Month: January 2014

20th International NPNR Conference: call for abstracts

Early news of this year’s International Network for Psychiatric Nursing Research conference, and a call for abstracts, have just appeared. The event takes place at Warwick University on September 18th and 19th, and more information can be found by following this link. With support once again from both the Royal College of Nursing and Mental Health Nurse Academics UK this promises to be a special occasion, this being the 20th running of this esteemed event.

Monitoring the Mental Health Act: what’s happening in Wales?

Just enough time this morning to note this week’s publication of the Care Quality Commission’s annual report into the use of the Mental Health Act in England, and to pose a question. Here are word-for-word snips taken from the CQC report’s summary, covering the year 2012/13:

Our findings on the experience of people detained under the MHA are in the context of a system where:

  • The number of people subject to the MHA continues to rise.

  • There are nationally recognised problems with access to care during a mental health crisis. There is evidence that pressure on services continues to obstruct timely access to less restrictive crisis treatment. Service commissioners in local authorities and clinical commissioning groups need to give a higher priority to translating local needs assessments into evidence-based commissioning of services.

And:

  • On almost all wards, patients had access to independent advocacy services. This is a considerable improvement.

  • We saw improvements in helping patients draw up advance statements of their preferences for care and treatment.

  • But more than a quarter (27%) of care plans showed no evidence of patients being involved in creating them. More than a fifth (22%) showed no evidence of patients’ views being taken into account. This is no improvement on the previous year, and is unacceptable. Services who do not demonstrate good practice in this area should learn from areas who are demonstrating that it is possible to deliver best practice.

  • We continue to see widespread use of blanket rules including access to the internet, outside areas, room access, and rigid visiting times. Some type of blanket rule was in place in more than three quarters of the wards we visited. Such practices have no basis in law or national guidance on good practice and are unacceptable.We continue to hear accounts of patients’ experiences of being restrained. In this report we promote examples of good practice where providers of inpatient mental health services have taken positive steps to reduce the use of restraint.

  • Health-based places of safety, for people experiencing a mental health crisis, are often not staffed at all times. Some have lain empty while a patient has been taken to police custody.

  • Only 17% of recorded uses of hospital-based places of safety under section 136 resulted in further detention, following assessment by mental health professionals.

  • Carers have told us they are not always provided with enough information on how to get help in a crisis.

  • In one area police told us that 41 young people had been detained in police cells over the previous year; the youngest was 11. This is unacceptable.

  • In 2011/12 and 2012/13 we were notified of 595 deaths of people subject to the Act. There were 511 deaths of detained patients, and 84 deaths of patients subject to CTOs. The majority of deaths reported to us were natural causes with a third of those taking place before the person reached the age of 60. Attendance to the physical health needs of people with mental illness must be a priority for all services. We will be working with partner organisations to review national data on all deaths and how this can be combined and shared to improve scrutiny and embed learning.

There’s plenty here to think about and act upon, but as a COCAPP researcher I immediately spot the CQC’s observation on the general lack of service user involvement in care planning. In its coverage, The Guardian emphasised the rise in numbers of detained patients, whilst Community Care ran with the headline, ‘Mental health system failings breaching patient rights and damaging care’.

In this part of the UK the work of monitoring the Mental Health Act falls to the Healthcare Inspectorate Wales. In addition, statistics on admissions in psychiatric hospital in Wales are published here, from which data from 2012/13 can be downloaded. Back on the HIW site I see a Mental Health Act monitoring report for the year 2010/11, which states in its summary:

We generally found detained patients to be cared for and treated by staff who have the necessary knowledge and skills, however, there were gaps in provision. We are particularly concerned that record keeping in relation to consent to treatment was not always appropriately followed. As the Act allows for some medical treatment for mental disorder to be given without an individual’s consent it is important the correct procedures are followed by organisations. We are also concerned that patients were not always being made aware of their rights in a timely manner.

The lack of activities and therapeutic input that was evident in many settings needs to be addressed and we will continue to focus on this matter in the year ahead. Access to therapies including psychologists was found to be variable between organisations. This is concerning as such therapeutic input can assist in recovery and lead to shorter periods of detention.

The HIW states in this document that it has responsibilities to publish its Mental Health Act monitoring findings on an annual basis. It is entirely possible that I’m looking in the wrong place, but I find it odd that the last report available online appears to be that covering the year 2010/11. Am I missing something?

Closing the Gap?

Earlier this week, over the border in England Deputy Prime Minister Nick Clegg put his name to a new policy document titled Closing the Gap: Priorities for essential change in mental health. The foreword to this includes the line that ‘Mental health is moving up the policy agenda across government’. This is a welcome assertion. It is also one which deserves to be examined alongside evidence of recent cuts in funding and retractions in services at a time of rising demand (see here and here for my earlier posts on mental health in an era of austerity).

This is a document listing 25 areas for change in four areas: increasing access to mental health services; integrating physical and mental health care; starting early to promote mental wellbeing and prevent mental health problems; and improving the quality of life of people with mental health problems. It closes with the maxim that mental health is everybody’s business. Initial coverage in The Guardian included a fairly straightforward description of the document’s content, and particularly its promise of increased choice for people using services and the introduction of waiting time targets. In The Independent, Paul Jenkins (from the organisation Rethink Mental Illness) was more searching, contrasting Closing the Gap‘s aspiration with what we know about frontline services:

[…] historically, mental health has always had a raw deal when it comes to NHS spending and accounts for 22% of illness in this country, but only gets 11% of the NHS budget. On top of this, over the last two years, we’ve seen a 2% cut in mental health spending despite increasing demand. Services which were already struggling are being squeezed even further. So how can the Government now make real inroads into significantly improving care and introducing choice when the services simply aren’t there? People are waiting months, even years for treatment.

If politicians really want to improve the lives of people with mental illness, we need to see investment in mental health services – in the very least services should not be cut. We should also be making sure that people who are too ill to work are properly supported with the benefits there are entitled to and with services that respond when and where they are needed. And when we see an action plan, it needs to set out specific commitments on how things are going to change and by when.

Well said. Personally I am minded to think, again, about the mental health field’s wicked problems, and how large-scale policy always contains just one version of what a system’s most pressing challenges (and their solutions) might be. Closing the Gap has plenty to say on what ought to be happening at local level (better preparation of commissioners of mental health services, more mental health training for primary care workers, more psychological therapies, and so on). What it does not unequivocally say is that ‘the problem’ may also be one of underfunding relative to levels of need.

I am also reminded of how local service change in response to national policy can lead to unintended consequences (something I have written about at length here). Here’s a speculative example to illustrate this point. Typically, mental health teams have responsibilities to respond in timely fashion to new requests for help (from colleagues in primary care, for example) whilst simultaneously providing care to people already using their services. Who knows, then, what the wider system effects might be when waiting limits for mental health services are introduced next year, as Closing the Gap promises they will? At local level, will redoubled efforts to respond to new referrals mean that the delivery of ongoing care and treatment will suffer? Will NHS organisations be tempted to establish new types of service specifically to reduce waiting times? If so, how will these find their feet in systems which are already organisationally complex? None of this is to say, of course, that waiting periods are problems which do not deserve to be tackled, but it is to say that actions to address perceived deficiencies always reverberate.

Using digital tools to promote research and scholarship

This week I received an invitation from a colleague at Cardiff Metropolitan University to spend an hour or so sharing my experiences of integrating my use of the ORCA institutional repository with this blog and my Twitter account in the service of promoting research and scholarship. This has given me the impetus to create this set of slides, embedded here:

Activity based funding and student research in the NHS

Yesterday I spent time with a group of MSc students, talking about research review processes. I’ve written on this blog in the past about my experiences of seeking approvals for my PhD, and in Monday’s session I urged people to be exceptionally cautious about planning NHS-related research in pursuit of their Master’s degrees.

Preparing for and securing NHS research ethics committee and R&D office approvals takes time. In this part of the world at least, some healthcare organisations are also likely to ask researchers to cover the costs to the NHS of supporting studies which are not portfolio adopted. Here I’m thinking of, for example, the costs arising when staff leave the workplace to participate in interviews or join focus groups, or suchlike.

The relatively new practice of directly seeking payment from research teams for the costs of studies which are not eligible for portfolio registration has appeared with the shift to activity-based funding. Here in Wales, the National Institute for Social Care and Health Research (NISCHR) has published criteria for entry to its portfolio, which are summarised here and are elaborated on here. It is from this second document that I have snipped the following:

A research study is a structured activity which is intended to provide new knowledge which is generalisable (ie of value to others in a similar situation) and intended for wider dissemination.

Studies eligible for the NISCHR portfolio should involve face to face contact with NHS patients, social care service users or people involved with their care. Studies must be led from and/or recruiting participants from Wales. All studies must already have research funding before they can be included in the Portfolio.  Research Costs cannot be provided by NISCHR CRC.

The following types of study are not eligible for inclusion in the NISCHR Portfolio:

  • audit,
  • needs assessments,
  • quality improvement projects,
  • directly commissioned studies,
  • secondary research such as systematic reviews,
  • purely laboratory based studies,
  • routine biobanking of samples would not be eligible but a hypothesis based sample collection would be if appropriately peer reviewed and funded,
  • own account funded studies,
  • studies closed to recruitment.

MSc projects invariably do not meet these criteria, meaning that numbers of taught postgraduate students get to cut their dissertation teeth on non-NHS research studies or (where academic regulations allow) on other types of project altogether. Examples are service or quality improvements, service evaluations and systematic reviews. And, in my view, these are sufficiently testing options for students working at MSc level, with some (like local quality improvements) having the added advantage of immediately and obviously benefiting the NHS and those who use its services.

However, a problem arises in the case of postgraduate research degrees. In some disciplines, including nursing, these are often undertaken part-time and are carried out with limited or no external grant income. Opportunities for studentships are relatively rare, and where they are available may be financially unattractive to practitioners who have already built careers in the health service. As with MSc projects, ‘own account’ doctorates will struggle to get onto the portfolio. They therefore run the risk (in some circumstances) of not being supported by organisations within the NHS unless their associated costs are explicitly met. One way of achieving this may be for local NHS managers to agree to carry the costs of non-portfolio studies which it is planned will take place within their services. But securing this kind of support is not straightforward, and for would-be research students the added challenge of finding a means of paying costs is hardly an encouragement. And, where MSc students can usually opt for non-research projects this is not so for those aiming for PhDs or Professional Doctorates. These are awards made only to those who generate new knowledge using sound and defensible research methods.

So what does all this mean? It’s early days, but one likely outcome may be a reduction in small-scale research projects within the NHS, along with an increase in the preparations and negotiations which precede data generation. Another may be the proliferation of non-portfolio projects which are explicitly designed to meet ‘research’ criteria for academic award purposes, but which are constructed to be something else (typically ‘service evaluation’) within the context of NHS research governance. A reasonable, longer-term, concern is that research capacity-building in fields like nursing may falter as potential students rethink their plans. And that, in my view, would be a big step backwards.

‘Psychiatric Ideologies and Institutions’: 50 years and counting

Happy new year. In the midst of a series of holiday period email exchanges Michael Coffey happened to mention that 2014 marks the 50th anniversary of the publication of Anselm Strauss and colleagues’ Psychiatric Ideologies and Institutions.

This is a fine book indeed, which during my time as a PhD student concerned with work and roles in mental health care was an absolute essential. In it, Strauss and his collaborators reported findings from prolonged and intensive fieldwork conducted in two North American psychiatric hospitals. Whilst today’s qualitative research reports will typically include lashings of direct data extracts, Psychiatric Ideologies and Institutions has little in the way of what Strauss et al referred to as ‘illustration and quotation’. Yet I never once recall, as a reader, doubting that Strauss and his team were truly there, participating in and recording everyday hospital life and its organisation.

It is at this descriptive level that the book initially works: as a meticulous account of the interplay between ideas, professions and practices in an area of health care which (both then, and to this day) happens to be particularly contested. One part of the dataset drawn on in the book comes from a questionnaire, designed to capture information about affiliations to particular treatment ideologies. From this nurses emerge as being ‘ideologically uncommitted’. In a later, detailed, section Strauss et al wrote of the problems faced by nurses in reconciling their managerial, administrative and therapeutic tasks and in answering the still-pertinent question:

…at the heart of her professional identity: What does therapeutic action toward patients actually involve for a psychiatric nurse?

My copy of Psychiatric Ideologies and Institutions is the edition published in 1981, for which a new introduction was added. In this, Strauss and his collaborators wrote of their original ambition to produce a book which was not only descriptive, no matter how detailed or accurate, but which was also theorised. It was the fieldwork and the findings reported most completely in this monograph that gave rise to the idea of the negotiated order. This is a sociological theory of importance which, in the decades following its introduction, went on to develop a life of its own. As Strauss et al wrote in their 1981 introduction, their original observation that theory might emerge from data represented a considerable methodological departure, more fully articulated at a later point with the introduction of grounded theory. Here, then, is a second way in which Psychiatric Ideologies and Institutions works, and remains of interest to people unconcerned with research into the world of mental health care: as an exemplar of how data and theory can dance together.

Today I’ve turned up this review of the book, which appeared in 1965 in the journal now called Psychiatric Services. In it the reviewer sums up with the recommendation that:

All in all, most professionals will find this book profitable to read, study and think about.

I concur, and commend this classic text to professionals and others alike. And as an aside, perhaps this short celebratory post can help persuade students (usually undergraduates, in my experience) that books and articles which happen to be more than five years old can still be worth reading.