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Purpose This paper aims to introduce Seikatsu Rinsho, a values-based approach to supporting recovery based on identifying service user values and aspirations that have been developed since 1958 in Japan where mental health services are still hospital-based and user involvement is not well-developed. This paper believes this will be of great implications for future practices around the world. Design/methodology/approach Hope is essential to recovery and that hope is dependent on identifying what service users really want for themselves (aspirations) and then ensuring that these are communicated to – and supported by – professionals and carers. This is achieved through examining the life events, which are likely to trigger relapse for a specific individual, the important choices that the person has made throughout his/her life course and the reasons behind them. Through a process of “co-production”, an attempt is made to understand the values expressed in these choices in the context of family history over several generations. Findings The attempt to examine both life events throughout the life course and family history over generations was found to be an effective way to understand a service user and his/her family and then support recovery. The cases where even people with severe and persistent mental health problems have successfully achieved full recovery have been accumulated. Research limitations/implications The limitations of the approach in the context of Japanese mental health services, and the necessity of additional evidence are acknowledged and some thoughts shall be given to future development. Originality/value Seikatsu Rinsho approach can provide a new angle to understand service users and family and a new way to support recovery.

Background No co-productive narrative synthesis of system-level facilitators and barriers to personal recovery in mental illness has been undertaken. Aims To clarify system-level facilitators and barriers to personal recovery of people with mental illness. Method Qualitative study guided by thematic analysis. Data were collected through one focus group, which involved seven service users and three professionals. This group had 11 meetings, each lasting 2 h at a local research institute, between July 2016 to January 2018. Results The analysis yielded three themes: barriers inhibiting positive interaction within personal relationship networks, roots of barriers from mental health systems and the social cultural context, and possible solutions to address the roots. Barriers were acknowledged as those related to sense of safety, locus of control within oneself and reunion with self. The roots of barriers were recognised within mental health services, including system without trauma sensitivity, lack of advocacy support and limited access to psychosocial approaches. Roots from social cultural context were also found. There were no narratives relating to facilitators. A possible solution was to address the roots from systems. Social cultural change was called for that makes personalised goals most valued, with an inclusive design that overcomes stigma, to achieve an open and accepting community. Conclusions The analysis yielded system-level barriers specific to each recovery process. Roots of barriers that need transformation to facilitate personal recovery were identified within mental health services. Social interventions should be further explored to translate the suggested social cultural changes into action.

Background Deinstitutionalisation in Europe has led to the development of community-based accommodation for people with mental health problems. The type, setting, and intensity of support provided vary and the costs are substantial. Yet, despite the large investment in these services, there is little clarity on their aims and outcomes or how they are regarded by staff and the clients. Methods We interviewed 30 staff and 30 clients from the three main types of supported accommodation in England (residential care, supported housing, floating outreach) to explore their perspectives on the purpose of these services, and the components of care considered most helpful. The interviews were coded and analysed using thematic analysis. Results There were generally consistent understandings amongst clients and staff across service types on the goals and purposes of supported accommodation services as: building independence and confidence; supporting people with their mental health; and providing safety and stability. We also noted a competing theme of anxiety about the continuity of support when clients move on from a service. Themes on the experience of what aided effective practice centred on: the supportive presence of others; incremental steps to progress; working together to avoid deskilling and dependency; feeling known and personally understood; tailoring support for social and community engagement; and building confidence through encouragement. Conclusions The findings provide an understanding of the commonalities in service approach, and goals of clients in these services, as well as the facilitators of goal attainment. However, they also highlight a common tension between providing safe and supportive living environments, whilst also promoting independence and facilitating rehabilitative change.

The ideas of ‘recovery’ arise from the experiences of people with mental health problems. The recovery approach emerged in the North American civil rights and consumer and survivor movements from the 1970s onwards. It is concerned with social justice, individual rights, citizenship, equality, freedom from prejudice and discrimination. In this paper we discuss a project in England that has examined how mental health services may be transformed to be more supportive of recovery and the implications that this has for professional practice.

Background Across England, around 60,000 people live in mental health supported accommodation: residential care, supported housing and floating outreach. Residential care and supported housing provide on-site support (residential care provides the highest level), whereas floating outreach staff visit people living in their own tenancies. Despite their abundance, little is known about the quality and outcomes of these services. Objectives The aim was to assess the quality, costs and effectiveness of mental health supported accommodation services in England. The objectives were (1) to adapt the Quality Indicator for Rehabilitative Care (QuIRC) and the Client Assessment of Treatment scale for use in mental health supported accommodation services; (2) to assess the quality and costs of these services in England and the proportion of people who ‘move on’ to less supported accommodation without placement breakdown (e.g. to move from residential care to supported housing or supported housing to floating outreach, or, for those receiving floating outreach, to manage with fewer hours of support); (3) to identify service and service user factors (including costs) associated with greater quality of life, autonomy and successful move-on; and (4) to carry out a feasibility trial to assess the required sample size and appropriate outcomes for a randomised evaluation of two existing models of supported accommodation. Design Objective 1 – focus groups with staff (n = 12) and service users (n = 16); psychometric testing in 52 services, repeated in 87 services (adapted QuIRC) and with 618 service users (adapted Client Assessment of Treatment scale). Objectives 2 and 3 – national survey and prospective cohort study involving 87 services (residential care, n = 22; supported housing, n = 35; floating outreach, n = 30) and 619 service users followed over 30 months; qualitative interviews with 30 staff and 30 service users. Objective 4 – individually randomised, parallel-group feasibility trial in three centres. Setting English mental health supported accommodation services. Participants Staff and users of mental health supported accomodation services. Interventions Feasibility trial involved two existing models of supported accommodation: supported housing and floating outreach. Main outcome measures Cohort study – proportion of participants who successfully moved to less supported accommodation at 30 months’ follow-up without placement breakdown. Feasibility trial – participant recruitment and withdrawal rates. Results The adapted QuIRC [QuIRC: Supported Accomodation (QuIRC-SA)] had excellent inter-rater reliability, and exploratory factor analysis confirmed its structural validity (all items loaded onto the relevant domain at the > ± 0.3 level). The adapted Client Assessment of Treatment for Supported Accommodation had good internal consistency (Cronbach’s alpha 0.89) and convergent validity (r s = 0.369; p p = 0.306), whereas autonomy was greater for supported housing users (mean difference 0.145, 95% confidence interval 0.010 to 0.279; p = 0.035). Qualitative interviews showed that staff and service users shared an understanding of service goals and what constituted effective support. After adjusting for clinical differences, those in floating outreach were more likely to move on successfully at 30 months’ follow-up than those in residential care [odds ratio (OR) 7.96; p p p = 0.04). Successful move-on was positively associated with scores on two QuIRC-SA domains: the degree to which the service promoted ‘human rights’ (e.g. facilitating access to advocacy) and ‘recovery-based practice’ (e.g. holding therapeutic optimism and providing collaborative, individualised care planning). Service use costs for those who moved on were significantly lower than for those who did not. Recruitment in the feasibility trial was difficult: 1432 people were screened but only eight were randomised. Barriers included concerns about accommodation being decided at random and a perceived lack of equipoise among clinicians who felt that individuals needed to ‘step down’ from supported housing to floating outreach services. Conclusions We did not find clear evidence on the most effective model(s) of mental health supported accommodation. Indeed, our feasibility study suggests that trials comparing effectiveness cannot be conducted in this country. A range of options are required to provide appropriate support to individuals with differing needs. Future work Future research in this field requires alternatives to trials. Service planners should be guided by the mental health needs of the local population and the pros and cons of the different services that our study identified, rather than purely financial drivers. Trial registration Current Controlled Trials ISRCTN19689576. Funding This programme was funded by the National Institute for Heath Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 7. See the NIHR Journals Library website for further project information. The fundholders are Camden and Islington NHS Foundation Trust and the research is a collaboration between University College London, Queen Mary University of London, King’s College London, the University of Ulster and Durham University.

BackgroundAround 60 000 people in England live in mental health supported accommodation. There are three main types: residential care, supported housing and floating outreach. Supported housing and floating outreach aim to support service users in moving on to more independent accommodation within 2 years, but there has been little research investigating their effectiveness.AimsA 30-month prospective cohort study investigating outcomes for users of mental health supported accommodation.MethodWe used random sampling, accounting for relevant geographical variation factors, to recruit 87 services (22 residential care, 35 supported housing and 30 floating outreach) and 619 service users (residential care 159, supported housing 251, floating outreach 209) across England. We contacted services every 3 months to investigate the proportion of service users who successfully moved on to more independent accommodation. Multilevel modelling was used to estimate how much of the outcome and cost variations were due to service type and quality, after accounting for service-user characteristics.ResultsOverall 243/586 participants successfully moved on (residential care 15/146, supported housing 96/244, floating outreach 132/196). This was most likely for floating outreach service users (versus residential care: odds ratio 7.96, 95% CI 2.92–21.69, P < 0.001; versus supported housing: odds ratio 2.74, 95% CI 1.01–7.41, P < 0.001) and was associated with reduced costs of care and two aspects of service quality: promotion of human rights and recovery-based practice.ConclusionsMost people do not move on from supported accommodation within the expected time frame. Greater focus on human rights and recovery-based practice may increase service effectiveness.

Purpose – The purpose of this paper is to review the available evidence regarding the effectiveness and cost effectiveness of Recovery Colleges. To make suggestions for future research. Design/methodology/approach – Selective review of relevant published studies, including reports in the “grey” literature. Findings – Despite methodological limitations, it has been consistently found that attendance at Recovery Colleges is perceived to be useful and to help people progress towards their recovery goals. There is some evidence of reductions in service use (and therefore costs). In addition, there is evidence of beneficial effects for peer trainers and possible positive impact on staff attitudes. Research limitations/implications – The existing research highlights the need for further robust studies, using both qualitative and quantitative methods, to understand better the overall impact of Recovery Colleges and the underlying mechanisms of change. Practical implications – There is a need for further studies of the relationship between the “key defining features” and outcomes. This means the collection and pooling of systematic, “practice-based” evidence. Social implications – The introduction of an explicitly recovery educational (“learning”) model into mainstream mental health services seems to have a profound effect on reducing the power differences inherent in traditional professional/patient relationships. If this can be replicated across organisations it could facilitate the kind of fundamental cultural change necessary to give back recovery to the people who have always owned it. Originality/value – The information collected together in this paper is already publicly available, however it is difficult to find. The analysis and interpretation is original.

This paper describes a co-produced pilot evaluation of secondary care services. The study was designed and run jointly by people with expertise through experience, and expertise though training. The results support the feasibility of co-production in such governance procedures in the NHS, which we suggest should now be expected as routine good practice.

Recovery has come to mean living a life beyond mental illness, and recovery orientation is policy in many countries. The aims of this study were to investigate what staff say they do to support recovery and to identify what they perceive as barriers and facilitators associated with providing recovery-oriented support. Data collection included ten focus groups with multidisciplinary clinicians (n = 34) and team leaders (n = 31), and individual interviews with clinicians (n = 18), team leaders (n = 6) and senior managers (n = 8). The identified core category was Competing Priorities, with staff identifying conflicting system priorities that influence how recovery-oriented practice is implemented. Three sub-categories were: Health Process Priorities, Business Priorities, and Staff Role Perception. Efforts to transform services towards a recovery orientation require a whole-systems approach.

BackgroundIndividual placement and support (IPS) is effective in helping patients return to work but is poorly implemented because of clinical ambivalence and fears of relapse.AimsTo assess whether a motivational intervention (motivational interviewing) directed at clinical staff to address ambivalence about employment improved patients' occupational outcomes.MethodTwo of four early intervention teams that already provided IPS were randomised to receive motivational interviewing training for clinicians, focused on attitudinal barriers to employment. The trial was registered with the International Standard Randomised Controlled Trial Register (ISRCTN71943786).ResultsOf 300 eligible participants, 159 consented to the research. Occupational outcomes were obtained for 134 patients (85%) at 12-month follow-up. More patients in the intervention teams than in the IPS-only teams achieved employment by 12 months (29/68 v. 12/66). A random effects logistic regression accounting for clustering by care coordinator, and adjusted for participants' gender, ethnicity, educational and employment history and clinical status scores, confirmed superiority of the intervention (odds ratio = 4.3, 95% CI 1.5–16.6).ConclusionsEmployment outcomes were enhanced by addressing clinicians' ambivalence about their patients returning to work.

The value of peer support for people with mental health problems has long been recognised. However, it is only relatively recently evidence has begun to accumulate that adding appropriately trained and managed peer workers to the mental health workforce can have significant beneficial effects in terms of outcomes for those receiving this service and for those delivering it. In particular, peer workers seem to be effective in terms of increasing service users’ (and their own) feelings of empowerment and social inclusion. There is also evidence to suggest that peer workers can be highly cost-effective. Having said this, it must also be acknowledged that the available outcome research is methodologically limited. There are few randomised controlled trials and there is little empirical evidence regarding the characteristics of effective peer support. This chapter will provide a detailed description of the intervention based on extensive experience with the approach. It will also discuss some of the practical problems of implementation. Finally, it will propose a theory of change based on a reduction in stigma for those receiving this kind of support and its impact on the organisations in which it is located. Proposals for further research based on this model will be suggested.

Mental health services in most countries are facing fundamental challenges in terms of their capacity to meet ever-increasing demands with limited resources and limited powers to increase the availability of funding. Mental health conditions represent the single, largest source of disability (World Health Organization 2008), and the mismatch between demand and supply has been so great that we may have to rethink our traditional assumptions about the content and “style” of service provisions – both “what” is delivered and “who” delivers it.

Summary Background Little research has been done into the effectiveness of mental health supported accommodation services. We did a national survey to investigate provision and costs of services and assess service user quality of life and outcomes across England. Methods We randomly sampled three types of services from 14 nationally representative regions—residential care, supported housing, and floating outreach—and recruited up to ten service users per service. Service quality and costs and service users' quality of life, autonomy, and satisfaction with care were assessed in a standardised manner with validated tools and compared by multilevel modelling. Findings 619 service users were recruited from 22 residential care, 35 supported housing, and 30 floating outreach services. Those in residential care and supported housing had more severe mental health problems than those in floating outreach. 348 (57%) were assessed as being at risk of severe self-neglect and 229 (37%) as being vulnerable to exploitation in the previous 2 years. Residential care was most expensive but provided for people with the greatest needs. The mean annual budget was £466 687 for residential care (range £276 000–777 920), compared with £365 452 for supported housing (£174 877–818 000), and £172 114 for floating outreach (£17 126–491 692). Quality of care was best in supported housing. People in supported housing and floating outreach were more socially included but experienced more crime than those in residential care. After adjustment for service quality and service user sociodemographic and clinical factors, quality of life was similar for service users in residential care and supported housing (mean difference −0·138, 95% CI −0·402 to 0·126, p=0·306) and lower for those in floating outreach than in residential care (−0·424, −0·734 to −0·114, p=0·007). However, autonomy was greater for those in supported housing than for those in residential care (0·145, 0·010 to 0·279, p=0.035). Satisfaction with care was similar across services. Interpretation Supported housing might be cost-effective, but the benefits need to be weighed against the risks associated with increased autonomy. Funding National Institute for Health Research.

SummaryAppropriate housing and support are essential elements in the care of many people with mental health problems, and housing has a major impact on the quality of their lives. In the post-deinstitutionalised services of most high-income countries, a complex range of supported accommodation is available, mostly in the private (for-profit and not-for-profit) sector. We describe the different forms of accommodation and consider recent trends in policy and practice and the evidence base in this area. We also discuss quality issues and the potential impact of the recovery movement.

PurposeThe purpose of this paper is to review representative literature on social inclusion and evaluate the usefulness of the concept in current mental health policy.Design/methodology/approachThe paper employs a selective review of the cost‐effectiveness of interventions aimed at improving social inclusion in children, young adults with first episode psychosis and unemployed adults of working age.FindingsSocial inclusion remains a useful concept in understanding both the causes of mental health problems and how these might best be addressed. Although measurement is not easy, it can be operationalised through a mixture of subjective and objective indicators. There is strong evidence for the effectiveness and cost‐effectiveness of interventions aimed at improving social inclusion for the groups selected. These findings provide strong support for prioritising these interventions, especially in times of severe financial restrictions.Research limitations/implicationsThe selection of literature for review limits the generalisability of the conclusions.Originality/valueThe paper sets out a clear and simple analysis of the concept of social inclusion and how it may be measured. It also brings together the cost‐effectiveness literature on attempts to improve social inclusion for three, key high‐risk groups. The paper strongly supports the value of retaining the concept of social inclusion, despite the fact that it has become temporarily unfashionable.

PurposeThe purpose of this paper is to present the outline of a methodological approach to help address ten key challenges for the implementation of Recovery‐orientated services.Design/methodology/approachAt the onset of the project the authors produced a policy paper, Making Recovery a Reality. This formed the basis of a series of workshops on implementing Recovery in organisations that were held in five mental health trusts in 2008 and 2009.FindingsA key element driving the transformation of Recovery‐orientated mental health services will be the joint work of local systems, setting priorities, agreeing goals and contracts and then monitoring progress and reviewing.Originality/valueThe impetus for the project arose out of the increasing attention being given to the principles of recovery in government policy and in local mental health services, combined with an increasing frustration that there was little to guide how these principles could be put into practice.

BackgroundAcute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years.AimsOur aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations.MethodNational cross-sectional survey of alternatives to standard acute in-patient care.ResultsWe found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions.ConclusionsAlternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

Background No standardised tools for assessing the quality of specialist mental health supported accommodation services exist. To address this, we adapted the Quality Indicator for Rehabilitative care-QuIRC-that was originally developed to assess the quality of longer term inpatient and community based mental health facilities. The QuIRC, which is completed by the service manager and gives ratings of seven domains of care, has good psychometric properties. Methods Focus groups with staff of the three main types of supported accommodation in the UK (residential care, supported housing and floating outreach services) were carried out to identify potential amendments to the QuIRC. Additional advice was gained from consultation with three expert panels, two of which comprised service users with lived experience of mental health and supported accommodation services. The amended QuIRC (QuIRC-SA) was piloted with a manager of each of the three service types. Item response variance, inter-rater reliability and internal consistency were assessed in a random sample of 52 services. Factorial structure and discriminant validity were assessed in a larger random sample of 87 services. Results The QuIRC-SA comprised 143 items of which only 18 items showed a narrow range of response and five items had poor inter-rater reliability. The tool showed good discriminant validity, with supported housing services generally scoring higher than the other two types of supported accommodation on most domains. Exploratory factor analysis showed that the QuIRC-SA items loaded onto the domains to which they had been allocated. Conclusions The QuIRC-SA is the first standardised tool for quality assessment of specialist mental health supported accommodation services. Its psychometric properties mean that it has potential for use in research as well as audit and quality improvement programmes. A web based application is being developed to make it more accessible which will produce a printable report for the service manager about the performance of their service, comparison data for similar services and suggestions on how to improve service quality. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0799-4) contains supplementary material, which is available to authorized users.

A small-scale study is described in which qualitative interviews were carried out with women from Gypsy Traveller communities exploring their perceptions of mental health problems, causes and possible ways of helping. The results suggest that a combination of improved access to conventional services and attempts to build the existing capacity of the community to deal with its own problems would be most effective.

The authors describe the main forms of supported accommodation available to people with mental health problems in the UK. They address the questions of who needs supported accommodation and how people may be selected for the differing types of unit. Historical trends and policy in this area are reviewed and the general research evidence and evidence of cost-effectiveness are considered. A ‘total system’ approach to assessing accommodation need in a locality is advocated. The authors also consider key quality issues that should be addressed for supported accommodation to be effective.

Aims and Method To develop an evidence-based approach that supports the improvement of front-line delivery of adult acute in-patient services. Key factors of effective organisational change were identified from the literature. These were adopted as part of an ‘evidence-based service development’ programme. This approach was used by the Health Advisory Service in a project with an NHS Trust in south east England. Results Significant progress was made in improving the quality of local acute in-patient services. Clinical Implications Further development and evaluation of this approach should be undertaken, since it seems to offer significant opportunities to deliver real improvements in the quality of services.

The ideas of ‘recovery’ arise from the experiences of people with mental health problems. The recovery approach emerged in the North American civil rights and consumer and survivor movements from the 1970s onwards. It is concerned with social justice, individual rights, citizenship, equality, freedom from prejudice and discrimination. In this paper we discuss a project in England that has examined how mental health services may be transformed to be more supportive of recovery and the implications that this has for professional practice.

Background De-institutionalization has led to the provision of various forms of housing with or without support for people with mental illness in the community. In this paper, we review the conceptual issues related to the provision of supported housing schemes, the characteristics of residents, research methods and outcomes, and the factors influencing the quality of care provided. Methods A Medline and hand search of published literature was complemented by information derived from contacting expert researchers in the field. Findings There is considerable diversity of models of supported housing and inconsistent use of terminology to describe them. This makes it difficult to compare schemes, processes, and outcomes. Patients in supported housing are characterized by deficits in self-care and general functioning, whilst behavioral problems such as violence, drug abuse and extreme antisocial habits predict exclusion from supported housing. Most evaluative studies are merely descriptive. In terms of outcomes, it seems that functioning can improve, social integration can be facilitated, and residents are generally more satisfied in supported housing compared with conventional hospital care. Further evidence suggests that most patients prefer regimes with low restrictiveness and more independent living arrangements, although loneliness and isolation have occasionally been reported to be a problem. Little information is available on the factors that mediate outcomes and on skills required by staff. Conclusion Research in supported housing for psychiatric patients has so far been neglected. Large scale surveys on structure, process, and outcomes across a variety of housing schemes may be useful in the future to identify some of the key variables influencing outcomes. The use of direct observation methods in conjunction with other more conventional, standardized instruments may also highlight areas for improvement. In conducting research, structure and process, as well as outcomes, need to be considered. Thus, we need to know not just what to provide, but how to provide it in such a way that it will maximize beneficial outcomes. This represents a considerable research agenda.

The health service spent £2.0 billion on services for people with psychosis in 2012/13. Over half (54%) of this total was devoted to inpatient care. This means that spending is currently skewed towards the more expensive parts of the system, at £350 average cost per day for inpatient care compared with £13 average cost per day in community settings. There is a strong business case for investing in the early intervention and community-based interventions proven to generate savings or value-for-money gains through reduced inpatient admission, or through other routes. This report provides the most up-to-date economic evidence to support the business case for investment in effective, recovery-focused services. Drawing on a wide range of data, evidence for the cost-effectiveness of recovery-focused interventions is set out: • Early Detection (ED) services • Early Intervention (EI) teams • Individual Placement and Support (IPS) • Family therapy • Criminal justice liaison and diversion • Physical health promotion, including health behaviours • Supported housing • Crisis Resolution and Home Treatment (CRHT) teams • Crisis houses • Peer support • Self-management • Cognitive Behavioural Therapy (CBT) • Anti-stigma and discrimination campaigns • Personal Budgets (PBs) • Welfare advice Many of these interventions are shown to be cost-effective, in some cases due to the role they play inpreventing or delaying relapse, or reducing the need for the most expensive care. Some have much wider benefits related to wider recovery outcomes, such as employment, settled housing and better physical health. There is particularly clear evidence for interventions such as EI teams, IPS for employment, CBT and CRHT teams. However, there is evidence to suggest that all of the above interventions contribute to recovery outcomes, reduced costs and/or better value for money. Illustrative examples of the savings incurred through particular interventions include: • Early Intervention: net savings of £7,972 per person after four years. Over a ten-year period, £15 in costs can be avoided for every £1 invested. • Smoking cessation: £1,255 to gain an extra Quality-Adjusted Life Year (QALY), which lies well below the upper threshold of £30,000 recommended by National Institute for Health and Care Excellence (NICE). • Peer support: £4.76 can be gained for every £1 invested. • CBT: Cost per QALY gained of £27,373 for CBT compared to usual care, which is below the upper threshold used by NICE. Local and regional commissioning and pathway development should draw on this evidence, since these interventions are both clinically effective and many will contribute to savings to be reinvested in care. While the scope of this report is primarily at intervention level, the intention is to inform local implementation.

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis-uses (“abuses”) of the concept of recovery: recovery is the latest model; recovery does not apply to “my” patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically-validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.

Detailed progress and outcome data for a small group of ‗new long-stay‘ patients living in a ‗ward-ina-house‘ (hospital hostel) were examined. There was no evidence of pre-existing differences related to final outcome. Those residents who were eventually resettled showed more evidence of improvement over the length of their stay, and had significantly better overall functioning in the period immediately prior to their resettlement. The group who were eventually transferred out of the unit showed less evidence of improvement and more evidence of deterioration, albeit commonly following some initial improvement. They also showed an increase in violent and aggressive behaviour in the weeks immediately prior to their move. The ongoing group of current residents appeared to be specifically characterised by significant fluctuations in their functioning over their length of stay. The implications of these findings for the long-term rehabilitation and care of these patients are discussed.

Finding employment is often a key element in recovery from mental ill health but, argues Professor Geoff Shepherd, few professionals place work at the top of their list of priorities during their efforts to support clients through rehabilitation. It is, he suggests, time for change. Mental health services need to recognise the importance of employment and accept that it is their business.

RIASSUNTOScopo — Esaminare la letteratura riguardante gli effetti della riduzione del numero di letti per lungodegenti nei Servizi di Salute Mentale della Gran Bretagna. Metodo — Revisione selettiva della letteratura, con particolare riferimento a ricerche condotte dall'autore e dai suoi colleghi presso il Sainsbury Centre for Mental Health.Risultati — Le evidenze suggeriscono che gli effetti della riduzione dei letti dei lungodegenti dovrebbero essere esaminati separatamente, distinguendo i «vecchi» dai «nuovi» lungodegenti. Mentre i «vecchi» lungodegenti, che sono stati più direttamente toccati da questi cambiamenti, hanno avuto generalmente risultati positivi, lo stesso non può dirsi per i «nuovi» lungodegenti. Questi pazienti vengono correntemente accumulati in Unità per pazienti gravi, spesso in reparti di ospedali generali o entrano nel meccanismo della «porta girevole», che è rappresentato dai trattamento dei pazienti acuti a cui segue un inadeguato supporto sociale. Nonostante sia evidente la scarsita di letti per acuti, specialmente nelle aree centrali delle città, molti di questi letti sono attualmente occupati da pazienti che sarebbero curati meglio (e con minore spesa) in strutture territoriali alternative, se esse fossero disponibili. Le evidenze suggeriscono che e possibile migliorare gli esiti per questo gruppo di «nuovi» lungodegenti, se fossero utilizzabili specifici team territoriali che si occupino di reperire alloggi e lavoro e di assicurare adeguato sostegno. Conclusioni — Gli effetti della riduzione dei letti di pazienti lungoassistiti dovrebbero essere considerati in una prospettiva sistemica. Si possono organizzare servizi sociali efficaci, ma, per ottenere una efficace sostituzione di un tipo di servizio con un altro, ci deve essere un sistema ben coordinato, con obiettivi definiti e tecnicamente efficiente. Attualmente tali tipi di servizi sono rari. Comunque è improbabile che mettere a fuoco semplicemente un singolo elemento del sistema (ad esempio, il numero di letti) produca soluzioni efficaci ed efficienti.

Rehabilitation is as necessary for a good outcome in major psychiatric illness as effective symptom control. The majority of first-episode psychotic patients do not recover fully and are left with social problems. Rehabilitation aims to minimize these secondary social handicaps. Effective social reintegration depends on the provision of a comprehensive infrastructure of community supports, particularly in the areas of housing and employment. Recent shifts from sheltered living and working arrangements towards supported models, driven by user preferences, are welcome, but have created problems for the most disabled. The lack of high-support housing and work programmes is causing these patients to accumulate inappropriately on acute admission wards in the United Kingdom, stimulating a government initiative for 24-h nursed care beds which is similar to the ward-in-a-house approach. Such models are effective for many, but do not suit all, largely because of the stigma that is attached to quasi-institutionalized settings. User surveys indicate that success of housing and employment programmes depends critically on users' perceptions of the general public's attitude towards them. Issues of stigma and public prejudice must, therefore, be addressed. Services are bound to fail unless they are acceptable to users, professionals and public alike.

This article traces the changing focus of care from institution to community and outlines the range of service models and their key ingredients, essential to successful community care. Specialist community teams - including assertive outreach and home-based treatment - show considerable advantage, but lack of fidelity to the service prototypes is a particular problem. The content of care must include evidence-based psychosocial interventions, but users' needs and priorities must be the guiding principle and with this in mind, work and employment should be afforded the highest priority with the ‘place and train’ model preferred to the traditional ‘train and place’ approach. The paper concludes with some considerations about the training and mix of staff needed to undertake these challenging roles.

Peer support workers - people with their own lived experience of mental illness - provide mutually supportive relationships in secondary mental health services. Increasing numbers are being employed, both in this country and elsewhere. But good quality evidence on the effectiveness of this form of service delivery is in short supply and even less is known about its cost-effectiveness. This paper makes a first attempt at assessing whether peer support provides value for money, looking specifically at whether peer support workers can reduce psychiatric inpatient bed use. Because of the very high cost of inpatient care, the savings that result from even small changes in bed use may be sufficient to outweigh the costs of employing peer workers.

In the last few years, the British National Health Service, local government social services departments, the welfare benefits system, and the organization of primary health care in the United Kingdom have undergone major reforms that have had significant effects on mental health services. Local social service departments were given the lead role in purchasing and coordinating community supports for persons with mental illness, but were not given enough funds to arrange adequate services. In the National Health Service, an internal-market approach, in which local health authorities could contract with any provider or group of providers, was introduced. This purchaser-provider split has created a climate of competition in a traditionally collaborative environment and has reduced staff morale. Similar but separate case management models were introduced in both the health service and the social service departments, which has led to inefficiency in planning care for individual patients. Opportunities were created for general practitioners to use capitated funds to purchase specialty care directly from providers. This arrangement resulted in an initial emphasis on care for less severely mentally ill patients, although some general practitioners are beginning to explore new approaches for supporting severely ill patients in the community. On the positive side, the reforms have led to greater involvement of patients and their families in planning service delivery. However, the authors suggest that policy makers in the U.K. seem to be repeating many of the mistakes made by American mental health systems in the 1960s and 1970s.

Over the past few years important changes have occurred in the organization and financing of mental health services in the UK.These developments are described from a structural and financial perspective and how these changes have created a system that replicates many of the policy mistakes that have

This paper is concerned with the care of the most difficult and severely disabled new patients presenting to mental health services in the U.K. Questions of definition will be examined and the clinical and social characteristics of the population discussed. Since the defining characteristics (and prevalence) of this group are strongly affected by the overall service context, the range of community provisions within one health district (Cambridge) will be described. Examples of a new kind of institutional solution-the 'ward-in-a-house'-will then be presented, together with the underlying principles of management and care. The benefits and limitations of the model will be discussed.

Providing effective care for people with schizophrenia living in the community is one of the central challenges for community based mental health services. However, little progress has yet been made to develop comprehensive interventions which take into account the expressed wishes of the key groups. This paper reports the results of a survey using a combination of structured questionnaires, individual and group discussions with users, family carers and mental health professionals regarding the most important elements of such packages of care. There was a good general consensus, but some differences in the priorities as seen by each group. Users gave more emphasis to practical help (housing, finance, occupation) whereas the professionals emphasised treatment and symptom monitoring. Families felt that everything was important. There were also differences within the professional group between psychiatrists and other members of community mental health teams. The qualitative data supported these quantitative ...

This Audit Commission report has been eagerly awaited. The Commission is an extremely influential and prestigious body and previous reports have quite literally determined government policy with regard to services for people with mental health problems. Is this report going to have the same kind of influence? If so, in what direction is it likely that policy will shift? Does it comprehensively address the key issues? Are there any major ingredients which appear to be missing from its analysis? Does it provide an adequate prescription for changing and improving services? These are the questions that will be addressed in this paper.

The process of implementing the 'Care Programme Approach' (CPA) in a community-based rehabilitation team is described. Details of the operational policy and procedures are given, together with data describing the client group and examining the match between levels of disability and levels of services received. A relationship was found between levels of disability, type of living situation, frequency of contact with 'care coordinator' and frequency of contact with main carer. No relationship was found with frequency of attendance for day care or contact with closest relative. The implications of these findings are discussed.

Activity and outcome data for two ‘ward-in-a-house’ projects for new long-stay in-patients are described. The results confirm that up to a third may be successfully resettled providing that good quality sheltered housing is available. However, a similar proportion appear to find such environments too demanding and may be transferred after an acute exacerbation of symptoms or a violent incident. The remainder need high quality, ongoing care.

Sheltered work settings offer continuing care clients the opportunities of work within a protective environment. However, little is known about which particular aspects of work environments positively or negatively affect mental health. Fourteen features of sheltered work environments were identified according to the model proposed by Warr (1987). The Work Environment Survey (WES) was developed to assess clients' perceptions of the degree to which each feature was present in their work environment. The relationship between clients' mental health and different features of the work environment was then examined. Contrary to prediction, only one feature of the work environment was found to be associated with psychological well-being. Clients' levels of self-esteem were positively related to the degree of importance they felt the general public ascribed to their job. This finding provides empirical support for the notion that sheltered work provision within rehabilitation services should reflect the principle...

BackgroundDifferences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched.AimsTo compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction.MethodPerspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews. Quantitative investigation of the care provided at four alternative and four standard services was undertaken using three instruments developed for this study. The relationship of care received to patient satisfaction was explored.ResultsNo significant difference was found in intensity of staff– patient contact between alternative and standard services. Alternative services provided more psychological and less physical and pharmacological care than standard wards. Care provision may be more collaborative and informal in alternative services. All measured types of care were positively associated with patient satisfaction. Measured differences in the care provided did not explain the greater acceptability of community alternatives.ConclusionsSimilarities in care may be more marked than differences at alternative and standard services. Staff–patient contact is an important determinant of patient satisfaction, so increasing it should be a priority for all acute in-patient services.