Who should pay for mental health?

Money by CJ Isherwood CC licenced http://www.flickr.com/photos/isherwoodchris/It’s impossible to talk to anyone involved in mental health at the moment, whether as a user of services, a planner of services or as a deliverer of services without one topic cropping up.

Everyone is asking the question ‘Where’s the money going to come from?’

So far, so familiar.  Mental health has always been an area where money is tight.  However, there’s a new urgency since the effects of deficit reducing cuts began to be felt.

It’s instructive to think about this question in a slightly different way.  Rather than asking ‘where will the money come from?’ it’s more interesting to look at the question as being ‘just who is going to pay for services in mental health?’

Prior to the advent of the coalition government, for many people the answer to this question would have been simple.  Either the state in one form or another would be paying as part of the public services, through directly contracted services or through strategically awarded grants.  If it wasn’t the state paying, then the answer would have been grants made by charitable organisations in one form or another.

Very rarely would the answer to who was paying be people with mental health difficulties themselves.

By their nature, mental health related services are based on the idea that services are being provided to those that need them but who would not be in a position to pay for those services themselves.  When a mental health service is funded by, say, a local authority what is happening is that service is being bought on behalf of the people who use it to meet their needs.  When a service is funded by a grant funder, the same is happening.  The funder is recognising a need that will be met by the proposed funded service or project and is putting up the money for some or all of that service to be carried out.

In both cases, the service is being purchased on behalf of people with mental health difficulties.

In the NHS, this process is repeated.  Commissioners put into action strategic plans to meet the needs of people with mental health difficulties by commissioning services while managers allot funds.  In essence, they are again buying services on behalf of people with mental health difficulties.

Many would say that for medical based services, it’s the NHS who should be providing and that for everything else there should be grant based funding.  For organisations such as The National Coalition for Independent Action, voluntary sector groups and organisations chasing contracts to deliver what local authorities have decided is important has reduced their independence and ruined their relationships with the people who use their services and the communities in which they’re based.  As Rachael McGill says in NCIA’s recent report Voluntary action under threat: what privatisation means for charities and community groups:

“Some voluntary sector organisations have helped to further this agenda by entering into competitions to deliver services on their local authority’s terms. They fail to recognise that although they themselves are not the private sector, they are still conspiring with a practice which turns community provision into a market place.”

The NCIA paper claims that this is a significant step towards eventual privatization of public services:

“The coalition government has embraced this conflation of ‘charity’ and ‘business’. It wants to institutionalise the idea that the preferred way to fund traditionally charitable activity is through social enterprise methods: loans and income generation through contracts, charging or trading, rather than grants or other public subsidies.”

While this point may or may not be true in principle, it does leave the massive question of who will be paying for the provision of services.  In the appendix to Voluntary Action Under Threat, there is an attempt to suggest ways that this might be brought about beyond campaigning against cuts (changing policy):

“Can we lobby independent funders to support needs-led work, preventative and holistic work and campaigning?” the report asks.

Which delivers us back to the question: just who should be paying?

It isn’t who’s selling, it’s who’s buying

Social Enterprise is often presented as a solution to problems that community and voluntary sectors are having financially.  Set up a social enterprise and you’ll be able to do business and raise money at the same time as doing good. We recently met with someone from a major social funder who was looking for social enterprise models in mental health for investment.  We thought about this a lot and advised her that there were fewer social enterprises in mental health than you might imagine, and those that we did know of were facing significant challenges.

The reason for this, we explained, was that although many people were good at identifying what needs people have and developing effective ways of meeting them, this was not the same as coming up with a winning business model.  The reason it was not the same was not that the social enterprises in mental health were not well run, well structured or not delivering high quality services but that they were lacking one important aspect of any business model.

Money.

Whatever was being ‘sold’; was not, at this time, what people were buying.

Business usually begins by working out what people want to buy and whether it is possible to supply them it in a way that generates profit.  Social action starts from working out what people need and then finding out ways to fund meeting that need.

Social enterprises ‘spun off’ from being previously part of the public sector have the problem that even as spun off services, their main client is the kind of service of which they were once part.  Local charities previously maintained by council grant that become social enterprises have the same difficulty: if the council isn’t paying, then neither is anyone else.

In effect, cuts at a local level close off that large area of revenue generation.

‘But,’ asked the representative of the social funder, ‘isn’t there room for people with mental health difficulties to pay for services themselves?’

We thought about this point for a moment before explaining that for many, the idea that people with mental health difficulties might pay for services out of their own pockets was seen as another step on the slippery slope toward the state providing no support for voluntary and community organisations.  In fact there are those that see asking people with mental health difficulties to pay for services as profiting from the disability of others.

On a less political level, it’s also the case that people with mental health difficulties who need services just aren’t in a position to pay the market price for them.

This makes things very difficult for those organisations that are sticking to their guns and delivering what people with mental health difficulties want them to deliver.

Filling the gap

In the current wash of ideas around The Big Society, there is the notion that with the withdrawal of the state will come a deluge of civic action to fill the space that withdrawal of state funding has left.

This poses us some problems in mental health.  If the state isn’t funding what organisations do either by grants or through commissioning, and people with mental health difficulties themselves are not paying for it directly out of their own pockets, then this leaves three rough areas from where money might come.

The first is from grant making bodies.  This is a tricky area.  For many there is a doubt that mental health is far enough up the list of priorities for most grant making bodies and charitable trusts.  There are few grant making charitable trusts that have mental health as a specific area of focus.

The second is from philanthropy.  Distinct from charitable grant making, philanthropy is the individual giving of time, money or other elements.  Again, as with charitable grant making, it may be possible that individual organisations or projects find patrons who can support their work, but it is not something that it is possible to put in your business plan.  Tech company start ups might be able to find angel investors, but they’re looking for a return on their investment.  Finding rich individuals to fund mental health projects might well be harder.

The third is charitable giving.  It is nice to think that the general public would be happy to raise funds for mental health projects and organisations across the country, and in many cases they do.  This however is an enterprise that benefits from economies of scale.  Organisations need large infrastructures to effectively raise funds from the public, which in turn cost money, which in turn increases the overall need of that organisation to keep pulling in money from the public keep running.  This means that larger organisations have an advantage over small organisations not only in terms of practical fundraising ability and capacity but also in terms of brand awareness and exposure.

The problem is that, as a group of people, people with mental health difficulties are currently not quite at the top of the list of people for which the general public feels worried.  In fact, some might argue that our standing with the public has gone down as a result of media coverage and government policy at exactly the time that we need the public to consider our needs more.

Is there any hope?

There are potential chinks of light coming through the darkened skies, but they are only that at present – tiny slivers of possibility, and it isn’t one that will appeal much to people ideologically opposed to organisations other than the state delivering mental health services or to the idea that organisations must avoid thinking like businesses.

The move to personal budgets both for health and social care present a new possibility for organisations.  For the first time, the theory goes, people with mental health difficulties will be able to draw down a personal budget and then spend that personal budget on buying the services that they want.  No more will others purchase things on our behalf.  In theory we will be able to give money to the services we value and those services will, in turn, try to meet our needs in ever more inventive and satisfying ways.

The problem is personalisation is moving slowly in mental health, and it isn’t clear how organisations will survive long enough for people using their personalised budgets to plug the gap.

What is clear is that for many organisations the clock is ticking, if it hasn’t stopped already.

There just isn’t enough money coming into our sector.  We must strongly advocate for the fact that it should.  We must also be cunning, be charming, be inspiring.  In fact we must do everything we can to bring in that money, from whichever source possible.

Even volunteers need support.

We must by all means make the case for who we feel should pay in mental health, but we also have to be finding out who might pay and finding ways of helping them to do so.

This NCVO / Funding Central advice and information ‘Life After a Grant – The exit strategy’ is useful for organisations facing some of the challenges outlined in this post.

Mark Brown is editor of One in Four magazine and development director of Social Spider CIC.

What’s coming up in One in Four Summer 2011?

Wondering what’s coming up in the Summer 2011 issue of One in Four?  As ever, it’s a mix of advice, inspiration, information and a little bit of hope.

Due mid June, you can expect see these exciting articles  in the next issue:

  • What effect does experiencing mental health difficulties have on your friendships?
  • Work Capability Test and ESA: Navigating your way through the maze
  • Un-great expectations: Does how others see us hold us back?
  • A report from One in Four’s conference ‘What do we do now? – Mental health, user leadership and communities’
  • Our friends in the north: Did you know how different mental health was in Scotland? We talked to Chris O’Sullivan and were surprised
  • Supplement on money management support produced with the Money Advice Service
  • Seaneen Molloy tells us why she’s a summer Scrooge and why summertime can bring its own blues
  • Plus latest news, busting the myth that people with mental health difficulties are lazy workshy scroungers and more including at least one photo of a cake because it’s our third birthday!

If you get there in time you might be able to find a copy of One in Four at your local Mind shop or at a local mental mental health organisation, but to make sure of getting your copy, why not take out a subscription?

Subscribe to One in Four for £10.00GBP per year!

List of mental health publications

Unfortunately we can’t use all of the articles submitted to us, so we’ve compiled a list of other mental health publications. A lot of these are very different to One in Four, and some may come and go, but we still hope that this will be a useful resource for writers and readers alike.

We compiled this list since we couldn’t find one anywhere else. If we’ve missed any publications that you’re aware of, please let us know!

You can find the list here.

Why should you come to our conference?

These are belt tightening times.  Cuts, reductions, new forms of contracting, The Big Society…  All of these things and more are making us worry about our ability to make things happen in mental health.

It feels like we are seeing an erosion of what had been provided for people with mental health difficulties.  All we seem to hear of is stories of services and projects running to a stop.

Our conference, taking place in London on the 16th of May is about looking for ways that we can take forward some of the most exciting and transformative ideas in mental health into this new and uncertain territory.  A lot of us are feeling under siege.  Whether we like it or not, we’re going to be making decisions about how we do things in future.

What if people with mental health difficulties were at the centre of these decisions?  How can people with mental health difficulties and organisations make sure that this happens?

At a very basic level, the conference will be focusing on the ways in which people with mental health difficulties can be the people that drive forward projects and change by either starting their own organisations or working in partnership with other existing organisations and services.  We’ll be making sense of terms like co-production, peer services and user leadership and looking at the ways that these things might be taken forward practically.

If you have an interest in where the world of mental health outside of medical practice might be going next, then we hope you’ll be able to make it.

There’s potential for many of the more exciting and empowering ideas in mental health to meet current ideas like The Big Society halfway.  One strand of the Big Society is about giving more control to communities about the services that they receive, which is something that people with mental health difficulties have asked for a long time.  Another is about finding new ways for the public sector to work with voluntary or community groups, another thing increasingly hoped for by many people with mental health difficulties.

There’s been a lot theoretical stuff spoken about ‘empowerment’, ‘involvement’ and ‘putting people in control of services’ but what does that actually really mean in practice?  We think that there’s a new wave of organisations, projects and groups coming through that blur the line between practitioner and user, expert by profession and expert by experience.  We hope the conference will be a day long opportunity to catch up with and tie together a lot of the ‘next wave’ ideas in mental health with good practical examples of how they’ve been done.

There will also be a Question Time style panel discussion about what the landscape for mental health featuring Andy Bell – Centre for Mental Health, Sarah Yiannoullou -National Survivor User Network, Ceri Jones, Head of Policy – Social Enterprise Coalition and others which will be a good chance to work out just where policy is and where smaller mental health and community organisations might be headed.

There’s also opportunities to meet your fellow attendees and find ways that you might share your experiences and work together.

As a small organisation making our way in the world, we can’t make this (unfunded ) conference free to attend.  Tickets can be bought here and a limited number of bursary places are available.  You can also check the line up.

Hope you can make it!

Cheers,

Mark Brown, One in Four

What would you change?

It’s nigh on impossible at the moment to escape from news stories about the National Health Service and the current government plan to reorganise it.

It won’t have escaped your attention that health secretary Andrew Lansley has called a two month halt to the passage of the Heath Bill through Parliament to listen to the views of NHS professionals.  You can find the web pages for the listening exercise here.

Reading through the Guardian Heathcare Network on the Guardian website I came across this excellent article from The Patient from Hell ‘Will Lansley consult me, the patient?’

It seems that I’m not the only person wondering how the wishes of the people who just use the NHS are going to be reflected in the upcoming changes.  More specifically, I wonder how much the views of people with mental health difficulties will be considered in any future shake ups.

In the spirit of that thought, I’d like to ask for your help.

In the next issue of One in Four, out in June, I’d like to do an article about what we’d like to change about the way we receive treatment and support for mental health.  Rather than focusing on what it is that we don’t like now, I’d like to pitch forward and talk about what we’d like things to be like.  And I’d like to ask for your help.

If you’ve got an idea for how mental health treatment or support might be done better, put it across in no more than 200 words and send it to me at Mark@socialspider.com .

They can be big ideas, little ideas, easy to implement ideas or complete changes f policy.  They just have to make it easier for people to have the best level of mental wellbeing that they can.

You can discuss your ideas here if you’d like to, but please also send them to me via email.

If your idea makes it into the magazine you’ll win a years free subscription to One in Four for either you or a friend.

How does that sound?

 

 

Risk – An idea big enough to stop change in its tracks

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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Mental Health and Big Society: Opportunities?

works in progress by http://www.flickr.com/people/koalazymonkey/ Attribution 2.0 Generic (CC BY 2.0)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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NHS re-organisation: Too much, too fast?

Photo of a roadsign saying 'too fast' by http://www.flickr.com/photos/sumlin/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 2nd 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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Conflict of Interest?

Conflict is so 2008 by http://www.flickr.com/people/adam_prince/ used under Attribution-NonCommercial-ShareAlike 2.0 Generic (CC BY-NC-SA 2.0)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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Just where is the frontline in mental health?

An image of some maps by http://www.flickr.com/photos/alpoma/ used under CC Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0)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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