New Zealand

A range of peer support services in New Zealand work closely with public mental health providers. ‘Peer supporters’ accept referrals from clinical teams, work with patients on hospital wards and in crisis services, and hold joint meetings with patients and clinicians (Reference Scott, Doughty and KahiScott 2011). Much of this work is located within the parameters of holistic Maori health frameworks in which spiritual, mental and physical aspects are considered as a whole and not treated as separate entities. Peer support is grounded in relationship and mutuality, understanding and not judging peers’ world views, and creating a genuine learning environment (Reference Scott, Doughty and KahiScott 2011).

The USA

Recovery Innovations of Arizona (RIAZ) is a ‘consumer run’ agency in the USA that employs ‘peer support specialists’ in the majority of posts in community and hospital-based mental health services (Reference Daniels, Grant and FilsonDaniels 2010). Peer support specialists act as recovery role models to help patients engage with and develop personal recovery plans. Plans are designed to promote key concepts of individual recovery such as hope, empowerment, personal responsibility and social inclusion. Based on each individual’s goals, peer support specialists offer a wide range of support activities, skill building and case management (Reference Daniels, Grant and FilsonDaniels 2010).

England

In England, Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) launched one of the earliest statutory sector peer worker programmes in the UK, training peer support workers using the Arizona training programme to be employed as members of multidisciplinary teams throughout the Trust. CPFT defines a peer support worker as ‘someone with significant experience of mental distress, who works alongside others with similar difficulties in order to facilitate recovery through promoting hope and providing support based on common experiences’ (Reference Pollitt, Winpenny and NewbouldPollitt 2012: p. vii).

Nottinghamshire Healthcare NHS Trust similarly employs peer support workers across its adult mental health services, but developed a bespoke, accredited training for peer workers – in partnership with the University of Nottingham and local user-led organisation Making Waves (Reference Repper and CarterRepper 2012) – that includes a focus on peer support workers telling their own ‘recovery stories’ in their work.

A different approach has involved an established peer-led service provider – CAPITAL Project Trust – being commissioned to introduce independent peer workers to in-patient wards in Sussex Partnership NHS Foundation Trust (Reference OckwellOckwell 2012). These roles are in addition to the existing statutory mental health service team, unlike the NHS approaches referred to earlier where peer workers have been employed in place of other support worker roles. Some of the issues around these different approaches are considered below.

Benefits for peer workers

Other qualitative studies have suggested that the role helps peer workers to move forward in their own recovery. Consumer-providers working on a peer support programme for people with co-occurring mental health and substance use disorders reported that adopting a helper role benefited them by way of skill development and personal discovery (Reference Salzer and Liptzin ShearSalzer 2002). More recently, it has been shown that working as a peer worker can fulfil individual autonomy, competence and relatedness needs where that work corresponds, respectively, to personal values, uses personal experiences as a resource to help others, and provides opportunities to connect and reciprocate with others (Reference Moran, Russinova and GiduguMoran 2014).

Peer support has also been found to be beneficial for peer workers in more practical ways. **Mowbray et al (1998) found that, 1 year after being employed, peer workers reported improved financial situation, and valued the structure, supervision and safety which the job provided in their daily lives. Experience of stigma in the workplace has been identified as a reason for not seeking employment by people with experience of mental health problems (Reference Marwaha and JohnsonMarwaha 2005). In a study conducted by Reference Ochocka, Nelson and JanzenOchocka and colleagues (2006), peer providers explained how being involved in peer support made it less likely that they would identify stigma as an obstacle for getting work and more likely to seek and sustain employment.

Benefits to mental health service delivery

The organisational benefits of introducing peer workers into mental health service teams have also been identified. In a qualitative study in New Zealand, peer workers and their managers described the importance of peer support services working in an integrated way with clinical services (Reference Scott, Doughty and KahiScott 2011); peer workers were able to improve information-sharing with patients and developed a non-clinical, non-judgemental and ‘hopeful’ approach to writing notes. Patients have noted that peer workers have better understood the challenges patients face, enabling different relationships to develop with peer workers compared with non-peer staff (Reference Coatsworth-Puspoky, Forchuk and Ward-GriffinCoatsworth-Puspoky 2006).

In a study of a peer support programme for veterans in the USA, it was noted that patients, administrators and providers were enthusiastic about peer workers serving as a ‘bridge between the mental health system and the patient to improve service delivery’ (Reference Chinman, Shoai and CohenChinman 2010: p. 185). Finally, in an evaluation of a peer-run decision support intervention at an out-patient psychiatric medication clinic in the USA, medical practitioners reported that peer workers gained a more holistic understanding of their client’s needs, whereas patients found that their concerns were more likely to be heard by peer workers (Reference Deegan, Rapp and HolterDeegan 2008).

Service use and cost outcomes

A number of quantitative studies evaluating the peer worker role have indicated potential beneficial service use and cost outcomes of employing peer workers. For example, in a US comparison group study contrasted a peer support out-patient programme with traditional care, there was a 50% reduction in hospital readmissions over a 1-year period among out-patients receiving the peer support programme (Reference Davidson, Chinman and SellsDavidson 2006). Another comparison group study found that consumers involved in a peer support programme demonstrated longer community tenure than those who had not been involved in the service, as well as significantly fewer hospital readmissions over a 3-year period (Reference Chinman, Shoai and CohenMin 2007).

Reference Lawn, Smith and HunterLawn and colleagues (2008) conducted an observational study which evaluated a peer support service in Australia over a period of 3 months and found there was a reduction in readmission rates and that 300 bed-days were saved compared with historical controls. The cost and productivity case for introducing non-professional roles into the UK health and social care workforce has been made (Department of Health 2009). Claims have been made on the basis of these and similar pilot studies for the cost savings of employing peer workers (Reference Trachtenberg, Parsonage and ShepherdTrachtenberg 2013).

Improvements in psychosocial outcomes

Improvements in individual psychosocial outcomes have also been indicated. A US cross-sectional survey (Reference CorriganCorrigan 2006) demonstrated a significant association between receiving support from ‘consumer-operated services’ and individual levels of empowerment and recovery. A US before-and-after study of community-based peer support (Reference Resnick and RosenheckResnick 2008) found significant improvement in empowerment in the cohort as a whole, and in the ‘as treated’ subsample (those receiving more than ten sessions of peer support) significant improvement in confidence as well.

Although the potential for improvement in outcome is indicated, randomised controlled trial (RCT) evidence is more equivocal. A recent Cochrane review (Reference Pitt, Lowe and HillPitt 2013) reviewed 11 RCTs, all of which were based in statutory community mental health services (2 of the trials were partnerships between statutory and peer-led providers). Nine studies were from the USA, one was from Australia and one from the UK. Five trials compared peer workers with mental health professionals in similar roles (four of these were case management roles and one a group therapy facilitator role). Six trials compared mental health services with and without peer workers in an additional role (four of these were mentoring or advocacy roles and two were referral to additional peer-led services). The review found no evidence of significant differences in a range of psychosocial, satisfaction or service use outcomes, with the exception of a small reduction in use of emergency services in two of the studies. There were no significant differences in costs in any of the studies considered.

The review authors caution, first that the quality of existing evidence is low because of issues about randomisation, masking of assessment and contamination between study aims, and second that clearer description of the peer worker role (including tasks, training and supervision) as well as greater differentiation between peer worker interventions and treatment as usual is necessary to aid evaluation (Reference Pitt, Lowe and HillPitt 2013).

Distinctiveness of the peer worker role

Distinctiveness in the tasks associated with a new role, compared with other roles in the team, has been shown more widely to be a key facilitator of new role adoption (Reference Dierdorff and MorgesonDierdorff 2007). There is qualitative evidence that suggests that the absence of a clear job description for peer workers creates challenges for team working (Reference Kemp and HendersonKemp 2012). In a survey of managerial and human resources staff in agencies employing peer workers in the USA, role conflict and confusion, allied to poorly defined job structure, were identified as undermining role integration (Reference Gates and AkabasGates 2007). In addition, where new roles become a repository of unwanted tasks for the team, it has been noted how the role can become diluted (Reference Bach and Della RoccaBach 2000); for example, a peer worker might not have sufficient time to focus on core relational aspects of the role if generic support tasks take up the bulk of their time. Where peer workers are to be introduced as members of the multidisciplinary mental health team there are arguments in favour of standardising and regulating the role (Reference Stewart, Watson and MontagueStewart 2008). However, others have suggested that such formalisation will undermine the peer ‘essence’ of the role (Reference Faulkner and BassettFaulkner 2010), that there is a risk of peer workers becoming ‘socialised’ into the working culture around them, and of the distinctiveness of the role being lost (Reference Schmidt, Gill and PrattSchmidt 2008).

Role distinctiveness can be easier to achieve where peer workers are introduced in new roles that complement the existing mental health team, although in these cases a different set of challenges can arise. Peer workers have described the experience of being ‘othered’ by the professional team (Reference Berry, Hayward and ChandlerBerry 2011) or of having to negotiate a complex identity that is neither staff nor service user (Reference Gillard, Borschmann and TurnerGillard 2013) and of feeling disempowered as a result.

Shared expectations of the peer worker role

Shared expectations, across the organisation, of a new staff role has been indicated as another key facilitator of role adoption (Reference Dierdorff and MorgesonDierdorff 2007). A Delphi study of 92 practitioners, researchers and peer support practitioners from 17 countries (Reference Creamer, Varker and BissonCreamer 2012) suggested that placing clear boundaries around what is and what is not expected of the role, particularly in training, could help identify appropriate distribution of tasks between peer and non-peer staff. Allied to this, the ability of workers to bring power to a new role, especially in the case of non-professional roles is crucial (Reference TurnerTurner 1990). For peer workers, power lies in the knowledge they bring – derived from their own lived experience – and the capability of using that insight to build relationships with patients (Reference Gillard, Borschmann and TurnerGillard 2013).

The potential benefits of introducing peer workers can be undermined where expectations of the role are not shared; for example, where peer workers are not given sufficient autonomy to use their lived experience in their role (Reference Moran, Russinova and GiduguMoran 2012). Difference in expectation of whether or not peer workers should work to conventional, clinical practice boundaries has been highlighted (Reference Mead and MacNeilMead 2006), and resistance among existing staff can also be encountered where there are perceived challenges to professional jurisdiction (Reference Currie, Finn and MartinCurrie 2009). This might especially be the case where a peer worker role has been introduced into a team in place of an existing staff role.

Strategic alignment

Alignment of a new role with other strategic drivers in the system has been indicated as a generic facilitator of role adoption (Reference TurnerTurner 1990), and innovative practice in UK mental health services has been shown to lead to sustainable organisational change where it aligns with a number of strategic agendas (Reference Gillard, Borschmann and TurnerGillard 2012). Where the introduction of peer workers is specifically linked to organisational delivery on a recovery or social inclusion agenda, for example, there might be greater clarity of expectation around the function of the role. Conversely, peer workers have reported that their role felt undermined where attitudes to individual recovery were not shared by their managers and co-workers (Reference Moran, Russinova and GiduguMoran 2012). It has been suggested that strategic alignment has to be established on a number of levels – organisation, team and individual – for it to be effective (Reference Nadler and TushmanNadler 1980). There is evidence to suggest that demonstrating the value of peer worker roles, through explicit reference to the role in organisational mission statements, further supports successful introduction of the role (Reference Gates and AkabasGates 2007).

Organisational support

Practical support on an organisational level, including provision of appropriate training and supervision, also facilitates role adoption (Reference TurnerTurner 1990). Specific challenges for peer workers, related to the demands of using their own lived experience in their work, have been identified (Reference Davidson, Chinman and SellsDavidson 2006). Qualitative research from the UK has indicated that peer workers do not always feel that the support they are provided with responds to role-specific challenges (Reference Gillard, Borschmann and TurnerGillard 2013). The need for role-specific training that focuses on when and how to share lived experience has been indicated (Reference Repper and CarterRepper 2011). In the UK, new guidance has been issued that responds to these needs (Repper 2013).