Monthly Archives: July 2013

Marija Trachtenberg and Michael Parsonage ~ Peer Support in Mental Health Care: is it good value for money?

Peer Support in Mental Health Care: is it good value for money?

by Marija Trachtenberg and Michael Parsonage
(Posted by the Centre for Mental Health on 23 July 2013)

Peer support is the provision of practical and emotional help for people with long-term mental health problems by people with their own lived experience of such problems. The underlying idea is not a new one. For example, there is evidence going back to the 1840s of peer support in the old asylums, provided by Alleged Lunatic Friends (Hervey 1986).  Indeed, for as long as people have used mental health services, they have provided each other with friendship, mutual support and shared coping strategies, but it is only relatively recently that the value of such relationships has been formally recognised in the development of paid employment roles. Peer support workers may be employed in place of traditional staff, for example as case managers, or – more commonly – as additional members of a mental health team, fulfilling such roles as befriending, mentoring, social support and advocacy.

Increasing numbers of peer support workers are now being employed in mental health services, both in this country and elsewhere, but good quality evidence on the effectiveness of this form of service delivery is in short supply and even less is known about its cost-effectiveness. A recent Cochrane review was able to identify only 11 randomised controlled trials and came to largely agnostic conclusions (Pitt et al. 2013). Other reviews have taken a more inclusive approach, including evidence not derived from RCTs, and a number of broadly positive conclusions on effectiveness have started to emerge (Repper and Carter 2011). These include benefits not just for the service users who receive peer support but also for the peer workers themselves and at the organisational level, where the introduction of peer support is increasingly seen as a powerful way of promoting a more recovery-focused approach to mental health care. In no study has the employment of peer support workers been found to result in worse health outcomes for those receiving the service and, although not replicated in all studies, findings have been reported of improvements across a range of outcomes including: patients’ feelings of empowerment and self-confidence; self-reported physical and emotional health and clinician-assessed global functioning; satisfaction with services; community integration and social functioning; stability in employment, education and training; and reduced alcohol and drug use among patients with co-occurring substance abuse problems.

A first attempt at assessing whether peer support provides value for money is set out in a paper just published by the Centre for Mental Health (Trachtenberg et al. 2013) and launched at this year’s annual conference of the NHS Confederation. The analysis looks specifically at whether peer support workers can reduce psychiatric inpatient bed use, either by preventing admissions or by reducing length of stay. We chose to look at the impact on inpatient bed use partly for reasons of data availability but also because of the very high unit cost of hospital care and because this has been an area where service users’ experience of care has consistently been reported to be rather poor (Care Quality Commission 2009) and thus it seemed an area where the impact of peer workers might be particularly strong. If peer support can improve patients’ feelings of empowerment, self-esteem and confidence, this may help them to manage their lives in the community better, with a correspondingly reduced need for inpatient care.

We identified six studies in the research literature which give some evidence on the relationship between peer support and inpatient bed use. Five of these were from the US and one from Australia. Only two were RCTs, although three of the others did have some form of comparison group.  Study authors were contacted in all cases for additional information and on this basis we were able to produce estimates of the number of hospital bed-days saved per full-time equivalent peer support worker in each study. These figures on bed-days saved and peer worker input were then converted to £s using unit costs for England in 2011-12, resulting in a simple benefit:cost ratio of the following form: value of hospital bed-days saved per peer support worker divided by cost per support worker.

Four of the six studies show a benefit:cost ratio substantially in excess of one, i.e. the value of bed-days saved comfortably exceeds the cost of employing peer workers. In one study, the ratio is positive but less than one (some savings but not enough to fully offset the costs of employment) and in one the ratio is negative, implying that in this case the use of peer workers is associated with an increase rather than a reduction in bed use. Aggregated across all six studies, the benefit:cost ratio works out at 4.8:1 on a weighted average basis (with weights determined by the size of each study’s patient sample). The overall conclusion suggested by these figures is that peer workers bring about significant reductions in hospital bed-use among the patients they support, leading to savings which are well in excess of additional pay costs. These savings are of course over and above any positive impact on non-financial outcomes relating to the mental health and quality of life of service users.

A number of major limitations must be acknowledged. First, the evidence base is extremely modest, both in scale and in quality. Second, there is a good deal of variation between the studies in the nature of the intervention being evaluated (e.g. the roles played by peer workers, the amount of training they received and the frequency and duration of their contacts with patients). Third, no allowance is made for the possible impact of peer support on service costs other than hospital bed use. And fourth, none of the studies is from this country.

Notwithstanding these and other shortcomings in the analysis, our conclusion is that, overall, the available evidence is sufficient to justify continuing developments in the use of properly trained and supported peer workers in mental health teams, alongside more research evaluating their effects.


Hervey N (1986) Advocacy or folly: the Alleged Lunatic Friends SocietyMedical History, 30, 245-275.

Pitt V, Lowe D, Hill S et al. (2013) Consumer providers of care for adult clients of statutory mental health services, Cochrane Database of Systematic Reviews 2013, issue 3.

Repper J, Carter T (2011) A review of the literature on peer support in mental health servicesJournal of Mental Health, 20, 4, 392-411.

Trachtenberg M, Parsonage M, Shepherd G, Boardman J (2013) Peer support in mental health care: is it good value for money?Centre for Mental Health, London.

Care Quality Commission (2009) Mental health acute inpatient services survey 2009, Care Quality Commission, London. 


Marija Trachtenberg is a graduate of the LSE Masters course in health economics and has worked as a research assistant at the Centre for Mental Health.

Michael Parsonage is Chief Economist, Centre for Mental Health.

This post was first published on the LSE Health and Social Care blog (July 15 2013)


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Event ~ Therapeutic Communities and Enabling Environments Research Afternoon

The Consortium of Therapeutic Communities Research & Development Group is hosting a research afternoon focusing on therapeutic communities (TC) and enabling environments (EE).  Come and hear about ongoing and recently completed research, discuss ideas, contribute suggestions.  The afternoon is free and open to all with an interest in TC and EE research.

Date: 26 September 2013
Time: 1-4pm
Location: Community of Communities offices at the Royal College of Psychiatrists in London

If you are interested in presenting, would like more information or to book a slot, please email

TCTC logo

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Events ~ Art in the Asylum: Lectures, Gallery Tours and Documentary Film

As part of the recently advertised ‘Art in the Asylum‘ exhibition running from 7 September – 3 November 2013, there are a series of upcoming lectures, gallery tours and documentary film that may be of interest:

Image: ‘I Spit on Life’ 1956 by William Kurelek (Adamson Collection, London © Estate of William Kurelek, courtesy of the Wynick/Tuck Gallery, Toronto)

Image: ‘I Spit on Life’ 1956 by William Kurelek (Adamson Collection, London © Estate of William Kurelek, courtesy of the Wynick/Tuck Gallery, Toronto)


All lectures are held in the Djanogly Art Gallery Lecture Theatre *unless stated otherwise

Admission free 

Friday 6 September 6.30-7.30pm
Followed by Preview


Dr. Esra Plumer and Dr. Victoria Tischler on the historic use of art in mental health institutions and the interplay between creativity and madness, introducing some of the spaces, places and key figures in the fascinating history of crossover between visual art and mental health care.

Wednesday 11 September 6-8pm 
Edward Adamson’s life and work: creativity and the evolution of art as therapy

Dr. Susan Hogan (University of Derby, author of Healing Arts: The History of Art Therapy 2001) with contributions from John Timlin (Adamson Collection) and Dr. David O’Flynn  (Consultant Psychiatrist & Chair of the Adamson Collection). The groundbreaking work of the ‘grandfather of art therapy’ Edward Adamson is considered alongside associations between therapy and Surrealism.


Wednesday 18 September 6.30-7.30pm
A hidden gem: Dr. W. A. F. Browne’s collection of patient art at Crichton Royal Institution, Dumfries

Dr. Maureen Park (University of Glasgow, author of Art in Madness 2011) discusses the pioneering work of Dr. Browne and his collection of patient art, the oldest surviving collection of asylum art in the world.

Wednesday 2 October 6-8pm
Ancient and modern mental healthcare

Jules Evans (author of the bestselling Philosophy for Life: and other Dangerous Situations 2012) with Dr. Ben Di Mambro (Consultant Psychiatrist) and Dr. Arun Chopra (Consultant Psychiatrist). From ancient philosophy to Cognitive Behavioural Therapy (CBT), recent controversies in psychiatric diagnostics and the launch of the DSM-V, the speakers discuss how old and new approaches might interact in the provision of mental health care today.

Wednesday 16 October 6.30-8.30pm
*venue: Nottingham Contemporary
Book on-line

Looking into art from the asylum: Prof. Roger Cardinal (author of the seminal text Outsider Art 1972); and Richard Dadd and Asylum Art of the 19th century: Dr. Nick Tromans, Curator, Watts Gallery, Surrey.

Artists whose approaches diverge radically from average expectation and from officially sanctioned approaches and styles are discussed alongside Richard Dadd, one of the best- known British asylum artists


Wednesday 30 October 6.30pm-7.30pm
Marat/Sade and the ‘theatre of cruelty’

Dr. Gordon Ramsay and Dr. James Moran (English Dept. University of Nottingham) consider Peter Brook’s 1964 production of Peter Weiss’s play Marat/Sade in the context of Antonin Artaud’s ‘theatre of cruelty’

Gallery Tours

Djanogly Art Gallery
Admission free

Thursdays 1-2pm:

12 September: Victoria Tischler, Curato
26 September: Rob van Beek, artist
10 October: Ruth Lewis-Jones, Learning Officer
24 October: Neil Walker, Curator, Djanogly Gallery

Please note that Gallery Tours are not seated events. Every effort will be made to accommodate elderly and disabled visitors.

Gallery Tour: New Perspectives on…

Djanogly Art Gallery
Admission Free

Thursday 17 October 7-9pm

A walkabout tour led by a relay team of six post-graduates researching at the University of Nottingham in a variety of disciplines who will each bring their expertise to bear on one work in the Art in the Asylum exhibition. Each speaker will have 8 minutes before handing the baton on to the next with an opportunity for a Q&A session at the end of the evening.

For all Lectures and Gallery Tours above (*unless stated otherwise) please book in advance by calling the box office on 0115 846 7777.


14-18 Broad Street
Book at Broadway Box Office or on-line
Broadway ticket prices apply.

Wednesday 23 October 8.30pm 
All Divided Selves (2011) Dir. Luke Fowler 90 mins

Documentary on the radical Scottish psychiatrist R. D. Laing, author of The Divided Self 1960. Introduced by Dr. Joseph Berke, psychotherapist, who worked with Laing in the 1960s.

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Coid et al. ~ Gang violence cause of high levels of mental disorders

If you are interested in mental illness and gang membership, perhaps this BBC report and the related journal article may be of interest:

“Young men in gangs are significantly more likely to suffer from a mental
disorder and need psychiatric help than other young men, says a UK study”.

“Prof. Jeremy Coid, lead study author and director of the forensic psychiatry research unit at Queen Mary, University of London, explained the likely cause:

It is probable that, among gang members, high levels of anxiety disorder and psychosis were explained by post-traumatic stress disorder, the most frequent psychiatric outcome of exposure to violence”.

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Blog Posts Round-Up

This week the IMH Blog Editorial Team would like to highlight four blog posts published recently on health and mental health sites.  Three discuss the very timely issue of compassion within health and the fourth focuses on community budgeting to pool funds for services.  Have a read of each and let us know your thoughts!

Safe Care – The Fierce Urgency of Now 4 Compassionate Culture keeps us safe
By Dr Alys Cole King, Consultant Liaison Psychiatrist and Co-founder of Connecting with People training
(Published on Knowing You Matter on 27 June 2013)

‘The fourth blog in the Safe Care series is written by Dr Alys Cole King who is a Consultant Liaison Psychiatrist and Co-founder of Connecting with People training. Alys influences thinking around compassion in healthcare nationally and internationally powerfully collaborating with leading thinkers in the field.’  (continue reading…)

Power to the People
By Paul Hodgkin, GP, chief executive of Patient Opinion
(Published on E-Health Insider on 26 June 2013)

‘Paul Hodgkin, a GP and chief executive of Patient Opinion, says that if the NHS really wants to regain compassion it is going to have to get a lot better at understanding where it comes from.’ (continue reading…)

The Unexpected Benefits of Compassion for Business: Compassionate workplaces – good for employees AND the corporate bottom line
By Emma M. Seppala, PhD,  Associate Director of the Center for Compassion and Altruism Research and Education at Stanford University
(Published on Psychology Today, 22 April 2013)

‘Managers often mistakenly think that putting pressure on employees will increase performance. What it does increase is stress—and research has shown that high levels of stress carry a number of costs to employers and employees alike.’ (continue reading…)

Mental Health: The Whole Picture
By Sean Duggan, chief executive of the Centre for Mental Health
(Published on Centre for Mental Health Blog, 24 June 2013.  Originally published in Public Finance Magazine.)

‘Community budgets that pool funding for services could dramatically improve mental health provision. This ‘whole place’ approach should be backed in the Spending review.’ (continue reading…)

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