Category: Uncategorized

Mental healthcare funding: Letter to Jeremy Corbyn 22 September 2017

Dear Jeremy,

I submitted a series of Freedom of Information (FOI) requests to Treasury, Department of Health, and NHS England, asking:

  1. Who is responsible for decisions made in relation to mental health care budgets?
  2. How are budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration?

Treasury and DH both replied citing s35 of the FOI act. Releasing discussion of options available, Treasury argued, might inhibit future “rigorous and candid assessments of options available” [1]. DH replied similarly: “Premature disclosure of information protected under sec tion 35 could prejudice good working relationships, the neutrality of civil servants” [2].

NHS England did reveal something of their decision making processes, naming Paul Baumann, Chief Financial Officer for NHS England, as responsible for budgets, and citing a technical document [3], the technical annex of which [4] sketches an estimate of likely growth in mental health costs over the coming years.

But Treasury and DH’s responses indicate that other factors have been taken into consideration that are not currently in the public domain. A rigorous debate about options, involving the people who need mental health services as well as those who provide them, requires transparency.

I am therefore writing to ask for more information concerning the reasoning behind decisions made. In particular, what discussion has there been of the following?

  1. The effectiveness of mental healthcare treatments and support, e.g., in comparison to physical health care;
  2. The costs of the various treatments; and
  3. The potential for reducing costs, e.g., by employing lower band staff or increasing involvement of voluntary services.

It is important that reasoning on these issues is made public so they can be openly debated.

Thanks,

Andy

[1] https://www.whatdotheyknow.com/request/293922/response/723453/attach/html/3/DOC231015%2023102015120744.pdf.html

[2] https://www.whatdotheyknow.com/request/299123/response/734036/attach/html/2/966789%20Fugard.pdf.html

[3] https://www.whatdotheyknow.com/request/mental_health_budgets_2#incoming-736647

[4] https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf

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The social model of disability as a case study of social ontology

Ontology is the study of what kinds of entities there are in the world and how they relate to each other. As Effingham (2013, p.1) explains, “You will not find ontologists rummaging around your wardrobe” cataloguing everything they find. Rather, the idea is to conceptualise more broadly the kinds of things there are, including material and abstract “things” like numbers and colours. Social ontology concentrates on entities relevant to social theorising at various levels of explanation from the sub-personal (including unconscious processes like those controlling finger tips on keyboards) to people, their interactions, institutions and beyond.

Debates in social ontology, such as on ontological individualism or emergentism, can be abstract and their relevance hard to grasp. There has even been a case to “rid social sciences of ontology altogether – of all philosophized metaphysics of how the social world is” (Kivinen and Piiroinen, 2007, p.99). This short post tries to make it clearer why it’s important to think about ontology, using an example from disability activism.

In 1975, the Union of the Physically Impaired Against Segregation, a group of disability activists, published a series of fundamental principles which challenged the ontology of disability:

“In our view, it is society which disables physically impaired people. Disability is something imposed on top of our impairments, by the way we are unnecessarily isolated and excluded from full participation in society. Disabled people are therefore an oppressed group in society. […] For us as disabled people it is absolutely vital that we get this question of the cause of disability quite straight, because on the answer depends the crucial matter of where we direct our main energies in the struggle for change. We shall clearly get nowhere if our efforts are chiefly directed not at the cause of our oppression, but instead at one of the symptoms.”

Here a distinction is made between impairment and disability. From this perspective, it doesn’t make sense to say that someone “has a disability”; individual people can have impairments, but it is society which determines whether someone is disabled. Note how the conceptualisation is used to unite people behind one social struggle.

This guide from the activist group Disabled People Against Cuts explains how social barriers cause disability:

“… we live in a society that’s designed by, built for, and used by non disabled people. Because of poor historic attitudes to disabled people […] disabled people were effectively locked away in hospitals, sanatoriums, in care homes or other kinds of institution.

“And that meant that we were excluded from the development of the way our society works, the way our buildings are designed, transport systems, education systems, machines and appliances, leisure activities and the world of work anything really that you care to think about was designed at a time when disabled people weren’t included in the process.

“And that means that all these things don’t work in a way that enables us to use them.

“And the upshot of all that is that in hundreds of different ways, some big, some seemingly small, its difficult for us to take a full part in all kinds of activities that non-disabled people take for granted.

“So we believe that its not our impairments that disable us, it is the social barriers that disable us. Our own impairments we can adapt and/or use aids to overcome, but social barriers are out of our control.”

Whether someone with a particular impairment becomes disabled is also affected by scientific and technological advances. For instance, many people who have a visual impairment wear glasses or contact lenses and wouldn’t consider themselves disabled (see Slorach 2016, p. 37).

A related example is illustrated in this piece on the difference between deaf and Deaf identity:

“To be ‘deaf’ (small d) is to fit into the medical definition of deafness as something to be cured and eradicated. Being deaf means you have a hearing loss, but you choose or don’t feel able to function within the Deaf Community. […] Deaf – with a capital “D” (and occasionally with capital E, A and F too) – is used to refer to people who are culturally Deaf. These people actively use British Sign Language; they see themselves as being culturally Deaf and part of the Deaf community. […] I consider myself to be culturally Deaf; this is my Deaf Identity. […] I don’t see it as a disability – there is nothing I feel I cannot do – rather, I see it as an important aspect of my character that makes and shapes me.”

These conceptualisations of impairment and disability, social barriers, adjustments, aids, deaf and Deaf identity, concern ontology. The debates on these topics occur naturally in social struggles and discussions of social policy, whether or not explicitly articulated as being about ontology. They also have clear implication for how social research is carried out and understood.

References

Effingham, N. (2013). An introduction to ontology. Cambridge: Polity Press.

Kivinen, O., & Piiroinen, T. (2007). Sociologizing Metaphysics and Mind: A Pragmatist Point of View on the Methodology of the Social Science. Human Studies, 30, 97–114.

Slorach, R. (2016). A very capitalist condition: a history and politics of disability. London: Bookmarks Publications.

Disease vs. drug-centred model of psychiatric medication

“The disease-centred model suggests that psychiatric drugs work because they reverse, or partially reverse, the disease or abnormality that gives rise to the symptoms of a particular psychiatric disorder. Thus ‘antipsychotics’ are thought to help to counteract the biological abnormalities that produce the symptoms of psychosis or schizophrenia… the ‘drug-centred’ model suggests that far from correcting an abnormal state, as the disease model suggests, psychiatric drugs induce an abnormal or altered state. Psychiatric drugs are psychoactive substances, like alcohol and heroin… The drug-centred model suggests that the psychoactive effects produced by some drugs can be useful therapeutically in some situations. They don’t do this in the way the disease-centred model suggests by normalising brain function. They do it by creating an abnormal or altered brain state that suppresses or replaces the manifestations of mental and behavioural problems.” 

Blog post by Joanna Moncreiff

Critical realism in 100 words

A summary of an introduction by Margaret Archer and colleagues:

Critical realism is a mess, but there are four themes in the literature. The first is ontological realism: there is some sort of reality out there existing independently of people’s minds. The second is epistemic relativism: our knowledge of reality is conditional on particular contexts, e.g., standpoints, theories, communities, conflicts of interest. The third is judgmental rationality: it is possible to decide whether one theory is better than another at explaining some phenomenon. The fourth is ethical naturalism: although “is” does not imply “ought”, the two are not independent; empirical research can help us determine what values we should hold.

Letter to MP: Mental health funding

Dear Tulip Siddiq,

I submitted a series of Freedom of Information (FOI) requests to Treasury, Department of Health, and NHS England, asking:

(i) Who is responsible for decisions made in relation to mental health care budgets?
(ii) How are budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration?

Treasury and DH both replied citing s35 of the FOI act. Releasing discussion of options available, Treasury argued, might inhibit future “rigorous and candid assessments of options available” [1]. DH replied similarly: “Premature disclosure of information protected under section 35 could prejudice good working relationships, the neutrality of civil servants” [2].

NHS England did reveal something of their decision making processes, naming Paul Baumann, Chief Financial Officer for NHS England, as responsible for budgets, and citing a technical document [3], the technical annex of which [4] sketches an estimate of likely growth in mental health costs over the coming years.

But Treasury and DH’s responses indicate that other factors have been taken into consideration that are not currently in the public domain. A rigorous debate about options, involving the people who need mental health services as well as those who provide them, requires transparency.

I am therefore writing to ask for more information concerning the reasoning behind decisions made. In particular, what discussion has there been of the following?

(i) The effectiveness of mental healthcare treatments and support, in comparison to physical health care;
(ii) The costs of the various treatments; and
(iii) The potential for reducing costs, e.g., by employing lower band staff or increasing involvement of voluntary services.

It is important that reasoning on these issues is made public so they can be openly debated.

Yours sincerely,

Dr Andy Fugard

[1] https://www.whatdotheyknow.com/request/293922/response/723453/attach/html/3/DOC231015%2023102015120744.pdf.html
[2] https://www.whatdotheyknow.com/request/299123/response/734036/attach/html/2/966789%20Fugard.pdf.html
[3] https://www.whatdotheyknow.com/request/mental_health_budgets_2#incoming-736647
[4] https://www.england.nhs.uk/wp-content/uploads/2013/12/cta-tech-Annex.pdf

Mental health services should not be paid by outcomes

The UK government promised a “drive towards an equal response to mental and physical health” in England as part of a five-year plan. Two years later and there is little sign that any progress has been made. Calls to improve mental health services peaked this month when 20 years’ worth of former health secretaries wrote an open letter criticising the government for “warm words” but no action.

There is a consensus that more funding should reach mental health care. But what should be funded and exactly how? From April 2017, payments to adult mental health services must be linked to the quality and outcomes of care provided. National guidance published by NHS England and NHS Improvement claims that doing so will improve care, “ensuring value for money and the best use of limited resources”. But there is worrying evidence that doing so might have little impact and, at worst, actually be harmful to services.

How will payment for performance work?

The money flows are complex. Here is a picture showing key parts of the system.

How funding flows to mental health services.

At the top end is the Treasury, which determines how much money health care receives, alongside all other public services. The Treasury does not directly determine how much money goes to mental health, however – it receives advice from below in the hierarchy so it can calculate a total including all other areas of health.

The money flows on to the Department of Health, NHS England, then Clinical Commissioning Groups which are distributed across the country. They may choose to commission an NHS Foundation Trust. They may also commission a commercial company such as Virgin Care, which recently won a £700m contract.

Payment for performance will be at this final stage between commissioner and provider, and will be agreed locally between them. National guidance on how to implement the approach suggests that the chosen targets should be achievable yet stretching; informed by clinicians and people with experience of mental health problems; avoid creating an adversarial relationship between commissioners and providers; and should be used for the “reinforcement of positive behaviour”.

Oxford Health NHS Foundation Trust is provided as an example in the guidance. A fifth of its income will be linked to performance, which will include ensuring that people “improve their level of functioning”, determined using two measures.

One is the Mental Health Recovery Star, which tracks the progress of people who use mental health services by their ability to manage their mental health and feelings of hopefulness. This measure is completed jointly by people who use mental health services and staff providing care (such as psychiatrists, psychologists or nurses).

The other measure is a checklist rated only by staff which is used to track changes in symptoms such as depression and self-injury. The service has also promised its commissioners that it will ensure people live longer.

Does payment for performance improve services?

A recent systematic review of research found no evidence of impact when payment was linked to health outcomes, such as how long people live – which makes Oxford Health’s choice of outcomes puzzling. There was a small benefit when payment was linked to what services actually did, for example, providing cancer screening or recording whether someone smokes, as this was much easier for services to control than were the consequences of care.

Given national advice to involve people who use mental health services in decisions about outcomes chosen, it is also curious that the recovery star has been chosen. An increasingly influential group who use mental health services, called Recovery in the Bin, singled out the measure as “redundant, unhelpful, and blunt”, and suggested an alternative focusing more on the social causes of mental distress which are often ignored in outcomes.

UnRecovery Star, developed by Recovery in the Bin as an alternative to an outcome measure used in services.
Recovery in the Bin

Putting high-stakes targets on measures tends to mean that the measures stop measuring what they are supposed to measure because people cheat to achieve the targets. The effect is so common that it has a name: Goodhart’s law. For example, ambulance services had a target to get to the patient in eight minutes for life-threatening emergencies. This led to a third of services fiddling their timings towards the target.

There are various subtle ways to cheat outcome measures in mental health, such as by not bothering people who drop out of services with questionnaires to complete. People who drop out are less likely to have benefited from treatment, so excluding their answers from data analyses will improve a service’s apparent outcomes. Given the complexity of people’s experiences and predicaments, reducing them to scores on questionnaires can feel absurd, so it might be easy to justify this kind of gaming if it results in more funding which could improve the care provided. It seems especially easy for measures completed by staff who are under pressure from management to tick the right boxes.

Outcomes measures have an important role to play in understanding and improving the care people receive and should be tracked as part of care, but linking them to payment risks demoralising staff and making the measures meaningless. This seems a dangerous path to take given the state mental health services are in. A better solution might lie further upstream at the Treasury when it decides how much money is available for mental health.The Conversation

This article was originally published on The Conversation. Read the original article.