Category: Research

On not lying-in

I’m not very good at lying-in. Once I’m awake (which, on most mornings, is earlier rather than later) I’m up. It’s then a matter of creeping downstairs to do some soundless chores, before making my mandatory mug of strong coffee and grabbing breakfast. Whilst in the kitchen I’ll have the radio on, tuned (at low volume) to BBC R4, for company. Invariably I’ll then make my way to the computer: the very one I’m sitting in front of now.

This blog is about a week old, and a number of my posts have started life in this pre-dawn window of opportunity. Papers I’ve written for publication have often been chipped away at at a similar time. So far the relationship between my writing-for-this-blog and my writing-for-journal-submission has been one-way, in that I’ve used this space to share ideas rehearsed at greater length in already-published academic articles. Indeed, this was one of my purposes in setting this site up: I wanted to experiment with blogging as a way of promoting work, and as a means of engaging beyond the production of lengthy outputs for paid-for journals.

It now occurs to me that this blog might also become a working space for the development of new ideas, and that the relationship between writing-for-journals and writing-for-the-blog might sometimes run in the opposite direction. This forum will never be a substitute for my academic journal-writing, and I’m not proposing to dump heaps of unmanaged data here (even if I had it!) for some kind of public write-in. But I might bring fledging ideas which I’m in the process of working through in my head.

Which brings me to…

At this year’s Network for Psychiatric Nursing Research conference I gave a talk titled, ‘Past, present and possible future in the system of community mental health care’. I intended this to be a kind of reflective run-through, taking in a decade-and-a-half of research and writing in the field. I wanted to touch lightly over a string of studies and papers I’ve had the good fortune to be involved in, and to knit together something cumulative around the themes of system interrelatedness, complexity and change. I’m not sure I pulled this ambition off in that forum, and in the longer term I’d like to work this all up into a full-blown paper. This space might become a repository of some sort for this type of work-in-progress. We’ll have to see, though, and I’ll need to think through how this might happen.

Unrelatedly: I’ll be opening the Mental Health Nurse Academics UK Vice Chair elections on Monday. My congratulations, too, to Louise Poley (Consultant Nurse in Substance Misuse, Cardiff and Vale UHB) for becoming RCN Wales Nurse of the Year. Lou has done outstanding work improving the health of people who are homeless, collaborating with partners across the statutory and non-statutory sectors.

Now I’m off out for run. Thanks, again, for reading.

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.

Complexity and changeDavina 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.

The Mental Health (Wales) Measure 2010

This is important, if you happen to use (and/or work in) mental health services in Wales. The Mental Health (Wales) Measure 2010 sets out to drive up standards across a number of areas: mental health in primary care; care coordination and care and treatment planning; the assessment of people who have previously used mental health services; and independent advocacy.

For ‘Measure’ read ‘law’, because that’s exactly what it is. I applaud the Welsh Government’s commitment to improving services, though I’d love to know more about the politics behind the decision to attempt this through the use of statute. What we now need is high-quality, independent, research to find out what impact (intended and unintended, helpful and unhelpful) the Measure is having.

Some opening thoughts (2)

Yesterday I opened this blog with a reference to a paper Michael Coffey and I published in 2011. I briefly talked about ‘wicked problems’, linking back to Rittel and Webber’s original article introducing this term.

In our paper Michael and I commented on the pace of change in mental health policy and services across the UK. We were particularly interested in the years from 1997, beginning with the election of New Labour. At the start of this period there were some bold statements from members of the then-new government, including the claim that community care had ‘failed’. At the time I thought this to be far too bald and simplistic a formulation of ‘the problem’. I still do, as it happens. As a solution, more (and different types of) community mental health care became the policy prescription. It was in this context that assertive outreach teams and crisis resolution and home treatment services appeared.

What struck Michael and me was how quickly this problem/solution formulation yielded to a replacement, this time emphasising shortcomings in professional practice. Policy pronouncements in the early/mid 2000s referenced occupational boundaries as a problem. Now, eroding demarcation became a key goal of policy: and it is in this context that new ways of working emerged. This was all about redrawing divisions of labour, and I’m sure this is something I’ll return to in the future because it interests me very much.

Some opening thoughts (1)

So, what to say in a first post? Perhaps introduce some of the ideas I’ve had the opportunity to work up in more detail in recent articles.

As a starting observation I’ve come to think of the whole business of organising and providing health (and social) care as being exceptionally complex. Hardly a novel insight, but worth pausing over awhile. Think of the problems which face policymakers and to which policy action might be directed. These do not arrive ready-packaged, but have to be named, identified and argued about. Values and politics come into play, and ‘the evidence’ for policy is likely to be incomplete and open to challenge. Problems and their solutions are also inseparable. So if ‘the problem’ facing health systems is defined as one of bloated public services inefficiency, then ‘the solution’ might be to inject some competition using market mechanisms. Readers familiar with contemporary NHS policy in England will recognise this problem/solution combo. I also recognise it from the time I worked as a community mental health nurse in east London in the early to mid-1990s. That was the era of the purchaser/provider split, and of quasi-markets. As it happens, I reject this particular inefficiency/marketisation problem/solution formulation. So just as I said above: any combo is open to contest and challenge.

This kind of thinking can be pushed a little further. For any given problem/solution combination, how might we know actions have ‘worked’? What, indeed, does it mean for a large-scale policy to ‘work’ at all given that actions and innovations which improve things in one locality might have very different effects elsewhere? And what about the unintended consequences of policy and service change? Or that realising grand aspirations often requires lots of agencies, organisations and people all having to pull together at the same time?

These are some of the reasons why many of the problems facing people who make health policy and develop services are of the ‘wicked’ variety, to use the memorable term coined by US academics Rittel and Webber in 1973. In 2011 my friend Michael Coffey (who works at Swansea University) and I published this paper in the journal Health Policy in which we employed a ‘wicked issues’ perspective to consider recent policy and service change across the UK’s system of mental health care.

In this paper Michael and I argued that different problem/solution combos have been wheeled out over the last 15 or so years, and that distinct (but overlapping) policy formulation phases can be discerned. And what did we say these phases were? I’ll blog some more on this at a later point, and see if I can create a link to an ‘author accepted manuscript’ version on Cardiff University’s ORCA repository.