a tool for mental health services

Evaluating socially inclusive practice: part one – a tool for mental health services Clio Berry Assistant Psychologist, Sussex Partnership NHS Foundation Trust Mark Hayward Director of Research, Sussex Partnership NHS Foundation Trust, Academic Tutor, Department of Psychology, Surrey University Andy Porter Associate Director of Social Inclusion, Sussex Partnership NHS Foundation Trust

Abstract This paper gives an overview of the development and pilot implementation of a tool to evaluate socially inclusive practice. There are strong links between social inclusion and better mental health outcomes for people who access services, yet a very limited amount of research exists concerning ways to evaluate socially inclusive practice within mental health services. The paper describes the creation of a tripartite tool to access the views of mental health teams who work with service users, and the service users themselves. As part of the movement towards recovery and social inclusion, the Department of Health requires that social and occupational needs become embedded in care plans alongside health needs (DoH, 1999), and so an analysis of care plan documentation completed the evaluation tool. A pilot evaluation was conducted with three mental health teams in Sussex and found issues with engagement and response rate. Lessons learned and future implications are discussed.

Key words social inclusion; mental health outcomes; mental health services; service users

Introduction The need to increase social inclusion for people with mental health problems has been a paramount feature of government policy and literature concerning mental health services since the publication of Mental Health and

Social Exclusion by the Social Exclusion Unit (ODPM, 2004), which highlighted associations between social exclusion, mental health problems and suicide. Although the body of research is continuously expanding, social exclusion and inclusion are still somewhat contested concepts. The definition from the work of the Social Exclusion Unit seems synonymous with poverty, ‘a shorthand label for what can happen when individuals or areas suffer from a combination of linked problems such as unemployment, poor skills, low incomes, poor housing, high crime environments, bad health and family breakdown’ (SEU, 2001 p9). However, there is a suggestion that stigma and discrimination or ‘societal responses’ to mental health problems (Sayce, 2001), may be a cause of social exclusion, rather than a component. Indeed, it is important to consider that a lack of friendships, relationships, social roles and (free or low cost) leisure activities do not necessarily stem from a lack of economic resources. It is likely that societal attitudes towards those with mental health problems are a participative cause of their exclusion from relationships and social networks (Burns et al, 2007). Sayce (2001) proposed a definition of social exclusion that focused both on impairments and societal responses: ‘the interlocking and mutually compounding problems of impairment, discrimination, diminished social role, lack of economic and social participation and disability’, also stating that ‘repeated rejection and consequent restriction of hope and expectation’ are factors in exclusion (p122). Perhaps this restriction of hope and expectation leads people to ‘voluntarily’ exclude themselves even if they have opportunities for participation.

The Journal of Mental Health Training, Education and Practice Volume 3 Issue 4 December 2008 © Pavilion Journals (Brighton) Ltd

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Evaluating socially inclusive practice: part one – a tool for mental health services

It has been suggested that mental health services themselves may contribute to the ‘restriction of hope and expectation’, as staff may have low expectations of people with mental health problems (ODPM, 2004), which may be exacerbated for people who are given a diagnosis of severe mental health problem, such as schizophrenia or bipolar disorder. In such cases, staff may succumb to what the Social Exclusion Unit term as a ‘waiting to get well’ fallacy (ODPM, 2004) and restrict the opportunities of the service user, preferring to wait for their symptoms to diminish before increasing participation, particularly in mainstream opportunities. It is possible that a lack of awareness in the NHS concerning the links between overcoming social exclusion and returning to work, and better health outcomes (ODPM, 2004) may, alongside low expectations, contribute to a lack of encouragement of service user participation in social, vocational and recreational activities. Consequently, it is imperative that staff are made aware that evidence suggests that the social and behavioural impairments of people with mental health problems may be increased or even caused by social isolation (Sayce, 2001). There is some divergence of opinion as to how social inclusion for people with mental health issues may be realised. In accordance with a move towards conceptualising social exclusion as a combination of impairments and societal responses, there is an increasing suggestion that inclusion will require more than the targeting of selected indicators of exclusion. It has been suggested that it is imperative to address the processes of exclusion itself and achieve a society that is more inclusive and appreciative of difference. For social inclusion to be about more than just trying to change service users to enable them to fit into an unwelcoming society, it is necessary to address the stigma and discrimination against people with mental health problems both within and outside of mental health services (Dunn, 1999; Hacking et al, 2006; Sayce, 2001). The National Social Inclusion Programme (NSIP) was created to implement the 27-point action plan emanating from the report of the Social Exclusion Unit. One of NSIP’s aims was the development of the mental health workforce into one capable of practising in a socially inclusive manner. As part of this aim, NSIP and collaborators developed The 10 Essential Shared Capabilities (Hope, 2004)

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into a best practice guide for both organisations and individual practitioners. The resulting publication, Capabilities for Inclusive Practice (CfIP) (DoH, 2007), provides a framework to evaluate these capabilities (values, characteristics and abilities) in relation to the practice of mental health teams. CfIP identifies best practice as a dual approach of targeting selected inclusion indicators such as housing, benefits, employment and education, but also challenging inequality, minimising power differentials in the mental health service and putting the service user at the centre of care and care planning. Therefore, a tool mapped onto each of the 10 capabilities will enable evaluation of both the reduction of exclusion, and the promotion of inclusive values.

Method A three-part methodology was chosen for the tool in order to obtain a triangulation of data from the relevant stakeholders in team practice, including the team and the service users. Data from care plans was chosen as the third strand due to recent government policy detailing that care plans include occupational and social needs alongside the health care needs of service users. The tool was designed to follow CfIP as closely as possible in order to map practice to each of the 10 capabilities, so effecting a comparison between current and best mental health team practice.

Team questionnaire A group consensus methodology was chosen as the vehicle to obtain team data. Although government policy requires that socially inclusive practice be part of the remit of every staff member, it was decided to target the team as a whole rather than individual staff members and ask the team to reach a consensus on how each capability was practised. This method was hypothesised to generate both more representative and more reliable data. It was believed that errors of omission and commission would be minimised due to a sense of diffusion of responsibility across the team. Asking explicitly for consensus was designed to prompt the team into delivering a more representative picture of their practice, challenging the veracity of each others’ statements and providing a snapshot of team culture. It does not seem reasonable to attempt to extrapolate to whole team practice from a small sample of team



members, nor does it seem feasible to attempt to survey or interview all members of a team. A team questionnaire (appendix 1) was created, in which the definition of each capability was given and the team was asked how they utilised the capability in practice. A limited definition was given in order to minimise priming the team on what might constitute practising each capability. In piloting this questionnaire, one researcher both facilitated and transcribed the discussion. An ease of reaching consensus measure was taken for each team response to items on the team questionnaire (see appendix 1). The measure was dichotomous and scored from -2 to +2. This measure was designed to provide a snapshot of whether the team did or did not practise a particular capability (positive or negative respectively) and how strongly they agreed on this (0–2), with the zero value given when no consensus could be reached.

Service user questionnaire The second part of the tool, a service user questionnaire, was developed in order to access a large quantity of information from service users with minimum dependence on resources (see appendix 2). Like the team questionnaire, the service user questionnaire was designed to map onto CfIP, although excluding ESC10 ‘personal development and learning’ as it was not possible to gather data from service users with regards to team training and personal development. The questionnaire items were devised from CfIP and practice suggestions from the National Development Team (Bates, 2007). All capabilities were covered but ESC1 ‘working in partnership’ was over-represented due to its amenableness to service user data. Section 1 of the questionnaire included a list of potential inclusion opportunities (eg. vocational opportunities, support groups and leisure activities) and requested that service users tick any that they knew about, and those which the team had helped them to contact or attend, or any which did not apply. This was designed to provide a sense of which opportunities teams may be prioritising eg. housing and benefits services, and for which opportunities participation could be encouraged and increased. Section 2 of the questionnaire included a list of further services from the team or ‘support steps’ that could be offered to facilitate participation in the opportunities mentioned in section 1. Service users were required to tick

which support steps they had been offered and any that did not apply. Section 3 was a question and answer section designed to cover the capabilities not mentioned in sections 1 and 2. ESC 5 ‘promoting recovery’ was over-represented as the capability has two important components, encouraging friendship among service users and in the community, and encouraging service users’ independence from mental health services. Additional questions were included concerning: 1) any increase in social inclusion since working with the team, which could be used as an outcome indicator of effectiveness or inclusive practice; and 2) barriers to inclusion, which could be used to help teams focus on factors that maintain the exclusion of service users.

Distribution Although face-to-face information-gathering procures a higher response rate than postal surveys, posting the questionnaire was the most appropriate method for capturing a large amount of both qualitative and quantitative information with minimum load on evaluator and team resources. It was hypothesised that the response rate might be low for a service user population as there were likely to be issues of literacy, comprehension and engagement. In this pilot, the following measures, from a systematic review of postal questionnaire responses (Edwards et al, 2002), were taken to improve response rate: a cover letter was supplied; which was hand-addressed to the service user recipient and hand-signed by the research assistant; the questionnaire items were designed to be clearly worded and quite general; no sensitive information was requested; the questionnaires also had return envelopes with first-class stamps. The distribution of questionnaires to service users was made shortly after conducting the team questionnaire, during which each team was asked to encourage service users to complete the questionnaires and to assist them if necessary. Each team provided the researcher with a list of all active service users on the enhanced level of the CPA care plan, as these people were deemed to be at greatest risk of social exclusion, and therefore, most in need of socially inclusive practice. Service users residing in secure and forensic services at the time of distribution did not receive a questionnaire but all inpatient service users were included.


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Care plan documentation analysis The final part of the tool was a documentation analysis of care plans (see appendix 3). A checklist was chosen for this as it is a brief and simple method of recording the presence of inclusive features in care plans, and is potentially suitable for future use in care plan audits. The CPA Brief Audit Tool (CPA-BAT) was consulted in the creation of this checklist, and items were derived from CfIP. General practices or features of care planning suggested in CfIP, for example that care plans consist of clear and accessible language (ESC3), were covered in the first section of the checklist. The features were recorded as present (‘yes’) or absent (‘no’) depending on the evidence in the care plan, with an N/A response also available when evidence was provided as to why a feature or practice was not suitable for a particular service user. For example, when a service user is currently an inpatient and is not ready to consider any voluntary or paid employment, it is unlikely that an employment/ vocational adviser will be consulted in the care plan. More specific practices for care planning with regards to social inclusion were included in section two of the checklist. These items were believed likely to manifest as a ‘service user need’ and ‘corresponding action’. For example, ‘spirituality’ (ESC2 respecting diversity): a service user may express a need to become more involved with his or her religion, and a corresponding action could be for staff to allocate a private room for prayer in a day service, or give the service user information and support for participation in a local church or spiritual group. This type of response was recorded as need and action present (column two ‘yes’ and three ‘yes’). ‘No’ responses were recorded either when there was no information as to whether a particular need item applied to the service user (‘no’ and ‘no’) or where the need was recorded but no corresponding action has been offered or considered (‘yes’ and ‘no’). The checklist also included a N/A column to record when a particular need did not apply to a service user eg. if the service user in the above example was not religious or spiritual and had no desire to participate in any faithbased activity. Unless reasoning was given as to why staff had deemed certain services or needs as inapplicable to service users, it was not possible to elucidate whether the given item was actually relevant or not and therefore the item was recorded as absent (no and no).

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Only a record of the presence of items was taken from the care plan, rather than any actual information. This limited the amount of sensitive information lifted from the care plan, thereby encouraging service users to share their care plan and also reducing the time taken to administer the checklist. Finally, for each item in both sections of the checklist, there was a space to record the presence of a service user comment relating to that item. While it was not expected that care plans would include service user comments on every single item, some service user involvement into care plans is required. It was decided that ‘agreed action plan’ would not be considered to constitute a service user comment as the entirety of the care plan is supposed to be an agreed plan between staff and service users. Instead, the presence of direct comments from the service user (ie. quoted first or third person) was recorded (‘yes’ or ‘no’) to allow some interpretation about the level of service user involvement with regard to particular capabilities.

Procedure A single researcher performed the pilot evaluation. The team questionnaire was completed with each team during one of their planned business meetings. The service user questionnaires were distributed at approximately the same time as the team questionnaire was performed, with the care plan analysis being conducted upon receiving consent from service users. The researcher both facilitated and transcribed the team questionnaires over a 50-minute period. The service user questionnaires were delivered by post to each service user on the enhanced level of the care programme approach except those in secure and forensic services. Upon returning the questionnaire, service users were asked to give explicit consent for the evaluation of their care plans. The researcher analysed electronic care plans on receipt of service user consent forms.

Participants Three mental health teams from Sussex Partnership NHS Foundation Trust participated in the pilot of the evaluation tool: a community mental health team and two assertive outreach teams. Service users within each team were invited to participate if they had an enhanced care plan. The average response rate from service users across the three teams was 17% (45/271). Of these participants, 71% (32) gave permission for their care plan to be evaluated, but three



of these care plans were not finalised or absent for some other reason. The specific findings from the evaluation of one team are reported in part two of this paper.

Results Methodology The evaluation tool can be used to extract data relevant to the CfIP and so assess socially inclusive practice. The main limitations discovered in the pilot use of the tool related to engagement with the evaluation. Although no formal feedback was requested from teams with regards to the team questionnaire, verbal feedback was obtained. Two teams found the team questionnaire ‘interesting’, however, a team member from one team stated ‘I feel like I’m at a job interview’, although later stating that the feedback from the pilot was ‘helpful’. There was a sense in which the ‘ease of consensus’ measure was more of a summative measure of the whole discussion and an aide memoir for the researcher. It would be necessary to establish inter-rater reliability in order to ensure the reliability of the measure. In addition, it may not be useful to compare results from this measure across teams as the qualitative data is needed to qualify the numerical measurement. For example, one team received a score of 0 (no consensus) for ESC2 respecting diversity. This score alone might suggest that the team could not decide whether they respected diversity at all. However, the qualitative data suggested that the team had an in-depth discussion about what it means to respect diversity, with one staff member denying that the team really did respect diversity as there was no sense of understanding what mental health means to different cultures and how this should affect peoples’ treatment, management by mental health and other services and recovery in general. Therefore, instead of failing to agree on whether they practised the capability, as might appear from the numerical measure, the team had a more sophisticated discussion about what the capability might actually entail. Therefore, it is recommended that the ease of consensus measure is used as a summary alongside qualitative data from any given team. A major limitation of the pilot was the low response rate for the service user questionnaire. Although it was felt that some interesting information was gained from these responses, the response rate was too low to draw robust conclusions about the overall experience of service users under the care of each team.

Anecdotal evidence from team managers suggested that some service users found the questionnaire ‘too much’, ‘too personal’ and ‘too intrusive’. The service user questionnaire was revised (appendix 2) following the pilot evaluation. Similar items in sections one and two were amalgamated into single items (for example, items concerning travelling to inclusion opportunities, such as information and someone to travel with, now form one statement), and two questions concerning service user desire to be included, and opportunities that the service user felt to be inaccessible, were removed from section three as only a limited number of service users responded to these questions. Possible revisions to reduce the perceived sense of intrusion were not apparent, as the questions are quite general and are about the service received, rather than the service users themselves. Perhaps the request to view care plans can be seen as intrusive. Nevertheless, the request itself is necessary as analysing care plans is important to thoroughly evaluate inclusive practice, and within this pilot, inclusive care planning was found to be the area that required most improvement. The CPA care plan checklist is a pragmatic way of recording inclusive aspects of care plan documentation, however, two items (participation successes and problems) were conflated and a revised version was produced (appendix 3).

Measurement Assuming that the capabilities within the CfIP framework do define socially inclusive practice, the clear mapping of the tool onto the CfIP framework lends credibility to its validity as an evaluation measure of socially inclusive practice. Ideally, the tool should display internal consistency in that items relating to different capabilities should correlate with each other as they are all part of socially inclusive practice. In this way, the tool can be used to isolate instances of a lack of correlation (ie. between capabilities) or corroboration (ie. between the team, service users and/or documentation evidence), which can then be used to improve practice overall. Conducting a pilot study has highlighted the apparent variability of team practice, and has emphasised that good practice in one capability does not necessarily indicate good practice in another capability.


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Data handling Triangulating the data is important in order to find inconsistencies in the team practice ie. where the team deliver socially inclusive practice but do not record doing so in care plans. The close adherence of the tool to the CfIP document simplifies this process. Triangulation of the data from the pilot is discussed in a separate paper. Using a forced choice method in the service user questionnaire also proved useful in terms of meaningful data being collected ie. not just ‘unsure’ responses.

Conclusion This tool can be used to evaluate the socially inclusive practice of mental health teams from three perspectives, staff, service user and care plan documentation. Issues of engagement and response were found in this pilot and recommendations are suggested to overcome these limitations. For the team questionnaire, it is recommended that one researcher facilitates and one transcribes. This would allow both researchers to record the consensus score and then inter-rater reliability could be established thereby increasing the robustness of this measure. It is also recommended that researchers consider riskassessments in addition to care plans if sufficient time and resources exist, so that information as to whether socially inclusive practice features in risk-management procedures is obtained ie. whether mental health staff consider how risk and safety issues can be managed without constraining opportunities for inclusion. Due to the concerns about engagement and response rate, two further changes are suggested. If the tool was to be deployed with greater resources, the service user questionnaire could be used in a semi-structured interview format, which might yield a higher response rate, and was suggested by the teams in the current evaluation to be a more pleasant experience for service user participants. In addition, it is likely to encourage service users who may feel excluded from a written questionnaire due to issues with literacy. A focus group of service users is also suggested as a possible means of securing a higher response rate as it too provides a more interactive method of information gathering. However, it would be difficult to extract Likert scored data from focus groups and could minimise the ease and effectiveness of using the tool as a monitoring exercise over time. In addition, this method might

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exclude those service users who have issues with confidence and social interaction – arguably some of the people most in need of socially inclusive practice. With more limited resources, further measures could be taken to improve the response to a postal questionnaire, such as distributing a preparatory letter inviting participation from service users, and distributing additional copies of the questionnaire to the residences of service users, which have been found to increase response rate (Edwards et al, 2002). These methods would encourage participants to feel that their response is important to the research, and make the questionnaire more accessible and a part of everyday activity. It is concluded that it would not be appropriate for mental health teams to evaluate themselves using this tool as this would lead to doubts about the influence of social desirability bias, both from the team and from service users. Instead, the responsibility for administering socially inclusive practice evaluations should be given to audit staff, as they currently take responsibility for auditing CPA documentation and risk-assessments. Due to the increasing profile of socially inclusive issues as part of government guidelines for mental health care, audit teams should be assessing care plans and risk-assessments for social inclusion needs alongside other health care needs. The current evaluation tool offers audit staff a pragmatic and simple method in which to do this and match current inclusive practice against the ideal best practice set out in CfIP. Sussex Partnership NHS Foundation Trust audit staff are currently in the process of rolling out this tool to all assertive outreach teams.

Acknowledgements The authors wish to thank all service users who participated in this pilot evaluation and all staff at Sussex Partnership NHS Foundation Trust who facilitated or participated in this evaluation, especially the three mental health teams. In addition, the authors wish to thank Naomi Hankinson of the National Social Inclusion Programme.

Address for correspondence Clio Berry Assistant Psychologist Sussex Partnership NHS Foundation Trust Email: [email protected]



References Bates P (2007) Accidents at the Inclusion Traffic Lights: Mistakes and misunderstandings in supporting people to achieve social inclusion [online]. Available at: http://www.ndt.org.uk/ETS/ ETILT.htm (accessed October 2008). Burns T, Catty J, Becker T, Drake R, Fioritti A, Knapp M, Lauber C, Rossler W, Tomow T & van Busschbach J (2007) The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial. The Lancet 370 (9593) 1146–1152. Department of Health (1999) National Service Framework for Mental Health Modern Standards and Service Models. London: DoH. Department of Health (2007) Capabilities for Inclusive Practice [online]. London: DoH. Available at: http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGui dance/DH_078095 (accessed October 2008). Hope R (2004) The 10 Essential Shared Capabilities: A framework for the whole of the mental health workforce. London: DoH. Dunn S (1999) Creating Accepting Communities: Report of the MIND inquiry into social exclusion and mental health problems. London: Mind. Edwards P, Roberts I, Clarke M, DiGiusepi C, Pratao S, Wentz R & Kwan I (2002) Increasing response rates to postal questionnaires: systematic review. British Medical Journal [online] 324 (7347) 1168–1169 Available at: http://www.bmj.com/cgi/ content/abstract/324/7347/1183 (accessed October 2008). Hacking S, Secker S, Kent L, Shenton J & Spandler H (2006) Mental health and arts participation: the state of the art in England. The Journal of the Royal Society for the Promotion of Health 126 (3) 121–127. Office of the Deputy Prime Minister (2004) Mental Health and Social Exclusion: Social Exclusion Unit report. London: ODPM. Sayce L (2001) Social inclusion and mental health. Psychiatric Bulletin 25 121–123. Social Exclusion Unit (2001) Preventing Social Exclusion: Report by the Social Exclusion Unit. London: Cabinet Office.

Appendix 1 Team questionnaire Please consider the brief definition of each capability and come to a team consensus regarding whether or not and how the capability is built into the day-to-day practice of this team. Further elaboration as to what the capability is about can be given if required. Capability is used here to refer to values, attitudes, characteristics, skills and abilities. So the consensus will be an agreed summary of the team’s beliefs, abilities and actions related to each particular capability. I will stop the discussion if it reaches four minutes in order to cover all items.

1. Working in partnership concerns developing and maintaining constructive relationships both with formal organisations, for example, Jobcentre Plus and informal community networks, such as an arts project. How is this capability utilised in the practice of this team? (ESC1) 2. Respecting diversity refers to working in ways that respect and value diversity including age, race, culture, disability, gender, spirituality and sexuality. How is the capability practised? (ESC2) 3. Practising ethically means acknowledging and minimising power differentials where this is necessary and possible to so. How is ethical practice achieved by this team? (ESC3) 4. Challenging inequality means recognising the effect of social inequality and exclusion on recovery and challenging the causes and effects of stigma on users, carers and mental health services. How does this team challenge inequality? (ESC4) 5. Promoting recovery means working positively to empower people to achieve a life that has a sense of meaning, belonging and participation in the community. How does this team promote recovery? (ESC5) 6. Identifying needs and strengths refers to collecting information regarding the needs and strengths of individual service users. How is this capability used in this team? (ESC6) 7. Providing service user centred care refers to negotiating achievable goals and working to achieve these goals with the resources available to the service user. How is service user centred care provided by this team? (ESC7) 8. Making a difference refers to delivering evidencebased and values-based practice to meet needs and aspirations of service users and their families and carers. How does this team make a difference? (ESC8) 9. Promoting safety and positive risk-taking means understanding the risk of harm to the service user and others and empowering service users to decide


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the level of risk they are prepared to take with their health and safety. How does this team promote safety and positive risk-taking? (ESC9) 10. Personal development and learning refers to keeping up-to-date with changes in practice and participating in personal and professional development. How does this team facilitate personal development and learning? (ESC10) General questions regarding all capabilities: 11. Are there any capabilities for which this team believe more training is required? 12. To what extent do you value practising in a socially inclusive manner? Questionnaire measurement: ease of reaching consensus score +2 Positive consensus The team quickly reach a consensus shared by all team members as minimal differences of opinions exist or

differences are quickly reconciled. The consensus is that the capability is utilised in team practice. +1 Positive consensus The team arrive at a consensus more slowly as opinions are more divergent and slower to reconcile. The consensus is that the capability is utilised in team practice. 0 No consensus The team do not arrive at a consensus as one collaborative conclusion cannot be reached. There is no consensus as to whether the capability is practised by the team. If the discussion continues for more than four minutes without agreement, a verdict of no consensus will be recorded and the researcher will move on to the next question. -1 Negative consensus The team arrive at a consensus more slowly as opinions are more divergent and slower to reconcile. The consensus is that the capability is not endorsed in practice. -2 Negative consensus The team quickly reach a consensus shared by all team members. The consensus is that the capability is not endorsed in practice.

Appendix 2: Section one questions Do you know about this service?

Has the team helped you get in touch?

Has the team N/A This helped you visit service does not or use the service? apply to you

Job or voluntary work eg. getting or going back to a job Community projects eg. conservation, community garden Housing advice or support Benefits advice Public transport eg. bus service Training/advising other services eg. giving your views to a new recovery project Support groups eg. Alcoholics Anonymous Education eg. evening class at local college Arts activities eg. painting group at local school or college Sports activities eg. joining the local gym Leisure activities eg. relaxation class at local community centre, chess club, music group

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Appendix 2 Service user questionnaire (SUQ) Section one (ESC1) This section is about the types of opportunities that this team has helped you to get involved with. Please look at each service on the left and tick whether you know about the service. Please also tick whether the team has helped you get in touch and visit or use the service, or if the service does not apply to you. Section two This section is about what support you have been offered to help you get involved with any services you have chosen to join. Please read each statement and tick AGREE if you have been offered this help or DISAGREE if not. Please tick N/A (not applicable) if the statement is about a service that you have never been in need of. Section three This section is about your feelings about the team. It is also about your feelings about being involved in your local community. Please tick the answer that you feel applies to you. Please also write down any other comments you may have in the space after each question.

Appendix 2: Section two questions

1. Do you feel that your gender and sexuality, religion, ethnicity and culture have been taken into account by the team? (ESC2) Definitely yes Possibly no

Possibly yes Definitely no

Any comments………………………………....................…… ……………………………………………………………………... 2. Do you feel that the team has taken account of your skills and strengths? (ESC6) Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………... 3. Do you feel that the team has been interested in goals that are meaningful to you? (ESC7) Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………... AGREE

DISAGREE

N/A

I have been offered help with travelling to other services or activities, for example, information, someone to get the bus with. A staff member has offered to come with me for one or more visits to another service or project. A staff member has helped me to find another service user to visit another service or class with me. I have been offered job skills advice or training to help me with getting voluntary or paid employment or returning to a job. I have been offered help or advice with making friends in the community, for example, clubs or a local church. I have been offered help for my social skills to help me make friends and join in, for example, helping me overcome shyness or arguments with other people. The team have asked me what I think about any service or classes that I have joined or visited. The team have helped me with any problems I have had with joining in another service or class, for example, not understanding what I have to do.


ESC 1 1 5 7 5 7 8 8

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4. Do you feel that the team has been positive about you getting better? (ESC5) Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………... 5. Do you feel that the team has helped you to overcome the problems of other people judging you or preventing you from doing things because of your mental health difficulties? (ESC4) For example, the team may have given you help or advice on how to deal with people’s views or ideas about you or supported you in a meeting with an employer. Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………...

8. Do you feel that the team has helped you to become gradually more independent from mental health services? (ESC5) Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………... 9. Do you feel more involved in your local community since you have been in contact with this team? Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………... 10.What do you feel are the three main things that stop you from being more involved in the local community or in other services? 1)………………………………....................……

6. Do you feel that you have had enough input into your care plan? (ESC3) Definitely yes Possibly no N/A


2)………………………………....................…… 3)………………………………....................……

Any comments………………………………....................…… ……………………………………………………………………... 7. Do you feel that the team has helped you to manage your own problems? (ESC9) Definitely yes Possibly no N/A


Any comments………………………………....................…… ……………………………………………………………………...

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Appendix 3 Documentation analysis (DA) 1: Features of the care plan Was this present?

Service user input

N/A

ESC

Information regarding inclusion opportunities

yes/no

yes/no

1

Employment adviser

yes/no

yes/no

1

Record of service user’s support network

yes/no

yes/no

3

Clear and accessible language

yes/no

yes/no

3

Exclusion experience

yes/no

yes/no

6

Positive inclusive features already in place

yes/no

yes/no

8

Review of participation successes/problems

yes/no

yes/no

8

2: Identifying inclusion needs and actions in the care plan

Ethnicity/culture

Was this issue in the care plan?

Was an action/ service specified?

yes/no

N/A

Service user input

ESC

yes/no

yes/no

2

Spirituality

yes/no

yes/no

yes/no

2

Gender

yes/no

yes/no

yes/no

2

Sexuality

yes/no

yes/no

yes/no

2

Stable community role

yes/no

yes/no

yes/no

4

Stigma encountered in community

yes/no

yes/no

yes/no

4

Making/maintaining friends

yes/no

yes/no

yes/no

5

Enhancing independence mental health services/ tapering down service

yes/no

yes/no

yes/no

5

Service user strengths

yes/no

yes/no

yes/no

6

Inclusion desires/interests

yes/no

yes/no

yes/no

6

Barriers to inclusion

yes/no

yes/no

yes/no

6

Goals/aspirations

yes/no

yes/no

yes/no

7

Developing skills for participation

yes/no

yes/no

yes/no

7

Positive risks

yes/no

yes/no

yes/no

9


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