NHS Foundation Trust lead social worker and trained mental health nurse Paul Blakeman and Edinburgh’s Strategic Programme Manager for Health and Social Care Linda Irvine Fitzpatrick, have a big picture dialogue that explores what we should value and invest in when thinking about the transformation of our mental health systems.
They examine the drive for decisions to make best on evidence-based practices that meet the needs of people today that often sits in tension with investing in practices with promising potential to meet people’s needs in the future.
‘We should focus our investment in what has been proven to work to meet people's needs today'
'We should focus our investment in what is showing promising potential to meet people's needs in the future'
Since the NHS started, we’ve had the idea of “cradle to grave” and being looked after and care and all of these words that are more than just words, there’s a lot of merit in that, but what does that mean in the 21st Century is it a very different kettle of fish. … what we’ve tried to do in the past historically is, we’ve got a certain range of tools so we’ll try and match people’s problems to the tools that we’ve got as opposed to saying, “well, what is it you want some help with, how can we get you to where you want to be and how can our tools support that.
[Narrator]: Welcome to the Living Well Dialogues a series of podcasts of intimate conversations between people striving to understand how our mental health system is shaped and seeking to find new possibilities to continue to grow their Living Well systems in places across the UK.
What do we value? When working in public organisations the question of what we value is an evolving and often contested question. It asks us to balance a range of different, often seemingly competing demands. Quality can sit in tension with efficiency. Even rights and social justice can be in tension with safety and risk and meeting current needs can sit in conflict with investing in meeting future needs. So, when we ask the question, what do we value, it asks us to make choices or find alternatives that balance these factors as best we can in order to create the greatest possible value that we can.
To help us make good choices about the value we invest in we often need to rely on evidence to help us. The complexity of people’s lives means that getting the right evidence isn’t simple either. In fact, seeking to try and evidence everything can be corrosive to innovation and reinforce unhelpful power dynamics that we might be trying to move away from. So, when it comes to the question what we value in our mental health systems we are often faced with a key tension between valuing and investing in what has been proven to meet people’s needs today or valuing and investing in what is showing promising potential in meeting people’s needs in the future. Sounds complex? Well, it is, but that’s why we need the help of people like Linda and Paul to tease out how we might navigate this tension in our mental health systems.
Linda Irvine Fitzpatrick has worked for the NHS for over 25 years and is currently leading on the development and implementation of Edinburgh THRIVE, the Cities ambitious mental health and well-being strategy. She is also a Senior Research Fellow at Queen Margaret, and Strathclyde Universities.
Paul Blakeman has practised in the NHS as both a mental health nurse and a social worker since 1995. He has also been an academic in the fields of mental health nursing and more recently in social work. Paul is currently the Professional Lead for Social Work in an NHS Foundation Trust in the East Midlands.
So, we start the dialogue with the context of our mental health systems in England and Scotland and how this is shaping the way that we think about value and what this means for the future of our mental health services.
I mean in Scotland of course we’ve got legislation for integrated health and social care, which I think is where England is going to, and we’ve got another massive policy change coming up which is to create a National Care Service. So that has potential to be incredible but also has the potential to be really disruptive to a lot of local working and really hyper-local working which is kind of where we have been focusing over the last couple of years. Where are the communities, where are people living, how can we make sure that people have more good days in the community that they live in. How they are describing the National Care Service is that it is going to be as big as the creating of the NHS in 1948.
Yeah. I can imagine, yeah. Yeah, and it’s interesting from this side of the border, the English side, the current thinking certainly seems to be pointing to an integration between health social care and the voluntary sector. So rather than setting up a National Care Service it feels as if it is all becoming one organisation. And I suppose that is two different views of integration, I guess. A local, personalised, and flexible provision that hasn’t been there before. So, it’s interesting that they are both approaching this from perhaps different ideological perspectives, but towards the same place. Which might imply it’s the right place to be!
Absolutely, and by making this a single entity if you like do we then dilute some of the more freedoms that some of the of 3rd sector have sometimes and do we just dilute that down a bit by trying to encompass it all - do you know what I mean? So that has always been our fear that we lose some of the agility and creativity of the 3rd sector by harnessing it to two big institutions, the Council, and the Health Board?
Yeah, absolutely. And it is a challenge isn’t it. The way people are more dynamic - those are things we want to learn from, not kind of curtail, because it’s not going to work - in some ways it’s the battle for the 21stcentury is about how you bring diversity together but without making it into just one thing that all looks and sounds the same. How do we live with diversity as opposed to how do we assimilate it … we’re coming to those stages now I think, where we are asking those questions about how does one person work that way and another work another together?
Linda: Yeah, that fear of diluting is always in the back of my mind and the permission to innovate. Who has the permission to innovate? And do people just take that? …’cos I would hate if people didn’t take and had to wait for permission. Sometimes in our big institutions that’s what people feel they have to do.
Jo: So, we hear that there is a general movement in both Scotland and England towards a greater degree of integration across our mental health systems. But Linda and Paul highlight that this desire to better harness our collective efforts might take us toward a greater level of uniformity for mental health support. As Linda highlights this risks limiting innovation needed to integrate the diversity and dynamism of support that parts of the system provide like in our voluntary and community sectors, better connecting in the value of which has been key to driving the agenda of greater integration in the first place. So, what is shaping the future of mental health practice and why does this risk diluting the diversity of mental health support rather than amplifying it?
If we are sticking solely to evidence-based practice then the question for me is always whose evidence?
One hundred percent.
So, you get into a whole power dynamic around that.
And I’m a big advocate of using evidence … but … you’re absolutely right, whether it’s right or wrong, there’s hierarchies of evidence aren’t there. I’ve always taken the view … and I don’t think it is that controversial - that evidence based practice should actually be evidence informed practice where you actually use that evidence to make a judgement about what you do, otherwise you run the risk of making everything just an algorithm and it turns into almost a form of medical ‘perfected Taylorism’ which I think is the kind of production line … everything’s just so perfect, but that doesn’t allow for humans with different needs. Yeah, so I think there is a challenge there between how we interpret evidence and what we class as evidence.
That’s my biggest fear I think … that and reverting to not recognising the tensions between the discourse around being person centred and how that can contradict if you are following evidence based. If you’re doing that kind of ridged interpretation of what evidence based are you using here. Because if we are truly being guided by what people we are serving are asking for … that might not be matching what the evidence would tell us … because the evidence itself has been flawed.
Yeah - massively - And I think there’s a huge amount of discussion in the academic journals around how evidence perhaps isn’t what you might think it is, it’s been oversold. Since the NHS started, we’ve had the idea of “cradle to grave” and being looked after and care and all of these words that are more than just words, there’s a lot of merit in that, but what does that mean in the 21st C is it a very different kettle of fish. … what we’ve tried to do in the past historically is, we’ve got a certain range of tools so we’ll try and match people’s problems to the tools that we’ve got as opposed to saying, “well, what is it you want some help with, how can we get you to where you want to be and how can our tools support that” … and that way the evidence thing is almost like the ‘tail wagging the dog‘ because we are trying to put people in evidence based models as opposed to choosing how we interpret evidence and what evidence based models we use to get people to where they want to be. There’s so many different things that feed into somebody’s presentation of what a mental health problem is - it’s never as simple as a treatable medical problem there’s always social things and psychological and spiritual, all of these things we’ve perhaps ignored a little bit.
Linda and Paul help us to understand how we engage with evidence might be key to what shapes the future of our mental health support. They outline that if we solely rely on value defined by evidence-based interventions, often those that we have had the value measured through control tests, we risk creating a production line of support that doesn’t meet the reality and complexity of people’s lives - as Paul describes in his reference to Taylorism - the theory born in the industrial age of factories that promoted efficiency through the perfection of repeatable tasks. But evidence matters, we can’t just rely on assumptions to make good decisions about what we should value. Paul suggests a more evidence informed approach that might enable us to still draw on evidence whilst remaining people centred in how we work. So, what kinds of evidence might we want to draw on in order to shape the future of mental health support and why does this matter.
I would say if you look at the evidence from things like the social determinants of health, the Marmot Review, all the epidemiological stuff from all around the world that looks at income inequality and how that effects the number of people who are affected by social ills including things like mental health problems, but also their prognosis within that, I think it is inescapable within that we are perhaps looking at the wrong end of the problem really, because we are always looking at the consequences which is that people have become unwell … I’m certainly not anti-medical in this but I don’t think the diagnostic approach is necessarily always a very helpful approach to take. If we just take that then we are very busy trying to diagnose and apply treatment when the cause is maybe what we should be looking at - which often has a much more social and emotional component to it that has always been missed. Historically it has always been medically led health because health’s been, I think - again might be a controversial thing - but health seems to have been more dominant in social care in terms of the way budgets have been allocated and the views of consultants versus the views of a social worker for example, hierarchically perceived differently, which is completely wrong because they are two different experts in different fields. If we are going to treat experts by experience and carers and service users with a parity of esteem, we’re going to have to change that way of thinking. It’s not disadvantaging medicine, or saying medicine is not important, it’s just recognising there’s other things that are important as well.
For many years I’ve been sitting in rooms with people and quite often it is trauma related. You’ll be sitting in a room with somebody who has had a childhood young adult’s trauma and you’re thinking “I’m not sure a medical prescription is going to offer you much here”. It just seems the wrong tool for the job, and I think there’s quite a few people who might share that view nowadays. And again, it’s not because medics are evil it’s just that those are the tools that we have, and we use those tools to try to make people’s lives better. These new models that we talk about that involve closer cooperation and working with people’s assets resonate quite nicely … they do feel like they are intellectually and ethically in some ways better ways of working than we have done before.
I’m just struck by - just coming out of Covid … hopefully coming out of Covid! … obviously the massive impact that has had on all of us. But people who were already more disadvantaged have been even more harder hit by Covid and everything that went with it. We keep hearing there is a tsunami in mental health crisis and more and more in particular children and young people - but what have they missed for the last 2 years? They’ve missed social connections, they’ve missed connectivity, they’ve missed normal rites of passage that people would just be expecting to have at certain times of their life … so surely a response to that can’t be a traditional response either?
Absolutely. And although they did miss out two years of their life, I guess there is a compensation that may be all of us did [had] to a certain degree of the online world as well - and I think science is beginning to show that although there are a lot of benefits to get from being able to communicate remotely with people, is it outweighed by all the harms people have? And they do say don’t they that in the past before the days of the internet sharing meant dividing something and of course now sharing means multiplying, so if you are sharing a comment or a post or a picture, it’s 24 hours a day, seven days a week, can be round the world in literally milli-seconds - we’ve never lived like that before and most of the treatments and models that we use are very positivistic in that sense in that they come from this idea that there is a thing called a mental health problem and it’s probably largely biological and we will be able to use medical treatment … but I’m not sure if that is going to be the root of many people’s problems as we go forward … what goes on behind that screen in particular… it can be for good, but it can also be for ill and I don’t think we are really talking about it.
So, there’s a bit for me about how whenever we talk about mental health we just jump straight into talking ‘services’. If we were reframing it and thinking, how can we create a society that is more accepting, how do we keep making things relevant for people and how then is that reflected in our services? Services don’t exist in isolation - they are delivered in the communities in which we live in. But sometimes I feel they are quite apart from that and maybe by bringing people in that have different types of lived experiences that are more diverse, that might be a way to keep things active and constantly questioning and I’m just really struck that I’m sitting here in my 50’s talking about young people and feeling what’s my experience of young people except for what my nephew and nieces tell me in their 20’s. And what we found recently was that our average age of people who come in to use our services has gone down, but our workforce has got older and there’s wisdom in the years of practice there but also the world is a lot different.
Definitely … it comes back to that idea of what evidence is and what expertise is … because I have absolutely no expertise about what it means to be a fifteen-year-old girl living in a big City, because that’s not my experience - and again it’s about recognising these different types of wisdom and different types of strengths that people bring to a team. But there’s possibly an idea of delivering the best that we know how to, and when we know better to do better, and how do we know how to do better? Well maybe that’s a different type of conversation that we have with the people that we work with using that evidence, less as feedback but more about feed forward … so what are we going to change in the light of your experience?
I really like that, and I like the feed forwards rather than the feedback - creating evidence as it happens.
Jo: So, we need to take a broader look at the evidence and situate that within the evolving context of 21C life, like the pandemic, Covid 19, or our relationship to technology and understand how this might be impacting on our mental health. This seems key in making our services fit both for today and for the future. At the heart of this though is acknowledging the value of the evidence of lived experience and responding to it. To embrace this form of expertise in relationships of support that use this to feed forward - as Paul describes - to draw on the wisdom to generate the right support together. So, what have we learnt from our Living Well approaches about how we might better connect to and shape support in ways that respond to both each individual person and their experience of this wider context?
Linda: … one of the things we did with the THRIVE Teams, the first question starts with a conversation, it starts with the question “how can we help you” to the person … just trying to hold on to that I think is so, so important, it’s so simple, but it is so symbolic.
Paul: Absolutely and I think the strength-based approaches and asset-based approach are absolute right, they are the future. Because if you ask ‘what’s the problem’ or ‘what can’t you do’ you’ll be told that, how it stops me achieving the things I want to achieve in my life. But by asking that question of course you get to open up a whole range of options don’t you, so … Then historically of course we have not given credence to experts by experience and in hindsight you have to ask that question, ‘why’? Because it’s such an obvious … kind of source … that we’ve not utilised properly. So, yeah, that’s one of the changes I am really looking forward to is the integration of like more peer and experts into our service models and planning than we ever had before.
Linda: Yeah, I mean we’ve got peer workers embedded in our teams, which is great, and we had one of our GP’s out to visit and they were just like “oh my goodness the role that the peer workers make to this team is massive”. But it’s also still we then get caught in a dialogue around do peer workers really know how to manage risk. I was like we don’t talk about managing risk we’re talking about safety planning which is something different. So, it’s really easy to slip back into the old narratives and the old language that we have all been used to using in our health and social care systems …’
Paul: I’m stumbling a bit here … because at the back of my mind I’m thinking I know how hard this is because you’ve already brought up the custom in practice and how people slip into old dialogues and discourses about things like risk. We talk now about a much bigger system wide holding of risk rather than individuals … but what does that mean? People are going to struggle to get their head around that. It’s going to take a few years and the risk is in those few years it all just goes back to exactly as it was but with a new name. And it will be a missed opportunity. … And of course, one of the big problems that we have is inertia.
It takes a very long time for systems to actually change. You can go in and you can write new protocols and new standing operating procedures etc., etc. but people have got to use them and it’s really stressful and it’s really difficult to suddenly change what you have been doing after you have been doing it to the best of your ability for a long time. But then of course you’ve got the problem of change fatigue. And philosophical resistance … some people might not agree this is the way to go forwards. Again, people are people, they’re not sausages in a machine or anything … so we can’t just say now on Wednesday you’ll speak a different language, and you’ll act in a different way. It’s a lot more complicated and a lot more difficult.
If you’ve got values of putting people first, whether they are people who use services or people who provide services, … they’re all people … it’s very hard to do that [change] without putting a lot of pressure on people to change the way they work in a very short period of time. So, how that’s done safely is the source of a lot of conversations.
Jo: So, maybe it is as easy as taking it back to a simple question like “how can we help you?” and how this transforms our relationships in ways that better recognise and responds to peoples assets and strengths, but when we ask these kind of questions we can find ourselves coming up against the weight of existing customs and practices on issues like risk for example that can feel insurmountable. Paul reminds us that being people centred is also about recognising the people delivering support not just treating them like sausages and acknowledging that change is hard, it may face resistance, feel exhausting and importantly take time. So, what might it take for us to weather this change and move toward the greater value that we see might be possible in these different kinds of relationships?
Linda: I remember when I first started developing a strategy for Lothian 15 years ago - we had a big consultation event as you do, and service users were sitting at a separate table from other people. I actually cringe when I think of that now. It’s so far removed from what we do now … we’ve moved so much, but there’s so much more that we could push … despite everything that is happening I do feel actually really optimistic. We’ve made changes, things are changing and it’s holding on to that energy and creativity.
Paul: Optimism is a resource like anything else isn’t it. It soon gets burnt up if it doesn’t go anywhere. So, there is something about how you manage yourself and within teams how you manage that positive mindset to be able to push forward with these changes we need to do. Because it’s so easy to become disheartened.
Linda: Yeah, and just turning some of the conversations on their heads sometimes. Instead of going to a meeting about how are we going to write a risk register? Well, how about how are we going to write a resilience register. … reframing.
Paul: Absolutely and there’s something about strengths focused language that, I don’t know what the psychology of it is … it just seems to access a different database in your head. So, when you start talking about risk management it’s very different to safety management. People need to be able to take some of the risks they would like to take, and we need to support them in that as opposed to saying ‘No, it might upset you’. We need to think how can we help you to do that. If you want to give your job up, buy a van and sell sausages on the seashore, why can’t we support you in that? It’s about what is the point of mental health services are they to manage risk rather than invest in people. That’s a really good question that has stuck with me.
Linda: Yeah. For me it would be definitely to invest in people because you can’t be where they are today and be accepting of that, not see that as just a limiting factor for their future.
Paul: Yeah, and that’s one of the big changes I’m really hoping to see in services going forward. That move from risk averse, paternalistic, “got to keep you safe” - and what caring actually means, ‘cos caring can be a wonderful thing but at the same time it can be quite suffocating. There’s an English Judge [Munby] talked about there’s no point in making people safe if you merely make them miserable.
Linda: Why do we insist that everybody who lives in community whose got a mental health problem has to have this really full community spirited life! Everything is viewed through the lens of the person’s condition, or their history rather than how do we just insure people have more good days … however they define that for themselves.
Paul: Definitely, and I think that’s a really good example of trying to give people the best life that we know how, … asking somebody “what is the life that you want and how can we help you to get that?”
Linda: And if we heard the response.
Paul: And acted on it, yeah!
Linda: It’s been lovely talking to you!
Paul: Yeah, not bad for a blind date really.
Linda: Yeah! I’m gonna swipe … is it right or left?
Paul: Hahahahaha - that’s way out of my scope I’m telling you!
Jo: Listen to people and act on it. A simple idea of value but one that perhaps asks us to transform the purpose of our mental health systems from a prescriptive offer of evidence-based support, or in Paul’s words “providing the ways we know how” to meeting needs we diagnose they need, but instead to a renewed purpose of investing in people in the life they want. This purpose requires an understanding of value as something we make with people that needs us to build the evidence as we go and that calls on a diversity of wisdom to feed forward into a future. A future that might well sit beyond our current understanding of what is possible.
The Living Well Dialogues is brought to you by the Living Well UK Programme, funded by The National Lottery and delivered by the Innovation Unit.