On mental health and digital: avoiding all or nothing, not knowing what to back and ‘bigness’

Below is the text of a talk by Mark Brown on the subject of mental health and digital tech at the HANDIHealth Spring symposium at The Royal College of General Practionioners, London on 14th May 2014.

I’ve only got a little bit of time to talk to you today, so I’m going to rush through a few things about mental health and digital technology.  Over the last couple of years I’ve been involved with the development of a web application called Doc Ready. It helps young people get ready for their first mental health related visit to the GP.  That’s all it does.  It helps to make a difficult situation a bit easier.  I increasingly do work around innovation in mental health.  I’m the co-director of a small social enterprise that has sold things to the public sector and failed to sell things to the public sector.  I also have a mental health difficulty myself.

I’ve been asked to give a bit of an overview of some of the challenges of making digital mental health tech projects happen.  Not to give away my conclusion: but it’s basically often the wrong people listening to the wrong people and then building the wrong thing;  Something I’ll come back to later.

First off, a bit of definition is needed.  A mental health difficulty is an experience of mental distress, upset or disorder, affecting mood, thoughts, physical sensations, actions or motivations that lasts over a period of time and gets in the way of doing the things that you want or need to do.  While mental health services exist to help people with mental health difficulties, the interests of mental health services aren’t always exactly the same as the interests of people with mental health difficulties.  Making your service better isn’t always the same as people having a better life.  Similarly people with mental health difficulties have problems to be solved, we aren’t a problem to be solved.

In general it’s been very hard to get innovative mental health and wellbeing projects off the ground in the public sector. In mental health, as with any other field of human endeavour, there is not a uniform penetration of ideas and practices.

Tech is already solving huge and small human problems.  Just not in mental health so much, yet. William Gibson author and the parent of cyberpunk nearly said way back in the eighties  “The future is already here, it’s just not evenly distributed yet” (well, he agreed that it sounded like something he might well have said) and it still remains as true as ever.

What happens always looks inevitable when you’re looking back at it.  At the time, though, it often seems incredibly risky to try to second-guess the future.  The problem is that we’re entering a period where many of the things we know are being shaken up.  Public mental health spending has fallen for first time in a decade.  The NHS is still continuing to make sense of the largest top down reorganisation in its history.  Austerity continues to bite  and mental health need is rising.

And there lies one of our first challenges for digital mental health and wellbeing.  At present our mental health services, quite rightly, commission things based the idea of commissioning what works.  If you’re spending your own money on a bit of technology, no one will die if you spend your holiday money on a Betamax video system or a Sinclair C5.  When you are in control of public funds, you don’t want to be wasting them.  So it can be easier to avoid risk, always ask for greater evidence of efficacy or, indeed, decide that only you understand well enough the needs of the people for whom you are commissioning so only you could design something that would help them.

Meanwhile, technology enabled by the internet, portable tech and ever growing processing power is beginning to change our expectations for how things should be done and can be done.  Not for everyone, in every way, all the time, but for ever growing amounts of people in some ways.

It’s very difficult to see which way you should jump when presented with a new opportunity.  Should you stick with what you know,  or should you be confident in your ability to pick a winner?  At present, commissioners often feel out of their depth when evaluating whether a particular piece of tech might be worth investing in. ‘New!  Exciting!’ to developers is ‘Hmmm. No evidence base’ to sceptical commissioners.  So, how to know when to take a gamble on the future? There is an answer to this, which I’ll get to in a moment.

Second challenge:  All or nothing tech thinking.  There’s sometimes an idea, one sometimes 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.  In mental health, as in other areas of public service delivery, there are some who feel this digital encroachment as literally that: an army of computer screens and ill-understood  gadgets skulking in the shadows a bit like in The Terminator, ready to leap out and take away everything they hold dear, including their jobs.

Some people with mental health difficulties are clamouring for more digital solutions.  Others are dead set against them.  People with mental health difficulties have the same range of experiences and feeling about tech as the rest of the population, even if the combination of discrimination, lack of opportunities and the financial impact of long term conditions means that they might not have so much money to spend on it.

It doesn’t have to be either/or with tech. Different people will want and need different things.  As will staff of different services. Imagine what we could do if tech 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.

The third challenge for digital mental health is something I’ll call ‘bigism’.  Commissioners want to commission big things.  Developers love the idea of big things.  Go big or go home people say.  Those people are wrong.

People tend to treat commissioning of digital mental health things as a kind of shopping list:  ‘we want it to track mood and we want it to digitise Care Plan Approach and we want it to give advice and we want it to resurrect the dead and we want it to play videos and we want it to collect data and and and…’.  People love the idea of one-stop shops and digital silver bullets.  That pressure creates unholy Frankenstein apps that try to be all things to all people and end up doing nothing very much for everyone.  People picture digital Swiss Army knives when they’re really commissioning or building a vacuum cleaner with built in nasal hair trimmer that is also a filofax and mp3 player.

There’s another variety of ‘bigism’ that affects developers.  This is trying to satisfy too many markets at once, often because you’ve spent too much developing so need to have as broad an appeal as possible.  An all singing, all dancing app is often all singing, all dancing, all failing app.

So, three challenges: not knowing enough to know what to back; all or nothing tech thinking and ‘bigism’.  When you get the three of them together you get digital solutions full of features that no one wants, being commissioned on behalf of people who don’t want them at a price that makes everyone fed up (unless they’re getting paid directly to build them).  Sound like any tech projects that you’ve come across?

So how do we avoid this curse?

The answer is really, really simple.  We talk to people.

At present the interface between commissioners and developers is rubbish because the wrong people are doing the wrong job.  Commissioners who don’t know much about tech sit down and write specifications for applications while developers who don’t know much about mental health spend ages trying to develop apps with other sources of funding.  At present the public sector is awful at identifying the problems that need to be solved by tech because there’s a fundamental misunderstanding about how you use tech to solve problems.  You can’t do good design from abstracts.  Statistics and data are a great start, but that only tells you where the challenge is, not the shape the answer to that challenge might take.

Developers are great at solving problems.  That’s what they do.  Set them a challenge and they’ll do everything they can to solve it.  At present commissioners aren’t delivering them problems to solve by applying technology: they’re sending them shopping lists of features and asking them how much they’ll cost without knowing whether anything on that shopping list will actually resolve any of the issues it is intended to resolve.

It’s vital that commissioners get better at working out how to communicate with developers When you don’t understand your problem you can’t even begin to evaluate whether one approach will work to solve it or not.  You are, in short, absolutely wide open to being sold digital snakeoil by people who promise the earth knowing that you can’t tell a good solution from a bad one.

Deeper than that, if you are designing something to meet a need, the easiest, best and most exciting way of developing it is to actually to talk to people who are going to use it.  Commissioners aren’t the target audience for digital mental health products, even if they hold the money: it’s the end user, the people who will actually use the bloody thing.

With Doc Ready; the original idea for the app came from young people.  That idea was checked with other young people.  Young people pulled apart every stage of the app and helped us put it back together.  They were involved directly with team the developing.  Far from taking ages we got the money in February and launched the public beta you find online by June.  It didn’t get big.  In fact, young people helped us to throw features out.

None of this stuff is revolutionary.  It’s even part of the current government’s digital guidance.  But, like I was saying, the future’s already here, it’s just not evenly distributed yet.

In my experience it’s very hard to sell an existing mental health project into the NHS, but hopefully more opportunities for developers, commissioners, mental health folk and mental mental health staff to actually meet and chew the fat might change that.

Maybe, if we do have a choice of futures those of us here today can make this future happen beginning today?

And that’s me done!

Thank you!

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

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