Category: Policy

Nursing and the approved mental health professional role

AMHP Further to my mentioning of a new paper on the development of the approved mental health professional (AMHP) role, and what this might mean for nurses, here now is a link to a full text open access version downloadable from ORCA.

In this article, my friend Michael Coffey and I discuss the implications of the changes made in 2007 to England and Wales’ Mental Health Act for the role of the mental health nurse. We were helped on our way by Jackie Neale, Michael’s colleague and Co-Director of the AMHP programme at Swansea University and by Dr Martin Webber, Reader in Social Work at the University of York, both of whom read and commented on an initial draft of our paper. Writing for this blog, Michael says:

Nurses for the first time can make applications for detention in hospital based upon their independent judgement and with regard to the opinions of their medical colleagues, based upon a social perspective and the principle of least restriction. This is as far as we know unprecedented in UK mental health law. In many ways this changes the provision of mental health nursing in ways that have as yet to be measured. These changes reflect similar moves internationally in mental health law. There are huge challenges here though. Nurses are creeping into the territory of other professions who are not exactly welcoming them with open arms. Specific occupational knowledge and values are claimed by social workers who have traditionally fulfilled the approved role. These may be seen as jurisdictional claims and nurses have to show that they too can ‘pass’ as workers with a social perspective who are able to be independent of doctors. This is easier said than done and nurses have a chequered history in relation to occupational biomedical dominance. Added to this nursing is chiefly a biomedical task nowadays despite all the claims to being ‘holistic’ and being as focused on the social aspects of people as on anything else. Claims by nurses to be ‘psycho-social’ oriented or even ‘bio-psycho-social’ should be treated with some scepticism as many of these nurses subscribe to ideas of genetic determinism and are overly chemotherapy-focused. So can nurses actually juggle both a primarily biomedical focus and a social one to come to independent decisions in cases where the person might lose their liberty?

The backstory to this publication includes the fact that, with Jackie Neale, Michael runs Wales’ only AMHP programme. You can find out more about this post-qualification, postgraduate, course here. Our new article also comes out of Michael’s and my shared interest in mental health work and roles, and in thinking about (and researching) what nurses and others do. Another piece of behind-the-scenes detail is that Michael and I were once part of a team which came pretty close to getting a large grant to investigate AMHPs, and the experiences of people on the receiving end of their services.

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Cash for compassion?

After Francis, what is to be done? Should we employ new hospital staff, and improve the ratio of nurses to health care assistants? Invest in the development of a cadre of strong clinical leaders, equipped with the skills and vision to drive up quality? Abolish gagging clauses? Overhaul professional regulation? Or perhaps instigate a regime of tough external inspections, including unannounced spot-checks? Take nursing education out of universities, and return it in its entirety to the NHS via a new apprenticeship model? Or expand the role of universities by giving them some responsibility for the preparation of health care assistants? Should we draft people in from private companies to show frontline public sector staff how it should be done? How about increasing local accountability by requiring senior hospital managers to report directly to elected councillors or similar? Or might we look to science, by commissioning a research team to design and validate a robust measure of caring of a type which might be administered to all potential entrants to nursing, to newly qualified members of the profession, and to experienced staff at intervals thereafter? We could even link periodic re-registration to the securing of a minimum score.

Who is to say which of these (or any other) solutions, alone or in combination, is what the NHS needs? And how might we know if any selected course of action has ‘worked’? Truly the problems facing the health service are complex and intertwined, and proposed responses to them value-laden and open to challenge. In the event, February 7th’s Guardian led with the headline David Cameron’s prescription for NHS failings: target pay of nurses. The paper went on to say that the Prime Minister:

[…] wants nurses’ pay to be tied to how well they look after patients as part of changes to banish poor care in the NHS in response to the devastating findings of a report published on Wednesday into the Mid Staffordshire hospital scandal.

Well, that’s another ‘solution’, for sure. And how might we determine how well a nurse performs, and quantify this for the purposes of financial reward or sanction? In this version of what ought to be done we might need that researcher-designed measure of caring after all. But let’s think about this further: at what scale would performance and pay be linked? Should the salaries of all staff in a single hospital or organisation be bound together? Or might workers in a ward or team be grouped, each paid a sum reflecting some aggregated measure of performance or collective compassion? How about differentiating at the level of the individual practitioner? And what might the unintended consequences of each and all of these options be (because I can think of a few)?

So, as you will have gathered, I contest the idea of cash for compassionate care. I also thought that Chris Ham from The King’s Fund spoke sense when he wrote, in February 6th’s Independent, that Edicts from Whitehall are not enough. Dignity, quality and a culture of care cannot be driven solely by a deluge of initiatives from the top. If they could, we would by now have created the perfect health system.

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Noting the publication of the Francis Report

Today is all about the publication of the final report from the Mid Staffordshire NHS Foundation Trust Public Inquiry, as chaired by Robert Francis QC. So not a day to be blogging about the normal rhythms of work and life. More a case of listening and reflecting, I think.

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Giving a fig about roles

In a paper published in the Journal of Psychiatric and Mental Health Nursing at the start of 2011, Davina Allen and I drew on detailed, qualitative, research data to examine the relationships between policy, local organisational context and the work of community mental health practitioners. A version of the article, which carries the short title Giving a fig about roles, can be downloaded from the ORCA repository here.

Our paper drew on many of the social scientific ideas previously introduced on this blog in my Sphygmomanometers, remedial gymnasts and mental health work post, and which are rehearsed more fully in this earlier Complexity and change paper. Davina and I observed how recent mental health policy had triggered disruption in the system of work, with occupational groups advancing new, public, jurisdictional claims in response to perceived threats to their positions in a dynamic division of labour. One of the examples we gave was the response by sections within the profession of psychiatry to the policy of new ways of working, and its emphasis on ‘distributed interprofessional responsibility’ in particular.

The larger part of our paper reported new research findings. In the project from which it was drawn I had the opportunity to compare and contrast the organisation of community mental health services in two parts of Wales. With a view to understanding each site’s contextual features I read local policy documents, interviewed senior managers and practitioners and observed people at work. I was also interested in gaining a detailed, micro-level, view of the actual delivery and receipt of care. To this end I had permission from three service users in each site to follow their journeys through the mental health system, each over a period of four to five months. I interviewed all six about their experiences, and using snowball sampling mapped out the range of people providing them with care, whether paid or unpaid. The nurses, social workers, psychiatrists, psychologists, occupational therapists, general medical practitioners, pharmacists, health and social care assistants, family members and neighbours identified in this way were invited to take part in interviews focusing on work and roles. I also observed interprofessional care planning meetings and home visits, and read the written notes about each of the six service user participants made by practitioners.

As the full text of the paper reveals, in the analysis developed here we were particularly interested to explore the relationships between workplace characteristics and what practitioners actually did. Not unexpectedly, nurses carried out medication tasks, social workers (as the sole group able to do this at the time data were generated) fulfilled the ‘approved’ role during the operation of the Mental Health Act, doctors diagnosed and prescribed, and the sole participating psychologist provided structured therapy.

Beyond this we also found that the work of professionals was ‘patterned’ (to use the phrase coined in this context by Anselm Strauss) by immediate organisational forces. In one of the two sites nurses and social workers had enlarged ‘bundles of tasks’ (this being Everett Hughes’ term). This shaping of what people did could be understood with reference to a variety of contextual features. Key informants in this site described a particularly long and positive history of health and social care staff working together. This manifested during fieldwork in an approach to care provision which emphasised shared tasks and downplayed rigid demarcations. Single community mental health workers, rather than multiple representatives of different groups, tended to be attached to the care of individual service users. Health and social care organisations in this site were also small, lacking pools of staff from which people might be drawn to cover gaps left by departed colleagues. In this constellation of circumstances nurses and other members of staff fulfilled roles which were more ‘generalist’ than was the case in the other of the two sites.

Davina and I were interested to set our findings in the new and emerging context for mental health care. We pointed to larger policy trends favouring unpredictability in working practices, and to the idea that competency (rather than professional background) should determine practitioners’ eligibility to fulfil roles. We observed that ‘flexible, boundary-blurring, professionals competent to carry out multiple tasks may find favour with managers concerned with meeting local needs in local ways’. We reflected on the implications of this for continuity of care, capability and the preparation of new professionals. The paper ended with our thoughts on the challenges all this poses to professions and their jurisdictional claims.

In a later post I’ll return to this study, and in particular to what I learned about the experiences of the people whose unfolding care I followed as each moved through the different parts of his or her local, interconnected, system of mental health care. But that’s for another day.

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Student nurses and degrees (once again)

Writing in today’s Guardian Peter Wilby asks ‘if our long love affair with education is coming to an end’. He refers back to this earlier article reporting a UK government announcement that future accountants, lawyers, engineers and others will be able to qualify without having a degree. Noting that the children of affluent parents do best in education, Wilby argues that the raising over time of the academic bar for entry to many professions has effectively blocked poorer children from getting a foothold.

I agree that we should be concerned over post-compulsory education becoming the preserve of the privileged few, which is why I believe charging tuition fees for university study is a bad policy likely to deter many from applying. I’m also reminded of the efforts that colleagues in my workplace go to in order that people with non-traditional educational backgrounds put themselves forward for university entry, and the work that goes on to help students succeed once they have enrolled. Like Peter Wilby, I too think that education should be something which people engage in over the course of a lifetime, and not in their first two or three decades only.

What I object to is that part of Wilby’s argument where he turns to nursing specifically and says, ‘As Ilora Findlay, professor of palliative medicine at Cardiff University, has put it, “a nurse can graduate without being able…to apply the scientific basis of illness to real patients or respecting the importance of hands-on care”. This is not a scenario I recognise. Student nurses spend half of their time on placement, and whilst there have to demonstrate to the satisfaction of their mentors their ability to perform in practice. This includes providing real care, to real patients.

For more on this, here’s a link back to an earlier post on this site referencing the Willis Commission on Nursing Education.

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The Mayan apocalypse and The King’s Fund

According to some interpretations of the Mayan long count calendar, tomorrow – December 21st 2012 – will see the end of the world. If the apocalypse does happen then none of us, I’m afraid, will get to know how accurate the predictions contained in Future Trends might otherwise have been.

I came across this report earlier today via a link tweeted by @TheKingsFund. It’s part of the organisation’s new Time to Think Differently programme, and sets out ‘the significant trends and drivers that we [The King’s Fund] believe will affect health and social care services over the next 20 years’. Properly speaking this is all about the outlook for England, though I think Future Trends offers plenty of food for thought for those of us in other parts of the UK, too.

The document addresses issues across a number of areas: demographic change, health-related behaviours, disease and disability, the workforce, attitudes and expectations, determinants of health, medical advances, information technology, sustainability and economic pressures. Future Trends also has some important, specific, things to say about mental health and illness and about services in this area. One is to restate the connections between mental and physical health. As The King’s Fund says, poor physical health is associated with poor mental health and vice versa. Future Trends also points to the existence of significant unmet mental health need, and to the fact that demand for services can be expected to rise at times (like now) of economic downturn. Elsewhere there are sections dealing with the workforce, and the risk of a growing ‘care gap’ as sources of informal care diminish. Changing patterns of disease are likely to increase demand for home (rather than hospital) care, and for new types of worker able to cross traditional professional boundaries.

To my mind the broad picture Future Trends paints is an entirely plausible, and simultaneously challenging, one. More plausible, certainly, than predictions of an imminent end to the world. I think we might want to start thinking, sooner rather than later, about how we improve the physical well-being of people using mental health services. We should consider what the rise of chronic conditions means for education and training, and how to better meet need.

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On writing a paper about mental health systems, and running in mud

A fortnight ago I blogged about a paper I gave at this year’s Network for Psychiatric Nursing Research conference. My aim in this presentation was to move lightly through a series of completed studies I’ve previously been involved in, with a view to saying something cumulative about the mental health system. I mentioned my ambition of working this talk up into something a little more substantial and enduring, and sending this to a journal for peer review and (hopefully) eventual publication.

Progress has been slow, largely because of competing priorities. But I have at least made a start, of sorts. One of the points I’m going to make is that, taking the long view, the story of how mental health care in the UK has evolved remains a quite remarkable one. A quarter of a century ago, which is when I first began working in mental health care, untold numbers of people remained resident in outdated institutions. Community services certainly existed, but were relatively under-developed. Many teams were uni-professional, and lacked a clear focus. Ideas of recovery, personalised care and collaborative working with service users were in their infancy.

It’s all very different now. I suspect it’s possible to qualify as a mental health nurse without having many hospital placements at all, and to spend the greater portion of practice time in varieties of community setting. There are locality community mental health teams (still the bedrock of specialist services for working age adults), and similar teams serving older people, and children and adolescents. There are crisis resolution and home treatment teams, assertive outreach teams, primary mental health teams, and more besides. I also think that the values which underpin care have changed. So, whilst it may not be a perfect system, it is much improved.

How much the investment in mental health systems which took place over the late 1990s and throughout the first decade of the new century can be sustained, in the face of crushing public services cuts, I do not know. In Wales, which is far more public services oriented than England, a strong case was made a few years ago for the importance of investing in mental health. Mental ill-health affects individuals, families, communities and the economy. I hope that the Welsh Government’s emphasis on public mental health in its new cross-cutting strategy ‘works’, without pulling vital resources away from dedicated services for people with long-term and disabling mental illnesses.

On the non-work front, this morning’s run entirely lacked the clear, hard, frostiness of recent Saturdays. It was wet, and muddy. Clinging, in fact, and thoroughly energy-sapping. It will take a few days for my (tired-looking) shoes to dry out, so I’m glad to have my second pair to hand (to foot?) should the need arise. Now it’s Christmas tree purchase time.

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Sphygmomanometers, remedial gymnasts and mental health work

For an example of how health care tasks can become attached to different groups of people over time, then look no further than the measurement of blood pressure. One of the stories my grandmother told me when she was alive was how, whilst working as a nurse in the 1920s, whenever a new-fangled sphygmomanometer was to be used a doctor would come to the ward to operate it. The recording of blood pressure then became a task that nurses and midwives routinely did, and indeed support workers. Now it is something that anyone can do, using electronic gadgets purchased from the high street.

Tasks move around in mental health systems, too. Think, for instance, of the provision of formal therapies. Cognitive-behavioural family work used to be something which only a sprinkling of nurses did. Not any more. In this part of the UK, some of the tasks which only social workers used to fulfil as ASWs (approved social workers) during the operation of the Mental Health Act are now equally fulfilled by others working as AMHPs (approved mental health professionals).

Just as tasks appear and move between groups, so too do whole groups emerge, change and sometimes merge or even disappear. Remedial gymnasts appeared in the years after the second world war, before being subsumed within the profession of physiotherapy. Peter Nolan has told the story of mental health nursing growing from the keepers and attendants found within the asylum system. Community mental health nursing, as a particular sub-division, did not exist until the early 1950s. Now within the mental health system there are peer support workers, carrying out tasks which professionals and health care assistants might once have done.

Davina Allen and I wrote about processes of this type in a paper called Complexity and change in the United Kingdom’s system of mental health care. This appeared in the journal Social Theory & Health in 2006, though a post-peer-review version of the article can also be downloaded from here. Davina is a nurse and sociologist (and was one of my PhD supervisors; the other was Philip Burnard), and in this article we drew on sociological theories to explore the changing division of mental health work in the post-war years. We used the ‘ecological’ ideas of Everett Hughes and Andrew Abbott to frame our analysis, about which you can read more here. These emphasise the division of labour as a complex and dynamic social system, which is responsive to all sorts of internal and external forces. Technology is one driver for change (for example, no-one could measure blood pressure until a device to do so had been invented. Mass production brought this work to the masses). Hughes had lots of interesting things to say about ‘mandate’ (the kinds of things groups say they ought to be doing) and ‘licence’ (what they actually do), and the ‘bundles of tasks’ which become attached to occupations at particular times and places. Abbott writes about the things that professions do to secure and advance what he calls their ‘jurisdiction’, in the face of claims made by competitors. ‘Jurisdiction’ refers to a group’s control over work.

In our Complexity and change paper Davina and I wrote about the historic success of the profession of psychiatry in drawing on biomedical knowledge to underpin and maintain a position of power in the mental health system. But as I’ve already suggested, interrelated systems of work are in motion, and in our paper we were also interested to explore sources of change. So we wrote, for example, about the challenges to biomedicine raised by dissident anti-psychiatrists in the 1960s and 1970s. We also wrote about the claims of mental health nursing to the possession of profession-specific knowledge underpinning the maintenance of helpful therapeutic relationships, and the appeals of social workers to having profession-specific ‘social model’ insights.

We also made quite a thing about the significance of community care for work and roles, and reflected on the expansion of state intervention in the mental health system (via a proliferation of policies) in the early years of this century. Now I think about it, there’s a link here between the wicked problems paper I wrote with Michael Coffey, and blogged about in both this and this earlier post. Policymakers’ recent formulation of ‘the problem’ as being one of unhelpful professional demarcations and restrictive practices has been a source of considerable disturbance in the mental health system of work. I’m thinking here, again, about the opening up of the Mental Health Act ‘approved’ role to nurses, psychologists and occupational therapists as well as to social workers, and what the longer-term implications of this might be. I’m also thinking about the division of labour consequences of peer support workers, and mental health nurses who prescribe medications, and graduates without ‘professional’ qualifications providing psychological therapies in primary care. Whatever the merits or otherwise of developments of this type, I think we should look carefully at their wider impact. Sometimes change can manifest in unpredictable ways.

And that brings me to another matter altogether: the intended and unintended consequences of action in interconnected systems. But that’s for another day, and for another post, entirely. Thanks for reading.

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