Getting back to it

IMG_1414A quick post following a half-term break. Cornwall proved to be a fine place to spend last week. It is, truly, a most beautiful part of the country. Here’s a photo of the beach at St Ives to prove it.

Now it’s back to it. This week I’m working on two projects, and in the case of one will hope, by Friday, to be clearer on local arrangements for making payments to service user researchers. There’s some work to be done on preparing NHS R&D applications, too. Over the next week or so I also need to put some time aside to respond to Cardiff University’s consultation on the reorganisation of schools within the College of Biomedical and Life Sciences. The idea has been formally proposed that the School of Nursing and Midwifery Studies (where I work) and the School of Healthcare Studies (home to the academic occupational therapists, physiotherapists, radiographers and operating department practitioners) might merge. A move of this type has been on the cards for some time, so no surprises there.

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.

Research, open access and academic blogging [2]

In last month’s Research, open access and academic blogging post I neglected to ask the obvious question: why are the article processing charges (APCs) levied by some open access journals so high? In that post I gave the example of BMC Health Services Research, which (unless a waiver is applied for and granted) demands the sum of £1,290 before each accepted paper progresses to online publication. What, exactly, is all that money for? It’s certainly not to pay peer reviewers for their time or expertise, because if it was I would have received some additional earnings from BMC by now. Does it really cost so much to iron out the typos, format to house style and upload an article to the journal’s servers?

I pointed out in my original piece that it is neither reasonable nor sustainable to systematically expect individual academics to pay APCs. This being the case, universities and grant awarding bodies are going to have to stump up. But via this post on the Sussex (and former Cardiff) physicist Peter Coles’s In the Dark blog I was alerted to this cautionary note from the Royal Historical Society on the unintended consequences of this arrangement. For the interested reader there’s also this RHS President’s letter on the same. The argument goes like this: if universities are going to be paying the APCs associated with individual open access articles then academic freedom will be eroded, as the final decisions on which publications are to be financially supported and which are not will be made by budget-holding managers.

The problem, then, is not with open access per se but with the extortionate costs currently associated with some versions of it. These need to come down, and quickly.

Giving a fig about roles

Hannigan and Allen 2011In 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.

Word cloud 02.02.13Beyond 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.

Resilience and community mental health nursing in Palestine

With his permission, let me introduce you to Mohammad Marie. I know Mohammad as a PhD student in the Cardiff School of Nursing and Midwifery Studies. He is also a mental health nurse and teacher, who (when he isn’t attending to his thesis in south Wales) works at An-Najah National University in Nablus, in the Palestinian West Bank.

Mohammad is interested in resilience, both generally and in community mental health nurses in particular. Through his writing I have gained a glimpse of mental health needs and services in the occupied Palestinian territories, and of the day-to-day realities of living and providing health care in this part of the world. Quite rightly, nurses in the UK complain about lacking resources, of coping with high caseloads and of the dangers of burnout. Here, however, we can barely comprehend the enormity of the challenge facing those who do nursing in Palestine. Human rights are violated, and free movement restricted. Access to medicines is limited, and rates of trauma and mental ill-health high. Few practitioners have had opportunities to develop knowledge and skills specific to the provision of mental health care. For readers wanting to know more, the World Health Organization has made available information on health and health services in Palestine here.

A simple question drives Mohammad’s study: given their circumstances, what are the sources of resilience which help community mental health nurses continue in their caring work? As part of laying out the background to his project Mohammad has introduced me to the uniquely Palestinian concept of ‘samud’. ‘Samud’ and ‘resilience’ look, to me, to be close cousins, with the former referring to steadfastness in the face of adversity. It manifests in individual and social action, as well as in specific policy (for example, to support the development of an infrastructure for public services). From what Mohammad tells me, samud has become an important part of Palestinian culture and identity.

To get answers to his research question, Mohammad returned home last year to generate data. In ethnographic style he observed nurses and other staff going about their day-to-day tasks, basing himself in a series of government and non-governmental community mental health centres. He read local documents relating to the organisation of services. In order to explore nurses’ experiences and views in depth, Mohammad conducted detailed interviews with a sample of practitioners. The absolute number of participants in this phase was modest, but still a majority of the total population of community mental health nurses working in the West Bank.

Right now Mohammad is surrounded by transcripts and notes, doing his best to make sense of everything he has seen, read and heard. It’s for him to tell the story of his findings, but I know these will be both interesting and important. I’m looking forward.

Research, open access and academic blogging

Martin Webber, social work academic at the University of York, is inviting discussion on why researchers should blog. Martin will be drawing on what people say at a seminar he’s giving early next month as part of a York Social Research in the Digital Age series.

So, why indeed? Here are some personal reflections, on blogging and also more generally on the process of writing in an internet-connected world. These I’m basing on my (very) preliminary experiences on this site, some thinking done over the last couple of days, and an awareness of how academic practice is changing.

Word cloud 28.01.13First, researchers might want to blog because this is a very direct, free-to-access, way of communicating. This is especially important in disciplines in which most research papers are published in journals which sit behind paywalls. In applied areas like my own (mental health nursing, systems and services), a blog can be one way of connecting with important audiences (practitioners, policymakers, managers, service users) likely to lack the necessary subscriptions

This does not mean that academic blogging is therefore redundant in disciplines where all or most research outputs are publicly available, and for free. To say why this is so, I probably need to say something about open access. Here in the UK a big shift is taking place in favour of publishing in journals which are both peer reviewed and free to the reader. Check out, for example, the 246 titles currently offered online by BioMed Central. Plenty of longer-established publishers are now also offering open access options to authors submitting to their titles. Increasingly this means that, within single issues of journals, open access content sits side-by-side with subscription or one-off payment content.

A major driver behind these developments is the Finch Report, which appeared last year. This recommended open access as the preferred publishing model for the future, particularly in the case of papers reporting research supported by public funds. Making further progress along the open access route, however, means finding new ways of covering the costs. In the traditional model authors pay nothing to see their papers in print, the costs of publishing being recouped via institutional (or individual) subscriptions or from payments made by readers of single articles. Publishers like BioMed Central do things differently, requiring authors (unless they secure waivers) to pay an ‘article processing [or publishing] charge’ (APC) for each peer reviewed and accepted paper. APCs can be hefty. For example, the current submission checklist for the journal BMC Health Services Research indicates that it usually levies an APC of £1,290 on each accepted paper. The Times Higher Education reports that in the majority of open access papers published in the new social sciences and humanities journal Sage Open, the APC has been paid by individual authors. I’m not sure that’s either fair or sustainable. In the future, financial support for what Finch and others have called ‘gold [APC] open access’ will surely have to be provided by funders and universities (presumably using money currently being used elsewhere). Government and charitable funding bodies will require applicants to include in their bids the costs of open access publication, and universities will sign up as members of organisations such as BioMed Central with the aim of waiving or reducing the costs associated with individual article processing.

There are other ways of making available, freely and publicly, the full text of published research outputs. Publishers’ policies in this area differ, but under the terms of their copyright agreements many allow versions of accepted papers to be uploaded to institutional repositories for access, at no cost, by interested readers. The best deals allow authors to deposit post-peer review versions of papers as soon as they have been accepted for publication. Other deals allow the same, but after an elapsing of time to make sure that readers wanting immediate access have to obtain paid-for versions. The text in these author-own manuscripts is the same as that appearing in journals’ versions, but the papers lack the ‘added value’ of volume and issue details, layout and formatting as per journal house style, and so forth. This ‘green open access’ model is one I have been making use of in this blog, via links to post-peer review versions of papers saved in the Cardiff University ORCA repository. Check out my Enduring posts page, which has examples of posts and linked papers on wicked problems, work and roles in mental health systems, and research ethics and governance.

So if the gathering pace of the open access movement means that research papers will be more likely to be publicly and freely available via ‘gold’ and ‘green’ routes in the future, does this reduce the need for research blogs? Not at all, in my view. Blogs can be vehicles for making clear the connections between multiple papers and projects, giving researchers opportunities to write in-the-round overviews of cumulative bodies of work. They can also help contextualize research, and unpack the detail of full-text papers irrespective of whether these are open access or paid-for. In this way blogs can perhaps help translate ideas, promote uptake and increase the use of findings. This, I think, is part of the task researchers now face to maximise what the Research Excellence Framework (REF) refers to as ‘impact’. As an aside, I am reminded in this context of the excellent material on using social media to promote research available at the LSE’s Impact and the Social Sciences blog. If anyone working in the health and social care fields has examples of blogs, tweets and the like being successfully used to promote impact outside of academia, I’m sure I’m not the only one who would like to hear more.

Blogs are also interactive, allowing fast-moving, two-way, communication between writers and readers via the use of the ‘comments’ function. This is very different from traditional academic publishing, which can be distinctly one-way. This said, there are some journals (like the BMJ) which directly encourage readers’ online responses to published papers, and which host journal content and supplementary material (blogs included) at single sites. Further, whilst publishers will often accept study protocols in their journals they are less keen on progress reports. The immediacy of blogging offers an option here. For instance, Martin Webber on his site has some excellent examples of using his blog to keep interested parties aware of his ongoing projects.

To sum up what has turned into a lengthier-than-expected post. Martin Webber asks why researchers should blog. Based on my (admittedly brief) excursion into the genre, my response is that a more appropriate question might actually be, ‘Why are researchers not blogging as a matter of course?’ I have also taken this opportunity to think, in a more general way, about blogging in the context of changing academic practice. Blogs are a way of sharing research ideas, progress and findings, and can be used to wrap around and support full-text open access content. They have the potential to promote engagement between research producers, and research consumers. They allow connections to be made, and they encourage interaction. What’s not to like?

More on health and social care

A second brief post, now that Andy Burnham (Labour’s Shadow Health Secretary) has delivered the speech I heard mention of earlier today. I’ve found this version on the Labour Party’s website, and also this response from Chris Ham at the King’s Fund.

It’s interesting, and bold in places, and there’ll be more on the way as this is the start of a major Labour Party policy review. I see that Andy Burnham describes the mental health system as being quite separate from the system of social care, and from the system providing care for people with physical conditions. I also see that, in England, a future Labour government would seek ways of improving integration and coordination without imposing a further round of top-down structural change. I guess there might be different ideas about what counts as ‘structural change’, as some of what is proposed here is pretty radical: single points of access for all care, single budgets for all services provided, just one body (the NHS) providing ‘whole person care’. And whilst I like what I’m reading, I’m also aware that there are no ‘final fixes’ for the challenges facing public services. Change, even that which is driven by laudable ideas like promoting integration, can trigger unintended as well as desired consequences, and solve problems in one place only to create new problems elsewhere. Which takes me back to wicked problems and complex systems

Here’s to hearing the next, more detailed instalments: and indeed, any initial response from within Wales where responsibility for health and social care is a matter for the devolved Government.

Integrating health and social care

I caught a brief news item on this morning’s Today programme pointing to a speech that Labour’s Shadow Health Secretary Andy Burnham is expected to make introducing the idea of combined NHS and social care budgets in England. This is interesting, particularly if it develops into proposals Labour puts into its next election manifesto.

The fragmentation of health and social care is a problem. NHS organisations and local authorities have to work together, but have different obligations, priorities and funding. Accountability arrangements differ, and geographical boundaries are often not shared. Variations exist in models of commissioning and providing services.

These are hardly new observations. Years ago I wrote about the problem of fragmented community mental health services, and more recently have argued that the separation of agency responsibilities is one of the reasons the mental health system is so complex. It also contributes to the proliferation of wicked problems.

So, Andy Burnham: let’s hear what you have to say.

Remarkable stuff, snow

IMG_1393As an aside, with no bearing whatsoever on my last post describing what I do using only the commonest words in the English language, here are two photographs revealing what snow is capable of.

IMG_1394These were taken over the weekend, deep inside Fforest Fawr. The branch of this tree has entirely split, presumably under the weight of accumulated snowflakes. Parts of the Taff Trail, and certainly the Penrhos Cutting, were littered with branches (and indeed, whole trees) brought to the ground in this way. The second photograph is of the branch, collapsed following the break.

I can’t quite recall seeing this kind of thing happening during previous snowfalls. What’s different, I’m wondering? Unusually sticky snow, perhaps?