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.
- Peer-led services
- Services responsive to specific local needs
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