Outcomes-based commissioning and public service transformation in Mosaic Clubhouse Lambeth

Mosaic Clubhouse in the London Borough of Lambeth works with people with mental health issues based on co-production principles to improve their wellbeing and employability. Learn about  Mosaic Clubhouse’s experiences with the outcomes-based commissioning approach of the London Borough of Lambeth and NHS Lambeth and how it managed to adapt its business model to provide even more co-produced services to new clients.

The Clubhouse Model seeks to address the social isolation, the loss of confidence and skills, and the educational and vocational disadvantages that accompany a diagnosis of mental illness. There is an international network of over 330 Clubhouses in 30 countries.

Specific objectives of the Clubhouse Model are:

• To encourage Clubhouse members to provide mutual support in their journeys towards recovery;
• To assist members to regain self-confidence, self-belief, and self-esteem by identifying their current strengths, as well as developing new skills;
• To enable members to achieve their own personal goals and improve their employability.

In particular, Clubhouses provide opportunities to return to paid employment and voluntary employment through a successful employment programme.  Clubhouses also encourage their members to access basic, further and higher education.

Mosaic Clubhouse was established in Lambeth in 1994 as a partnership between the London Borough of Lambeth and the NHS Lambeth.. At the time of its establishment in Lambeth, the borough was experiencing six times the national average level of psychosis.

The work of Mosaic Clubhouse is based on a non-clinical co-production approach which is a key characteristic of the Clubhouse Model. This means that doctors and psychiatrists don’t visit the premises, and there is no group therapy. Instead, Mosaic Clubhouse provides its members with:

• a place to come
• meaningful work
• meaningful relationships
• a place to return.

In particular, Mosaic Clubhouse aims to bring structure to the lives of its members with an eight hour work day – paralleling typical business hours.  Staff and members work side-by-side to carry out the work of Clubhouse – from administration to cooking meals in the Clubhouse kitchen. The model is deliberately understaffed which means that the work members do is genuinely needed and valued.

In 2010 the business model of Mosaic Clubhouse was challenged when a contract with the London Borough of Lambeth came to an end and the local council asked the Clubhouse to expand its services to the 100 clients of a day-care centre for people with mental health issues. The new service contract was to be based on an outcomes framework. The main outcomes to be achieved included:

• clients leading more productive lives by sharing their talents with a vibrant, inclusive community, resulting in stronger social networks, better mental health and improved skills;
• increased take-up of education and employment opportunities;
• increased self-confidence to make informed choices about their future.

The expectation was that people could be fast tracked through the system in 12 weeks by identifying their own recovery goals and could be supported to meet them quickly. The Clubhouse was also asked to run an information service in partnership with Lambeth Mind for anyone in the borough with any queries and to form partnerships with other organisations who would use the building on a sessional basis to enable people to be seen rapidly for talking therapies, housing advice etc.

Furthermore, the existing building where Mosaic Clubhouse had been based for 16 years was no longer ‘fit-for-purpose’, so a new location was needed as well.

In 2010 Mosaic Clubhouse began negotiations with Lambeth Council about moving to new more central premises in Brixton and running an enhanced service. The new service specification was a potential threat to the well-established co-production values and principles enshrined in the Clubhouse Model.

There are 36 recovery and co-production standards that govern all Clubhouses and they include standards such as “membership is voluntary and without time limits.”  Performance against the 36 standards is assessed very closely by the international Clubhouse faculty and includes a lengthy self-assessment and a three day visit by a faculty staff and faculty member. This then gives a “licence to operate” for between 1 - 3 years depending on adherence to the standards.

As Mosaic Clubhouse is one of only 10 international training bases, it must always achieve 3 years accreditation. In the case of standard number 1 (above) commissioners were pressing for a “reablement” model, suggesting that it should be possible to offer anyone with a serious mental health condition an individualised twelve week programme that would enable them to set and achieve their recovery goals. This was not envisaged as being part of a Clubhouse programme, but as a separate 1:1 support. Standard 9 states “Clubhouse staff are sufficient to engage the membership, yet few enough to make carrying out their responsibilities impossible without member involvement”.

Standard 10 states “Clubhouse staff have generalist roles. All staff share employment, housing, evening and weekend, holiday and unit responsibilities. Clubhouse staff do not divide their time between Clubhouse and other major work responsibilities that conflict with the unique nature of member / staff relationships.”

Standard 13 “The Clubhouse is located in its own physical space. It is separate from any mental health centre and is impermeable to other programmes…”

These standards (and others) were at risk of being compromised by its new role as hosts of the Lambeth Living Well Partnership – that required the Clubhouse to offer space to other agencies; to deliver a 1:1 twelve week programme to individuals; and to run an information service open to the public five days a week as a drop-in, e-mail or telephone service (the so-called information hub). It was also expected to open an enlarged café to the public so that people could “drop in” for information food and drink and so that mental health professionals could use the café to meet their patients in a community setting. Finally, it was informed that the space identified for its education and employment department would be available for any other mental health organisations in the borough for use either for meetings, or running traditional drop-in activities, all of which fundamentally seemed to threaten the Clubhouse Model in the worst possible way.

However, the Clubhouse managed to agree on a wider co-produced service model which meant that the Clubhouse involved members in the design and delivery of the new services. As a result, Mosaic Clubhouse agreed to deliver the information service “side by side” and to integrate the new 12 week offering into the regular Clubhouse work.

Clubhouse members were also heavily involved in the discussions at all times when a £1million refurbishment was planned on an existing council (ex-day hospital) building. The building was adapted to meet the needs of a 21^st century Clubhouse.  It is light and airy with open spaces in all departments to support members to see the work being done each day, thereby encouraging engagement and a recovery journey.

The move on 30^th April 2013 gave staff and members time to work together to fully equip the new building, plant the garden, review all policies and procedures, carry out all necessary training (in particular, health and safety and food hygiene as the café and information hub are both open to the public). The expanded service meant recruiting six extra staff and ensuring that all staff and more members were trained in the Clubhouse Model. The information hub formally opened in September 2013 while the Clubhouse component was operational immediately.

Mosaic Clubhouse now hosts the “Living Well Partnership”, a partnership of organisations that provide sessions for individuals by appointment on issues such as benefits advice, smoking cessation, Asian mental health as well as a walk-in, email, telephone information service for the residents of Lambeth who have any issue related to mental health. It also provides a twelve week “enablement” service to support anyone with a mental health condition to “get back on their feet” following a period of instability. All these services are integrated into the three Mosaic Clubhouse departments and run by staff and members together “side by side”.

Business and administration department

Here, members can learn to use computers, meet and greet people at reception, book rooms, answer the switchboard, type documents, pay invoices, use the database, prepare board papers, make videos, take photographs, prepare presentations, use Facebook and Twitter … and more.

Employment, education and information department

This department contributes to compiling the Clubhouse newsletter in any number of ways from writing, typing, photography, research, interviewing, helping to run large events, support the educational programme or working with the public in the information hub… and more. Employment opportunities for members include transitional employment posts (now 18!) supported employment and independent employment.

Hospitality and horticultural department

Express yourself through, cooking, baking, serving in the café, menu planning, helping to keep the Kitchen and café clean and tidy, or there are four garden spaces to tend, daily maintenance tasks, shopping, ordering, arranging flowers, washing up, catering for large events, driving the Clubhouse people carrier and more…

So all aspects of the new service offered are co-delivered by staff and members. This means that there are even more opportunities for members such as organising and hosting external agencies meetings; which includes laying out the room, meeting and greeting, signing in, giving directions, providing IT support, supplying food and refreshments, cleaning up, producing leaflets for the information hub, taking calls, face to face enquiries, presentations to other agencies etc. The Clubhouse now offers peer support in the community (as always) and externally to people in the information hub.

The potential threat originally posed by this significant change has instead become a really positive outcome for all concerned and built an even stronger Clubhouse as demonstrated by this testimonial:

“My name is D and I was born and raised in South Lambeth, London.
I first attended Mosaic Clubhouse in July last year and found the staff and members pleasant and helpful. On attending Mosaic I found a sense of purpose by allowing me to participate in administrative tasks and arranging social activities for members to attend.

I have been unemployed for the past three years and miss being in full time employment terribly. At Mosaic Clubhouse I was told about TEP (Transitional Employment Placements) for members to attend to gain work experience, up-to-date job references and the confidence to move ahead into independent employment.

I myself have had a TEP arranged for me at Cambian Churchill Hospital in Kennington to work as a receptionist. This placement will enable me to provide good customer service and gain additional administrative skills.

My future hopes at Mosaic Clubhouse is to continue with the great friendships I have formed with members and the support and advice of the staff which is helping me rebuild my confidence and make real progress in my achievements.”

In 2012/13 we supported 328 members and had 133 referrals to our service.

• 107 of these members attended board, policy or standards meeting
• 15 secured paid employment
• 110 attended social events
• 40 achieved recovery goals
• 61 secured educational opportunities

From April 2013 to March 2014 we have supported 489 members with 389 referrals.

• 124 of these members attended board, policy or standards meeting
• 30 secured paid employment
• 198 attended social events
• 67 achieved recovery goals
• 96 secured educational opportunities

In our latest satisfaction survey from 2014

• 76% of members feel valued supported and have gained confidence while attending Mosaic.
• 75% of members feel they participate in meaningful work opportunities
• 75% of members feel that they are given a choice about the work they do at the Clubhouse.
• 68% of members feel that Mosaic has helped them think about educational opportunities and assisted them to make choices around courses.
• 55% of members feel that Mosaic has helped them to think about work opportunities.
• 75% of members feel that they are learning new skills or remembering old ones by attending Mosaic.
• A significant number of members hope to use the skills they have learned to progress into further education and/or employment.

Download a recent research summary with more evidence of the outcomes of the Clubhouse Model.

Just prior to the move Mosaic achieved a three year accreditation from Clubhouse International and is once again functioning as an international training base.

Maresa Ness, the chief executive of Mosaic Clubhouse is now on the board of the Clubhouse Europe and is chair on the subcommittee responsible for supporting Clubhouse growth in Europe as well as training and accreditation. 

The Clubhouse requires 428 hours per week of paid support workers’ time. This is supplemented by Clubhouse members providing 1263 hours per week, making the service affordable and effective.

This was the most significant and fundamental change for Mosaic Clubhouse in its history. The wrench from its glorious Georgian Building with an acre of land, to a single story building in the middle of Brixton; the three year delay to the move caused firstly by squatters when the building was left unoccupied and then by the discovery of asbestos; the change from delivering one model of service governed by 36 recovery and co-production standards to a service that is now more complex and is also facing the public on a daily basis and still meets all those standards; the requirement to merge two historically hostile services - Mosaic Clubhouse and the clients of a closed social services day hospital - with very different cultures, values and expectations, were the challenges that Mosaic rose to and met magnificently!

Staff and member morale was low in 2012 due to constant delays and uncertainty. Constructing systems and processes to open regular communication with everyone concerned was the biggest priority. Involving everyone in the design, decoration and equipping decisions was paramount. Monthly meetings for members/clients from both services with staff and commissioners, to update information and listen to hopes, fears, dreams and aspirations ensured that people had a forum to share information and offer support.

Reviewing all policies, procedures, job roles, job descriptions, the staffing structure, health and safety requirements and training needs meant there was a lot of work to be done and it kept the buzz going. Whilst “mocking up” the reception, kitchen and café as much as possible to enable people to try out new ways of working, all brought back a sense of purpose, expectation and fun while everyone we waited for the date.

The Clubhouse was up and running within two weeks of occupation of the new building. This gave members/clients the opportunity to train “in situ” and to prepare to meet for demand from the public. More training needs were identified and staff and members were trained together as always. Almost one year on and the partnership between members and staff at Mosaic Clubhouse has never been stronger. The Clubhouse delivering the information service “side by side” and it has incorporated the 12 week offering into its regular Clubhouse work and discovered that it is indeed the only intervention that some people require whilst others require the support of the Clubhouse structure for slightly longer as part of their recovery journey. All members set two self-defined recovery goals (currently 76% of our membership). 292 people have joined the enablement programme (August 2013-November 2014) of those 78 joined the Clubhouse for longer term support to achieve their goals. It has become clear that the Clubhouse Model is so powerful and that the co-production and recovery principles are so embedded in its DNA that it could embrace the requirements of the new service model and apply its side-by-side working and the requirements of the 36 recovery standards to deliver an exciting and enhanced service with huge success. And everyone learned this lesson (painful as it was at times) as a community together!

The Clubhouse model proves its success again and again and has recently led to our American counterparts, Clubhouse International and Fountain House New York (the first ever Clubhouse), being selected as co-recipients to receive the 2014 Conrad N. Hilton Humanitarian Prize! The $1.5 million award, the world's largest humanitarian prize, is presented to organizations that are doing extraordinary work to alleviate human suffering. We are extremely proud to be part of this network.

Mosaic Clubhouse has also been shortlisted for three awards this year, achieving highly commended in The Charity Awards 2014.

To read more testimonials about recovery journeys, check the
Mosaic Clubhouse website www.mosaic-clubhouse.org