Category: Services

Doing crisis work

Here’s a new paper just accepted for publication, and about to appear in early online publication form. Titled ‘There’s a lot of tasks that can be done by any’: findings from an ethnographic study into work and organisation in UK community crisis resolution and home treatment services this will be appearing in Health: an Interdisciplinary Journal for the Social Study of Health, Illness and Medicine. Health is published by SAGE, and the copyright agreement I have signed allows me to deposit a post-peer review version of the accepted manuscript in my employing university’s digital repository. So, for a green open access version of this paper which is almost identical to the version which will appear in the journal, follow this link.

For a quick summary, here’s the abstract:

Across the United Kingdom (UK) large numbers of crisis resolution and home treatment (CRHT) services have been established with the aim of providing intensive, short-term, care to people who would otherwise be admitted to mental health hospital. Despite their widespread appearance little is known about how CRHT services are organised or how crisis work is done. This article arises from a larger ethnographic study (in which 34 interviews were conducted with practitioners, managers and service users) designed to generate data in these and related areas. Underpinned by systems thinking and sociological theories of the division of labour, the article examines the workplace contributions of mental health professionals and support staff. In a fast-moving environment the work which was done, how and by whom reflected wider professional jurisdictions and a recognisable patterning by organisational forces. System characteristics including variable shift-by-shift team composition and requirements to undertake assessments of new referrals whilst simultaneously providing home treatment shaped the work of some, but not all, professionals. Implications of these findings for larger systems of work are considered.

I’ll be adding this post, with its embedded link to the open access version of this article, to my ‘enduring posts’ page. I’ll group it with other posts and publications addressing the theme of ‘work and roles’.

All change in East London

How pleasing it was to discover, during a return trip this week to East London, that the site of the now-disused St Clement’s Hospital (this being where I trained as a mental health nurse) is becoming the UK’s first community land trust. This means that the space will be developed for permanently affordable housing for local people.

Having cast an eye through the windows of London estate agents during this trip away I can see why there’s a need. The capital has become a prohibitively expensive place to live and work, it seems.

As it happened, our visit on August 8th coincided with the opening of the Shuffle festival. Curated by Danny Boyle (who made an appearance) this is bringing film, music and other good stuff to the St Clement’s site ahead of its redevelopment.

Further west, in Whitechapel, we discovered that the Royal London Hospital has been built anew under a private finance initiative scheme. The front parts of the old hospital remain, but are unused and propped up from behind for purely ornamental purposes.

At the back, the original nurses’ homes and other notable venues (including the Oxford Arms pub) have been entirely demolished to make way for a tall, exceptionally shiny, new main building. For the time being the Princess Alexandra Building, this being the old School of Nursing site in Philpot Street, remains.

All in all It is – we had to conclude – looking very different.

Thoughts on the occasion of having written 100 posts

My first post was written and uploaded to this site on November 24th last year. I wrote about my interest in exploring the mental health system’s ‘wicked problems’, and drew attention to an article Michael Coffey and I had recently published in this area. In this, my 100th post, I want to think a little about what I have learned using a blog as a medium of communication.

As a mental health nurse academic my job involves researching and writing. I have wanted this site to be a vehicle for bringing some of this work to a wider audience. The main way I have gone about doing this has been to write posts to surround published articles, and where copyright makes this possible to add links to full-text green open access versions of papers stored on Cardiff University’s ORCA digital repository. The link above to Michael’s and my paper on wicked problems is an example. I’d like to think that this strategy has had some effect. As I wrote in this post last month, copies of papers I have deposited and then blogged about have been downloaded. By whom I cannot know. Nor can I be sure what use, if any, people have made of what they’ve read. If anyone wants to let me know, then that would be all to the good.

Over the last eight to nine months I have also learned that a blog needs looking after. So in addition to writing about research I have taken the opportunity to write generally about other things I do at work or am interested in, or about stuff which has simply caught my eye. My approach has been to write little, but to write often. I reflect that adding small pieces here and there has helped me in my teaching, as I noted earlier here. I also realise that in blogging beyond research I have blurred my boundaries somewhat, having added notes along the way about (for example) the simple pleasures of running. As an aside, I’ve been plagued by minor, but annoying, running-related injuries over the last few months and am missing my forest jaunts very much.

Just as a peer reviewed, published, article can be given a leg-up by a post on a blog, so too can a new blog be supported by a tweet. I have taken to using Twitter to draw attention to newly published posts, and indeed have started using this (sporadically, it has to be said) as another, independent, way of exchanging ideas.

That’ll do, for now. But I conclude that I’ll maintain this site in its small niche for a while longer yet.

COCAPP gets a blog

Time only this morning for a super-speedy post to draw readers’ attention to COCAPP’s new blog. COCAPP is funded by the NIHR Health Services and Delivery Research Programme, and is a cross-national study of care planning and care coordination in community mental health. I’ve written about COCAPP on my blog before, but now recommend interested people get over to the project’s dedicated site to meet the team and to find out the detail of what it’s all about.

Care work and health system complexity

Two interesting collections of papers have caught my eye in the last week or so. Davina Allen has edited an online volume of articles, all previously published in the journal Sociology of Health & Illness, addressing the sociology of care work. In her editorial Davina sets the scene with reference to the Francis Inquiries and concludes with this:

[…] in the wake of Francis the predominant response to raising the quality of care and compassion has been to focus on the attributes of individuals and wider regulatory arrangements. As we have seen, however, the kind of care that can be provided depends fundamentally on the social organisation of care work, which in turn hinges on what we (society) are prepared to pay for. Francis has called for national fundamental care standards, but this requires more careful attention to the models of care-giving practice that will sustain them, including care-giver roles, the inter-relationship of care work components and features of the organisational context. The papers in this collection reveal there are no easy answers to these questions, but the insights they yield make an important contribution to these debates. In bringing the papers together in this virtual special issue the aim is to both raise the profile of the individual contributions, but also their collective value to this critical issue of public and policy concern.

Meanwhile, Tim Tenbensel, Stephen Birch and Sarah Curtis have edited a special issue of Social Science & Medicine devoted to the study of complexity in health and health care systems. I have a personal interest here, as it is in this collection of new papers that my article Connections and consequences in complex systems: insights from a case study of the emergence and local impact of crisis resolution and home treatment services appears. Describing himself as ‘a sympathetic outsider to complexity theory’, Tim Tenbensel in his editorial closes with this:

[…] perhaps the most important conceptual issue for complexity theory seems to be the place of ‘top-down’ interventions in complex systems. Are they part of the landscape of complexity, or are they things that ‘impede’ the unfolding of self-organising, emergent phenomena? More sophisticated applications of complexity suggest the former answer, yet the will to control through linear, rational, prescriptive mechanisms remains an ever-present shadow – something that should be minimised – because it this a defining trope of complexity theory applied to the social sciences. This theoretical challenge is perhaps most pressing in contexts in which health services are directly funded from public sources.

My apologies to the doctoral students whose ‘complex systems’ module I taught a few weeks ago, who may erroneously have thought that I knew what I was talking about, but like Tim Tenbensel I regard myself as being a relative newcomer to this whole complexity approach. So I for one am looking forward to reading the other papers in this new collection, and to learning plenty that is new.

Critical junctures (reprise)

This morning Nicola Evans’ and my paper on Critical junctures has appeared in advance online publication form on the Social Theory & Health website. This is very pleasing, though as I noted in my original post the terms of Palgrave’s copyright agreement mean that we have to wait for a period of 18 months from now before depositing a green open access version of the full text to accompany the article’s ORCA entry.

In the meantime, here again is the article’s abstract, which I hope at least whets readers’ appetites:

This article makes an original contribution through the revitalisation, refinement and exemplification of the idea of the ‘critical juncture’. In the health and illness context, a critical juncture is a temporally bounded sequence of events and interactions which alters, significantly and in a lasting way, both the experience of the person most directly affected and the caring work which is done. It is a punctuating moment initiating or embedded within a longer trajectory and is characterised by uncertainty. As contingencies come to the fore, individual actions have a higher-than-usual chance of affecting future, enduring, arrangements. These ideas we illustrate with detailed qualitative data relating to one individual’s journey through an interconnected system of mental health care. We then draw on observations made in a second study, concerned with the improvement of mental health services, to show how micro-level critical junctures can be purposefully used to introduce instability at the meso-level in the pursuit of larger organisational change. In addition to demonstrating why scholars and practitioners should pay closer attention to understanding and responding to critical junctures we are, therefore, also able to demonstrate how their emergence and impact can be examined vertically, as well as horizontally.

Learning about complexity and systems

Today has reminded me of the pleasures of university teaching. A day in a classroom with lively doctoral students is to be savoured. Most (but not all) of the group were nurses, and most (but again, not all) were completing the taught elements of their professional doctorate programme ahead of beginning their research.

The module is concerned with understanding health system complexity, and is liberally sprinkled with local research (my own included). Today we began with an overview of the territory, and then discussed policy and services at the large scale using the idea of wicked problems. Pauline Tang gave a fabulous talk based on her study of electronic health records, before we closed with a whistlestop tour of systems of work and divisions of labour.

We meet again tomorrow for sessions led by students, to think about trajectories and critical junctures, and to hear Nicola Evans being interviewed about change in organisations. I’m looking forward.

Vivas, research projects and the Welsh Government on the Francis Report

There’s plenty going on in the continuing baking sun this week. I was pleased to spend yesterday at Sheffield University (where I was once a student) examining, and recommending awarding, a doctorate addressing the use of problem based learning in mental health nursing education.

Meanwhile COCAPP is now generating data, and the RiSC project has reached a critical point as a search strategy is devised for its second phase. And tomorrow and on Friday I’ll be in the classroom with a group of professional doctorate students, talking and learning about systems and complexity.

Elsewhere, via the twitter account of the Minister for Health and Social Services, Mark Drakeford I’ve spotted the Welsh Government’s response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. I see there will be an annual Quality Statement for the NHS in Wales from next year, and a future NHS Wales Quality Bill.

Better late than never: thoughts on the mental health system and the DSM5

I drafted a post in May to coincide with the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM5). Having pitched it to a multi-author news and analysis site which didn’t bite, I then promptly forgot about it. Doing some blog housekeeping this morning I spotted the post squirrelled away in my draft folder, and decided to resurrect and refashion it for uploading here. Apologies in advance for repeating some messages and for linking to green open access papers addressed in other, previous, posts:

As was reported in the spring, the process of revising the DSM prompted fresh debate over the recognition, naming and causation of mental health conditions. For some biological psychiatrists the new DSM has been premature, arriving ahead of advances in understanding promised by genetic, brain imaging and other basic science research. Elsewhere, in a statement released in May members of the British Psychological Society’s Division of Clinical Psychology argued for an entire shift away from psychiatric classifications on the grounds that these lack validity.

So far as I am aware the DSM is not widely used in the UK. Here the day-to-day experiences of people using, and providing, mental health services may not be much affected by its revision. What the furore has been a reminder of, however, is the extent to which knowledge and practice in the mental health field remain open to contest. I have written before about the development of a system of mental health care in the UK, and how knowledge has been important in supporting professional claims to fulfil roles and to do certain types of work. This includes the work of deciding what should be done in response to people who are distressed, and whose thoughts, feelings and behaviour are perplexing and a cause for concern to others. In the case of the profession of psychiatry, its authority has been built on a biomedical knowledge base and on the development and application of associated treatments. Throughout its history, however, psychiatry has also been divided. Some of its sternest critics have come from within.

Historically, as the UK’s mental health system transformed into one in which more and more services were provided in the community new opportunities opened up for other professions, each claiming specific underpinning knowledge to inform their work. Modern mental health teams are staffed by psychiatrists, nurses, psychologists, social workers, occupational therapists and others. For each of these groups public statements and standards appeal to the distinct contributions their members make. In reality the boundaries between staff are often blurred, and the relationships between professions and their tasks are fluid.

All of this makes the UK’s mental health system an interprofessionally complex one. It is also only in the last 10 to 15 years that the challenge of improving mental health has been taken seriously by policymakers. But the problems to which policy action might be directed are not self-evident. They have to be named, and remedies proposed, implemented and defended. Recent policy for mental health has moved through phases. In the late 1990s ‘the problem’ was presented as one of community care failure. New types of team (for example, providing crisis resolution and home treatment, and assertive outreach) were set up as part of the solution. A controversial amendment to England and Wales’ Mental Health Act made provision for compulsory treatment in the community.

Later policy emphasised ‘new ways of working’. This explicitly encouraged professionals to do work previously done by others. Examples include nurses and other health workers taking on the role of approved mental health professional and therefore carrying out tasks previously done exclusively by social workers.

Now, in a context of austerity policy has strands concerned with the promotion of public mental health and wellbeing, and with enabling ‘recovery’ and personalised care for people using specialist services. As Simon Wesseley has argued, for most people using or working in the UK’s mental health system a more immediate and pressing concern than the publication of the DSM5 is protecting existing provision at a time of service retraction.