Collaboration is a phrase or ‘buzzword’ we hear all the time. It’s seen across many sectors as an ideal way of working. This blog post, written by Esther Curtin (University of Bristol), Joyce Coker and Hannah Scott (University of Cambridge) draws on two studies within the Public Mental Health programme in the NIHR School for Public Health Research. It aims to highlight the importance of collaboration within and across statutory health and social care services (within the NHS) and voluntary support networks (in the community) to improve the public’s mental health.
What is our work about?
The authors of this blog although working on different studies had a shared goal: evaluating interventions that aim to improve the mental health of adults in the UK. This is a public health priority, with national figures showing that around one in six adults have symptoms of a common mental disorder (mainly depression and anxiety) (1), and concerns that mental health has been worsening during the pandemic due to financial and food insecurity worries, job loss, and social isolation (2).
The Bristol team were exploring a new care pathway in the NHS’ talking therapy service (known as the Improving Access to Psychological Therapies [IAPT] service) in the Southwest of England that aimed to address the wider determinants of mental health (3). Specifically, they were interested in how two new roles: ‘Wellbeing Navigators’ that link people up with community services to tackle problems around poverty, unemployment and social isolation, and ‘Health and Wellbeing Coaches’ that focus on building motivation to improve people’s health related behaviours, work together to offer a better course of treatment for people. To do this, they spoke to 47 staff and service users to understand their experiences and views of the pathway.
The Cambridge team were using a realist-informed approach to explore the role co-located community interventions play in supporting the mental health and wellbeing of older adults (65 years and older) (4). They were specifically interested in exploring what is it about co-located community interventions that work? How they work? Who they work for? And under what circumstances do they work? To do this, they spoke to a variety of stakeholders in the voluntary and community sector. They had two case studies sites (Age UK Cambridgeshire and Peterborough and Care Network’s community navigator services) and used interactive postcard packs and interviews to explore the views of older adults, volunteers, and staff across both sites.
As we researchers talked about the interventions we were evaluating, we realised that despite having some clear differences (one functioning in a statutory space and the other in a community space), they also had several similarities in the type of support they provided. Firstly, they both acted as ‘connector interventions’ (signposting people to wider services but also physically connecting people with these services when they needed the assistance). Secondly, they also offered ‘direct interventions’ (in-house, structured activities such as guided exercise programmes, befriending and social activities, practical help around the home and with everyday tasks) (5). This provided a holistic approach and meant both interventions offered support from a variety of services and/or professionals from a single point of access, which can be seen as reflecting ‘co-location’ (6, 7).
Both studies found that effective collaboration and communication was key to enhancing the relationship between services, and between the service provider and service user.
The relationship between services
Timely and appropriate signposting and onward referrals were central to both interventions and allowed them to function to their full potential, although this did not always happen. For example, staff in the IAPT service explained that they worried community interventions were too specific and had strict eligibility criteria that limited which service users could access them and benefit from their support. But when researchers from Bristol spoke to community staff, they explained that they had experienced some early teething problems and were now able to provide a fuller range of support. As the staff at IAPT were unaware of this, they continued to feel reluctant to make regular referrals, and the support provided by community services was underused. To tackle this, plans were underway to increase interaction between the services by adopting features of physical co-location and bringing IAPT staff to the community sites to let them experience it first-hand. However, IAPT staff were sceptical about the logistics of doing this, partly due to COVID-19 restrictions, and saw it more as an ‘away-day’ idea and not as a priority for the service. Now that restrictions have been lifted, making this happen is likely more feasible, although with the shift to working from home, staff members instead expressed a desire to improve communication remotely. Examples included having named contacts within organisations who take ownership of maintaining the relationships between services.
In their discussions with voluntary and community sector stakeholders, the Cambridge team found that co-location can take on several different forms. The ‘away-day model’, where organisations come together in one place for a day and then return to their own sites, could encourage collaboration and mutual understanding within and across the statutory and community spaces. In fact, community sector stakeholders said that to improve signposting, reduce unnecessary duplication, and provide real-time (24/7) support, the ideal scenario would be to develop a sustainable co-located space that functions as a collaborative local hub. They did however question whether this sort of hub was realistic and sustainable.
The relationship between the service and service user
Trust is key. In the statutory and community spaces explored by Bristol and Cambridge teams, it emerged that trust helped unlock access into individuals’ homes and lives in a manner that facilitates the provision of meaningful support to improve their wellbeing. Service users needed to trust the organisation as a whole and have faith that the support they are being offered would work.
In the IAPT service, clearly explaining the new pathway during the referral process helped to manage expectations of service users. Some expressed disappointment when they expected standard therapy but received something different, while most felt happy that they were at least offered something while they were waiting for psychological therapy as this was often a long and difficult period.
People also need to build relationships with the members of the organisations with whom they interact. The Cambridge team found that this is made easier when there was someone acting as a single focal point. Similarly, in the IAPT service, service users spoke of appreciating having one-on-one telephone sessions alongside the online group sessions as this meant they built rapport with one person who was more familiar with their distinct needs. These one-to-one discussions enabled the development of joint goals and person-centred action plans that took account of the individual’s readiness to change to promote improved health-related behaviours in a way that suited their level of motivation and situation in their wider life.
The challenge in reaching certain more marginalised groups was mentioned in both studies, and strategies were put in place to overcome barriers to access due to language and cultural differences (8). The IAPT service had a team who dealt with translation so that they could support people who did not have English as their first language, and managers from this service discussed wanting to increase the diversity of their workforce to encourage more service users from minority groups such as BAME and LGBTQ+. Likewise, the community sector stakeholders providing co-located community services for older adults echoed the desire to diversify their volunteer pool to provide person-centred support for all members of the community. Therefore, it seems that there is still some way to go to ensure services can be accessed by all, and that new interventions are not contributing to health inequalities already present in society.
What does this mean?
To sum up, the two studies looking at co-location concluded that the statutory and community interventions had a focus on collaboration between services and with the service user to create a safe, empathetic, and inclusive environment in which goals could be met and mental health and wellbeing could be supported in a holistic way. It was clear that there was a common desire to create a co-located hub for professionals to communicate and interact, allocate a single focal point for service users to go to for their support, and diversify the staff and service user population. This model, however, is not without its challenges. Firstly, as the support given to people is not a ‘one size fits all’ and is tailored to individuals’ unique needs, there is an ongoing challenge to quantify and demonstrate impact in a manner that justifies or advocates for stable, long-term funding. To tackle this, we need to consider other ways of gathering evidence, such as championing the public’s voice in policy and funding decisions. Secondly, the set up and sustainability of services in both the statutory and community space are heavily dependent on the ideas and priorities of multiple stakeholders, which are sometimes competing and not originating from those who need to access the services. Again, if we could strengthen collaboration between the service and service user, we could ensure statutory and community support is given in the right way to the right people to improve the mental health of adults in the UK.
As the IAPT interview study was part of a larger evaluation, at least two academic papers will be published – one reporting the interview findings and one reporting the quantitative and cost-effectiveness analysis. We have already delivered a public engagement workshop in collaboration with Bristol’s Independent Mental Health Network, and created an infographic to summarise people’s views. We have also held meetings with the Bristol, North Somerset, and South Gloucestershire Clinical Commissioning Group to discuss how our findings can be translated into practice.
For the study by the Cambridge team, two academic papers will be published also – one reflecting the findings of the realist-informed evaluation and the second about the use of creative methodology to collect data from older adults. We also plan to develop blog posts and illustrated case studies in collaboration with our peer researchers from the The McPin Foundation that will be shared with and disseminated by Age UK Cambridgeshire and Peterborough, Care Network Cambridgeshire and other public engagement and community groups affiliated with this project.
TagsAgeingCommunityHealth and wellbeingInterventionMental HealthPHPESPublic Mental Health