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.

Troubling Definitions of ‘Mental Health’

Troubling Definitions of ‘Mental Health’

Image result for mental health

Lately thinking over dialogues I have been observing and participating on twitter, online and in practice has led me to the conclusion that there is a significant socio-political problem at the heart of ‘mental health’ practice. This comes from an assumed idealism of what constitutes ‘mental health’ itself. Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (World Health Organisation, 2013).

Perhaps on the face of it this positive spin on what constitutes good ‘mental health’ may seem benign and aspiringly inclusive. I find it question-begging. Shouldn’t we all wish to ‘work productively and fruitfully’ and ‘contribute to our community’? Shouldn’t we all wish to realize our potential? And it’s in reflecting upon the superficially desirous goals that I strike upon some potentially stony ground. If mental health is about realizing potential, getting on with life and being a contributing citizen – to paraphrase the definition – then what if my circumstances are such that I am obstructed from attaining any or perhaps all of these? Am I thus devoid of a state of mental well-being as a result? Are these truly necessary conditions for flourishing mental-well-being? If so then what of those who are for whatever reason unable to deal with the stresses and strains of day-to-day living and contribute to their national insurance contributions?

I had a troubled phase of my life (in the mid-latter part of my 20’s) where I was deemed unfit to work and signed off sick. This was because of my ‘mental health’. Already we are in some a kind of tautological trap before we’ve even got started. What sense does it make that I can be deemed ‘unfit for employment’ by virtue of my mental health that is defined as partly as a capacity to contribute to working life? Excluding me from work on these grounds is excluding me from a component of activity that constitutes my mental health! How do I regain this part of my mental health and be seen as ‘fit for employment’ despite my mental health if being in employment is considered to be a necessary feature?

Let’s look at this from a slightly different angle. Looking at research into retirement indicates that we are treading some very swampy ground here. On one hand some research recently published by the Institute of Economic Affairs demonstrates that retirement increases the chances of suffering from clinical depression by 40% and the chances appear to increase the longer you spend in retirement (Sahlgren, 2013). This research isn’t the last word on the matter. A cohort study of people working for Electricite de France (EDF) looked at the annual trend in reported mental fatigue, depression or physical fatigue over the seven years before and the seven years after retirement. It found reductions in depressive symptoms and mental and physical fatigue comparing the year before with the year after retirement. This led to the conclusion that retirement is related to improvements in well-being (Westerlund et al., 2010). So we have conflicting evidence – some suggesting that being out of work contributes to a healthier lifestyle and better mental health and another, equally credible that it leads to a deterioration.

This suggests to me that a serious danger to guard against are adopting ways of working that map goals and outcomes that perhaps generalise well to larger populations (and are the output of research) without care and attention, unthinkingly, to the individuals with whom we are working. Whatever ‘mental health‘ is will differ significantly from person to person and will vary through time – what affords my mental health now is not the same as 20-odd years ago. So for example with a client I worked with in a community service as a CMHN (community mental health nurse) her physical disabilities precluded her from paid employment (as deemed by her and the health and social care organisations). Thus for her mental health defined as necessarily being constituted out of working contributions was pretty toxic and irrelevant. Instead her mental health was living well and having control of her life within the infrastructure of services that provided her with care. She thrived from having support that she could flex around her – being more supportive at certain times, and stepping back with confidence when she was feeling more capable of self-support. For her skills of being able to differentiate between the two and communicating this level of support need accurately – and for that to be heard – scaffolded good ‘mental health’. She felt a sense of mastery and satisfaction from being able to direct her own care as it fluctuated over time.

References.

Sahlgren, Gabriel, (2013), Working Longer, Live Healthier: The relationship between exonomic activity, health and government policy, http://www.iea.org.uk/publications/research/work-longer-live-healthier-the-relationship-between-economic-activity-health-a [Accessed on 17/03/2014].

Westerlund H, Vahtera J, Ferrie JE et alEffect of retirement on major chronic conditions and fatigue: French GAZEL occupational cohort study. British Medical Journal 2010; 341:c6149

World Health Organisation, 2013, Mental health: a state of well-being, http://www.who.int/features/factfiles/mental_health/en/ [Accessed on 17/03/2014].

Why the Mental Health Act needs a review of Community Treatment Orders #ChallengeCTOs

Community Treatment Orders: What’s the Evidence for Legally Enforced Treatment?

In my upcoming book on Recovering from Psychosis (Williams, In Press) I have a chapter that critically reflects on the potential abuses of the widely discussed ‘recovery’ movement. Within this reflection a point I make is  that an organisational requirement to developing clinical practice founded upon partnership in decision-making necessitates a shift in terms of power and authority within professional roles and practices (Slade et al., 2014). This is particularly problematic in the case of treatment under section within the Mental Health Act (1983; 2007) and it is hard to see how services can maintain a recovery approach when this legal enforcement of aspects of treatment are in place. What follows now are my reflections on CTO’s excerpted from my current book draft.

Community Treatment Orders (CTO’s) were introduced as a means of reducing the need for admission and detention in inpatient settings. The data on rates of admission and implementation of CTO’s does not support these ideas, and neither do early randomized trials evaluating the efficacy of CTO’s. According to the Health and Social Care Information Centre (2009; 2013) rates of detention to inpatient facilities in the U.K. increased from 47,600 in 2007/2008 – 2008 being the year in which CTO’s were introduced – to 50,408 in 2012/2013.

Within the limitations of designing and implementing randomized control trials those conducted to investigate the efficacy of CTO’s in reducing the need for admission to hospital each unequivocally indicate that CTO’s do not have an impact statistically on such outcomes (Burns and Molodynski, 2014). There is in counter-balance to this some evidence that the use of CTO’s can reduce the length of hospital stay for certain groups of people (Light, 2014).

As Light (2014) points out in discussing the whys and wherefores of the legitimacy of CTO’s in the face of unfolding contradictory and in places unequivocally negative evidence is that the process of study design, choice of ‘outcomes measures’ and what kinds of evidence inform evidence-based care are philosophical matters. An implication of such studies thus far on CTO’s is that inpatient treatment in some sense is the result of a failure of the CTO. That is there is an assumption that the function of community care is to prevent the need for inpatient treatment. In a clinical context this does not always make particularly good sense – sometimes the purpose of community mental health care is to facilitate access to inpatient care. It has also been argued that CTO’s, like recovery, amounts to a process – wherein what benefit is entailed within the treatment order is in the improved access and availability of clinical resources to the person (Kisely et al., 2013).

These studies also fail to speak as to the qualitative nature of experiencing a CTO – the most recent studies of which in Australia (Light, 2014) paint a consistent picture of distress and ambivalence about the use of CTO’s there. Strangely, whilst studies of lived experience or qualitative data tend to have a reduced regard in terms of health-economic decision-making where randomised trials are seen as the gold-standard for research, a rebuttal of the OCTET trial evidence by Mustafa (2013) argues against the withdrawal of CTO’s based largely on evidence from a fictitious case of anecdotal evidence of its efficacy! It’s a perversely inconsistent world where on one hand we have arguments against the narrow use of existent psychological therapies for psychosis based stoutly and solely on hard-won expensive scientific empirical evidence (via RCT’s) that has limited room for the complexity of user-experience outside of often researcher originated numerical scales of symptom intensity. Yet again we have arguments for the persistence of a typically unpopular form of legally enforceable intervention in the face of the same kind of evidence that draws on a putative case of user-experience to justify this. We are well overdue embracing mixed-methodologies in psychological health ‘science’ and finding ways to draw upon user-experiences so that we can provide interventions that are both empirically valid and experientially attentive.

Given that mental health services is under-pinned by professional mandate to be ‘evidenced-based’ (Goodman and Ley, 2012) and so far CTO’s fail to meet the much prized and costly gold-standard of evidence – how can we be justified in their persistent mandatory usage in the Mental Health Act as is?

This, amongst other arguments, is the basis for the #ChallengeCTOs campaign. We are calling for a review of the relevant legislation that governs the usage of CTO’s. If you agree that a review is warranted you can help get this heard in Parliament by signing up to our e-petition: http://epetitions.direct.gov.uk/petitions/67906.

References:

Burns, T. and Molodynski, A.(2014), Community treatment orders: background and implications of OCTET trial. Psychiatric Bulletin, 38, pp3-5.

Goodman, B. and Ley, T.(2012), Psychology and Sociology in Nursing, London: Sage Publications.

Great Britain. Mental Health Act 2007. London: The Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/2007/12/contents (accessed 30/06/14)

Health and Social Care Information Centre (2009), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment – 1998-1999 to 2008-2009, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].

Health and Social Care Information Centre (2013), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment, England – 2012-2013, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].

Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, et al. (2014), An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res,47,pp 650-6.

Light, E. (2014), The epistemic challenges of CTOs: Commentary on Community treatment orders. Psychiatric Bulletin, 38, pp6-8.

Mustafa F., (2013) On the OCTET and supervised community treatment orders. Med Sci Law doi:10.1177/0025802413506898

Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., Perkins, R., Shepherd, G., Tse, S. and Whitley, R. (2014), Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13(1), pp12-20.

Williams, S. (In Press), Recovering from Psychosis: Empirical Evidence and Lived Experience, Routledge Press.

An @WeNurses Twitter Chat on NICE Guidelines and Evidence in Nursing

Are NICE Guidelines Enabling Our Caring Professionals to Meet NMC Standards of Evidence-Based Practice?

By Stephen Williams, Sian Jackson and Sarah O’Donnell (2013)

15042014wenursesThis is a proposed @WeNurses chat co-written by Steve Williams aka @MHNurseLecturer, Sian Jackson aka @firecracker1305 and Sarah O’Donnell aka @sarah_searz. This proposed twitter chat came about as a result of a pre-registration nursing @BradfordUni debate on evidence-based practice in healthcare. This represents a strand of ‘SoMe’ (Social Media) integration and dissemination of student-nursing practice as explored in Williams (2013).

The NMC (Nursing and Midwifery Council) (2008) code states we must: “deliver care based on the best available evidence” (p.6) and keep our “knowledge and skills up to date” (p.6). NICE (National Institute of Health and Care Excellence) guidelines have assisted practice since 2001. With a variety of treatment options/pathways it seeks to enable professionals to provide evidence-based advice and care. However is the evidence assessed by NICE sufficiently contextually relevant for our patients’ clinical needs?

Research evidence can become rapidly out dated and some academics and practitioners might argue it’s not always sufficiently well developed for practice. Nurses establish their practice in a variety of ways and their ability to critically evaluate research varies (Funk et al., 1991; Kirkevold, 2008). NICE guidelines take two years to be developed prior to publication. This suggests that upon publication they are already out of date and indeed may not be updated for a further three to four years.

An example of such issues with NICE guidance can be seen in the development of guidelines for self-harm (Pitman and Tyrer, 2008). Pitman and Tyrer (2008) point out that this was developed on research evidence with only one recommendation based on a RCT (randomised controlled trial) quality of evidence. Most of the research at the time was on the physical impact of self-harm and the guidelines received criticism for amalgamating self-poisoning and self-laceration as a single kind of problem (Barker and Buchanan-Barker, 2004). Is it pertinent to argue then that a culture of ‘following NICE guidelines’ perhaps disables nurses obligation to critically review nursing research and related evidence themselves?

NICE guidelines set out to reduce inequalities in treatment provision. Whilst this is a laudable ideal the reality of treatment provision is considerably murkier. Take the provision of IVF (in vitro fertilization): NICE guidelines in 2004 recommended three full cycles of treatment for those who met agreed clinical criteria. By mid-2005 PCTs (primary care trusts) were being asked to make at least one cycle available by the secretary of state. There was no mandate or mechanism for ensuring the recommendations were implemented (House of Commons Health Committee, 2008). A further critical point is that PCT’s in England were able to set the eligibility criteria for access to NHS funding above and beyond clinical criteria set out in the guideline (House of Commons Health Committee, 2008). This being the case – are they really addressing health inequalities and are we confident the advice they prompt us to give is sufficiently empirically robust?

A twitter chat in conjunction with @WeNurses is scheduled for Tuesday 15th April 2014 at 8pm online.

References

Barker, P. Buchanan-Barker, P., (2004), NICE and self-harm: Blinkered and exclusive,Mental Health Nursing, 24,6,pp. 46.

Funk, S.G., Thornquist, E.M., Wiese, R.A. and Champagne, M. T. (1991), Barriers to using research findings in practice: The clinicians perspective. Applied Nursing Research. 4, pp 90-95.

House of Commons Health Committee (2008), Health Inequalities: Written Evidence, Session 2007-08, Volume II, Her Majesty’s Stationery Office.

Kirkevold M. (1997), Integrative Nursing Research – An Important Strategy to Further The Development of Nursing Science and Nursing Practice, Journal of Advanced Nursing, 25, pp 977-984.

Nursing and Midwifery Council (2008), The Code: Standards of conduct, performance and ethics for nurses and midwives, NMC.

Pitman, A. and Tyrer, P. (2008), Implementing clinical guidelines for self-harm – highlighting key issues arising from the NICE guidelines for self-harm, Psychology and Psychotherapy: Theory, Research and Practice, 81, 4, pp. 377-397.

Williams, S. (2013), Embracing Digital Education for Nursing (An @WeNurses Web-blog Article), The Inside Skinny Latte Blog, September 9th 2013, Available from: http://mhnurselecturer.co.uk/?p=8, [accessed 19th November 2013].