Tag: mental health systems

Horatio Festival of Psychiatric Nursing

Horatio is the European Association for Psychiatric Nurses. On the group’s website it says:

The aims of the Association are twofold: to advocate for the interest of the members by providing input into the decision-making processes on issues relevant to psychiatric and mental health nursing in Europe and to promote the development of psychiatric and mental health nursing practice, education, management and research.

I’m just back from Horatio’s latest gathering: the Third European Festival of Psychiatric Nursing, with its theme of ‘Creativity in Care’. This took place between November 6th-9th in Malta, which (unfortunately for those of us aiming to sightsee on our single free afternoon) happened to be experiencing some unseasonably miserable weather.

As an event, this was a large and properly international one. Whilst there I delivered two presentations: one from the RiSC study, and one a knitting-together of ideas, methods and findings from a series of interconnected and now-completed studies into changing mental health systems and nursing work. My themes in this second presentation will be familiar to readers of this blog, but if it’s worth saying once it’s worth saying again. Here are my slides, for anyone interested:


Prospects and challenges: revisited

In 1999 I wrote a paper for the journal Health and Social Care in the Community titled Joint working in community mental health: prospects and challenges. The back story is that the work for this article was mostly done during my first year of part-time study for an MA in Health and Social Policy, during my time working as a community mental health nurse in East London.

Frustratingly, I can’t find my original wordprocessed copy of this paper from which to create a green open access version for uploading to the Orca repository and for embedding a link to here. But not to worry. The abstract, at least, is a freebie:

This paper reviews the opportunities for, and the challenges facing, joint working in the provision of community mental health care. At a strategic level the organization of contemporary mental health services is marked by fragmentation, competing priorities, arbitrary divisions of responsibility, inconsistent policy, unpooled resources and unshared boundaries. At the level of localities and teams, these barriers to effective and efficient joint working reverberate within multi-disciplinary and multi-agency community mental health teams (CMHTs). To meet this challenge, CMHT operational policies need to include multiagency agreement on: professional roles and responsibilities; target client groups; eligibility criteria for access to services; client pathways to and from care; unified systems of case management; documentation and use of information technology; and management and accountability arrangements. At the level of practitioners, community mental health care is provided by professional groups who may have limited mutual understanding of differing values, education, roles and responsibilities. The prospect of overcoming these barriers in multidisciplinary CMHTs is afforded by increased opportunities for interprofessional ‘seepage’ and a sharing of complementary perspectives, and for joint education and training. This review suggests that policy-driven solutions to the challenges facing integrated community mental health care may be needed and concludes with an overview of the prospects for change contained in the previous UK government’s Green Paper, ‘Developing Partnerships in Mental Health’.

Fifteen years on the structural divisions remain. As with other areas, community mental health care continues to be funded and provided by a multiplicity of agencies, with ‘health care’ and ‘social care’ distinctions still very much in place. This year’s Report of the Independent Commission on Whole Person Care for the Labour Party and the King’s Fund’s work on integrated care are examples of recent initiatives aimed at closing these gaps. Labour’s Independent Commission recommends the creation of a new national body, Care England, bringing together NHS and local authority representatives at the highest level. Note, of course, that these proposals are for England only: these are ideas for health and social care in one part of a devolved UK.

In my article I drew attention to the problem of competing policies and priorities for NHS and local authority organisations, the lack of shared organisational boundaries, non-integrated information technology systems and separate pathways bringing service users into, through and out of the system. An illustrative example I gave was the parallel introduction, in the early 1990s, of the care programme approach (CPA) and care management. Here in Wales, with the introduction of the Mental Health (Wales) Measure there is now, at least, a single care and treatment plan (CTP) to be used with all people using secondary mental health services. But how many health and social care organisations in Wales and beyond have managed to integrate their information systems? This, I suspect, remains an idea for the future.

And then there are the distinctions, and the relationships, between the various occupational groups involved in community mental health care. In my Joint working paper I emphasised the differences in values, education and practice between (for example) nurses and social workers, and (perhaps rather glibly) suggested that the route to better interprofessional practice lay through clearer operational policies at team level. Getting mental health professionals to work differently together became, for a time at least, something of a policymakers’ priority in the years following my article’s appearance. Here I’m thinking of the idea of distributed responsibility, and ‘new ways of working’ more generally, of which more can be found in this post and in this analysis of recent mental health policy trends (for green open access papers associated with both these earlier posts, follow this link and this link).

Two other things strike me when I look back on this 1999 article and reflect on events in the time elapsing. First is how much I underemphasised, then, the importance and influence of the service user movement. Over 15 years much looks to have been gained on this front, and I detect improved opportunities now for people using services to be involved in decisions about their care. Services have oriented to the idea of promoting recovery, as opposed to responding solely to people’s difficulties and deficits. This all takes me neatly to COCAPP and Plan4Recovery, two current studies in which I am involved which are investigating these very things in everyday practice. Second, I realise how little I foresaw in the late 1990s the changes then about to happen in the organisation of community mental health teams. Not long after my paper appeared crisis resolution, early intervention, assertive outreach and primary care mental health teams sprung into being across large parts of the country. More recent evidence suggests a rolling back of some of these developments in a new era of austerity.

And what of the community mental health system’s opportunities and challenges for the fifteen years which lie ahead? Perhaps there’s space here for an informed, speculative, paper picking up on some of the threads identified in my Joint working piece and in this revisiting blog. But that’s for another day.

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’.

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.

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.

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.

Visiting the Netherlands

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.

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.

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:

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.

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.

Nursing and the approved mental health professional role

AMHPFurther 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.