1. and not necessarily those of the NIHR School for Social Care Research
Co-producing mental health care Introducing the Connecting People Intervention
Martin Webber
International Centre for Mental Health Social Research, University of York
Research team: Meredith Newlin, Samantha Treacy, David Morris, Sharon Howarth, Paul McCrone
Quick run through of some of the background to the CP project, to allow you to see where the intervention that we will be talking to you about today has come from.
This presentation presents independent research funded by the Department of Health’s NIHR
School for Social Care Research. The views expressed in this presentation are those of the author
and not necessarily those of the NIHR School for Social Care Research

2. Background Key roles of mental health social workers
Promoting recovery and social inclusion with individuals and families.
Working co-productively and innovatively with local communities to support community capacity, personal and family resilience, earlier intervention and active citizenship.
Don’t go into too much detail on this slide
Marx’s originial idea of ‘capital’ spoke about the fat cat factory owners who paid their employees minimum wage, and created a lot of economic capital – but where does this capital go is a key question..!
Putnam’s work is based more on the importance of trust, whereas Bourdieu’s lies more on the importance of networks. Our model lies closer to the Bourdieu perspective.
Human capital speaks about developing capital through eg education
Social capital is developing capital through the other people that you know, who are in your network.

3. Background
Care Act (2014)
Duty for local authorities to promote individuals’ well-being, which includes an individual’s contribution to society (s.1)
Priority for local authorities to prevent need for social care (s.2)
These outcomes are very general – all great ideas but little help for the implementation of them – that is what policies do
Underneath this is the idea of payment by results – how do you feel about this?

4. Background
Economic capital: Resources that can be used to produce financial gains (Marx, 1867)
Cultural capital: Information resources and socially valued assets, e.g. knowledge of the arts, music or literature (Bourdieu, 1997)
Human capital: Qualifications, training and work experience (Becker 1964)
Social capital: Sum of resources (actual or potential) that accrue to a person or group from access to a network of relationships or membership in a group (Bourdieu, 1997)
Community capital: Combination of capitals within a defined area or community, required to help people fulfil their potential (Hancock, 2001)
Erotic capital: Beauty, sex appeal, charm, liveliness, presentation (Hakim, 2010)
Don’t go into too much detail on this slide
Marx’s originial idea of ‘capital’ spoke about the fat cat factory owners who paid their employees minimum wage, and created a lot of economic capital – but where does this capital go is a key question..!
Putnam’s work is based more on the importance of trust, whereas Bourdieu’s lies more on the importance of networks. Our model lies closer to the Bourdieu perspective.
Human capital speaks about developing capital through eg education
Social capital is developing capital through the other people that you know, who are in your network.

5. Background
Wealth, power and status of network members can benefit other individuals in that network (Lin 2001)
There is a cross-sectional inverse association between trust and common mental disorders (de Silva et al 2005); and between access to social capital and depression (Webber & Huxley 2007; Song & Lin 2009)
Social capital is associated with improvements in quality of life, though insecure attachment styles pose a barrier to people with depression accessing their social capital (Webber et al 2011)
Higher access to social capital is correlated with fewer experiences of discrimination amongst people with severe and enduring mental health problems (Webber et al 2014)
Most of these studies are around work – that it is good to meet people at work, and that if you know lots of people you are more likely to get into work/back into work

6. Background
Most of these studies are around work – that it is good to meet people at work, and that if you know lots of people you are more likely to get into work/back into work

7. Background
NICE Clinical Guidelines for Psychosis and Schizophrenia (2014) social interventions:
family interventions
vocational rehabilitation
NOT social skills training
(nothing about connecting people or engaging with local communities)
This is a way to check that the agency is doing what they say they are doing – that they are faithfully following the intervention processes. – For example, if an agency said ‘we do CBT’ they are actually doing CBT rather than something similar.
We need to know that we are actually measuring the efficacy of the Connecting People Intervention – and therefore we are trying to scale it, so that we should see that agencies who are following it more faithfully yield better outcomes.
We are taking measures from the worker and the individual’s perspective to check that they are (hopefully) similar!

8. Systematic review – MH 18-65
Interventions to enhance social participation of people with mental health problems (18-65)
Used EPPI-Centre methodology
16 studies met inclusion criteria:
2 RCTs, 8 quasi-experimental, 3 mixed methods, 3 qualitative
Quality of studies was not great:
Risk of bias: high (2), moderate (10), low (4)
Intervention components:
Asset-based approaches; building trusting relationships; goal setting; social skill development; resource finding; peer support
Most quantitative studies reported positive findings on social participation
(Newlin et al, 2015)
Most of these studies are around work – that it is good to meet people at work, and that if you know lots of people you are more likely to get into work/back into work

9. Systematic review – MH 65+
Interventions to enhance social participation of people with mental health problems (65+)
Used EPPI-Centre methodology
7 studies met inclusion criteria:
1 RCTs, 1 quasi-experimental, 5 mixed methods
Quality of studies was not great:
Risk of bias: moderate (4), low (3)
Intervention components:
Matched peers, multidisciplinary collaborative care, social skills development, asset-based approaches, psychoeducation
Only 4 studies reported positive findings on social participation
(Newlin et al, under review)
Most of these studies are around work – that it is good to meet people at work, and that if you know lots of people you are more likely to get into work/back into work

10. Systematic review – LD
Interventions to enhance social participation of people with learning disabilities
Used EPPI-Centre methodology
8 studies met inclusion criteria:
All quasi-experimental
Quality of studies was not great:
Risk of bias: high (1), moderate (5), low (2)
Intervention components:
Person-centred planning; befriending; activity scheduling; skills-based group sessions with parents; network mapping; housing
5/8 studies reported positive findings on social participation
(Howarth et al, 2014)
Most of these studies are around work – that it is good to meet people at work, and that if you know lots of people you are more likely to get into work/back into work

11. Social intervention development
Implementation
Incidence and prevalence
Explanatory knowledge
Practice knowledge
Local knowledge
Effectiveness testing
Efficacy testing
Intervention design
The aim is to reach the top – the implementation
At the start, Martin began at the epidemiology stage where the numbers showed a link.
Hannah has been concentrating harnessing what the agencies that we studied are doing (see box) through interviews and observations
Meredith and Sharon are now working on the efficacy of the model – in a laboratory setting (where agencies are willing and engaged with the model) will there be positive outcomes?
We will then move on to the effectiveness – in the ‘real world’ where agencies aren’t doing it or something similar and have to be taught from scratch.
If this shows to be effective, it will hopefully be implemented through the NICE guidelines as a recommended treatment for the NHS.
Modelling
Epidemiology
(Webber 2014)

12. Reducing power differentials works
Findings
Reducing power differentials works
“They’re trying new things as well so you’re on an even field” (service user)
“…it creates a level playing field for them because it takes the pressure off them to deliver and they can just, really, buddy up with the guys and take part in the activities” (worker)
Very thorough

13. Non-stigmatised locations bring people together
Findings
Non-stigmatised locations bring people together
“I remember working with a young lad in Dartford who did not want to come onto the Charlton project because he didn’t want to be around people with mental health problems” (worker)
Very thorough

14. Local knowledge is essential
Findings
Local knowledge is essential
“But I, you know, we’ll sort of ask each other on the team, ‘Oh does anyone know of a place where so-and-so can volunteer’ or whatever” (worker)
Very thorough

15. Connections occur through shared activities
Findings
Connections occur through shared activities
“They’ve suggested it on their…sheet and we’ve matched it up with five others who have said that they want to do that [activity]” (worker)
“But I think that they sort of felt that I, I play guitar, I was a singer in a band, sort of have got a lot of sport interests, sort of like a lot of different things and I think that they felt that perhaps some of the people there are harder to engage. And because I might have more in common with them…” (worker)
Very thorough

16. Focus on an individuals
Findings
Focus on an individuals
“…the way they’ve helped me connect with things… like going to college, that will stay with me forever. Because I’ll get an education…” (service user)
Very thorough

17. Informal contacts provide access to resources
Findings
Informal contacts provide access to resources
“Well my mate goes there and she rung me up and told me about it because she knew I needed maths and English. So I rung the key skills and got an interview and then they said that I could go through.” (service user)
Very thorough

18. Social capital is not a panacea
Findings
Social capital is not a panacea
“Because even though I’ve got friends to hang around with, some of them are not very good friends. Some of them drink, drugs, and even though I drink the odd time, but, they do drugs and you know, it’s just sort of like, they’re wrong ones, do you know what I mean? And I want to hang around with decent people who want to get their life on track and not destroy their life”. (service user)
Very thorough

19. Partnership Worker Individual Agency
Equality
Confidence
Flexibility
Lived experience
Openness
Hope
Trust
Worker
Empathy
“Can-do” attitude
Natural networker
Individual
Ownership
Enthusiasm
Individual can leave and re-enter the intervention at any point of the cycle as desired/required
Physical environment
Community resources
Help accessing the service
Building
relationships
Exposure to new ideas
Introduction to new people and activities
Identifying opportunities
Fostering trust
Engaging with local community
Network assessment
Objective development
Inspiration
Facilitation
Meeting expectations
Orientation/signposting
Skill recognition
Feedback
Development of
skills and interests
Developing own networks
and resources
Development of
social confidence
Adapting to new ideas
Animated version
Building currency
Social
Network
Knowledge
Development
Utilising contacts
Social
Network
Development
Physical health
Lack of local knowledge
Cultural/ diversity factors
Attitude: self
Complicated external lives
Barriers
Barriers
Stigma
Extra Support
Reassessment
Advice Seeking
Self awareness
Lack of information
Lack of resources e.g. time, funding
Attitude: self/ organisation
Poor processes/ bureaucracy
‘Bad’ social capital
Access to service
Agency
Modelling of good practice Skill sharing Community engagement Local knowledge

20. The Practice Guidance

21. Social intervention development
Implementation
Incidence and prevalence
Explanatory knowledge
Practice knowledge
Local knowledge
Effectiveness testing
Efficacy testing
Intervention design
The aim is to reach the top – the implementation
At the start, Martin began at the epidemiology stage where the numbers showed a link.
Hannah has been concentrating harnessing what the agencies that we studied are doing (see box) through interviews and observations
Meredith and Sharon are now working on the efficacy of the model – in a laboratory setting (where agencies are willing and engaged with the model) will there be positive outcomes?
We will then move on to the effectiveness – in the ‘real world’ where agencies aren’t doing it or something similar and have to be taught from scratch.
If this shows to be effective, it will hopefully be implemented through the NICE guidelines as a recommended treatment for the NHS.
Modelling
Epidemiology
(Webber 2014)

22. Aims
To evaluate effectiveness and cost-effectiveness of the Connecting People intervention model with adults with mental health problems (below and above 65 years of age) and adults with learning disabilities
To evaluate the implementation of the intervention model in health and social care agencies
To gather data in preparation for a larger trial
This is a way to check that the agency is doing what they say they are doing – that they are faithfully following the intervention processes. – For example, if an agency said ‘we do CBT’ they are actually doing CBT rather than something similar.
We need to know that we are actually measuring the efficacy of the Connecting People Intervention – and therefore we are trying to scale it, so that we should see that agencies who are following it more faithfully yield better outcomes.
We are taking measures from the worker and the individual’s perspective to check that they are (hopefully) similar!

23. Method Quasi-experimental study to pilot intervention Main Outcomes:
Intervention model adapted for use with adults with learning disabilities and older adults with mental health problems
Scoping study identified about 16 agencies who are willing and able to implement intervention in the three social care user groups
2-day intervention training provided to each agency
155 new referrals interviewed at baseline and 9-month follow-up
Main Outcomes:
Access to social capital (RG-UK, Webber & Huxley 2007)
Social inclusion (SCOPE, Huxley et al 2012)
Mental well-being (WEMWBS, Tennant et al 2007)

24. Method Quasi-experimental study to pilot intervention
Hypothesis: Higher fidelity to CPI will be associated with improved outcomes
Economic evaluation:
Service use (CSRI, Beecham et al 2001)
EQ-5D (EuroQOL 1990)
ICECAP-A (Al-Janabi & Coast 2009)
Process evaluation involves qualitative interviews with service users, workers and managers
Study 2 is testing that the intervention will work – 240 ppl will be involved across all agencies (not just you don’t worry!) – all will be new referrals.
This is where you come in. We have info sheets and consent forms – you need to talk to the new referrals about the study at a convenient time, and they will get in touch with us using the contact details if they are interested. Then Sharon or Meredith will come and do and interview with them (no longer than 1.5 hours) at a convenient time/place. They will be taking some standardised measures.
Economic evaluation will also be completed as this has not been completed before.
Process evaluation – the nuts and bolts – will be taken 12 months later to see how things have gone. We want opinions and perceptions therefore this will be qualitative and discussive. We will also be asking you as the workers for your perceptions on the model.

25. Study sites
International Centre for Mental Health Social Research

26. Sample (n=155) Mental health <65 (n=121) >65 (n=9)
Learning disability (n=25)
55% male
Mean age = 42 years
19% black or ethnic minority
69% from NHS/local authority site
9% employed or self-employed
48% no car in household
10% had income > £13,500 per annum
116/155 (75%) followed up at 9 months
High fidelity group: n=30

27. Access to social capital

28. Social inclusion

29. Social inclusion

30. Social inclusion

31. Mental well-being

32. Change in total cost
Difference at follow-up = £1331 (95% CI, £69 to £2593)

33. Utility scores
Difference in change in QALY = 0.02 (95% CI, to 0.06)

34. Findings Broader context
Barriers to engagement exist within local communities
Personalisation can enable connecting, but eligibility thresholds for direct payments are high
Service changes, cuts and reconfigurations impacted negatively on service users and on CPI implementation
Service users lacked money to undertake even cheap activities
Housing was a more important problem for some than social connections

35. Findings Agencies / teams
All but one of the high fidelity agencies were in the third sector
Ethos of the agency influences adoption of model by workers
Workload / capacity of workers to take on different / new work
Supervision rarely focuses on models – more about management objectives
On-going training, support and supervision is required to embed model in practice
Leadership is required within agencies to implement it successfully in practice

36. Impact on social participation
Findings
Impact on social participation
Activities: leisure, recreational activities, voluntary & paid work, attending courses, groups, not doing any activities
Meeting new people: mixed picture of some new friends/contacts made, others haven’t but would like to
Existing relationships: some are socialising more and have good relationships, others report no changes
Community: some references to being more part of the community, helping neighbours/receiving help from neighbours, participating in time banks.

37. Reflections
Complex social interventions can be modelled, articulated and evaluated
Social networks can be enhanced by health and care workers
Improved social outcomes at no greater cost
Implementation of new models and working practices need to be fully supported by agencies to maximise their effectiveness
Workers need to be ‘given permission’ to undertake community-oriented or community development work
Performance targets, service reconfigurations, public sector cuts and the wider austerity environment hampers innovation
Is Connecting People possible in the statutory sector? (We’ll see…)

38. Think Ahead Communities Families / groups Individuals
Asset-based community development
Connecting People Intervention
Systemic practice
Family group conferences
Family therapy
Supported employment
Volunteer
befriending
Wellness Recovery Action Planning
Arts-based therapies
Personal budgets
Safeguarding
Solution-focused therapy
Motivational interviewing
Housing
Welfare rights

39. Thank you www.connectingpeoplestudy.net www.icmhsr.org