One in Four Magazine

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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Having heard from a few people that there was going to be a demonstration by people with disabilities against cuts to services and benefits, I thought it’d be a good idea to nip down to Trafalgar Square and see what was happening. Head full of scenes from previous demonstrations, I put on an extra jumper and packed supplies of chocolate in preparation for being kettled.

As it turned out, it wasn’t that kind of demonstration. The demonstration, organised by Disabled People Against Cuts (DPAC) was a relatively small affair protesting against cuts in housing benefit specifically and wider cuts for people with disabilities in general.

The demonstration first protested in front of Downing Street before moving on to Trafalgar Square to stage a nativity scene. You can see the donkey and the innkeepers with the names of various local authorities in the photos.

The slogan most chanted by the protesters was ‘Save our benefits, save our homes’, arguing that cuts proposed by government, taken as a whole, put people with disabilities at far greater risk of exclusion.

Protesters were told to refrain from shouting and chanting as the demonstration had not been authorised by The Greater London Authority.

The organisers claim that this is the first of a series of days of action across the country. Brilliantly, people wove through the crowd handing out festive mince pies with a cheerful smile.

It’s interesting to contrast the size of this demonstration with the size and visibility of recent demonstrations about university funding, or the range of flash-mob style actions against high street retailers perceived to be involved in tax avoidance.

I don’t think that it indicates any degree of apathy or detachment amongst people with disabilities, but I think that it does suggest certain differences between any campaign to fight benefits cuts and the campaign against changes in university funding.

One very obvious difference is that students have been better networked. The ease with which large number of people have mobilised is a combination between the fact that university is a place that you and lots of people go to at the same time and the fact that within that there are huge numbers of social and official connections. Add to that the use of mobile phones, social networking and all of the low-cost technology for producing your own media with a very strong overall sense of how the media works, and you have almost perfect conditions to mobilise a large group of people around a particular idea.

Students also have one target for their ire, at least in an overall sense. They are unhappy with the removal of funding from the university system and the suggestion that the balance should be made up by money taken from students future earnings.

In contrast, we people with disabilities are not concentrated in large numbers in particular places, nor do we have the experience of being around large numbers of other people in the same boat as us on a regular basis. Often, we don’t feel ourselves to be part of a wider movement of people, even though we are affected in similar ways by changes to policy and practice in the provision of support.

People with disabilities, including those with mental health difficulties, should they be unhappy with the direction of government policy, are often fighting on a number of fronts which can make it difficult to focus efforts and to engage people. The nebulous phrases ‘disability issues’ covers everything from wheelchair accessibility to employment law reform through medical treatment options to political debates about the meaning of disability. Factor into that the huge variety of ways that people can be disabled, and you have what looks from the outside like a significant minority of the population who experience similar difficulties but who have little in common with each other.

What makes things complicated is that disability isn’t a single issue. Disability in a political sense is the sum total of the life experiences and situations of a huge variety of people. People have varying ideas of what it means to be disabled.

What is common is the sense of living in a world that is harder to navigate than it is for someone who does not experience a disability. I won’t go into the different ways that disabilities pose people challenges in life, mainly because the Office for National Statistics Life Opportunities Survey has done that job extremely well.

Once people accept that a disability is something that makes more difficult doing things you might expect to do, then it becomes easier to see how changes in benefits and government spending might greatly affect those who are currently, quite rightly, receiving a range of support to help them to have what anyone in society might reasonably expect to have.

Students and their supporters have a message that is easier to communicate and which is easier to either agree or disagree with. A campaign by disabled people is more tricky to sell, because it can often take an understanding of the ways in which services and benefits help and support people to be able to see the effect of removing or altering those services and benefits.

It has been noticeable how much less sure footed politicians of all parties have been in discussing the effects of changes to benefits and the implications of cuts to services, which I’m sure reflects the situation in the public at large.

This raises a number of questions.

What would a mass movement of people with disabilities look like? How would it function? What would it do?

And, as importantly, how would people feel about it?

Here’s a video from the day that was posted on twitter:

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.