Summary of the impact

University of Nottingham research in the field of recovery has had a major influence on changes in mental health policy. It has led to a new model of service provision both in the UK (including through NICE guidance and the NHS's outcomes framework) and internationally (including in Western Europe, Scandinavia, Canada, Australia and Asia). The work has contributed to a reduction in the use of mainstream services and has enhanced the quality of life enjoyed by people with mental health problems. It has also been central to the Department of Health's Implementing Recovery through Organisational Change programme, which has pioneered the use of Recovery Colleges and peer support workers in mental health care in the UK.

Underpinning research

In mental health the term "recovery" describes the process through which people find ways of living meaningful lives with or without the symptoms of their condition. It involves making sense of and finding meaning in what has happened, becoming adept in self-care, building a new sense of self and purpose and discovering one's own resourcefulness. The University of Nottingham's Mental Health Group has been at the forefront of this developing and increasingly influential field since the early 1990s.

Dr Julie Repper (Associate Professor, 1990-1996; 2000-2001; 2007-present) began her research in this area by carrying out a series of studies of mental health service users' experiences. Crucially, this work took into account those who rejected or were rejected by services as well as those who used them. The first study, published in 1995, examined the progress, characteristics and views of a hundred consecutive referrals to an exemplary community care service, comparing those who were accepted with those who were refused care or chose to refuse it themselves [1]. This was followed by examinations of the mental health experiences of women [2], "difficult" patients [3] and other marginalised and excluded groups, including "drop-outs" from services and members of the traveller community. These studies highlighted strengths, weakness and gaps in service provision, the need to "work across boundaries" to address the social and economic factors underlying mental health problems and the importance of ensuring consistency and communication between primary and secondary care.

The findings were subsequently used to inform and refine the concept of recovery in mental health and its potential implications both for service users and practitioners. In close collaboration with Dr Rachel Perkins, a clinical psychologist working in mental health services in South West London, Repper advanced "recovery" from an abstract notion to a practical possibility, offering an accessible and evidence-based definition, model and guide for a full range of stakeholders, including people with mental health problems, mental health practitioners, service managers and policymakers. This was comprehensively articulated in Repper and Perkins' 2003 book Social Inclusion and Recovery: A Model for Mental Health Practice [4], the research for which was conducted during her tenure at Nottingham in 2001.

During the past six years Repper has led a number of knowledge-transfer projects that have explored the transformation of organisations through the implementation of recovery-focused practice, including in the UK, Western Europe, Canada, Australia, Turkey and Japan. These have particularly focused on the changing relationships between service providers and service users as a result of the introduction of peer support workers (PSWs) as paid employees who embody recovery, inspire hope and facilitate practical competencies. In 2011 Repper published the first systematic review of the literature on PSWs working in mental health, describing the development and impact of their employment and the accompanying challenges. She noted the potential of PSWs to drive recovery-focused changes in services but cautioned that careful training, supervision and management would be required to develop further PSW support [5].

References to the research

Key publications (Nottingham researchers in bold):

Grants:

Repper, J: Investigation of the assessment of carers of people with mental health problems, NIHR SDO, 2005-2009 - £299,000

Callaghan, P, Repper, J, Lovell, K, Playle, J, Baker, J and Watkins, M: Evaluation of the Chief Nursing Officer's Review of Mental Health Nursing, Department of Health Policy Research Programme, 2007-2009 - £189,000

Repper, J: Changing hearts and minds, NIHR SDO, 2008-2009 - £99,000

Repper, J: Implementing Recovery through Organisational Change, Department of Health, 2010-2012 - £500,000

Repper, J and Callaghan, P: Closing the gap: transforming the culture of mental health services through peer support, Health Foundation, 2010-2013 - £396,000

Repper, J: Implementing Recovery through Organisational Change, Phase 2 (ImROC2), Centre for Mental Health (£40,000) and NHS Confederation Mental Health Network (£40,000), 2012-2014

Repper, J: Advancing Recovery in Ireland, Genio Funding, 2013-2014 - £75,000

Details of the impact

Research by the Mental Health Group has played a significant role in shaping a new model of mental health service provision. This has helped improve mental health outcomes both in the UK and internationally throughout the impact period.

Repper and Perkins' model of recovery for mental health practice, as first articulated in their 2003 book, has continued to serve as a key reference point for various policy documents and tools for commissioning services in the UK. These include the NICE Guideline on Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care, published by the British Psychological Society and the Royal College of Psychiatrists in 2010 [a], and the latest Joint Commissioning Panel for Mental Health Cases for Change [b]. A recovery framework now explicitly underpins all mental health professionals, with professional documents produced by the Royal College of Psychiatrists (November 2009) [c], the British Psychological Society (November 2009) [d], the College of Occupational Therapy and the Royal College of Nursing among those citing Repper's research.

Repper's work has also been widely cited in policy guidance outside the UK, including the Republic of Ireland (Recovery: What You Should Expect from a Good-Quality Mental Health Service, published by Mental Health Reform in 2013) [e] and Canada (Mental Health Promotion in Ontario: A Call to Action, published by the Canadian Mental Health Association in November 2008) [f]. It has also featured in policy guidance elsewhere in Western Europe, Scandinavia, Turkey and Australia. Repper is frequently asked to work with services and researchers further afield and during the past three years alone has delivered invited papers in New Zealand, the US, Canada, Japan, Uganda and India, as well as recovery-focused workshops in Holland, Denmark, Sweden, Switzerland, France and Italy. Key materials have been translated into Italian, German, French and Japanese.

Repper's research has been crucial in shaping Implementing Recovery through Organisational Change (ImROC), a two-year project managed by the NHS Confederation Mental Health Network and funded by the Department of Health [g]. As a core member of the ImROC team, Repper secured funding to pilot a methodology for implementing recovery in six NHS Trusts — Central and North West London, Devon Partnership, Southern Health, Mersey Care, St Andrew's Healthcare and West London Mental Health — from 2010 to 2012. A February 2013 report outlined the scheme's impact on health services across England, including the introduction of Recovery Colleges, the employment and training of PSWs and service users' involvement in decision-making at all levels in the participating Trusts. Further funding has been secured for the second phase of ImROC, to run from 2013 to 2015, and 21 more Trusts have so far elected to buy into ImROC organisational development and membership of a network of action learning sets. Speaking in February 2013, Care and Support Minister Norman Lamb remarked: "Through ImROC, mental health service providers are recognising that people with direct experience of mental ill health can offer just as valuable expertise as medics and clinicians. Combined, they can gently revolutionise mental health care in this country." [h] Repper is now Deputy Director of this project, which is advising the Department of Health on measuring outcomes to reflect recovery, and has also developed a methodology for implementing recovery principles in clinical teams, which is being used in 26 Trusts and by two Clinical Commissioning Groups as part of their CQUIN targets.

Recovery Colleges, which use an education paradigm to complement traditional treatment approaches, have been a key element of the ImROC project, with Repper's research central to their introduction in the UK. Repper led the pilot establishment of Nottingham Recovery College in 2011 and later co-authored a briefing paper highlighting Recovery Colleges' positive effects on service user satisfaction, confidence, recovery and inclusion [i]. The success of the four Recovery Colleges that opened during the first phase of ImROC has led to plans for 22 more, with spread into primary care services and a focus on long-term conditions. In addition, Repper has instigated and supervised the development of Recovery Colleges in Brescia, Italy; Kerala, India; and Tokyo, Japan.

Drawing on her review of the evidence in support of their development, Repper has also been at the forefront of the introduction of PSWs. She worked with Nottingham's Institute of Mental Health to create the UK's first accredited PSW training programme, which to date has been used by 12 different organisations. Some 150 PSWs have been employed during the first phase of ImROC, approximately 98% of whom have been taken out of long-term unemployment, with more than 400 more trained. Repper has led two innovative projects to develop learning around the employment of PSWs — the first funded by the East Midlands Research Innovation Fund and providing six PSW posts within Nottinghamshire Healthcare Trust, the second funded by the Health Foundation and creating a further seven posts, a further 13 people taken out of unemployment into salaried positions. These developments have driven the commissioning and writing of an ImROC briefing paper [j], an overview for mental health charity Together and further guidance for the Mental Health Network Workforce Commission and the Centre for Mental Health. Peer support is now supported in national policy, and more than 25 NHS Trusts currently employ PSWs.

Sources to corroborate the impact

a. Schizophrenia: The NICE Guideline on Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Updated Edition), British Psychological Society and Royal College of Psychiatrists (2010) - see page 30
http://www.rcpsych.ac.uk/usefulresources/publications/niceguidelines/9781854334794.aspx

b. Joint Commissioning Panel for Mental Health, Cases for Change [Accessed 14 October 2013] - see reference 8
http://www.jcpmh.info/commissioning-tools/cases-for-change/introduction/references/

c. Enabling Recovery for People with Complex Mental Health Needs: A Template for Rehabilitation Services, Royal College of Psychiatrists, (November 2009) - see page 39
http://www.rcpsych.ac.uk/pdf/fr_rs_1_forwebsite.pdf

d. Psychological Health and Well-Being: A New Ethos for Mental Health, British Psychological Society Professional Practice Board (November 2009) - see page 23
http://www.bps.org.uk/sites/default/files/images/psychological_health_and_well-being_-_a_new_ethos_for_mental_health.pdf"

e. Recovery: What You Should Expect from a Good-Quality Mental Health Service, Mental Health Reform (2013) - see pages 12 and 17
http://www.mentalhealthreform.ie/wp-content/uploads/2013/03/MHR-Recovery-paper-final-April-2013.pdf"

f. Mental Health Promotion in Ontario: A Call to Action (November 2008) [Accessed 14 October 2013] - see references 3.0 and 3.6
http://ontario.cmha.ca/public_policy/mental-health-promotion-in-ontario-a-call-to-action; http://www.wellesleyinstitute.com/publication/mental-health-%E2%80%9Crecovery%E2%80%9D-users-and-refusers/"

g. Supporting Recovery in Mental Health, NHS Confederation/ImROC briefing, June 2012 http://www.nhsconfed.org/Publications/Documents/Supporting_recovery_in_mental_health.pdf

h. `Ministerial backing for nationwide roll-out of mental health recovery support', NHS Confederation, February 14 2013 [Accessed 14 October 2013]
http://www.nhsconfed.org/PressReleases/Archive/2013/Pages/Minister_backs_ImROC_roll-out.aspx"

i. Recovery Colleges, Centre for Mental Health/NHS Confederation/ImROC briefing, May 2012
http://www.centreformentalhealth.org.uk/pdfs/Recovery_Colleges.pdf

j. Peer Support Workers: Theory and Practice, Centre for Mental Health/NHS Confederation/ImROC briefing, June 2013
http://www.nhsconfed.org/Documents/ImROC%20Peer%20Support%20Workers%20Theory%20and%20Practice.pdf