Closing the Gap in mental health – four observations

Four quick observations on the publication of Closing the Gap: Priorities for essential change in mental health (pdf).

1. It’s good to see it published and it’ll be a useful document to refer to.

2. The significant changes needed will come about only through an alliance of everybody affected by the mental health system, from both the top down and the bottom up. The target audiences explicitly identified in the document miss one half of this equation by not including people with mental health problems, their (representative) organisations or families/carers.

3. As @shaunlintern over at HSJ highlighted, the focus on parity in mental health is a sham when NHS England and Monitor have cut the 2014/15 tariff price for mental health (and community) services by a fifth more than the reduction proposed for acute providers

4. The signatories to the policy are Nick Clegg and Norman Lamb. No Jeremy Hunt, in his role as Secretary of State for Health, or (perhaps more noteworthily) as a Conservative. Are the Lib Dems looking to claim mental health as their own ahead of 2015?


Survey update what next for mental health and co-production

Mind and nef have recently published a literature review on how coproduction is being applied in mental health settings, which you can find here.

The natural question that follows from this publication is: “What next?” To help answer that question, a survey was put together by some folks* with a real interest in this and a little bit of time.

This post briefly gives an updated on the types of responses received so far.

In total, there have been 83 responses so far, which is pretty good going. Just over a third of responses are from people who identify as having a mental health problem. The next biggest response comes from mental health providers in the voluntary and community sector (15%) and then User-Led Organisations (12%).

The biggest barriers to coproduction in mental health are felt so far to be the following:

  • Lack of engagement from people who deliver services (24%)
  • Lack of understanding of the concept of coproduction (23%)
  • Lack of commissioner support (12%)
  • Other answers regularly mention lack of resources, including both time and money and insufficient recognition of people’s contributions/resources.

To take forward coproduction in mental health, the following so far were felt to be the most useful:

  • A network of people specifically interested in mental health and coproduction (25%)
  • Training to help understand what coproduction is, the difference it makes and how to do it (13%)
  • A campaign to promote coproduction in mental health (13%).

Other than a notable number of respondents who think all policy areas should be prioritised, people who have completed the questionnaire so far think that health (46%) is the policy area that should be prioritised for mental health and coproduction, followed by social care (16%). Very few have mentioned, for example, employment (4%), welfare (0%) or criminal justice (3%).

This is all really useful information so far, and want to make sure there are as many views shared as possible. As such, the survey will be open until the end of January. If you, an organisation or someone / an organisation you know might be interested in completing the survey, please do pass it on.

Mental health and coproduction survey:

*Paola Pierri (Mind), Julia Slay and Lucie Stephens (nef), Shahana Ramsden (National Coproduction Advisory Group), Rich Watts (NDTi)


Mental health: on our minds?

Parity of esteem in mental health is something we hear a lot about: it essentially means putting mental health on a par with physical health.

Underneath this, though, it feels to me that there isn’t a parity of attention when it comes to mental health – it doesn’t feel to be discussed or debated anywhere near as much as other topics.

This feeling is borne out by two excellent reports published on the topic of Joint Strategic Needs Assessments (JSNAs) and Joint Health & Wellbeing Strategies (JHSWs) by the Children & Young People’s Mental Health Coalition and the Centre for Mental Health respectively.

The Children & Young People’s Mental Health Coalition found two-thirds of JSNAs didn’t have a section specifically on children and young people’s mental health. They also found that risk factors were highlighted which put children and young people at greater likelihood of having mental health problems, but the links between these factors and mental health weren’t made.

The Centre for Mental Health found 91% of JHSWs aimed to tackle at least one mental health issue, or 9% didn’t mention mental health at all. They too found that the majority of JHSWs highlighted health risk factors (such as drinking or smoking) but didn’t make the relevant links between these factors and mental health.

More encouragingly, though, where mental health was a priority in JHSWs that priority tended to be children and young people’s mental health – somewhere between 55-67% of JHSWs made it a priority.

Nevertheless, we have a situation where around one-third of JHSWs make no reference to children and young people’s mental health, and 10% make no reference to mental health in general.

Is mental health on our minds? These figures would suggest it isn’t as much as it should be. We also need parity of attention on mental health.

Two questions for #NCASC13

It was great to read Jon Rouse’s blogpost ahead of the National Children’s & Adult Social Care conference (commonly referred to as NCASC).

In his blog, the Director General for Social Care, Local Government and Care Partnerships at the Department of Health talks about topics he hopes will be debated alongside the biggies:

High on my wish list would be discussions as to how we improve mental health services for children and young people, challenging whether we are truly changing commissioning practices post-Winterbourne View and seeking to advance the personalisation agenda.

All very good stuff (and not just because all 3 are close to my own heart and work.)

What, though, of those biggies? Perhaps the biggest of the biggies is Integration – so important it is regularly capitalised (cf Internet circa 2001).

SCIE’s research briefing on the factors that promote and hinder joint working and integrated working between health and social care services (pdf) is a fantastic overview of a good portion of the evidence on integration at all levels (such as multi-agency teams, co-located teams, intermediate care and structurally integrated services).

It’s also realistic. For example, it notes (p6):

Improvements in quality of life, health, wellbeing and coping with everyday living are reported across a number of studies. However, where evaluations are based on a comparative design which assesses different types of joint working, including integrated and non-integrated care, no significant differences or only marginal differences were reported.

Similarly, it notes (p8):

Sophisticated analysis of costs across four districts providing community mental health services illuminates the impact of service need – rather than service organisation − on costs… Differences in costs reflect case mix, with services targeted at people with severe mental health problems increasing costs by 50 per cent.

The briefing’s discussion on the factors that aid or hinder joint working is excellent. A reasonable amount of the evidence it cites comes from integration in mental health services – which is relatively well advanced – and, to my mind at least, offers pause for thought when it comes to integration.

I say this because there’s a strong argument that integration across health and social care in mental health services – symbolised by Section 75 agreements (see this scintillating Audit Commission report, pdf) – has created an environment which is less conducive to personalisation for people with mental health problems. The numbers of people with a mental health problem who have a Direct Payment is one measure of this. It makes you wonder if hindering integration factors like (1) cultural differences in professional groups; (2) different philosophies of care or treatment; and (3) placing different value on the inclusion of users have contributed to this.

If those hindering factors have contributed to slower progress on personalisation in mental health than for other people, then what might the drive towards Integration across the piece mean for social care in the world that’s currently being created?

The two questions I’ll thus be interested in people’s views on at NCASC are:

  1. What can we learn from the impact of integration on personalisation in mental health services and on people with mental health problems?
  2. How can we work to ensure the same doesn’t happen as the biggest biggie show (aka Integration) rolls into town?

If anyone wants to share their thoughts before NCASC, feel free to comment below or tweet me (@rich_w).

(By the way, if I was being cheeky, the third question ahead of NCASC I’d want to ask is: just what the hell is the hashtag for the conference? Despite George’s best efforts I’m still not quite sure! Let’s go with #NCASC13 and see what happens…)

#WMHD13 – round-up of interesting links

World Mental Health Day was on Thursday, and it was great to see so much coverage in both traditional and social media about the day.

There was a huge range of information, research and personal stories shared throughout the day – a look through #WMHD is well worth the time if you have chance.

Here are my top few links from the day, with a very brief explanation of why:

  • Time to Change’s aggregated page of everything it’s doing on WMHD – ‘nuff said!
  • Esteem for people with mental health issues – Dr Geraldine Strathdee is NHS England’s Clinical Director for Mental Health, and this is a great summary of (a) what NHS England think is important about mental health, and (b) what they’re doing about it
  • Doc Ready for older people? – Doc Ready supports young people with MH problems to get the most out of appointments with their GP. The natural extension is that it’s available for all, and starting with older people is a great idea for an area that doesn’t get the focus it needs
  • A £500k investment in Mindfull – supporting online the mental health of children and young people
  • The mental health of LGBT people – great collection of research from Stonewall. Mental health – just like people and protected characteristics – is never an isolated issue

And a nice tweet from Norman Lamb, who I suspect will be doing some great stuff on mental health whilst he’s Care Services Minister.

Though it didn’t happen exactly on World Mental Health Day, any round-up like this must include Lisa Rodrigues’s post about her own mental health:

Some readers might think my disclosure is self-indulgent psychobabble. Others may feel that someone so flaky shouldn’t be running a big mental health trust. My reason for writing it is because of views like these.

That someone so senior (Lisa is Chief Executive of a mental health provider trust) can share such experiences is both progress and reassuring, in all senses of both of those words.


A valuable contribution to employment for disabled people

Disability Rights UK has today published an excellent paper, written by Neil Crowther and Liz Sayce, about disabled people taking control of employment.

It’s a short paper worth reading in full, so below are just a few quick reflections.

  • Recognising disabled people as a seriously under-used resource that can contribute to the UK’s position in the “global race” and our overall economic performance is an excellent frame
  • It’s hard to argue with the conclusion that the general and specialist work programmes aren’t working for the people who need them most because they’re, erm, not working! The data brought together to show this is the case is excellent and thorough.
  • The programmes are also incredibly poor value for money. At a time when there’s even more need for every £1 to be spent well, we should ensure as many of those £1s are spent on interventions that are known to work for people who need them (such as Individual Placement and Support, IPS, for people with mental health problems)
  • Where to start with end-to-end, behemoth providers? Let’s just stick with (a) they don’t make the most of the expertise that other providers have when it comes to specialist employment support; and (b) they don’t enable personalised approaches (possibly because they don’t get personalisation?)
  • There’s a significant role for peer support to play in supporting people into and retaining employment.

One final point: it’s great to see the report’s recommendations pushing so hard for personalised approaches in employment. There has been a tendency for personalisation to be seen only in the context of health and social care ; important as it is in those policy areas, personalisation is something we must strive for in public sector provision that affects all areas of disabled people’s lives.

Spending in mental health: 80% in and out

In 2011/12, the total spend on Direct Payments for Mental Health was £30.5m. This was 0.56% of all mental health spend.

Of the total mental health spend, over 80% (83.3%, in fact) is spent in the NHS. However, when someone with a mental health condition is given money to spend to meet their mental health outcomes, over 80% (84.5%, in fact) is spent on non-statutory providers.

That is, when there is no choice for mental health services users, over 80% of mental health spend is in the NHS. When there is choice, over 80% of mental health spend is outside the NHS.

What does this tell you?

A #dpulo success: Impact MH’s peer support programme

On the Strengthening DPULOs Programme Facebook page, I often see fantastic work that DPULOs are doing. After reading about the brilliant peer support work Impact MH are doing and discovering some of the outcomes they’re achieving, I asked their CEO, Déanne Clark, to tell us more about it… 

Impact MH is a mental health service user-led charity delivering services to promote recovery, raise awareness of mental health and tackle stigma and discrimination. We work in partnership with local providers, commissioners and service users to improve the quality of local mental health services through engagement, consultation and creating an effective communication channel.

We have been operating for over nine years and became an independent charity in 2010, increasing our service user engagement and contact to over 240 members. Through the tough economic times and changes in local funding, Impact MH has fully embraced change and created a new service – the Peer Support Programme – based on the changing  needs and comments from our members.

It was a daring move in such uncertain times, but one we feel is already proving a fantastic success!

The Impact MH Peer Support Programme, funded by SEPT and the Strengthening DPULOs Programme, is a six-week peer led programme that aims to increase confidence and wellbeing and provide opportunities for enhancing recovery and wellness. Importantly, this programme offers a safe environment in which a group of people can share their experiences, their ups and their downs, whilst supporting each other and making new friends. At the end of the six weeks, there are many options for people to get further involved with our monitoring work, including becoming volunteers by attending the Peer Volunteer Induction sessions, going on to support individuals in the community and, within secure settings, to help with transition and signposting.

Other exciting opportunities involve new friendships and networks formed during the programmes, establishing self-support groups based on common interest, such as fishing, reading, dancing. Encouragingly, these groups are supported by existing community-based organisations willing to provide advice and resources.

The Peer Support Programme, in our opinion, is the best thing to happen since someone discovered peanut butter and jam went well together! You know when you’re on to a good thing when the evidence is overwhelming and staff, volunteers and members walk around grinning from ear to ear.  Half way through our third programme, we have already seen:

  • Four people attend job interviews
  • Six people apply to become volunteers
  • Three self-support groups begin the process of setting up.

I could go on but sometimes, and more often than not with a user-led organisation, it is best to let those who are experiencing the services to say what they need to say:

With the right help, mental wellbeing and strength I believe any job is attainable – I would recommend the Impact peer group to anyone.

It has been incredibly useful and I would like to help others the way the programme has helped me.

This course helped me to look at myself in a different way and redefine my focus on my pathway to recovery with the parameters set by me.

This is a massive thank you to all for the best six-weeks ever! I have learnt so much and enjoyed every second. My mind has been re-booted and I feel ready to launch myself into whatever life throws at me – not only that, I am ready to be Mistress of my own destiny!

You can read more about Impact MH’s work on their website  and on their Facebook page. Detailed information about their peer support programme is here.

Modernising mental health day services: a user-led success in Birmingham

Last year, I was fortunate enough to meet Jane Thakoordin. She shared with me some brilliant work that has been going on in Birmingham over the last 3 years regarding the modernisation of day services for people with mental health conditions.

The modernisation drove forward that most complex of issues that often involved lots of different views: moving from day centre provision to and offer that increases personalisation and continues to provide good support for people.

What I particularly liked about this work is how fundamental user involvement and direction at every stage of the process has resulted in an incredibly successful service for everyone, known as Support, Time and Recovery (STaR). For example:

  • STaR involves people who were once recipients of day services as volunteer workers in the service to the running social drop-ins and group work
  • There are now 18 user-led projects in the city to provide drop-ins, which provide a cost effective prevention pathway in the community using peer support
  • There is now a much stronger focus on personalised services, including through a bespoke 1-to-1 service using person centred planning tools that in themselves form a short term enablement pathway
  • The new, coproduced service has delivered a saving of £120k in its first year of operation whilst supporting more complex referrals in a more personalised way – namely, the fabled “more for less”

Jane has kindly shared with me some documents that contain more detail about the STaR service and how it came to be. These are embedded below and are:

  • A short paper explaining the background and context of the work, how it developed and the results its delivered
  • A short presentation providing an overview of STaR
  • An article from Mental Health and Social Inclusion featuring STaR
  • A video of the personal experience of Simon of STaR.

If ever there was an example of how user-led approaches can support local authorities to achieve service modernisation for people with complex needs that also achieves more for less, then this is it.

What is a #dpulo?

Those who follow me on Twitter (@rich_w) will have seen me use the #dpulo hashtag quite a lot.

In your quieter moments, you may have asked yourself: what on earth does he mean by this?

A DPULO is a Disabled People’s User-Led Organisation, and I use the hashtag whenever my tweets relate to work I’m doing on the Strengthening DPULOs Programme for the Office for Disability Issues.

As with most issues of language and definition relating to disability and/or the voluntary sector, the definition of “DPULO” isn’t, necessarily, straightforward. Thus, the following describes the definition the Strengthening DPULOs Programme is using (this is the “we” below) and some of the debates that often go on around this topic.

It should be noted, though, that one of the key pieces of work we’ll do over the course of the 4-year programme is work towards a (possibly new) definition of a DPULO. This is therefore something of a work in progress.

The core definition

At a fundamental level, a DPULO is an organisation run by and for disabled people. That’s the easy bit, but let’s unpack what this means.

By “disabled people” we mean anyone who has rights under disability law. This includes people with learning disabilities, long-term health conditions, mental health conditions, physical impairments and/or sensory impairments. Some DPULOs also include people who self-identify as having an impairment.

By being run “by and for” disabled people, we mean:

  • At least 75% of the people on the “governing body” of the organisation (such as the Management Board) are disabled people
  • At least 50% of staff are disabled people
  • At least 50% of volunteers are disabled people.

We also want the organisation to be run on the basis of the social model of disability, rather than any of the other models (such as the medical model or charity model).

Since not all organisations can start immediately with these proportions of trustees / directors / staff / volunteers, we also appreciate those organisations that can concretely demonstrate they are working towards becoming DPULOs.

What about carers / older people etc.?

Previous work on user-led organisations included in the definition of ULOs (rather than DPULOs) the explicit involvement of carers and/or older people.

It’s important to note that the definition of DPULOs doesn’t exclude this – a carer or older person could be part of the 25% on the governing body. It’s also important to note that carers themselves can be disabled people.

Recognising the similar-but-different issues relating to carers and disabled people – as well as the associated power dynamics that can underpin relationships between the two – the definition of DPULOs doesn’t include explicit reference to carers. Where carers aren’t involved in the management of a DPULO, though, then one of the things I personally look for is how a DPULO works with carers organisations.

Similarly, explicit recognition of age isn’t included in the definition of DPULOs. As well as DPULOs working with age-specific organisations (both young and older people), it’s also worth noting the positive correlation between impairment and older age.

What about BME / sexual orientation etc.?

DPULOs should, of course, aim to be representative of their local populations as far as possible. In this, they are no different to any other good public, private or voluntary sector organisation.

What about the Department of Health’s 21 Design Criteria?

Those folks who have been around user-led policy and practice for a while will know that the Department of Health previously did some great work on User-Led Organisations. In doing so, they coproduced a definition of a ULO that resulted in the 21 Design Criteria. Though these criteria were good and very useful, I think it’s fair to say they were a bit onerous. There was also the interesting dichotomy – arising from self-assessment against the design criteria – whereby some organisations you would expect to be a ULO didn’t think of themselves to be a ULO and vice versa.

What other organisation descriptions are there?

As with any question of language and definition, there are other descriptions of disabled people’s organisations. Below are a couple of the main ones I’m aware of, and how (in the context of the definition of DPULO used above) they differ from a DPULO.

  • Disabled People’s Organisation (DPO) – This is an organisation for disabled people. The key distinction here is that, though the DPO may work on behalf of disabled people, it may not necessarily be controlled or run by them.
  • User-Led Organisation (ULO) – This is an organisation that is controlled or run by users of the organisation, but these aren’t necessarily only disabled people. Typically, ULOs include carers or older people. Similarly, a ULO can also be an organisation run solely by the “beneficiaries” of the organisation’s work, e.g. people from a BME background, LGBT people.
  • Disabled and D/deaf People’s Organisation (DDPO) – This is an organisation possible of and/or for disabled people that explicitly includes D/deaf people.

Dissertations and theses running to 100s of pages have been written on this topic. A relatively long blogpost such as this is therefore only likely to scratch the surface of what is or isn’t a DPULO. I hope, though, that this has given a flavor of what is meant by the term DPULO.

At a fundamental level, I hope I’ve conveyed the idea that – drawing on some basic building blocks – a DPULO is whatever local disabled people want it to be and is an organisation over which they have control.