The employment of non-professional community support workers to work with people with mental health problems grew rapidly in the 1990s.1 The schemes are popular with mental health service managers and have particular benefits in helping clients to find meaningful activities and build up their social networks.2
But many observers have queried how well such workers can be supervised and have stressed the need for evaluation of effectiveness and safety.
Clients eligible for this support have severe and complex needs and support workers are often employed within teams of non-professionals, and visit clients alone in their own home.
Flexicare, a scheme jointly funded by Westminster city council and Kensington, Chelsea and Westminster health authority, has been in operation since 1993. It is run by Westminster Association for Mental Health, and employs three full-time organisers and a co-ordinator. Funding is£200,000 a year.
In late 1997 it was employing 55 people to provide support to 158 clients. Carers start on£4 an hour, rising to£4.50 and£5 after two satisfactory reviews. Many are students who need to supplement their grant and most support two, three or four clients for a few hours a week.
Students, and particularly psychology students, were considered ideal, having the inclination - and sympathy - to befriend people with mental health problems in their own homes. Carers interviewed as part of this evaluation confirmed that they considered benefits to their education, personal development and curriculum vitae were more important than the financial reward.3 The evaluation monitored 33 new referrals over a six- month period from late 1997, compared basic characteristics of these referrals to those referred in 1994, gained postal feedback from those making the referral, followed up the 26 people referred in the first year four years later, and interviewed 11 clients and 18 carers.
Most of the carers work between two and nine hours a week. Most are under 35 though a few are over 60. Carers are asked to commit themselves to the scheme for a minimum of 12 months, and this is emphasised in their initial two-day training, which includes mental health awareness and care management. Records show that about two-thirds of them honour the commitment.
It appears that many of those who decide to stop have ceased to take new clients long before withdrawing from existing relationships.
Of the existing relationships that are ended when the carer wants to withdraw from the scheme, those stopped first are the furthest away geographically, and the people with whom the relationship was least successful and rewarding to the Flexicarer.
Examination of the support given to the 26 clients referred to the scheme in 1994 and followed up in 1998 showed that the majority had received good continuity of care. For 21 people, at least one of their carers had stayed at least a year before leaving, or before the arrangement came to an end.
Many pairings lasted much longer. Three people were still seeing the same carer four years on.
Thirteen of the 26 people starting with the scheme in 1994 were still receiving Flexicare support at the four-year follow-up. Of those who stopped, only two did so because they no longer wished to see a carer. Other reasons were death, moving away and becoming very ill and rejecting all services. Four clients withdrew from the scheme after the departure of a carer they considered irreplaceable.
An audit of the contact file, noting telephone feedback from carers to organisers, revealed considerable commitment and some apparently highly successful pairings which endured throughout the four years. The audit also gave an insight into the difficulties of maintaining a service for some clients who were intermittently quite rejecting toward their Flexicarer.3
The organisers' skills appeared to be central to the success of the scheme. Telephone contact with carers was required at least weekly for the first six to 12 months, and in some cases after every single visit.
Seven of 18 carers interviewed cited an example of an emergency situation, though none of these was so worrying as to result in a 999 call. One in three had felt unsafe on at least one occasion, and half had felt concerned at some time about the safety of a client. Four crises were acute mental health breakdowns, where a carer arrived to find their client in an extreme state of distress, or in one case, the client became acutely disturbed and aggressive in a public place. Carers are advised to leave the situation and telephone the organisers immediately if they are worried.
Management priorities for established services are quite different from those in newly established schemes. At the beginning, the client list is low, enthusiasm for a new service high, and an early priority is to establish a reputation with referrers and clients. Four years on, the scheme had reached the ceiling number of hours paid for (400 hours of Flexicare visits per week), had a change of manager, and a waiting list was beginning to build.
Those making referrals were asked to consider indicating priority among people referred. Any delay in advertising, recruiting or training new carers meant a waiting list would develop. It was agreed that clients already in the scheme and needing new carers should take priority over new referrals. People most likely to face a wait were those needing a male carer. The scheme initially received more female than male referrals, but as its reputation and popularity grew, so more men, and more ethnic minority clients, were referred. The proportion of black clients rose from 19 per cent in 1994 to 36 per cent in 1997. The proportion of men rose from 33 per cent to 45 per cent.
In June 1998, 55 carers were employed. But a total of 119 people had started work with the scheme over the first three-year period. In 1997 training sessions were needed every three months to keep up with demand and turnover. Eleven clients were interviewed in the evaluation. They particularly valued the friendship, sympathetic ear, having something to look forward to and having someone to go out with. This echoes previous findings.2
Care managers and community psychiatric nurses making referrals also valued the service. Fifteen regular referrers who completed a postal questionnaire were all quite or very satisfied with the scheme, and said they would be concerned if it was no longer available.
They felt it was most important for clients who were isolated, vulnerable to self-neglect, and those who were not engaging well with other services. Half said they had used the scheme to provide practical help for their clients with daily living skills, and they all sought help for their clients to improve social contacts and activities outside the home.
Some clearly valued the fact that an additional person was going to be seeing their client on a regular basis, half of them agreeing that one of the objectives was to reduce their own anxieties about the client. Six of 15 referrers also aimed to be able to reduce their own contact with the client.
The scheme's popularity was also evident from the level of referrals - which almost doubled each year - and had reached the ceiling covered by the contract in late 1997, leading to a growing waiting list.
Care managers referred people they felt were most likely to benefit rather than those who most wanted to be in the scheme (see box). Non-professionals can supply elements of care package that cannot easily be provided by mainstream services, and bring a normalising experience for clients, who appear to value in particular the ordinary quality of the relationship.
Time was spent in such ordinary, but important activities as shopping, cooking, swimming, sorting out household chores and bills, chatting, and walking down to the cafe for a drink.
Allowances are paid for joint activities. Carers brought their own interests to the relationship and some of the most successful partnerships were those where a good match was achieved.
The large number of sessional workers made such matching much more likely. Of the 55 employed in June 1998, 24 were of African-Caribbean origin, three were from South America, Thailand and Asia, while nine were white Europeans from Italy, Spain, Germany and Greece.
Recruiting, training, monitoring and supporting support workers is far from cheap. A high level of supervision, from the three full-time organisers and the co-ordinator, appeared to be crucial to ensuring effectiveness and safety.
It might ease some of the practical difficulties of support for the more complex cases to employ a small number of workers on part-time or full- time contracts, though this might further increase costs. But the scheme provides what many of us imagined would be at the heart of good community care - social support which facilitates ordinary living.
Jennifer Newton is senior lecturer in community care, North London University.
A scheme that trains students to become part-time community support workers to people with mental health problems has proved popular with clients.
A third of the carers had felt unsafe on at least one occasion and the service requires a high level of supervision.
Professionals considered the service particularly useful for clients who felt isolated, and those at risk of self-neglect.
1 Johnson S, Brooks L et al. Sending in the paras. HSJ 1997; 107 (5570): 30-31.
2 Murray A, Shepherd G, Onyett S, Muijen M. More than a Friend. Sainsbury Centre for Mental Health 1997.
3 Newton J. Evaluation of Flexicare. Report to Westminster social services department and Westminster Association of Mental Health, 1998.
People identified by care managers as their priorities for referral
Those who are very isolated 13
Those vulnerable to self-neglect 12
Those with no other services 10
Those I am most worried about 6
Those on whom I need regular feedback 3
Those very keen to have the service 2