“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

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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11 tips for Live Tweeting Events

Social media can carry messages around the world at the press of a button.  Live tweeting from an event can jailbreak the information there and give it to anyone, anywhere, who wants to listen, says Mark Brown.

There have been many recent publications and events imploring us to have a national conversation about mental health.  Why then do so many fascinating discussions happen at conferences, uncaptured and inaccessible to people wanting to join them?

In an age of social media, it’s possible for an event to reach far further and to have far greater impact than just including people in the room.

Live tweeting can allow people who aren’t at an event to see the event as it unfolds and to also take part in what happens at that event.  It’s different from reading a write up after the event as live tweeting is a real-time rolling news record of the event, and as such isn’t fixed.  People not in the room can ask questions, feed in views and ideas to the event hashtag if it has one and even take part in proceedings by passing on their views via those present in the room.  It’s bringing people to the party who never even got an invite.  This democritisation of access is vital if we want to broaden our mental health discussions and raise the level of sophistication in our arguments and debates.  For this to happen we need some brave souls who know how to cover an event via live tweeting and who are prepared to do so out of a sense of public service.

As @markoneinfour I now live tweet public mental health  most things I attend, working on the basis that I find the event interesting there’ll be others not present who will, too.

The following is a list of eleven tips for people looking to live tweet events and conferences.

It’s a companion piece to these tips for conference organisers wanting to make their conferences social media friendly produced by my colleagues @shirleyAyres and @paulbromford


11 Live Tweeting tips

  1. The purpose of live tweeting an event is to give people who aren’t an event and in the room as it unfolds a sense of what’s happening.  The best way to think of it to think of yourself as a radio journalist covering a sporting event for radio listeners.  The objective is to give people a useful idea of what is happening, who is doing it and what your response and the response of those around you is to what is occurring.

  2. Live tweeting from conferences requires you to listen, to understand and to summarise what the speakers are saying in such a way that’ll make sense to someone who isn’t in the room with you.  That means you’ll want to make sure that anything that is being said is attributed to the person saying it.  It’s a good idea to introduce the speaker in your tweets when they begin and to include their name in any subsequent tweets about what they’re saying.

  3. People follow conference hashtag for two reasons:  They have spotted the conference on twitter and think that it’s something they’re interested in or they are actually at the conference and are interested what other people are saying while at the conference.  For those in attendance the hashtag can be a great way to make others aware of what’s going on; what’s happening and as a way of finding other like-minded people at the event.  Interest is the primary reason for those following a hashtag remotely from wherever they are in the world.

  4. The objective of live tweeting is to provide value.  If you just tweet about how awesome the event is without giving any sense of why it’s awesome people won’t share any of the tweets and you won’t really be able to increase the reach and impact of your conference.

  5. The worst kind of event live tweets are ‘X is taking the stage to applause’; then nothing for ten minutes until ‘What an excellent speech from X!’  If the person isn’t saying anything you can share, why do you think that anyone who isn’t there might find them interesting?

  6. If you are live tweeting a conference as an attendee, it’s a good idea to remind your own followers that you’re at the conference and tweeting links to the event page throughout the idea so that people have some context to what it’s you’re tweeting.  Tell them to check out the hashtag every so often to make, suggesting it’ll give a better idea of what the event is about.

  7. Adding context to the hashtag by tweeting links to information about speakers such as their biography, media articles about them or other media can really help to give value to a conference hashtag both for those attending and those ‘listening from home’.

  8. If you are live tweeting be prepared for tweets from people who aren’t at the event asking you questions, arguing with what the speaker the words of whom you are relating is saying or even complaining about the premise of the event you’re at.  This is natural and normal; remember you are broadcasting via twitter to the world.  Answer people when you feel it’s appropriate, clarifying where necessary, directing to the purpose of the hashtag if someone has misunderstood the context of what is being tweeted.

  9. When live tweeting you can’t catch everything that someone says.  Try to catch salient facts and figures and notable quotes.  If there are enough people also in the room live tweeting you’ll build a fairly rounded aggregate account of what is said.  It’s fine to make comment, like ‘Interesting point from X, she’s outlining low prevalence of Y in Z group of people’.

  10. If you’re live tweeting you might like to warn your followers that’s what you’re doing, telling them that you’re going to be tweeting a lot over the period of the conference so they might like to mute you if they think that’s going to overwhelm their timeline.

  11. Remember, live tweeting is doing a public service by taking what happens in a room where only a limited people can be physically present into public so that far more people can take part.  It’s a great tool for promotion, but only if the information that it creates is worth sharing. The more people at an event that live tweet the better because that brings a multiplicity of voices about an event rather than just one corporate voice.

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

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Gap market, market gap; or why your mental health idealism might not overcome the market

Social enterprise isn’t always the best way to get something to happen, but sometimes it’s the only way. Mark Brown wonders what the demise of mental health magazine One in Four, which he edited, can tell social entrepreneurs and potential mental health disrupters 

(This is an extended version of an article which first appeared at Guardian Social Enterprise Network on June 2nd 2014 titled ‘My mental health magazine and the sadness of closing a social enterprise’)

If you’re all about the money, making the decision to finally bring to an end a failing project that hasn’t paid its way is a relief.  Finally: no more sleepless nights trying to make the balance sheet add up; no more time explaining the gap between your aspiration and you achievement.  If your motivations are social rather than financial, the final end of a project that you’ve invested your time, your money, your energy and your belief in is far more difficult.  Social enterprise, making social good happen through selling goods and services, may seem like a win-win, but it has some difficulties than aren’t always apparent when you begin.

For more than six years, One in Four has been a magazine written by people with mental health difficulties, for people with mental health difficulties, conceived and edited by me, a person with mental health difficulties (amongst other attributes).  It has never been a magazine for mental health professionals, the worried well or of any particular therapeutic or philosophical approach to mental health.  Launched by the social enterprise Social Spider CIC just as the banks began to collapse in 2007, it’s a project that I threw my heart into and one that I’m having to sadly bring to an end with the next issue.  The story of One in Four tells us some valuable things about the ways in which idealism can’t bend economic realities to its vision and the way in which a great social idea isn’t always a brilliant social business.  As with anyone launching themselves into an ambitious project led by ideas rather than market analysis, our enthusiasm and social drive blinded us to one oft-uttered platitude: there may be a gap in the market but is there a market in the gap?

The first thing I can say with hindsight to idealistic social enterprise is building a market for your social enterprise is hard if there isn’t one there already.  Mental health is one of the areas where social enterprise approaches social challenges remain in their infancy.  It has been dominated by three main business models; state provided medical or social services funded through taxation; charities funded by public and philanthropic donation and latterly by public contracts and, to a much lesser extent, projects originally derived from subsidised therapeutic work situations producing goods and services produced by people with mental health difficulties for sale to the public.  None of these models are about selling something directly to survive.

This means there isn’t really an established market in mental health.  The public sector is the main spender; we don’t actually have any statistics for how much private individuals spend on mental health related products.  Historically, a diagnosis of severe and enduring mental health difficulty meant an individual left the market completely.  Prejudice, stigma and loss of earning potential meant that the people who experienced mental health difficulty were shunted to the margins of society where we became a social problem to be solved by others spending on our behalf.  It still remains true that a mental health difficulty means that you are more likely to end up skint.

When we first began work on One in Four we reasonably expected that it would be the kind of project that a charitable funder would support: a mass circulation publication given out via places like libraries, doctors surgeries and hospital and clinic waiting rooms for free as vehicle for useful information, practical tips and the sharing of life experience so people wouldn’t feel alone and isolated with their experience of mental health difficulty. We initially assumed there wasn’t a market but that there was a wide open gap ready to be recognised by the types of funding that exist to meet social need where the market fails to do so.  When the kind of funding wasn’t forthcoming, we moved on to looking for other ways to sell the publication so it would stand on its own feet.  We thought: if charity won’t provide the necessary funds, enterprise will.  This is the point from which many social enterprises begin.  First we thought: we’ll sell it in bulk to NHS trusts; they have an obligation to provide information and we can do it cheaper in a way far more in touch with the wishes of people with mental health difficulties.

You can’t disrupt your customer

That they didn’t buy gives us our second lesson for UK social enterprises.  Whilst the spending freeze in the run up to the 2010 general election and the NHS spending cuts that followed it didn’t help; there was another reason why the NHS and major charities weren’t up for spending:  disruption.  We’d always intended that One in Four would shake up the way that public information about mental health was provided, being written by people with direct experience rather than communications departments.  What we didn’t realise was that a disruptive model like this can only work where customers are free to move to your product from other products.  In mental health, it isn’t the people who use NHS services that control the spending on information; it’s the people who are currently creating and disseminating information.  It’s so obvious looking back that our accidental disruptive model, at a basic level, required the market we were disrupting to say ‘Oh yes! You’re right, we are out of date and a bit rubbish’.  Then give us money.  One in Four, to work on this model would have had to disrupt its customer, rather than disrupt its market.

In an effort to broaden our base of subscribers we offered individuals the opportunity to subscribe to the magazine at a price of £10.00GBP a year for four issues by post.  Around the same time a publication partially inspired by One in Four launched to the newsstand direct to consumer market and survived around six months before its investors pulled the plug.  During the same period, publications in broadly the same area as One in Four with much longer histories quietly shuffled into the printed night.

Why should anyone trust you when you say ‘We’re the good guys?’

Again, the historic dominance of state/charity funding presented a problem for a new entrant.   People in general, while used to paying for a whole range of goods and services were not used to paying for mental health related goods and services.  This meant that it was harder to sell directly to them when there was a range of other services in the same space available to them for free.  We were on occasion accused of profiting on the back of the suffering of others, an unfair charge but not an illogical one.  If you are committed to the public sector, why should you take the word of a social enterprise that they’re ‘the good guys’ and not just a bunch of people in it for the cash?’

State/charity dominance means something that is not apparent to many who haven’t tried to produce socially useful media for a mental health audience: there is no advertising spend targeted at people with mental health difficulties, partially because there is no notion that people with mental health difficulties might spend on their own care, support or wellbeing.  Or indeed anything.  This gives us our third lesson for idealistic social enterprise: being the first social enterprise in an area is really, really hard, because being morally and ethically committed to the area and looking for social profit doesn’t mean you can overcome the lack of customers and revenue streams.

We take the decision to end One in Four at the point where it has managed to cover its direct costs and could have continued if I and my colleague could continue to keep it going as a charitable activity, giving our time for free.  In the end, we made what funding we could get go as far as possible, cut our costs to a bare minimum, continued to pay our writers (something that far larger media combines don’t always do), built up a subscriber base and survived for nearly six years.  Have we made a difference?  I hope so.

Which leads us to the final lesson, and a general one that is possibly the most dangerous to ignore: if no one takes a risk, nothing new will happen.  Things still need to change in mental health and we need more money that is prepared to take risks on new ideas.  One in Four managed something new.  Some people took a risk with us.  I hope more people will take better risks in mental health in the future.

Mark Brown is development director of Social Spider CIC, the publishers of One in Four.  He continues to develop a variety of mental health projects and services and is increasingly well known as a mental health commentator.  He is @markoneinfour on twitter.

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3 minutes on the future of mental health: Everything has its time and everything dies

Three minutes talk by Mark Brown (@markoneinfour) on the future of mental health to the Dublin Dialogues: Discussing the future of mental health event, 16 June 2014

I’m the director of a social enterprise. I’m a person who does mental health stuff.  I’m also a person who experiences mental health difficulties.  I spend a lot of time thinking about the future of mental health.

Many of the mental health systems we have were designed before we even had the idea that people with mental health difficulties had any sort of views about what we wanted out of the future. Many of us find ourselves campaigning to try to save services that, if we’re honest with ourselves, we don’t actually find that useful. Younger people with mental health difficulties don’t take on the political identity of a ‘service user’ now.  That doesn’t mean that they don’t care about others with mental health difficulties. It’s just that they want to be the change rather than asking someone else to make the change.

The aspirations of people with mental health difficulties have grown more quickly than the ability of existing services to respond to them.  Each generation defines its struggle based upon where it finds itself now.  What was once new is now old. Everything has its time and everything dies, as the ninth Doctor said in Doctor Who.  Unless we’re talking about a mental health service which, of course,  is designed to last forever.  Services themselves don’t spot how out of date they are.

Maybe we should stamp them all with a best before date so we know when to chuck them in the bin.

A generation is growing up that has had a different experience of mental health difficulty precisely because of the gains made by previous generations.  We’re closer to the future, because we’re living it and increasingly we want to be making it.

In little pockets, often with people working in isolation from each other, we’re seeing a new approach.  What someone who is nineteen needs to help them get through life hearing voices isn’t the same as what someone who is forty nine needs to help them get through life hearing voices.  While people may have the same symptoms, they don’t have the same lives.  People with mental health difficulties are saying ‘hang on, what if I didn’t spend all of my time trying to fix a system or service that I don’t have control over?  What if I expended my effort in producing something for people like me?’  That’s the moment where what I’ve called The New Mental Health comes into being.

It’s people with mental health difficulties trying to fill the gap between what is needed and what is currently available.  These plucky outsiders are pragmatic people with mental health difficulties making stuff happen ourselves, outside of state or large providers, because that’s the only place where really different things can happen without being smothered at birth.   It might be a business.  It might be a small charity.  It might be a group of people around someone’s kitchen table.

This New Mental Health tends to start small and to meet the needs it finds directly. It grows from identifying a particular problem that a particular group of people have rather than attempting to find an answer that will work for everybody.  The answer might be digital, but more often it’s about people.

In mental health scarcity means the most arguments are about how we meet basic needs.  This means mental health as a whole only thinks about its next meal because it has been starved too long.  If there is more money secured, the temptation is always for the big providers to keep it to serve their hunger first.  Doing that is ignoring the organisations and people with direct experience of mental health difficulties building the kinds of things and the kinds of communities big providers will need in the future.

If there’s two things that the New Mental Health needs it’s for larger providers to learn to ‘get money out the door’ and for those of us with mental health difficulties who are already making things happen to offer the opportunity for those who come after us to learn from our example, mine us for our knowledge and skills, and then look us in the eye and say ‘sod you, I’m going to something completely different, better and closer to what we need now.’

The New Mental Health happens, and will happen more, when people stop asking politely to be included in the planning of existing services to draw attention to the gap between what is being provided and what people need and start asking: ‘what do we need to solve this problem ourselves?’   People with mental health difficulties are asking questions that no one in services has even thought of, never mind answered.

And that’s one of the places you need to be looking to for your laboratory of the future.

Thank you!

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

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

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

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

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

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

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

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

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

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

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

Second challenge:  All or nothing tech thinking.  There’s sometimes an idea, one sometimes unfortunately propagated by telehealth providers, that technology will allow you to ‘do away’ with staff teams.  Andrew McAfee Co-author of The Second Machine Age refers to this as digital encroachment, the direct replacement of human labour with machine labour.  In mental health, as in other areas of public service delivery, there are some who feel this digital encroachment as literally that: an army of computer screens and ill-understood  gadgets skulking in the shadows a bit like in The Terminator, ready to leap out and take away everything they hold dear, including their jobs.

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

It doesn’t have to be either/or with tech. Different people will want and need different things.  As will staff of different services. Imagine what we could do if tech could free up more staff time to do the really important things that only humans can do?  Tech needs to make things easier and  better in ways that work for people.

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

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

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

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

So how do we avoid this curse?

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

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

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

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

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

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

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

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

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

And that’s me done!

Thank you!

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

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