Difficulties in restructuring mental health services in Bromley

Ben Taylor and Sandi Lowing outline the difficult – but worthwhile – year-long journey to restructuring mental health day services in Bromley

In March 2005, trustees and managers of Bromley Mind faced a room full of angry service users and tried to explain, over chants and stamping feet, why they were consulting on a proposal to change the way mental health day services were delivered.

Navigator, a new model of working, had been introduced two years earlier to promote recovery and social inclusion. Some service users embraced it with enthusiasm.(1) Others did not, choosing just to continue dropping in to centres regularly for social support. For most, the centres continued to look and feel like they had for the past 20 years.

There were two triggers for change. The first was a serious funding gap. The second was the knowledge that new commissioning guidance on mental health day services was in the offing.(2)

It made perfect sense to accelerate the change started with Navigator and plan a new service with a new staffing structure, all within a reduced budget that would anticipate the new guidance. But at that March meeting service users made their views clear. Too much “new” and not enough “old and familiar”. Too much change.

One year later to the day, an evaluation of the new day service structure was presented to the trustees. It showed new, improved outcomes for service users, greater staff job satisfaction and high levels of service user satisfaction. This time there was no dissent, just sighs of relief.

Aside from addressing the funding gap, restructuring aimed to increase the benefits of accessing services and the range of service users who would do so, by:

  • Increasing opportunities for social inclusion.
  • Providing opportunities to discover new and uncover lost skills.
  • Providing person-centred support to achieve individual goals.
  • Increasing the number of service users.

    To meet these aims effectively, it was important to engage with the needs and concerns of existing and potential users. Those who had been comfortable with the more traditional day centre provision stated clearly that “safe space” still had an important role. This is particularly true for people who are acutely unwell, whose needs are recognised in the commissioning guidance.

    However, it was also clear that something more structured and dynamic was needed if the services were to interest service users who found a traditional centre stultifying.

    A new structure was devised containing three distinct elements: focused sessions; open access sessions and an out-of-hours service.

    The focused sessions offer structured Fresh Start courses in a range of areas – managing your mental health, practical skills, physical activity and engaging the mind. They also offer one-to-one, person-centred support to enable service users to work towards individual goals and support them to engage with their local community.

    Open access sessions have informal safe space for peer support, to socialise or to take part in informal groups. The out-of-hours service of evening and weekend social opportunities, many taking place in local social and leisure venues, help people feel confident in these settings.

    An initial evaluation of the new structure drew on monitoring information, group feedback forms and discussions with staff, volunteers and service users. The focused sessions were well received, with service users scoring the groups an average of more than eight out of 10 when asked how beneficial they had been. Twenty-four groups were run in the first three-month programme and were attended by 181 service users.

    As a result of the focused sessions, user feedback identified increased confidence and skills; tangible changes in service users’ lives as a direct consequence of involvement in a group; increased knowledge and confidence to access mainstream community resources; and development of practical, creative and emotional skills

    Thirty-four service users received focused one-to-one support from staff during the first four months of the new structure. Most were working towards a personal development plan. Outcomes relating to this work included:

  • Taking control of problems with debt.
  • Developing strategies to deal with hearing voices.
  • Taking control of household tasks.
  • Improved personal safety and hygiene.

    As expected, the evaluation found that the process of change was difficult for many service users. But most had adjusted well and were seeing benefits in the new way of working, including having more structure to their week and motivation to access activities in the wider community.

    Though the full impact of the changes for potential service users may not be seen for some time, people had begun applying just so that they could attend specific groups, particularly those around coping skills. This was the start of the services being used in a more flexible way by people who had previously not sought help from mental health day services.

    Finally, despite significant adjustments in roles and responsibilities, day services staff were experiencing personal and professional development, increased job satisfaction and an improved sense of working in a team.

    Change in modern mental health services is, of course, an ongoing process. To survive and flourish, day services will have to rise to the challenge of meeting the needs of service users and the expectations of commissioners.

    In light of recently published commissioning guidance, some areas for development in Bromley Mind’s day services have been identified, including increasing community bridge building activity; more focus on learning and skills development; broadening the client group to include people who may have a negative perception of day services and those referred by primary care; better meeting the needs of diverse groups; and developing peer support services.

    So, what can be learned from this experience? In essence, that change can be a painful process with its gains often not felt until long after the losses are perceived. This supports the findings of a Social Exclusion Unit report which says that “where services have been re-designed, there has been initial opposition to the change, but outcomes and the range of services for people with mental health problems have improved over time”.(3) Perceptions can and do change over time and, as Bromley Mind found, a year can be a long time in day services.

    Ben Taylor is head of mental health services at Bromley Mind. Before joining the organisation last year, he managed mental health supported housing and day services.

    Sandi Lowing has been chief executive of Bromley Mind since 2001.

    This article looks at the process of modernising mental health day services, using the experience of Bromley Mind in south London as an example. The article reflects on the impacts that such a change can have and seeks to identify challenges for the future, in light of the recently published commissioning guidance for mental health day services.

    (1) Navigating Change: Modernising Traditional Day Services in Bromley Mind, Bromley Mind, 2005 (for a copy contact the author)
    (2) From Segregation to Inclusion: Commissioning Guidance on Day Services for People with Mental Health Problems, Department of Health/Care Services Improvement Partnership, 2006
    (3) Mental Health and Social Exclusion, Social Exclusion Unit, 2004

    Further information
    Redesigning Mental Health Day Services: A Modernisation Toolkit for London, Department of Health/Care Services Improvement Partnership, 2005
    Bromley Mind

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