“The future of #mentalhealth is as yet unwritten”: The Marion Beeforth Memorial Lectures 2017

The following is the text of The Marion Beeforth Memorial Lecture ‘The future of mental health is as yet unwritten’ delivered by Mark Brown to the 18th Annual Carer User Education Mental Health Conference on 5th April 2017 at The University of Brighton Faculty of Health and Social Sciences.

I’ve been doing mental health stuff for over a decade.  I started off by inventing a mental health magazine written by people with mental health difficulties, for people with mental health difficulties.  It was called One in Four. We did it for seven years.  It nearly killed us.  Some people liked it.  Some people didn’t.  From there I ended up doing lots of different mental health related things and I got to see a lot of what happens in mental health.

So, I have a confession to make: I want to believe in the future for mental health.  And that’s what I want to talk to you about today.  What makes the future in mental health happen?  Who gets to decide?  What might we expect?

We are always present as the future happens.  We just don’t notice it.  It’s happening now.  By the time I finish this speech the world will be different in millions and millions of ways to when I began.  In mental health we can often be fooled into thinking that things have always been this way and will always be this way in future.

The mental health systems we have now are not the same as they were twenty years ago.  They’re not the same as they will be in twenty years.  Things change.  Often things that we thought would turn out one way turn out another way.  Mental health is not outside of economics or politics or outside of broader social change.  Mental health, as an area of activity, is about people and their lives.  And people are impossible to divorce from the times they live in.  What for one generation seems like a liberation might seem for the next a new form of oppression – ‘It was meant to be great but it’s horrible’.

Over the course of this lecture I’m going to to look at our present, then at our possible futures and then then have a stab at working out how we might start to build the beginnings of some preferable ones.

I came to be doing mental health stuff because of my own experience of mental health difficulties.  There was a time when I didn’t think I had a future.  There are times where I still don’t.  Living a life with mental health difficulty can rob us of our sense of the future; reduce to living from moment to agonising moment.

So that’s why I think the future is so important.  To live in a big long now and to accept that nothing will ever be better is a kind of exquisite torture.

Levels of illness and distress are rising while all we have is the same old suggestions and the same diminishing pool of ideas. There isn’t a past to return to for mental health.  Things were not better in the old days.  We have to face the future.

The lack of attention paid to mental health has given me a permanent sore in the side of mouth where I bite my cheek in frustration.  It feels like making the lives of people with mental health difficulties better is as much of a utopian dream as fully automated luxury communism or holidaying on Neptune.

Often experiencing mental health difficulties saps our hope, hollows our bones, makes everything seem impossible and insurmountable.  Like rising damp or mildew, this lassitude afflicts our institutions and saps their will to make things better.  Nothing will change, we just have to stop things getting worse.  We’re losing the battle for a mental health future that we can make and influence.

In mental health we can’t see a line to the future. All we see are long days of struggle and even longer nights of doubt and terror where everything is like pushing a rock up a mountain.

The hardship and suffering of living with mental health difficulty can erase any vision of a better life or a better world.  Our mental health services seem to constantly teeter on the brink of collapse; surviving from month to month like a family trying to make ends meet, stretching out the final pounds in the bank at the end of the month in tight-lipped desperation.

The international symbol for improving the lives of people with mental health difficulties might as well be a shrug and a ‘dunno’.  Many of the breakthroughs made in medication, oversold as they might have been, are already decades old.  There are few new approaches on the immediate horizon because no one funds research and new thinking.  What does exist is done on a shoestring.

People with a diagnosis of schizophrenia run the risk of dying 20 years earlier than the average British person without a diagnosis of schizophrenia and we don’t know what to do about it.

Psychological problems during childhood can lead to 25% lower earnings by age 50.  Being unwell young can have an impact on the rest of your life and we don’t know what to do about that either.

So why doesn’t it seem like a crisis? Mental illness and mental health difficulty are glacial apocalypses.  Few people die immediately; societies don’t collapse.  There’s never one dramatic moment where society looks around itself and says ‘We never thought it would get this bad. Now’s the time to sort things out.’

The future is slow in mental health because, when it comes to it, people don’t put their money up. There’s always something more pressing, more important to spend it on. Every year that we neglect spending on mental health is another year we waste.  We don’t know where the answers to some of the challenges we face every day with our mental health difficulties might be found; but without the funding of a broad range of research, exploration and doing things they’ll remain forever hidden.

So how might we think about the future?  How might we begin to write it?

Futurists or futurologists are people who have the job of making guesses about what the future might be like.  They usually do this by studying the present and trying to discern which way things are going.  I’m not a futurist, but my time spent doing mental health stuff has given me the opportunity to look pretty hard at the present world and the way it does or doesn’t help people have the lives that they should reasonably expect.

Futurists often use a relatively simple way of trying to understand what the future might hold so they can make better guesses.  They deal in three kinds of futures: probable, possible and preferable.

Probable futures

Probable futures are the futures that seem likely to happen if nothing major changes from now, they’re about extrapolating from present events.  They’re the futures that are like now, but morer.  In mental health, those futures don’t look very rosy.

I was recently speaking at an event about mental health and digital technology.  I told the audience:

“We are in the middle of the biggest roll back of public spending in generations.  In the form of brexit we’re embarking on the biggest experiment in leaping into an economic and geopolitical unknown that our country has seen in at least a lifetime.

“In mental health we can often assume that the world we see around us will always look much the same as it does.  That institutions like this one we’re sitting in will always be here.  That there will always be an NHS.  Always be social care. Always be human rights.  Always be helplines.  Always be homes and jobs and opportunities.  I think right now we can assume no such thing.

“This might sound alarmist, but in mental health we have always been too complacent, too cautious and too ready to accept that things will turn out all right contrary to what we know and we see every day. Life for people with severe and enduring mental health difficulties has been getting worse.

“That is what makes our job in mental health all the more important and desperate…  In much of the adult mental health world our possibilities are plateauing, either because we have gotten everything we can out of a particular technique, idea, practice or treatment; or because public and political will to provide the resources to fully use something to change people’s lives has flatlined.  There is nothing traditional on the horizon that will save us from failing people with mental health difficulties in worse and more painful ways in future than we are today.”

So, in England at least, we are looking at a probable future where there is less funding for the NHS, less funding for local authorities, a possible recession on the horizon and a continued squeeze upon the Welfare State and the benefits to which people are entitled.  More broadly, we’re looking at what might be a period of new instability.  We might think that things won’t change overnight, but sometimes things do.  Brexit, Trump, broader geopolitics, climate change.  Generally it’s easier to see what might turn out badly when you’re already seeing it turn out badly.  The probable future in mental health is that things will be a bit like they are now, but probably a bit worse.  There may be rays of sunshine, a windfall here, an unexpected win there, but generally speaking the direction that we’re going is that for people with severe and enduring mental health difficulties life has a chance of getting a bit worse.

It’s not all doom and gloom though.  We find ourselves at an interesting time in relations to public and governmental attitudes toward mental health.  Nearly a decade of concerted work, much of it funded by the coalition government and beyond through national campaigns like Time to Change, has driven mental health up the agenda as a social concern. The message that people with mental health difficulties should not be discriminated against has stuck.

This gap between public goodwill and detailed knowledge makes mental health the perfect area for a politician who wishes to be seen to be doing unequivocal good. People with mental health difficulties are the new innocent and untainted victims. Or at least the right sort of people with mental health difficulties are. Where once we may have judged the goodness of our society by our behaviour toward recent migrants or to those with whom we did not share political or religious ideas, now in this age of polarisation it has been harder to find victims to help that do not tread on the political sensibilities of one regressive group or another. At the moment, people with mental health difficulties are those people, sort of.

Once the go-to group for governments wishing to earn humanity points was people with cancer; but it’s difficult to make policy pledges about cancer without it costing the Treasury a lot of money. Mental health, on the other hand, is often embarrassingly grateful for even the smallest of crumbs from the top table.

The idealised vision of people with mental health difficulties; quiet, tragic figures wilting for want of a course of CBT or a mental health first aid course in their school has created a kind of victorian urchin analogue; a group of people you can offer a tiny sliver of comfort to and then bask in the glow of their ‘god bless you sir’’s; convinced in your heart that you are both caring and kind.

Conservative social ideas have often been uncomfortable about disruptive or ungrateful beneficiaries. While those who are born with disabilities, or who are unwell from childhood often win the hearts of conservative policy makers; those who acquire their challenges later in life are often considered to be more suspect; somehow less pure in their neediness. Adults with severe mental health difficulties are often people who have had and, currently have, complicated lives where they are not so obviously victims. This often means that they are treated with a lack of care, subject to control rather than nurturance and made to carry with them a sense that somehow society does not know how to fit them (us) in.

But, the suggestion is that this interest in mental health will remain on the agenda for at least the immediate future, though whether it will translate in genuine change is another question.  To the general public not immersed to any great degree in the detail of what kind of things might actually be good or needed by people with mental health difficulties an extra anything for mental health is seen as a revelatory step forwards.  What isn’t happening so much is people without mental health difficulties actually listening to people who do about what they (we) want to happen.

And that’s where we come in, though it might not be something that comes naturally to us.

Possible futures

Our second kind of future is the possible future.  Possible futures are the kind of futures you explore by being playful.  Sometimes they’re explored through stories, or films, or art or imagination.  They’re the futures where we look at how bad, how good, how weird the future might be.  They’re the versions of the future where we explore our desires or look at how one particular thing might change everything.  It’s the jetpacks and flying cars future, if you like.  The future that we try on to see how it makes us feel.  Possible futures are where we try on our ‘what-ifs’ for size.

I went to the Beyond Bedlam exhibition at the Wellcome Collection in London last year.  It told, in some detail, the story of the old Bethlem hospital and by extension a sort of history of the treatment of mental health in England.  It tried to be very fair, to stress that people with mental health difficulties are, you know, people, but it couldn’t quite escape from telling the story of mental health through the institutions and services we build to provide treatment rather than through the lives of people..  All the way through I was wondering:  Are there other stories we could tell about the history of mental ill-health and mental distress? Of course there are. But what might the organising principle be? What would happen if we removed psychiatric treatment from being the sun at the centre of the astrolabe of discussion? Would all of the different moons and planets of ideas and experiences fly off in eccentric spirals and loops, a terrible disordered mess? Or would we find new ways to organise the story or new stories to tell?

This is where our thinking about mental health in general gets stuck, too.  We end up assuming that the existing mental health services that we see are like a kind of unchanging, unshifting map where nothing will ever change and nothing will ever move.  This means we can get trapped in the process of envisaging the future as being much like now but where everything works.  We get stuck in the probable future.  What we need to be able to do is roam further in our thinking, to do more exploring and to stop ourselves from automatically limiting ourselves to what looks like now.

Mental health isn’t just about mental health services. As people with mental health difficulties we know that we carry our difficulties with us, that everything that touches us interacts with those difficulties.  Services might be nine to five, but we’re us 24/7, regardless of what we’re doing

A few years ago I was at an event with a number of mental health folks from across the world looking at what the future for mental health might be.  I got all excited and started to throw out all manner of weird ideas like ‘what would happen if we removed referral criteria for mental health services?  What if we put a use by date on mental health services so that every five years we reviewed them to see  if they were still doing what they were supposed to and if they weren’t we closed them down?  How will we provide mental health services in a world where people move around more, possibly from country to country?  How will we provide mental health services for entire communities that have been traumatised by war or discrimination or violence?’

What was interesting was the people most directly involved in running and managing existing services found it most difficult to play with these ideas, these possible futures.  They were like ‘nope, no, that wouldn’t work, that’s impossible’.  It was as if they were so good at managing the present they couldn’t even feel comfortable playing with the possible future.  They just couldn’t play.

And play is what it’s all about.  I do lot of work these days around digital technology like apps and devices and mental health.  I mainly got into that because it felt like the area where there was the most room for play and for trying out new things.  It felt like an area where it was easier to look at possible futures because it felt new.

Digital technologies are one of the areas where there are new frontiers to be explored.  Digital technology creates hybrids: it takes what we know in one area and finds new ways of doing it.  Technology as helper, not as threat.  As such, digital technology is one of our best bets for better mental health because we already know a lot about mental health. And other people know a lot about tech and also make a lot of money out of getting it right.  So, we’re halfway there.  The direction of travel is that there will be more breakthroughs and research in digital technology each year, which means if we carve out a space for mental health in that we will reap the benefits of a direction of innovation that is already unfolding.

People with mental health difficulties and people who support us and provide us services are often very afraid of new technology, fearing that it will be a new way for things to be done to us rather than done for us.  It’s a reasonable fear, given how much historically has been done to us rather than for us without any digital technology being involved at all.

In any sort of consideration of a possible future you are always balancing the questions of ‘could we do it now or in the future?’ with ‘should we do it now or in the future?’  This is why it important to keep your eyes open to innovations and to weigh them up in your head:  What would it be like if that happened?  Would it be good or bad for us? Would it be desirable?  What would we gain and what would we lose?’

There’s some great examples of this.  People have been working on meds that know if they’ve been taken or not.  They have a little microchip that can tell whether the medication has been swallowed.  That might be awesome if you really need reminding, but could be terrible if it was used to check up on you say, to make sure that you were taking your meds.  What if your employer got that information?  What if your benefits depended on you taking your meds? It could be a very heaven or a merry hell.

Another example might be creating very tailored medications.  It’s theoretically possible to monitor using a smartphone exactly what kinds of effects a medication is having on you in real time.  That could be fed back and you could put together a dosage is that is tailored specifically to you.

We could develop ways we could pre-agree that you might need to stay somewhere safe for a few days if you need.  Somewhere that isn’t hospital, somewhere you could just book yourself into if you need to without having to get to crisis point.

We could if we wanted to each become our own little data mine, choosing to kit ourselves out with smartphones and various apps and sensors and record as much data as we could about our health and activities,  like how much we sleep or our heart rate and then choose to contribute that to organisations who would use the data to better inform knowledge about the particular challenges we face.  So, instead of researchers trying to test hypothesis about things by involving us in trials, we could be making our own data and then saying ‘ok, make use of this.’

At a more basic level, we could design a benefits system that works better for people with mental health difficulties that makes it easier to move on and off benefits and in and out of work more flexibly.  We could, if we wanted to, lobby for a law that makes sure no person ever slips into poverty because of their mental health difficulties.  We could create specific environments and supports for people with specific needs.  I love that some gig venues are building in quiet spaces to support people with autism, so if they want to they can get away from stuff for a few minutes before going back to the dancefloor or moshpit.  Imagine doing the same kind of designing places in for people with anxiety, or people who hear voices or people who have flashbacks.

As long as we can define a need or desire, we can play with ideas for the future as much as we want.  As long as we think: what do I want the future to be like?

In 2013, The World Health Organisation published a paper called  Investing in mental health: Evidence for action, which they described as examining “potential reasons for apparent contradiction between cherished human values and observed social actions.” What the WHO was interested in was the fact that despite the evidence being there that investing in mental health, governments often don’t do it. They say that they believe in stuff and make all the right noises but when it comes to it, they just don’t stump up the cash. One of the barriers the authors identified to getting more to happen in mental health was “Low expressed demand/advocacy for better services”  What that means is that not enough people expressed strongly the belief that a better world was possible for people with mental health difficulties.

And that’s where all of us come in:  we can do the dreaming, we can do the thinking and trying out of possible futures.  That’s our mission, or duty even: to picture that better world for people with mental health difficulties and to be brave about it.  To think of where we want to get to with imagination.  There’s an old Situationist slogan that goes ‘Be reasonable: demand the impossible’.  In our process of exploring possible futures that’s what we need to be doing so that we can better see the gap between where we are and where we want to be.  And that’s something we have to do as people, not as institutions.

If there’s one thing that my time doing mental health stuff has taught me it’s that people have different needs and people have different desires and that at the moment we aren’t very good at meeting either those needs or those desires very well.  We try to design things that work for the most amount of people but that just means that a lot of us don’t get very much of what we want.  Some of us a desperate for more treatment.  Some of us a desperate to have less.  Some of us really want to have more people to talk to about what’s troubling us and some of us would rather send a text.  Some of us want meds that work and others of us want other things that work instead.  Sometimes it will be mental health services that are the appropriate vehicle for delivering some of our possible futures and other times mental health services would be the absolute worst people to make them happen.

Preferable Futures

So, if we’ve done the imagining, what next? This leaves us the final kind of futures that futurologist deal with: preferable futures.  Preferable futures are the futures that are somewhere between the probable futures and the possible ones.  Preferable futures are the ones that we look at and think ‘that’s where we’re trying to get to’.  Preferable futures are the ones that we try to bring about by making decisions and taking actions now, bending the path of the future further towards where we want the future to be and away from the things we think will happen if we don’t do anything and just let events unfold.  A preferable future is the one you get to by playing through a possible future and playing through the probable one and thinking ‘how do we get closer to what we want to happen, rather than what will happen anyway’.

Preferable futures are the way that we begin the process of making sure that the future doesn’t just happen to us. Because the thing about the future is that it’s going to happen whether we try to opt out of it happening or not.  It’s happening now, so it’s up to us to do that dreaming and thinking and playing and examining and analysing so that we can begin to influence it.  A preferable future is one that you start working towards, or one that you convince other people is worth working towards.

So, look at the probable future, look at the possible futures and then decide on the preferred future and start the process of working out how to get that to happen. Simple.  Or not.

I know I’m making it sound easy, but I actually know it’s really hard, especially when we have experience of mental health difficulties.  As people with mental health difficulties sometimes the hardest thing to do can be to dream of better and to find ways to make it happen.

As people experiencing mental health difficulty and distress we are socialised to be ashamed of our failures and our malfunctions. We internalise our fuck ups, paint the walls inside of our heads with never-drying persecutory graffiti. We do not need police to to tell us what we should do because those cops are stationed eternally within ourselves. Though some of us won’t escape the police outside ourselves either. With mental health we are trained to formulate the enemy as ourselves. Our beautiful, magnificent, terrifying broken selves. We turn into incarnate apologies; walking talking IOUs to society. Damaged goods, we every day feel our distance from the shining path of productivity and growth. Each of us marooned on an island of one; isolated by an ocean of self judgement.

In mental health we have yet to go through the political revolution that Disabled people went through in defining exactly how those without physical impairments made life impossible for those that do. We know that many things are wrong. We know so much in the world does not work well for us yet we still find it difficult to name our enemy and turn our discomforts into demands. The question is not why we are broken, but why no one cares enough to change the things that break us still. To come to a similar moment we must analyse where we are and then we must identify what keeps us there. If the hopes and dreams of people with mental health difficulties are a force, there is an equal and stronger force that pushes against them.

We are trained to see our mental health difficulty as what we take from other people, but never trained to see it in terms of what the indifference of others takes from us, our families, our lives and our communities. We feel embarrassed, guilt flushing our faces at our anger, as if hoping that things could be different is somehow a childish tantrum, like shaking a fist at a thunderstorm or shouting at the sea as it rolls onto the beach.We accept that mental distress is a problem situated within us. We feel that it is adult and mature to make ourselves responsible for our own inability to find our equilibrium. We feel like we must accept the endings, must accept the loss, must accept the never weres and might have beens. But we do not. We should not. If we accept this version of realism we will never conceive of changes big enough to turn into demands; will never conceive of our situation as anything more than personal misfortune. We will actively fight against the possibility of collective change.

We shouldn’t have to make the choice between things being better in the present and things being better in the future. That’s a false choice born from forever being starved of funds and resources: we deserve both. The next breakthrough might come in the most unexpected place or through the funding of research or activity so speculative that its immediate application to day-to-day life seems unclear.

We must fight the view that Mental health difficulty is an individual tragedy; resolved through individual action or inescapable. This is blaming a worn out cog for not sharpening its own teeth, railing against a seed for not sprouting in a soil that is barren; admonishing each individual brick in turn for its failure to prevent the collapse of a house on a cliff as it slides into the sea.

For us to be everything we can be we must learn to demand what we need to be that best version of ourselves. If we experience mental health difficulty we have been dealt a shit hand, sometimes one that runs the risk of erasing our sense of self and agency completely. To overcome yourself you will need additional help, support and understanding from others. It is impossible to untie a knot when you are at its centre. Social organisation is the means by which we extend our lifespans, pool our resources, create collectively what would not be possible in one lifetime with one brain and one body. Instead of extending that social organisation to afford the help and support needed by those experiencing distress, disorientation and mental crisis, collectively our society draws arbitrary lines of convention and practice saying ‘society will go this far in assisting, but no further’. We must begin to ask those who do not experience mental distress: what are you prepared to give up so that your fellow humans might in enjoy the same pleasures you do?

The reality of mental health difficulty is this: if you have a mental health difficulty you are more likely to end up poor. If you have a mental health difficulty you are more likely to end up dead sooner. If you have a mental health difficulty you are more likely to have poor physical health. If you have a mental health difficulty you are more likely to end up estranged from family, to never taste love, to never find a comfortable home. The years spent unwell takes money from your pocket and years from your future. These are the result of social organisation, not of individual illness. These facts result from decisions about the limits to put upon help offered and the amount of resources to be allotted to that help. The amount of help and support offered those experiencing mental distress is not a result of how much people want to help but how much help our dominant way of organising society will tolerate being given to those in need.

It is not our fault that we need different things. Our self respect must be based upon being the best we can be and making it clear that we matter.

I am unlucky with my mental health, but far luckier than many. I have some of what I need and am an able advocate for myself. No person should fall into poverty or live in poverty because of their mental distress. No person should settle for a horrible half life when a life fully lived could be theirs. No one should suffer alone when there could be support and community. It’s up to us to envision a future for mental health that is not limited by the logic of those who would rather we did not inconvenience them. No one should die when they should have thrived. People being nicer will solve nothing if underlying assumptions about the way the world should work remain unchallenged.

We need research. We need exploration. We need doing things.  We need new alliances between people who have desires and dreams and wishes and those who can help make them happen. We need to work out what future we actually want.  We need hope.

We need to find ways that we can dream and scheme together, find ways that we can try stuff out.  Experiment, explore.  Ways that we can work together whether we experience mental health difficulties or we just really want to be an ally and an accomplice in making a better world.

We need to be writing the future of mental health now.

Look around you: without spending on mental health research; without new thinking; without new knowledge this is all we’ll have – a world and treatments that aren’t good enough.

We need to make the future happen for mental health now. Because it’s already too late.

So get out there and start dream and doing and making a future we’d all prefer.

Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter.

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Winter is coming: moral duty in digital mental health #mhqt

The following is the text of a short talk given by Mark Brown as part of the panel discussion ‘Digital Mental Health: Waiting for the Great Leap Forward‘ which took place at The institute of Education, London as part of a series organised by the UCL Division of Psychiatry, The Lancet Psychiatry and the National Elf Service.

We are in the middle of the biggest roll back of public spending in generations.  In the form of brexit we’re embarking on the biggest experiment in leaping into an economic and geopolitical unknown that our country has seen in at least a lifetime.

In mental health we can assume that the world we see around us will always look much the same as it does.  That institutions like this one we’re sitting in will always be here.  That there will always be an NHS.  Always be social care. Always be human rights.  Always be helplines.  Always be homes and jobs and opportunities.  I think right now we can assume no such thing.

This might sound alarmist, but in mental health we have always been too complacent, too cautious and too ready to accept that things will turn out all right contrary to what we know and we see every day. Life for people with severe and enduring mental health difficulties has been getting worse.

That is what makes our job in mental health all the more important and desperate.  Right now digital technology is one of the areas of exploration where the promise exceeds the probability in mental health.  In much of the rest of the adult mental health world our possibilities are plateauing, either because we have run to the end of possible ways to wrestle anything better outcomes from a discovery or a practice; or because public and political will to provide the resources to fully use something to change people’s lives has flatlined.  There is nothing traditional on the horizon that will save us from failing people with mental health difficulties in worse and more painful ways in future than we are today.

Digital technologies are one of the areas where there are new frontiers to be explored, potentially in ways that avoid existing strictures that prevent more traditional means of helping people from doing more to change people’s lives.  Digital technology creates hybrids: it takes what we know in one area and finds new ways of doing it.  As such, digital technology is our best bet for better mental health because we already know a lot about mental health.  And other people know a lot about tech and also make a lot of money out of getting it right.  So, we’re halfway there.  The direction of travel is that there will be more breakthroughs and research in digital technology each year, which means if we carve out a space for mental health in that we will reap the benefits of a direction of innovation that is already unfolding.

We have the grounding, in theory, to shape technology into something transformative and caring and sustaining for mental health.  We need to get out there and get messy and get building and talking and gossiping and building and breaking in the understanding that a lot of things won’t work on the path to what does.

If you do not let yourself travel close to the edge of your domain of interest you will never see the domains that neighbour it. Safe in the capital city of mental health, where the streets stay familiar and the sound of change hasn’t brought angry voices to the streets and their barricades, you will be able to comfortably assume that nothing will ever change. you will never see the winter is coming.  And it is coming.

In large parts of the world, though not everywhere, we are in the age of ubiquitous computing.  People carry with them the most amazing, powerful tiny computers in the form of smartphones.  We tend, if we are not careful, to see these tiny computers just a vehicles for information or apps but they are much more than that.  They can process information. They can collect data.  They can receive and they can broadcast.  They can overlay one reality with another.  And they can take phone calls, sometimes.  People choose to carry these amazing devices because they love them and because these devices both make sense of their world and make sense in their world.

To play at William Gibson quotes again, ‘the street finds its own uses for technology’.  People are already using digital technology in amazing, nuanced, inventive and shocking ways and we know next to nothing about that in mental health. We do not know how people who experience mental health difficulties and distress actually use technology now.  We occasionally recruit thirty people and ask them if facebook makes them sad.  We occasionally prod some people into a trial of a digital technology that we think they should like. We keep asking the arse-about-face question ‘what is digital technology doing to our mental health?’ when we could be asking ‘what could digital technology be doing FOR our mental health?’

A colleague said to me that when you are developing technology, or indeed anything, in health and social care you are never building on a green field site.  We’re always building on reclaimed brownfield land.  There are always neighbours, always NIMBYs, always hidden deposits of gas and uncharted subterranean catacombs.  Making something new is all barriers.  It needs to be all barriers if you don’t want to kill someone. Or even if you do I suppose, thinking about it.  Regulation and safeguarding is important as the way that innovation is prevented from causing harm.  We need to use that as a positive force, not a negative one.

We have two tasks, should we chose to accept them.  The first is to immerse ourselves in the possibilities of technology, to look at how we make technology happen, how we can marry it with mental health knowledge and mental health need.  The second mission is to actually understand how people use technology now and how they might use it in future and what that means for how we need to make things that work for them.  Right technology, wrong user experience is the same as wrong technology.  Understand people’s interactions with digital technology and you’ll understand how to put a life changing technology in a form that will work for them, not against them.

The TL;DR here is: Things are looking shit in general, and things are looking really shit for people with mental health difficulties, so we have a moral duty to not make sure digital technology isn’t shit too.

Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter.

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In defence of frugal innovation in public sector space #pddigital16

This is the full text of a talk given by Mark Brown at People Drive Digital in Leeds on 28th of November 2016 in support of the motion: This house believes frugal innovation has the potential to create better solutions to citizen challenges than traditionally designed digital technologies

I don’t think the logic of frugal innovation works in quite the same way in spaces where the market is dominated by state providers funded through taxation, but the practices remain true.  I’m going to try and set out the case for frugal innovation in public or social sector spaces.

The basic idea of frugal innovation in product, profit terms is finding ways to tap markets of people that have been excluded from previous thinking: poor people or people without economic or other power.

The logic is basically this: find a way of providing something to lots and lots of people who aren’t rich at a price they can afford; instead of providing something top of the range to a much smaller number of people who can afford it at a much higher price.  This might look like an i-phone (sort of) but it’s actual a knock off android mobile from China that does everything a first generation iphone could, better and for about £80 quid.

So: initially early adopters will prove whether a particular goods or service is viable or desirable and then frugal innovators will come into play, finding a way of taking the essentials of the product to as many people as possible in a way that works for them.

So, make something a bit cheap, a bit dirty and no frills and then you open out something to people who may not ever have been able to access it before.  Frugal innovation in the context of people driving digital is about getting down to ground level and really understanding what does and doesn’t make things happen to people.

Areas like health and social services in the UK are, for most people, not something that they are closed out of due to price coming out of their own pockets.  Thank the goddesses that we invented social security and a welfare state to attempt to provide basic standards of care, support, services and lives.

So it’s not that rich people have access to top of the range health or social care innovations that could trickle down to people who are poorer. It’s that rich people have access to top of the range lives, and that those who do the innovating come from similar circumstances. In this context,  frugal innovation is looking at the ways that tech can rebalance inequalities by by striving for the same outcomes while also being aware that not everyone has an effing perfect life.  We still design health systems for people with stable jobs, stable houses and stable lives.

In countries where people have regularly been excluded from accessing social goods by weaker social protections or a smaller state, the process of opening markets and the process of widening access to social goods is the same time.  For example: If everyone can afford a very cheap car out of their own earnings, the state does not have to concentrate funds on travel networks.

While it’s true that traditional public and charity sector space is very adverse to the idea of markets and customers and segmentation in its rhetoric, in practice it still faces the same challenge: how do we get people to access something in enough numbers that it pays off for us?  If any of you in the room tonight are from these sectors you’ll know what your organisation is trying to do and how it will judge its value.  It’ll be getting something to happen to, for or with someone.  The financial exchange might not be as simple as ‘that’ll be £29.99 please, bish bosh, into the cash register’ but the principle is still the same.  You have to get something to happen which will generate a value for an individual, a family, a community, your organisation and the country and world at large.

Where frugal innovation differs from other approaches is that it starts with the smallest units: people and the problems they have. It asks:  How can you find something little and relatively cheap that will pay back the money and resources spent on it by making the world a better place in even a tiny way?

Health and social care as provided in UK public sector spaces is not taught to see little problems.  It’s taught to see big problems.  It’s taught to think of big systemic changes, incremental changes, glacial changes that will unfold over decades.  It’s taught to think ‘go big or go home’.  The market in public sector tech has always been between large institutions.  On one hand there is academia, where new things are thought up and older things evaluated.  Then there are our large public sector actors like the NHS and the multitude of different organisations that make it up, or local authorities, or mega charities.

What has been lacking, and this is where people as citizens have been shut out of this market, is the actual aligning of what is developed with the actual lives people live.  So, unlike people who weren’t considered because they fell beneath the radar of the people who want to be rich speaking to the people who already are rich, your average punter in the UK in public sector spaces is closed out of defining what the market offers because, in the end, they aren’t needed by the industries that make public sector tech happen.  In the NHS, for example, the NHS is the purchaser and the tech maker is the supplier.  As long as the NHS is happy, then so is the supplier.  And, if it doesn’t quite work for people?  Well, we just blame them for being non-compliant, or expect some other body of person  to step in and make that online form comprehensible or to make sure that they read the insulin levels or similar.  The average punter is in the same position of someone who doesn’t have enough money to take part: no one cares.

In an Article for Forbes India, HARICHANDAN ARAKALI wrote about definitely a taxi service/definately not a taxi service depending on what country you live in Uber:

“going truly local, is far more interesting: it’s as much about getting the tech and the business model right as it is about figuring out the psyche of the people here. Uber is here not just for frugal innovation, but to innovate for the frugal.”

By trying to understand where people are at, it’s possible to align what resources are available with what people most want to happen.

As the most recent Autumn statement has shown, there is bugger-all new money for many areas of social good and the ever increasing spectre of a post-brexit recession is suggesting that things are going to hurt a lot more for a lot longer for both institutions and individuals, families and communities.  Everyone will be rushing to get their massive tech plans signed off before the tide of money goes out even further.  If we have the power to align tech in social sector spaces far more closely by working out how we serve the needs of people excluded from the discussions at the top table, then it’s our duty to do so, even if it means thinking smaller and deeper rather than bigger and loftier thoughts of progress.  If public goods are going to become increasingly more difficult to access; from education to health to social care to even democratic structures themselves, we have to start designing and building things that don’t require a perfect bloody life to access.

If the money is going away for a top table level of big things, then our focus must be many and small ones.

If you currently are sitting pretty with all of your reasearch and roll out money in the bank; leaving speaking to people about what they want and need to an afterthought or a bit of window dressing for presentations and award ceremonies you’ll be fine.

It’s the poor buggers who really need something to be different that’ll be in the crap, closed out of influencing their own lives and outcomes by the very people who claim to help them.

A cheap and dirty world can be a horrible world unless good people make cheap and dirty work for people.  If lots of cheap and dirty can make life better and more livable, none of us should ever go to bed with clean hands.

Ever.

Thank you!

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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New research beginning into safety in mental health inpatient spaces

Mark Brown explores a newly launched research project exploring safety in mental health inpatient settings

Mental health inpatient wards are supposed to be safe places.  They’re where we find ourselves when we are at our most vulnerable.

The question of safety and who has responsibility for making these spaces as safe as they should be is often an unspoken question in mental health.  This question came into sharp focus last month when patient leader Alison Cameron brought to public attention an incident she witnessed while an inpatient.

Kathryn Berzins, a Research Fellow in the School of Healthcare, and John Baker, Professor of mental health nursing, both at the University of Leeds are beginning a project to bring questions of safety into sharper focus which will involve collecting experiences of receiving, providing and caring for someone receiving inpatient care for their mental health.

Says Berzins: “Safety in mental health care has not really been thought about in much depth. There has been a lot of focus on suicide and homicide, and other things you would expect to see in hospitals like infection control and falls prevention. We certainly don’t know about service user and carer’s priorities for safe mental health care and treatment, or their suggestions which could make services safer.”

Baker says that “safety incidents are recorded in very physical terms, such as ‘did somebody need medical attention as a result of a fall?’” He is keen that we also begin to think about the psychological consequences of being a patient on an inpatient ward: “We think psychological consequences are just as important. My whole career I have believed that service user and carers should have more involvement in the care that is provided. I have seen and heard about countless examples when care or treatment has either exposed people to risk or just not been safe. Often at these times services users and carers are excluded from discussions about how things could have been changed or improved.”

To begin this process, Berzins and Baker are carrying out an initial survey with people with mental health difficulties, those who care for people with mental health difficulties and mental health staff looking at attitudes to safety. Says Berzins: “This is the start of our project looking at safety in mental health services, it is very important to us that service users and careers are involved from the start, tell us what their priorities are and help keep us on track throughout the study. We’re also hoping that collecting people’s opinions will allow us to develop future research studies looking at specific areas of concern in more detail.”

The pair are currently developing a range of studies investigating safety issues for both service users and professionals in mental health care, in both hospital and community settings. Berzins is particularly interested in the use of restrictive practices, service user and carers experiences of care and treatment (particularly that carried out under the Mental Health Act), and criminal behaviour in hospital settings.

Both feel this work is vital in the current climate: “The NHS and Mental Health services in particular seem to be under increasing strain,” says Baker. Enabling services to provide safe and effective care is undoubtedly important. Finding out about the most important priorities now is key to developing this work in the future. Initially we want people to complete the survey, and if they are interested they can become more involved afterwards by taking part in a telephone interview or even becoming a member of a steering group.”

To take the survey here: https://leeds.onlinesurveys.ac.uk/safety-issues-in-mental-health-care-services

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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Mental Health and Brexit: there is no new normal

Mark Brown (@markoneinfour) tries to collect together some of the questions and worries for mental health as a sector and for those that experience mental health difficulties posed by June 23rd’s EU referendum vote.

On 24th of June 2016, a narrow majority of people in the UK voted to leave the European Union in a national referendum.  As I write this on Sunday afternoon it is not clear exactly what the next immediate steps are for the UK.  It isn’t clear what Bexit as a policy, if indeed it becomes a policy, will mean for mental health as an area of activity and for people with mental health difficulties as a whole.

The first rule of mental health is that it always falls low down in the pile of funding priorities.  Political reality defines whether mental health is a funding priority.  If something else more pressing comes along; mental health falls off the bottom of the list.  And that list in the UK just grew incredibly long.  Whether you are pro-bexit or anti-brexit; it is impossible to deny that the UK has had in the space of 48 hours the greatest single change of political priorities since the beginning of World War II.  As yet, there is little-to-no specific expert opinion about the effect that this change might have upon the lives of people with mental health difficulties, so I’m doing my best to cobble together some thoughts.

The first is that it is unlikely, no matter how hard we hope, that voting for leave will give us an immediate end to austerity.  Benefits, affordable housing and other social protections will not see a rush of funding.  In fact, little will change immediately.

As such, the following aren’t so much predictions as reasons why people might be worried or questions that are currently in need of answers.  The answers will not be forthcoming immediately.

There are three real tracks of reality here.  The first track is everyday experience.  The on the ground reality is that, practically not much has changed since 10pm on Thursday the 23rd of June when the polls closed in the EU referendum.  The buses are still running.  Food is still the same price in the shops.  No part of any government policy or british or scottish law has changed.  If you’d avoided the papers and had a long weekend on the sofa watching Netflix in your pyjamas with your phone off it wouldn’t be immediately apparent that anything much had happened.  We haven’t left the European Union yet.

The second track is what we can predict will happen to government; organisations; bodies; services and circumstances.

The third track is perception and what people believe will happen.  The first manifestation of this is the volatility of financial markets.  Money people don’t like uncertainty; and from the point that the referendum was called in the favour of Leave; the status quo was upended.  Something had changed; even if its practical effects were not yet clear.  Until it’s clear; things will be financially unstable for the country as a whole.  The resignation of Prime Minister David Cameron on the morning of June 25th underlined this: whatever happens next it’ll be different.

If there was anyone waiting for business in mental health to return to normal anytime soon: it won’t.  There isn’t a new normal yet.  

The National Health Service

Whether we like it or not, many of us with mental health difficulties find the NHS is something upon which a degree of our wellbeing is dependent.

At present the leaders of the Leave campaign are desperately backpeddling from the claim that the disputed £350m the UK sends to the EU would be saved and spent on the NHS instead.

Despite the claim featuring prominently in the campaign, including on the side of a massive bus, it’s currently being discussed as a mistake or a misunderstanding.

I’ve not come across (yet) anything on the potential effects on the health services of Wales, Scotland and Northern Ireland but am happy to add if you get in touch in the comments.

The Health Service Journal were quick off the mark in looking at the potential effect of Brexit on NHS in England.  The single biggest risk to the NHS is recession.  If the UK does not successful steer its way through the choppy waters post Brexit, the something will have to go.  The current government has been committed to moving to a budget surplus by 2019-20, which was looking dicey anyway.  Any big drop in tax income would would blow that out of the water further meaning that the NHS will either need to provide less things or people will need to pay more taxes; the taxes option being pretty impossible if there are overall fewer people making enough money in work to pay those taxes.

The shorter term view from the HSJ is that even prior to the leave vote the NHS didn’t have enough money.  On the immediate risk, HSJ quotes Chris Hopson of NHS Providers:  “We would expect there to be a debate among system leaders about whether more needs to be done in 2016-17 to offset the risk that comes from choppier economic times. But our members would argue that they are already doing everything they can and if more money is taken out consequences will inevitably follow in service and staffing levels.”  In other words; the riskier the present seems the more likely it is that NHS providers will cut what they can now to try to keep something in the bank for later.  The instability in government; and potential increased volatility of the House of Commons makes the present seem riskier.

Dave West, writing for HSJ, notes that: “Jennifer Dixon, Health Foundation chief executive, warned that a vacuum of political oversight in coming months – along with the likely departure of patient safety champion Jeremy Hunt from the health brief – meant more risks may be taken with the quality of care.”  NHS England was already facing a new settlement being drawn up from Government, as the NHS had collectively been given a deal where more money has been awarded upfront on the understanding that savings would be made.  Those savings haven’t been made and prior to Brexit, the NHS was worried about having to try to find savings from its staff bill.

The worry is, then, that the NHS will be told to make savings on top of savings.  Given the resignation of David Cameron as PM and the potential for a General Election to be called, it isn’t clear who will be in government beyond October when David Cameron’s successor will have been chosen by his party and what their attitude toward the NHS will be.

A further pressure would be the potential departure of NHS staff from EU countries, as noted by HSJ journalist Shaun Lintern.  This would not only depend on changes to law, but to the also on the extent to which people feel welcome in this country.

Historically, mental health has not fared well in the NHS and it’s probably unlikely that any future leader of the Conservative Party will look so favourably upon mental health, given the possible upheaval in other areas of policy.  Looking forward in 2017, the future is, as yet, unwritten.

Voluntary sector

The voluntary sector, unless it is involved in direct humanitarian crisis, generally needs a degree of stability to flourish.  The voluntary sector in mental health in England and Wales has claimed a number of wins in the last five years such as the funding of national anti-stigma Time to Change and the prominence of mental health in David Cameron’s now dead in the water Life Chances strategy.  The recommendations of the much trumpeted, oft-delayed Mental Health Taskforce The Five Year Forward View on Mental Health,  the first independent mental health strategy headed by the voluntary sector which reported finally in February this year will now probably turn out differently.  The next five years does not now look like it did when the Taskforce began drafting and redrafting.

Given the great potential changes underway, it’s fair to say that the voluntary sector in mental health is going to find it more difficult to get the ear of decisions makers. And more difficult to get people and funders to open their wallets, if indeed those wallets contain anything but pennies.

The voluntary sector as we currently know it is a direct product of the New Labour years between 1997 and 2008.  During those years the voluntary sector grew, in part due to New Labour’s discomfort with being seen to spend too heavily on public services apart from the NHS.  The NHS, in turn, looked toward funding voluntary sector mental health services as an add-on to their core business of treatment.  Similarly, local authorities answered calls from community members for additional social care-ish services and funded some mental health related organisations and services via block grants.

As such, the voluntary sector in mental health grew but remained dependent on public sector money.  The donor base, that is how much money mental health charities can raise from members of the public and companies giving voluntarily, remains low in mental health and is skewed very strongly toward the largest mental health organisations.

Grants were available from a number of grant making bodies and grant funders, with some funds made available from government for particular initiatives or schemes.

From 2008 onward, all of these streams of funds began to constrict.  Not uniformly across the country or across all activities.  The NHS and local authorities began to spend less on the funding of mental health related activities.  Central government began to spend less.  There was a kind of firesale where money was ‘got out of the door’ before it disappeared.

The 2010 general election ushered in a five year period of austerity spending policy.  Money that was once there was no longer there, apt as a mirror of the financial crisis of 2007/2008 where this was literally the overnight reality as markets dipped and debt went toxic.

The voluntary sector in mental health was slow to wake up to this; focusing on keeping its head down and waiting for the money to come back.  This, it seemed, was a policy change, a slowing of a general upward curve in the funds available for mental health-related work.  Soon, business as usual would be resumed.

Except it wasn’t.  The financial crash wiped a lot of money out; including money that charitable funders has invested in stocks, shares and other financial vehicles.  The NHS reorganisation created by the cul de sac of the Health and Social Care Act 2013 and various decisions made about funding to Local Authorities meant that the squeeze continued.  As satellites of the NHS and local authorities, with few avenues open to them smaller mental health charities began to collapse, larger ones tried to reconfigure to deliver what low level services were currently being put out to tender and the largest ones consolidated their positions as service providers.

The events of the last few days have the potential to shake up this situation even further.  The politicians that were available for meetings and launches will probably be otherwise engaged.  It’s not clear whether the opposition Labour party will even have the role of shadow minister for mental health, a role at time of writing occupied by Luciana Berger.

Writing for Civil Society on Friday 24th, David Ainsworth  set out the stark challenge for charitable funding in wake of a full brexit:  “The charity sector receives over £200m a year in grants from the European Union, and it seems unlikely that the UK government – free of an obligation to distribute this money – will continue to hand out this money. Given the lack of enthusiasm in government for grant funding – the minister for civil society himself suggested that grants were “unsustainable” – this money is unlikely to be replaced.”  Whether much of that money is money at risk in mental health I’m not able to establish with what I have to hand; so it may be that this has little direct effect on mental health organisations but may have a large effect on people’s mental health through loss of other services.

Even starker was his warning about the effect of the drop in sterling and the possibility of recession on the money grant making bodies would have available to make grants.  There have not been huge grants to mental health over the last five years; but funders have been there.  Says Ainsworth:  “Each year, charitable foundations make grants of about £2.5bn to the sector – as well as considerably more outside it – and the vast majority of this relies on income from £123bn of investment assets.

“At least, it was £123bn yesterday. The charity sector holds about half its assets in the UK stock market, and has therefore probably lost about £5bn since six o’clock this morning.

“A significant chunk of the money distributed by grant-givers comes from capital appreciation – the fact that shares go up in value faster than the economy as a whole. Unless there is a recovery over the next few months, there will be no capital appreciation to speak of this year, and grant-giving could be heavily affected.”

Who is allowed to provide services has been governed by EU procurement law (or ‘EU red tape’ depending on your preference). Some mental health organisations have increasingly become service providers to the NHS or to Local Authorities, in part due to the lack of available charitable funds or direct donations.  If the UK actually formally exits the EU one potential change an exit might bring is a change in how services are contracted.  Says a sector source: “many mental healthier services are being commissioned and retendered to deliver the ambitions of the Five Year Forward View on Mental Health. These contracts (because of their size) would be under EU procurement rules, which in some areas have prevented smaller, organisations led by lived experiences from being a lead partner in the contract. Leaving the EU might mean that we could diversify the provision within the local health economies. Alternatively a response might be bigger contracts for independent providers (but under domestic competition rules rather than governed by EU procurement). With the removal of state aid rules we could see greater investment by the state to continue support the ailing and underfunded mental health system or alternatively leave its survival to market conditions”

Writing for the voluntary sector as whole, Sir Stuart Etherington of the National Council for Voluntary Organisations said on Friday 24th: “We are just recovering from the previous economic crisis. Further years of economic difficulty would scarcely seem like a change to young people who have known nothing else. But they would mean more years of struggling to fulfil our organisations’ complete potential to do good, more years of seeing people struggle in the face of hardship. We can only hope for skilled and thoughtful leadership in the coming weeks and months in order to avoid the worst of the financial predictions.”

It can only be hoped that the mental health voluntary sector itself will generate such thoughtful leadership at this difficult time.

Social Care

Crossing over to an extent with the story of the NHS and of the voluntary sector, social care is a far more fragmented area which some of us with mental health difficulties are lucky enough from which to still benefit.

Community Care’s Andy McNicoll writing on Friday 24th surveyed the main challenges ahead.  On funding he points to the warnings of the Remain campaign prior to the vote: “During the campaign, chancellor George Osborne said he would have to slash public spending and put up taxes in order to plug a £30bn “black hole” if the UK voted to leave. Speaking alongside his predecessor Alistair Darling, Osborne said £15bn would have to come from cuts. Spending on local government could be reduced by 5% and the ring-fenced NHS budget cut, the pair warned.”

McNicoll also points to the fact that at current estimates over 80,000 people from other EU countries are currently employed in social care, about 6% of the overall workforce.  While nothing legally has yet changed, as with the NHS, it will depend on current and upcoming events as to whether those people feel secure enough on the UK to remain.

The same concerns about funding and political priority remain; especially coming at a point where health and social care are meant to be moving closer to integration across England.

As to where this leaves conversations about personal budgets, access to advocacy and mental health social work is not yet clear.  Funding remains a strong concern in the advent of a further recession.

Given how diverse the activity is that falls under the heading of social care; it’s going to take people much cleverer than me to capture the full range of issues as they relate to both Brexit and mental health.

Research

I’ve not got to hand details of how much of the mental health related research in the UK derives from the EU, but it’s clear that the relations between EU membership and research is more complex than just funds; relating as it does to the ability of researchers to move freely across Europe and to collaborate.  A worry is that UK research organisations will experience a ‘brain drain’ as people leave what may feel like a less hospitable country or that those born in the UK will look to move to EU countries if it looks like the UK will enter more challenging times.

[UPDATE 15.00 28th June: After a bit of asking about, a sector source suggested that the answer to this question is not clear cut.  The second highest contribution after germany from Horizon 2020, the EU Framework Programme for Research and Innovation.  According to the Association of Medical Research Charities the UK: "UK charity-supported researchers received over £260 million in further funding from the European Union, covering disease areas from arthritis to Parkinson’s disease in the period from 1st January 2012 – 31st December 2014."

My source suggests that if the weighting of funding toward mental health for EU funded work follows the pattern in the UK, 6 to 7% of those funds will have been used in mental health related research carried out by charities.  My source also said it'll probably be a while before anyone is quite able to put a figure to the possible loss of funds to mental health-related research.  But as mental health research is chronically underfunded already; it's unlikely that any variety of Brexit will lead to more; especially not in light of the potential effect on charitable funders noted above.]

Change and wellbeing

For some the Leave verdict was a blessed, long hoped for relief. For others it’s been accepted with trepidation and worry.  Those who are happy about the result will be no less immune than those who voted for the alternative. For many people in the UK who were born in other EU countries it has cast a long shadow over their feelings of comfort and confidence about their lives in the UK.  As we work through the potential paths forward from the vote and the implications of various courses of action it becomes clearer and clearer that what this all means is change whether we like it or not and whether we wanted it or not.

People with mental health difficulties are not generally well disposed toward change and uncertainty.

We also know that financial hardship, the experience of racism and that lack of security in our lives tends to exacerbate our mental health difficulties.  We also know that people with mental health difficulties tend to end up experiencing more the effects of wider economic and social changes as we tend to be more vulnerable to changes in public policy, changes in the labour market and changes to the availability of social supports and social protections.

We also know that how people feel about their lives and their futures interacts with mental health in ways too numerous to mention.  For a number of with mental health difficulties the last six years of austerity has felt like a collision between a worsening practical reality and a dimming belief in the future.

We don’t know how the majority of people who experience mental health difficulties voted in the referendum but we do know that a continued perception of chaos and uncertainty will not make people rest more easily in their beds; especially if this perception is backed up by increasing practical results of the referendum decision that do not directly benefit them.

Almost certainly people of other EU nationalities currently living and working in the UK will not be feeling comforted by the result.  Nor will those who worry for the effect of general economic upheaval on services, benefits, jobs.  Also, arguably, those who voted for Brexit may well find that the things they felt they were promised by the campaign are longer in arriving than they hoped.

If there’s one concrete fear that I have for mental health it’s that, despite all of our protestations, mental health will be at the back of the queue for the duration of the settling of the Brexit question.  Something that might take years.

Whatever happens, we need to find ways to keep ‘buggering on’.  This may be easier said than done, especially if there is a vacuum at the top.  We all hope that people from different sides of the vote will be able to pull together within families, communities and other places to get on with life.  At the time of writing this does not appear to be a process that will be led by Westminster; at least not until it actually becomes clear who is actually in control and who isn’t.  Add to this the potential for, hopefully isolated, racist attacks emboldened by the overall turn against the EU and it seems that discord may be the order of the day for at least the immediate future.

Which will do no one’s nerves any good.

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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Provocation for innovation 3: Frugal innovation – making good stuff happen with eff-all cash

On 14th of April 2016, Mark Brown (@markoneinfour) ran a mental health minihack at Marmalade, the fringe of the Skoll World Forum in Oxford.  In preparation he prepared three provocations to put to attendees for areas where it would be possible to innovate in mental health as actors coming from outside of the established publically funded system of mental health treatment and support.

Attendees were told to apply their knowledge and experience to addressing these presenting issues.

Below is the third of these provocations  ( (The first ‘Payment by Results – outcome measures – getting data – arranging payment’ can be found here and the second ‘In mental health communication is flakey’ can be found here)

Provocation 3: Frugal innovation – making good stuff happen with eff all cash

According the Mental Health Taskforce report published in February 2016:

  • People with severe and prolonged mental illness are at risk of dying on average 15 to 20 years earlier than other people

  • Nearly two million adults were in contact with specialist mental health and learning disability services at some point in 2014/15

  • Nine out of ten adults with mental health problems are supported in primary care.

  • Of those adults with more severe mental health problems 90 per cent are supported by community services. However, within these services there are very long waits for some of the key interventions

  • Mental health accounts for 23 per cent of NHS activity but NHS spending on secondary mental health services is equivalent to just half of this. Years of low prioritisation have led to Clinical Commissioning Groups (CCGs) underinvesting in mental health services

While many objected to the Conservative Big Society idea; it did represent one answer to the emerging crisis which, depending on your viewpoint, was either caused by or resulted from austerity.  At present there is little investment in mental health research and the available charitable funds for the actual provision of activity to support people with mental health difficulties has dwindled over time.  The crunch on local government funds has also reduced greatly the available funds for mental health.  Big Society suggested that frugal innovation might provide an answer to some of the unmet need in our communities.

Innovation has not been easy for organisations structured with business models developed in an era of public spending expansion.  It’s possible to argue that larger organisations lack the agility and the entrepreneurial skills to be able to develop, prototype and test new ideas. It’s also possible to argue that this is not entirely a bad thing if we are talking about maintaining the welfare of people who are having a variety of challenging experiences and who rely on a consistent and reliable service.  It’s more difficult to argue that the interests of a provider always align with the interests of a consumer when the consumer is a person with mental health difficulties who has funding allotted on their behalf by commissioners but is not a direct ‘consumer’ in the traditional sense.

The problem is that entry into the market is extremely difficult for smaller organisations who need to raise the funds to do before they can build they evidence that they can do.  The bootstrap paradox is strong in mental health.

In a marketplace where funds are dwindling while need is rising, there has been much discussion of ways in which people with mental health difficulties might find solutions to their own problems with little discussion about ways in which that might be made a reality.  As an area there has been much rhetoric but the reality has tended to be tiny amounts of funds mostly inaccessible to the kinds of small autonomous groups that form to solve particular problems.  Government backed initiatives like Community Organisers, the DWP’s Developing Disabled People’s User-Led Organisations Programme and empowerment style organisations such as NHS CItizen have failed to touch much in mental health.

While many have ideas about what might be solved; the question of how such people might be resourced, supported, funded, matched with resources and how they might find some kind of sustainability still remains.

Presenting Problems

What financial devices might support small groups to deliver high quality mental health related services?  How would investment in such groups be made possible, considering the considerable risk?

How might the knowledge gap around innovation, product development, design and management of human and other resources be bridged?  How might innovation activity be focused on unmet need?

How could larger organisation find ways of working with a wider range of people to meet unmet need without requiring large amounts of additional investment?

How can innovation be fostered in low investment; low return areas such as mental health?  How might we make mental health stuff happen when there is f*ck all money?

How might innovation serve the unmet needs of people with mental health difficulties rather than the provider interests of organisations? How might frugal innovation in mental health be supported?

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

 
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Provocation for innovation 2: In mental health communication is flakey

On 14th of April 2016, Mark Brown (@markoneinfour) ran a mental health minihack at Marmalade, the fringe of the Skoll World Forum in Oxford.  In preparation he prepared three provocations to put to attendees for areas where it would be possible to innovate in mental health as actors coming from outside of the established publically funded system of mental health treatment and support.

Attendees were told to apply their knowledge and experience to addressing these presenting issues.

Below is the second of these provocations ( (The first ‘Payment by Results – outcome measures – getting data – arranging payment’ can be found here and the third ‘ Provocation for innovation 3: Frugal innovation – making good stuff happen with eff-all cash’ can be found here)

Provocation 2: Communication is flakey

The NHS is the prime provider of mental health services in the UK.  The target of a paperless NHS has remained an ever-postponed target.  The latest target for this is 2018.  Even if the NHS does go paperless internally; it still has a preference for letters and faxes.

From a user perspective, the hierarchy of communication is often

  1. Letter

  2. Phonecall

  3. Follow up phonecall

  4. Maybe another letter

Large mental health providers are still at the stage of central switchboards and extension numbers.  People in offices take messages for colleagues who are not there.  A patient must, for example, know exactly what service any professional they are trying to communicate with falls under and the their exact name.

The NHS mental health workflow has not been updated to include instant or asynchronous electronic messaging.  Internally, the ‘ring round’ is often the way in which tasks are achieved ‘in real time’ (the traditional ring round to find a bed); with email functioning more as an analogue of letters and memos rather than as a form of instant communication.  There is still a lot of ringing to check to get things done.

Electronic communication is considered differently by different trusts and organisations.  Some consider it risky; especially if it involves text messaging via mobile service.  Others are concerned by the privacy aspect communication that is non-paper or isn’t face to face.

Patients, clients and service users are still at the mercy of letters, photocopied letters and telephone calls which present obvious challenges for those without secure housing; those with communication difficulties and those for whom their mental health gets in the way of doing things like opening letters or taking unexpected phone calls.

Internally, patient records and patient notes are still in many ways analogue.  They are often physical files with accompanying digital notes.  Record keeping can be unwieldy; subject to differing levels of diligence by staff and often creates something that is not translatable fully into data.

While patient accessible electronic records are always ‘on the horizon’; in practice it often isn’t clear what the use case for these will be.  There are a number of projects working upon the idea of patients being able to amend or add to existing records.

At present much of the communications traffic from service provider to service user is one way.  The organisation tells or informs; the patient or service user acts.

In situations where support is provided by telephone such as Crisis Home Treatment teams, only 14% of people feel they receive the support they need according to 2016’s Mental Health Taskforce Report.

A number of organisations have developed apps and similar to help colleagues communicate with each other.  One NHS Trust has developed an app that allows any member of staff to locate another member of staff while they are on the hospital estate; and a similar app so that clinicians can locate patients when they have been moved around the estate, for example when they are being prepped for surgery.  In many hospitals there is one telephone per ward.

Presenting problems

How might mental health service providers better communicate with those they serve?

How might service users or patients collaborate on a meaningful health record, if a health record is what the collaboration should be?

How might different mediums of communication be used within mental health services to increase efficiency and patient or user satisfaction?

How could information and communication be used to match resources with need better?

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.
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Provocation for innovation 1: Payment by Results – outcome measures – getting data – arranging payment

On 14th of April 2016, Mark Brown (@markoneinfour) ran a mental health minihack at Marmalade, the fringe of the Skoll World Forum in Oxford.  In preparation he prepared three provocations to put to attendees for areas where it would be possible to innovate in mental health as actors coming from outside of the established publically funded system of mental health treatment and support.

Attendees were told to apply their knowledge and experience to addressing these presenting issues.

Below is the first of these provocations. (The second  ’In mental health communication is flakey’ can be found here, and the third ‘ Provocation for innovation 3: Frugal innovation – making good stuff happen with eff-all cash’ can be found here)

Provocation 1: Payment by Results – outcome measures – getting data – arranging payment

Roughly speaking, the three areas where it is possible to help people with mental health difficulties to live lives where they can do what they want and need to do centre on

  • Treatment

  • Care

  • Enablement (either augmentation of the individual or alteration to the conditions of their life, surroundings or the workings of the society in which they live)

Helping and supporting people with mental health difficulty is an area where it can sometimes be difficult to assess impact.  Unlike other areas of health, it can be more difficult to see the relationship between activity and outcome.  In surgery it is possible to look at operations carried out versus recovery rates.  In mental health ‘recovery’ is a more challenging idea and one that is more difficult to measure.

The effectiveness of interventions or services in mental health is often judged either by a proxy measure, which are often imperfect, or by self submitted information about the effect the intervention has had.

What people such as charitable funders, governments and investors are prepared to pay for is what it is possible to measure.  To measure things that happen inside people’s heads and in their lives is often considered to be difficult.

Public services, including the provision of mental health support or treatment, are increasingly moving toward a Payment by Results model.  This has led to concerns both from professionals and from people with mental health difficulties who may or may not use services.

The concerns include:

  • Collection of data is difficult, time consuming or challenging for providers

  • Collection of data involves prying further into the personal lives of people using a service than those people are comfortable

  • Data is not robust and does not really reflect results

  • Data does not give a clear enough picture of what is happening to make changes in the way that a service is delivered or in the way in which it is paid for

There are also concerns that any process of measuring impact will transform the service into something that measures its clients progress against the required or intended impacts rather than measuring the ability of the organisation to deliver the results intended.  In mental health, tools such as the Recovery Star have shifted from measuring activity to being an activity in themselves where the measurement tool becomes a goal setting tool instead.  The tools intended to measure impact of services are often used to measure the progress of individuals.

Mental health is also struggling to work out methods of paying for individual activities or services.  Personalised services, while in theory possible, are often tied up mires about contracting, managing and payment.  Personal health budgets or personal care budgets are intended to make it possible for eligible people to commission or contract support or care that they choose but currently have a high level of bureaucracy involved.  There is, at present, no strong methods of managing the contracting, payment and funding of small blocks of personalised care and support.

At present the NHS takes the majority of all government spending on mental health.  Charitable funding is not to the level of other areas of health, despite mental health difficulty being a significant area of expenditure.  At present investors find it difficult to know what they would be investing in were they to invest in mental health .

Presenting problems

How might impact be measured in mental health in a way that will drive both delivery and efficiency?

How might a payment by results model be developed that actually fits mental health?

How might mechanisms be developed to enable more efficient use of personal budgets?

How might investors structure investment in mental health in a way that does not short change people with mental health difficulties and how might investees evidence impact of that investment?

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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Just what *is* the role of digital tech in health and social care? #EHWK16

The following is the text of a talk  ”Why Digital Technology Might be our Best Ally Rather than our Worst Enemy” given at London’s Olympia by Mark Brown as part of UK e-health week 2016.

Today I’ve been given the job of talking to you about why digital technology might not be our worst enemy in health and care and why it might, in fact, be our best ally.

What I want to do is make the case for certain ways of approaching e-health technology by first looking at reasons why it can be difficult to engage with the idea of digital tech; then looking at some of the things digital tech might do in health and care then finishing off with some ideas about what you might do to help a good e-health future happen rather than an awful one.

Generally speaking, the promise of e-health is that it can make things happen in different ways.  In my view, we’ve reached, at least for the time being, the end of the era of big breakthroughs in health.  A lot of people need things they currently aren’t getting.  We’re stuck with the treatments we have, many of the structures we have.   I think the area where our advances will be made, at least in the short term, are in the sweating of what we do have; continuing to explore new ways of making a bigger impact.

In social care and in health care, the single most valuable resource is people.  If we get tech in health and care right it could free up more staff time to do the really important things that only humans can do.  Tech needs to make things easier and better in ways that work for people.  For example, digital technology might be able to reduce the burden of paperwork meaning we could spend more time with people.

So, why do people worry about tech?  Why does it look sometimes like more of an enemy than a friend?

Best case scenario / worst case scenario

It will not have escaped your attention that the NHS in England is going through what, to the mind of some commentators, is its longest ever time of crisis.

The picture in social care is similar.  Local authority budgets are being squeezed until their pips squeak.  The money that was there to pay for things isn’t there anymore.

The first flickerings of austerity began during the global financial crisis in 2008.  As banks collapsed and debt became toxic; money just evaporated from the economy.  It became clear that public spending wasn’t going to be able to expand indefinitely as it had for much of the previous decade.

Whatever your view, the story is the same: there’s less money in the kitty than we’d like and any of us who work in health or social care have to find ways of being more efficient.

At the same time, something incredible was happening.  While the global economy went into meltdown and the UK government desperately attempted to avoid us going bust; almost without many of us noticing, the boundaries of what was possible with digital technology began to widen.

The iPhone was released on June 29, 2007 in the United States.  The first commercially available smartphone running Android was released at the end of  2008 in the US.  The first iPad was released on April 3, 2010, with Android and Windows tablets following soon after.

Digital technology was becoming mobile and, as importantly, it was plummeting in price.

At the same time that it was looking like we were going to hell in a handcart with socks darned so much they were all thread and no wool; a brave new digital future was unfolding.  While people are cuing for the food banks we’re uploading selfies like there’s no tomorrow. The credit crunch was happening at the same time as we all started to fall for Candy Crush.  What if, the question seemed to be, this digital thing might be the answer to our public service problems?

And there we hit our first snag.  At the same time as trusts and local authorities were preemptively trying to slash their budgets (2008-2010) and then government were reorganising and cutting (or not cutting depending on your political viewpoint), this flower of digital possibility was blooming.  For many, the idea of efficiency savings, of working smarter, of pushing for better outcomes, of doing more for less become a codeword for cuts, erosion of duties, unmet need and greater job insecurity.   The choice looked like either maintaining everything that we had before, health capacity being about warm human bodies or about embracing the digital future and having empty rooms filled with bleeping screens.  Digital transformation looked like a code word for ‘loss of jobs’.  People still ask: why are you farting on with technology and spending all that money instead of employing more nurses or other frontline staff?

‘Unleashing the power of e-health’ runs right into this. The easiest way to avoid the implications of tech is to do everything you can to avoid using it.  There’s sometimes an idea, one at times unfortunately propagated by telehealth providers, that technology will allow you to ‘do away’ with staff teams.  Andrew McAfee Co-author of The Second Machine Age refers to this as digital encroachment, the direct replacement of human labour with machine labour.

Four challenges

For almost as long as the NHS has existed we’ve all watched digital technologies make other people’s jobs obsolete.  Remember typing pools?  Or indeed bookshops?

I think there’s four challenges in embracing digital in health.  Our first challenge in thinking about digital technology as an ally is that we fear it might take away our job.  It’s a myth that all human endeavours are equally likely to be completely disrupted by digital encroachment.  Some things will always need direct human labour. Health care is one of those things.  Nursing especially.  Nursing and midwifery are primarily at their heart about doing things with people and the construction of systems, processes and knowledge to enable that to happen in the best possible way.

There’s a second challenge in the sense in which, for some people, the use of digital technology in healthcare feels antithetical to NHS values.  This is especially true if you see the job of the NHS is to care for people not in an abstract sense but in a real skin to skin, face-to-face sense.  It can feel as if the potential of technology to remove the human work from a lot of tasks makes people very scared that this will be pushed to a limit, as if the strongest voice is the one pushing for no humans at all.

The truth is that some patients want far more contact with lovely NHS staff and some want far, far less.  People tend to have a preference for the level of face-to-face care that’s comfortable for them.  There are times when I absolutely would love to talk to someone about my healthcare but I have no reason to make an appointment and other times where I have to go to the doctor for a routine procedure when I’d much rather be somewhere else.  Digital might provide a way of getting that balance right for more people.

Our third challenge in thinking and dealing with the idea of new technology is that it makes us feel out of our depth. It challenges us by making our workplace practice unfamiliar.

We have spent years training to be what we are.  We’ve spent time and money and blood and sweat and tears building our professional toolkit; turning ourselves into useful tools.  Our job is what we spend most of our time doing.  We worry about having that professional competency undermined or taken away from us.

New technology feels like magic, something arcane, something only controlled by other people, not us.  It feel like something built by people very different to us.   Science fiction writer Arthur C. Clarke, writer of 2001 amongst other things, back in 1963 wrote  ”Any sufficiently advanced technology is indistinguishable from magic.”

Our fourth challenge is that we are scared that we don’t understand tech or that we’ll be helpless if it breaks.

This can be disconcerting if you grew up, as I did, in the age before apps and smart phones and ipads. Then computers were something you had to learn; like learning a new language.  The computer was like a foreign exchange student that sat in the corner, not understanding most of what was being said and only leaping into action when exactly the right command was issued in exactly the right language for it to understand.

To be fair these fears are not unfounded.  A lot of the technology rolled out by the NHS internally has been a bit rubbish.  When that happens we fall back upon the ways we have ‘always’ done things.    Internally in the NHS and in the wider world of social care, the ‘ring round’ is often the way in which tasks are achieved ‘in real time’ (the traditional ring round to find a bed); with email functioning more as an analogue of letters and memos rather than as a form of instant communication.  There is still a lot of ringing to check to get things done.  Many wards only have one phone.  There are still NHS sites where there isn’t wifi.  When record keeping software isn’t very good we end up keeping hand written notes and ‘typing them up later’.

The problem of bad tech is that it makes the thing it was intended to replace look even more correct. That’s because it doesn’t solve the problems we have in a way that suits us.  It’s easier to remember the times that a ‘new thing’ didn’t get the result we wanted to happen than to think back on the inefficiencies of ‘the way it has always been done’.

What we think about when we think about tech

It can be difficult to get into tech from a standing start.  It feels like there are far too many things to learn about and far too many different things to try.  The best thing to do is to start by thinking about what digital tech can do in health.

At the beginning of 2016, independent health charity thinktank The King’s Fund published an article listing eight digital technologies that they feel will revolutionise health and care.

The authors Cosima Gretton and Matthew Honeyman divided the article between technologies that are “on the horizon” and those “already in our pockets, our local surgeries and hospitals.”

Number one on their list was The Smartphone.  Gretton and Honeyman claim that in 2015 two-thirds of Britons used them to access the internet.  The smartphone is ultimately a tiny powerful computer that is very, very good at sending and receiving data and interfacing with other things.   It also makes and receives phonecalls.  In the main, though, the smartphone is an amazing thing for health because, unlike just about every other health intervention, people love their phones, value them, look after them and carry them around with them at all times without being asked.

Other entries on their list included:

Something they call ‘At-home portable diagnostics’, the use of particular bits of kit either on their own or in conjunction with other devices like smartphones to provide diagnostics, readings or measurements and that help professionals and patients to interpret the results.  A familiar example of this will be things like blood glucose monitors for diabetes.

The authors also included smart assistive technologies in this category.  Lots of people use devices and apps to help them to do things they want or need to do.  With addition of sensors and ways of communicating the data they produce; these things – from adapted cutlery to walking sticks can track how they’re used over time – hopefully feed back lots of useful information about how, when and where they’re used.  It’s not always clear whether people will want their walking stick grassing them up to their medical professional for not going for a walk or their inhaler telling their doctor when they’ve had a cheeky fag.

Also on the King’s Fund list were digital therapeutics.  These are health or social care interventions delivered wholly or mostly on computers, tablets or smartphones.  Mental health, my own area, is rife with these interventions.  Everyone is trying to crack the model for delivering evidence based psychological therapies at scale using digital devices.  To my mind no one has quite managed it yet.  Probably of more interest is the use of such apps or services to support people in the management of long term conditions, where a combination of health positive activity needs to be sustained over time and to be reviewed.

They also included machine learning.  If you’ve ever used the google search engine you’ll have noticed that over the last few years it’s gotten better at guessing what it is that you’re searching for or what you’re asking it to do.  This is because google is learning from the inputs of people who use it.  Machine learning is about programs that are set-up to process data and to find things in that data they haven’t been specifically asked to discover.  Machine learning means that programs used to recognise things can begin to spot new patterns not obvious to human observers or to make suggestions about new things that it is shown based on previous things it has seen.  The implication is that if we have programs that look at data for patterns we’ll end up with programs that can make guesses when exposed to new data.  There are thoughts that this might be useful for diagnostic decisions or for analysing lots of health data.

The King’s Fund were also keen on connected communities as a big health and care impact.  Given that social media and apps and services with social functions can now bring us together; Gretton and Honeyman suggest that this might be something that’s harnessed to support or create patient communities; enable peer to peer knowledge and support and to generally help stitch us together into a mutually supportive fabric that can take some of the weight of keeping as well as possible.Patients supporting patients; peers supporting peers; patients supporting professionals and so on.

If we combine Gretton and Honeyman’s list you get a glimpse of the potential for digital technology to fill in many of spaces where health and social care finds it difficult to reach, especially focusing on the bits of people’s lives which don’t take place in hospital or the consulting room.

These however are what you might call technologies.  The world is full of technologies that no one knows what to do with.  The key is to find the application of a technology that works for people and solves a problem that they have.  We had touch screens for decades before apple arrived with the iphone and made us realise that they were really useful for things that we could hold in our hands.

Similarly, there’s lots of things that are possible it’s about working out what’s desirable.

Roughly speaking,  digital tech can do the following things in health and care

Automation – basically digital can use machine power to do things that would be routine but would take person time.  For example, an app could check blood test results and only bring them to attention if they are abnormal.  Similarly, an app might dispense treatment advice or a device paired with an app might monitor a condition.  If it’s boring, repetitive, involves the same thing over and over you can bet it’s possible to automate it. Repetitive and rote tasks are where we’re most likely to make mistakes.

Build better Interfaces – there are lots of sources of data and information in the world. Digital can make better ways of getting that information and sharing that information.  Electronic patient records are an example.  Another might be a way of displaying patient information in such a way as to minimise clinical mistakes.  Digital technology is all about how people interact with things.  Touch screens make things possible for people that were complex or impossible before.  If there’s more than two things that need to interact with each other somehow, digital tech can probably make it happen better.

Communication – digital technology makes messages follow people, makes it possible to speak to multiple people in real time, makes it possible to make contact with thousands of people at once.  Everything from social media to text messages to voice-to-text to text-to-voice to handwriting recognition: there’ll be a digital way of getting the message across differently.

Data – digital technology makes it possible for something to collect data as it does the thing it was intended to do.  A toilet might tell you via sensors how many times it has been used in twenty four hours, a bed might tell you how many times the patient has turned in twenty four hours.  If something is happening; digital tech will probably help you find a way to measure it and give you results in a form you can use.

You’ll hear many of these ideas applied over the course of today’s presentations.

I liked very much University College London Hospital’s app ‘Find my Patient’.   It’s an iOS app that “ is able to securely display a variety of imaging and pathology results, as well as locating the patient’s bed within the hospital. Hospital patients sometimes need to be moved to a different ward or area due to clinical requirements or for practical reasons. The FindMyPatient app means that doctors no longer need to locate patients using printed information from hospital terminals or by calling wards to find where their patients have been moved to.”

That feels to me like a neat little solution to an actual problem that people really have.  If you can use digital to solve a problem people actually recognise in a way that works for them they’ll love you for it.

How can health and care get comfortable with the idea of tech?

The NHS is one of the most complex experiments in human healthcare ever undertaken.  There are few who understand it in its entirety and it’s often baffling to even people who work within it.  Social care continues to become more complex by the day. Often e-health solutions are instigated to solve system problems and it’s up to people ‘on the shop floor’ to make them work.  I’d like to see it work the other way, with digital technology being used to solve shop floor problems.  And that’s where you come in.

One of the first ways we can get comfortable with tech in healthcare is to just be interested.  The world is full of amazing tech things.  There’s more processing power in your pocket or bag then there was to put a person on the moon.  The best way to get a feeling for tech is to just play with it.  Instead of saying: this isn’t for me; even reading just the tech stories in the newspaper will start to bring the possibilities of digital technology alive.

The second thing is keep your eyes open for problems to be solved.  In some ways; I think the most powerful partnership for influencing what technology in health and social care can be is between the frontline and patients or clients.

One of the really cool things about medical and social care people is that you tend to be problem solvers; but you don’t need to be able to make an app or a website yourself to come up with a really good problem that someone should solve. People who build tech are engineers. Engineers like solving problems.  Health and care professionals know about health and care.  People know about their lives and how they feel about them. The mix of those three things makes good digital things happen.

Looking toward digital in health doesn’t need to be about massive transformation; it just has be about solving a particular problem and solving it well.  If we spend our time with people, people we care about, we will see problems without solutions all of the time.  E-health doesn’t have to be massive. It gives us a chance to build things that might initially change the lives and health of a few people, then a few more.  And then more.

Think about your daily practice: what things really get on your nerves? What things never work very well?  What things do patients complain about most?  Think about what things do most to take you away from the bit of your job that patients most value.  The chances are you’ll be able to turn that into a question for which e-health might have an answer.

The formula I would use for thinking about digital technology and innovation is:

Knowing what kinds of cool stuff technology can do + thinking about small, well defined problems = ideas for possible digital solutions.

Sometimes the answer is a new thing.  Sometimes the answer is an old thing in a new way or at a new time or in a new place. Sometimes the answer turns out not to be digital at all.

Not paying attention to digital technology doesn’t mean it won’t happen in health and care.  It just means that the digital technology in health and care will be bought and built by people who understand the people sized problems of health and care less than we do.  Digital technology is not a possible future, it’s an unfolding present.  Digital is already changing things.  A change you choose is much less painful than a change forced upon you.  We have the opportunity to make the best of digital technology so that we can make the best use of ourselves, our skills and resources.  That’s why need to stay at the table, get our head around the possibilities and the things people need and influence what happens.

Out there, amongst the stands and the speeches and the presentations and the celebratory editorials, it’s like Gods speaking to each other over the heads of us mere mortals. Big companies talking to big bosses.  Technology will wing its way in, solve all the problems, be seamless they promise.  The debate is like first world war generals discussing a map of the Somme while the rest of us are shivering in the mud of the Somme, ducking bullets and trying not to die.

Roughly speaking, tech people tend to get really excited about the application of something while the rest of us get worried about the implication of it.  Or to put it another way, tech people ask ‘could we do it?’ while the rest of us ask ‘should we do it?’

At the moment; it’d be easier for google or apple or Microsoft to open a hospital than for the NHS to get fully up to speed with the possibilities of technology.  I don’t want google or apple to be running my healthcare if it means the NHS won’t be here.

If we don’t stay interested, if we hide from digital, somewhere in the NHS or a local authority, miles away from the frontline, someone will come along and commission the wrong digital things for the wrong reason, doing the wrong things in the wrong way. Probably for the wrong people.

If you want to get started, get out there today and talk to people.  Ask them to explain to you exactly what problem their shiny new tech solves.  Ask them ‘if your technology is going to be my ally, what’s in it for me; my colleagues; my patients, my NHS, my social care?’

We have a chance to make digital something that makes healthcare better.  Technology isn’t the opposite of healthcare; it’s a way for health and care to get better.

We’re making the future of the NHS and the future of social care right now and I want to make sure we do them proud.

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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Just what is the point of health professionals in social media? #wgt16

The following is the text of a talk given by Mark Brown at We Get Together 2016 at Salford University on 29th February 2016

I want to share a speech that I first made at NHS Expo in 2014 about social media and public professionals, sharing a stage with our very own Teresa Chinn and Victoria Betton. (The full text of the original speech can be read here.) It was written in an attempt to define and to stake out a role for health professionals in social media in a period where they were running the risk of being shut down and hemmed in overly rigid corporate cultures.  Once I’ve done that I want to bring us up to date a bit with where I think we are now.

At a time when the NHS is experiencing its biggest challenges for at least a generation, I want to talk to you about the way in which social media can help to root the NHS in the fabric of communities. I want to talk to you about the ways that social media creates an opportunity for a whole new generation of ‘public professionals’, professionals doing their jobs while maintaining social media enabled relationships with a whole range of people..

But first I want to take you on a little journey…

It’s Sunday evening. The house is filled with the smell of ironing and leftovers and the sound of grumbling kids and grumbling adults all counting down the hours to Monday morning.  You and the family settle down to watch something comforting and gentle on the television.

It’ll be set in some time between about 1920 and about 1963-ish.  If it isn’t set then it’ll be set in a rural community somewhere as if it were 1920 to 1963-ish.  It’ll feature an affable public servant. It might be a police officer.  Or a doctor.  Or a midwife.  Or a district nurse. Or a coastguard.  They’ll spend each episode doing their job but also being involved in a whole variety of shenanigans.  The message will be they are a valued part of this particular, peculiar community of people.  Occasionally they’ll come to blows with someone from The Ministry or similar, someone who represents the far-distant bureaucracy ‘who don’t understand our local ways’.

What these Sunday night comforts all share is the nostalgic appeal of a world where public services were explicable, knowable and human sized.  It’s the fantasy of the local GP having a few pints in the snug of the local pub or the beat bobby who slurps tea in the local cafe.  It’s a yearning for the days when public services felt like they grew from communities, rather than being distant, complex structures that lurk at the edges of everyday life. It’s the wish to feel like there’s someone who is part of our world that can also help to understand the world of public services.

Social media is in some ways the latest village square or local cafe.  It’s a place where people check in to hear the latest news, catch up with friends, debate, flirt, ferment revolution and/or swap dirty jokes.  In short, it’s a place where people do people stuff.  Social media is where people are.

It’s very easy to underestimate how much of how the NHS works is opaque to the public. It’s like a big castle with high walls.   It’s very easy to underestimate how much of how the NHS works and what the NHS does is opaque to the people actually working for the NHS.

There’s a difference between giving health advice and discussing health issues, just as there is a vast difference between individual treatments and the service which delivers them. The NHS isn’t staffed by robots.  In fact we’re so scared that the NHS might be losing its human touch that we’re talking about training people in compassion and empathy.

So, what’s this got to do with public professionals and social media?

Public professionals talk about their job via social media.  They combine two things: they appear in the public realm talking about their job in way that used to only be possible if a journalist thought you interesting enough to interview. They talk about the pleasures, they talk about the joys, they talk about the difficulties, they talk about the issues that arise from doing it.  They put a human face and a human voice to what otherwise might seem a semi-robotic function.  They help the public to understand the process, the practice and the limitations of healthcare.

Public professionals inform the public of their practice and in turn have their practice informed by the public.  This is the second thing public professionals do: Public professionals talk to each other, they talk to non-professionals, they carry information into areas where it isn’t usually found.  Using social media they get ‘out and about’. Public professionals learn from the blogs, tweets, videos and discussions that they find themselves in and carry this understanding back into their work.  It’s easy to forget just how much taxpayer funded knowledge and wisdom is currently sitting within the staff of the NHS.  It’s awesome but it also ends up hidden from the people who paid for it.  Public professionals jailbreak that knowledge and carry it out into the community via social media.

In social media, information doesn’t just flow outward from providers, it’s a two-way traffic.  People increasingly expect that organisations will speak back to them and listen to them.

It’s hilarious to me that the NHS has a challenge with engagement and involvement.  Public professionals mix with people via social media (and often in real life too): they’re the person you talk to who is also a nurse, or a the person whose blog you read who is also a doctor.  Public professionals are engagers and connectors by nature.  You can’t do social media well without connecting with people.  For people like me, who aren’t in the NHS, public professionals are a point of entry, a way into understanding it better and a guide to navigating the complicated flows of information, misinformation, spin and rumour.

If we trust people to make life or death decisions over others we can trust them to have opinions.  If we’re battling for hearts and minds, which I think we are with the NHS, then public professionals are the best ambassadors there are.

Public professionals are a two-way conduit.  They take information out of its NHS castle and while they’re outside, in the bustling town square of social media they learn, and talk, and listen and they take information back into the castle, too.

And, being part of a social media communities and relationships means public professionals stick around through the good times and the bad times because they’re a person relating to other people.  You can’t be all ‘share our good messages, retweet our opportunities, big us up’ and then lock down your twitter account when a scandal breaks.

Doing social media isn’t a separate job from doing a ‘proper job’. Public professionals fit in blogging, podcasting, tweeting around the rest of their work.  You don’t need to be a social media expert to do social media. You just need to know your subject and just need to be really, really passionate about discussing it.

The rules for being a public professional via social media are really the rules for any healthcare professional: Listen, speak with respect and care, know your subject, don’t talk about the benefits of your work without discussing its limitations, don’t think you know everything, be proud of your job but not blind to its failings and be an advocate for the best of possible worlds by understanding where things are worst.

I’ll just leave you with this:

While social media isn’t the be all and end all of things: The public sector sometimes only gets the urge to engage with people when it wants something.  How do you expect to engage the community, care for the community and be supported by the community if you’re not part of the community? That’s what public professionals do. And that’s why I love ‘em.

So, all you public professionals around the room, bask in the glow of my praise.  That was me making the case for your existence.

Now, more specifically, I want to talk about now.  And what you can do about now.

The three spectres: Cynicism, ignorance and minding your own business

In our national debate about what healthcare is, what it costs and where it should be in future years there are three great spectres haunting the land.

The first terrible ghost is cynicism.  There’s a lot of people who feel disenchanted and disenfranchised.  Patients.  Professionals.  Observers.  Despite stated intentions that healthcare would never again become a political football; we’re living through a period where there is an ever increasing sense of panic, of imminent collapse, a feeling of siege and of mounting horror.  People are losing their trust in public institutions.  Everyone in power is suspect.  Everyone seeking power is suspect.  Everyone questioning power is suspect.  In a social media age; everyone who wants to be is barraged by waves of spin and counter spin. Far from focusing people on what really matters it makes people feel so far from being able to change what really matters that they begin to believe that nothing will ever change.

Good things; things that people on the inside of healthcare believe in; work hard for and which really make a difference become drowned in a sea of political announcements and press releases.  People begin to lose their faith in you; in healthcare professionals and in the possibility of things ever being better.  It’s people like you in this room; people who work in healthcare who really care, who can help to change that.  Not by being relentless cheer leaders or by arguing with every critic and rebutting every accusation of self interest and ‘wasting taxpayers money’, but by being people online.  By showing that far from a distant professional class; you’re people doing vital jobs in difficult circumstances with diligence; thoughtfulness and humour.  The healthcare that we have rests upon the belief of the public in the reasons for its existence.  It’s you, out there in social media, thinking and learning and talking and promoting in public that are one of the strongest weapons we have.

The second spectre chilling the bones and turning all around it sour is ignorance.  Healthcare is complicated.  Healthcare systems even more so.  If we don’t work in healthcare we will usually count ourselves as lucky that we don’t know how it works.  Most people only have a passing knowledge of what the real engines of health care look like.  This is perhaps as it should be.  We don’t , after all, all need to be trainspotters to get on a train.  We just want to trust that the healthcare we need will always be there for us.

When the money starts to falter, though, the public is asked to make choices about what is and isn’t important.  What should and shouldn’t be funded.  Who should and shouldn’t take priority.  Even those of us who a deeply dug into the business of healthcare often shrug, crumple our faces and say ‘well, it’s, err,  complicated’.

The public is regularly asked to make or to accept decisions regarding health care policy that they have no way of fully understanding.  You all understand that how we do healthcare is as important as the individual treatments from which that healthcare is constructed.  In the vacuum; tabloid newspapers get to set health policy and public debate becomes a battle between bullshits.  You all, as health care professionals or healthcare professionals to be, have the power via social media to bring truth; to add light and shade; to explain; and to help give context and human faces to what might otherwise look like dry debates held by grey and faceless people in offices or thundering headlines above lurid scare stories.  You are the people who can bring debate back to what really matters: how do we help everyone to have the longest time in life with the least suffering and pain.

Every time you talk about the realities of your job and the questions it throws up; every time you share with others the best ways to get the best outcomes; every time you tweet, blog or facebook as a professional that cares enough to add to people’s understanding of how things work and how things are; you are helping others to understand and to see what really is important.

When political pressure to do one thing or another intensifies, you can be a professional who brings real knowledge and value to public debate rather than being a corporate robot or a political flagwaver more in love with winning an argument than making sure people don’t suffer.

The third and final spectre wrapping its ghostly arms around us is austerity and minding your own business.  When there isn’t enough to go around; everyone turns to their own plate.  At just the time when we need to be finding new answers to wicked problems, there will be many who want to concentrate on the frontline.  On keeping their head down.  On avoiding anything that might distract from the job at hand.  ‘Just do your job,’ they’ll say, “and everyone else will do theirs.’  The problem is that this is exactly what people do while things around them are falling to bits.  They bunker down; focus; stop looking around them.  The visible horizon shrinks and life becomes a series of tasks one after another after another until it’s time to go home.

At a time where it’s becoming clear that more of healthcare is about what happens outside of the hospital on the hill, social media is giving us a unique way of building new relationships; finding new things out and connecting with both professional peers and with people on the other side of healthcare.  At the time when we need to be helping people, including ourselves, make sense of the healthcare challenges ahead of us; too often we will be silent, inaccessible, absent.  We’ll withdraw into our professional shells at just the time when we need to be reaching out to each other and to the world at large.  We’ll let connections wither rather than tending to them.  We’ll become the very thing that others accuse of us of being: inward facing; set in our ways; aloof and out of touch.  At the point where we need to be making the case for the best possible healthcare and putting our heads together to see how it might happen we’ll instead isolate ourselves further as things crash down around our ears.

What is to be done?

If you are a social media user you have access to things that your non social media using peers and the generations who came before us do not.  Geography, time and space no longer limit who you can meet and converse with.  You aren’t limited by what books are in the library or which reports are on the shelf.  You have a freedom of movement and association that allows you the chance to be in many places at once; in many conversations; with many people you’d never have met in real life.  You can jump barriers and ignore boundaries.  You never have to be alone with your ideas and your concerns and your ideas.

You can be the people who bridge the gaps; the people who know how patients feel; the people who can see what effect the changes of policy and practice have on wider public opinions and sentiments as well as within your profession and within the systems they sit inside.

You can make things happen in ways that were impossible before.  Social media makes relationships possible that would never have even begun prior to its existence.

In social media you can build the trust we need to make sure that good things can happen.

So, that leaves me with one final question, as public professionals just what is it we going to make happen?

In social media, through things like we nurses and the things that will come after it, we have the possibility of building what has always been more theoretical than actual: a living, breathing community of people, both professional and not, committed to making whatever healthcare system we have the best it can be.

Social media can’t solve anything on it’s own.  But when it brings us together and when it makes the usually invisible visible, we might just be in with a fighting chance.

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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