Observations from a rooftop in 2012: mental health, technology, innovation and why we’re tit awful at it sometimes

By way of an introduction from Mark Brown: The below is a blog post written March 2012 after attending a mental health and technology ‘unconference’ organised by the Young Foundation which details the results of what, for me, was probably the one of the most formative days of thinking I’ve ever done.  In it you’ll see the beginnings of many of the thoughts I’ve developed further about mental health, technology, the business of innovation and how and why change does and doesn’t happen.  I haven’t edited it since it originally appeared on the One in Four blog but thought it made sense to pull it together with the rest of the articles at The New Mental Health.

 

I spent Friday at #mindtech (http://unconferencementalhealth.wordpress.com/) [Note: this link will be dead but may be archived somewhere] An unconference to discuss using technology to make mental health better at Coin Street Community Centre on London’s South Bank.

The idea of the day was to get a load of people together in a big room, get them thinking and talking then get them to split up into groups and come up with ideas for projects. It was similar idea to the Innovation Labs I attended a few months ago.

Once people had come up with ideas for what could be discussed and we began to divide ourselves into groups, me and a couple of other people realised that what we were interested in didn’t seem to quite fit into the broad themes that others had identified. We decided it would make more sense for us to set up a little breakaway group of our own and see if we could come up with some ideas to present back to the unconference as a whole at the end of the day.

We made a break for the roof garden. As people who are intimately involved in mental health innovation rather than coming to it as a new idea, we tried to dig down into questions about how we do mental health innovation, how we can make it sustainable and what innovation actually means in mental health.

Below are some of my observations  on the day and some of the things we ( Chris O’Sullivan ( @mentalcapital ), Katie Brown (@Re_connection) and Clodagh Miskelly (@miskellaneous )and me @markoneinfour) discussed up on the roof, sitting under a beautiful blue London sky.

 

Observation 1: There were less tech people than I would have expected

At an unconference about mental health and technology, I would have expected there to have been a larger contingent of people who were not mental health specialists but who were specialists in ‘doing tech’.

I think we sometimes have the idea that mental health is such a mystical and secluded area of endeavour that no outsiders will never get it. Tech people like solving problems. That’s why they are an asset (of which more further down).

 

Observation 2: Think big doesn’t mean make big things

Lots of people at #mindtech had big ideas.

This is brilliant. What we in our little rebel group explored a bit was what that actually means in terms of business models and sustainability.

The thing about things like apps and websites, that is tech that doesn’t involve manufacturing or giving people actual nuts and bolts bits of kit, is that the actual cost of development and delivery is more or less the same whether one person uses that app or website or one hundred thousand.

So, if you have a brilliant idea for an app and you spend £200.00 making it and twenty people use it and like it, you’ve spent £10.00 per person on making something positive happen. If a hundred people use it and like it, you’ve spent £2.00 per positive outcome.

The value of that form of tech is low-cost multiplication of impacts, like having a photocopier where you never have to refill the paper drawer or buy more ink. Once it’s built and launched, you should know exactly what you’re spending on each person who uses it and you should see the cost per person come down over time as more people use it.

At #mindtech I picked up a bias towards thinking about web applications or websites that would take on huge a weighty challenges and would provide all-singing, all-dancing solutions to them. This is a great and laudable aim, but it’s not how innovation or tech really works.

When presented with the question of how we can use technology to make the lives of people with mental health difficulties better, people can find themselves thinking about magic bullet solutions to make everything better which leads to very big, very broad project ideas.

The problem with massive ideas is that they have massive development costs. ‘ So what?’ you might say. The problem is that massive development costs massively increase the amount of people you need to use the thing you’ve created to make it worthwhile.  Or in other words, to get a reasonable return on your investment you need a large amount of users and outcomes.

To come up with a tech answer that would provide an all-singing, all-dancing solution to a series of broad challenges that people with mental health difficulties will be time consuming, complicated and costly. If it’s taking on a massive range of challenges faced by a massive range of people, then I’d say that the cost of developing that will mean that you’ll also need a massive amount of people to use it to make for a good return in outcomes from the cash you’ve spent (or, more usually, the cash other people have spent by investing in you. It’s rare to find people who risk their own in developing stuff in mental health.)

If you want to be all things to all people by doing general things, then your innovation is going to need to be used by nearly all people to make it worth the investment.

The point that we would raise is: What’s wrong with small projects for specific purposes and people?

 

Observation 3: Improving mental health services isn’t synonymous with helping people with mental health difficulties to have a better life

This is a fairly self-explanatory observation.

 

Observation 4: We are awful at market research in mental health 1

One of the things that really struck me at #mindtech is that for the most part we still seem to be tit-awful at market research in mental health.

Market research is, very simply, the process you go through to take a product to market. It’s simple A level business studies stuff.

You find out what value the potential market has, you find out what other people are doing or have done in the past, you look for gaps or opportunities, you come up with products, you find what would be reasonable to charge for them, you find out how you offer them to the people you hope will buy them.

What really hit home to me in our rooftop discussion a #mindtech was just how disconnected and jumbled up this process is mental health. I was asked by John Loder of The Young Foundation to come and talk to the group he was helping out who were looking at ways to change perceptions of people with mental health difficulties. When they explained that they thought it would be great to do a big campaign collecting peoples stories and sharing them via social media to reduce stigma and that it could lead off with famous successful people through history who’ve experienced mental health difficulties I had to congratulate them. In the space of a few hours, a group of ten folk who’d never met before had run through all of the issues and ideas and possible solutions and had, in essence, come up with a plan that was pretty much the same as Time to Change’s plan for the first three year phase of their existence.

This is awesome, and shows that from a standing start, there are solutions that people will hit upon following logic, but that’s not really where the process of innovation begins.

Our small rooftop breakaway group was rooted, to an extent, in the fact that we have been doing that market research, we do know what others are doing or have been doing. In essence, our starting point was different. We spend our days thinking and working on projects that are about innovating and to do that we need to know what other people have done and are doing because that’s how we learn and how we make sure the time and resources we have can be used to their greatest value.

At present there isn’t really a primer in mental health innovation. I’m trying to raise the money to write and research one, but at present there isn’t really an easy starting point. [Note: despite trying crowdfunding we failed to raise the money to write and research this primer in mental health innovation. I hope that I've managed to capture and explore some of those issues over the following years of just getting on and doing stuff]

The first rule of Fight Club is you don’t talk about Fight Club. The first rule of mental health is that next to no one knows what anyone else is doing or has done in mental health.

There is isn’t a trade journal for mental health innovation, there are few websites, there isn’t a network. There’s some people doing stuff.

As Chris O’Sullivan suggested, we need a way of somehow creating a repository for stuff about mental health innovation so that we don’t reinvent the wheel.

For me, I wonder whether the default expectation that the state and the NHS will be the ultimate solution to the challenges that a mental health difficulty presents actually prevents us from seeing mental health innovation as an intellectual area in its own right.

When it comes to people with mental health difficulties trying to sort stuff out it sometimes feels that rather than speaking to each other, we go straight to speak to services. I wonder if we mirror that in our thinking about projects and innovation by just talking to funders and decision makers and failing to actually speak to our peers?

More broadly than that, at a very basic level you can’t innovate without knowing what’s happened before, which makes me think some thing even more intriguing: Maybe all of these ideas really were new to people who were used to working within services and structures? What seemed like a revolutionary eye opener to someone new to this notion of innovation and change in mental health may have been what had me sticking my hand up and saying ‘that’s great. There’s been projects that have done similar before.’

Innovation of course doesn’t need to be a new idea. It can be a very old idea applied in a new way. What to someone all wide-eyed with the rush of excitement that comes with first exploring a new ideas  sounded like me pooh-poohing and saying ‘it’s all been done’ was actually me saying ‘the paths that have been explored in that direction have been interesting, explore further’.

At a more fundamental level, most people don’t know what people with mental health difficulties actually want, because they’ve never asked them. More broadly, most people don’t have a broad idea of where mental health difficulty fits into a life.  We don’t see people with mental health difficulties in demographic terms.   It’s still ‘take your medicine’. It’s like identifying that a) people like tea b) teapots sometimes leak and then trying to issue each person who likes tea in the country with a galvanised steel tea funnel which needs to be fitted to their tea cup by a qualified fitter.

The point we would raise is: How are people going to get ‘up to speed’ with what’s been happening and what does it say about the current situation that they aren’t?

 

Observation 5: We are awful at market research in mental health 2: The mental health pound

In our roof top breakout we were thinking a lot about sustainability, or to put it more bluntly, where’s the money?

What we realised is that in a situation where 82% percent of mental health services are still commissioned by by the NHS, it’s going to be a challenge to unshackle innovation in mental health from the particular needs and wishes of existing mental health services. They have the cash. They may not think they do, but they do.

This set us thinking more broadly about models for sustainable projects and sustainable innovation in mental health.

For something to be economically sustainable and to be able to offer a financial return on investment it needs to do the following: “it needs to sell people something they want, on terms they understand, at a price they’ll pay”.

Again, so far, so A level business studies. But, this gets complicated in mental health. Who really is the customer for mental health innovations? In other words, who is actually the consumer?

When we’re innovating we tend to think first of selling it to funders in mental health. We tend to think about selling to people with mental health difficulties last.

Let that sink in: We think last about selling our projects to the people who will use and benefit from them.

What kind of a sustainable business model is that? Think of the customer last?

What we realised is that no actually thinks of people with mental health difficulties as consumers in the classic sense, as people who can vote with the feet, purses and wallets.  We didn’t even know any stats about how people with mental health difficulties actually use tech like the internet and smartphones, which you’d think would be important for something like #mindtech.

We realised that a major barrier to investment from beyond the NHS was the fact that we don’t actually know what people will and won’t pay for and at what price, because we’ve never found out. This set us wondering: What is the value of the overall mental health economy in the UK? How much is actually spent? We can get figures for NHS spending and perhaps social care spend and maybe charity spend. What about self funders? What about things that people with mental health difficulties spend their money on to help them to feel well?

Just what is the value of the mental health pound in the UK?

This may seem like an odd question but look at it in these terms: We complain about the under-investment in mental health, by which we usually mean the lack of money collected via taxation that in given to mental health services delivered by the NHS. If that is going to be increasingly squeezed by recession, what steps can we take to bring other investment into mental health and specifically mental health innovation?

The money has to come from somewhere (although there are ways of making money go much further by using it differently)

The NHS can be an excellent catalyst in mental health, but it still holds too many of the reins to make it possible for innovation to be truly disruptive.  Very often it’s the people making the investment decision who are most challenged by radical innovations in mental health because those innovations don’t just modify how they do something but, in the way that the recovery model conflicts with the medical model, they modify what that something is.

In the spirit of disruptive innovation we would ask: Just what is the value of the mental pound in the UK and why don’t we find out what people want and would pay for?

 

Observation 6: Everyone can’t use it so no one can?

One thing I found really interesting at #mindtech was the idea that using a tech platform that more people use is better than using a specific platform that you definitely know some people use. When one of the introductory speakers was talking about Buddy, the mood feedback system, they said that they had decided against creating what they did as a smartphone app because many of their potential users don’t have smartphones.

This seemed to be translated by most at #mindtech into the assertion that most people with mental health difficulties don’t have smart phones therefore projects should be only be done on the platform that most people have access to, so in the case of all of the ideas that came out of #mindtech that meant doing websites.

In response to the point about smartphones, I tweeted that maybe we could stop whinging about people with mental health difficulties not having smartphones and just give people one if they don’t have one. Chris O’Sullivan pointed out that there are projects that have done just that and that it was a far cheaper thing to do than you’d imagine.

I think everyone who came to #mindtech passionately wants to change things for all people with mental health difficulties and this lent a utilitarian tone to many of the projects and ideas: the greats possible good for the greatest number of people.

I think that this either comes at tech innovation from a services improvement angle (How can we make tech part of services so services run better?) or an information provision angle (How can we give lots of information to lots of people?)

What was left out, I think, was the idea that tech is elective: You chose what you do and don’t choose to use. In existing services even the most simple forms of technology are elective; for example, some people choose to telephone to make an appointment, some would choose to do so in person, others might choose to use a different method if it was available.

There was still an air of medical thinking hanging over #mindtech, at least for me. There was a sense that the (probably accidental) consensus in some of the groups was how do we do a project for people to use? rather than how do we do a project that people will choose to use?

Yes, it’s obviously wrong to make the only way to book an appointment for your services an i-phone only app. That would be stupid. However, what if there is something that i-phones can do really well that an application related to people’s mental health might make use of?

Just because you can’t replicate the experience of using something for all people doesn’t mean that it should be discounted. My GP doesn’t know my email address because the practice has never asked. For my GP to send me emails rather than letters would be great for me, would save them money on postage and would be all together more efficient. I’d love it. It wouldn’t mean that alternative forms of communication shouldn’t be available. By the access logic, there’s no point in my GP exploring sending emails because we know ‘some’ people don’t have email addresses.

The point I’m driving at is that the idea of being able to build tech solutions to challenges that can be applied universally from day one is flawed.

The observation I’d feed back: Specific projects that do specific things with or for specific people are cheaper and less risky than big ones that do lots of things apparently for everybody

 

The observations we actually presented back to #mindtech (more or less)

High cost developments that need to be rolled out across thousands of people to justify the money that has been spent on them just mean that, counter intuitively, far more money is being risked, even if the universal nature seems to make them a better bet.

The NHS is rich with assets. Those assets are people and their knowledge, skills and ideas. At present they are sitting like funds in a dormant bank account, their additional potential to unlock mental health innovation unused.

Similarly, there is a huge amount of people with technical and business skills who want to make their communities a better place. These are assets that are not currently drawn into the world of mental health either.

Rather than bringing people to mental health tech projects that have been made by people with ‘their best interests at heart’, we would ask how can we take tech and mental health assets to people?

Instead of keeping assets locked up in statutory services and using them only to draw further funds into those services, instead of reinventing the wheel or do-gooding on behalf of people with mental health difficulties, why don’t we work on ways of giving knowledge and tech assets to existing groups to find ways of using those assets to come up with projects that meet their mental health needs?

Or even to come up with micro enterprise ideas that involve coming up with services that can be sold or invested in?

We’d suggest small amounts of money can go a long way to supporting the process of innovation for solving problems for small groups of people and that fostering small innovations in communities in mental health and tech might actually come up with more ideas that can be developed or tried in other places or with other groups.

People in communities may not have specialist knowledge but they have ideas and experiences. If we are sitting on a huge store of knowledge and expertise then we should be looking to spread innovation to community level so that when mental health and tech ideas happen they happen with the full involvement of the people who are supposed to benefit from them.

Big isn’t always better and for innovation to be disruptive and really change things it needs freedom to happen. Improving services is awesome, but that’s not the only thing innovation in mental health can do.

 

There’s a lot more that I could say about what we were discussing up on the roof, but I think that’s enough to be going on with. Hopefully Chris O’Sullivan ( @mentalcapital ), Katie Brown (@Re_connection) and Clodagh Miskelly (@miskellaneous ) will be blogging or writing up some of their thoughts.

(This post originally appeared under the title ‘#mindtech – Observations from a Rooftop’ at the One in Four blog

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


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People, design, tech, mental health and avoiding shovelling money in a hole #EHWK15

Text of talk given by Mark Brown in the session ‘Co-design for Mental Health – Patients, Clinicians and Minecraft: How We Need to Work Together in the Digital World’ at UK Health Week 2015 on 4th March 2015 at London’s Olympia

In some respects I think I might be preaching to the converted here, but bear with me for 15 minutes.  The title is “How we need to work together in a Digital World”; so I’m going to share with you the process by which the HTML5 web app Doc Ready came into existence and share some observations along the way.

Hands up:  I’m not a tech person, or a design person. I’m a mental health person.  I experience mental health difficulties myself and I spend the majority of my working life in mental health.

I was lucky enough to be involved with the development of Doc Ready, a very simple web based app that does one thing and one thing only: it helps young people (or anyone else) prepare for their first visit to the GP to talk about their mental health.  It was delivered by a team comprising of Enabled by Design, FutureGov, Neon Tribe and my own company Social Spider.  For securing the contract to begin development to launching a public beta of the app took five months.  Which was pretty nippy, I reckon.

Often in mental health we make services that people don’t like. It’s really easy.   All you need to do is not spend time listening to people,  follow only what desk research tells you is best, don’t show users what the service will be like and then only let them try it once it’s finished.  Unfortunately with Doc Ready, we didn’t do this.

Working with people makes sure you avoid putting loads of effort into solving a problem that doesn’t really exist with a solution that doesn’t really match the issue it addresses.  I keep looking at mental health services in general and thinking: ‘I can’t imagine what user expressed problem is is being answered by the way this service is designed.’

All projects have constraints.  These may be financial, technological, political, knowledge-based.  Blue sky thinking, that is thinking without taking account of constraints,  is brilliant when you’re trying to come up with ideas.  It’s bloody awful when you’re trying to solve problems.  The way that Doc Ready was developed involved the people making it directly interacting at all stages with people feeding in their views, ideas, preferences and insights.  In doing so they could respond directly to ideas being fed in.  This constant feedback forced us to think differently about aspects of the projects and our responses to that feedback invited those providing it to bring their own invention and ideas to the problem.

Traditional public sector involvement mechanisms generally begin from the position that the problem has already been identified and that ‘stakeholders’ will feed into its eventual solution.  The professionals set the agenda, shape the interaction then weigh up the contributions.

Doc Ready came into being by a different route via The Paul Hamlyn Foundation/Mental Health Foundation Innovation Labs programme.  Across two Labs ideas for digital mental health projects were created by young people; then a selection were refined through further collaborative work.  These were then put out to tender, with funding coming from Comic Relief and, in the case of Doc Ready, the Paul Hamlyn Foundation itself.  I was there at every stage, from Lab one all the way through to launch and beyond.

Engineers solve problems. Co-production in tech is about delivering great problems to engineers then telling them their solutions don’t work repeatedly until they do.  Rather than assuming people already know the solution to the problems they identify, the process of honing the problem to be solved down should move from people knowing stuff about their own lives, to thinking about what that means, to thinking about how that might be changed.

This process can be seen in the way that Doc Ready only became Doc Ready in the second Innovation Lab.  It began the day as an evolved Lab 1 idea about building a Star Trek type translator for GPs that would turn teen speak into doctor speak.  The problem that had been identified was a real one – young people feeling that GPs didn’t understand them – but the solution wasn’t quite right.

In my experience when put on the spot and asked to come up with a solution to a wicked problem; people usually come up with an idea that isn’t actually THE answer but one that actually helps to clarify the problem further.  By the end of the second Lab, our small group of participants had turned it around to being something that young people could use to prepare what they said and the basis of what later became Doc Ready was established.

One of the basic rules of innovation is ‘listen to people, but listen to the right people’. We co-produced Doc Ready by making sure that everyone involved in the process was doing the bit that was best for them to do.  You can’t bolt on co-production to an existing project model, it’s about making sure that the right people are in the right place at the right time to move a project forwards.

Throughout Doc Ready’s development we spent time with people, checking all the way along the production process to see that what we were developing was in line with what people actually thought might work.

This isn’t what usually happens in mental health.

Traditionally involving people with mental health difficulties in projects has been done in two distinct ways, neither of which is particularly innovation friendly.

The first way is consultation. Usually this involves asking people what they think of a particular thing prior to it being developed or put into action. It can also be asking them what they thought of that thing once it has been put into action (or ‘brought to market’ for all of you product development types).  This can usually be reduced to the question:

‘How much did you like our goods and/or service? a) Loads, b) lots, c) quite a lot, d) loads and loads and loads or e) I hated it.

The other form of involvement is the strange beast that is now masquerading under a number of guises, the most recent of which is ‘crowdsourcing’. Crowdsourcing is actually a term that describes ways of people feeding in small bits of something (ideas, money, processing power) to build a bigger something.  It doesn’t mean just asking people for ideas, like when a  service or project will ask a group of people with mental health difficulties ‘so, tell us what you would like or tell us your ideas.’  This is often accompanied by lots of open gestures inviting people to share their ideas.

It may sound like this is more likely to generate good ideas for change, but usually it doesn’t. Putting people on the spot and asking what they’d like generally delivers responses that look very like what people have had before.  Innovation is a process, not an endpoint   It also makes no difference at all if the organisation doing the asking holds all of the cards and plays them very close to their chest, failing to give any indication of whether it financially or organisationally possible to take any of these ideas forward.  Most people aren’t app developers.  Most mental health professionals aren’t app developers.  Both groups might be app users; both will have different perspectives on what problems need to be solved.   Both will probably not pull a winning tech idea out of their hats like an end-of-the-pier stage magician.

Consultation doesn’t change things because it only asks how much people like your idea, product or service.  It doesn’t really involve any collaboration at all.  ‘Crowdsourcing’ looks as if it changes things but actually doesn’t, as the there is a fundamental dishonesty at work; we’ll ask you for your ideas but we’ll only do the ones that suit us and we’ll never tell you the reason why. It looks collaborative but is, in most cases, just a way of dressing up consultation as participation without fundamentally changing the way it works.   Being cynical, ‘crowdsourcing’ just assumes that no one who belongs to a category of people who experience difficulties could come up with a worthwhile idea in the first place because it separates them from any of the mechanisms they might be involved with to make the solution to a problem happen.  People who say ‘ideas don’t care who has them’ are usually people who want your ideas for their own and have no intention of involving you in any future application of them.

The Innovation Labs used persona work (collaboratively making up a fictional character representative of a particular set of user needs based upon real experience) to enable those involved to bring their knowledge of the real world of mental health difficulty to bear upon the question of ‘what could be made that would make life better?’  The development of Doc Ready used the same technique.

Instead of saying to people ‘what are your problems and how do you want them solved?’, the process asks ‘what kinds of challenges might different young people with mental health difficulties face and how haven’t they been answered so far?’  Using persona allows people to move from just discussing their own experience to collaborating on ways of solving problems faced by others.  In essence, it helps us to move on from either of the two traditional involvement mechanisms in mental health.

For anyone’s involvement in a project to count for something it must have a weight and a value. The best way to give it that weight and value is to make sure that it is directed toward advancing the progress of that project. If you’re trying to build something for people to use, how can it make sense to leave people out of the process of building it?

Often people who experience mental health difficulties are involved in projects on the basis that ‘they have lots of personal experience’ but in ways that are actively structured to minimise the importance of their contribution. Asking for people’s opinions or people’s ideas without any idea of how they’ll change the shape of your project might be market research, but it sure isn’t involvement. And it definitely isn’t co-production.

When I talked to people about the Doc Ready idea their response ranged from ‘cool’ to erm…’. Some of them had plenty of opinions about how it might, or might not, work.  However, as expected this didn’t really give us any solutions about how to make Doc Ready happen or what the final thing should actually be like.

This is why it makes sense to co-produce and co-design.

In app development it’s also pointless showing people a photoshop mock-up of your app and asking them what they think.  They’ll either say ‘lovely!’ or ‘rubbish!’.  This won’t tell you anything about the thing that you’re actually making.  As the folks from Neontribe are fond of saying “Photoshop mockups sign checks with the end user that your development team can’t cash.” The point being it’s only worth showing people things they can break, play with and make fall over.

Adopting ‘fail often, fail fast’ and other similar lean development mantras we sprinted ahead and created six paper prototypes of ways the app could work. Made entirely out of paper, these were real concrete devices with sliders, buttons, text panels, menus, and even pop-ups. Watching testers try them out and pull them to pieces gave us direct, experiential insight into the functions and methods of interaction that people would value most in the app.

Using this learning we built a quick, rudimentary working version of Doc Ready. It included a version of the cloud of experiences and feelings that was very detailed. When we showed this version to people they hated it.  So we created the same function in a different way, with more space for people to input their own experiences and far less ‘symptoms’. They much preferred this.

What’s important to realise here is that it didn’t matter how much we’d talked to people about how this core bit of the app would work, it was only when they saw it and used it that they could see what they did and didn’t like about it.

It’s vital in innovation to have this kind of flexibility in your development process. You may need to change, change and change again before something works; so quickly getting to the point where you have something you can test is vital.  If you don’t, you’ll be a year and 90% of your budget into your project before the people who you’re building it for get the chance to tell you it’s crap.

In a mental health service world of limited resources and squeezed funding it’s tempting to see doing stuff with people and spending time with them as a luxury.

But if you don’t spend time with people, if you don’t get up really close to how they feel about the problem you think needs to be solved and as importantly keep returning to those people every time you think you’ve solved one of the problems they set then you might as well dig a great big hole in the grounds of your building and shovel in bundles of cash each day gnashing your teeth, shaking your fist at the sky and howling inconsolably ‘we built it and they didn’t come.’

Which is no fun at all.

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

(Much of the content in this talk appeared in a different form at the Innovation Labs website)

 

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Is #mentalhealth anti-stigma work a drive for acceptance or a driver for change?

The below is the original draft of an article by Mark Brown which appeared in a different form at BBC Ouch under the title ‘Viewpoint: Talking about mental health is just the first step’

More people in the UK than ever before are talking about mental health and mental illness.  On February 5th this year, people will be encouraged to spend five minutes talking about mental health as part of the second annual Time to Talk day, an initiative of the national anti-mental health stigma campaign Time to Change.

Launched in 2007, Time to Change is a partnership between Mind and Rethink Mental Illness, two of Great Britain’s largest mental health charities.  Its website states that it is a “groundbreaking anti stigma campaign across England to challenge attitudes and change behaviour around mental health problems”.  Time to Change is based on the idea that more people speaking about mental health difficulties will remove judgemental attitudes toward those people who experience them.

Stigma is the interaction between people or characteristics that society feels unacceptable and the people this labels.  Experiencing a mental health difficulty can be isolating and frightening.  We can find ourselves unwilling or unable to talk to others about the things we experience because we are fearful of the consequences.  People experiencing mental health difficulties like schizophrenia, bipolar disorder, eating disorders and depression have often experienced prejudice, discrimination and have often been  excluded from areas of life and community in which they might otherwise expect to take a full part. Part of stigma is the internalised feeling of shame for being what you are, and receiving positive responses rather than negative ones can help to dispel this feeling.  From an individual perspective, it can be liberating and validating to be able to ‘come out’ and speak about difficult experiences or sensations.

To date, Time to Change has received £38million in funds to change our minds about people with mental health difficulties: £18m in its initial phase, £16m from the Department of Health and £4m from Comic Relief in 2011; with more funds promised to carry the programme beyond the end of its current funding March 2015.  According to Mind, the most recent National Attitudes to Mental Illness survey, carried out in 2013, found that “since the beginning of the current programme of Time to Change (2011) an estimated two million people – or 4.8% of the population – have improved attitudes towards people with a mental illness.”

Whether the rise in positive attitudes translates into an improvement in the lives of those with mental illnesses is something critics of the programme question.  Time to Change was launched at the beginning of worldwide financial crisis and has run alongside  austerity reforms to social security protections such as the removal of Incapacity Benefit, the introduction of the Work Capability Assessment and cuts to social care and NHS funding which some source allege disproportionately affected the lives of many people with mental health difficulties.  Critics of Time to Change claim its approach is too shallow and does not examine ways in which prejudice and discrimination can be structural as well as personal.  Some liken Time to Change to similar campaigns in the broader Disability world which have focused on slogans such as ‘See the person, not the disability’ which focus on being ‘nicer’ to individuals rather than changing structures, laws and circumstances that disadvantage Disabled people collectively.

Some argue that Time to Change actually makes it more difficult for people who do have stigmatised experiences such as voice hearing; or who have periods of illness or symptoms that disrupt their lives; by pushing these less palatable experiences to the margins in an effort to sanitise the image of mental health difficulty for public consumption.  A subsection of campaigners and activists feel that the focus on the telling of personal stories of mental health difficulty to fight stigma has individualised understandings of mental illness, moving the debate further away from what concrete, collective social changes need to be made to support people with their mental health.  These people would claim that shame is not their problem but systematic prejudice and discrimination.

Over the lifetime of Time to Change discussion about mental health has risen in prominence in the public sphere, as have media portrayals and news coverage. The Liberal Democrats, as partners in the current Coalition government have given prominence to mental health within their campaign for this year’s general election and have promised new funds and standards for NHS mental health care.

As with all mass campaigns; a message clear enough to penetrate the background chatter of everyday life is in danger of losing some of its nuance and context.

The focus of Time to Change is not solely on encouraging people to have their first conversation about mental health, but this has been its most prominent call to action. The conversations that Time to Change encourages, from five minute chats to grand media saturated political performances are an attempt to build the platform for a wider change.  There is a danger that the people talking about personal experiences and others accepting them is seen as the goal.  For each year that it and programmes like it continue, the number of people who have already had their first conversation about mental health will grow.

Today, on Time to Talk day, some already comfortable speaking about mental health and mental illness will asking: if we’ve started people thinking and talking about mental health and how they behave towards people with mental health difficulties, how will we move people on to thinking about the way that society as a whole treats those same people?

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

 

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The best effing lonely – social media and #mentalhealth

The following is the text of a talk given by Mark Brown as part of a panel discussion at London’s Dragon Cafe on February 2nd 2015 addressing the topic ‘We need to talk about… The impact of of technology and digital culture on mental health’

Hello.  I’m @markoneinfour off of that twitter.  I do mental health stuff and I bloody love social media, even when I really hate how some people use it.

I wouldn’t be here talking to you if I hadn’t come across the madosphere, the mental health blogosphere (what we had before we did twitter).  It was people like my fellow panelist Seaneen Molloy-Vaughn who showed me that people like me could own language and ideas about mental health and that it was possible for ‘us’ to define an identity that wasn’t limited by what ‘they’ said we could and couldn’t say. It was the madosphere that inspired the mental health magazine One in Four that I ran for six and a bit years and which still inspires the mental health and digital stuff I do now (which I’ll tell you more about later!)

 So first thing: social media is here, and rather than being something new, it’s like telly, it’s like radio, it’s like text messages, phone calls, cinema, telegrams, the printing press, telephones.  Just more so.

The social web is a lot older than you’d think.  Think widespread blogging is new?  Blogger the blog platform launched in August 2000.  Think tweeting or facebooking is a new thing?  Twitter launched in July 2006, a few months before facebook got its first newsfeed and started to look like the facebook we know and love (or hate).  Youtube launched in November 2005.  Social media is weird.  It feels ‘new’ at the same time as feeling like it’s been around forever.

We still struggle to work out where it fits in. Opinion varies from ‘it’s completely irrelevant’ at one end of the spectrum to ‘it’s the most dangerous thing that has ever happened in the world EVAH’ at the other.

Social media doesn’t just happen in front of a desk top PC.  It happens in your pocket or bag, it happens on the bus, it happens in hospital (if you’re lucky), it can happen anywhere you’re getting an internet signal.   The price of things like tablets has dropped through the floor over the last couple of years and the UK has a surprising amount of free wifi hotspots.

People from all around the world who experience mental health difficulties are ‘meeting’ each other in social media.  We’re reading blogs written by each other.  We’re watching youtube videos starring each other.  We’re listening to audio recorded by each other.  We talking to each other in facebook groups, in comments sections of websites, on twitter…  Anywhere there is a space for people to share, speak and comment there is a space for people with mental health difficulties to run into each other.

According to an Ipsos Mori survey carried out for the National Audit Office published March 2013, thirty seven percent of of people with a declared disability were offline compared with fifteen percent of people without a declared disability.  We do not currently know how many disabled people, or people with mental health difficulties are regular social media users.

Still, though, social media has become a space where people with mental health difficulties are finding each other in large numbers

And, in the tradition of large families finally managing to meet for the first time, we’re finding all of the things we all have in common and all of the the things where we really have nothing in common at all.

I think we’re seeing the beginning of a real mental health public opinion, where different groups of people assemble around different ideas.

It used to be really difficult to organise something or to find something out.  Most of the time you needed to know lots of other people and they needed to know lots of things.  Your ability to publicise what you did depended on your budget and access to a photocopier.  Your social relationships were limited by who you could actually run into where you lived.  Loads of people with mental health difficulties never ran into anyone who experienced similar things to themselves unless they were lucky or currently in hospital or accessing some kind of care or support.

For many of us, our mental health difficulties have been misunderstood and in some cases shameful facts of our lives.  Unless we were lucky and met people near us, in the past we have tended to communicate vertically with public services and charities providing us mental health support (evaluation, consultation). Social media lets us go horizontal, talking ‘peer-to-peer’ with others with similar experiences across the world.

Social media, has created conditions where people who were previously isolated or marginalised can meet each other ‘face-to-face’ to share, debate, argue, build, destroy, criticise, praise, organise and develop.  It’s also created spaces where mental health difficulty isn’t hidden.

Social media then, is a space where we can learn from each other, debate with each other, band together and try to make change with each other and challenge the idea that who we are, want we want and what are lives mean should be defined by others.

For many of us social media at its best is a space where we meet with other like minds, discuss, share and learn, both about others and ourselves.

What’s interesting is that social media is, still, somewhere there is a more level playing field between established ‘professionals’ and the rest of us.  Some mental health bloggers have more readers than the trusts that provide them services.  Some people with mental health difficulties on twitter spark far larger debates than professionals in the same space.

Social media is still, for the time being, a place where we can find power we might not access in other ways and other places.

Most of social media happens to some extent ‘in public’ or at the very least involves interacting with people, often strangers.  People keep talking about the risk of social media.  There’s no doubt this risk exists, but it is, sadly, no different from the risks that exist in the offline world.  Women experience misogynistic abuse online and offline too. Racism, sexism, homophobia, hideously prejudiced ideas about mental health, all exist online too. But without risk there’s no possibility of something new.

Social media is here to stay.  It can be awesome.  Much of my life after my period of ill health and unemployment is, in some way, related to taking risks in social media.  I literally wouldn’t be doing the speech today if I hadn’t posted some bits of writing online back in 2002 and got talking to people.

There are huge potential benefits and also sometimes huge drawbacks.  When awful stuff happens on social media it doesn’t feel like it happened in a distant computer place.  It feels like it happened whereever you checked your facebook or looked at twitter.

We need to stop asking ‘is social media bad for our wellbeing?’ and ask ‘how can we make sure people are getting what they want and need from social media?’

I just want to finish on a brilliant tweet I saw someone retweet on twitter.  I know nothing about the person who tweeted it, nothing about where it’s from,  but I thought it was a good place to end.  It’s from:

https://twitter.com/NJPsychDoc/status/294599813322928128

‏@NJPsychDoc and the tweet goes:

My Therapist said that twitter is for lonely people. That dumb-ass idiot doesnt realize this is the best fucking lonely ive been in years.

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

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“An entirely uncynical, cynical move”: On #mentalhealth and politics in election year

On Thursday 7th May 2015, the UK will elect a new government.  Mental health has been a surprising issue in the early stages what will feel like a long campaign.  Mark Brown examines why this is and what it means.

So, what are we to make of the the foregrounding of mental health in the run up to the General Election of 2015?  Chris Naylor of The King’s Fund, writing on January 22nd, summarised much of the political activity around mental health of the opening months of the election campaign,  raising the issue of the potential for the gap between rhetoric and reality.

Mental health blogger and tweeter @sectioned_ has drawn together all of the various mental health manifestos of recent months, into one handy blog post and it’s clear from looking at them that there is an ever accelerating sense of jostling for advantage in the run up to the election.  All demand that something be done, but most tend to situate that something roundly within the health policy arena or within the agenda of returning people to the workforce.  There is little discussion of things like stronger social security safeguards to protect people with mental health difficulties from things like poverty and exclusion and next to no discussion of mental health within the context of other areas of policy, human rights and law.  The various manifestos appealing for change broadly reflect the interests of the organisations that drew them up.

But how did mental health arrive so prominently on the agenda?  To understand that, we have to understand the interplay between Coalition politics, the major pressure groups and lobbies in mental health and the growth of pubic opinion in favour of positive approaches to mental health.

 An uncynical, cynical move

The Liberal Democrats have very few things from their time in Coalition that they can say are uniquely theirs.  There’s a number of things that they can say they prevented happening; and a number of things that they can say that they reduced, altered or otherwise modified before they became policy.  Few of these give them good, clear, untainted LibDem space.  They’ve hit upon mental health as an area where they can add something and receive relatively uncomplicated positive coverage.  ’We secured X-million from the Treasury that otherwise have been spent on something else‘ is an achievement that is measurable, concrete and which very few people are likely to describe as a bad thing.  In some respects its a way of appeasing the left of their own party, as the Liberal end of the party (Orange Book LibDems) has mostly dominated the party in its recent period.

It’s true that Norman Lamb, LibDem Care and Support Minister and Libdem Deputy Prime Minister Nick Clegg have secured some Treasury money for mental health that might otherwise have gone somewhere else but that is in a situation of reduced overall spending on mental health as a whole.

Of course, any promises and commitments have no validity past the General Election.  If it’s promised for post-2015 it’s an aspiration, not a commitment.  Which is great for all involved politically, and for less critical campaigners, as its possible to make great talk of principles, growing the idea that we are moving out of the dark ages by sheer volume of discussion.  As a lobby it makes sense to grab what wins are possible in mental health by capitalising on the LibDems hunger for a legacy; the need for differentiation; and the need to be the unequivocal good guys is great.

But for all of the noise, the overall political, policy and economic situation hasn’t actually shifted.  Mental health is one of the greatest public policy challenges we face.   It’s fantastic that the LibDems in government are signaling that they understand the extent to which mental health and mental illness constitute hugely challenging problems, even if their own party doesn’t see mental health as a vote winner (This blog post by Mark Pack is worth a look: “For people to vote Lib Dem on the basis of this policy requires people to believe the Liberal Democrats will implement it – that the party is effective, can be trusted and has a political future.”).  My assessment is that its an absolutely cynical non-cynical set of actions, which is exactly what all politics really is.  And, of course, the much trumpeted spending is desperately inadequate to achieve the policy end that it talks about.

The Time to Change moment

We are in the midst of something that I’d call the ‘Time to Change’ moment.  There have never been more people aware of mental health as an issue.  This is a different to previous periods in that this awareness is broadly benign, but it isn’t quite a social justice movement either.  More people than ever are ‘getting’ the message that mental health difficulty is difficult, challenging and can throw a spanner in the works of someone’s life.  This differs from previous periods of visibility in that Time to Change has reached shallow and broad: more people know a little bit about mental health than ever before, sometimes to the extent that there are two distinct mental health worlds: the world of generalised visibility raising campaigning and the more specific, gristly world of trying to make specific things happen.

The result is that more people than ever have a sense that ‘someone should do something about mental health’.  This is generally a good thing, but it tends to be slightly less discriminating and strategic than previous periods where there were strong and specific campaigns for particular things (the last I can think of is the campaign around the amending/ replacing of the Mental Health Act in 2007).  This means that any increase in funding or indeed conversation about mental health from Westminster circles will be applauded in an environment where people see the fact that these things are being discussed as a step forward.  This ‘Time to Change’ moment has swelled the gallery with people who are easy to please: people who are committed to mental health as an issue without necessarily being committed to following the policy detail of what makes for a good societal response to mental health.

At the same time: increasingly via social media, we are seeing the beginning of what we can call ‘mental health public opinion’.  People are finding that their ideas and analysis can and does shift offline events (mental patient costume, Samaritans Radar App).  This collective voice is quick to snowball; quick to move to fire and anger.  It is volatile; mercurial; and increasingly hungry for change while being despairing that change will come.  It wants things to do and it wants things to happen.

This developing, growing, changing group of people are creating a space where mental health change can happen and see themselves as actors not subjects.  They want to make things happen using the tools that they have but it’s worth remembering they are not online as campaigners or lobbyists as much as they are online as people.

Of course, money that is new money is great in a situation of systematic underfunding (see Shaun Lintern’s great work for Health Service Journal and Andy McNichol’s great work with BBC and Community Care).  The problem is that the Big(small) gesture doesn’t tackle structural issues.

The campaigning charity bind

Over the last five years or so the major campaign charities have found themselves wrong-footed by austerity and by a Coalition with which many individuals and organisations are less comfortable.  They’ve adopted a logic dictated by the need to maintain their place at the table ( some would cynically say maintain continued flow of taxation funded contracts, though this is less true now than it was in the New Labour period 1997-2010) that makes them celebrate every new piece of funding news as if it were a stepping stone to the levels of funding they, and many people, are desperate for the Treasury to release.

What exists in terms of specific news is often refracted through the lens of large public or civil society bodies; meaning that it is shaped ‘to meet the needs of our beneficiaries’ or worse ‘to meet the aims of our organisation’.  There is a simultaneous ‘writing down to ‘approach (‘we must make this understandable to our beneficiaries’) at the same time as there is a confusion as to what is being provided: information? Guidance? Reassurance?

This leaves much of interest that happens in mental health and the broader policy world taboo, as it is extremely difficult to write or speak about it in a way that does not imply a political or strategic endorsement on the part of the organisation.  The broader organisational imperatives of charitable or public organisations makes them reluctant to be seen to be pushing out contentious material or material which represents stories and events as they unfold.  Broader organisational aims may think in terms of responses and statements, but this removes much of the information and content required for people with mental health difficulties to widen their knowledge and to keep pace with unfolding and developing stories which concern them.

So, on one hand there is a knowledge gap where individuals are not receiving a continuous stream of interesting and potentially galvanising mental health-relevant material.  On the other hand the material they are often receiving has be ‘made safe’ by organisations placing themselves between the unfolding story and people with mental health difficulties; translating unfolding or historic events into messages for donors, policy makers, media or other stakeholders.

There has been some healthy friction betwen the large mental health charities and smaller autonomous campaign groups with no bridges to burn such as Disabled People Against the Cuts and Black Triangle Campaign over their lack of focus on areas such as social security cuts, benefits sanctions and cuts to social care.

The major mental health charities have felt they had their hands tied in broader campaigning as they felt the Coalition was fundamentally opposed to some of the things that their existence relied upon: mainly public contracts and general public sector spending.  As organisations situated within a political reality, they needed to avoid a protracted battle with the government which they didn’t trust to play fair.  That’s Realpolitik.  But the government wasn’t a single party government, it was a coalition.  With one junior partner looking to differentiate itself from the other, linked with a need to appeal to people within and without its party who felt that coalition wasn’t the best of ideas, there was grounds for the major mental health charities to help support some quick wins for the LibDems and some money coming into mental health that otherwise would have stayed in the Treasury.

It is also noticable that in the run up to the election, the more critical action by major mental health charities is also picking up pace: witness Mind’s recent amplification of calls for change in the benefits system and their Freedom of Information Act request based research into local authority spending on public mental health.

And in other political news

My sense is that mental health is an area that Labour are less comfortable on, as they are trying to avoid any discussion of increasing spending.  Where the LibDems are liberators of the Treasury gold for mental health, Labour are trying to avoid being painted as its pirates.  Labour’s focus is on the mental health of children and young people, the easiest sell to the electorate as it is couched in money saved and potential prevented from being squandered.  Their record on mental health during the Blair years was one of failing to really grasp the nettle and spending, spending spending but not necessarily on the best or rights things.  They’ll be playing up the failings and the underinvestment while making sure to acknowledge their mental health progressive colleagues in the LibDems.  It’s worth noting that the one policy that really did broaden the reach of mental health services, the Improving Access to Psychological Therapies programme, was a policy put into action by Gordon Brown after the ‘election campaign that wasn’t’ in 2007 when there was a real political need to show a positive spending action and few costed proposals on the table.

All of the large vested interests in mental health (major charities, royal colleges, trade bodies etc) are currently jostling to make sure that their particular interests are at the heart of the programme for the future government.  Mental health is in crisis.  Good things can happen in mental health.  Both of these things can and are true every single day.  New money to solve one problem doesn’t solve problems that don’t have enough old money.  Pledges and policies without spending set direction  but can’t drive it home.  Good things happening don’t also mean that bad things aren’t happening at the same time.

Given the likelihood of another coalition government, parties such as Plaid Cymru, the Scottish National Party, the Green Party, Democratic Unionist Party and others might well have an influence on the final shape of any mental health policy or spending through to 2020.

For better or for worse, Conservative plans and ideas for mental health are for many impossible to divorce from the large scale policies that are their legacy for this Parliament: The Health and Social Care Act 2012 and The Welfare Reform Act 2012.  Needing little extra help to claim the spotlight, the other party in the current coalition have been happy to clap approvingly at their junior partners mental health aspirations.

And UKIP doesn’t even have a bloody mental health policy.

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

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The debate about wellbeing and mental health: babies and bathwaters?

It seems obvious that our wellbeing influences our mental health; but recent debates in public health have complicated this view. Mark Brown explores where this debate came from and what it means for mental health

‘A little bit of what you fancy does you good’ would appear, on the face of it, to be an uncontentious idea.  ‘If I do things that will make me happier,’ we might say, ‘surely, I’m less likely to become unwell and experience mental health difficulties?’, but is it true?

Anything from having a cup of tea to meditation to throwing a stick for the dog might affect our sense of wellbeing positively.  For something so concerned with making life the best it can be, there is a surprising amount of discord around the idea of mental wellbeing.  Wellbeing, though, has unexpectedly turned out to be a surprisingly contentious idea.  And the idea that wellbeing (or its lack) and mental illness are connected has recently proven to be even more so.

In an extension of the idea that an ‘apple a day which keeps the doctor away’, Mindapples, a project originated by social entrepreneur Andy Gibson, takes forward the idea of five-a-day for mental health.  What began in 2008 online has grown into a series of workshops and training sessions. When you encounter Andy or one of his colleagues you’ll be asked it to take a card in the shape of an apple and write on each a thing that you do in your life to look after your mental wellbeing.  If you’re lucky, you’ll get to stick your apples on the six-foot high Mindapples tree and share what makes you feel better with others.  Writing for The Guardian in 2012, Gibson explained that he conceived Mindapples to “encourage people to think positively about the health of their minds. I wanted to create a campaign that did for mental health what the five-a-day campaign has done for physical health: to make taking care of our minds a normal, natural thing for all of us… public health has a bad reputation for telling people how to live. That doesn’t work for mental health.  It’s too personal, and in any case the evidence suggests taking prescribed actions to boost our wellbeing doesn’t really work.”

Mental health and wellbeing

Many of us are familiar with the idea that we should eat five portions of fruit and vegetables a day to remain healthy.  We’re mainly aware of it because, deep in the bowels of government, someone decided that we should know about it.  When Mindapples launched it was riding a wellbeing wave.  In the first decade of the 21st century before global austerity arrived European governments were turning increasingly toward the idea that the prosperity of nations depended on more than Gross Domestic Product.   No new mental health drugs were in the pipeline, so prevention seemed to be better than cure. Wellbeing was in and this time there was going to be an evidence base for it.

In October 2008, the Government Office for Science published the results of a two year Foresight review future-scanning exercise into mental wellbeing. The report Mental capital and wellbeing: making the most of ourselves in the 21st century suggested that as mental health conditions were rising it was vital that action was taken to attempt to reduce their severity and their cost to the public purse.  The report proposed that “achieving a small change in the average level of wellbeing across the population would produce a large decrease in the percentage with mental disorder.” If everyone looked after their mental wellbeing, the report suggested, then fewer people would develop treatable mental health difficulties.

As part of the review, thinktank The New Economics Foundation (nef) were commissioned to develop an equivalent of ‘five fruit and vegetables a day’ for wellbeing; an easy, catchy but science-based set of things that individuals could do to promote or safeguard their own mental health and which public sector agencies could promote.  These were: connect with people around you; be (physically) active; take notice of the world and people around you and find time for reflection; keep learning; and give your time and support to something that helps someone else.

The Foresight review also stated that wellbeing is influenced by the circumstances of your life.  Beyond strengthening individual’s wellbeing, it also suggested strengthening communities so that people could better support each other; reducing structural barriers such as poverty, discrimination and inequalities, increasing access to good-quality employment and housing; and improving where we live and the things around us.

The hypothesis of the Foresight review was that focus on general wellbeing could ‘pull the curve of the normal distribution’, meaning that if more people had lives with greater wellbeing these people would have greater stores of social capital, less outside stresses and more satisfaction with life meaning that mental health difficulty would be less likely to manifest with with severity requiring long-term treatment and support.  In essence, if more people had better lives then the incidence of poor mental health would be reduced.

 Promoting wellbeing

Action for Happiness is campaign to promote individual action to create greater happiness and wellbeing.  It has on its board a number of the luminaries of the pre-austerity wellbeing field including Lord Richard Layard, credited with making the case for greater government investment in talking therapies through Improving Access to Psychological Therapies, and Nic Marks, leader of nef’s wellbeing work.  According to Action for Happiness: “Although our genes influence about 50% of the variation in our personal happiness, our circumstances (like income and environment) affect only about 10%.  As much as 40% is accounted for by our daily activities and the conscious choices we make. So the good news is that our actions really can make a difference.”

Fast forward through five years of austerity and one change of government.  An early feature of David Cameron’s time in office had been discussion of the wellbeing and happiness of the nation.

When the reorganisation of the the NHS came into effect on April 1st 2013 as a result of the Health and Social Care Act, along with a number of other bodies Public Health England’s Mental Health and Wellbeing directorate came into existence charged with the job of thinking about the mental health and wellbeing of the public.  Building on the work of the Foresight report, for them wellbeing is “a dynamic process that gives people a sense of how their lives are going, through the interaction between their circumstances, activities and social, emotional and psychological resources or ‘mental capital’.”  Public health duties were also reassigned in to local councils, who have always had at the heart of their duty the promotion of the wellbeing of the people who live and work in their area.

Upsetting the applecart

On 9th of September this year the Chief Medical Officer (CMO) for England Dame Sally Davies upset the applecart by publishing her annual report.  Her topic this year was public mental health, looking at the ways in which the available evidence could be best used to improve the mental health of people in England.  Davies says she refuses to take a “leap of faith” and recommend wellbeing programmes without the evidence to support them. She advises that work to promote mental wellbeing should not be paid for out of funds for the treatment or prevention of mental illness or the promotion of mental health.  While supporting evidence-based programmes to act upon things like bullying, violence, employment difficulties and similar the CMO’s report also states that there is no evidence that promotion of wellbeing, through things such as the Five Ways to Wellbeing has any effect on the amount of people currently experiencing mental illness.

The definition of mental health promotion in the CMOs report is adapted from the World Health organisation:  ”Mental health promotion activities imply the creation of individual, social and environmental conditions that enable optimal psychological and psychophysiological development.”

For her, mental health promotion is about having systems and knowledge in place that get people to treatment early for mental illness, helping people to self managing their existing conditions and tackling things that evidence says leads to mental illness which crosses over with preventing things like bullying, better parenting, reducing problematic drug and alcohol use, reducing violence in families and acting on other risk factors for the development of mental illness.

In her introduction to the report Davies says:  “I conclude that our approach to this subject should no longer be framed in terms of ‘well-being’. I do not refer here to the concept of ‘well-being’ more generally as it applies more broadly across the business of Government or indeed to ‘health’ more generally. I welcome the consideration of the wider determinants of health in policy making. I reiterate that I refer here to the concept of well-being as relates only to mental health.

“After reviewing the evidence I conclude that well-being does not have a sufficiently robust evidence base commensurate with the level of attention and funding it currently receives in public mental health at national and local government level. Well-being, as a field within mental health, has not evidenced an acceptable definition or set of metrics. It is unclear how concepts and measures that do exist relate to populations with mental illness.”

Davies specifically targets the hypothesis contained in the Foresight review, setting mental health needs against overall population wellbeing:  “Contrary to popular belief, there is no good evidence I can find that well-being interventions are effective in primary prevention of mental illness, or can ‘shift the normal distribution curve’ described by Rose and hypothesised by the Foresight report in 2008. The result is that the public health needs of approximately 1 in 4 of the population who have a mental illness, 75% of whom receive no treatment, risk being side-lined in the enthusiastic pursuit of a policy agenda that is running ahead of the evidence.”

She goes on to say: “If we take the lead from the WHO and frame the subject as ‘mental health promotion’, ‘mental illness prevention’ and ‘treatment and rehabilitation’, then it becomes immediately apparent that we already have a good deal of evidence supporting a public health approach to mental health, and that effective and cost- effective interventions should be the priority.”

The report states that while wellbeing promised much and features in many government policies, including the current national strategy for England’s mental health No Health Without Mental Health, definitions of wellbeing differ and it is something difficult to measure.

The report caused consternation for those in public mental health, signalling for some a return to heavily medical models of mental health focusing on illness rather than health.  Some questioned it was too early to state that the evidence wasn’t there for wellbeing.  Others questioned whether political and policy perspectives might be shifting in the face of austerity-era policies. Others were disappointed that the agenda was moving away from changing policy and challenging inequality.

Of the report Dr John Middleton, Vice President for the Faculty of Public Health, said: “The CMO’s very comprehensive report makes some important and powerful recommendations, many of which FPH thoroughly endorses.  It is important that health and social care commissioners, public health practitioners, clinical commissioning groups and local authorities realise that her report looked at wellbeing in the context of mental health. The conclusions do not apply to the considerable role mental wellbeing plays in the promotion of physical health and the prevention of unhealthy lifestyles and physical disease.”

Paul Farmer, chief executive of national mental health charity Mind sounded a similar note: “Our own research into ‘ecotherapy’ initiatives such as gardening or outdoor exercise shows the impact that general wellbeing programmes can have but we agree that the evidence-base for wellbeing services isn’t as strong as it ought to be. This, for us, is another example of how far mental health lags behind physical health. We have come to understand a great deal over many years about preventing heart disease and stroke, with robust evidence that underpins a national public health programme. We need to see the same sort of investment for research into the impact of public mental health programmes.”

In a blog post public health professional Mark Gamsu pointed out that the medical nature of the CMOs discussion of wellbeing avoids looking at inequality, meaning wider social determinants of mental ill-health are missed, turning the mental health focus back to mental illness services and away from the potential of public policy to affect people’s mental health:  “This is primarily a clinical report (not surprising with approximately 90% of the authors being medics) the wider social conditions that people live in receive insufficient attention. Frankly, given the evidence that the bottom quintile are more than twice as likely to be at risk of mental illness than the top quintile this is more than a small omission – this is very poor – not good use of the evidence.”

Confusion or clarity?

In October this year Mind published the results of a series of Freedom of Information Act (FOI) requests to local authorities in England that found that they on average spend 1.36 percent of their public health budgets on mental health prevention.  Mind stated:  “The total annual spend by local authorities on preventing physical health problems is considerable, including increasing physical activity (£76m), anti-obesity (£108m), smoking cessation (£160m) and sexual health initiatives (£671m). Mind’s research indicates that the equivalent spend for preventing mental health problems is a fraction of this, at less than £40m. When reporting on spend for different public health priorities, local authorities file public mental health under ‘Miscellaneous’.

“Responses from many areas also painted a picture of enormous confusion about what local public health teams should do to help prevent people becoming mentally unwell. In others, it was clear that public health teams didn’t know it was part of their responsibility in the first place.”

Reasonably, some have questioned whether it was too early to state that the evidence wasn’t there for wellbeing and its interaction with mental health and mental illness .  Others have questioned whether political and policy perspectives might be shifting in the face of austerity-era policies.  It’s possible to see the CMOs report as a kind of back-to-basics approach centering public mental health in the provision of services rather than in the modification of policy.

There is, of course, a difference between what we ‘know’, what we can prove and what we are happy for taxes to spent upon.  While it may feel ever more important that we do what we can to look after our own mental health in the face of difficult times, it seems that, at least in some quarters, the tide is shifting away from the idea that anyone can advise on a set formula to help us to do so.  For some, including people with mental health difficulties fed up with being told to ‘go for a run’ or to ‘take up a hobby’ this may be a relief but for others it will feel like a re-medicalisation of mental health.

While it may be true that many wellbeing for mental health projects have lacked a strong evidence of impact, it seems there is potential to throw babies and bathwater into the same re-medicalisation of focus.  There has been little work to date focusing on the wellbeing of people with mental health difficulties.  The arena of wellbeing has been a place to begin this work, even if it has not yet hit its stride.  While the CMO may be correct in her assertions they do not suggest a path forwards for understanding and developing services that will make life with a mental health difficulty better; an area that inevitably leads us away from medicine and into the realm of politics, economics and social organisation.

It is notable that the CMOs report is very favourable towards Time to Change and anti-stigma work in general; seemingly supporting an idea that people who experience mental health difficulties will become a population indivisible from those without mental health difficulties given a reduced level of stigma, timely treatment and strong prevention work.

Simply looking at mental health in terms of diseases, cures and preventions may take focus away from the role that policy and government has in helping create the conditions for people with mental health difficulties and those without to have a good, fulfilling and enjoyable life.

This is a much extended version of an article that was commissioned by BBC Ouch which appeared on 8th October 2014 under the title ‘Does wellbeing improve your mental health?

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

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Psychiatry versus the robot army

Short talk given by Mark Brown at Mind, Body, Spirit: Psychiatry in context in London as part of a panel debate Digital Psychiatry: will advancing technology support or destroy the patient-professional relationship?

I love the title of this panel discussion: will advancing technology support or destroy the patient-professional relationship?

Right there, first and foremost you have a title that presents psychiatry as an embattled state, surrounded on all sides by the mechanised forces of technology.  Think John Connor in the Terminator films, the last chance of humanity triumphing over the never-sleeping, never-resting, relentless loss of ground to the grinning, robotic, unfeeling machines that threaten to make such fleshy, inconsistent, emotional creatures obsolete.  Support. Destroy. Advance. Exterminate!

Is this really the case, though?  Is there are anything that is really under threat right now that wasn’t under threat ten years ago?  Twenty years ago?

The language that we’ve chosen to frame this debate with speaks very much to the idea that digital technology is increasingly moving into areas that previously had been the domain of non-digital effort.  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 again, ready to leap out and take away everything they hold dear, including their jobs.

Digital encroachment is not always a comfortable experience, especially when it’s your labour that’s being encroached upon.  There’s a tendency for all of us to see the way that we do things as being vital to the final outcome of what we’re doing.  We take pride in our craft, in our method, in doing the things we’ve been trained or learned to do.  When new possibilities for methods of achieving that outcome become available we begin to feel worried.  What if our craft become obsolete? What if something is lost in the process of something being gained?

This must have been how the monks felt when Johannes Gutenberg turned up with his new fangled printing press, and look how that turned out.  If your purpose was to make books more widely available it was awesome.  If your purpose was to continue to engage in the practice of copying by hand, well, history shows that your role was to become slightly less central than you might have hoped.

One question we must really be asking is ‘which technologies are we talking about?’ Are we talking about a particularly threatening copy of OpenOffice here? Or are we really talking about the potential of digital technologies, including the advances in internet enabled devices and methods of communication to redefine what it means to ‘do’ psychiatry with people?  Similarly, we must also be asking: ‘which patient-professional relationship are we talking about?’ Are we talking THE patient-professional relationship as an abstract principle or are we talking about a multitude of different forms of relationship between professionals and patients?

It’s worth remembering that we are currently in the middle of the single largest experiment ever in modifying the behaviour of human beings by the widespread adoption of technology.  In the western world it has completely redefined the way in which we live our lives and has rewired the majority of our daily routines.  It’s massive, and no one has even noticed it happening.  It’s not the web, not telephones, not the combustion engine.  It’s the widespread availability of artificial light.  No longer is humanity limited and regulated by natural light.  That’s huge, but because we all grew up with that we don’t even notice it.  Digital technologies look and feel new to people who are coming to them as if they are new.

It’ll terrify you to know that Facebook first became available to UK users in October 2005 and that twitter launched in early 2006.  Livejournal, the blog sharing platform launched in April 1999.  The first i-phone? June 2007. Skype? August 2003. The point is: digital technologies have already been changing people’s lives for decades.  As William Gibson, the oft-quoted parent of cyberpunk is often quoted as saying: “The future is already here, it’s just not evenly distributed yet”.  The point is not ‘will digital technology change things;  but how has it changed things already?

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.  Psychiatry is probably one of them.  This does not, however, mean that psychiatry shouldn’t explore digital technology as a way of better meeting the needs of those that the profession seeks to serve.  Just as we wouldn’t think of sitting in the dark today at half four when the sun goes down, so digital technologies are tools at our disposal to change the environment or to enable things to happen that otherwise would be beyond our reach.  Psychiatry needs to look for its place in the post digital world rather than debating whether it needs to maintain its separation from it.

Digital technology isn’t that ‘that weird thing on computers’, it’s a part of people’s lives.  Increasingly it’s a layer of connectedness between people and between people and tools and information. We need to stop asking ‘is digital technology bad for people’s wellbeing?’ with a view to suggesting they just unplug and go off and do something less bothersome instead and ask ‘how can we make sure people are getting what they want and need from digital technology?’

As to whether digital technology changes the relationship between patient and professional?  For some people it will, for some people it won’t.  It all depends on how digital technology is approached and which choices are made, both in terms of redefining the ways in which psychiatry works and the ways in which people interact with it.

Relationships change. One of the immense changes brought about by digital technology is the exponential increase in the amount of information available to any individual who can get an internet connection.  That has all manner of effects, all of which change the ways in which people view their position in a patient-professional relationship.  There’s no genies to return to bottles.  There’s just people and relationships and social and economic conditions.

We would view as suspect anyone who defined the only valid family relationship as being the ‘Mummy, Daddy and baby’ that they grew up with themselves.

I’d suggest we should also be suspicious of anyone who claims that the only valid patient-professional relationship is the one that looks exactly like the ones we knew back when everyone was in black and white and psychiatrists all smoked pipes.

It presents opportunities for the practice of psychiatry and the development of new forms of relationship or provision but also asks psychiatry to consider digital technology not just as a thing people use but also as an integral part of who they are.

Digital technology is not a possible future, it’s an unfolding present and I’d suggest that psychiatry might benefit from getting out of the embattled bunker and joining the rest of us.

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

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The NHS versus the ghost of failed IT past

Talk given by Mark Brown as part of a panel discussion ‘There’s an app for that, but does it work, is it safe and should the NHS adopt it?’ at Mind Tech Symposium 24th November 2014 in London.

Apps are applications.  An application is the act of putting something into action.  That’s all apps are; some kind of technological process that is being applied to a particular problem.  In some respects it’s ridiculous that we should be asking questions about whether it’s safe for the NHS to be ‘adopting’ applications, because what we’re really asking is ‘should the NHS use or suggest others use a tool developed to solve a particular problem to solve the particular problem it was developed to solve’.

The people who build apps are engineers.  What engineers do is they solve problems.  Give them a problem and they solve it.  So on one side we have problems and other the side we have problem solvers.  Where’s the problem then?  Surely the NHS should be falling over itself to enable the production of a whole variety of apps that meet patient and clinician defined needs.  Everything from electronic patient records through new ways of managing conditions to mitigating their effects. It should be simple. Simon Stevens’ NHS Five Year Forward View  talks about ‘harnessing technology’ like technology is an unruly stallion and the NHS a kind macho horse wrangler wrestling it into submission.

I think there’s a confusion in NHS land about apps and tech more generally.  Apps, for whatever reason, have been placed in the category of services that the NHS provides or treatments that it it prescribes rather than placing them in the category of tools that patients or clinicians use to solve specific problems.

There is a sense in which apps are still seen as things that are commissioned as a finished package: a finished package that must look like a digital version of an existing real world service and which must have the evidence base to match.  Apps must be big and showy and promise to do everything.  There’s an enticing, and wrong, idea that apps that actually really solve problems can be commissioned from a statistical analysis of need and a spec drawn up by someone sat in an office.  That’s not how apps work.

Every time we talk about apps or tech I feel the dread Ghost of Failed IT Past rearing up behind us, rubbing its bony hands together and promising baffling interfaces, top down edicts and ‘you will use this, we’ve bought it now!’

At present the NHS finds it difficult to lock step with the world of app development.  There are three main ways that it fails to do this: failing to understand ‘tech time’; not understanding business models; and not serving up good problems and not allowing good development practice to happen.

One of the first problems there is tech time. The world of technology moves on even if you want to slow it down.  We aren’t talking about building special bits of technology (although we might be, if we can get this bit right) we’re talking about making apps that run on platforms that people actually have. The time it takes to build an evidence base for an app to the standard that some would demand is often longer than the life of the platform it might run on.  By the time the thing is actually implemented it’s already woefully out of step with users expectations.  This matters because apps that are right for one particular moment and one particular set of needs go off quickly like bags of salad in a fridge.  How someone wants something to work and how much it works the way they want it to is the heart of adoption.  Unless you want to force apps on people (I can see the Ghost of Failed IT Past rubbing their hands again), a great app for a platform no one uses anymore is the right answer three years too late.  Tech time has moved on.

Business is an uncomfortable idea for the NHS, but tech doesn’t happen without money.  We have a huge log jam here.  Often the NHS wants evidence before it will put up any money, but it can’t have evidence until some work has been done and something has been tested.  But, the main game in town is selling to the NHS for most apps, unless they are going direct to the consumer.  So the rules of the game are ‘you put up all of the money for development, testing and building the evidence base and we still might not buy it’.  At present it’s impossible even to cost how much you’d need to spend to get an application approved by the NHS as being clinically safe, never mind how much it would cost to establish whether it was clinically effective.  This kills most investment stone dead.

The NHS is famously sniffy about direct-to-consumer health apps, talking about them being unsafe, untested and ill-conceived.  It can’t have it both ways.  The NHS as a major customer needs to get better at inviting in developers to solve problems and better at investing in the evidence base by giving opportunities to actually build things and, as we’ve heard and will hear, making sure that useful processes for development that meet people’s needs actually happen.

Good apps come from engineering solutions to well defined problems. Unless the NHS is a clever investor, it will always be buying big things created at a distance from the needs of real people.  (I can hear the Ghost of Failed IT Past cackling in anticipation now.)

As far as I see it there are two choices: either the NHS dives in and helps to make happen the world it wants to see; or it stands there,  crosses its arms and complains as the world happens around it.

The idea that there is an app already in existence to solve all problems is obviously nonsense, as is a blind faith in a digital solution always trumping a human-faced one.  Both are straw men that suit people to maintain.  Boundless, unfounded optimism is really the same as absolute arms crossed cynicism: both are just ways of refusing to engage with the messy business of how we actually make technology happen.

I’d say it really is the job of people in the NHS, and those that support them, to really get their hands dirty and think about how good apps happen.

Thank you!

 Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter
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A Day in the Life: A new project to snapshot day-to-day life with #mentalhealth difficulties #adayinthelifeMH

Four days; the people of England who experience mental health difficulties; a snapshot never seen before

The everyday life of people with mental health difficulties has tended to remain hidden. There’s been combination of prejudice, shame, stigma and sometimes, most damagingly, a lack of interest on the part of professionals and policy makers. We have a large literature around clinical interactions with people who have or do experience mental health difficulties but very little around what it actually means to live with a mental health difficulty.

Professionals see people with mental health difficulties for an hour a week, if at all. Most of life with a mental health difficulty is lived outside of services; away from the gaze of researchers. Policy is made based on the tiny bit of people’s lives that is seen by professionals. When it comes to treatment and support, evidence is all about services; not the bigger or smaller things in people’s lives.

That’s why Social Spider, the creators of One in Four magazine, with support of Public Health England are launching on Friday 31st October ‘A Day in the Life’: a year long project to collect the everyday experiences of people who experience mental health difficulties in England.

All we’re doing is something very simple: we’re asking people with mental health difficulties in England to share four days in the life via a website. If you experience a mental health difficulty you’ll be able to sign up to share with the world what your day was like on four calendar dates across the length of the project, the first one in November. So that’ll be lots of people with mental health difficulties across England all blogging about the same day: once in November, once in February, once in May, once in August.

Everyone will be asked to share up to 700 words about the same four days in the year, one each season; building a library of personal stories that answer the question: what things make life with a mental health difficulty worth living and what things make it more difficult? Together the four days in the lives of people with mental health difficulties will give a snapshot of what it’s like to be be a person with mental health difficulties in England in the 21st Century.

Once uploaded, the stories will be available to view and search; giving a window into the everyday lives of people who experience mental health difficulty in England previously not attempted.

A Day in the Life isn’t a scientific research study but will show what can be discovered by the simple act of simply asking people with mental health difficulties what they think and what they experience. We’ll use the stories submitted to tell very simple stories like: ‘of the people who submitted blogs in November, 35 percent said that their neighbours had a positive impact on their wellbeing’. A Day in the Life isn’t a research project but it is a bit of an experiment. As far as we know, no one else has taken the time to ask people with mental health difficulties to share days like this.

We won’t be asking for loads of personal details and we’ll be encouraging you to remain anonymous. There’ll be lots of guidance on the site to help you. We also want you to be honest about what your day was like. What made it better and what made it worse? Which are the important things that negatively and positively affect your wellbeing?

Anyone who cares about people with mental health difficulties and their everyday lives will be able read what people have been sharing.

A Day in the Life will help to set a challenge for policy makers, health professionals and decision makers to consider people with mental health difficulties as just that: people.

If you’re interested in taking part (one blog four times a year) go to the A Day in the Life website and sign up: http://dayinthelifemh.org.uk/

The first day to share will be 7th November 2014.

We’re hoping this will be the start of a new debate about mental health.

Mark Brown, Social Spider CIC
@markoneinfour
#adayinthelifeMH

Mark Brown is the development director of Social Spider CIC and originator of One in Four magazine. Mark experiences mental health difficulties. He is one of Health Service Journal and Nursing Times Social Media Pioneers 2014. His work in mental health was recognised by The Independent on Sunday’s Happy List 2014. Contact: mark [at] socialspider.com.

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“Lack of money for mental health is not a natural fact. It is a decision taken by people”

Mark Brown examines the reasons why we accept the idea that there is no money for mental health services and asks what happens when we move from ‘Why? No money’ to ‘Why no money?’

If there’s one thing many of us ‘know’ about mental health is that there is never enough money to provide support for people to maintain it.  Mental health is the ‘Cinderella Service’ people say and we all nod.  ‘It’s true, isn’t it?’ we say and then get on with trying to cope with whatever deficiency in the support or services.  But why do we accept there’s no money?

It’s possible to find money in government if the will is there. Health secretary Jeremy Hunt announced in June 2014 an extra £250million for elective surgery to clear a backlog of operations over the summer months to reduce waiting times. A vote winner; but also proof that there is money that can be found if a need to is recognised

Lack of funding for mental health is not a natural fact. Lack of money for mental health is a result of decisions made by people. Decisions about what receives funding and what does not are made by people, not abstract forces like institutional bias or lack of parity of esteem.  Governments make decisions, people in organs of government make decision, voters make decisions about for whom they cast their vote.  Rhetorical abstractions move us further from analysing why money does not flow.

Crisis? What Crisis?

The run up to a general election is a funny time.  All of the voices of sectional interests who have remained quiet for the length of the government so far suddenly find their voice.  There is a ratcheting up of coverage of problems and perceived problems; bodies and organisations that have notably avoided public tussles find new stridency in their criticism of elements of government policy on which they had been surprisingly quiet in recent memory.

Whichever party or parties are in government, the temperature of debate always rises in the year running up to an election.  So it is in mental health.  There has been a hum of news stories, increasing in pitch, signifying an ever growing sense of crisis.  Pulse reported that in their survey of GPs a fifth claimed to have “seen patients come to harm as they were unable to access appropriate support from their community mental health teams, with some patients committing suicide, being sectioned or admitted as a result”; and that “More than eight out of ten GPs saying their local community mental health service could not cope with its caseload”.  (worth noting that committing suicide is the incorrect term for UK as suicide is no longer a crime, but you know what they mean).  Labour’s shadow public health minister Luciana Berger used Freedom of Information (FOI) requests to Clinical Commissioning Groups to find out that, according to The Guardian’s reporting of the story, “72 of the 142 (67%) which responded spend less than 10% of their budget on mental health services.” .  The Royal College of Psychiatrists announced in June “mental health services were approaching a “tipping point” due to lack of beds.   Add to this increasing pressure from NGOs and third sector organisations over the effect of benefits reform and you have quite a stew of mental health discontent.  Something has to change, the ‘official’ voices say at a point where, almost as if they’d planned it, there is strong possibility of policy change via democratic vote.

The elements of the press interested in mental health have consistently covered mental health stories, of course, but even they are sensing that in a post-Health and Social Care Act world mental health is one of the elements of social provision that is suffering disproportionately.  The Guardian and the Sunday Express have kept up a notable stream of stories covering the failings of our current mental health settlement.  In May 2014 Andy McNicoll (@andymcnicoll) of Community Care Magazine wrote a magestic post picking away at why the problems in mental health persist. This built upon October 2013’s collaboration between Community Care and BBC News who worked together on a series of FOI requests to NHS mental health trusts that found a 9% reduction in available mental health beds since the year 2011/2012.  Health Service Journal’s Shaun Lintern (@shaunlintern) has expressed similar enthusiasm for getting to the bottom of what’s up with mental health.

So, at a basic level, we know things aren’t quite where they should be.  As everyone always points out; if this were any other national service it would be a national scandal.  So why isn’t it?

The cinderella service cop out

If there’s one thing that people know if they know that there is a challenge in providing mental health services it’s that mental health is the ‘Cinderella service’.  Poor old mental health: when her sisters cancer, or dementia, or maternity or Accident and Emergency get whisked off to the funding ball she has to remain at home cleaning the hearth and peeling the spuds.  Mental health – always the bridesmaid, never the bride.  What does that mean, though?  To describe mental health as a cinderella service is presented as some great insight.  People will nod in approval of the grasp that the utterer has of the dire challenges we face.  They, the listener will think, they really understand the challenge we face.

The problem is that ‘Cinderella Service’ is not an analysis of the problem but merely a description.  It in essence says ‘there is no money for mental health because there is no money for mental health’.  It is deployed as an answer to the questions ‘why can’t we have more of X in mental health?’ and ‘Why doesn’t Y work in mental health?’

Writing for Liberal Democrat Voice, Minister of State for Care and Support Norman Lamb acknowledged the cliche replacing it with a seemingly more concrete concept: “It’s a bit of a cliché to say that mental health is the Cinderella service of the NHS but it’s essentially true. There is a real institutional bias against mental health. It loses out financially when budgets are tight for local commissioners and significant advances on choice and access for patients introduced by the Labour Government left out mental health.”

In the manner of many pseudo-profundities ‘cinderella service’ is a metaphor which merely restates the initial premise in more poetic terms, obscuring the fact that it fails to move the inquiry any closer to any concrete answer.  It’s a rhetorical device to obscure uncomfortable truths and to abstract analysis from the real questions. It makes the answer to any question about failings within mental health ‘because there’s no money.’

But that isn’t an answer it’s a statement of the situation.  Similarly, the idea parity of esteem (an idea that features large in rhetoric but currently features three priority areas: Improving Access to Psychological Therapies for people with anxiety and depression; improving diagnosis and support for people with dementias; and improving awareness and focus on the duties within the Mental Capacity Act) is an abstraction suitable to mandate on behalf of but very difficult to grasp day-to-day.

The current priority areas for parity of esteem also confirm the feelings of many people with enduring, more severe mental health difficulties that there is no commitment to ongoing support, never mind commitment to increasing the wellbeing of those with conditions other than anxiety and depression related disorders.

Even a commitment to mandating maximum waiting times and access standards for psychological treatments only covers a tiny element of the needs of people with mental health difficulties.  It does not, for example, cover social care support or other services. It also introduces the perverse incentive well known to rail companies when fines exist for late running trains: you will accrue less fines if you cancel in advance services you know will be late running, meaning that while you provide no service to the passenger you do not affect your record of trains in service that arrive on time.

From ‘Why? No money.’ to ‘Why no money?’

It’s notable that a search of Closing the gap: priorities for essential change in mental health published by the Department of Health in January 2014 and detailing their short to medium terms aspirations for mental health in England, reveals eleven mentions of ‘funding’: none of them relating to new funding available to commissioners to pay for services.  The strategy stresses the need for change and better use of what’s there.  It’s unclear what framework will achieve that strategy

It isn’t, however, often that easy to work out what actually is there in terms of funds and investment that can be used better. The final official compilation of overall national spending on adult mental health available is the 2011/12 National Survey of Investment in Adult Mental Health Services published in March 2013 published by The Department of Health.  The data for 2012/13 may be available if pieced together from different sources, but the FOI requests from which current stories of crisis are built may indicate otherwise.

It is possible to pull rabbits out of hats.  The art of the Chancellor of the Exchequer on Budget day is doing just that.  As are most cabinet ministers close to election time.  If we are always happy to accept that the reason for our failure in mental health is that there’s no money, we’re avoiding asking why there’s no money.  Instead of ‘Why? No money’ we need to be asking ‘Why no money?’

In 2013 The World Health Organisation (WHO) published Investing in mental health: Evidence for action, an excellent paper which in their own description examines: “potential reasons for apparent contradiction between cherished human values and observed social actions.” The paper examines the case for governments across the world to invest in mental health by acting upon avoidable risks, providing essential care and enforcing fundamental rights.  It also examines why governments do not make these investments despite convincing evidence to encourage them.  As the report has it; there are a “number of barriers that continue to influence collective values and decision-making – including negative cultural attitudes towards mental illness and a predominant emphasis on the creation or retention of wealth (rather than the promotion of societal well-being).”

It’s worth looking at what WHO regards the justification for state intervention in mental health.  The UK, even with our currently falling level of investment, still has one of the best funded systems of social support for people with mental health difficulties in the world.  The report states: “ there is ample international evidence that mental disorders are disproportionately present among the poor, either as a result of a drift by those with mental health problems towards more socially disadvantaged circumstances (due to impaired levels of psychological or social functioning) or because of greater exposure to adverse life events among the poor.”

The WHO feel there are a number of key actions, not limited to treatment, requiring state intervention to promote mental health:

  • provide better information, awareness and  education about mental health and illness;

  • provide better (and more) health and social care services for currently underserved populations with unmet needs;

  • provide better social and financial protection for persons with mental disorders, particularly those in socially disadvantaged groups;

  • provide better legislative protection and social support for persons, families and communities adversely affected by mental disorders.

Recognising global variation in methods of government, The WHO says: “The exact nature of these collective actions or responses (e.g. the extent to which governments actually offer social protection) will vary according to prevailing notions of social choice in a country and the existing health system structures and constraints. In other words, governments do not need to pay the entire mental health budget or provide all services themselves (a nongovernmental or private entity may also contribute), but governments do have an obligation to ensure that appropriate institutional, legal, financing and service arrangements are put in place to protect human rights and to address the mental health needs of the population.”

Democratic governments maintain their position by remaining popular. UK government maintains its ability to make things happen by gaining the support of the electorate and by gaining agreement of elected representatives to make, amend or remove laws; set taxes; and decide budgets.  Centrally controlled spending can be centrally controlled.  Devolved spending, such as spending within the current NHS and Local Government budgets can be mandated or incentivised.

The discussion of barriers to investment within the WHO report is not extensive but suggests that one of the reasons why governments do not invest in mental health is because there is always something more important to spend money on.

From a policy perspective mental health difficulties are not leading causes of mortality in populations.  In other words people do not usually die from mental health difficulties in large, definite numbers in a way that pricks the public conscience and the ways in which mental health difficulty and other problems which may result from them interact is obscured.  If someone loses their job as a result of a mental health difficulty and becomes homeless that is seen as a housing problem.  If someone with mental health difficulties becomes involved in crime this becomes a criminal justice problem.  If you don’t meet people’s mental health needs they drift into other services and thus out of the mental health budget entirely and as such the investment in mental health can always be put off to address the more direct demands placed by reactive services.  In this way reactive spending always trumps other forms of spending.  This is particularly problematic in mental health as reactive spending is often a response to people’s needs after their wellbeing has been destroyed, undermined or otherwise lost to them.

The WHO paper also suggests that while governments may be fully aware of the individual and community costs of unmet mental health need, they are also aware that to pay for meeting that need would mean removing funds from another potentially more valued activity.  So, in essence, the decision is made to underfund mental health on the basis that other areas of spending are considered to be more important either to government or to voters.  In essence, the moving of funds from one or more things to mental health is considered to be too much of an electoral risk.  In the UK at present, for example, it has been argued that the decision to attempt to cut spending on social security benefits and reduce government spending has been at the cost of the mental health and wellbeing of many people involved in the claiming or receipt of those benefits. (see Royal College of Psychiatrists statement for one amongst many.)

 The WHO also identify the fact that “persons with a wide range of health conditions currently lack access to appropriate health care” as a potential barrier to greater investment in public mental health.  In other words: why should mental health come top of the list when there are a number of other competing claims on public funds? Governments, and commissioners in turn, choose where to direct their funds based on evaluating competing demands.

Further to that the WHO suggest that negative perceptions of mental illness (stigma) influences decisions as well as “Low expressed demand/advocacy for better services”.  There is, in other words, a lack of political will and political pressure to spend on mental health other than in the ways already decided upon.

While England is is investing historically unprecedented yet still modest amounts of funds in combating mental health stigma its arguable that this is not creating a demand for better services.  While it is true that there has been a recognition of underfunding, there has yet to be a clear, strong, coherent and attractive vision for where the lives of people with mental health difficulties should be in the UK.

While it would not be true to say that lip service alone is being paid to the challenges of mental health, it is true to say that the decision to invest has not taken place during the course of the current Parliament.  The work of mandating and setting policy in process has occurred, but there has not been the political will to move significant funds into improving the lives of people with mental health difficulties or even to return existing services to previous levels.

Scarcity thinking or ‘can I have the crumbs from your table’?

Ultimately, the widely held belief that we can’t have more, better and more diverse mental health supports and services because there just isn’t enough money to go around is both a result and a cause of our inability to believe it can be otherwise.  Eldar Shafir speaks about scarcity and its effect on our decision making.  When we feel there is not enough of something we need, we become preoccupied with how we’ll manage to get through situations where we might need it.  When we are hungry all we can think about is food.  When we don’t have enough money to live on, we can’t do much else but worry about the fact that we don’t know how we’ll make it to the end of the week.  Mental health as an area of human endeavour is rife with scarcity thinking; with every service, every professional worrying about how they’ll make ends meet or continue to deliver what they can with ever decreasing resources.  This uses up any energy and any space to ask questions about the future or to really consider the direction in which services and support are travelling.  It makes us in mental health hugely grateful and excited about even the smallest morsel of succour or sustenance at the same times as we know that it will plug the hole for minutes at best.

Mental health is slowly starving. It make bad decisions when every service or sector fights to fill its own belly first.  And perhaps it always will until we are prepared to move from dumb acceptance of talk of cinderella services and ‘more for less’ and actually ask the question: Why has the decision been made not to spend on better mental health for all and who made it?

And then, if the scarcity can end for more than a fleeting moment we could, maybe, begin to ask: ‘How should we spend money for better mental health?’

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

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