The final version of the Competence Framework for Mental Health Peer Support Workers was released last week. It sets out the core skills, or competences, of mental health peer support workers in order to support commissioning, training and development in the NHS. This follows an initial draft put out to public consultation in March, and focus groups to reflect on and discuss the feedback over the summer.

Some changes have been made, which I welcome. But my broader critique remains: it is no longer enough, in 2020, to bring in an Expert Reference Group and settle for involvement. 

The Competence Framework is a product of deeply flawed processes and, as such, a lot of its content is problematic. The wider issue here is who led the Competence Framework – and this, our key demand, was not up for negotiation.  

We will be publishing a series of blogs from NSUN members responding to the Framework in more detail. Here, I would like to focus on what the publication of the Framework means for NSUN.

Clearly, it represents a failure of influence. NSUN was a member of Health Education England’s New Roles Implementation Group: Peer Support Workers, which was tangentially and tenuously involved in the development of the Framework. We also submitted a robust response to the draft publication in March, and were invited to subsequent discussions. Some changes were made, but the document remains broadly similar. Despite our best efforts, our voice had minimal impact.

So, where does NSUN go from here?

I believe that we, as NSUN, need to consider if we want to continue being involved in influencing the development of peer support work within the NHS - and, separately, if we can.

This is an urgent question for us. We have been invited to join the implementation group of the Competence Framework which will look at how it is rolled out across England, including through training. For us, an opportunity, of sorts. However, what is the likelihood that our voice will be heard? Is it worth us winning a few small concessions if we disagree with the overall premise of the Competence Framework?

For a long time, NSUN, and others involved in similar work, have been lured by the riches promised “in the tent”. Being invited inside is the first step to influence; and, of course, everyone compromises, that’s how policy work. But some tents are more amenable than others. Perhaps, in this case, it was not our role: we are not an employer of peer support workers, nor do we represent them as a union would. What we bring is too often seen as critical, or obstructive, or “interesting – but”. It is my view that we cannot positively influence the roll-out of the Competence Framework. Additionally, our involvement in it would increase its legitimacy when we have serious concerns about it. We can see this play out in the Competence Framework itself. The perceived input of the Expert Reference Group (ERG) effectively rubber stamps the Framework – lending an air of credibility and authenticity that is misleading. The ERG was recruited in a haphazard and opaque manner, and met intermittently. A number of individuals have stepped down from it, and important comments submitted by the ERG prior to the March draft publication were not taken into account by the lead authors. Some last-minute changes were delegated to the ERG in response to the feedback from the public consultation, but these were in discrete areas. As always, it is authors who are in control of how involvement is heard and framed.

However, this debacle- and debacle it is, if we are to go by the anger and dismay the Competence Framework has caused, has revealed a serious gap at the heart of peer support in England. Whilst I think the National Collaborating Centre for Mental Health (and by extension the Royal College of Psychiatrists) and UCLPartners were entirely the wrong organisations to lead the development of this document, there was not an obvious alternative which would command widespread support. There is no national policy body focusing on peer support work in England. NSUN is involved in this area, but it is not our core business, nor do we think of ourselves as somehow representative of this world. What there is instead is a multitude of small grassroots groups who do not have the funding, capacity or inclination to get involved in this kind of policy work. There are individuals who have been doing this work for decades, and who have deep and wide expertise to bring from different sectors including the VCSE. There are peer support workers within the NHS, most of them with limited structural influence because until recently - and still now - promotion opportunities are few and far between. And there are national charities like Mind or Together who do policy work in this area, and smaller providers in the VCSE who deliver peer support in the community. These individuals and bodies are often isolated, with limited funding or opportunities for connection. No wonder it is easy to talk over peer support.  

An additional complication is that peer support is a complex world. One of the rookie errors of the draft Competence Framework was to not see or acknowledge this: there are different iterations of peer support, many histories, complex politics. So much in peer support is contested: trying to find “one” directive framework was always doomed to failure. The strangely insular first draft of the Competence Framework did not pick up that peer support is a global movement, that there is cross-fertilisation across and within countries and regions. Recovery-oriented peer support, heavily pushed by the Competence Framework, is just one iteration of peer support.

But the challenge for NSUN is to engage with this complexity without becoming in thrall to the purity wars which can spring up in this area. Clearly, peer support is an area which elicits strong, passionate reactions. Some people feel that their model is closer to the true values of peer support. A policy level engagement around paid peer support work in the NHS can only work if we recognise the pragmatic compromises inherent in NHS implementations. It has to engage with the reality that peer support work within the NHS is here to stay: it is a clear target within the Long Term Plan. It has to differentiate between peer support more broadly, and professionalised peer support work within the NHS. Where peer support workers in the NHS and VCSE are paid, they are subject to the responsibilities, protections and restrictions employment brings. Arguing that the work shouldn’t be paid, or that what’s on offer in the NHS is not “real” peer support is an option- but it would also mean NSUN disengaging from debates around how peer support work and Lived Experience work more broadly are systemically misunderstood, undervalued and underpaid within NHS settings. This is not something I am prepared to do.

It is not, I believe, NSUN’s place to become the unifying, authoritative England-wide peer support voice. We are one of many. But it does beg the question: is this, somehow, needed? Would it be possible or desirable to create an alternative Framework(s) of sorts, developed by a broad community of people and collectives involved in peer support? The idea of unionising peer support workers and Lived Experience practitioners, based on the distinct nature of their work and expertise, could perhaps be revisited. And we need to consider how we move from the situation we have now- a disparate group of people who care about peer support, to a collective which values plurality and doesn’t replicate the violence of speaking “on behalf of”.

I would like the failure of the Competence Framework to be led by experts in peer support to act as a catalyst for some of these discussions. Things will not change if we continue to accept invitations to be involved in areas which we should lead. Things will not change if those in power accept commissions in areas which they have no business to lead on. The failure is on the National Collaborating Centre for Mental Health (and by extension the Royal College of Psychiatrists), Care City and PPL Consulting, who should not have accepted this commission. The failure is on Health Education England and UCLPartners, who should not have commissioned it in this way. Even in the absence of a collective national voice for peer support, there were better ways to go about this. An interim step for this Competence Framework could have been to bring in peer support leads from a variety of NHS trusts, alongside peer support leads from the VCSE as well as peer support researchers. They could have consulted with individuals, groups and organisations involved in wider peer support, and been supported by an Expert Reference Group of individuals such as Steve Pilling and Tony Roth who would bring much-needed expertise on how to draw up Competence Frameworks. Fanciful? Perhaps. But I can only echo what others have said: no other profession would have stood by and watched this happen.

For those of us who care about peer support, and peer support work within the NHS: there is a need to organise and to start creating spaces where collective and diverse knowledges around peer support can be brought together to influence policy. Supporting the development of these spaces is perhaps a path forward for NSUN.

Akiko Hart, CEO of NSUN

November 2020