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Risk is an idea that seems to hover over mental health like a dark blanket of cloud. Public discourse around mental health is suffused with it. It runs through every discussion of how mental health services might be better delivered.

One of the most radical (and contested) suggestions emerging from Big Society ideas is that people are better placed to decide what they should do than the state. Rather than the state services coming up with solutions on their behalf, the Big Society idea believes that people can come up with their own answers and find their own ways of doing things.

This questions the idea that it is the role of decision makers to decide courses action to the people upon whose behalf they make decisions. This is why Big Society is often described as a ‘bottom up’ movement.

The model is that people work out what they want to do and it is the job of the state to help them do it.

If the Big Society is to have a legacy in mental health, it is this bottom up empowerment that will be its lasting legacy.

Perception of risk and creation of extensive structures and processes to manage it are generally regarded as a major impediment to innovation in the public sector in a general sense. So much so that it often seems that the burdensome effects of risk management can be negative as the potential dangers that they have been introduced to mitigate against. But perceived risk is a particularly significant issue in mental health, even when compared to the public sector as a whole.

Why would the issue of risk be of more concern in mental health than in other fields of activity?

Knowing that someone experiences mental health difficulties often brings into play a highly developed set of concerns about risk that would not be present if that person’s mental health difficulties had not been disclosed.

The NHS tends to see its role as a ‘looking after’ people with mental health difficulties, which can lead to a paternalistic concentration on preventing the possibility of harm to either themselves or others.

Local authorities tend to see its role as risk managing potential events, reducing the possibility of hazardous outcomes.

Both of these can come into direct conflict with the wishes and aspirations of people with mental health difficulties to do and decide things for themselves.

Rather than preventing things that we know have a good chance of occurring otherwise, risk management can often slide into preventing things that may happen or may not happen.

This partly has its roots in the historical role of mental health services, which were often literally conceived as mechanisms to prevent harm to self and others, partly to an honourable intention to safeguard individuals and staff from harm and partly as a response to wider political and media narratives about the ‘responsibility’ of mental health services for the conduct and actions of people within their care.

This focus on risk and safety, while often welcome where deployed in the right situations, can lie like a stifling blanket over the possibilities for people with mental health difficulties to do what they choose to do with their lives and with their time and energy.

It can also have a toxic effect when combined with existing stigmas and prejudices about people with mental health difficulties where controlling risk becomes more important than enabling possibility.

It creates a situation where the question is not ‘how can we make the best of this situation or services? But ‘how can we make sure that nothing bad happens for which we’ll be held responsible?’.

EXAMPLE: An NHS trust instigated the setting up of an innovative co-produced and peer led training and education project. The project was to be led by as many people with direct experience of mental health difficulty as possible and would use people with mental health difficulties to train both peers and professionals.

Some debate was had amongst clinical staff involved in the project that the physical setting and furnishings in the place that the project would take place were insufficiently ‘safe’ and could pose a risk should someone attending or employed wish to undertake violent or threatening behaviour.

In essence, the idea that people with mental health difficulties would use the space was taken as an indication that all risks should be controlled to the highest level.

In this case, these concerns were not upheld as suggested changes would have confounded what the project as a whole was trying to achieve.

In the context of personalisation, the same wish to control risk is at work but in a less obvious fashion. The tension for many is between stepping back to let people make their own decisions and intervening when those decisions do not seem to be in their best interests.

As noted elsewhere in this piece, the growing understanding of mental health difficulty and the growing range of aspirations that people with mental health difficulties hold have led to the extension of mental health services into areas where they are ill-suited.

One effect of this is to medicalise all aspects of an individual’s life once they have received a mental health diagnosis. All actions are then seen through the prism of their mental health.

The idea of personal recovery requires that someone find themselves an identity outside of a mental health diagnosis. Personalisation seeks to free people to use funds allotted to them in the ways that they see fit to support their own recovery.

Carrying over the mindset of risk has the possibility of stifling both of these processes.

Services have to let go of ideas of people who use them as passive recipients of services and work with them to develop their independence. They cannot do that in circumstances where the individual, because of their mental health difficulties, is always considered to remain a patient for which the service has an ultimate paternal responsibility.

To enable this to happen it makes sense to divide treatment, which is medical, and support which may be underpinned by medical principles but is not, in itself, medical. In treatment settings it makes sense to treat patients as patients. In everything else, people are people and should have the same expectations of agency as anyone else.

Recovery and personalisation should always enable people to make good choices, but the true measure of whether the shift in mindset has been made is whether services can allow individuals to also make what might be considered bad choices.

Services must let go of their attempts to control risk where it conflicts with people’s wishes to develop, grow and recover. To do so will mean, at least initially, stepping back and and enabling change to happen rather than stepping in to intervene to minimise the effect of change.

The prevention of risk must stop being used as a way to prevent uncertainty. If people are to make the decisions about what their recovery means and what their choices should be to get there, they must be able to supported and advised to the highest standard but free to take decisions themselves.

The same is true of organisations and groups formed by people with mental health difficulties. Paternalistic views of the needs and potential weaknesses of organisations run and staffed by people with mental health difficulties have led to an over-focusing on the risks of working with such organisations rather than a recognition of how much additional value they can add to service delivery. It is as if even as professionals, people with mental health difficulties cannot leave behind the idea that risks involving them or caused by them cannot be left behind.

Risk management can be a way of saying ‘we don’t think people like you should do things like that.’ Often people do not know what risk they are trying to minimise except for ‘the risk that people with mental health difficulties pose’

EXAMPLE: I have a mental health difficulty. In my professional role I regularly meet with leading healthcare professionals in a variety of settings.

When I receives treatment, I am treated very differently. As a patient I must step away from the desk, not demand to speak to someone, must sit down and wait to be called.

I am not different, but in the category of patient rather than professional I am considered to pose more of a risk.

(This blog post originated as part of a think piece Social Spider CIC is carrying out exploring how Big Society ideas interact with mental health.  The full piece will be published in late March.)

Mark Brown is the editor of One in Four magazine.

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The following is the introduction to a piece of work we’re currently working on for the NHS Confederation about the ways that the ideas suggested by The Big Society might help the NHS to make sure that people with mental health difficulties are in control of the services they receive and ways that those services can support people to make their own decisions about the directions that services, support and opportunities should take.

And don’t worry, the full piece discusses the necessity of funding, both for treatment and for community organisations.

Introduction

This discussion paper was prompted by the unfolding policy narrative of The Big Society and the potential outcomes it might have for people with mental health difficulties.

As a group that are already more likely to experience unemployment, other health difficulties and social exclusion, there is a distinct danger that as a Big Society approach is rolled out in geographical communities, people with mental health difficulties will find themselves disenfranchised or, at worst, actively acted against.  It is important that the NHS recognises that the situation in wider society influences the outcomes for people with mental health difficulties in a way that it may not with other conditions.

The NHS needs to support and enable people with mental health difficulties to become actors rather than subjects.  While this is already the idea in practice, it must extend into the more higgledy-piggledy real world.

Where such good work exists, we must find ways to support and nurture it.  Where it does not we must find ways, in these difficult times, to make sure that it is not snuffed out before it begins.

Working with projects and organisations already rooted in the ‘real world’ of the community is the most obvious and most desirable way to do this, as this paper explores.

As authors we are approaching the Big Society question not as academics or public sector professionals but as a small social enterprise, Social Spider CIC, involved in making mental health related things happen in the community; a social enterprise run by Mark Brown, who has a mental health difficulty himself and created and developed One in Four magazine for Social Spider CIC and David Floyd, an experienced veteran of a number community-based projects and social enterprise thinker.

In the process of our work, we see many of the issues around mental health and wellbeing from both sides of the desk, working as much with other professionals and people with mental health difficulties as we do with professionals who are providing services.

While not all of us necessarily subscribe to the ideas put forward as part The Big Society agenda as it is developing, we all have a duty to make sure that people with mental health difficulties can work within new circumstances and structures to enjoy the best outcomes that they set for themselves.

The Big Society analysis grows from recognition of a number of significant challenges faced by the agencies and organizations responsible for the delivery of public services.

Whether we agree either with the political beliefs behind these ideas or with the overall conclusions that this analysis arrives at, it is inescapable that some of this thinking creates an opportunity for taking forward many ideas within the mental health world where people with mental health difficulties and professionals are in agreement.  It also provides a wider policy context within which these ideas can be viewed and understood.

It is this wider context that allows us to step outside of seeing any of the ideas discussed in this paper as simply mental health ideas and allows us to draw from experience, learning and expertise from across sectors and groups in the community.

It helps us to see that while mental health treatment is necessarily specialist, the people whom it treats are part of communities and that the challenges that they face are not only medical but encompass all of the stuff of life.

This Big Society moment gives us opportunity to look at new ways of making things happen that do not rely on old, often exhausted, ideas of service delivery.

One of the most radical possibilities of Big Society is the breaking down of barriers and divisions between different types of people working towards a common social good.  Rather than the answer being state services, charities and community groups working in their own separate spheres only coming together when each needs something from the other, Big Society suggests ways all of these different forms of organisation can work together as peers, aware of the different role each has, but finding exciting new ways of bringing those roles together to best met the needs of those that need them.

Despite any political reservations that individuals and organisations might hold, the broad scope of the Big Society idea encompasses many of the ideas that both people with mental health difficulties and those who provided them services have been pushing forwards for over a decade.

While there are range of views on the rights and wrongs of the steps that the current government is taking, what is clear is that Big Society is being implemented during a period of deficit reduction and a difficult contraction of public sector spending.

For the National Health Service the Big Society coincides with the plans significant NHS reorganisation outlined in the Health and Social Care Bill 2011, the new mental health strategy for England No Health without Mental Health, changed priorities in public health, changes to local council responsibilities and budgets and alterations to the benefits system.

In many of these proposed changes of policy, resource allocation and direction, the path leads back to Big Society, as a means of making sure that the needs and aspirations of people are met.

Opportunities

This discussion piece seeks to explore some of the ideas of Big Society and the way in which they represent new suggestions for meeting some of the aspirations and challenges held by mental health services and the people that use them.

In many cases, Big Society presents a new way of approaching tasks, obligations, aspirations and goals that mental health services are already exploring or delivering. It also suggests new avenues that the NHS can begin to explore and presents an opportunity to remove some of the negative systemic factors which have plagued the development of true community mental health services and which have frustrated both professionals and service users alike.

It suggests a new settlement between individuals and the services that they use, and a new landscape where the NHS is one provider of services amongst many.

As many critics rightly note, the Big Society should not give license to ignore the question of funding for mental health related work but, as this paper shows, does suggest some new possibilities for making mental health funding ‘work harder’ and help develop lasting structures that will support future work.

It also presents possibilities for advances in the way that people who are experiencing mental health difficulty are supported and, most excitingly, suggests pathways towards people with mental health difficulties escaping from the position of being passive recipients of services and become true partners in defining the direction of the support they receive.

Seeing the opportunity to support and work with small, community based projects and organisations creates an environment that brings together a number of the positive, forward looking streams of thinking within mental health.

• Peer led services – Small community based organisations and projects are far more likely to involve self-determination on the part of those that use and deliver them.  The flexibility of these services allows for the incorporation of individuals with varying levels of disability and experience.

• Services responsive to local need – With the correct support, local people with mental health difficulties can find ways of meeting their own non-treatment needs

• Personalisation – Small community based organisations and projects can serve a variety of roles:

1. they can be the providers of services purchased by those with personal care budgets
2. they can be the organisations that act as brokers and fixers for personal care purchasers
3. They can be the result of personal care purchasers own decisions

• Meeting needs that NHS services cannot – The NHS is structured to be very good at some things.  Where it is less good at things is as much a result of structure as it is of failure of intention or policy.  This is not a criticism of the NHS.  Conceptions of mental health and wellbeing have evolved greatly since the creation of the NHS, as have the expectations and aspirations of those experience mental health difficulty.  In some senses, there is an inherent conflict for the NHS between providing specialised care and treatment in mental health and taking a holistic approach to mental wellbeing.  Smaller, more flexible, non-medical projects and organisations can meet these needs where the NHS cannot.

• Minimising the cost of innovation – Innovation is an expensive business, but vital.  Within large organisations innovation is expensive.  Small community based organisations and projects are less likely to carry expensive overheads and have more flexibility in how they resource projects.  They do not carry the weight of the NHS on their backs.

• Co-production – This is an obvious area where Big Society ideas overlap with the existing direction of travel in mental health.

Big Society ideas give us an opportunity to make people with mental health difficulties the centre of the mental health world, rather than passive recipients of services provided on their behalf.

This paper seeks to pose the questions:

How can Big Society ideas help advance existing desired outcomes in mental health?

and

How can Big Society ideas help people with mental health difficulties do the things that they wish to do?

We’ve got some answers for these questions, but we’re sure that we have only scratched the surface.

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The re-organisation of the health service has won few supporters outside coalition ranks as senior mental health professionals, GPs, health managers, unions, campaigners, activists, service users and politicians all line up to voice serious concerns. Embarrassingly for the government, the ranks of critics have even been joined by coalition MPs and a member of the prime minister’s own family.  In preparation for the new mental health strategy to be announced on 2^nd February, One in Four examines responses to government plans for reforming the NHS.

The scrapping of Primary Care Trusts (PCTs), handing commissioning of £80bn a year of care for their patients to GPs from April 2013 and the sheer pace of the changes have drawn most flak to health secretary Andrew Lansley’s Health and Social Care Bill.

Two mental health charities warned the government about GPs’ competence to commission mental health services while the bill was being drafted. A Rethink survey revealed that only 31% of GPs feel equipped to take on the commissioning role for mental health. And Mind gave written evidence to the Health Select Committee saying: “Many GPs do not have sufficient understanding even of mental health in primary care, and may not be best placed to commission secondary care. The expertise of those involved in the delivery of services – e.g. psychiatrists, social care professionals, nurses and occupational therapists – should be utilised, as should the expertise of the third sector and, most importantly, mental health service user groups and individual service users themselves.”

As the health proposals were being laid before the Commons, an all-party committee of MPs warned that the decision to go for rapid root-and-branch restructuring has made the plans more risky and more expensive. They acknowledged that the challenge in 2009 to NHS chief executive, Sir David Nicholson, to make £15bn-£20bn in savings is central to the reforms. But the politicians don’t like the way the coalition is going about it. They say: “The failure to plan for the transition is a particular concern in the current financial context. The Nicholson challenge was already a high-risk strategy and the white paper increased the level of risk considerably without setting out a credible plan for mitigating that risk.”

Former Conservative health secretary and chairman of the committee, Stephen Dorrell, criticised “the surprise proposal” to scrap PCTs and hand commissioning to GP consortiums that appeared in the white paper last July but was omitted from the coalition’s programme published two months before that. He said: “We share the government’s objectives. We also say that this is in several respects not the most effective way to deliver them.”

Former GP and now Tory MP, Sarah Wollaston, said there is so much uncertainty at the moment that there is an uncontrolled exodus of experienced people out of the NHS. She said: “If the expertise is not there in the remains of the PCT clusters, inevitably they [GP commissioners] are going to have to turn more to the private sector.”

Liberal Democrat MP, Andrew George, also on the committee, told the BBC: “Most of the informed and authoritative commentators on this all agree this might result in a race to the bottom, and it certainly will. I think there is a big risk it could compromise quality as well.”

Dr Laurence Mynors-Wallis of The Royal college of Psychiatrists agrees: “There is a danger that, in the new system, services will go to the cheapest provider at the expense of quality. There is also a danger that, if a multiplicity of providers are delivering different aspects of care, that care may be fragmented and patients may fall between gaps in services.

More than half of the country’s family doctors disagree that GP commissioning will create a patient-led NHS. In a survey by the Royal College of GPs which attracted more than 1,800 responses, more than 70 percent of the doctors also said they disagreed- or strongly-disagreed that the concept of services being commissioned from ‘any willing provider’ will improve healthcare outcomes. Dr Clare Gerada, head of the Royal College said: “We must guard against fragmentation and unnecessary duplication within a health service that is run by a wide array of competing public, private and voluntary sector providers, that delivers less choice and fewer services, reduces integration between primary and secondary care and increases bureaucratic costs.

The respected medical journal, The Lancet, ran an editorial saying that for the Tories to call themselves “the party of the NHS” is “a commitment that seems pretty hollow now”.

The general public have given a distinctly lukewarm response to allowing profit-making companies a greater role in the NHS. Only 27 percent backed giving GP consortia the ability to commission from ‘any willing provider’. Exactly half of the nearly 2,000 respondents to a YouGov poll said they opposed the change.

Paul Hammond who has bipolar disorder told One in Four: “I get a 10 minute slot when I go to my GP. Is that long enough to take commissioning up to the next level? Key to these changes is having coherent and robust evaluation to see if the commissioning is working and the level of patient care is achieved.”

Chris Ham, chief executive of The King’s Fund, a charity seeking to improve health services in England, said progress in NHS performance over the past decade is now under threat: “These gains are at risk from the combination of the funding squeeze and the speed and scale of the reforms as currently planned.”

His theme was taken up by Paul Farmer, Mind’s chief executive, who said the quality of current mental health care must not be jeopardised: “ There is a real risk that valuable mental health knowledge and skills could be lost in the transition process and that some mental health services will be vulnerable to closure or disruption. We know from past experience that mental health services often bear the brunt of health budget cuts and we can not allow history to repeat itself. GPs have limited specialist knowledge on mental health and we’re worried that this lack of understanding will affect commissioning choices.”

As parliament began debating the reforms, Dave Prentis, general secretary of the health workers union, UNISON, said the government was taking “another step down the road toward the destruction of the NHS”. And Gail Cartmail, head of the Unite union, said the changes would “shove NHS patients to the back of the queue, as private greed will leapfrog health need every time”.

The prime minister has defended the NHS changes saying he’s on a personal crusade to make our hospitals the best in the world. David Cameron said: “Pretending that there is some easy option of sticking with the status quo and hoping that a little bit of extra money will smooth over the challenges is a complete fiction.” However he has had to admit that his own brother-in-law, a cardiologist at an NHS hospital, is not convinced by the changes, telling the PM he’s giving too much power to the GPs.

The Department of Health says 141 GP consortia covering half of England have already signed up as ‘pathfinders’ to trial the new commissioning arrangements. This is music to health secretary Andrew Lansley’s ears: “It is clear that GPs and nurses are ready and willing to take on commissioning responsibilities. The pathfinders to date demonstrate this, but most importantly, the changes will enable them to make the decisions that better meet the need of their local communities and improve outcomes for patients.”

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Earlier this week someone on Twitter drew my attention to this story from Benefits and Work blog about mental health charity Mind being part of Disability Works UK, a consortium bidding for a role delivering back to work and other services as part of the government’s Work Programme.

This means that Mind and other charities will be bidding to provide services contracted as part of Government plans to get more people off benefits and back into jobs.

Responses to this news tend to fall broadly into two camps. One camp feels in principle that charities should remain completely independent of funding from sources that may compromise their ability to represent their beneficiaries. You might call this the ‘how dare they betray us by getting into bed with our enemies’ camp. The other camp feels that charities, like any other organisation, need to make sure that they can bring in enough money to keep going and doing good things. This could be called the ‘business is business’ camp.

In a broad sense I can see both sides of the debate about large charities taking on sizable government contracts in areas around which they are currently campaigning.

For charities like Mind there is an awareness that it might be inappropriate to campaign about a particular policy with one hand while assisting its implementation with the other. This they more or less state in their response to Benefits and Work. In terms of their position, as far as many mental health activists are concerned, business isn’t just business.

Those who see that such organisations should refuse all such offers on principle can, however, be blind to the realities of the situation.

The logic used by large charities in going for these contracts is that they are the best placed to deliver a service that meets the needs of people with mental health difficulties. They would argue that, in effect, their delivery of the contract would take the edge off potential harshness of the regime by using their knowledge of what people with mental health difficulties need and want to make it work better. Whether you believe a particular charity’s claims to have superior knowledge, involvement or peer support available is not the same as being able to claim that these beliefs are a cynical ploy to justify wanton money grabbing.

The situation is that the services being contracted for will be delivered by someone. Charities such as Mind reason that it is better for them to provide these services, as organisations with some involvement of people with mental health difficulties, than other corporate providers that have no special understanding of people with mental health difficulties.

But there’s more to it.

A conflict of interest?

For many, it feels instinctively wrong that a charity like Mind should be involved in trying to get money from government contracts to help deliver elements of the benefits system. Why is this?

For some, it’s the idea that this represents a hypocrisy or a conflict of interest – How could a charity like Mind continue to campaign against a benefits system that they are somehow complicit in delivering?

For others it’s the idea that a body in theory representing the views and aspirations of people with mental health difficulties should, acting on their behalf, be involved in delivering something so detested by many who experience mental health difficulties themselves.

Both of these arguments are based upon the idea that Mind is a representative organisation and that its main aim is to take the views of people with mental health difficulties to power. This may be one of its aims but it isn’t quite where Mind is at now. Mind isn’t the equivalent of a mental health trade union with thousands and thousands of signed up people with mental health difficulties across the country feeding their views into the organisation democratically. Mind is a central body that campaigns, fundraises and researches and a federation of local Mind associations (LMAs) who vary greatly from place to place and from each other.

Mind nationally is still an organisation that for the most part does things on behalf of people with mental health difficulties. The public gives it money to help people with mental health difficulties. Over time Mind has quite rightly included more and more people with mental health difficulties in running their organisations, working for them, volunteering for them and steering them, but it is still recognisably a organisation for, not of, people with mental health difficulties. (Look out for future posts on this topic)

There is another argument, mostly coming from within the voluntary sector, that in moving into tendering for large contracts available to provide specific services, large charities are behaving like the large contract corporations to which they feel superior, edging out smaller community level charities and social enterprises. In this vision, large charities move in when services go out to tender like a plague of locusts, leaving only withered stalks to nourish the local voluntary sector.

The real issue, and one that I think will reoccur increasingly as the current spending squeeze continues, is not one of actual conflict of interest but perception of it.

Organisations need cash to stay alive. Many organisations survived on various forms of funding which are beginning to be cut or removed all together. Public services are moving increasingly in the direction of outsourcing their functions, leaving less and less money to be allotted at arms length and more tied to contracts.

Many organisations will find themselves having to play the only game in town to get in money, and the only game in town will often be providing services that their beneficiaries and supporters feel compromises their ability to trust in that organisation overall.

No matter how honourable the motives of Mind’s involvement in the Work Programme, there will always be some who see this as a taint on all their work, asking how they will be able to advise and support people on getting access to benefits while at the same time delivering some of the services they are advising about. Even if the parts of the overall Mind organisation doing this work are separate and firewalled from each other, as I’m sure they will be, it will be perception as much as reality that people go on.

This isn’t a problem that will dent Mind too much outside of mental health circles, as they are big enough with a wide enough donar-base to ride out any choppy waters, but for small charities and organisations this conflict is of pressing day to day importance.

The question is: How do mental health charities in these increasingly turbulent times maintain the trust and goodwill of those which they exist to serve?

And, as importantly, can individuals with an interest in mental health influence how charities behave on their behalf? And if they can, should they?

Mark Brown is editor of One in Four magazine

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With all of the talk about resourcing ‘the frontline’ in the fight against mental ill-health recently, I’ve been wondering where the frontline actually is in this battle.

Is it in the mental health inpatients wards across the country where treatment is provided for people who are very ill?  Is it in the community mental health teams where people’s needs are met in the community?

Is it in GPs surgeries where people first turn when they feel unwell?  Is it in social services departments where people receive help and support with the complicated challenges that can come with mental health difficulty?  Or in social care services?

Is it in the community organisations that provide support, advice, encouragement and inspiration to people with mental health difficulties?  Is it the HR departments of companies trying to find the best ways of supporting their employees who experience mental health difficulties?

Is it at neighbourhood advice services like Citizens Advice where many people look for support with issues in their life that affect their mental health?  Is it in the consulting rooms of therapists or counsellors where people explore what’s troubling them?  Or in the case work of advocates and the meetings of service user representatives?

Is it in Back to Work providers and JobCentres, or in benefit decision making bodies?  Is in the offices and premises of small and large mental health charities, or in the activities they carry out?

Is it in the media, or the communications departments of places that provide services and support?  Or the research teams and in the campaigning groups that draw sustenance from them?  Or the advice and support helplines and websites and new technology ways of keeping in touch?

Is it in Accident and Emergency departments where people find themselves when things go wrong?  Is it in the places where people with mental health difficulties meet to try to find solutions to their own problems? Is it in the police stations where people end up when they’re sectioned?

Is it in our homes, or in our workplaces or in the relationships we have with people?

I think that people with mental health difficulties often lose out because the frontline of any individuals own mental health is spread across many of these areas of operation.

Mental ill health isn’t like a traditional disease.  There isn’t one front to fight on that will eventually win the battle decisively, or one force that could be deployed that would win the war outright.  The correct medical attention and useful treatment is a vital component for anyone’s mental health, as it is for their physical help, but it isn’t the only thing that determines how well someone is.

I think we’re beginning to see that as much as the question of what makes someone ill is important, the question ‘what keeps someone well?’ is probably as, if not more, important.

This has huge implications for people with mental health difficulties at a time where many of the above frontlines are facing a period of simultaneous change.

If you had to look at the map and survey the field of battle against mental health difficulty, where would you draw the frontline?

Mark Brown is editor of One in Four magazine

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As some of you might know, we’re doing some work about the ways that the current ideas around The Big Society might be applied to mental health services.

We’re trying to see what opportunities there are in Big Society ideas to make mental health services better and what might need to happen to make that possible.

To this end, I’ve been revisiting Phillip Blond’s Red Tory: How the Left and Right have broken Britain and how we can fix it. Positioned by some as the ideological driving force behind David Cameron’s new vision for a Conservative Britain and the weight behind the ideas of The Big Society, in Red Tory Blond lays out an analysis of the failings of both Labour and Conservative thinking on how to build a prosperous and happy country.

From the point of view of mental health, the most interesting chapter of Red Tory is ‘The Civil State’, which also happens to be the final full chapter of the book.  In it Blond lays out a potential new vision for the provision of public services.  For Blond, the way forward is to break up the large, centrally run services into smaller service providers.  This would happen when workers and managers of those services decide to become social enterprises.  These social enterprises would know better what their customers needed by involving them in the design and management of services.

In one respect it’s very like current government’s plans for GP consortiums in that it has as its basis that frontline on the ground workers have a clearer sense of local priorities.  Blond’s vision differs in relation to how local people, people who use these services, would be involved.  Blond sees joint ownership of services as keys to their success.  For him this means employees having joint ownership of the service they work for, an opportunity to influence how they are run and an opportunity to benefit from that organisations success.  It also means that through involvement those using the service will also be deciding how it is run and, as importantly, what it actually is and does.

While this is quite exciting for people who like to debate the internal workings of large state run organisations, it’s not so interesting from the point of view of people who just want to get to the services that they need and don’t really care too much how they’re actually done as long as they work.

So, more interesting to me is some of his analysis of what he thinks needs to change, mainly because I think it’s important to look at the diagnosis separately from the suggested cure.  In it there’s a lot most of us would recognise from our experiences of either receiving services from state run bodies or working with or within them.

Many of the solutions he suggests are already happening within the wider world of mental health, but in isolated pockets, on a project-by-project basis or in a way where they conflict with other factors, something I’ll return to once we’ve established what Red Tory actually says.

So what’s up with public services according to Phillip Blond?

One of the frustrating aspects of Red Tory is Blond’s mixture of analysis of current (at time of writing) situations, possible alternatives and suggested solutions, often with the same short section, so I’ll do my best to pull some of them apart.

Blond does not think that big organisations, either state or corporate are the best ways of delivering public services.  As he says:

“Traditionally managed organisations in both the public and private sectors grew up as fundamentally managed closed systems – that is, they are machines that operate with limited interchange with their environment.  They are instrumental, designed to carry out certain tasks, and planned and managed from the top.  Consumers function as essentially passive receivers of products and services.” p249

To a certain extent, this is what many of us have felt when interacting with the NHS, whether the actuality of that experience is correct or not.  The NHS is just there, like a big castle on the horizon. We walk up to it and say ‘treat me’ and it does so following its own internal logic and moving to its own internal rhythm.  Blond thinks of this as a closed system.

Blond feels that the NHS in providing services has often thought too much about controlling budgets and managing productivity, looking at how much work is done and what that work costs rather than looking at whether that work is actually doing what it’s meant to be doing.  He talks about this in terms of ‘value demand’ and ‘failure demand’, the difference between “productive work and waste”:

“‘Failure demand’ is the valueless, cost-creating work generated by the failure of an organisation to deliver services that from the customer’s point of view actually work.  Examples of failure demand include: ‘I don’t understand this form’ or ‘Why haven’t my benefits been paid?’  This can be contrasted with ‘value demand’, which is productive.  Examples of value demand include: ‘I would like to apply for benefits’ and ‘Can you fix my window?’” p255

This is an observation that ‘feels’ true for many of us who have been involved in trying to sort out our mental health, either through accessing services or through trying to sort out problems that were making our mental health worse.  Blond thinks that large structures and organisations can be blind to the fact that they aren’t really doing what people need them to do, or are doing those things in a way that is causing as many problems as it’s solving.  As he says:

“Front-line staff frequently confront problems or become aware of opportunities long before strategic managers.  Many of the most important issues affecting productivity and efficiency are not vague questions arising from a detached, bird’s-eye view, but detailed questions of implementation and execution.” p254

So for Blond, the people who are actually involved in making a service happen (the front-line) don’t make the decisions about what the service should be and how it should be done, but neither do the people who actually receive that service:

“In cases such as the NHS, the purchaser of the product is not the same as its consumer.  This creates a challenge for the system: how do you ensure high quality outputs?  Under the current structure, the purchaser is more likely to pay attention to senior managers and political masters, on whom jobs and prospects depend, than weak consumers” p248

The picture this creates of public services is a one where distant decision making fails to match conditions on the ground and the wishes of people actually using those services.  Taking this to mental health services, the picture he paints is of a series of forts and castles with high ramparts, where subjects turn up at the drawbridge to ask for help without ever being allowed in to see the baron who makes the decisions.  They might see at best a member of the court, but more often will see the men and women standing guard at the gates.

When looking at how the average person in the street is involved in decision making about public services, Blond presents four ways in which this might happen:

“Representative political democracy – affecting change through the ballot box and elected representatives;

Consumerism – through market-like arrangements in the public services

Participatory democracy – through self-organisation in unions, churches, third-sector organisations, and suchlike;

Involvement as co-producers.” p264

He suggests that in the last 30 years the focus in public service delivery has been on the first two of these methods, either ‘vote for who you think will do it best’ or ‘make your own choices from what’s on offer’.

The situation regarding involvement as it stands in mental health is slightly different from this, or at least has the potential to be so.  People with mental health difficulties are involved in some consultation, some service co-design or co-production and via community or charity organisations that provide services, provide advocacy or lobbying or which do a bit of both.

So carrying on with our castle analogy, for Blond, mental health as provided by the NHS would be an old style castle, that occasionally invited people in to see the baron, but only on the baron’s terms.

The castle might choose to work with people outside of the walls to do things, but it wouldn’t ever let them forget who the boss is.

So what changes does Red Tory suggest?

In contrast to the rigid, distant structures that he sees as limiting possibility and making sure that services don’t actually meet the needs of those who use them, Blond advocates for a new way of doing them by largely suggesting the opposite of the situation he outlines.

He suggests that small organisations are better than big, responsive ones better than unresponsive ones, ones that involve better than those that don’t and where the state has provided and planned, he sees a new settlement where services are provided by lots of different kinds of organisations all working together.

He believes that services are best run by the people who can see what effect they have, in other words is people on the ground who either provide them or use them.  He also believes that there needs to be a new openness, bringing down those castle walls.  He is keen on open systems, where organisations are adaptive and constantly change, grow and contract:

“Open systems are organic rather than mechanistic, and require a completely different management mindset to run them.  Strategy and feedback from action are more significant than detailed planning…; hierarchies give way to networks; the periphery is as important as the centre; self-interest and competition are balanced by trust and cooperation; initiative and inventiveness are required rather than compliance; smarting-up rather than dumbing down.  I intend that the structure I propose meets these baseline requirements.” p250

For him, the objective should be to have services that are directly responsive to the needs of those that use them and that are prepared to change how things work if what is being done isn’t working:

“Open systems… recognise that uncertainty and change render traditional command-and-control ineffective.  Instead, the aim must be to adapt continuously to the environment.  Instead of top-down, such organisations aim to function ‘outside-in’, as John Seddon puts it.  The consumer is a source of intelligence, as are suppliers and competitors.  In production terms the goal is to make to order, at the rhythm of market demands, rather than to make to a company-defined schedule or plan.” p249

To do this, Blond suggests that we need to find new ways of putting both service users and service providers together:

“Overhauling our rigidly structured public services will also require us to change the way that the public interact with the services that they receive – not just as customers but also as stakeholders, designers, deciders, implementers and evaluators… p263

“What is needed is a system that will give the public, as individuals and client groups, a literal stake in their service providers.  The state must enable new associations of service-users, community members, voluntary contributors and existing social organisations to take ownership of their services, as partners with direct influence over providers.” p268

Possibly without realising, Blond makes a point about why this has not happened previously that resonates incredibly with many people’s experience of both delivering and receiving mental health services:

“While engaging service users in new ways has long been considered desirable, it has proven incredible difficult to realise in practice…  Genuinely treating the public as partners requires, by its very nature, flexibility in the way services are delivered.  One prerequisite for developing partnerships between the front-line and the public is sufficient autonomy for the front-line to respond to demand.  Structures which create excessive aversion to risk or overly pressurise performance at the expense of personal relationships render user-engagement meaningless.” p267

Many involved as ‘service-user representatives’ or ‘voices of lived experience’ have found it difficult to see where their contribution has made a difference at the same time that many working closely with users of services have found it frustrating trying to take their views and needs to decision makers.  There is a massive gap marked involvement that has been difficult to fill for some services, while others have managed it well.  Often there is a feeling that people use services and those who commission them are both speaking languages in which the other is not fluent.

In essence, Blond is calling for more flexibility, more responsiveness to need and greater involvement from those who actually use the services in question.

Which, as I alluded to above, is exactly the direction that thinking about the best ways to make sure people with mental health difficulties get the help and support they need has been heading.

Mental health and Big Society?

Within mental health, there is a number of forward looking strands of thinking and practice that have been bubbling under for a fair period of time without reaching a critical mass.

These include:

• Peer-led services
• Services responsive to specific local needs
• Personalisation
• Co-production

I’ll be returning to these in future blog posts to look at the way that Big Society ideas interact with what is already happening for mental health in these areas.

In many senses, the actual position for the overall field of mental health is partly already what Blond suggests as the best way of delivering services co-existing with many of the structures that he identifies as problems.

There is a vibrant non-NHS sector of mental health organisations, groups, charities and services which interact with larger, structurally dense NHS mental health services.  Alongside this there are the range of state-run and non state-run organisations and services that exist to support, assist and help people to overcome difficulties in their lives.

In any person’s experience of mental health difficulty and getting it sorted, these different services crossover and interact in various complicated ways.

There are NHS services and charity, for-profit, social enterprise and community organisations that operate in exactly the way that Blond identifies as being the best to maximise good outcomes for those who use them.

These services, however, often find it difficult to sustain themselves financially and to evidence exactly how strong their impact is, operating as they do in a less rigid, more responsive manner.

The relationship between innovative services and the new kinds of thinking they involve and more traditionally conceived or run services is often best defined as ‘prickly’.

There are some areas of public provision where traditional service is exactly what people want and what works best.  There are other areas where the innovation and, for want of a better word, entrepreneurial problem solving or small community based charities, social enterprises or groups has significantly shifted practice and principle far beyond that of more traditional structures.

In mental health, new ideas have tended to come from what at the time has been seen as the periphery before becoming integral to our expanding understanding of what it is that makes sure people are okay.

The three areas where organisations outside of the NHS currently offer huge potential are:

• Meeting needs that NHS services cannot
• Minimising the cost of innovation
• Meeting needs flexibly and efficiently

I’ll also be returning to these areas in future blog posts to examine where Big Society ideas intersect with mental health.

Suffice to say, there is much in Phillip Blond’s analysis that is of interest to those of us committed to making sure that people with mental health difficulties can get on with the lives we want to lead.

The challenge is whether it’s possible to get the good stuff to happen during a time of austerity.

But isn’t the Big Society all about privatisation and cuts?

Blond certainly believes that it isn’t the state that is best placed to provide services that work.

Pre-empting critics, he talks about the fact that that in the last thirty years

“reform becomes seen as an intractable right-left dichotomy between a consumer approach that grants consumer sovereignty at the risk of inequality but with a focus on individual satisfaction, and a social-democratic approach which emphasises equal treatment and due process, at the expense of outcomes.” p264

Blond sees breaking up the large monopolies of service provision, both public and private as the best way out of this impasse.  In other words, let people take over the running of things if they want to and they’ll use their wits, intelligence and creativity to make it work, or not.

For Blond, the state providing all is, in itself, disempowering:

“The fact that most of our public services are still owned by government or their contracted-out partners, rather than the people who use them or the people who work in them, sends and unspoken message of disempowerment more clearly than any putative endorsement by policy makers.” p271

For Blond, the way forward is to give away the bricks that build the castles and to support people as they build smaller castles of their own, of their own design.

This isn’t, however, the only way that the ideas he suggests might be put into practice.

With the launch of the successor to New Horizons, the framework for developing mental health in England scheduled for later this year, it’s going to be interesting to see exactly what emphasis it places on the more radical implications of involvement, partnership and co-production and just how it suggests they might happen.

(All page numbers refer to the paperback Red Tory:  How Left and Right have broken Britain and how we can fix it by Phillip Blond, Faber and Faber, 2010)

Mark Brown is editor of One in Four magazine

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People with mental health difficulties have long held the opinion that newspapers fail us on a number of levels by playing up the sensational aspects of mental health difficulty and reinforcing negative ideas about mental health difficulties and what it means to experience them.   Now there is new research to see if we’re right.

On Tuesday night, in a free public lecture at Gresham College in London former Guardian journalist Mary O’Hara launched the findings of her year long research into the ways that UK and US newspapers report mental health.  As Alistair Cooke Fulbright scholar, Mary spent a year based in the US, working with a small team of researchers to answer the question of what UK and US newspaers actually say about mental health.

I’ve been looking forward to the publication of Mary’s research because, believe it or not, it’s one of the first times than anyone has done this kind of research into the way mental health is discussed in newspapers.  The findings of the study are surprising, and I think this might be the first chance the internet has had to have a peek at them.

What was the research?

The research set out to evaluate the coverage of mental health difficulty in a range of mainstream newspapers over a significant timeframe in the US and the UK and to chart trends in that coverage.  It also looked at whether there was a difference between the headlines of stories and the actual story presented.

They looked at stories from the years 1985, 1995 and 2009 to see if there was any change over time  The study looked at the The New York Times, The Washington Post, The Chicago Tribune and the LA Times in the US and The Guardian, The Times, The Daily Mail, The London Evening Standard and The Sun in UK.

They identified stories concerned with mental health difficulty, looked at what condition (if any) they discussed and divided their subject matter into topics.  They used a four point scale to grade each story positive, neutral, negative or sensationalist.  The researchers also looked at the messages that were communicated by stories and their headlines.

What did they find?

In general the researchers found that news coverage was more likely to be negative in tone than features.  In the UK, news accounted for 54% of overall coverage but 60% of negative coverage.  In the US, news accounted for 47% of coverage but 57% of negative coverage.  It seems, therefore, that there is something in news values in both the UK and US that make mental health more likely to be covered negatively.

They found that pejorative language, words like ‘crazed’, ‘maniac’ or ‘monster’, were evident in all years studied and in both countries, but that US newspapers were much less likely to use such language than their UK counterparts.

They also that specific conditions were much less likely to be mentioned in headlines than general references like ‘mental illness’ or ‘mentally ill’ and that this was true in all of the periods they studied.

Where mental health was mentioned in headlines in the UK, the four most likely topics to be discussed were suicide, mental health services, lifestyle and wellbeing and murder by a person with a mental health condition.  The research found that in the UK, while there was no evidence that there were more negative headlines than articles, there were more sensational headlines than sensational stories.

While headlines in the UK usually reflected the contents of the stories that they announced, there were instances where the headline was more sensational than the story it preceded, suggesting that newspapers still see mental health difficulty as an eye-catching bit of spice to make a story more interesting.

The picture in the US was broadly similar.  In both, suicide was the most headlined topic, but US headlines tended to be more negative in their overall messages about mental health.

Where there were secondary topics discussed in relation to mental health in headlines, they found that for the UK newspapers the five most common were gender, first-person accounts, criminal justice, inquests and children or teens.  In the US, in contrast, the five most mentioned secondary headline topics were inquests, children or teens, the mental health profession, gender and the armed forces.

When looking at article topics, they found that in the UK the four most common topics were mental health services, suicide, lifestyle and wellbeing and murder by a person with a mental illness.  Where there was a secondary topic discussed it was most likely to be gender, with other common topics being public policy or legislation, wider healthcare system, symptoms or celebrities or public figures.

In the US, articles were most likely to discuss mental health services, suicide, prevalence and causes of conditions and murder by a person with a mental health condition.  Where there was a secondary topic it was again most likely to be gender, followed by children or teens or inquests.

The research found that the psychiatric profession and therapists and therapies featured much more in US coverage, along with a higher number of stories about people overcoming adversity.  Mentions of discrimination featured rarely in headlines or articles on either side of the Atlantic.

According to their findings, race and ethnicity in relation to mental health was rarely mentioned in either UK or US coverage.

UK articles and headlines were much more likely to mention celebrities and public figures in relation to mental health and that the number of mentions jumped significantly in 2009.

The pharmaceutical industry barely registered in either headlines or articles in either country.

Where conditions were mentioned specifically, they found that depressive conditions, including bipolar depression, were the most commonly mentioned in both countries but that thee was no evidence that they were covered more now than 25 years ago.  Schizophrenia was the second most mentioned condition but was rarely referred to specifically in headlines.

Suicide was an area of intense newspaper interest with the level of coverage of suicide was extremely high in both the UK and the US, with broadsheet and tabloid newspapers equally interested in covering it.

Disturbingly, they also found that out of a total of 166 US newspaper articles, only 7 included a mention of a helpline or other mechanism for seeking help.  In the UK, only 8 out of 155 articles provided signposting to a source of help, and all of these were in published in 2009

Most shockingly for the UK, they found that in terms of tone, negative coverage of mental health had actually risen between 1995 and 2009, with an actual reduction in the percentage of overall coverage that could be coded as neutral or positive.  As shockingly, this was at a time where UK broadsheet coverage of mental health actually improved, out performing US broadsheets in the same period, indicating a rise in negative coverage from UK tabloids.

So what does it mean?

The implications of this research are interesting.  2009 was the first full year of operation for the national anti-stigma campaign Time to Change and was also the year where the BBC’s  Headroom initiative succeeded in making mental health related stories part of a number of major BBC television programmes.  Both of these initiatives have been successful in raising the amount of coverage of mental health related issues in the media.  The findings of the study suggest that while this has been effective in the UK, it hasn’t necessarily decreased the negative coverage of mental health at a time when overall coverage was rising.  It’s possible to see the ‘Time to Change effect’ in the prevalence of stories that mention celebrities in the UK, as time to change has raised awareness of the mental health difficulties of a number celebrities such as Frank Bruno or Stephen Fry.

It’s also interesting to see just what angles journalists have to take to try to interest their editors in covering mental health stories.

What we see is that editors is the UK think we the public are most likely to want to read about mental health if it includes suicide, services, lifestyle and wellbeing or murder, especially if they can get an angle like the difference between men and women, first-person accounts, crime, inquests into things that have gone wrong or kids and teens.

When it comes to the actual stories, we see that UK newspapers are most likely to tell us about services, suicide, lifestyle and wellbeing or murder, again with a gender twist.  It seems that the possible angle of stories in the UK might be wider, with articles that discuss policy or legislation, the NHS, symptom spotting or celebrities stories.

All of this is in a context where news stories in the UK papers examined account for 60% of negative coverage and where headlines at least tend to avoid specific mention of particular conditions.

I’m sure that the final research published in the spring the will compare and contrast UK broadsheets and UK tabloids for their coverage.  It will be interesting to see which newspapers scored which way when the stories were being categorised and whether the overall picture would look different if you took out either The Daily Mail or The Guardian.

Notable is the lack of coverage of discrimination, which could be understood ‘good bad news’, in that it is news that brings to light things that might make change happen.  This suggests that there is little coverage that sees people with mental health difficulties as in charge of their own destiny and able to make changes in their lives.  Though, as a small ray of sunshine, it’s possible to take heart from the UK prevalence of first person narratives and, maybe, learn from the US newspapers prevalence of stories based on people overcoming adversity.

Overall, the study sets me wondering:  Is it possible that as people with mental health difficulties have become more visible and collectively more open about the reality of our experiences that in response newspapers have paid more attention to us?

If it is, then it seems that editors have been unable to shake off older ideas about what makes mental health news.  Are editors out of step with the public, or when it comes to mental health coverage, does the public get what the public wants?

Mark Brown is editor of One in Four magazine

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Welcome to the new One in Four blog!

We’re going to use it to discuss all of the mental health and wellbeing related issues and events that we can’t manage to cram into the magazine.

We’re hoping to make contact with more of you, our readers and supporters.

We’ll also be hosting guest posts, flagging up stuff we think is interesting and looking at events as they happen with a One in Four eye.

Building upon his twittering, Mark Brown, Editor of One in Four will be blogging regularly on mental health and wellbeing issues and keeping you up-to-date with what he’s been up to and who he’s been talking to.