Does Health Education England need an organisational competence framework for working effectively with Peer Workers?
By Tamar Whyte
Image by Bethan Mair Edwards
Twitter is a great place to keep up with all the latest developments and controversies within the Survivor Movement. It’s where I’ve stolen (with permission) this wonderful meme by Bethan Mair Edwards. Our activists are some of the most creative with works of satire. This time, the rage was directed at Health Education England’s (HEE) Peer Support Worker Competence Framework. I’d heard about this prior to its completion, and not been impressed. Why were Health Education England leading on this? Isn’t Peer Working something that Mad people invented? I joined in with a furious rant about this. Lived Experience working is my passion, and this development threatened the work Peer Workers and by association anyone else working within the Lived Experience Professions – whether we are researchers, consultants, trainers – or any other post within our discipline.
After noting the initial emotional response, and reading the document itself, I have reflected more on why the framework is problematic. My colleagues have already written about the problems with the process and its contents, offering professional and personal views on this. NSUN’s response has been heartening, as they have transparently written about their presence on the Expert Reference Group and spoken of the difficulties of working in a way that does not allow for authority within final decision making. What can I say, to add anything to the conversation?
I am writing this from the lens of someone who works within the NHS as a Lived Experience Practitioner – I receive services and I deliver & design them. I am multi-disciplined – some of this including training in organisational change: open systems theory, group theory and applying this through an experiential lens. In simple terms: a lot of the theory services apply to us and use to deliver our services, is applied back into the services and organisation itself. How can this knowledge be applied to this framework?
I’ve identified three core issues which stood out to me:
- Experience/issues of co-working
National Survivor User Network (NSUN) CEO Akiko Hart & NSUN Member Vikki Price’s responses on NSUN’s website have both raised the issue of leadership – a Peer Support Worker Competence Framework should surely be led by people who work within this discipline, as all other disciplines working within mental health. Imagine the uproar if the Royal College of Nursing decided to write a competence framework for the Royal College of Psychiatry, with psychiatrists being on an expert reference group but not deciding the completed framework itself?
Aside from this obvious issue, there are some underlying ones too. The question is why this issue keeps happening, again and again, in many different contexts that goes beyond this current controversy.
Two years ago, I completed an MSc which actively recruited at least two lived experience consultants to each of its cohorts. There were six in all, I was in Cohort 5. There was an infamous module on leadership. It was infamous because on every cohort before us, this was the module that had divided students. There were stories of people who were previously friends never speaking again, as competition and infighting grew in each of the student groups who were competing to win a fictional competitive tender. The proposals were finally presented to real life commissioners. Nobody wanted to appear like a prize knob in front of key figures in the field who were also potential future funders of our services. The interesting thing was that in every single MSc cohort, every group that contained a service user consultant relegated these to the bottom of the pile in the pecking order of the group. If anyone was going to be ignored, it would be one of us. It didn’t matter that many of us had experience in other disciplines – at least three of us previously worked in nursing AMHP roles, or that several of us had higher level qualifications than our peers. We were all different, but we were all treated in the same way. By the time of the fifth cohort, most of the students had heard of this module. Our cohort got on well. We knew they were setting us up. We would be the cohort to buck the trend, because we knew better. We wouldn’t fight!
Oh, how the mighty fell.
I was in one of the groups and yes, I occupied the lowest position within that group. It was fascinating to see how the hierarchy was constructed. It was a mirror of what you would see within the NHS. Psychiatry or psychology occupied the top spot. The middle ground was held by people within the forensic sector – probation officers, prison officers, etc. A nurse and I were the two underdogs in our group. We felt denigrated by the psychologists, who seemed to feel frustrated with us as we backed away and supported each other because of the way we felt. The forensic staff just seemed to watch the tennis match between us, as each hit the ball back to the other’s side of the court. We were encouraged to use Bion’s theory of how groups of people work and interact with each other. Reading Bion is like wading through syrup. Suffice to say, he spoke of the leadership position, pairings of people and the scapegoat position at the bottom of the group. The leaders could only lead with the permission of the group, without this, they were ejected. The scapegoats had all of the group’s issues projected into them. At some point, once they had served their purpose, they were ejected by the group, with the fantasy that all the group’s problems would miraculously disappear when they were gone. Conversely, when charismatic leaders left a group, the group would likely mourn the loss of all their knowledge and ability being lost, the fantasy being that all of this was held within one person. Whether you believe in this idea, or think it is a load of bollocks, it seemed pretty evident amongst our small groups, competing again other groups, competing within ourselves.
Does this sound familiar to you, if you have ever worked in ‘co-produced’ or participation groups? From what I her from my colleagues, these issues are fairly standard, like one of those infinity spirals where we are never able to progress beyond our scapegoat position within the group.
The other question is why we occupy that position. The fact that we work within systems where there is clear hierarchy within disciplines sets the structure for this to happen. We are also the ‘other’ – the people being treated by a service. We are intruders in a system that was never set up to work with us, rather to do to us. It is so deeply embedded that it is not surprising that this happens – in fact, it should be expected. Leaders lead with the permission at the group. The group is currently not giving us permission.
Why is it so important for us to lead, within these hostile atmospheres? The question is, how can these hostile atmospheres become tolerant (ideally welcoming and friendly), until we model this from the top? Working with (co-producing) or leading a project demonstrates to people that this is possible, that it is acceptable to ask them to work in this way within their own teams. It was important that HEE recognised this and gave up some of their decision-making power to do this. Looking at the Expert Reference Group, there were many existing national leaders within the Survivor Movement who could have led on this, with HEE in either a co-lead or advisory role.
The very first step in this process was to recognise and acknowledge existing stigma. The second step was to then respond to this within the design of the group. This necessitated consultants and/or organisations working from an experiential lens who have expertise in Peer Working leading this project.
The Leadership reflections have touched on the importance of process. This flows from a Leadership and structure that understands the value of experiential working. Expert reference groups and advisory groups are needed, but they do not replace the need for employed roles that share responsibility, accountability and financial recompense that is equal to their colleagues. Whose job is it to ensure that the advisory groups recommendations are reflected within final decisions, that there is someone with adequate experiential knowledge of how we work not just sat at the table but making decisions and embedding within the organisation.
Shery Mead, the person who first brought Peer Support Worker training to the UK, stated that Peer Support Workers’ role was not in service improvement – it was in social change. When people work within services, they begin to understand that their very existence within teams challenges the way that staff think about and refer to service users. They have to develop a working relationship with us. Some of those relationships are warm and friendly. Some irritate us. Some make us very angry. Some break our hearts.
These relationships are often a huge chunk of the work itself. As staff strt to navigate how to work with us, are faced with our presence at meetings, in operational or strategic work, we are a visible reminder to keep service users in mind, before we even open our mouths. This opens up the way for thinking about relationships and interactions they have with service users, lessening the idea of the ’other’. Peer workers are in a position to bridge – providing a connection inside to the wider Survivor Movement, creating communication flow between each. Currently people who work in our discipline do this to different extents. Maybe a competency framework should include the ability to do this, rather than making targets that fit with the organisation a person is working within?
If an estimated 75% of staff have some form of lived experience, isn’t it time we acknowledge that there is less that separates us than we think? Imagine if all staff started to work from an experiential lens. What would that mean?
This opens up the recognition that maybe it is not a competence framework for Peer Support Workers that HEE needs to create. Maybe it is a competence framework for organisations that is needed, to get them ready for the privilege of working with us, of learning from us. To ensure that they will not chew us up and spit us out, or use us like the canaries were used in the mines, to use their song to warn of danger – then left behind, trapped in their cages to die, while the miners scurried to safety.
This brings me to the last point: the issues of co-working.
Issues of Co-working
Until I worked within the NHS, I did not even contemplate that structural discrimination based on my mental health even existed. I had previously worked all my life. I’d worked in Market Research, been a Research Officer in the Arts Sector, worked as an artist. I had degree and post grad qualifications in each of my disciplines. My mental health condition may have irritated colleagues, but no one ever questioned my ability to work. In an NHS organisation of 4000 staff, I assumed I would easily be able to work my way up from a menial banding to one that reflected the work I was previously doing with a service user led organisation. Eight years later, I have not progressed. I have had the realisation that my ability, qualifications and experience is secondary to daring to work openly with a mental health condition. How dare we have the audacity to do this? Remember – anyone else in that 75% works in disciplines and environments where they are encouraged to not speak of this, a barrier between themselves and service users, as well as their colleagues. Does the psychiatrist want her team knowing she experiences psychosis? Does the Mental Health nurse want his colleagues to find out he experiences crippling low moods? Is any of the sick leave staff take as colds or flu in fact stress caused by work? Amongst the complexity of feelings that staff have when working with us, there is the potential for envy, at a perceived freedom that we have.
NHS systems inviting – or at times, being compelled to – Lived Experience workers is extremely complex and brings issues to the surface that otherwise remain hidden. We as people within the Lived Experience Professions need to decide if and how we want to write our own competency framework, if it is called that. We need to set our own priorities, state our own needs and approach.
Before that, Health Education England needs to work with us to co-produce an NHS organisational competency framework, with basic understanding of the dynamics that will occur before employing us within teams or individuals that may feel hostile towards us or threatened by the change to how they work. They need to understand how to work with us to support us and the teams we work with through the initial difficulties and lifelong learning process this will be.
This blog has been cooking for a while in my brain, written as a flow of consciousness from the part that never stops thinking about how to solve the puzzle that is LXP working. A bit like Escher’s hands, it is a never-ending process – there is no final answer. I’ve dipped into knowledge from various papers, books and Mad Knowledge. Being a little Mad myself, and knowing that I’m not the best completer finisher, I present it here in its unfinished glory… and will add references later.
Thank you if you have read this far 😊
2nd December 2020