Tag: wicked problems

Papers update

Papers July 2020Back in summer 2019 (which seems, for pandemic-related reasons, to be much longer than a year ago) I wrote a short post introducing the 3MDR study. Here, now, is the main findings paper in early view in the journal Acta Psychiatrica Scandinavica. Working on a clinical trial has been an interesting, learning, experience for me and this feels like an important project to have made a contribution to.

I realise, too, that I’ve neglected to draw attention on this site to two papers co-written with Ray Samuriwo, both drawing on systems perspectives, wounds and mental health: see here and here. Ray is an original thinker, and makes interesting connections across different fields: check out, too, Values in health and social care for which Ray was lead author.

Understanding mental health systems and services — Mental Health / Iechyd Meddwl

Here’s a link to my first post for a new Cardiff University Mental Health Blog. The content will be broadly familar to people who have dipped into my personal blog in the past, insofar as I have chosen to say something general about doing mental health services research.

Working in collaboration with colleagues across the UK, including with people who have directly used services, researchers in the School of Healthcare Sciences at Cardiff University study mental health systems.

via Understanding mental health systems and services — Mental Health / Iechyd Meddwl

Clicking the hyperlink above, which appears beneath the brief snippet of text, will take you to the full piece. There are already some interesting other posts on the site, too, including a piece by Mike Owen written as an opener.

Spring election, and the politics of mental health

It hasn’t always been like this, but mental health is something which politicians now talk about. In the run-up to next week’s general election mental health has even featured in public appeals to voters. The Liberal Democrats have particularly campaigned in this area, and in their manifesto promise £500 million per year for better mental health, and specifically make a case for investing in research. Labour talk about giving mental health the same priority as physical health, and the Conservatives say pretty much the same. Reviewing all the main parties’ manifesto promises for evidence of concrete plans for post-election improvements to mental health care, over on his blogsite the Psychodiagnosticator observes ‘that many of them were so vague as to amount to no promise at all‘. I think he has a point.

Possibly the broad manifestos produced in the run-up to a general election are not the places to look for fully worked-up blueprints of what future mental health policy across the UK might look like. Perhaps, more accurately, we should not think about ‘UK policy’ in this context at all. Members of Parliament elected to Westminster next week, from amongst whom a new government will be formed, will have authority to directly shape services in England only. Health and social care remain areas over which devolved authorities have jurisdiction, and for a ballot delivering a government with the power to pronounce on mental health care here in Wales we must look to the National Assembly elections to be held in 2016. I’ve indicated before that mental health policy here is different from that in England, and indeed from other countries in the UK. Consider again the case of the Mental Health (Wales) Measure. This is a piece of legislation for Wales alone, mandating for care and treatment plans, care coordinators, access to advocates in hospital and the right of reassessment within secondary mental health services following discharge. It was introduced in the face of some strong, pre-legislative, criticism from at least one senior law academic (Phil Fennell) who in 2010 began his submission to the National Assembly by saying,

The gist of my submission to the Committee is that this measure, although well-intentioned, is cumbersome, unduly complex, and will lead to a delay in providing services which ought to have been available already to service users and their families in Wales under the National Service Framework for Adult Mental Health and the Care Programme Approach.

Five years on the Measure has not only passed into law, but been subjected to a round of post-legislative scrutiny by the National Assembly’s Health and Social Care Committee (see my post here), to which the Welsh Government has now responded. With data from across both England and Wales, COCAPP (and in the future, COCAPP-A) will have something to say about how care planning and care coordination are actually being done, and readers will be able to draw their own conclusions on the extent to which changes in the law trigger changes to everyday practice. And, whilst we’re in policy comparison mode, for a view from Scotland try Paul Cairney. He argues that divergence in mental health policy across the UK, exemplified by contrasting English and Scottish experiences of reforming the law, reflect differences in both the substance of policy and in policymaking style.

In all of this I am, again, reminded of the wicked problems facing all policymakers who seek to intervene in the mental health field. Whatever direction it takes, future policy will be open to contest and will surely trigger waves of consequences.

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.

Closing the Gap?

Earlier this week, over the border in England Deputy Prime Minister Nick Clegg put his name to a new policy document titled Closing the Gap: Priorities for essential change in mental health. The foreword to this includes the line that ‘Mental health is moving up the policy agenda across government’. This is a welcome assertion. It is also one which deserves to be examined alongside evidence of recent cuts in funding and retractions in services at a time of rising demand (see here and here for my earlier posts on mental health in an era of austerity).

This is a document listing 25 areas for change in four areas: increasing access to mental health services; integrating physical and mental health care; starting early to promote mental wellbeing and prevent mental health problems; and improving the quality of life of people with mental health problems. It closes with the maxim that mental health is everybody’s business. Initial coverage in The Guardian included a fairly straightforward description of the document’s content, and particularly its promise of increased choice for people using services and the introduction of waiting time targets. In The Independent, Paul Jenkins (from the organisation Rethink Mental Illness) was more searching, contrasting Closing the Gap‘s aspiration with what we know about frontline services:

[…] historically, mental health has always had a raw deal when it comes to NHS spending and accounts for 22% of illness in this country, but only gets 11% of the NHS budget. On top of this, over the last two years, we’ve seen a 2% cut in mental health spending despite increasing demand. Services which were already struggling are being squeezed even further. So how can the Government now make real inroads into significantly improving care and introducing choice when the services simply aren’t there? People are waiting months, even years for treatment.

If politicians really want to improve the lives of people with mental illness, we need to see investment in mental health services – in the very least services should not be cut. We should also be making sure that people who are too ill to work are properly supported with the benefits there are entitled to and with services that respond when and where they are needed. And when we see an action plan, it needs to set out specific commitments on how things are going to change and by when.

Well said. Personally I am minded to think, again, about the mental health field’s wicked problems, and how large-scale policy always contains just one version of what a system’s most pressing challenges (and their solutions) might be. Closing the Gap has plenty to say on what ought to be happening at local level (better preparation of commissioners of mental health services, more mental health training for primary care workers, more psychological therapies, and so on). What it does not unequivocally say is that ‘the problem’ may also be one of underfunding relative to levels of need.

I am also reminded of how local service change in response to national policy can lead to unintended consequences (something I have written about at length here). Here’s a speculative example to illustrate this point. Typically, mental health teams have responsibilities to respond in timely fashion to new requests for help (from colleagues in primary care, for example) whilst simultaneously providing care to people already using their services. Who knows, then, what the wider system effects might be when waiting limits for mental health services are introduced next year, as Closing the Gap promises they will? At local level, will redoubled efforts to respond to new referrals mean that the delivery of ongoing care and treatment will suffer? Will NHS organisations be tempted to establish new types of service specifically to reduce waiting times? If so, how will these find their feet in systems which are already organisationally complex? None of this is to say, of course, that waiting periods are problems which do not deserve to be tackled, but it is to say that actions to address perceived deficiencies always reverberate.

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.

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.

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.

Blogging on the bus: floods, mental health and more wicked problems

A brief post as I make my way, by bus, to a meeting at the University Hospital of Wales.

What’s the connection between the prevention of floods (noting the terrible weather we’ve been having, again) and the promotion of mental health? Both are problems of the wicked variety. Here I’m using ‘wicked’ in the way I used it in my previous posts, with due acknowledgment of Rittel and Webber and their 1973 paper. Flood management and improving mental health and well-being are complex problems. Responsibilities are dispersed across different people, groups and organisations. There are no ‘stopping rules’, in that there is potentially no end to what could be done.

That’s it: bus journey over.