Current approaches

Responsibilities for promoting social inclusion for service users in the NHS are unclear, and this area is consequently often deprioritised. Nevertheless, legislation relating to the NHS Long Term Plan, the Community Mental Health Framework, Integrated Care Systems, and the Mental Health Act and the Care Act 2014, alongside guidance from the National Institute of Health and Care Excellency (NICE), notes that the NHS has an important role to play in promoting social inclusion.

The domain of paramount concern for contemporary policymakers – employment – is one of the most researched areas of social responses to severe mental illness. The most successful intervention in this space, Individual Placement and Support (IPS), aims to increase paid employment through a strict fidelity intervention.^{Reference Becker and Drake3} IPS involves intensive individual support, a rapid job search consistent with the individual’s preferences, followed by placement in paid employment, and time-unlimited in-work support for both the employee and the employer. The intervention is open to all those who want to work. This approach has been prioritised within the NHS. For example, it was a key commitment in the NHS Long Term Plan to support 55 000 people with severe mental illness into employment per year by 2023/24.

Meta-analytic evidence shows this intervention is associated with small-medium effect sizes on employment rate, job duration and wages; overall, 48.8% of IPS participants compared with 28.3% of controls were employed during follow-up.^{Reference De Winter, Couwenbergh, Van Weeghel, Sanches, Michon and Bond4} However, in the UK and Europe effectiveness is lower in than non-European countries.^{Reference De Winter, Couwenbergh, Van Weeghel, Sanches, Michon and Bond4} Local to our authors’ (M.B., S.W., S.M.) service, Lambeth Vocational Services (LVS), IPS currently results in 19% of individuals achieving employment.⁵

Presently, evidence suggests that IPS may not be effective for the most vulnerable individuals. For example, IPS is more effective for those with lower baseline levels of symptoms.^{Reference De Winter, Couwenbergh, Van Weeghel, Sanches, Michon and Bond4} Further, it is possible that those experiencing the most complex challenges are excluded from trials upon which such evidence is based. Finally, the existing literature does not investigate how effects vary by forms of marginalisation that are known to be associated with reduced intervention effectiveness in mental health services more broadly – such as ethnicity or multiple intersecting forms of adversity.^{Reference Greenburgh, Baldwin, Weir, Asif, Laporte and Bertram1}

In our view, this restriction of social interventions to the domain of employment sustains existing inequalities as the most vulnerable individuals are left behind. People facing complex mental health and social challenges require a broader range of help and opportunity in areas beyond paid employment to meaningfully rebuild their lives. IPS currently overlooks other valued activities that are crucial in earlier stages of recovery, such as stabilising housing conditions and accessing volunteering, education and community activities.

The narrow focus of IPS is recognised by some NHS trusts. However, little guidance is given on how or what extended support should look like. Indeed, social support is deprioritised, so that service users are only signposted to other activities. For example, National Institute for Health and Care Excellence (NICE) guidelines and the College Centre for Quality Improvement (CCQI) standards for Early Intervention in Psychosis services only require supported employment – whereas activities for those who are unable to attend mainstream education, training or work are listed as to be ‘considered’ (NICE) or ‘expected’ (CCQI) rather than essential.^{Reference Chandra, Patterson and Hodge6,7}

Here, we describe what an alternative looks like. This approach addresses two critical features of social support which are not currently widespread: support with a range of social inclusion activities beyond employment which are meaningful to the individual, and support addressing fundamental stability in areas such as debt, social security and housing. Members of our group facilitate this support at LVS in South London and Maudsley NHS Foundation Trust (SLaM). This approach is well established and consistent with extensive feedback from service users and supported by a formal qualitative evaluation. We detail the nuances of this approach and its core underlying principles below.

Service components

At LVS, we (M.B., S.W., S.M.) facilitate user-led, person-centred programmes to help people experiencing mental ill health find their own way forward and engage in vocational activities which are important to them.^{Reference Bertram8} Our experience shows that people in crisis often face severe adversities and require time-unlimited offers of flexible support, where fundamental needs, such as housing and social security, are met and stabilised, and where psychological safety and confidence is established, before more ambitious outcomes like paid employment can be considered. Individuals can self-refer to our service or be referred by healthcare professionals.

LVS facilitates several projects to foster social inclusion. First, through Vocation Matters, the first user-led project within SLaM, we provide one-to-one support to help people achieve their vocational goals, which involves ongoing support across a range of challenges (e.g. housing stability, access to social security, support during employment) and comprises peer support. Second, LVS runs the Community Opportunities Information Network (COIN), an online resource providing information on local opportunities, which can be supplemented with in-person tailored support through an open weekly drop-in support session. Finally, we house an employment creation service, Clean and Care, which directly employs service users and has obtained large commercial carpet cleaning contracts, thus providing steady sources of income and engagement for people who are seeking to find ways back into the workforce. LVS offers several other projects, including digital inclusion initiatives, newsletters, art groups, social inclusion training for in-patient staff and, previously, job creation programmes in forensic settings.^{Reference Samele, Forrester and Bertram9} LVS employs staff with a variety of professional backgrounds, including occupational therapy, psychotherapy and counselling, and service users with lived experience to deliver these projects. Stable funding of LVS allows new projects to innovate and be implemented to support people in new ways.

A co-produced qualitative evaluation of peer support and vocational services at LVS documented how the service helps individuals achieve their vocational goals. The seven participants, who had received support from LVS for a range of 2–7 years, all reported experiencing a range of benefits relating to health, personal well-being and community inclusion,^{Reference Bertram and McDonald10} including reduced use of secondary services, improved diet and sleep, greater confidence and optimism, employment, completion of accredited training courses and improved relationships with family. In addition to this formal evaluation, LVS continually collects feedback from service users, which highlights a high degree of positive outcomes and satisfaction with the service. LVS also monitors yearly project outcome data demonstrating that service users consistently achieve a range of vocational outcomes. For readers interested in finding out more, please contact the corresponding author, A.G., to receive a copy of the regular newsletter which often includes service user feedback and project outcomes.

While LVS programmes are specific and tailored to their unique context, the concept of prioritising social inclusion through holistic person-centred approaches and offering a wider range of support across a continuum of need can be applied by any service across the country. LVS is a stand-alone service with close links to mental health services and clinicians. Its independence from mainstream services is a key component and strength. Unlike IPS, which can be provided by existing NHS teams (e.g. community mental health teams), LVS offers non-clinical, friendly spaces which do not trigger the negative associations that many of the most vulnerable service users have with clinical services. Expansion of the LVS model would represent a new model of service delivery in many regions. Indeed, it goes above and beyond the simple signposting typically delivered in social prescribing services and is user-run to a far greater extent. Nevertheless, it is consistent with priorities outlined in community mental health transformation initiatives.

LVS has faced barriers to maximising impact – not least extensive cuts during austerity – and, as such, this description does not describe a ‘perfect’ service. Nevertheless, the core components and underlying principles represent an effective approach to helping vulnerable individuals in contact with mental health services find their own way forward.

Bridges of trust

The guiding principle underpinning work at LVS is to build bridges of trust with service users through offering genuinely person-centred care. This principle should be applied in any service seeking to foster social inclusion for people facing complex challenges and mental ill health. The aforementioned service evaluation identified the trusting relationships built by LVS as a key validating condition that supported learning, change and growth.^{Reference Bertram and McDonald10}

Staff at LVS create trusting relationships in many ways, including offering time-unlimited support to establish feelings of safety and community, ensuring user insight underpins the support offered, offering peer support, providing welcoming and non-clinical environments, offering self-referral and not imposing exclusion criteria based on diagnosis.

Perhaps most crucially, the individual is seen as the expert of their own experience. Unlike conventional services, which use assessment as the bedrock of the intervention process, a first meeting is characterised by an unstructured conversation – a dialogue – rather than formal assessments. This makes risk management transparent and more reliable, because people are more likely to share on a deeper level. The team focuses on a person’s experiences of life, interests and abilities, rather than only on their problems, thereby radically reimagining ‘assessment’, which typically comprises a pressurised focus on the individual and any deficits.