SECTION 13: SELF-DIRECTED SUPPORT FOR USERS OF MENTAL HEALTH SERVICES
233. This section should be read in conjunction with the general sections.
234. Self-directed support accords well with the new duties under sections 25-31 of the Mental Health (Care and Treatment) (Scotland) Act 2003 and its ethos of promoting social inclusion. Self-directed support used imaginatively can lead to a positive impact on mental health and reduce the need for crisis services or emergency admissions to hospital. It can also help reduce the amount of time spent in hospital if there is the support in place at home to enable the individual to return sooner. And it can help increase confidence, self-esteem, assertiveness, independence, participation in mainstream activities, as well as increasing an individual's sense of purpose and optimism. Self-directed support can help equalise access to the local community so that individuals can be integrated into Scottish society.
235. As a general principle, local councils should aim to encourage choice by enabling people to address their own needs as they consider best, whilst satisfying themselves that the agreed care plan outcomes are being achieved. This may be a particularly significant change of emphasis for mental health service users who may now be able to access a mixture of health and social care activities in the community.
236. Current thinking encourages people to live as full a life as they are able and to pursue a journey of recovery. This whole system recovery approach is about looking both within and beyond mental health service provision at the whole range of opportunities and support that a person with mental health needs might utilise to enable them to live their life as they wish. It is an approach that is vital to the effective development of mental health services, and one that is promoted by the use of self-directed support. It is about practitioners making the shift from assessing whether someone requires an arranged service, to assessing what their needs are to aid their recovery, perhaps assisting them to participate in a community activity.
'…If I am having a bad day I can alter days or times - that takes away the pressure of a set commitment. In return I am also flexible with her (employee) where necessary, so it works very well. Looking back over the last 18 months of being on this scheme, I feel I have come a long way from the isolation and depression. But the most important part of it all is that direct payments staff are always just a phone call away. I feel this is a vital part of the success of the scheme.'
Eligibility, assessment and support
237. Local authorities, community health partnerships 63 and non-statutory providers of mental health services and support must ensure that self-directed support becomes routinely available to those eligible people who use mental health services. Self-directed support may also be particularly valuable for those whose needs have been recognised as being less well served by collective provision or are less likely to access arranged services. Annex B lists those currently unable to receive direct payments under the Mental Health (Care and Treatment) (Scotland) Act 2003.
238. Self-directed support may include support for the person's mental health problems, such as support with a relapse prevention plan. It might be used for support at such times as evenings or weekends when mental health services can be more difficult to access. It can also be used to provide support for those with fluctuating conditions when the individual's support needs may vary and they may sometimes need more assistance than at other times.
239. Self-directed support will usually be used to provide an alternative to attending day centres or day hospitals. Subject to local circumstances, self-directed support might be there to enable an individual to go to mainstream computer, art or music lessons, join a fishing club or be supported to become a volunteer helping others. The service user might be assessed as needing a support worker to help them attend exercise classes at a local gym, or go swimming, instead of attending relaxation classes at a day centre.
240. Local circumstances will affect what is available to service users according to their assessed needs. Individuals might be assessed as needing day or night support workers, respite breaks, talking and complementary therapies, or training and career guidance if they are assessed as needing this to go to work. PAs may provide the support that enables someone to go back to work. All of these are uses of self-directed support which fall outside of the description of services in most peoples' understanding, but which have proved to be effective in meeting assessed needs. It may be there to provide social aspects of recovery, such as helping an individual do more with friends, family and the local community if this is what they are assessed as needing, and this is what they want to do. It is important to emphasise that although some individuals may require PAs to support their access to occasional leisure activities as part of their recovery, the user must fund the actual activities themselves, for example going to the cinema.
241. Mental health partnerships need to share an understanding of and commitment to the goals of recovery and independent living. Many already apply a whole systems approach to funding, enabling more flexible contracting arrangements, and training and other support to be provided by all partners. Increased expenditure by local authorities on self-directed support can be accommodated by changes in the balance of funding from health partners. There needs to be agreement over joint eligibility criteria to receive both health and social care services.
242. There also needs to be a local joint strategy for the implementation of self-directed support within mental health services that has fully involved users in its design. The strategy should include: joint training; shared language and straight forward systems; recognition that some needs can be met through either health or social care or a combination; provision of targeted support for individuals; guidance to mental health staff; and information to service users. For example, community psychiatric nurses ( CPNs) should feel confident that they are able to assess someone for self-directed support.
Meeting local needs
243. Local support services should be funded by joint mental health services (joint health and local authority teams), to work in partnership with mental health support organisations so that they may better accommodate these service users. This may be particularly challenging if local users are not accessing traditional community care services in the first place, or in contact with their council for other services, but instead are used to receiving services from the NHS.
244. Local support needs to be funded so that mental health service users are able to access the direct payment services offered to other eligible people. In addition to these however, there is a need to recognise and respond to the specific needs of mental health service users. For example, individuals may not have experience of user-led assessments. Where there are fluctuating needs, care will be needed to estimate how long a PA should be available to offer emotional support during periods of increased stress. Support in managing the package may be needed if someone is becoming suspicious or paranoid or is becoming very withdrawn, or if they need admission to hospital for non-psychiatric illness. People with mental health support needs may be stigmatised or thought of as dangerous so extra support may be needed during recruitment.
Lucy is a young woman with an enduring mental health condition who needs constant supervision as she hears voices and needs support to focus on activities and keep herself safe. For example, she needs assistance in using kitchen equipment, remembering to lock the house and crossing the road.
Lucy decided to become a PA employer with the support of her parents, and the local support service which provides her with a payroll service and help with recruitment. She employs a team of six carers who are close in age to herself. She uses her 64 hours per week of support at a local kennels where she works, and to attend her fitness classes, shopping, going to the cinema, and other interests she pursues. Although her hours are mainly fixed Monday to Friday, Lucy uses an allowance of floating hours to go to specific events such as concerts, or have days away occasionally.
How to mainstream self-directed support for mental health service users.
245. Ensuring that there is adequate funding of local support services is the key for local authorities and health boards to ensure that self-directed support is routinely available for users of mental health services. This support will help local authorities:
- promote self-directed support for mental health service users
- provide targeted information, for example, where readers are not able to concentrate for long periods or take in much in one go
- provide general advice on self-directed support as well as specialist mental health advice. For example, a specialist advocate or support worker may be needed for self-assessment and to prepare for the assessment process, care planning and care management
- provide training for council and health staff and users, include self-assessment training, advance statements and the use of crisis plans with particular attention to the use of third party support at times of crisis as a means of managing risk 64
- encourage imaginative use of self-directed support for individual users, perhaps introducing it as a small part of an overall package so that individuals and the professionals supporting them have a chance to try it out. Where individuals choose to do so, to develop partnerships between users, such that together they might be able to purchase training or education to assist their development ( e.g.IT, graphic design, and drama)
- encourage self-directed support as part of a culture of positive risk taking, enabling people to take first steps where previously they had encountered wariness or alarm associated with potential relapse. Health and social care professionals need a can-do attitude for promoting self-directed support that is about recognising individuals' potential and wanting them to succeed, and about managing rather than eliminating risk, and
- provide flexible funding to meet anticipated variable demand for self-directed support as part of a recovery plan.
246. Direct Payments for People with Mental Health Problems, A Guide to Action (Department of Health February 2006) 65.