Category Archives: Blog

5/12/2011

“Seeing people with mental health difficulties as people who can find solutions to their own challenges and ways of achieving their aspirations means taking a step on from seeing mental health simply as a range of conditions requiring care, support or treatment.”

This is a quote from ‘Better Mental Health in a Bigger Society?’, a new thinkpiece written by the people who bring you One in Four that examines the question: How will a Big Society approach affect the lives of people with mental health?

The thinkpiece,  to be published on December 5^th 2011 by Mental Health Providers Forum, discovers surprising overlaps between Big Society ideas and changes that many people with mental health difficulties have long hoped for but set within a climate where pressures on public finances risk destroying the potential for community innovation.

It suggests ways in which the NHS, local authorities and new health and wellbeing boards can support the development of a strong and diverse mental health landscape. This means supporting community groups to enable them to provide real choice and opportunities for people with mental health difficulties.

As an alternative to a Big Society vision based on altruistic volunteering, the thinkpiece explores ideas such as co-production, peer services, personalisation, user-led organisations, and other community-based activities that put people with mental health difficulties at the heart of their own recovery.

‘Better Mental Health in a Bigger Society?’ challenges the tendency for thinking about mental health to focus solely on discussions of medical services. It provides examples of innovative mental health projects delivering the non-medical support that people need to stay well – many of which will be under threat from lack of funding as local authorities and the NHS retreat ‘behind the front line’ to concentrate on ‘core services’.

Mark Brown co-author of the thinkpiece and a person with mental heath difficulties himself says: “We stand a point where there’s a great opportunity for positive change for people with mental health difficulties but there’s a real danger that innovation and change will be strangled at birth by inability to recognise that new situations require new thinking. We’re looking for a new settlement between NHS and local authorities and the communities of which they are part. If we are to have a Big Society, then change from the bottom up must not be an empty promise.”

Download a copy here http://www.mhpf.org.uk/information-centre/publications/better-mental-health-in-a-bigger-society

Contact mark@socialspider.com for further details or telephone 020 8521 7817.  Bloggers especially welcome! Both authors of the piece, Mark Brown and David Floyd are available for interview and comment.

The following is a speech I made to the Mental Health providers Forum AGM in 2008.  I’d completely forgotten about it until I was in a meeting recently and some said that they were there when I gave it.

The question of work and recovery is one that has the ability to inspire both visionary zeal and rancorous disapproval.  To some it seems to be self evident that people will have better lives if they are working, earning and enjoying a fulfilling professional life.  To others it seems as if people who are ill are being forced into jobs to get them off of benefits.

My own story isn’t too different from a lot of people’s.  After a number of years of being unwell without really considering myself to be ill, I finally had to drop out of university after a disastrous attempt to get a degree.  Very unwell, I found myself excluded, unable to claim benefits and at a loss as to what my future might hold.  I was twenty one.

Subsisting on benefits, my life entered a kind of grey period, where things never moved.  I was accessing treatments, and trying to achieve a level of being well, but still had no idea of where my life might go.  I was worried about the idea of work for a number of reasons:

• I was worried that I would be sent to do work I wouldn’t be able to do.
• I was worried that I wouldn’t fit in at work
• I was worried that people would stigmatise me for my condition
• And I was worried that the work I would end up with wouldn’t suit me as I didn’t have the qualifications to reflect my abilities.

But I was still stuck in this day-to-day existence where I wasn’t really moving on, and every month was taking my further from the world that friends and family existed in where two things; work and the money it brought in, were allowing them to do things that were interesting, to interact with others and to do things that were fun.

What couldn’t see was a way back into work from where I was at that point.

I actually found my way back into work through being involved first on a voluntary basis then a paid basis in a very small social enterprise, which set me off on the path to where I find myself today.

For me, it was getting back into work, slowly and step by faltering step, that helped me to move out of a grey period of uncertainty and stasis and into an active and rewarding period of which I am still reaping the benefits.

As I grew into my role, and them finally moved into my current position, I found myself thinking of myself less as a person with an illness and more as a person with certain legitimate limitations that I and my colleagues needed to be aware of and certain challenges that I had to overcome to get where I wanted to be professionally.

In essence, through seeing the fruits of my own actions realised in my working life, I began to hope for more in the future and moved into thinking of myself as someone who could achieve and prosper.

This is the real role of work in recovery.  Work in itself is not a panacea.  What really helps is the effect that the rewards of work can have and the feeling of rejoining the stream which everyone else is swimming in, of being part of life rather than at its side lines.  Finding the right work for you, your limitations considered, opens up life like a flower.  Like blood returning to a numb limb, money, personal relationships and the sensation of doing something and going somewhere do not solve the problems caused by your condition but they do bring feeling back and gradually begin to wake you up.

I think it’s the rewards of work, not something magic and intrinsic about work that makes the difference.

Social enterprise is, in theory at least, the more caring wing of business.  Concerned with creating outcomes beyond simple profit, it should be the perfect place for people with mental health difficulties to find work.

Many social enterprises can provide flexibility and support, and often being smaller organisation with less rigidly hierarchical structures and, on the whole tending to be much younger companies, a less ingrained sense of traditional practices.

In practice, social enterprises can also be les structured and be more pinched at the bottom line, requiring more from their staff.

To me, speaking professionally and as a person with mental health difficulties there are three main issues involved in the practicalities of helping people to access work as a way of supporting their recovery.

The first is adjustment.  What people with mental health difficulties need most when entering employment is a sense that their new employer is happy to take a creative approach to making sure that they can produce their best work within the limitations imposed by their condition.

In my own working life, my colleagues appreciate that I have a condition and that, to do my best work, there are some things in my professional life that need to be adapted both to make best use of my talents and also to work around the areas where my condition imposes difficulty.

If you think of it in the same way that you would think of the flexibility that working parents sometimes, you’re along the right lines.  A store of adjustment to be drawn upon as needs be.  A parent doesn’t need to rush off to the school everyday, but they might if their child is taken ill.  Similarly, in my own case, I don’t need to get to the office a number of hours later than everyone else every day, but some days I do.  It is not a matter of leniency or special treatment, just an acceptance of the fact that factors that are in play for someone with a mental health difficulty can be different to those of someone else.  We employ as similar approach with people who write for One in Four, adjusting deadlines or supplying additional research, doing what we can to make sure that the person can get stuff done.

The second important thing is trust.  People with mental health difficulties who are in work and those who have been away from work need to trust that their condition will be treated respectfully and even-handedly both by their employers and their colleagues.  There is nothing worse than feeling you are being done a favour, or feeling like you must beg for adaptations.  The conversation should always be a pragmatic one between equals.  When people are going through a crisis, as many people with mental health difficulties do, the effect of being ignored, fobbed off or not treated with due respect can often have a great effect.

The last one is hope and meaning.  Many conditions, my own included, can lead to an ebb and flow of energy and motivation.  What keeps someone going is the hope that things will improve and a certainty that things are going somewhere.  What we try to do with One in Four is to help people see that small positive steps can often lead directly or indirectly to large changes.  Feeling that you are having things done to you and that you are a passenger in a process rather than the person driving it makes it difficult for anyone to feel motivated.

For me, the most important thing to remember when discussing work and recovery is that work itself isn’t a magic four letter word; it’s everything that someone gains from being in work that is important.

Mark Brown is the editor of One in Four magazine.

In the first of our guest opinion posts, Judith Haire shares her thoughts on where money should go in mental health

I’ve experienced mental illness and been on the receiving end of unkind comments. I applaud the Time To Change anti stigma campaign run by the leading mental health charities Mind and Rethink Mental Illness.  One in four adults will experience mental health problems and one in four children. Stigma is a problem that can stop people seeking help, can erode already fragile self-esteem and confidence and can hinder recovery.

I am all for changing people’s attitudes and behaviour and removing the stigma associated with mental illness but we can take away the stigma and we are still left with the ever-growing problem of mental illness. I really can’t see the point of pouring endless sums of money into anti-stigma campaigns when this money could be deployed on researching the causes of mental illnesses and the best treatments for these illnesses

I believe the burden of mental illness in the UK is widely under-estimated. Poor mental health affects our ability to work, it affects our ability to have fulfilling relationships, it affects our physical health and our ability to have a fulfilling social life.

Poor mental health costs us £100 billion a year in the UK.

In one year there are 13 million working days lost to stress related illnesses.

A third of a GP’s time is spent dealing with mental health problems and around a quarter of people with mental health problems are taking prescribed medication.

Mental illness causes 15% of our country’s disease burden but only receives 5% of the total health research spending. £74 million is spent in a year on research into mental illness but this figure needs to be nearer £200 million over the next 5 years.

In fact, current spending needs to be trebled. The Department of Health and Comic Relief have given the Time To Change campaign a further £20 million – I would prefer this to be spent in different ways.

A strategic analysis of mental health research funding in the UK (Department of Health, 2005) identified some major gaps in research funding. For example, research into the promotion of mental health and well being and research into common mental illnesses like anxiety disorders and research into suicide.

More research is needed into the links between diet and mental health and there are more questions to be answered surrounding the diagnosis of schizophrenia

There is a need for laboratory and epidemiological research into the causes of mental health problems (genetics, environmental factors and their interaction).

More research is needed on the treatments for mental health problems and most importantly to look at interventions to prevent mental illnesses

We need scientists and researchers to look further into genetic aspects of mental illness and at developing newer and kinder treatments for mental illnesses; treatments that do not have devastating side effects like type 2 diabetes, obesity, cataracts, sedation, tremor, muscle rigidity, insomnia or fluid retention. These side effects are debilitating and can require specialist treatment and surgery.

Let’s reassess our spending and not make anti stigma campaigns the priority.

Judith Haire is a Sheffield University Politics Graduate. She is author of Don’t Mind Me (Chipmunkapublishing. 2008). She contributed to Mental Health Publishing and Empowerment by Jason Pegler (Chipmunkapublishing, 2009) and Our Encounters With Madness (Ed. Grant, Biley & Walker, PCCS Books, 2011). She has written for Mental Health Practice, Community Care and Your Voice (Sheffield) magazines. www.judithhaire.vpweb.co.uk

Guest posts reflect the views of their authors and do not neccesarily reflect the views of One in Four magazine.

As is traditional at this time of year, One in Four is preparing a round up of the year for our readers and we want to know what you made of the year.

It’s undoubtably been a turbulent one for many of us, but we want to know what your mental health high points, low points and hopes for 2011 are.

You’ve got two weeks to send us your thoughts. We want:

• One high point be it personal, political or other
• One low point be it personal political or other
• One hope for 2012

And

• One thing you’ve learned about mental health in 2011, be it a personal realisation, something factual or something general.

We’d like it if you could keep your answers to a maximum of 200 words for all four questions in total.

You’ll also need to provide us with the name you’d want your comments to be published under and an email address.

If we publish your comments we’ll send you three copies of the Winter edition in which your comments will appear.

Send your comments to mark@socialspider.com with ’2011 Thoughts’ as the subject line.

We need them by 24^th November so get thinking!

Cheers,

Mark Brown, editor, One in Four magazine.

I came across this interesting little snippet of research today: A team of Dutch positive psychologists claim 68.4% of people with ‘mental disorders’ that they studied claimed they “often felt happy” during the previous four weeks.

The link discusses the strengths and weakness of the study but as Ad Bergsma and his team write of their results: “The possibility of coexisting happiness and mental disorders is of clinical relevance… A narrow focus on what goes wrong in the lives of the client and forgetting what goes well, may limit therapeutic results.”

To many it may seem ridiculous that a study that recognises that people with mental health difficulties might also be happy or feel happiness is news. But is it?

We still tend, in public debate at least, to divide the world into those who have mental health difficulties and those that don’t. So there are people, and then there are those people.

A good example of this is the Daily Mail’s coverage of The Centre for Social Justice’s major intervention into the mental health public policy debate ‘Completing the Revolution: Transforming Mental Health and Tackling Poverty’

In the Mail’s article covering the launch ‘Care in the community is ‘a £100bn failure’: Mentally ill patients have been neglected for decades, says Iain Duncan Smith think-tank’ the opening paragraph sets a tone from which the rest of the article does not deviate:

“The controversial ‘care in the community’ approach to treating the mentally ill has been a £100billion failure, a report warns today.”

It goes on to insert a ‘same old, same old’ couple of paragraphs about violent mad people while acknowledging that the report it is covering refutes the high profile linkage of mental health and violence:

“But the big push came in the 1980s with the introduction of new laws giving mentally ill people more rights.

The policy has been blamed for allowing dangerous mental patients to roam the streets, and there have been high-profile killings involving care in the community patients.

But the study claims that the link between mental illness and violence is ‘vastly exaggerated’ and suggests that doctors are too quick to detain people unnecessarily or to put them on powerful ‘mind-numbing’ drugs.”

There’s a ‘those dangerous people over there’ attitude in evidence in the Mail piece that has its obvious results in outdated stigmatising ideas and prejudiced behaviour but there is also a much more subtle process of transformation at work in the way that the article is constructed.

Read as a whole, the piece (and many of the reader comments that follow it) position mental ill health as a country that you enter with no passport home. You cease to be a person with hopes, dreams, fears, relationships and achievements and become one of ‘the mentally ill’, a member of a strange and threatening tribe with incomprehensible practices and motivations who must be measured and discussed using arcane mechanisms and ideas. You become a problem that is dealt with by policy means.

It can be easy to forget the way that mental health difficulty is often perceived in public debate is there are passing mental health difficulties that people get over (like a kind of mental flu), the ones that people bravely battle through to arrive pretty much in one piece and back where they started, and the serious ones that completely change people and from which they never return. Neither of these cultural ideas really fit the actuality of mental health difficulty or have shifted very much from where they were when we had asylums and people desperately hid their difficulties under a blanket of shame.

The reality is that many mental health difficulties are disabilities. They’re things that get in the way of doing things that you want or need to do. Very often the challenges that you face as a person with mental health difficulties are as much social as they are medical. The things that you experience because of your mental health difficulty disable you in a world that is set up for people who do not experience the same. Something that would take a little adaptation or a tiny tweak can be the difference between having a fulfilling life and finding yourself excluded. You’re a person doing their best to play the hand that you’ve been dealt and trying to find the best way of getting from where you are to where you want to go. You might do things you enjoy on the way, or find things that you value. You might even have a laugh.

The ‘mentally ill’ of public debate don’t have those qualities. They can either be cured or are incurable. They sort of just hang about either causing trouble or needing to be looked after. They’re public discourse relatives of ‘the poor’, ‘the homeless’ and ‘the disabled’. They fill a rhetorical gap when someone needs to say something but doesn’t really have much actual experience of what they’re talking about, or many details to hand.

If you’re thinking of ‘the mentally ill’ you’re not really thinking of people, you’re thinking of a vague, hazy mass of malfunctioning humanity that needs to be somehow maintained or contained.

It’s hard to see human qualities in such ill-defined generalities. Which means a person might well be surprised that individuals in that pile of ‘the mentally ill’ that they’re having such trouble picturing with any clarity might have any feelings at all, never mind feelings of happiness.

Mark Brown is the editor of One in Four magazine.

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If any of you were following the news yesterday, you may have noticed a major story unfolding.  No, not phone hacking, but David Cameron’s launch of the Open Public Services white paper.

Much delayed, the Open Public Services white paper is this government’s vision of how public services will be delivered in future.

In many respects it is similar to the NHS Reform Bill which has just finished its ‘pause’.  It sets out five principles that will guide public service reform.

These are:

• Providing more choice
• Shifting power from the centre
• Ensuring diversity
• Guaranteeing fair access
• Delivering accountability

This is the government finally getting to the gristle of what a Big Society might look like.

But what does this mean for mental health?  It’s something that we’ve been thinking about since December 2010.  The eagle-eyed amongst you who have both been reading this blog and have been keeping up with the constant flow of government policies may have noticed that we’ve been saying stuff that has now become pretty relevant to what we who are concerned about making sure the mental health needs of people are met might do next.

Here’s three videos of me speaking about what the Big Society might mean for mental health that I did for the Mental Health Providers Forum’s Lightbox project, with links to some of the most relevant posts from this blog.

Our thinkpiece on mental health and Big Society commissioned by the NHS Confederation is scheduled for publication at the end of this month.  If you’d like a peek at a draft email mark@socialspider.com

Here’s me:

In many ways, our conference in May was about this question too.  There’s a write up and video here

Here’s some relevant posts from this blog and from One in Four:

So what about the Big Society thing? From One in Four Winter 2010

Mental Health and Big Society: Opportunities?

Where is the frontline in Mental Health?

What do Red Tory Big Society ideas mean for mental health?

Who should pay for mental health?

‘Walking in two directions’: A mental health and Big Society dilemma

Adventures in mental health and Big Society: Making stuff happen

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

Seven steps to changing the world: Article from One in Four winter 2010 examining ways to start and run your own projects or ‘How to change the world, Do-it-Yourself style!’

A more measured response to the white paper itself in the next few days!

Mark Brown is the editor of One in Four magazine.

Subscribe to One in Four for £10.00GBP per year

While much of the debate about health in England has been focused on the progress (or not) of the health bill through parliament reorganising the way that health services are run in England, those of us involved in mental health know that there is more to services than the NHS.

As this excellent piece by Mary O’Hara in The Guardian this week illustrates, the current economic and political climate is posing smaller organisations significant challenges.

These are often organisations that have come into existence because they have recognised a need that the NHS was not meeting. These can be anything from therapy services to art groups to advices services. As I’ve said in a previous post, there is no single frontline in mental health. Mental health is something that touches on all areas of life.

At present there’s a feeling of hatches being battened down, of feet being stamped down quite decisively on the funding hose that used to carry the flow of money that previously kept smaller organisations in business. As I’ve said, despite glimmers of hope, there’s not as much money in mental health as there should be.

I was at an event discussing mental health and big society last week where there was a marked scepticism for the idea that large state organisations would release some of their budgets to fund and support organisations from the community and voluntary sector. The view was that when it came down to it, large providers would generally choose to look after the jobs of people already working for them, rather than lose the jobs and enable others to deliver the service.

It’s a good an honourable thing to try to protect the interests of the people that work for your organisation and a good and honourable thing to try to keep the show on the road. With the public sector going through a period of being ‘slimmed down’ by the current government, it’s understandable that public sector decision makers will be looking to prop up their own houses.

But is this what’s best for people with mental health difficulties?  And what about the community, voluntary and other organisations that fall outside of the public sector but which deliver well loved services?

It’s here that lies the dilemma of our title.

Working as we are at a time of much reduced available funding, many of us trying to make sure that people with mental health difficulties don’t lose out from this current situation find ourselves captured on the horns of a series of dilemmas.  In a mental health and Big Society discussion we had today as part of the process of refining our thinkpiece (out next month), a mental health policy specialist described this feeling as ‘trying to walk in two directions at once’ and it’s a good description of the dilemma many of us face.

Some of us believe that there are possibilities for the current situation, especially the set of ideas and possibilities arrayed around Big Society, to bring about positive change in the way mental health services are delivered. This can mean we find ourselves arguing that the public sector should share some of its funds. In essence we find ourselves saying ‘make cuts to the public sector and give the money to other places.’ This is something that many of us find difficult to say.

At the same time, it’s our impulse to campaign hard to minimise cuts to services, even when we may feel like those services are not meeting our needs. In essence, we feel as if we should campaign to protect services that we support in principle but which we actually don’t like in practice.

Many of us would also like to find new and better ways of meeting the needs of people with mental health difficulties and supporting people to find solutions that suit them to the challenges that they face Sometimes these methods might be less specialist, less stable or less expensive. A good example of this is setting up a regular social drop-in where people had a chance to meet and find common ground to replace a now-closed day service provision. We sometimes feel that by finding alternatives that work and speaking proudly about them we are somehow betraying the case for the funding of services that are more specialist or more expensive.

Similarly within the broader debate about the opening up of public services, many of us want to see the smaller local organisations that we use surviving, but not at the cost of other more traditional state services that we use. We do want more choice but not if that means reduced quality. Many of us want greater access to medical treatments and interventions, but not at the cost of the community, charity and voluntary organisations that we love and rely upon.

This moment of reorganisation and redefinition does present us with opportunities to take forward many of the things we’ve been wishing for in mental health (see this and this report from our conference in May for more) but at what cost?

With the quality of life for those of us with mental health difficulties at stake, the dilemma is not an abstract or theoretical construction.

Even if we look at this period as an opportunity to move thinking around mental health services and opportunities forwards, by using this moment pragmatically to further these aims, it’s still a period where we will have to decide to do one thing over another or to follow one path while declining to follow others.

How do we make those choices? And how do we make sure that it’s people with mental health difficulties that don’t lose out?

Mark Brown is the editor of One in Four magazine.

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In which we borrow a room and ask people to come to a meeting and some do

In a meeting room in the really rather lovely Waltham Forest Town Hall, this afternoon saw the first meeting of Waltham Forest Mental Health Forum.

As some of you might know, we’ve been working on a thinkpiece funded by The NHS Confederation into what Big Society ideas might mean for mental health.

As we spoke about at our conference last month, the present moment is one that is filled with both challenges and opportunities.  The ‘big’ idea of the ‘Big Society’ is that local people are best placed to find solutions to local problems.  This comes at a time where shake-ups in local councils and the NHS are leading to reorganisations, repositionings and changed priorities and where money seems to be evaporating more quickly than the spray from Waltham Forest Town Hall’s beautiful fountains.

Part of the argument that we’re making in our thinkpiece, out in July, is that organisations, communities and public bodies are going to have to find new ways of making things happen if we hope to meet the same needs that we met previously.  Another part of the argument is that getting organisations and individuals together and thinking about we want to happen is the key to making sure that innovation continues in this difficult time and that, on the ground, people still have opportunities to have their needs met.

With that in mind, we did something quite simple in our home borough of Waltham Forest.

We called a meeting.

We contacted everyone that we could think of who might be interested in making sure that Waltham Forest is a borough that looks after the mental health of the people who live here and said: ‘We’re organising a meeting to see what we can do together in mental health and what we want to happen next.’

Quite brilliantly, people turned up.  Attendees included a local councillor, people from the local voluntary sector, people from local community groups and people interested in mental health.

What we’ve seen is that areas where voluntary, community and public sectors work well together are areas where more stuff gets done.  I haven’t been able to find a better term than ‘making stuff happen’ to cover the complicated interaction between talking, planning, plotting, persuading, politicking and advocating involved in getting something from being a nice idea to something that actually happens.  Stuff seems to happen when you get people with ideas and people with knowledge together and get them talking (especially if some of those people have resources too!)

We intentionally didn’t set an agenda apart from having a chat to work out what we could do together.  We weren’t inventing anything new, just trying to get some people together in a new way.

For the first half an hour we waded through all of the acronyms and all of the past rights and wrongs of what the local NHS had and hadn’t done, what the local council had and hadn’t done and what we thought was happening to groups and organisations in the current funding climate.

So far, so much like rounds of other meetings familiar to people who have been involved in engagement exercises.

Then we got onto the interesting things: what can we make happen, how do we do it and who might help?  To do that we had to shift from the kind of meetings that we’d been used to, where discussion focused on what the council or the NHS should or shouldn’t be doing and into seeing ourselves as independent of that and able to decide to do what ever we wanted.

Once we got away from the equally import conversation about what the public sector should be providing when people are ill, we got onto the question of how we could make stuff happen to help people be well.  What emerged was that there was already lots of extremely interesting stuff happening in the borough.  What also emerged was that there was work to be done in making a strong case to the local authority for the importance of mental health as a public health issue but also a case that gave practical information and suggestions.

Lots of ideas got knocked about, included going forward with a directory of local groups, organisations and services.  This would have a dual purpose of making people aware of those groups but also providing a practical resource to begin engagement with local GPs.  Another included widening awareness of our newly minted forum to get larger amounts of people along and where that wasn’t possible talking to people and finding out their ideas, wishes and fears.  A third was the development of a vision for what we, people with mental health difficulties and voluntary and community groups, would like to see in the borough.  We always expect local authorities to know what should be done, but Big Society ideas suggest that we might be the ones with a better and more useful vision.  Coming together on an equal playing field as people who want to make stuff happen is the first step for that.

A fourth and even more exciting idea that came across was that through talking to people, we might be able to find ways of making small community level projects happen.  One attendee said that she’d love to put on a regular group for people to meet and that all she’d need was a venue.  It transpired that there was a newly launched community hub that might be able to provide it.

This was the important aspect of what we were talking about; our ability as individuals and organisations to find solutions to problems and meet needs by working together, networking and doing that slightly messy yet vital business of ‘making stuff happen’.

I know they’ve been happening in some places for years.  Alisdair Cameron spoke at our conference about how far advanced this method of making stuff happen is in the north east of England.

As we filed out and past the wonderful fountains the conversations continued, as I hope they will for months to come.

If we’re going to make sure people have the best mental health possible, these are the kind of conversations that we need.  I’m glad we managed to start one here.

How are things where you are?

Mark Brown is the editor of One in Four magazine.

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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.

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!