Category: Policy

Summer sun

Just as predicted by those nice people at the Met Office, South Wales is warming up. The sun is high, and I hear the voices of schoolchildren playing football. I’ve been stuck inside all day, which in the circumstances has been something of a drag, but in the last hour or so I’ve gravitated outside to soak up some of this long-awaited summer.

This has been a working week as varied as any. I had a couple of School committees to chair (research ethics, and scientific review), some teaching (MSc), and a meeting with colleagues to plan some pre-registration interprofessional education in the autumn. This is a continuing mental health nursing/occupational therapy initiative (which I’ve posted about before), and on this occasion we’re planning some technological innovation involving the use of video recording and playback. On the research front I’ve been working on RiSC and keeping in touch with COCAPP, and found myself contributing to a rapidly convened meet-up to talk through a brand new project idea. I received page proofs for our new Critical junctures paper, peer reviewed a manuscript submitted for publication, and received a citation alert from Scopus. This was particularly pleasing as it took my ‘h’ index to 15, for what that’s worth. I also completed preparations for a doctoral examination taking place next Tuesday, and managed to squeeze in a pleasant catch-up with an esteemed colleague working in NHS mental health services. Mostly we exchanged news of developments in practice, services and research locally.

And with that, I’m off. Beer in the back garden calls.

Increasing the visibility of research

Where publishers’ copyright rules permit, since last year I have been uploading green open access versions of peer reviewed research papers I have written or co-written to ORCA, Cardiff University’s digital repository. I have then been adding hyperlinks to these papers to research-related posts on this blog. To round this all off I’ve been using Twitter to draw attention to what I’ve been up to.

Having a WordPress blog means that I get to see which hyperlinks anonymous readers are following, and I know that some onward clicks are taking people to my open access articles. At the end of last week I asked colleagues managing ORCA if any tools existed to help me find out which of my papers have been downloaded, and when.

What I now have is access to an application allowing me to interrogate ORCA in all sorts of ways. So I know, for example, that full-text papers I have authored and saved to the repository have been downloaded 360 times between January 1st 2005 (the earliest date I can select) and today, July 3rd 2013. Two hundred and eighty eight of these downloads have taken place since November 24th 2012, this being the date I created this blog and first posted.

Here is a summary of my ORCA ‘eprints’ and the number of times each has been downloaded up to today:

Eprint Fulltext Downloads
Hannigan, Ben and Allen, Davina Ann 2013. Complex caring trajectories in community mental health: contingencies, divisions of labor and care coordination. Community Mental Health Journal 10.1007/s10597-011-9467-9
file
150
Hannigan, Ben and Coffey, Michael 2011. Where the wicked problems are: the case of mental health. Health Policy 101 (3) , pp. 220-227. 10.1016/j.healthpol.2010.11.002
file
70
Coffey, Michael and Hannigan, Ben 2013. New roles for nurses as approved mental health professionals in England and Wales: A discussion paper. International Journal of Nursing Studies 10.1016/j.ijnurstu.2013.02.014
file
65
Hannigan, Ben and Allen, Davina Ann 2011. Giving a fig about roles: Policy, context and work in community mental health care. Journal of Psychiatric and Mental Health Nursing 18 (1) , pp. 1-8. 10.1111/j.1365-2850.2010.01631.x
file
24
Hannigan, Ben 2013. Connections and consequences in complex systems: insights from a case study of the emergence and local impact of crisis resolution and home treatment services. Social Science & Medicine 10.1016/j.socscimed.2011.12.044
file
20
Hannigan, Ben and Allen, Davina Ann 2006. Complexity and Change in the United Kingdom’s System of Mental Health Care. Social Theory & Health 4 (3) , pp. 244-263. 10.1057/palgrave.sth.8700073
file
18
Hannigan, Ben and Allen, Davina Ann 2003. A tale of two studies: research governance issues arising from two ethnographic investigations into the organisation of health and social care. International Journal of Nursing Studies. 40 (7) , pp. 685-695. 10.1016/S0020-7489(02)00111-6
file
13

All are papers I have specifically blogged about, and have subsequently flagged up on my Enduring posts page. I am therefore going to tentatively conclude that the approach I have taken to increase the visibility of my research is having an effect.

What I do not know is who has been downloading (and hopefully reading!) these articles, and for what purposes. I would like to think it has been a mixture of researchers, practitioners, managers, policymakers and service users. I also hope they have found what they have read to have been both interesting and useful.

Nursing beleaguered?

Catching my eye earlier this week was an interview in The Guardian with Jane Cummings, Chief Nursing Officer (CNO) with a place on NHS England‘s National Commissioning Board. Under the header, ‘Nobody can say care is brilliant all the time’ the article opened with this understated quote:

‘It was very clear that nursing was getting a bit of a bad name and it felt like the profession was being quite beleaguered and criticised.’

Nursing certainly has been under siege. Responses to descriptions of poor care have included the three year Compassion in Practice strategy introduced by the CNO and her Director of Nursing counterpart at the Department of Health, Viv Bennett. It is in this document that the 6Cs are described:

It is also in this general context, but specifically following the publication of the Francis Report into Mid Staffordshire NHS Foundation Trust, that the proposal was made that student nurses should spend a year doing health care assistant (HCA) work before beginning their training. This government plan has proven mightily controversial, and when announced provoked immediate broadsides from (amongst others) June Girvin (a nurse, and Pro Vice Chancellor at Oxford Brookes University) and Jackie Kirkham (a health visitor and researcher at Edinburgh University). Now it has drawn a closely referenced rebuttal from the Council of Deans of Health. Here is what the Council says in its conclusion:

The proposals for HCA experience prior to joining a pre-registration nursing programme are underpinned by a set of assumptions about nursing education and selection of prospective students that is deeply flawed. It paints a picture of students who have never had experience of caring and little interest in patient care, picked out for their grades by a group of academics in total isolation from staff working in clinical services. The message from current practices and the NMC Standards that govern them is that this mental picture needs to change. In particular, the assumption that students are not recruited for their values and that students do not have prior care experience are incorrect.

What about the nub of the proposal: that exposure to the clinical frontline as a HCA will create better nurses? The evidence here is equivocal at best. What care experience does seem to do is give prospective students exposure to the reality of working in healthcare and so it may reduce attrition from programmes. But there is also evidence that working as a HCA can socialise prospective students into poor practice and inhibit their development as nurses. Unless the evidence is looked at carefully, these proposals could therefore embed rather than challenge poor patient care. As the pilots of the proposals are developed, care must be taken both to recognise existing practice and carefully test assumptions against the evidence.

So, nursing practice and nursing education are in the spotlight, and the profession has responded. Senior members have asserted a set of fundamental values (the 6Cs), and in resisting the year-as-an-HCA idea have reminded people of the differences between what nurses and other health care workers do.

Nurses discomforted by this heightened scrutiny might consider their position alongside that of other public services workers. Social workers draw attention to the problem they face of being ‘damned if they do and damned if they don’t’. Then there are teachers, who fear the erosion of their professional standing as former servicemen and women prepare to enter the classroom without having to study for degrees. Back in the health service, some doctors (psychiatrists, in this instance) express concern over threats to their role and identity, whilst the profession as a whole is accused of greed.

We are therefore in good company. Other workers know what it is like to be told they have collectively fallen short, and understand how it feels to have their status undermined. Status-knocking sometimes happens because professional groups engage in ongoing division of labour skirmishes, as I have drawn attention to on this site before. But nursing’s current predicament, in which we are charged with having a ‘compassion deficit’ and sacrificing a commitment to care in the pursuit of academic credentials, is different.

Perhaps nurses have finally lost enough of the untouchable, ‘angel’, image (no bad thing, in my view) to now be viewed as ‘just’ another professional group in whom trust is conditional. We control entry to our profession, expect degrees from new entrants, have university departments and lead interprofessional teams and whole services within the NHS. In turn, we must expect to face questions when things go wrong, and to justify why we do practice and education in the ways that we do. For the record, I strongly favour system explanations for what happens in the health service (including its failures), see no evidence that student nurses no longer care and much prefer practitioners to be educated than not. But I also think we must expect, and should prepare for, more ‘bashing’ in the future.

What future the NHS (2)?

Further to my last post referring to Raymond Tallis’ staunch defence of the NHS, a second excellent health service-related talk at Hay was Andrew Edgar’s. Andrew is a philosopher at Cardiff University, and on Tuesday he gave a customarily considered account of (amongst other things) the principles underpinning the NHS and how these contrast with those associated with health care systems elsewhere in the world. I particularly appreciated Andrew’s view of the NHS as being more than a way of simply (simply?) funding and delivering health care. It is a unifying force, embodying the majority view that some things are best paid for and organised collectively. Insurance based systems, as Andrew observed, are abhorrent to many in the UK because they treat health care as a commodity and pay insufficient regard to need.

Beyond the principles, as Andrew also pointed out, lie some difficult day-to-day health service realities. These include the existence of rationing (which clearly exists, but is rarely talked about in an open way), and the fact that the system retains a capacity to grind down, and sometimes even brutalise, those who work within it. But opening the service up to market forces, along the lines happening in England with the passing of the Health and Social Care Act 2012, is no remedy. Note my reference to ‘England’ here. Quite correctly, in my view, Andrew was careful to talk of not one but four ‘NHSs’ reflecting the divergence in systems across the different countries.

What future the NHS?

Yesterday at the Hay Festival I heard Raymond Tallis deliver a strong attack on the coalition government’s ‘redisorganisation’ of the NHS in England. The Health and Social Care Act 2012 has opened the NHS to the market in unprecedented fashion. Tallis talked of the dominance of private providers on clinical commissioning groups, and gave examples of patients being cherrypicked by organisations more concerned with profit than with meeting need. He also contrasted the upheaval with pre-2010 general election promises by both the Conservatives and the LibDems not to unleash major top-down change on the health service.

Tallis was critical of his own profession (medicine) for having failed to coordinate opposition to the legislation as it worked its way through parliament. He did, though, pick out and praise Clare Gerada of the RCGP for leading the resistance. I’m aware that the RCN was against the proposed Act, but I’m not sure that nurses as a group were particularly visible during the debates.

The first question from the audience asked what needs to be done to prevent the Act infecting Wales. The balance of politics here is different than in England, but it was a good question nonetheless.

Learning from the study of trajectories

Trajectories paperHere’s a post about research, which draws on the paper Complex caring trajectories in community mental health: contingencies, divisions of labor and care coordination which I authored with Davina Allen.

One of the things I’m interested in is the study of ‘trajectories’. With colleagues, the US sociologist Anselm Strauss wrote about these in the book Social Organization of Medical Work. Most people will be familiar with the idea of illnesses ‘running their course’. To this everyday concept Strauss and his collaborators added a whole lot more, introducing the term ‘trajectory’ to refer:

…not only to the physiological unfolding of a patient’s disease but to the total organization of work done over that course, plus the impact on those involved with that work and its organization (Strauss et al. 1985: 8).

Trajectories are dynamic and often unpredictable, not least because they involve people. They are also vulnerable to being tilted by what Strauss et al term ‘contingencies’. Contingencies can have origins in the health and illness experience. So, a trajectory can (for example) veer off in a new direction because of an acute exacerbation of a chronic illness. But trajectories can additionally be shaped by contingencies which have organisational origins. These can relate to the biographies of workers, and to features of the system such as the availability of resources.

Trajectories can be studied. In my PhD I borrowed the design and methods used by Davina Allen, Lesley Griffiths and Patricia Lyne in their study of stroke care, and used these to understand the trajectories of people using community mental health services. In each of two contrasting parts of Wales I recruited three people currently using secondary mental health services. Each became the starting point for a detailed, small-scale, trajectory case study. Over a period of months I followed each person’s unfolding experiences, and the organisation of work surrounding. Using snowball sampling I mapped the network of (paid and unpaid) people providing care to each, and interviewed those identified in this way about their work. I observed care planning meetings, home visits, and read each service user participant’s National Health Service (NHS) records.

Community Mental Health JournalIn the publication for Community Mental Health Journal to which this post relates, Davina and I drew on these data to show how trajectories unfolding in the mental health field are shaped. We offered instances of trajectories being tilted by mental health crises, but also by key professionals leaving their posts and by a lack of resources within the larger system.

We then used data to reveal actual divisions of labour, in a way which has not (to the best of my knowledge) been done before  in the mental health context. By mapping the networks of care surrounding each user participant we were able to learn about work being done by all sorts of people, including many who (I suspect) are rarely thought of as making significant contributions at all. We wrote about the work of community pharmacists, support workers, lay carers and indeed the work of service users themselves.

Having laid all this out we closed by pointing to the importance of what Strauss et al called ‘articulation work’. This is the work associated with the management of trajectories, through mechanisms such as care coordination. Mental health workers in the UK know all about this through things like the care programme approach (CPA).

The detail of this paper you can read for yourself, with the link at the top of this post taking you to our author’s copy of the manuscript as stored on Cardiff University’s ORCA repository. This, word-for-word, is the same as the version of the article which is currently in press here.

For those interested in the paper’s back story, just to note that when it came to selecting a journal I was keen not to submit to a nursing publication. I have no problem with nursing journals per se, but this ‘trajectories’ paper was (and is) aimed at a wider readership. Community Mental Health Journal is based in the US, and publishes papers on, well, community mental health. And that fitted well with the intended audience. This said, one of the anonymous reviewers of the submitted manuscript had things to say about the language used, reminding us that the journal to which we had submitted is read by mental health practitioners and academics and not, primarily, by sociologists. Attending to the review meant some rewriting to improve accessibility. I’ll leave future readers to judge for themselves whether we succeeded.

NHS changes, and the state of research in nursing

Since publishing my last post the Health and Social Care Act has come into force in England. For a frontline NHS worker’s views on what this means, check out this commentary by East London GP Dr Youssef El-Gingihy. Personally I’m glad to be living and working in Wales. I am pleased to say that here there is still government support for an NHS which is funded, planned and provided with the public good in mind.

Elsewhere, within my corner of nursing (the academic bit) an editorial by David Thompson and Philip Darbyshire which appeared in the January issue of the Journal of Advanced Nursing has provoked a series of robust, just-published, responses. These have variously been penned by Bryar et al, Gallagher, Ralph, Rolley, White and Cross and Williams. JAN also carries Thompson and Darbyshire’s rejoinder, through which the responses are responded to.

The debate has a number of elements. In their editorial Thompson and Darbyshire argued that the quality of academic nursing has declined, and that some nurses working in some universities occupy positions of seniority which their experiences and qualifications have not prepared them for. They also accused those they termed the ‘killer elite’ of running departments as managerial fiefdoms, without tolerance for critical enquiry or dissent. This month’s responses include pieces both for, and against, the Thompson and Darbyshire position. Interested readers can follow all this up for themselves through the links I’ve given above, and I won’t attempt to summarise the full range of views offered.

What I will say is that, for all sorts of historical and contextual reasons, it remains remarkably difficult to sustain a career as a nurse doing research. Funding streams for nursing and midwifery departments in UK universities are largely earmarked for teaching, and relatively few university-based nurses have had opportunities to study for research degrees. Amongst those who have completed doctorates many have found it hard to progress to become independent researchers. Large numbers appear to have returned to roles which do not include significant research components. Only a handful of departments have a critical mass of research-active nurses and midwives, leaving the majority vulnerable when key people leave or retire.

But we have to keep at it. What nurses do touches the lives of millions, every day of the year. Research has an important part to play in improving the nursing contribution: from finding out ‘what works’, to learning about the experience of people on the receiving end of nurses’ services, and onwards to establishing how care might best be organised. Taking a research idea and turning it into a proposal which stands a chance of securing funding through open competition is tough (ask a scientist or a historian: it’s just the same for them), but if we truly want a sound base for nursing practice then this is work which has to be done. And as I am currently learning all over again, actually doing research once funding has been obtained is never as straightforward as the textbooks would have us believe.

Visiting the Netherlands

HAN 4
Bisschop Hamerhuis in Nijmegen, home to Dr Bauke Koekkoek and the Social Psychiatry and Mental Health Nursing research group

Michael Coffey and I have just returned from a four day trip to the Netherlands, an event supported with funding from the Mental Health Research Network Cymru. We were there to share and develop research ideas with the impressive Dr Bauke Koekkoek and colleagues, and to learn about the Dutch mental health system. Bauke, a mental health nurse, is Associate Professor of Social Psychiatry and Mental Health in the Hogeschool van Arnhem en Nijmegen (HAN) University of Applied Sciences, and is interested (amongst other things) in matching the needs of people with mental health difficulties with services. You can read more about Bauke’s work in his inaugural lecture.

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Bauke, in mid-flow

Bauke did a great job organising a full schedule of activities for our three working days away. Well done, Dutch train and bus companies, for delivering Michael and me to our various destinations in timely fashion. We were, though, reminded during our trip that it is the bicycle which remains the vehicle of choice for many Netherlanders.

We had the chance to meet with academics, practitioners and service users during our travels across Utrecht, Arnhem and Nijmegen. Our thanks to everyone who gave their time and who shared their expertise so generously: Dr Arjan Braam; Mark van Veen; the Kompas team at Pro Persona‘s Wolfheze site; Dr Ad Kaasenbrood and his colleagues in the Arnhem Functional Assertive Outreach Team (and particularly Vincent and Riska, who Michael and I spent Tuesday morning with); the Arnhem FACT Team service users who welcomed us into their homes; the HAN Social Psychiatry and Mental Health Nursing research group; and Hein, Rob and Leon who teach at HAN and have interests in developing international links.

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Michael, holding forth

The Social Psychiatry and Mental Health Nursing research group, who we met on Tuesday afternoon, are a capable and accomplished team. Their MATCH Project is supported by a significant grant, and Bauke and his collaborators have done exceptionally well in using this as a springboard for further, associated, studies. Examples include PhDs investigating the effectiveness of therapies, and a planned ethnographic examination focusing on discharge (and non-discharge) of people from community care.

It was good to hear people present and discuss their ideas, and in a spirit of collegiality Michael and I had the chance to share our interests and plans. I took the chance to talk about my research in a general sense, using as a prop this set of slides embedded below:

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Attentive listeners!

Interesting to learn during our time away was the system of preparing mental health nurses in the Netherlands. Yesterday, for example, we met Rob Keukens who runs HAN’s part-time, 18 month, post-qualification social psychiatric nursing programme. This is the nearest thing to what here, in the UK, we would describe as a post-registration course for community mental health nurses (CMHNs). For those interested, Bauke has described and analysed the Dutch CMHN profession in this paper.

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Me enjoying a joke. Or something like that.

The principal purpose of our trip was to further our research connections, and for Bauke, Michael and me to spend time putting our heads together to develop new research ideas. We know we’ll need to involve others, and target funding streams sympathetic to international research proposals which set out to create new knowledge to improve mental health and well-being and the organisation of mental health services.

More on all this to follow in due course, I am sure.

Disinvesting in mental health?

National Survey of Investment 2011-12Writing for The Guardian’s Healthcare Professionals Network this week, David Brindle reports that spending on mental health care in England has fallen for the second year in a row. He references unpublished figures disclosed last week to the House of Commons Health Committee, along with the 2011-12 National Survey of Investment in Adult Mental Health Services which appeared last August, and from which I have clipped these first two headline findings:

National Survey of Investment 2011-12b

The key figure here is the bit I have circled in red: that, in real terms, investment in mental health services in England in 2011-12 reduced by 1%. Last summer The Guardian reported the publication of this finding under the banner of mental health spending having fallen for the first time in 10 years, and if I am understanding David Brindle’s latest article correctly evidence of further cuts has been gathered since. Elsewhere in this piece Dr Hugh Griffiths, the Department of Health’s National Clinical Director for Mental Health, is quoted as having told the Health Committee last week of being ‘disturbed’ by reports of cutbacks to services in some English regions.

Meanwhile, via this piece in The Telegraph I see that the former coalition government Care Minister and LibDem MP Paul Burstow is heading up an independent Mental Health Commission with the liberal think-tank CentreForum. The Commission’s task is to ‘examine the state of mental health care provision in England’. This is a task made all the more urgent in the light of the finding, also contained in last August’s National Survey, of a £29.3 million reduction in investment in crisis resolution, assertive outreach and early intervention services.

All this paints a very bleak picture indeed. Reductions in funding and in services threaten to roll back the investments made in dedicated mental health care in the years following the publication, in England in 1999, of the National Service Framework for Mental Health. New Labour acted at tremendous speed in prioritising the mental health field. When in government Labour took action to develop community care through the creation of new types of services. It changed the law, put resources into improving access to psychological therapies and rewrote professional role boundaries. Some of the specifics were contentious, sure, but I for one did not doubt that the challenges of improving mental health and developing services were finally being taken seriously. In fact, Michael Coffey and I wrote about this period of policymaking in our wicked problems paper (which can be downloaded here). In this we urged careful consideration of the cumulative impact of policy actions, and the perils of trying to change everything in a complex system of health and social care all at the same time. But needless to say we made no case for cuts, which is what is evidently taking place around large parts of the country now.

As it happens, I can’t immediately find a Welsh equivalent for the Department of Health’s National Survey for England. If it’s out there, perhaps someone can point me in the right direction? It would be good to know the trends for investment in mental health services here in Wales. More generally, now I come to think of it, I want to learn more of the prospects for the future of the mental health system in this part of the UK now that the Welsh Government has a new Health Minister in Professor Mark Drakeford. The Minister is a Cardiff University Professor of Social Policy and Applied Social Sciences, and it will be interesting to see how future policy and services shape up under his direction.
 

The COCAPP crew, and MHNAUK comes to Cardiff

Yesterday’s COCAPP meeting in Cardiff was both productive and fun. It was lovely to welcome those members of the London contingent able to make the trip, and I extend my apologies (again, and for the last time!) to those I conspired to keep waiting in a darkened corridor before turning up with a room key.

COCAPPers 07.13.13COCAPP is an exciting research project to be involved in, and pretty soon it will have its own blog. I’ll then add links from here for those who are interested. Briefly summarised, this is an England and Wales cross-national investigation into mental health care planning and coordination, and into the relationships between these processes and recovery and personalisation. It’s funded by the NIHR Health Services and Delivery Research Programme, and has lots of distinct elements: about which more will follow, I guess, once the dedicated project blog is up. For now, here’s a photo of yesterday’s assembled COCAPPers (where from left to right there’s Aled, Jitka, Alan (COCAPP’s chief investigator), Sally, me and Michael. We very much missed Alison and Jennifer and their wise contributions, and when we’re all in one place I imagine we’ll take another, and more complete, photo.

Yesterday evening was the traditional social involving food and drink with fellow members of Mental Health Nurse Academics UK, ahead of today’s meeting proper. As Cardiff hosted we got to select the venues, and I hope everyone who was able to make it enjoyed the selection of fine ales and wines, and indeed the general ambience, at The Rummer Tavern. Likewise the food at The Mango House.

MHNAUK’s first meeting of 2013 was a good ‘un. Jen French talked about mental health strategy in Wales, and Ian Hulatt updated us on the Willis Commission. Eschewing the usual format of host universities presenting their research and teaching activities in the morning, Michael Coffey (in the photo above, and MHNAUK chair) and Joy Duxbury (newly elected vice chair) invited reflections and discussion on the aims and purpose of the group, and on the character of research in mental health nursing and what can be done to nurture it. There was some lively discussion in the two groups (facilitated by Linda Cooper and Len Bowers respectively) which convened to talk to these areas. It occurred to me unhelpfully after the event that we might have taken a MHNAUK photo, including the 35 or so members participating today: not least as MHNAUK, like COCAPP, is collectively thinking of increasing its presence via a blog.

Work aside, running has taken a big back seat this week, what with one thing and another. Must get out soon!