scmh.org.uk/