Tag: Wales

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 alGallagher, 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.


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.

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.

Moving and mental health

Craig yr Allt 23.12.12Yesterday’s torrential rain meant I skipped a run, which I’ve instead done this morning. Both the Taff Trail and Fforest Fawr are full of impromptu rivulets and debris. None of this has put off the walkers or mountain cyclists, or indeed the other runners. There were plenty of all types out there today.

Here’s the view from the top of Craig yr Allt, looking east. On this part of my journey I saw not a single other person. Remarkable, really, when you consider this is only a few miles from Cardiff.

I enjoy getting out and about, and that’s reason enough for me. For readers interested in the relationships between exercise and mental health, check out this blog and this blog, written by The Mental Elf (who also tweets via @Mental_Elf). Both posts have good links to individual research papers and systematic reviews. All very interesting, and by the looks of it an area where (not a phrase so often heard these days) more research is needed.

Thoughts on a first month, and a photo of a fallen tree

Officially I’ve knocked off for the Christmas and New Year holidays. I’m still awake earlier than I need to be, but the rotten weather this morning is (so far) putting me off a Saturday morning run. For today’s forecast, check out the clip to the left – which for the record I’ve extracted (in what I think is a permitted way) from the Met Office website.The weather! So for now it’s just me, my porridge, a mug of strong coffee and my computer. I reckon I have about 30 minutes before I’m joined by others, by then also awake and up for the day.

So I have a precious window in which to reflect on a first month of blogging. First up is to state how much I’ve enjoyed it. I began with the idea of writing about my research, drawing on my work as an academic mental health nurse at Cardiff University. I had the plan of blogging about papers and projects, and providing links wherever possible to articles available for public download via the University’s ORCA open access repository. I’ve certainly done some of this (as examples, check out my earlier posts on wicked problems here, here and here, my post on research ethics and governance and my post on the measurement of blood pressure and what this tells us about health care tasks).

But having gone to the bother of setting it up I’ve also found myself drawn to using this site as a place to record more general observations: on mental health care, nursing, policy, people and so on. That wasn’t completely planned, but I’m pleased to have used my blog for this purpose. It wasn’t a long post, but the short point I made in defence of student nurses earlier this week felt worth saying. I expect, as I head into what promises to be a very busy but exciting 2013, that I’ll continue to use this space in this additional way.

Fallen tree, Ridegeway, 15.01.12Others are now awake, and I should go. So without further ado, here at the right is the picture of the tree that’s mentioned in this post’s title. South Wales is full of trails, mountains and woodland. I enjoy this variety very much, as both a born-again runner and as a walker of longer standing. In January this year, heading out on a favourite route along the top of Craig yr Allt, I happened upon this enormous, fallen, monster. It had come down in high winds during the previous week, presumably missing by a whisker the telegraph wires you can see towards the top of the photo.

The tree rests, still, where it fell. For those using the path the way through is either over or under the branches to the right. Goodness knows how the horses are managing it.

University of South Wales

A quick post before I head off for the train. Interesting to see that the merger of universities in this part of the world has taken a step forward. Yesterday it was reported that the name of the institution which will bring together the University of Glamorgan and the University of Wales Newport next year is to be the University of South Wales. Some of this has been quite fraught, what with Cardiff Met strongly resisting pressure from Welsh Government to join the party.

I’ve worked through an institutional merger of this type, having first been employed in the University of Wales College of Medicine before moving across to Cardiff University in 2004 when the two joined. In a day-to-day sense I’m not sure I ‘felt’ the significance of this move initially. Sometimes the impact of a change of this type takes time to work its way through the system, but I’m sure the limbering up for merger which has been taking place across other local universities has been anxiety-provoking for some. In the fullness of time it will be interesting to catch up with colleagues in Glamorgan’s Department of Care Sciences to hear how things are progressing. I wish them all well.

The train calls.

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.