The Five Year Forward View Mental Health Taskforce

The FYFV for MH: The Independant MH Taskforce Report.

Following the NHS Five Year Forward View (5YFV) published in October 2014 work has been under-way to implement this. We are told from the foreword of the original document that this Forward View represents the:

“…shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders. It sets out a vision of a better NHS, the steps we should now take to get us there, and the actions we need from others.” (p.2).

Bold words. In some places putting my critical hat on highly improbable words I’d say. However putting all that aside I stepped forward to be part of the recent consultation for how the 5YFV might look for Mental Health in particular following the Mental Health Taskforce public engagement findings. This was held in Cambridge last week but for one reason or another I couldn’t make it on the day. So I added my tuppence via email having scrutinised the Taskforce documents and commentary from the other consultants. This is what I said. It speaks more to what was missing then what was present in the current plan for mental health. (I’ve lightly edited this for grammatical clarity. Some would say I should edit this more heavily in this regard!).

I have been able to review the slides and the strategy workshop documents. I largely agree with much of my colleagues comments I have to say – I would like to add the following points:

Models of research – the need for more ethnographic and autoethnographic approaches as a research methodology is clear as a means of both challenging and complementing the more biological models of research. A strand of funding then and a significant one at that is needed, e.g. from within a respected research funder such as the NIHR that is dedicated to funding qualitative research would serve to (a) legitimise these chronically disregarded and marginalised forms of research (b) foster parity between the disciplines rather than division.

This would also speak to the liberal sprinkling of comments around social determinants. Social determinants are well established – now we need interventions based on our understanding of social determinants – e.g. Haslam et al.’s work as well as continuing to explore the specific social determinants and factors in place for people with mental health difficulties that are geographically and contextually relevant (see: http://www.sciencedirect.com/science/article/pii/S0165032714000573,) . Hence the ethnographic/autoethnographic approaches mentioned above.

Topics

There has been some research into the impact of the current welfare system on the mental health and lives of people with disabilities and mental health problems. The direction of travel of the current research is clear.

More research is needed on:

  • income inequality and mental health
  • workfare/psychocompulsion
  • in work and out of work benefits,  sanctions and the process of assessment and mental health
  • housing and mental health
  • the efficacy, effectiveness and safety of recovery colleges

Policies and processes of benefit assessments should be subject to evidence-based scrutiny/direction. They are not. It seems that evidence is rarely the meaningful guide to policy direction and development in spite of the money spent on the civil service, evidence reviews, consultations and strategies. There is rising media, lived experience and scientific evidence of the distress and deaths (people killing themselves) due to the assessment and sanctioning processes. (see e.g. White 2016 https://kar.kent.ac.uk/59731/1/insights-32.pdf.,  Perkins et al. 2017 http://www.emeraldinsight.com/doi/pdfplus/10.1108/MHSI-12-2016-0039).

I would strongly suggest that a specific theme of social determinants and social interventions is merited to give due regard and credence to all of the above.

As part of the upcoming Critical Mental Health Nursing volume I am developing the argument that compliments my approach to mental health nursing education, namely that MHN’s  must shift towards political-psycho-social activism. This represents in some small way a bit of that on my part. The bullet points with the exception of the final point on Recovery Colleges were raised by MH activist colleagues Recovery in the Bin.

Courtesy of and with kind permission granted from: http://www.yearoftheduck.com/trojan-duck/

Critical Mental Health Nursing

I published Recovering from Psychosis: Empirical Evidence and Lived Experience in 2016 and having done that you would think that was enough and I should get on with business as usual. But no. I had already started working on a second book idea which was originally going to be a book on Recovery Oriented Nursing – a sort of how-to guide combined with a critical perspective on it. And then everything went pear-shaped. Well, no not really. I started approaching people and talking about the book looking for contributors because another solo effort seemed to be a bridge too far and one that I’ll revisit later (yes there is a Book III idea wanting to get out). Instead surely editing a book and having others write the chapters was easier? The astonishing naivete.

Now we are some 3 months into the writing process for book two. It’s not a Recovery Oriented Nursing book as you may have gathered as the conversations with contributors and gathering co-editors took shape. That and the fact that another book exactly on that topic turned out to already be in press. Instead we have a completely different animal – Critical Mental Health Nursing. Offered up in conjunction with the Critical Mental Health Nursing Network.

CMHN is a vehicle. For multiple perspectives from nurses being critical of nursing, from people who have had experience of being cared for by mental health nurses, from professionals of other disciplines working alongside nursing to be heard. It will have a strong applied to practice focus, an ethnographic and autoethnographic flavour along with empirical evidence, multiple-theoretical-analytical approaches, and is driven by the authors and not the editors. At least that’s the plan! More to come as I have it. We are looking to see it published in 2018 by PCCS.

Autoethnography, cognitive psychology, folk-psychology: Thoughts on connectionist approaches to mind.

So, a long time ago I made a casual promise on twitter to write a blog about connectionist implications of approaches to theories of mind and consciousness. Foolish. However, that idea has bubbled away and recently re-emerged in discussing some aspects on the inter-relationship between language, mind, and truth. I’ve edited this and reproduced it here. Make of it what you will.

Connectionist approaches to mind, particularly Smolensky’s sub-symbolic approach, would say in my interpretation of it that words are something like socioculturally negotiated categorical descriptors and are connected associatively to world-events by dint of learning-training experiences. Our experience of language/words/thoughts/beliefs in a computational-philosophical framework is of a virtual machine underpinned by Connectionist mechanisms that are highly attenuated informationally-primed sensitive pattern matching machines – amongst other things. Indeed the best connectionism networks we have to date ‘deep belief networks’ which are forms of boltzmann machines are able to make categorical distinctions of written numers for example – you can show them lots of example ‘1’s’ and it can recognise that it is a ‘1’ even when highly ambiguous or the mechanism is damaged. The learning process that does this is never specifically tutored on what is a ‘1’ or told the desired output it learns to discriminate without such labels. What I take from this is that language is arbitrary and negotiated and built on top of lower-level sub-symbolic cognitive consciousness supporting mechanisms that are primarily concerned with finding statistical regularities – reducing surprisal and anticipating and reducing information-error. Language itself is a virtual machine on top that enables us to express and converse but is subject to sociocultural influences and is in of itself not a necessary prerequisite of conscious experience. On this basis whilst I consider words to be necessarily useful and meaning rich vehicles for experience they can only ever be at best to ourselves partial approximate descriptors of ‘raw experience’ (or qualia) and are always thus potentially subject to revision, oppression and the imposition of others mediated ‘truth’.

This is a talk by Geoff Hinton on deep-belief nets recognising numbers, without instruction. The video starts at 21 minutes – his demonstration of brain states and mind states is cool. https://www.youtube.com/watch?v=AyzOUbkUf3M

With autoethnography I’m with Ellis and am not so concerned with ‘truth’ more with stories that impact emotionally upon the reader and stimulate empathy compassion. ‘Evocative’ autoethnography if you will to my mind has as much value – if not potentially more than ‘Analytical’ strands. I get different things from both. We are tasked in the nursing-education world, courtesy of the Francis report and our CNO, via the 6C’s, with imbuing nursing with requisite care and compassion – (amongst other empirically opaque ‘C’s’) and are forced to leave aside the political injustice of the government’s reduction of the myriad of recommendations to holding our profession accountable for these failings as we do so. I would argue that these, along with the Courage C, are sound reasons to promote the autoethnographic movement within mental health nursing in particular, and nursing in general.

In applying a connectionist approach I’m seeking to undermine the ‘psychological truth’ of psychological models by exposing what I consider to be the shaky foundations they rest on.

Geoff Hinton’s talk I linked you to is a classic example – he seriously talks about models of brain state and models of mental state. They are linked but not the same. As I’ve expressed before elsewhere in various talks about more philosophical-existential aspects of mind, based on my understanding and previous work on connectionist theory and models I see the mind as a ‘virtual machine’ or ‘extra-dimensional property’ – they are inherently hypothetical. Minds themselves and the associated language labels – beliefs, thoughts etc employed in cognitive and clinical psychology are a construct. I may behave and have experiences that can be described as ‘having a belief’ and that is a convenient way of talking about that experience and associated behaviour, but I’m quite convinced that what ‘really’ underlies this is nothing like either the folk-psychological account of mind and mental behaviour nor the clinical psychological version – they are both kinds of approximation. This is evident to me from how classical-AI systems can be built out of sub-symbolic AI systems. The former has rules, categorical labels and so forth much like a lingua franca of the mind. The latter is the machinery underneath that scaffolds all this and has no clue or interest in the above.  Thus I would argue that connectionist approaches are potentially quite liberating for this reason, and that it allows us to hold these folk-psychological, cognitive-psychological and clinical psychological models lightly as mere approximations, not by necessity truth.

The Politics of Nursing and Nurse Education

I’ve recently participated in two review consultations to present a commentary on the recent proposals by Health Education England to introduce a new support role on the back of the Shape of Caring review. In both of these review meetings the context of the proposals and potential implications of the wider context of recent changes to nursing and nurse education, in particular, was a common focus. I’m going to outline these here and voice the kinds of predictions that have been made by both groups about what the future of nurse education looks like.

So if we review the changes that have been happening across both the current Conservative government and the previous Coalition government we can see a number of interventions happening. Firstly in relation to nursing education, we have the establishment of £9,000 tuition fees amongst many Universities wherein the Liberal Democrats ditched their election pledge to not raise student’s fees. The impact of this has been a decline in undergraduate student numbers as quoted verbatim here from the Universities UK 2014 report in conjunction with the HESA (Higher Education Statistics Agency) on the Patterns and Trends in UK Higher Education.

“In 2012–13 there were 140,000 more students studying at UK higher education institutions than in 2003–04, an increase of 6.4%. However, the rate of change fluctuated across the period: 2009–10 saw the largest year-on-year increase, of 4.1%; between 2009–10 and 2011–12 numbers remained stable at around 2.5 million, and then in 2012–13 numbers decreased by 6.3% (156,000 students). First-year undergraduate student numbers increased by 13.7% from 2003–04 to 2009–10, followed by a 22% decrease between 2009–10 and 2012–13.” (Universities UK, 2014; p6). The devil is in the contextual details when it comes to monitoring student numbers – depending on which year we start measuring from and which subset of students get included in the counting.
This should be considered also in light of the upcoming proposals to move away from a student bursary for nursing students to a student loan arrangement. This led to a considerable outcry, protest, a professional and parliamentary debate about the relative merits and potential harms of such a move. It is worth considering that research indicates that in over 40% of such existing loan schemes in HEI institutions in 44 different countries the recovery of such loan monies is  40% or less (Shem and Ziderman, 2009). It’s also worth mentioning that bursaries for Social Workers are being mooted as next on the government’s agenda.

Nurse revalidation “to strengthen the … registration renewal process and increase professionalism” (NHS Employers, 2016) was introduced as one of the measures following the Francis Report (2013). I would argue that whilst this has been ‘spun’ as a way to strengthen nursing and validate our professionalism what has actually been taken away and implemented from the 290 recommendations is in places far removed from this. Whilst the report indicates a number of individualized failings and also managerial shortcomings amongst others the whole of the nursing profession has been made effectively, tacitly to accept as a professional group the responsibility for these failures.

For example, the Francis Report made recommendations regarding ‘safe-staffing’ that the government promised to implement by commissioning NICE to review this independently. They’ve already back-peddled on this and now it is in internal NHS/DOH hands and is only now at the time of writing starting this work picking up from NICE’s previous analysis.

We also now have the government led work-force development plan to create a ‘nursing associate‘ role that Health Education England (HEE) says is intended to sit between care-assistants and qualified nurses . Several issues spring out of this – if the intention is to improve the quality of care (as is alluded to in the HEE documentation and subsequent discussions) then what is the evidence that such a role would do so? (It’s worth noting that when looking at patient mortality rates from acute myocardial infarction in the States studies have shown lower mortality rates when the nursing staff ratio had higher proportions of RN’s and higher mortality rates when nursing staff ratios had higher proportions of LPN’s (Licensed Practitioner Nurses) – a role very similar to that proposed as the nursing associate Person et al. 2004).

HEE also intends that ‘nursing associates’ would form another career-pathway towards nursing qualification then the existing graduate-pathway. Exactly how this would work, and how we could be certain that this more apprenticeship style route would have equivalency in terms of the education delivered is highly contentious. What we would have in the interim however is a new tier of work-force that registered nurses would have to take responsibility for – more management and less hands-on nursing from qualified staff then – that decreases patient safety. Nursing associates will not for instance be putting together care-plans, so that’s a job left to the RN. Another consequence I see of this workforce change is that we have cheaper care and less of it directly in the hands of RN’s.  I would argue further that we also get less consistency in terms of how nursing education is delivered through the introduction of a new career pathway.

There is also the matter of the use of the word nursing in the job-title. Registered Nurse is a protected term, whereas ‘Nurse’ is not. Nursing associate implies the practitioner is of the nursing persuasion, and yet clearly they are a new tier of health-care support worker – not regulated by the NMC. I wonder if the average patient receiving care is going to appreciate what and who this new level of practitioner is and what their expectations will be of what nursing associates can and can’t do?

Once more we have poor work-force planning, not backed by evidence of improved quality of care, that is politically-led and austerity driven. This is coupled with the hanging of responsibility on nursing and education for the complex systemic and individual failings highlighted in the Francis Report. Alongside this we have changes pushed through to student nursing bursaries and graduate fees that will undoubtedly change the landscape of recruitment into the profession.

So, bottom line predictions: the move to a nursing associate will create a new pathway to a nursing qualification. This cheaper for employers option with an ‘earn as you learn’ sales pitch will compete and even become the dominant route into the profession. Regulate nursing associates in the NMC and we have a new two-tier nursing with employers recruiting for more nursing associates into their rotas because, well it’s cheaper. RNs will have an increased clinical-supervisory/managerial role as a result and decreased hands on care. Care quality will be threatened as a result. Nursing isn’t teaching with its attractive golden hello, TV marketing campaign and decent starting salary. Without a bursary a proportion of nurses that would train by the graduate route will go elsewhere or into the NA route instead. We will have less diversity in our workforce as a result. Having axed bursaries the government will turn to social work and claw back funds from there to shore up some other aspect of the incessant goal towards nullifying our countries deficit. To the cost of an already beleaguered health and social care system.

“Parity of Esteem, No Health Without Mental Health” : Political Sloganism

I found myself tweeting this the other day, in amongst tweeting about book writing and the excitement of new Dr Who episodes and Great British Bake Off:

— Stephen Williams (@MHNurseLecturer) September 10, 2014

Looking at governmental interventions that have affected mental health we have had years of NHS staffing cuts, resource cuts, bed losses, ‘back door’ privatisation and rhetoric and tokenism. Take Nick Clegg’s  recent pledge (not a good word to associate with Mr Clegg – notorious as he is for reneging on promises) of a £50M ‘boost’ into mental health research. What does this actually do for the much vaunted ‘parity of esteem’? Well firstly from a research perspective it could help maybe fund a few randomised control trials worth of studies. This may improve understanding or enable a new therapy to be trialled. As for what this would do for the experience of the service – next to nothing I would imagine. So this kind of pledge strikes me as nothing more than a misguided and empty political piece of misdirection. Sort of – don’t look at what a terrible dangerous mess this is all in, look at the offer of shiny-shiny money – aren’t we caring and doing something about it after-all?

Remember this one? Liberal Democrats 2010 Electioneering Slogan.

 

Let’s also consider this idea of ‘parity of esteem’ – that mental health which has pretty much from its inception within medical and health care practice always played second-fiddle to physical health services in terms of image, funding and priority. Perhaps it seems, at first glance, laudable to call for a parity? When I first heard the phrase it immediately seemed to me that this was going to be another bit of ‘rhetoric’ that would never translate into meaningful action – i.e. raising resources and funding for mental health services. The disproportionate cuts between acute services and mental health services seems to bear this assumption of mine out. (See  http://www.bbc.co.uk/news/uk-england-sussex-26530733, http://www.bbc.co.uk/news/health-25777429, and http://www.bbc.co.uk/news/health-27942416 for examples of how cuts demonstrate that ‘parity of esteem’ is a hollow political promise).

Given the potentially devastating impact that mental health difficulties can have on a person’s well-being, life circumstances, relationships, emotional state, livelihood, physical health, citizenship, personal security, status, longevity and employability is it reasonable to suggest that ‘mental health’ should just be ‘on a par’ with physical health? I’m bound to argue that in some respects addressing mental health difficulties should be given priority according to its own needs and impacts, in its own right. This might mean that it needs funding above and beyond acute and physical care and that calling for a ‘parity of esteem’ is doing mental health and healthcare in general a disservice. Is acute and physical care necessarily getting the attention, funding and resourcing it needs and deserves? Somehow I doubt it given the shear depth and breadth of the services encompassed. Equality is not necessarily about “treating everybody equally”, it’s more about making adjustments that enable those persons needs to be met – tailored to obstacles that are present within that person’s life circumstances.

Ok, extended grumbling over – as you were!