Mental health services - the future

The future is unknowable, but hopefully this one-off excursion into ‘futurology’ will be of use in raising awareness and informed debate.

All the issues raised here have already been discussed on the web, but many in the world of mental health appear to have either little knowledge of them, or only just begun to consider them. Reaction within ‘health and social care’ to the coalition government has been almost exclusively negative, focusing on budget cuts and the idea of services being taken away. The development of Conservative social policy over the last five years, has been largely ignored.

The most worrying aspect however is watching workers simply waiting to be told what to do by managers from failing providers and commissioners (who’s current role will soon cease to exist) little realising that the new government want them to take the initiative at local level, and transform their own work in a more autonomous way. There will be a Conservative led, or majority government for the foreseeable future, so time and money spent resisting reform, or endorsing the efforts of others to do so, is wasted and a disservice to clients.

The ‘new’ Conservatives do have a considered mental health policy developed over many years - explore The Centre For Social Justice ( http://www.centreforsocialjustice.org.uk/default.asp?pageRef=418 ). They do not ‘cut’ for the sake of cutting or just to reduce public borrowing. As a result there are new directions which any mental health organisation can take which will receive encouragement and support from reformers in national and local government. For a fast introduction see David Cameron’s 20 minute presentation at TED last February ( http://www.ted.com/talks/lang/eng/david_cameron.html ) and this article for The Observer from April ( http://www.guardian.co.uk/commentisfree/2010/apr/18/david-cameron-my-big-society ).

There are a few simple principles behind new Conservative thinking, which though often confused with Thatcherism actually come from an older tradition, and provide a certain logic to forthcoming policy:

a) You impose as little as possible on people’s freedom to act, minimising legislation and the bureaucracy it creates.

b) Governments do not seek to lead change in society, but enable individuals, communities and business enterprises in their chosen pursuits. There are no inherent, or permanent, ‘rights’ or ‘entitlements’ which people have, and which it is a government’s duty to bestow or uphold - rather it is expected that individuals and groups will lobby, vote and negotiate in their own interests to change the law to fit current social needs.

c) Governments tax and spend as little as possible, leaving the maximum amount of wealth and resources for people to use as they please.

d) You encourage anything that will sustain family and existing communities and devolve decision making to the lowest level possible.

e) Work (purposeful, productive or contributory activity) is undertaken on behalf of families and the community and is the principal way in which people maintain their self-esteem, achieve status and reward. It ought to lead to a fair exchange of labour, goods, services and education such that the costs and rewards match the real demand within a community - rather than being dictated by government.

f) You don’t reward failure, or reward people for doing the wrong thing (so in 2008 it was wrong to bail-out the banks, but right to guarantee personal savings). Equally risk (and a willingness to fail) is accepted as an inherent part of creating both wellbeing as well as wealth. Therefore seeking to regulate for most risks is folly, leading to a false sense of security, greater vulnerability and a less flexible response when the unexpected happens.

Social enterprise and social entrepreneurship

The idea of shared ownership amongst the workers and users of a business plus the principal of not taking profits out of an organisation has been around for a long time and taken many forms. The new Conservatives enthusiasm for social enterprises to take over services previously provided by national or local authorities is not so much ideological, since ‘public service‘ has always been part of their ethic, rather a result of it becoming lost in public bodies through the seemingly unstoppable process of bureaucratisation. Public organisations which set out with equality in mind, have ended-up offering a hugely inefficient and impersonal service, and often the people working within such organisations don’t realise how rule-governed, inflexible and risk-averse they have become. For an explanation of what is meant by social enterprise and social entrepreneurship see the website of Oxford University’s Skoll Centre for Social Entrepreneurship ( http://www.sbs.ox.ac.uk/centres/skoll/Pages/default.aspx ).

The new Conservatives don’t seek to impose how much health and social care is provided - that’s a matter for individuals, families and communities to decide. Nor indeed how it is financed, what mix of public and private, as long as it is responsive to public demand, and the public get value for money. What is paramount is an equitable relationship between provider and consumer. Therefore any form of business organisation may provide the best service in a particular location if it is responsive to local needs.

The idea that general practitioners should oversee the commissioning of health services in their locality arises solely from the observation that they are in the best position to assess need. It is a re-assertion of the idea of a family practitioner and an acknowledgement that a GP already acts as a ‘gatekeeper’ to services. Even today the most important decision affecting the outcome for a person in mental distress is probably their choice of G.P. Mental health professionals often assert that the average GP knows very little about mental health. Well - yes and no. A GP knows that many of their patients present with psychological problems, and they know about the psychology involved in the doctor-patient relationship. What they know little of is how mental health services are organised and what they actually do. What little they have seen, usually some parts of NHS mental health trusts, they don’t much care for - they know services rarely deliver because their patients tell them so. More worrying still, they know they’re boxed-in - forced to refer to services they have little confidence in because they know their patients have problems that go beyond their own level of expertise to treat. And herein lies the greatest opportunity for mental health organisations that are willing, and flexible enough, to go with the government rather than against it.

Mental health organisations

Despite being over-worked general practitioners do want to influence commissioning in their local area, they know of local needs but lack quality information about alternative providers.

(The principal purpose of making available government and local authority information and statistics, is to give anyone the opportunity to bid for contracts to provide public services).

Voluntary and ‘third sector’ providers, given that they tend to be smaller, more community based, flexible, efficient and the first to try-out more innovative practice, may well be better placed to form direct relationships with general practitioners and later the commissioning consortia they oversee, than the existing statutory providers. However a third sector organisation needs to pause and think twice about it’s existing collaborative practices in what will become a more competitive environment; existing open sharing of information and expertise, the informal ‘hands-off’ agreements based on geographical areas, deferring to the presumed expertise of statutory NHS mental health trusts etc. Smaller providers have often taken on trust the information and priorities handed down by commissioners. However there is already the opportunity for more equitable relationships given the amount of existing information and data placed on the web - but often their lack connectivity, coupled with an attitude of not needing to know, means they just don’t know they don’t know.

The larger statutory organisations have repeatedly shown over the last twenty-five years their lack of ability to reform themselves. The managerial bureaucracy cannot imagine that much of what they do is unnecessary. Eventually the only option is to cut-off the money. However, one common strategy of NHS managers to avoid reforming themselves is to ‘mothball’ one service in order to introduce another, with the consequence that the only increase in actually activity is amongst themselves. For the observant client the hypocrisy is staggering, for mental health professionals will daily be encouraging them to take more risks, be pro-active, and drop the routines and habits that have failed them!

The answer being proposed is in essence to personalise the process, whereby the person taking a decision at any level (in smaller, more local and devolved organisations), is placed in direct face-to-face contact with the people affected by their decisions - where the consumer has access to the same information as the provider. To be personally connected to an outcome. This also implies a radical change in the concept of expertise - which will be the subject of future posts on this blog.

A relatively good example of a current third sector provider, with which I was personally connected as a client, is the Community Care Trust ( http://www.community-care-trust.co.uk/ ) Although still unknown to many local general practitioners, it has a track record of reforming itself towards a recovery-focused approach, of being cheaper and smaller (more efficient) than it’s competitors, of understanding social networks (though it lacks knowledge of just how the web can facilitate this), and of introducing more flexible working practices that respond more to an individual client’s needs. It’s major weakness however is the lack of up-to-date IT skills and personal connectivity amongst most staff, plus a few who remain habituated to deferring to traditional expertise in mental health.

Mental health clients and carers

There is a common myth that most mental health clients don’t use the Internet, that they would be at a major disadvantage if they did because many lack conventional ‘functional skills’ (numeracy, literacy and IT) and besides they’re ‘vulnerable’ when online. This of course just tells us about the ignorance of mental professionals and the eagerness of conventional educationalists to make work. I’ll just note in passing that there is no reason why the technology which produces World of Warcraft cannot teach mentally healthy skills - fast! See Pandora’s twitter list for a sample of (200+) global mental health service users online ( http://twitter.com/serialinsomniac/mentalists ).

Public reaction amongst UK users of mental health services to the new government has been largely one of fear, panic, anger and outrage at the perceived desire of the coalition to take away financial benefits and services they believe they have an inherent right or entitlement to based upon a diagnosis of mental illness for which they believe there is limited treatment and from which they are likely to suffer for the rest of their lives. They believe themselves to be amongst the most vulnerable in society and that government has a permanent and comprehensive duty of care towards them. But they also believe that their disability should not prevent them from fully participating in society and that any government has a duty to facilitate this.

One objective of those who think in a new Conservative way is to reconnect the users and beneficiaries of public services with the people in society who’s productive work has paid for them. Many clients and carers do not seem to make the connection that other people's tax payments, combined with loans secured with that tax revenue, has in relatively recent history, allowed for the benefit payments, services and housing they consider to be their’s by right. Some younger clients seem to believe that a government has a free hand to provide or take away a public service, or indeed the power to create a prosperous economy. Equally, the protests of clients and carers in recent months appear to take no account of the fact that the entire population is facing cutbacks.

The new Conservatives believe the mentally ill need not be permanently dis-abled and dependant - that it’s financial support should be an incentive to be more independent from the state, more in the community. For them the tragedy of de-institutionalisation has been that unconditional financial benefits, better services and social housing have had an unintended disabling effect, a deskilling of social skills, leaving individuals isolated ‘in the community’. Their ‘model’ of provision comes from observation of people with physical disabilities, whose work prospectus and integration into the social life of the community has proved greater over the past 30 years than that of people with mental health problems. They have no problem with paying DLA for transport and to provide support at home to someone who is already doing some form of contributory work, paid or not, for just a few hours or full-time - which will boost the moral of a client, their acceptance by others, and be a public demonstration of a willingness to contribute to the wellbeing of all.

All of the above is of course my attempt to get inside the ‘mindset’ of new Conservative thinking. My own political views, as someone who has been permanently ‘on the sick’ for sixteen years and was a client of mental health services for twenty years, I’ll leave for another time.