Professional dilemma

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/