News

One of this week's blogs is a repost from the wonderful Centre for Mental Health.  The original blog was here, on the CMH's own blog, by Chief Executive Sean Duggan.  His post examines the current changes taking place in the NHS, and the potential positive impact on mental health services.
As clinical commissioning groups and NHS England take on their new responsibilities for real, the NHS mandate has become the key to ensuring that the new NHS commissioners make progress against the Government’s priorities for better healthcare in England.

‘Many of the objectives of the mandate require mental and physical health support to be far better integrated’

The mandate provides the vital link between the NHS and the public nationally, setting out what NHS England in particular will be accountable to the secretary of state (and Parliament) for achieving over the next two to three years.

As a briefing paper published by Centre for Mental Health this month shows, the objectives set out in the mandate cannot be achieved without a major focus on mental health for people of all ages throughout the NHS.

Following the government’s pledge to work towards “parity of esteem” between physical and mental health, the mandate includes a far larger number of commitments to improving mental health support than any of the operating frameworks that were its nearest equivalent in previous years. These include the expectation that NHS England and CCGs will continue to make progress on improving access to psychological therapies, not just for working age adults with depression but for children, older adults, people with long-term physical conditions and those with severe mental illness.

New challengesThe mandate requires the NHS to make progress in securing employment for more people with mental health conditions and to offer more personalised support to people in mental health services, including through the use of personal health budgets. It also seeks to ensure the service looks beyond its conventional boundaries, for example to work with colleagues in public health to improve support for young families and to continue the nationwide expansion of liaison and diversion services in police stations and courts.

It sets some important new challenges to NHS England in improving access to mental health care and bringing greater parity to waiting times. This will take action on several fronts, from speeding up access to care in a crisis to bringing down waiting times for psychological therapies and other forms of mental health support.

‘In the everyday actions of commissioners and providers the separation and inequality between the two will be tackled most effectively’

Many of the objectives of the mandate require mental and physical health support to be far better integrated. From improving maternal mental health to taking action to address the 15-year mortality gap for people with a severe mental illness, the artificial separation of mental and physical healthcare will need to be addressed throughout the NHS. Nowhere in the 21st century NHS should a person’s mental health needs be neglected or professionals lack confidence in dealing with a patient’s emotional or psychological needs.

The mandate will not on its own bring about parity between mental and physical health in the NHS. It is in the everyday actions of commissioners and providers at every level of service that the separation and inequality between the two will be tackled most effectively.

It will require local commissioners to look at where they invest scarce resources to get best effect. It will require continued action to collect robust and useful outcomes data both for mental health services and for people with co-morbidity conditions. And it will require concerted leadership and sustained commitment from NHS England and CCG boards to challenge existing ways of working that stand in the way of parity and integration.

The IMH held a strongly supported inaugural Research Day this month – and such was its success that a follow-up event will be held next year. The event showcased and celebrated the work of IMH-related early-career researchers (including research assistants and research fellows), doctoral students and the IMH Managed Innovation Networks, attracting a maximum capacity of 70 delegates.

Poster and oral presentations were given by 30 individuals with three plenary sessions from Prof. Nick Manning, Mat Kinton, and Dr John Milton.

The two presentation prizes were awarded to Bethan Davies and Bridget Roe.

Dr Melanie Jordan and Prof. Peter Bartlett, who chaired the event, are pleased to report that the event was well received by delegates in their evaluation feedback: “Excellent way to catch up on latest research and network. Please run again. Wish I could have been in both parallel sessions” and “Very beneficial and useful. Excellent ‘holding environment’ for researchers. Motivated to continue my work".

Jenelle Clarke’s reflection: “The IMH Research Day provided an excellent opportunity for researches to come together to share their work and gain valuable feedback on their research.  It was especially useful hearing innovative approaches to mental health and understanding the challenges currently facing the field.  The day also highlighted the diverse range of topics that IMH researchers are involved in.  Dr John Milton concluded the day by reminding us all that research should be beneficial and have a real impact within mental health, particularly to those working to deliver services.  To this end, assessing impact and increasing dissemination should be key considerations of research practice”.

So, what are you researching? ‘ is the perennial question.
‘Public Services,’ is my answer.  ‘Client expert relationships in the NHS and in Education.’
In the past, the eyes of my questioner would begin to glaze over.  Maybe, I would reflect sadly, it’s the combination of ‘public’, with its connotations of toilets, and ‘services’ conjuring up a tired Costa Coffee and a limpid bun …

But lately things have changed. We seem to be reaching a crisis point in the delivery of ‘care’ and ‘learning’.  Suddenly, my questioners want to carry on the conversation, if they are practitioners they want to be involved. ‘Healing’ and ‘learning’ have retaken the political centre stage. The clients, the practitioners and the policy makers, however different their entry point into the discussion,  have a shared understanding that a revolution in ‘care’ and in ‘learning’ is in the air.  There is a homogenous desire for a more ‘personalized’ delivery. There is a cry for ‘professional intimacy.’

My background in health was as Head of Rehabilitation Education for Long Term Patients for a Mental Health Trust.  Sounds impressive. In reality, I was head of a demoralized and paranoid team of teachers, who suspected (rightly, as it turned out) that they would be made redundant by ‘Care in the Community’. We met our clients in classrooms which were in the basement of a vast, decaying Victorian mental health hospital. I started work there when my son was eight weeks old. They were desperate for me to get into post, even for the few hours I could offer at that time, but it was an overly ambitious undertaking and on my first day I was, of course, late. On rushing up the steps, not knowing where ‘my’ basement was, I breathlessly grabbed the first chap in a white coat that I saw.
‘Where is the basement. I have to get to the basement,' I gasped, clutching his arm.
The man in the white coat smiled. ‘My name is Doctor Bob.  I don’t think I’ve met you before, dearie.’ He took a firm hold of my elbow. ‘What is your name? Now, why would you be after the basement?’

Finally we found someone who knew who I was and why I was there.  Bob relaxed. Then the penny clicked.
‘You thought I was a patient!’ I cried.
Doctor Bob smiled again. ‘In fairness to me,’ he said, ‘you do look a bit strange. And you were definitely agitated.’
He indicated my appearance. I looked in the mirror beside the stairs. There was a strange white patch of baby sick on my shoulder and my hair was sticking up. Who combs their hair when the baby’s hungry? I explained.
‘Well’, said Doctor Bob, ‘any woman with an eight week old baby is a bit, well,  mental.’
Bob was a Glaswegian, and in one fell swoop of colloquialism, he had wiped out DSM 3, 4 and probably 5.
A bit ‘mental’. Fair enough.

I thought of Bob a few years ago when I began to carry out workshops developing resilience for practitioners working in Health and Education. They often told me that they felt under increasing pressure at work.  They felt a bit, well, ‘mental’. My research question is to find out why.

The relationship between the ‘client’ i.e. the patient, the pupil and the ‘expert practitioner’ i.e. the GP, the senior nurse, the hospital consultant, the teacher is changing in our post industrial public services. The outdated ‘one size fits all’, industrial model NHS and Education services fail to provide the individualized,  relationship-led ‘healing’ and ‘learning that we all want.  Social policy and government directives ask for each pupil, each patient to be treated as unique. Each pupil, each patient wants to feel that they are known and understood by their teachers and carers.

The senior practitioners who have contributed to my research all want to design and provide an excellent service to society. They all recognize that to do it three  things are needed: an increase of ‘emotional labour’ amongst practitioners (Hochschild 1983); training  and support in what is called ‘deep care’ (Persaud 2004) and, above all, the time to offer this ’deep care’.

They go on to say that we may want this kind of relationship with our practitioners, but we are not providing the structure to allow it.  How can practitioners deliver 21^st century professional intimacy in a 20^th century structure? We have 30:1 teacher pupil ratio in our schools; an  8:1 patient/nurse ratio in our hospitals; GPs have 10 minutes for a consultation and, on nights, 1 junior doctor may be covering three hospital wards.  My participants, all senior practitioners in our public services, indicated that they recognized this mismatch between the expectations and the reality of delivery as the cause of an alarming increase in stress related illness amongst teachers, doctors and hospital nurses.

This longitudinal study of over 300 doctors by McManus et al  describes a possible causal model for the increase in stress related illness in our ‘healers’ and ‘teachers’.

[caption id="" align="aligncenter" width="300"] Please click to enlarge


McManus (2002) discusses the concept of ‘depersonalisation’. He is indicating the uncaring practitioner, too tired to be interested in their clients as individuals.  He suggests that the practitioners who are under stress but who then are driven by a sense of professional responsibility to become more efficacious may simply increase their stress, and eventually they may burnout. The practitioner who does not increase their involvement with the patient, or the pupil, survives. Thus, ‘depersonalization’, which we might describe as cynicism or callousness, is adaptive whilst increasing professional efficacy is maladaptive.

And we, the clients, get the very practitioners we don’t want. We get the ‘uncaring’ nurse, the ‘uninterested’ doctor and the ‘weak’, ‘uninspiring’ teacher. These undesirable practitioners do exist.  They are not a figment of the media’s imagination.  But we must examine the possibility described by McManus (2002) that shocking incidents of ‘unprofessional’ behavior are the product of a system which is, in some situations, unworkable and not always caused by an alarming increase in the employment of unsuitable staff.

The policy makers certainly point to the unsuitable individual as the root cause of the problem in the delivery of our services.  We have the introduction of psychometric testing for teachers in 2012 as a way of sifting out those who lack the emotional intelligence to be teachers (Smithers 2011); we have the introduction of ‘role play’ in the induction of medical students (Report. GMC 2012), in order to find those with the ‘empathy’ needed. Our trainee nurses are to spend a year working as HCAs to ensure that they have the necessary caring attitude (Denis Campbell, The Guardian. March 2013). Of course, we all want teachers with ‘emotional intelligence’, doctors who are ‘empathetic’ and nurse who ‘care’. In the 21^st century, we are increasingly needful of being offered ‘professional intimacy’ from our practitioners.

Head teachers, GPs, hospital consultants  and senior nurses have told me that prospective staff come to work in Health and Education precisely because they have those qualities, as they always have done.  But they have also told me that if the system is not redesigned to allow those qualities to be nurtured then we will continue to lose good practitioners from our services and the cry for ‘professional intimacy’ will become a wail.

Fiona Birkbeck BA MA
PhD researcher, University of Nottingham
Email:  This email address is being protected from spambots. You need JavaScript enabled to view it.

References:

Denis Campbell. Nurses must spend a year on basic care. The Guardian. March 26^th 2013
DfE 2010  Initial Teacher Education (ITE) Inspection Handbook. 2012
Guidance on Safe Nursing Levels; Staffing in the UK. Report. RCN Policy Unit 2010
MAGUIRE P., Piceathly C. Key Communication Skills and How to Acquire Them. BMJ 2002;325;697
MCMANUS. I.C., Winder B.C., Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet 2002; 359: 2089-90
Hochschild,  A. R. 1983. The Managed Heart: Commercialization of Human Feeling. Los Angeles, California, United States of America: University of California Press.
PATTANI S, Constantinovici N.,Williams S., Who retires early from the NHS because of  ill health and what does it cost? A national cross-sectional study. BMJ. 2001; 322: 208–9.
PERSAUD, R.  2004. Faking it: The Emotional Labour of Medicine. Viewed May 4^th 2013. Available from: http://careerfocus.bmjjournals.com/cgi/content/full/329/7464/87
RCGP Curriculum 2010, Statement 2.01 The GP Consultation in Practice. Revised 30 May, 2012
Recommendations of The Francis Report BMJ. 2013; 346; f854
Smithers, A., and Robinson, P., The Good Teacher Training Guide.  Report. University of Buckingham. 2011
The Black Review; Working for a Healthier Tomorrow. The Cross-government Health, Work and Well-being Programme. Report. 2008
The Education and Skills Committee Secondary Education. Teacher Retention and Recruitment. Report. Fifth Report of Session 2003-04
The State of Medical Education and Practice in the UK. Report. G M C  2012

The following article, How Austerity Kills, by David Stuckler and Sanjay Basu, was originally published in The New York Times on 12 May 2013.

 How Austerity KillsBy David Stuckler and Sanjay Basu

EARLY last month, a triple suicide was reported in the seaside town of Civitanova Marche, Italy. A married couple, Anna Maria Sopranzi, 68, and Romeo Dionisi, 62, had been struggling to live on her monthly pension of around 500 euros (about $650), and had fallen behind on rent.

Because the Italian government's austerity budget had raised the retirement age, Mr. Dionisi, a former construction worker, became one of Italy's esodati (exiled ones) - older workers plunged into poverty without a safety net. On April 5, he and his wife left a note on a neighbor's car asking for forgiveness, then hanged themselves in a storage closet at home. When Ms. Sopranzi's brother, Giuseppe Sopranzi, 73, heard the news, he drowned himself in the Adriatic.

The correlation between unemployment and suicide has been observed since the 19th century. People looking for work are about twice as likely to end their lives as those who have jobs.

In the United States, the suicide rate, which had slowly risen since 2000, jumped during and after the 2007-9 recession. In a new book, we estimate that 4,750 "excess" suicides - that is, deaths above what pre-existing trends would predict - occurred from 2007 to 2010. Rates of such suicides were significantly greater in the states that experienced the greatest job losses. Deaths from suicide overtook deaths from car crashes in 2009.

If suicides were an unavoidable consequence of economic downturns, this would just be another story about the human toll of the Great Recession. But it isn't so. Countries that slashed health and social protection budgets, like Greece, Italy and Spain, have seen starkly worse health outcomes than nations like Germany, Iceland and Sweden, which maintained their social safety nets and opted for stimulus over austerity. (Germany preaches the virtues of austerity - for others.)

As scholars of public health and political economy, we have watched aghast as politicians endlessly debate debts and deficits with little regard for the human costs of their decisions. Over the past decade, we mined huge data sets from across the globe to understand how economic shocks - from the Great Depression to the end of the Soviet Union to the Asian financial crisis to the Great Recession - affect our health. What we've found is that people do not inevitably get sick or die because the economy has faltered. Fiscal policy, it turns out, can be a matter of life or death.

At one extreme is Greece, which is in the middle of a public health disaster. The national health budget has been cut by 40 percent since 2008, partly to meet deficit-reduction targets set by the so-called troika - the International Monetary Fund, the European Commission and the European Central Bank - as part of a 2010 austerity package. Some 35,000 doctors, nurses and other health workers have lost their jobs. Hospital admissions have soared after Greeks avoided getting routine and preventive treatment because of long wait times and rising drug costs. Infant mortality rose by 40 percent. New H.I.V. infections more than doubled, a result of rising intravenous drug use - as the budget for needle-exchange programs was cut. After mosquito-spraying programs were slashed in southern Greece, malaria cases were reported in significant numbers for the first time since the early 1970s.

In contrast, Iceland avoided a public health disaster even though it experienced, in 2008, the largest banking crisis in history, relative to the size of its economy. After three main commercial banks failed, total debt soared, unemployment increased ninefold, and the value of its currency, the krona, collapsed. Iceland became the first European country to seek an I.M.F. bailout since 1976. But instead of bailing out the banks and slashing budgets, as the I.M.F. demanded, Iceland's politicians took a radical step: they put austerity to a vote. In two referendums, in 2010 and 2011, Icelanders voted overwhelmingly to pay off foreign creditors gradually, rather than all at once through austerity. Iceland's economy has largely recovered, while Greece's teeters on collapse. No one lost health care coverage or access to medication, even as the price of imported drugs rose. There was no significant increase in suicide. Last year, the first U.N. World Happiness Report ranked Iceland as one of the world's happiest nations.

Skeptics will point to structural differences between Greece and Iceland. Greece's membership in the euro zone made currency devaluation impossible, and it had less political room to reject I.M.F. calls for austerity. But the contrast supports our thesis that an economic crisis does not necessarily have to involve a public health crisis.

Somewhere between these extremes is the United States. Initially, the 2009 stimulus package shored up the safety net. But there are warning signs - beyond the higher suicide rate - that health trends are worsening. Prescriptions for antidepressants have soared. Three-quarters of a million people (particularly out-of-work young men) have turned to binge drinking. Over five million Americans lost access to health care in the recession because they lost their jobs (and either could not afford to extend their insurance under the Cobra law or exhausted their eligibility). Preventive medical visits dropped as people delayed medical care and ended up in emergency rooms. (President Obama's health care law expands coverage, but only gradually.) The $85 billion "sequester" that began on March 1 will cut nutrition subsidies for approximately 600,000 pregnant women, newborns and infants by year's end. Public housing budgets will be cut by nearly $2 billion this year, even while 1.4 million homes are in foreclosure. Even the budget of the Centers for Disease Control and Prevention, the nation's main defense against epidemics like last year's fungal meningitis outbreak, is being cut, by at least $18 million.

To test our hypothesis that austerity is deadly, we've analyzed data from other regions and eras. After the Soviet Union dissolved, in 1991, Russia's economy collapsed. Poverty soared and life expectancy dropped, particularly among young, working-age men. But this did not occur everywhere in the former Soviet sphere. Russia, Kazakhstan and the Baltic States (Estonia, Latvia and Lithuania) - which adopted economic "shock therapy" programs advocated by economists like Jeffrey D. Sachs and Lawrence H. Summers - experienced the worst rises in suicides, heart attacks and alcohol-related deaths.

Countries like Belarus, Poland and Slovenia took a different, gradualist approach, advocated by economists like Joseph E. Stiglitz and the former Soviet leader Mikhail S. Gorbachev. These countries privatized their state-controlled economies in stages and saw much better health outcomes than nearby countries that opted for mass privatizations and layoffs, which caused severe economic and social disruptions.

Like the fall of the Soviet Union, the 1997 Asian financial crisis offers case studies - in effect, a natural experiment - worth examining. Thailand and Indonesia, which submitted to harsh austerity plans imposed by the I.M.F., experienced mass hunger and sharp increases in deaths from infectious disease, while Malaysia, which resisted the I.M.F.'s advice, maintained the health of its citizens. In 2012, the I.M.F. formally apologized for its handling of the crisis, estimating that the damage from its recommendations may have been three times greater than previously assumed.

America's experience of the Depression is also instructive. During the Depression, mortality rates in the United States fell by about 10 percent. The suicide rate actually soared between 1929, when the stock market crashed, and 1932, when Franklin D. Roosevelt was elected president. But the increase in suicides was more than offset by the "epidemiological transition" - improvements in hygiene that reduced deaths from infectious diseases like tuberculosis, pneumonia and influenza - and by a sharp drop in fatal traffic accidents, as Americans could not afford to drive. Comparing historical data across states, we estimate that every $100 in New Deal spending per capita was associated with a decline in pneumonia deaths of 18 per 100,000 people; a reduction in infant deaths of 18 per 1,000 live births; and a drop in suicides of 4 per 100,000 people.

Our research suggests that investing $1 in public health programs can yield as much as $3 in economic growth. Public health investment not only saves lives in a recession, but can help spur economic recovery. These findings suggest that three principles should guide responses to economic crises.

First, do no harm: if austerity were tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects. Each nation should establish a nonpartisan, independent Office of Health Responsibility, staffed by epidemiologists and economists, to evaluate the health effects of fiscal and monetary policies.

Second, treat joblessness like the pandemic it is. Unemployment is a leading cause of depression, anxiety, alcoholism and suicidal thinking. Politicians in Finland and Sweden helped prevent depression and suicides during recessions by investing in "active labor-market programs" that targeted the newly unemployed and helped them find jobs quickly, with net economic benefits.

Finally, expand investments in public health when times are bad. The cliché that an ounce of prevention is worth a pound of cure happens to be true. It is far more expensive to control an epidemic than to prevent one. New York City spent $1 billion in the mid-1990s to control an outbreak of drug-resistant tuberculosis. The drug-resistant strain resulted from the city's failure to ensure that low-income tuberculosis patients completed their regimen of inexpensive generic medications.

One need not be an economic ideologue - we certainly aren't - to recognize that the price of austerity can be calculated in human lives. We are not exonerating poor policy decisions of the past or calling for universal debt forgiveness. It's up to policy makers in America and Europe to figure out the right mix of fiscal and monetary policy. What we have found is that austerity - severe, immediate, indiscriminate cuts to social and health spending - is not only self-defeating, but fatal.

David Stuckler, a senior research leader in sociology at Oxford, and Sanjay Basu, an assistant professor of medicine and an epidemiologist in the Prevention Research Center at Stanford, are the authors of "The Body Economic: Why Austerity Kills."

Professor Nikolas Rose will be giving a public lecture on 15 May 2013 at 4:30pm entitled, 'What is 'Mental Illness Today? Five Hard Questions'.  This talk is part of the School of Sociology and Social Policy's Seminar Series and will be held in B63 in the Law and Social Sciences Building, University of  Nottingham Main Campus.

Further information about Professor Rose and his planned lecture is below:

What is ‘mental illness’ today – five hard questions Nikolas Rose Department of Social Science, Health and Medicine King’s College London

Presentation Abstract In this talk I want to characterize the ‘territory’ of mental illness today by posing five hard questions that seem to me to represent genuine empirical, conceptual, professional and ethical dilemmas. My questions are: Is there an‘epidemic’ of mental disorder?; Does the path to understanding mental disorder lie through the brain?; What is the role of diagnosis and of diagnostic manuals?; Should we seek early identification of those at risk of future mental pathology? What is the place of patients, users, survivors, consumers in the mental health system? On the basis of this discussion, I will conclude by trying to draw out some lessons for the politics of mental health today.

Nikolas Rose Professor Nikolas Rose is one of our leading contemporary social scientists.  Currently he is Professor of Sociology and Head of the Department of Social Science, Health and Medicine at King’s College, London. He was previously Martin White Professor of Sociology, and Director of the BIOS Centre for the Study of Bioscience, Biomedicine, Biotechnology and Society at the London School of Economics and Political Science. He is also co-PI for the EPSRC funded Centre for Synthetic Biology and Innovation (CSynBI). His most recent books are The Politics of Life Itself : Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton, 2006); Governing The Present (with Peter Miller, Polity, 2008) and Neuro: the New Brain Sciences and the Management of the Mind (with Joelle Abi-Rached, Princeton, forthcoming, 2012). He is a longstanding member of the Editorial Board of Economy and Society, co-editor of BioSocieties: an interdisciplinary journal for social studies of the life sciences, Chair of the European Neuroscience and Society Network, and a member of numerous advisory groups including the Nuffield Council on Bioethics.

Booking Information All are welcome and entrance is free, but please contact This email address is being protected from spambots. You need JavaScript enabled to view it. to ensure a place.  Parking is unregulated from 4.00pm and light refreshments will be available afterwards.

In addition, the following poster is available for display and circulation:

Nikolas Rose Poster, 15 May 2013

Inside Out of Mind (as highlighted in the IMH Newsletter):

An innovative project, which has brought together ethnographic researchers with theatre practitioners to tackle the challenge of dementia care, has led to the development of a play, soon to run at the Lakeside Arts Theatre.

The play, Inside Out of Mind, brilliantly illustrates the multiple realities of life on a dementia ward, and is a unique collaboration between Meeting Ground Theatre Company, Lakeside Arts Centre at the University of Nottingham, the Institute of Mental Health (IMH) and the NHS.

The play, written by Tanya Myers, is based on extensive and rigorous participant observation in dementia wards by researchers Simon Bailey, Kezia Scales and Joanne Lloyd, and has taken three years to evolve into a theatre production from the original research. Inside Out of Mind shows the dementia ward from the perspective of the patients, staff and visitors, and aims to impact positively on the care of those with dementia, and to encourage empathy and intuitive listening.

Public performances of Inside Out of Mind will be held at the Lakeside Arts Centre on June 14, 15, 22, 28 and 29 at 7.30pm, with 2pm matinee performances on June 22 and 29. NHS performances and conference dates are scheduled for June 17-20 and 24-27 and are bookable through local contacts. To see the publicity flyer and a preview video, please visit the Institute website at http://www.institutemh.org.uk/x-news-and-events-x/general-news Professor Justine Schneider, who led research on the project, said: “Tanya (Myers) has managed to create a remarkable and original piece of theatre with genuine echoes of our observations in every character and scene.”

Shona Powell, Director of Lakeside Arts Centre said: “Lakeside is delighted to be a key partner in the realisation of this exciting project. It’s the first time we’ve worked with colleagues in the Institute of Mental Health to platform the outcomes of academic research through theatre and we’re excited about the enormous potential this play has to reach new audiences and to make a real and lasting impact in the care sector”.

To book, please visit the Lakeside Arts Theatre website.

Nottingham Contemporary

Forthcoming event ~ May 7th

The Influencing Machine with author, historian, and curator Mike Jay.

Mike Jay will discuss the case of James Tilly Matthews, an “incurable lunatic” confined to Bedlam in 1797. Matthews insisted his mind was being controlled by a machine. He is regarded as the first person to present clear symptoms of paranoid schizophrenia, and the Air Loom was an example of paranoid delusion now known as "the influencing machine".

Please see the link for full details:

http://nottinghamcontemporary.org/event/influencing-machine

Public Servant re-post: "Health check on Thatcher's legacy".

"The health of the nation has improved since Margaret Thatcher first walked through the door of 10 Downing Street, say Professors Brian Brown and Paul Crawford, but time has thrown up new challenges".

See the full post: http://www.publicservice.co.uk/publicservant/article/22632

This past Tuesday (23/04/2013), The Independent featured an article on anxiety by Markie Robson-Scott,  'The age of anxiety: a medical condition or just the new normal?'  Robson-Scott questions whether feeling worry is part of being human and whether it's helpful and/or necessary to rely on prescription medication.

As the article highlights, anxiety represents the fight/flight mechanisms in our brain. Yet rather than running from a hungry lion, we now worry about everything from our finances, relationships, jobs, health and wider societal issues such as the economy, politics and crime. The line between everyday anxieties and an anxiety disorder that requires medication is blurry. Moreover stress tolerance levels are not uniform and individuals respond very differently to various pressures and situations. Yet it is also the case that prescription use is often driven by patient/consumer demand. Particularly in the US where prescription drug addiction rates are high and insurance companies net a profit for every Xanax prescribed. Perhaps the problem is simply a reflection of our desire for quick fixes and instantaneous results. Or it may represent the privatisation of mental health issues more generally where there is an expectation that personal problems will be self-managed.

What is the best way forward? As we have developed as a society, have we forgotten how to self-soothe and help soothe others without meds? Have we over-medicalised anxiety, stress and worry? Conversely, how do we avoid judging and stigmatising those who do need to take medication for an anxiety disorder?

Have a read of the article and let us know your thoughts!

The IMH Blog Editorial Team
(Jenelle Clarke, Melanie Jordan and Amanda Keeling)

May 13th, 2013 ~ IMH Research Day ~ 9am-5pm

You are welcome to join us for this free event to learn about the work of the Institute’s doctoral candidates, Managed Innovation Networks, and early-career researchers.

Plenary Speakers:  Nick Manning (IMH Director), Mat Kinton (Care Quality Commission), and John Milton (Consultant Forensic Psychiatrist).

Over thirty posters and papers will be presented, including oral presentations from: Amanda Keeling, Melanie Stray, Susan Brown, Marcus Barker, Bridget Roe, Chris Sampson, Fiona Birkbeck, Chris Beeley, Lorna McWilliams, Hannah Jones, Jenelle Clarke, Elizabeth Shephard, Helen Quirk, Shireen Patel, Debbie Butler, Martin Clarke, Jennifer Tellett, Philip Willmot, and Gary Winship.   

Conference Chairs: Peter Bartlett and Melanie Jordan.

To register, or for further information, please contact Karen Sugars:(This email address is being protected from spambots. You need JavaScript enabled to view it. / 0115 82 32416).

Cost of Living blog re-post: "BLACK APRIL – There IS an alternative"

Ewen Speed, Simon Carter, Charlie Davison and Sasha Scambler

"On austerity, affordability, ideology and the changes to welfare and the NHS
that came into effect on the 1st April".

"Right wing politicians throughout Europe and beyond are working desperately hard to establish a new, shared and ‘objective’ fact – that the collective benefits of social care, community welfare, freely-accessible education and equitable healthcare are no longer affordable in the context of the modern state".

Access this Cost of Living blog post via:
http://www.cost-ofliving.net/black-april-there-is-an-alternative/

"The only thing that stops a bad guy with a gun is a good guy with a gun"Wayne LaPierre, NRA's executive vice president, 21 December 2012

The year 2012 saw some of the worst gun violence in American history. Unsurprisingly, this has prompted many discussions and debates about America's gun laws.  Topics currently include the interpretation of the Second Amendment (the right to bear arms) and whether it violates Americans' constitutional rights to make any amendments.  It has also prompted a string of suggestions and comments, some well intentioned and some woefully ignorant, regarding the link between gun violence, gun law reform and mental health.  Despite the diversity of discussions, one thing is fairly clear - gun law reform and mental health are two issues hotly linked in US policy discussions, whether this link is actual, imagined or inflated.

I should declare at the outset that I am an American and I am in favour of gun control.  If this sounds like an Alcoholics Anonymous (or more accurately Democrats Anonymous) confession, it's because coming from a conservative, gun-owning, Republican family, this is no small thing.  We disagree on many issues, but there are some issues on which we do agree: the problem is not just about guns and the solution should not focus solely on gun law reform.  Blaming guns and/or even 'bad guys' with guns for the problem is too simplistic.  Moreover expecting gun law reform to sort out the issue is also short-sighted.  Rather, the difficulties facing the US are multiple, complex and intertwined with a cultural values system that does not just begin with our Constitution and Bill of Rights, but with the individualistic principles we are founded on.   These principles still underpin and shape Americans' understanding of mental health and gun ownership.

Our system has its roots in the harsh life of the American frontier and still has remnants of John Smith's 17^th century principle, 'If you don't work, you don't eat'.  We have a limited social welfare system, no national healthcare system yet, and no national mental health care.  As Americans we are not protected by sick leave, as with our British and European counterparts.  Everything from minor to major physical ailments, doctor's appointments and maternity leave have to be squeezed into limited paid sick leave days (usually 5 days).  If this is our approach to physical illness, you can imagine the position taken with mental health.  There is little room for mental distress within our system.  Or, as is often the case, for understanding.

Furthermore, the American system is unapologetically individualistic.  It's our strength and our pride.  It’s also at times our weakness.  My American brother-in-law put it this way: in the States there is no ceiling on what you can do and who you can be, but there is no floor either.  If you fall, you will keep falling – there is no bottom.  Whether you jumped or were pushed is irrelevant.  You will get very little support in real terms.  Herein lies the crux of the matter: to many Americans, mental health is not a social issue.  It is in an individual problem.  Therefore if you are struggling with a mental health condition then it is your problem: yours to manage and yours to solve.

Our individualistic approach to mental health also extends to gun ownership.  Gun law opponents often point out that guns are an individual right, protected by the Second Amendment.  They argue that a few rogue shooters who go on a rampage is not the issue with the gun, it is the person holding the gun.  Everything from purposeful gun crimes to gun accidents is again, not a social problem, but an individual one.  Because it is people (not guns) that kill, the solution is not to amend laws, or to perhaps even begin to ask some challenging questions about the ethos of our society, it is simply to ensure that the person holding the gun is ‘good’ and responsible.

To this end, the National Rifle Association (NRA) has even suggested a national database.  Not for gun owners mind, but for those with a mental health condition. Which, according to the DSM criteria, would be approximately a quarter of our adult society.  And it's not just the NRA - 38 states already have such a system.  Many people who are proponents of this approach would not consciously intend to say that people with a mental health problem are ‘bad’ and irresponsible.  But I cannot help wonder where this trail ends, and where the distinctions lay in terms of morality and mental health.  As with many forms of prejudice within our society, the association is tacit.

It was only 3 short years ago that the White Paper was published aiming to establish a National Care service, free to service users. That was at a time when the recession had started and the Coalition Government had been formed. Now it looks like a completely different world with not a free service, but a cap to social care costs to be established locally in what many commentators are calling a `dogs dinner’ that will lead to multiple challenges and court cases for local authorities.

But it doesn't stop there… The NHS Confederation (who are meant to be one of the `good guys’) has this week (18/3/13) published a report which contains amongst its pages a suggestion of introducing charging to see a GP out of hours and to charge patients for home visits by GPs and by community nurses.

It’s not just the NHS confederation, the Daily Mail has also latched onto the idea and has included charging patients for their meals while in hospital.

It’s not surprising that the Twitter lines were burning last night in response to this and Roy Lilley blasted the idea as `What Were They Thinking’ (or more likely weren’t thinking) in his blog. One thing that Roy didn't pick up on – surprisingly for him – is that the costs of the pointless NHS reforms that come into force on April 1st are estimated to over £1 billion in redundancy payments alone and that doesn't include all the other costs of the NHS reorganisation… it seems patients are being asked to pay for that.

The government has recently had to hastily re-write Section 75 of the Health & Social Care Act 2012 regulations, the first draft of which would have forced commissioners to open just about every part of the NHS up to private sector competition. Following howls of protest from almost everyone. The re-write though was rushed, botched, and there are significant concerns about its intent and how it will be implemented. In particular, there are concerns that the fear of litigation on CCGs if they don't open up to the market will ensure they do anyway.

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on July 5 1948, it had at its heart three core principles: - that it meet the needs of everyone, - that it be free at the point of delivery, and - that it be based on clinical need, not ability to pay. - Publicly funded out of taxation

Despite earlier reassurances by The Kings Fund to the contrary, it seems these founding principles are coming under attack….

Ian Shaw, Professor of Health Policy, University of Nottingham (19/3/2013)

A date for the diary!  Professor Nikolas Rose will be giving a public lecture on 15 May 2013 at 4:30pm entitled, 'What is 'Mental Illness Today?  Five Hard Questions'.  This talk is part of the School of Sociology and Social Policy's Seminar Series and will be held in B63 in the Law and Social Sciences Building.

Further information about Professor Rose and his planned lecture is below:

What is ‘mental illness’ today – five hard questions Nikolas Rose Department of Social Science, Health and Medicine King’s College London

Abstract In this talk I want to characterize the ‘territory’ of mental illness today by posing five hard questions that seem to me to represent genuine empirical, conceptual, professional and ethical dilemmas.   My questions are: Is there an‘epidemic’ of mental disorder?;  Does the path to understanding mental disorder lie through the brain?;  What is the role of diagnosis and of diagnostic manuals?;  Should we seek early identification of those at risk of future mental pathology? What is the place of patients, users, survivors, consumers in the mental health system?  On the basis of this discussion, I will conclude by trying to draw out some lessons for the politics of mental health today.

Nikolas Rose Nikolas Rose is Professor of Sociology and Head of the Department of Social Science, Health and Medicine at King’s College, London.  He was previously Martin White Professor of Sociology, and Director of the BIOS Centre for the Study of Bioscience, Biomedicine, Biotechnology and Society at the London School of Economics and Political Science.  He is also co-PI for the EPSRC funded Centre for Synthetic Biology and Innovation (CSynBI). His most recent books are The Politics of Life Itself : Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton, 2006); Governing The Present (with Peter Miller, Polity, 2008) and Neuro: the New Brain Sciences and the Management of the Mind (with  Joelle Abi-Rached, Princeton, forthcoming, 2012).  He is a longstanding member of the Editorial Board of Economy and Society, co-editor of BioSocieties: an interdisciplinary journal for social studies of the life sciences, Chair of the European Neuroscience and Society Network, and a member of numerous advisory groups including the Nuffield Council on Bioethics.

In addition, the following poster is available for display and circulation:

Nikolas Rose poster, 15 May 2013

"A considered response to Francis should include a full assessment of what it will entail for mental health services".

http://blog.centreformentalhealth.org.uk/2013/03/13/what-the-francis-report-means-for-mental-healthcare/

 

There was an article in Time magazine last month, discussing the impact of a neoliberal ideology on the healthcare system in the United States.  Given the direction of the NHS currently, we felt it worth highlighting this article, perhaps to kickstart the debate within the IMH, and beyond.

The article is quite long, and as it is not a blog either, we have not reproduced it here, but you can access it on the Time website here.  Please do comment on this post if you would like to join the debate.

Before I was a PhD student, I worked as a research assistant in an intellectual disabilities research group on a project looking at the Deprivation of Liberty Safeguards. As an academic researcher, I was sceptical of the ‘DoLS’ – I thought they were cumbersome and missed the point. Now, my grandmother, who is in the ever-advancing stages of Alzheimer’s has recently been the subject of a DoLS authorisation process, and as a result, I’ve been thinking about them again, what they were for in the first place, and where we are with them now.

Firstly, what are the DoLS? The Deprivation of Liberty Safeguards are an amendment to the Mental Capacity Act 2005, designed to provide a framework for depriving an adult who lacks capacity to make a relevant decision of his/her liberty in his/her best interests. The legislation was brought about in response to the European Court of Human Right’s ruling in HL v United Kingdom. The case concerned HL, a man in his 40s with autism and intellectual disabilities who had been living in the community with adult foster carers, but had been re-admitted to hospital as the result of an incident of self-harming behaviour at his Day Centre. His foster carers wanted him back home, but the psychiatrist responsible for his care felt that he required further care and observation in hospital and would not let his foster carers visit in case he wanted to return with them. As HL was considered ‘compliant’, he was not detained under the Mental Health Act, but rather treated as a ‘voluntary patient’, and therefore not subject to any of the reviews, nor had any access to the tribunal system, embedded within the MHA. In theory, he was ‘free to leave’ whenever he wished – his ward was not locked – but he was sedated and his care team noted that had he actually tried to leave, he would have been stopped.

The challenge at the European Court was that the treatment HL had experienced was in breach of his article 5 right to liberty under the European Convention on Human Rights – that he had been deprived ‘arbitrarily’ of his liberty. The Court agreed with HL; while they agreed that sometimes, a deprivation of liberty was necessary for an individual, in the case of HL, he had been detained without his consent, and without any formal process or safeguards. There was no limit to how long he could be detained, and no formal review process for the end of that review – it was, therefore, in breach of the rules for lawful detention in European human rights law. The fact that he was in an unlocked ward was, the court said, irrelevant to the determination of whether his liberty was deprived. There was ‘complete and total control’ over his life, and he was subject to almost constant supervision.

This judgment resulted in the DoLS, an extraordinarily complex piece of legislation which sets out a framework for assessment of whether an individual is deprived of their liberty, and whether that deprivation is in their best interests. It does meet a lot of the criticisms of the ECtHR, setting out clearly who can do the required assessments, for how long any authorisation can be in force, and a procedure for review. However, it is immensely cumbersome and time consuming, and one can only assume that it is considerations of policy – the burden of both time and cost – that are at the back of the minds of the judges who have made domestic decisions on what a ‘deprivation of liberty’ is in domestic law since the coming into force of the DoLS. In a string of decisions over the past few years (most prominently, Cheshire West and P and Q), the definition of deprivation of liberty has been further and further narrowed, such that it seems almost impossible that a deprivation of liberty could be found unless someone was being terribly abused. The courts’ approach has been to adopt one of ‘normality’ – essentially, if it can be shown that the restrictions on an individual’s liberty are ‘necessary’ and are commensurate with the ‘normal life’ that someone with the same type of disability would have, then it could not possibly be a deprivation of liberty. There are many things wrong with this analysis from a legal perspective, not least that it is collapsing the objective test of deprivation of liberty, with the assessment of whether or not a course of action is in the individual’s best interests.

I can see why the courts have done this – they are no doubt concerned that, if the threshold for deprivation of liberty is set too low, then too many people will fall within the scope of the legislation and the number of DoLS authorisation processes will shoot up (though, at the moment, we are still some way below the estimates of application numbers suggested by the original impact assessment). However, to me, this approach somewhat misses the point. HL was a man who undoubtedly had multiple and complex needs – maybe he even benefited from that period of hospitalisation. What was wrong was that one person (his psychiatrist) was able to assume control over every aspect of his life, and ignore all and any other views on the situation, including his and those of people who cared for him day-to-day and knew him well. She was able to assume this control without any formal review process, or any appeal mechanism against it.

The point of the DoLS, what they should be for, is to ensure that adults with complex needs are never put in the position where any restrictions are put in place without some kind of monitoring. The direction of the case law has concerned me for some time as an academic, but being part of the process from the ‘other side’ if you will, with my grandmother, was my real ‘lightbulb moment’. Ultimately, the application for my grandmother was not authorised, as the assessor found that the restrictions on her life fell short of the (now very high) threshold in English case law. Yet, she is subject to some quite restrictive practices – in particular, the application had been made because of concerns about the frequency of restraint staff at the home were having to use to assist her personal care. My grandmother’s care home is not Winterbourne View – it is a great care home, with patient and caring staff, who only want to do what is best for the residents. However, it is inescapable that they are in a position of considerable power. My grandmother has my mother and aunt, who are very involved in her care and what goes on in her life; but what if they weren’t there, or were just happy to go along with whatever the care home thought was best? The restrictions on my grandmother may indeed be ‘normal’ for a woman with advanced Alzheimer’s disease, and the care home is entirely acting to ensure that she does not get ill unnecessarily, and that her quality of life can remain as high as possible for as long as possible. However, simply because their aims and objectives are admirable, does not mean they should not be subject to scrutiny.

The DoLS should not just be about ensuring that abusive practices, such as those at Winterbourne View, do not happen, nor, even, that some homes and hospitals’ practices are not ‘out of the ordinary’. It should be about ensuring that the any control exercised over an individual’s life is completely necessary, continues to be necessary for as long as it is exercised, and that it is done so for the shortest amount of time. The DoLS does not need to be the frankly bureaucratic nightmare of form-filling that it currently is, and in designing it this way, it seems to be a system which is only for the ‘really bad’ practices of a few, rather than what is should be, which is a constant monitor for the good care practice of all. A lower threshold for deprivation would probably require some reform in the structure of the DoLS, but then, I’m not convinced that would be a bad thing.

Amanda Keeling
PhD Student, School of Law

In continuing the discussion of the post-Francis Report, the IMH Blog recommends the post published last week on the 'Cost of Living' Blog about the way the report is being used by those with 'vested interests':

'Playing the blame game: political capital and Mid Staffs'By Ewen Speed and Simon Carter On the political implications of the Francis Report on the Mid Staffordshire NHS Foundation Trust Public Inquiry.

Published Friday the 15th of February, 2013: http://www.cost-ofliving.net/playing-the-blame-game-political-capital-and-mid-staffs/.

Prof. Paul Crawford ~ The NHS & Compassion

An interesting post-Francis Report publication …

Prof. Paul Crawford debates: NHS Leadership; Health & Social Care Reform; The NHS and the true meaning of compassion.

Published Friday the 8th of February, 2013: http://www.hscreformseries.co.uk/leadership/14747-the-nhs-and-the-true-meaning-of-compassion