Mark Brown (@markoneinfour) examines why debate about personalisation in mental health gets stuck and why micro-provision might get it going
Personalisation of services is something we take advantage of every day. When I go to the shop I buy strawberry bootlaces. I could have bought seven litres of vodka or a tin of shoe polish. I personalised my experience by purchasing what I wanted.
Simple? So, how come personalisation in mental health is such a complex subject? And why isn’t it being discussed as a great opportunity for people with mental health difficulties?
Personalisation: Much complications. Such debates
Personalisation in mental health is people ‘claiming’ and using personal health budgets and personal care budgets to purchase non-medical services, tailoring their support, care and treatment to their own personal preference.
From April 2013 personal budgets should be available to anyone with mental health difficulties on Care Plan Approach in England (I haven’t been able to find any readily accessible numbers for exactly how many people are eligible. If you know, leave a comment). It should be possible to picture this being the subject of a ‘tell Sid’ style advertising campaign: ‘Don’t forget to claim your personal budget, putting you in control of your mental health’.
In practice, the idea is far more heavily contested than someone outside of mental health would predict.
The real challenge for personalisation – personal health and social care budgets – is ensuring that people actually have a realistic opportunity to choose from a variety of options and to find something that works for them.
For an individual to tailor their support, care and treatment requires a variety of different things from which to choose; available in ways and at prices which makes it possible for them to be chosen if the individual wishes.
This requires providers of services. Providers of services need to be sustainable, at least to the extent that they can provide the services they promise to the customer for the period for which the customer has paid for them.
While this looks like a challenge for the customer in that it presents both a risk (what if what I buy isn’t what I want/doesn’t fulfil its promise?) it also creates a significant challenge for the provider.
Much discussion of personalisation is conducted from the perspective of either service delivery bureaucracies and organisations currently providing services who may or may not look at the potential of personalisation as an opportunity. What is often left out of the discussion is the examining the question from the perspective of people who may go on to provide services for people to purchase.
There is much discussion of the ways in which we might facilitate people exercising choices, but relatively little about the actual things that might make up that choice. While this understandable – we tend to be experts within the domains in which we usually work – it does leave a gaping hole: Just how do we provide personalised services?
In most places, personalisation isn’t going to work by trying to meet a huge number of needs and preferences on an industrial basis. That’s what we have now and why we might have got stuck with personalisation in mental health consisting of advocating for its existence and few opportunities to actually put it into action.
In what follows, I’m avoiding discussing personalisation from the perspective of those receiving services in any depth as it’s a complex and under-discussed area to which I want to do justice in future. We’ll have to accept that personalisation looks like a failure if it means having services you were familiar with taken away without anything obvious to replace them.
At present, the locus of discussion about personalisation is currently in the areas where people concerned are most comfortable (whether it is a good thing or not) and relatively moribund in the areas of personalisation that take the debate towards answering the question of how it might work.
A threat to everything we hold dear
Many underestimate how much of a threat to an established way of working personalisation presents.
In all other debates about meeting needs, the excitement is about start ups. Small, hungry businesses that have spotted a niche and who are going for trying to fill it. In the debate about mental health personalisation there is just the same established voices.
The existing model of ‘can we have some money to some things with some people’ confers significant advantages on organisations and those who work for them in that it has, in the past at least, made this world stable and predictable. Activity follows evidence of need. Evidence of need comes from analysis of conditions. It is the dream of rational central planning, where money flows down from central repositories, guided at every turn by rational technocrats. Your job in the organisation remained stable. If you were not hitting your targets, this was due to a lack of resources. In this world, pay and conditions can be altered by collective bargaining. It is a world where you know where you are. It’s a world where someone, somewhere else could work out how things should work and where you could petition them if they didn’t. Seen from this perspective personalisation profoundly destabilises this world and it’s disingenuous to argue that it doesn’t. How you feel about this destabilisation depends on how frustrated you are with things as they are.
When I look at large organisations talking about personalisation I think: ‘you can’t get there for here’. In other words, I keep thinking there is no way that an organisation structured like that can get to providing services that small numbers of people directly want to purchase.
The main reason for this is, for those organisations, the cost of providing large amounts of discrete, different services is far greater than providing the kinds of high volume services for which they structured. They just aren’t structured for personalisation and often are trying to replace sources of revenue that have been lost, such as block grants or contracts. Once organisations reach a certain size they become less agile. Staff recruitment becomes more specialised, with strictly delineated job roles. Contracts become honed and precise. Redundancy payments become an issue. This is stability: great from the perspective of working for this kind of organisation, but it does make it difficult for an organisation to change direction or to innovate quickly and iteratively.
To provide a service in a way that allows you to continue to provide it on an ongoing basis you need to be able to service any debts it creates while making, in theory, enough surplus to make it worth your while in actually doing it. This means that for any provider to enter into providing personalised services, there is no guarantee that the money spent on setting up the service will be recouped quickly enough by providing that service. The natural level of return for that service (the number of people who want to purchase it and the amount they are prepared to pay for it) may not be equal to the money it costs to provide it, or may not make enough of a profit to repay the money invested in keeping it going.
Larger organisations are asking the question ‘How can we deliver personalised services that will generate the revenue to replace the revenue we have lost so that our organisation may continue as it has done?’ The answer is: either you can do something that you call offering personalised services and get closer to that aim, but betray the idea of personalisation in the process, or you can try to develop and deliver smaller, more specific services but at a really high cost because you’re organisation isn’t the right shape and the service has a breakeven that is higher than the service can ever achieve
Micro provision – the answer that dare not speak its name
The answer to the question ‘how do we make personalisation meaningful in mental health?’ is glaring obvious: we support the development of a range of providers with business models that work. But it’s not proving to be that simple. In mental health we can’t imagine new entrants to the market. Indeed, we don’t really have any idea of what the value for personalised services in mental health is.
One of the only ways that I can see to find a way toward true personalisation, where people will either be able to find a service that really works for them or to bring a service that fits them into existence, lies with micro provision.
Community Catalysts define micro providers as ‘local people providing support and services to other local people, who work on a very small scale with 5 or fewer full time equivalent workers – paid or unpaid who are independent of any larger organisation’.
Traditional models build density by setting up a broad-based service in a building and saying ‘you come to us’. Personalisation can’t work like that. At the beginning, micro-provision will mostly be kitchen table businesses meeting needs drawn directly from people’s wishes or the hunches of plucky start-ups.
Micro providers, being very small, have a business model that is not based on achieving economies of scale but upon limiting the cost of each transaction. In practice this means delivering a service that is only supposed to have a limited number of clients. In a lot of situations, the needs and desires being met by personalised services will not lend themselves to density. The chances of there being sixteen hundred people in a town of 60,000 people, with long term severe mental health difficulties and who want to take courses in linux coding are slim. The chances that there might initially be ten is possible. It can be guaranteed by finding those ten initial people and setting up the micro-provision to serve them at a price that works for both parties, a process otherwise known as market research.
There is a a kind of virtuous circle in micro-provision in that it can be the opportunity for people with lived experience of mental health difficulty to start small businesses or charities to provide help and support to other people with mental health difficulties.
In many respects this is something for which small voluntary sector mental health organisations in mental health have been advocating for many years: for ‘professionals’ to get out of the way and for people with mental health difficulties to be able to choose from a range of different options, some provided by their peers.
Collectivist provision vs. market: Fight!
I think that there are very good reasons why the debate about personalisation always shifts away from the discussion of how you might actually provide either a flexible service or a limited objective service to a small number of people. Personalisation is a profoundly political idea, and responses to it are often either overtly or covertly political. Personalisation is caught in the conflict between market individualism vs. Collectivism.
The mental health services that we have today are built on the bedrock of a system created when no one cared what people with mental health difficulties wanted. The idea of choice in mental health and care is in part a recognition that what people want might differ from person to person and from year to year. The system we still have was set up for someone else, possibly in an office, to work out what was best for us.
In April last year, I was writing about the legacy of Margaret Thatcher for people with mental health difficulties, focusing on the idea of Care in the Community. As with personalisation, this is a stepping stone on the path away from the dream of universal mass provision of services. As I wrote:
“Collectivism is the idea that the state should provide for the needs of everybody as much as is possible by creating structures that meet those needs. Market individualism is where choice, lots of different providers and the ability of people to make decisions and put them into action is privileged. To those without mental health difficulties – and some with – Care in The Community looked like the dismantling of a collectivist solution to mental health difficulty, where everyone would be ‘looked after’ and its replacement with a a hodge-podge of different bits and pieces that might not manage to help everyone…
“Even taken as part of the changes that the policies of Thatcher governments instigated, hinging as they did on the idea of increasing choice while reducing the involvement of the state (in theory if not in practice), and the subsequent economic and social effects that busting the post war collectivist settlement caused; it’s still hard not to see a tiny positive in the policy.
“Of course, it’s impossible to divorce the good points of a government’s policy from the overall effects that the sum of all policies and events had during a period.”
In some respects, the public sector spending contraction from 2007 onwards has forced a change within the mental health sector, with the public sector spending less in a lot of places and getting less ‘out the door’ to the voluntary and community sector. Cutbacks have led to a reduction in services both within the public sector and without.
Add to this government policies about ‘allowing the market into public services’ and personalisation and personal budgets look like cutbacks and privatisation to many who work in the services that personalisation might destabilise. On top of this sense of wider economic instability for many personalisation raises a spectre of greater instability. Personalisation seems to be a mantra that will tug at the tablecloth and upset all of the dishes at the dinner table.
Collectivism is a brilliant mechanism for doing some things and not others. Personalisation gets caught in the wake of other arguments about what States should and shouldn’t do or in worries about the sustainability of the broader voluntary sector.
The alternative to this settled way of doing things, if you’re currently employed within the reasonably safe confines of a large organisation, looks significantly more scary.
The ‘what do I eat in the meantime’ conundrum
Any service, big or small, requires a flow of resources that are overall equal or more to the resources required to deliver the thing it delivers.
The challenge for personalisation from the perspective of delivering a service is that any service takes time and resources to build up to a level where it is possible to balance in income the resources required to continue to deliver it.
This is what I’d call the ‘what do I eat in the meantime?’ conundrum. Put simply, people need to eat. In starting up a business, the biggest question is where the resources can be found to pay for the time between devoting time to that business and that business beginning to generate cash returns. If a business needs a large amount of time and resource to get going, such that it is impossible to do other things to generate living money during that time, then the people starting that business will be very hungry if they don’t have either another source of income or a very long-suffering family. In the context of personalisation, micro-provision reduces this conundrum because it’s based on keeping costs as low as possible and growing as the demand from consumers grows, but it doesn’t remove it.
If you’re running a very small business providing half hour slots to people to help them answer their post and pay their bills on time, you may be able to do this as a part time job, but you will still require some form of investment to get this off the ground. All of the time you are building this micro-provision of a service, to a limited number of people who really want to buy it using their personal budgets, you are accruing an opportunity cost from not doing something else to make money.
A refreshing pragmatism
Micro-provision is the structure needed to begin the process of delivering personalisation but it receives scant attention and is, at present, a marginal topic in the debates about how personalisation might be delivered. It is caught between the anxieties of those currently providing services on one hand, and in the broader debates political debates about who and how public services should be delivered on the other.
Micro-provision is currently ill-served in the debate and is invisible to most forms of investment. The pump-priming of micro providers could be an inexpensive way of bringing to market services from which people could select while tailoring their care and support. These micro-providers would bring some of the benefits of start-ups to the personalisation of mental health care and support.
The development of micro-providers will be gloriously hands-on and practical, but will mainly lie outside of the spaces and domains where many participants in current debates are comfortable. Focusing on micro-provision (people setting up tiny businesses to meet specific needs for people) will ground the discussion of personalisation in something other than ideology and bureaucracy.
A perennial frustration in mental health is the inability to escape from the structures of thought imposed by an outdated model of what it means to have a mental health difficulty, a shape to which many of our existing services still conform. Personalisation presents an opportunity to change these shapes by redefining what good care and support can look like by starting with the wishes of the people receiving it.
Setting up a tiny business, researching your market, spending time with the people who are buying your service from you: it is impossible to do these things successfully without coming closer to providing a service people with mental health difficulties actually want.
In some respects, the best community based mental health organisations have remained homes of small-scales specific services when the commercial logic has insisted on large service delivery contracts at scale. People with mental health difficulties could begin to build their own services meeting the needs of people with mental health difficulties.
We should be discussing ideas, business models and micro-provision strategies. We should be doing everything we can to make it possible for people who wish to try to find start-up small enterprise ways of meeting people’s mental health needs. The country is full of people who can advise those who wish to take the plunge. It’s also full of people with mental health difficulties who are worried about losing any sort of service at all.
Small scale investments for small scale projects. Some will fail, some will succeed, some will grow, others will find their level and stick. All will provide choice where otherwise there may have been none.
The debate about personalisation in mental health has gotten stuck, maybe it’s only a new pragmatism that will bring in fresh blood.
Mark Brown is the editor of One in Four magazine (http://oneinfourmag.org) and development director of Social Spider CIC. He is @markoneinfour on twitter.