The (mental) health and social care benefits of social prescribing / supported signposting  (FIRST EDIT)

For twelve years InterAct’s mental health programme has been operating a social prescribing (supported signposting) service. Our experience suggests that the service aids recovery for those who have experienced mental health problems and that it acts as a preventative measure for those at risk of worsening mental health problems. Here we present evidence from clients of the health and social care benefits of our service and an estimate of some of the savings to Primary Care Trusts (PCTs) of one of our activities.

Our supported signposting service was for many years carried out under two separate banners. Reports on both, Bridges to Education (Faiers 2004) and Bridges to Work (Edwards 2005), have previously appeared in Life In The Day. Partly owing to the requirements of separate funding streams, the former placed emphasis on supporting clients into learning and the latter placed emphasis on supporting clients into paid employment. However, throughout the period of separate funding, InterAct attempted to offer a joined up service. In addition, with funding from other sources and in response to requests from clients and published research on the benefits, we extended the range of activities to which we signpost.

Under our current funding we offer one mental health service, which provides information, advice, guidance and support for:

·         adults (16+) experiencing or recovering from mental ill health

·         adults (16+) at risk of mental health problems

(There were additional referral criteria for ‘Bridges to Work’.)

The support is designed to enable clients to access and sustain evidence based beneficial activities such as:

·         meaningful work

·         learning

·         exercise / physical activity

·         clubs, societies and interest groups

·         self-help groups

We place strong emphasis on activities which are socially inclusive and which help clients to build supportive social networks. Also, evidence from other projects, such as the social prescribing service piloted in Lewisham (White, Glover and O’Brien 2002), has led us to develop a service which does not rely on social prescribing simply happening within existing frameworks.

We believe that social prescribing has to be carried out by dedicated client workers who are also able to provide support alongside the signposting and who can keep up to date with what is available and relevant in individual cases. From this point on, I shall therefore use the term supported signposting rather than social prescribing to describe our activities.

Within the context of the supported signposting service, InterAct’s own back to work programme included a range of activities such as accredited IT skills training, job hunting, CV writing, filling in application forms and interview skills. The most effective approach was found to be the individual placement and support model, finding employment for clients and then organising training and support, as opposed to ‘train then place’.

However, the European Social Fund (ESF) funding for that programme came to an end in July 2007, meaning we lost not only 14 members of staff, but also the expertise they brought to both InterAct and to the health and social care system. As far as possible, the activities have now been incorporated into the single mental health service (which is also ESF co-financed), but our capacity is clearly reduced.

Referrals

Referrals to InterAct’s mental health service come from a variety of sources such as self-referrals, GPs, Community Mental Health Teams (the majority) and voluntary sector organisations such as Mind, rethink and together. We are receiving increasing numbers of referrals from primary care, not least due to our employment of a hybrid Primary Care Graduate Mental Health Worker based in four Chelmsford GP surgeries.

Supported signposting General Outcomes

Table 1 summarises general outcomes for clients receiving our supported signposting service over a six month sample period from 1 April 2006 to 30 September 2006. The ‘existing’ column summarises outcomes for the 1512 who had registered before 1 April 2006 and whose files were still open. The ‘new’ column summarises outcomes for 195 new clients registering during the six month sample period.

Overall health and social care outcomes

We also measured health and social outcomes. One source of data within the supported signposting service was feedback from clients via course evaluation forms. Table 2 shows how these demonstrated the overall health and social benefits of learning. The differences between completers and non-completers should, perhaps, be treated cautiously given the difference in numbers of forms analysed for each group.

A key overall message is confirmation of the well established fact that learning has a very positive impact on mental health and motivation as well as on factors which help promote good mental health such as confidence and skills. There also appears to be a very positive impact on social outcomes as measured by a self-assessed increase in the ability to get on with life. Such results suggest a direct impact on both health and social care provision and associated budgets.

A second key message is that clients appear to value the skills they obtain from learning as much as the qualifications. This finding is confirmed by more detailed analysis breaking the results down into learners on accredited courses and learners on non-accredited courses. The judgement by learners is endorsed by the finding that, contrary to popular belief, gaining most qualifications as an adult has little or no impact on, for example, earning power.

Indeed, gaining an occupational level 2 qualification actually reduces earning power: by 7% for women and by 10% for men (Wolf, Jenkins and Vignobles 2006). By contrast, the same paper cites international research summarised by Ananiadou et. al. (Ananiadou, Jenkins and Wolf 2004, p.299), which demonstrates that unaccredited, on the job training, presumably training which provides directly relevant skills, does increase earning power.

Further data from Exit questionnaires

In their first interview InterAct’s supported signposting clients are informed that initially the service will last for up to a year, though they can both exit from the service before a year or request its continuation at the end of the year. Clients are asked if they want to continue with the service via an exit questionnaire, which is sent to them after twelve months.

The exit questionnaire also asks for their own assessment of the impact our supported signposting service has had on their achievement against a more detailed list of health and social outcomes. Results from our 126 most recent questionnaires are summarised in Table 3. Overall, 88% of clients achieved 3 or more of the health / social outcomes in the table.

The low impact on telephone skills is a useful control. What is remarkable, and what again demonstrates the savings to the economy (including DWP budgets) of a properly funded supported signposting service, is the percentage of clients obtaining paid employment. The cost per client for our standard supported signposting service is around £400.

A quantified saving

A single quantified saving, in this case for PCTs, is indicated by an initial measurement of the impact of supported signposting provided by our Primary Care Graduate Mental Health Worker. During her first months in post she provided nothing but a supported signposting service. Comparing a *five to six month period prior to intervention with the same length of period following intervention, GP presentations for mental health issues by ten patients receiving the service reduced by 50% from 62 to 32 (* analysis refers to six month periods for 7 clients and five month periods for 3 clients).

The sample is small, but based on this data, on the fact that a surgery based *supported signposting worker can see up to 15 new clients a week and that a short GP presentation costs around £20, one such worker at an inclusive cost of £30,000 a year could save GP presentations up to the value of £42,300 a year (15 clients/week x 47 weeks x 3 GP appointments saved per patient x £20), a nett saving to the PCT of £12,300 in GP presentations alone. If the reduction in GP presentations continues for a year, the saving per year will be £54,600. (* The role can be *badged as required. InterAct’s PCGMHW went on to additionally offer therapeutic interventions as is expected of that role.)

To this saving needs to be added savings such as prevention in referrals to secondary services (reducing demand on health and social care budgets), decreased need for medication etc. not to mention wider savings to the economy from having well, socially integrated people.

More detailed analysis

Space does not permit full coverage of all the more detailed information we have analysed. However, some of the more interesting results are presented below.

Currently, across most of Essex we are funded to provide our mental health service only to adults with lower than a level 2 qualification. To receive our funding we are required to encourage as many such clients as possible to embark on Skills for Life (accredited numeracy and literacy) courses.

On the plus side, 100% of the clients achieving a Skills for Life (SfL) qualification said that the course was a useful and valuable experience and 100% said it had given them valuable qualifications. The equivalent figures for the overall sample were 86.2% and 39.8% (Table 2). On the negative side the drop out rate was high at 32% compared with 10% for the overall sample. However, even amongst those dropping out of the course, 75% said it had been a useful and valuable experience.

Clients also reported better health and social outcomes after completing accredited courses such as access courses and IT courses compared with completing unaccredited confidence building courses. For example whilst, a still significant, 70% of those completing unaccredited confidence building courses reported an improvement in mental health, over 94% of those completing the accredited courses reported the same outcome.

However, it should be taken into account that, often, those embarking on non-accredited confidence building courses do not consider themselves ready for other types of learning. Also, the outcomes of such learning summarised in Table 4 still confirm the essential role it plays.

A more detailed analysis of information from exit questionnaires also gave useful information. Table 5 summarises the results, taking as a **representative example, the effect on self-esteem of various activities.

Secondly, accredited learning appears no better at achieving employment outcomes than non-accredited learning, whether or not it is combined with other activities. Indeed, non accredited learning appears more effective, especially if it is combined with broader signposting activities.

It is suggested that repeated messages about the importance of qualifications has more effect on their perceived significance (hence the increased self-esteem when they are obtained) than qualifications deserve in terms of their practical advantage compared with other types of learning and activity.

(** A full breakdown is available from the author via adrianfaiers at onetel dot com )

An additional consideration

We are sometimes concerned about our repeated interrogation of clients in order to obtain this kind of information. Interestingly, a recent independent ®Matrix quality assessment of our programme found that clients considered the process of completing questionnaires to have a positive impact on their wellbeing as it helped them to assess and acknowledge the progress they had made.

Conclusions

Whist the study is limited, the results support the following conclusions:

First, that far from such supported signposting programmes coming to an end because they can no longer be shoe-horned into inappropriate funding streams such as ESF co-financing, they should be rolled out more widely, using funding from the health, social care, DWP and community budgets (to which they bring such great savings), as well as from dedicated education and skills funding.

Second, that the government needs to re-consider its preoccupation with qualifications and to direct more funding towards non-accredited learning and a broader range of beneficial activities if it wants to achieve its own employment targets for adults with mental health problems. Perhaps it also needs to recognise that up-skilling the workforce is not necessarily the same as increasing its qualifications.

References

Ananiadou K, Jenkins A and Wolf A (2004) Basic skills and workplace learning: what do we actually know about their benefits? Studies in Continuing Education 26 (2) 289-308

Edwards P (2005) Building bridges to work: the changing face of employment training and support. A life in the day 9 (1)

Faiers A (2004) Building bridges to education. A life in the day 8 (1) 9-14

White C, Glover A and O’Brien A (2002) Summary report on the LSPP (Lewisham Social Prescribing Project) pilot

Wolf A, Jenkins A and Vignobles A (2006) Certifying the workforce: economic imperative or failed social policy? Journal of Education Policy 21 (5) 535-565