What do the Big Society ideas of Phillip Blond’s Red Tory mean for mental health?

Photo of New Castle by http://www.flickr.com/people/tawcan/ used under CC licenseAs 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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2 Responses to What do the Big Society ideas of Phillip Blond’s Red Tory mean for mental health?

  1. Mark

    Thank you for this really useful, informative and well laid out article, that explores some of my gut instincts and views to a much deeper and practical level.

    For me “The Big Society” also embraces the concept of empowerment, which I personally feel is a fundamental part of any individual’s journey towards recovery (whatever recovery may mean to that person). I did hear something about a pilot scheme where GP’s were going to try to hand out vouchers – so that patients could choose their own therapy.. Have you heard anything about this, and what are your thoughts around empowerment, choice and paying for services that were previously free?

    I’m just wondering if there is some connection between empowerment and actually choosing to pay for a service… as in – do you think there is something about a government funded service that reinforces a victim mentality? I’m struggling to see a balance between too much and too little… like caring for a child, if you offer too much support and comfort – you could potentially reduce their resilience…? Where do you think the balance is? A Big Question for The Big Society I think…

  2. Mark,

    Your blogpost doesnt really get to grips with the human side of the service evolution problem as predictably you focus on the more ‘stable and well’ end of the mental health spectrum where services are already evolving to meet take up of the new mediarised , ever expanding and sexier definition of mental health at the expense of those not so stable, capable and well who are held captive in the less sexy and unreformed mental health services in the castle keep or are just abandoned through the revolving portcullis to the mean streets on the other side of the castle moat .

    The ‘difficult customers’ as I’ve often heard services managers call them..

    This bias towards the more stable and/or worried working well – a bias shared by the main MH charities Time to Change campaign which has been accused of invisibilising the poor, unemployed, less stable and really unwell because they aren’t media friendly enough – previously led you to completely ignore the exclusion of mental health from the Patient Choice agenda , a ‘policy stance’ ( as you put it at the time ) that also enabled you to conveniently overlook just how monopolistic state mental health provision is and what little real power mental health service users have to get involved with or participate in the production of state mental health services or for that matter charity mental health services closely modelled on choiceless state provision.

    Dont take my word for it though. Ask Comrade Bray She’s a Govenor at her Trust but she’s suddenly finding out the hard way from the inside that services are still pretty sterile, asocial , system centred and crap.

    Rowntree have also highlighted the conflicted interests that prevent ‘involved ‘ users shaping service commissioning and delivery in any meaningful way and also questioned how representative these involved users actually are and they certainly aren’t the only party to do that as you know.

    Back then you were funded by the mental health system and annoyingly blindly pro New Labour ( One in Four ?…..) indeed I recollect you insisting that the National Mental Health Development Unit – a reincarnation of the secretive and authoritarian NIMHE and its boundaryless incestuous networks – absolutely had to centrally control the re-shaping of services and I also recollect One in Four hosting a conference fronted by Labour Spin Doctor Alistair Campbell on ‘How to Talk About Mental Health in the Media’.

    It was all control agenda.

    Since Labour’s demise you’ve democratised a bit, a plus , even allowed comments on the One in Four site but back then as One in Four you were part of the problem that the choiceless mental health service users at the neglected end of the mental health spectrum railed against as they and the issues they raised were officially dismissed as pathetic products of ‘dependency culture’ , a view that helped pave the way to a wider political class and media projection of claimants with mental health problems as scroungers.

    That’s the road to here but now back to Blond.

    There is nothing new about mental health service users running their own services, at least not on the small scale as we set up a local charity within your MH Trust’s catchment area to do this in the mid 90′s and we certainly weren’t alone . There were many problems we faced as ‘user’ service providers , particularly around organisational stability ,which I’ll get back to in a moment but what’s really new and in keeping with Blond’s general outlook that change is neccesary is the growing organised protest from mental health services users with the way state and charity mental health provision is being shaped to suit providers and a totally unrealistic DWP driven Recovery agenda . It’s a protest thats been enabled through the net and around the charities and providers and Peter Beresford wrote about this development in the Guardian earlier in the week .

    So the real question for me is how service users who obviously feel betrayed by Government and service providers are going to co-produce services with the same deeply conflicted providers who still have a vested interest , as you know, in keeping them choiceless and betraying them for funding reasons.

    It’s a legitimate question as for all the talk of user involvement and representation there are no functioning equal partnership communication mechanisms to facilitate co-production in a sector that saw nothing odd in dealing with selected few users in a perverse way , including dealing with you as a Recovered service user and solitary blogger being the funded voice of One in Four, that is , around 13 million people …..

    The main mental health charity directors also claim to ‘represent’ their ‘ service users ‘ without blushing and they certainly aren’t doing much to get down and dirty with ordinary mental health service users either . These execs are basically unapproachable , uncontactable and unaccountable just like their NHS counterparts , they are determined to defend the hierarchical pyramid and their own advantage over a group with few rights and Blond is right, there is a massive gulf between those who provide public services and those who use them , we all know that, what most people don’t realize is that in mental health it’s a gulf that’s wider than the gap between people with mental health problems and employers and other members of the public that NIMHE and the charities have received over £120 million in anti stigma funding to bridge. If someone calls me a nutter I can do something about it. If the £100,000 a year socialites who run the main mental health charities secretly form a consortium to negotiate contracts with the Government, ATOS and DWP on our behalf I dont get a say.

    None of us do.

    That £120,000 of anti stigma funding has never been properly audited for effectiveness as P Tovey found out through fiercely resisted FOIA’s to NIMHE and the DoH and what the easy money mostly did was corrupt the main mental health charity service providers into networking together to draw attention and more massively duplicated funding towards themselves as they grew more and more remote from service users.

    I did a quick poll of mental health service users I know one time and discovered that most of them wouldn’t touch Mind’s services with a bargepole as they felt the charity had become too close to Government, too political and too self-serving. I think that’s fair comment and worth pointing out when the charities look set to pick up service contracts on the cheap on the basis , at least in the for public consumption explanation anyway, that they are charitable and good when actually, they’re not , they”re just ruthless businesses.

    There was similar but slightly less hostile view to Rethink and it’s perfectly understandable as these mental health charities are now ideologically driven , they’ve decided with Government what services people need , they’ve decided CBT is a scientifically proven miracle cure even though its only slightly more successful a treatment than placebo and then only with a narrow group of conditions. Rethink and another charity have even put their names to a big pharma advertising app thats practically useless to their service users , an app that you described as brilliant.

    The charities have also decided that its their role to lash out at and chastise media figures and members of the public through massively duplicated anti stigma campaigns and the power has gone to their heads. They’ve also reinvented going out with users as ‘walking therapy’ and gardening as ‘green therapy’ etc. and it may well help these charities to get funding and seem more professional but it’s also the equivalent of over medicalising mental health problems , it’s completely unnecessary and totally demeaning for charities to insert pompous jargon between themselves and their service users to profit and self -aggrandize and slowly morph into the new unquestionable ‘mental health experts’

    Ditto with the relentless utopian Happiness crap.

    There is also the question of providing the practical help and person centred support frameworks that many mental health service with more severe, enduring or recurring mental health problems require to stabilise and cope . This support is necessary as many in this group of service users tend to crash and burn a lot , they can sustain and contribute in short bursts or require constant support to keep on an even keel over time but this is ignored because it contradicts Recovery dogma. We’ve even had some of the orIgInal architects and promoters of the Recovery model fiercely distance themselves from how the model is now used in a bullying way by services as a hard and deadlined ‘expectation’ rather than flexibly supported and person centred approach. .

    There’s very often a limit to what some service users can do but instead of accommodating this reality in accordance with disability equality legislation the official Recovery agenda rubbishes and further marginalises these people , they are seldom involved in their treatment and care or services and are routinely shunned to accommodate more stable , able and system favoured types who in turn learn to discriminate against and stigmatise those who are not as Recovered or as able or connected as they are. Quite often this simply reflects and compounds class inequality within services .

    When asked to address this issue , no lets call it what it is, prejudice you have always maintained that One in Four exists to represent ‘the many not the few ‘ – despite the few obviously adding up to a significant percentage of the 13 million people you write for – so ignoring what a slap in the face your funded comment is to the few , how are people with more severe and/or recurring mental health problems going to be involved in the co-production of their local mental health services when they don’t even show up on your radar ?

    When we provided some local services , mainly out of hours because services assume people simply have mental health problems during office hours , we encountered massive opposition when we crossed paths with other paid providers – we were a small registered charity run by volunteers – and we learned that services depended on instability, i.e. our mental health problems almost as a weapon as helpful staff members confided how their senior managers had planned around our disintegration rather than provide access to their professional training courses and support resources and where disputes arose they piled up bureaucracy to break people.

    The charities behave this way as well now.

    I know five service users who have worked for mental health related charities or state MH services who found themselves being bullied by managers for highlighting legitimate problems and then having their reactions pathologised and being discriminated against as they were maneuvered out of the door or forced to self exclude.I doubt that will stop if state mental health services are just handed over to the charities which already have deeply conflicted representative and provider roles that are important to note precisely because people with mental health issues have so few rights and are so easy to misrepresent and treat as ‘the problem’ .

    For this reason co -production cant just be about bolting service users on to professional mental health charities that keep them at arms length and then jettison them whenever a problem arises. Nor are personal budgets the main answer as they suit the most organised and I know service users who have been emburdened with crippling bureacxracy and accounts keeping and effectively transformed into employers just to get 3 hours care a week because – get this – they are depressed and cant cope.

    Worse the payments are shot through with Recovery expectation so whether the individual service user can cope with the bureaucracy or a pooled service emerges , its just going through the motions to tick someone elses boxes , save money, and it’s not really helping and hasnt been rolled out in any large scale way anyway and probably wont ever be now.

    It seems to me that service users would be better served by being offered involvement in resourced ‘frameworks’ enabled by a third party which had no other role other than ensuring that the partner provider remained person centred and never got the upper hand as trying to force people with mental health problems to Recover doesnt work.

    Blond is talking large scale major paradigm shift in the way services are shaped and delivered and how society can be organised more fairly and justly and he’s not alone in calling for this . I don’t really want to get caught up in the conflicting political perspectives – and lets remember here that you were happily Big Committee rather than Big Society when it was Alistair Campbell patting you on the head – but in reality we as service users can only change things on the small scale in our localities using sustainable frameworks that we can fit into or rejig and which hold and help us to practically support ourselves and others with stability and autonomy but which also don’t implode if people relapse.

    We don’t all want or need to work around mental health services and some of us probably wont be able to work in any traditional sense of the term yet will still require support , local social activities and financial stability to get by .I’m hearing from a number of people who fit into this category that they feel they are being pushed towards suicide because they cant cope, there isnt any work and the MH sector has an appalling record of placing people in jobs not because people are scroungers but because the employment schemes just conspire to juggle people around to each other because they are useless but no one important pushes for quality provision in mental health. Why would they? as Choicelessness still poisons the whole culture.

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