News

There is a programme running on Channel 4 at the moment called 999: What’s your emergency?   The programme follows calls through from when they are received at the call centre, to their resolution by one of the three (or a combination of all three) emergency services.  The programmes are themed around different issues, and this week’s episode focused on the use of 999 and the emergency services by people with mental health issues.

It was mentioned by several of the emergency services staff on the programme that they often felt that it was not really within their job description to attend to such issues related to mental health, and moreover that they were not the ‘right person’ for the job, and had neither the expertise or the training required to properly help the person who was asking for it, or needed it.  The programme itself showed that this was certainly the case in some situations, with police officers becoming increasingly frustrated with a ‘repeat caller’ who took overdoses ‘with no intention of killing himself’  (although, there were counters to this position, with a wonderful example of good practice from the paramedic who attended Alan Abbott when he relapsed into alcoholism and called 999 in fear of taking his own life).  Yet despite feeling that it was not strictly within their remit, and feeling inexperienced, they were concerned that there was no one else to do it.  They are, said one police constable, the ‘sticking plaster’ on society, trying to fill the gaps and provide one last safety net for people.

The police officers in particular clearly felt under equipped, under resourced, and lacking in the appropriate experience to perform the work that they felt was more within the brief of social services, but that there was simply no one else to do it and they did not feel they could just sit back and watch someone they perceived to be vulnerable harm themselves.  The programme only serves to highlight some of the issues the Chief Inspector of Prisons raised in his annual report published last week, concerning overuse of police cells as a place of safety under s.136 of the Mental Health Act.  Debate about section 136, and the appropriate place for people with a mental disorder found in a public place, has been on-going for many years, and concern over the excessive use of s. 136 in police stations is not new.  However, despite the academic research, and the opinions of officers themselves, use of the police force as a ‘stop gap’ does not seem to be diminishing.

It was suggested in the programme that the cause of the rise in this type of call to 999 was due to the diminishing number of psychiatric inpatient facilities, which is of course a deliberate scaling down with a view towards greater levels of community care, whether you believe the motivation for this to be an idealistic move towards community inclusion, or a more cynical cost cutting exercise.  However, reducing the inpatient facilities does not diminish the number of people with mental disorders who want or need help.  As one of the paramedics interviewed noted, the emergency services can provide short-term help – a police cell doubling as a place of safety, or a bed in A&E for the night - but this is no long-term solution.  One of the police constables noted that with the increasing cuts on the police force and their reducing numbers on the streets, there is going to be a growing need to define more clearly the parameters of ‘police work’, and they may have to start refusing to attend many of the types of incidents shown in the Channel 4 documentary.

This is not my particular area of expertise, but I was really struck by the issues this programme raised between the lines.  The police may not be the appropriate people to be dealing with mental health  issues, but the fact that they are doing so must raise the question ‘who should be?’.  As public sector cuts only look set to continue, we must start asking this question more pressingly, because if the emergency services ‘safety net’ is taken away, what will replace it?  I know there are those of you out there reading this blog for whom this is your area of research, and I would welcome discussion of the issue in the comments section below.

Amanda Keeling PhD Student School of Law, University of Nottingham

Any port(al) in a (information) storm

“Don’t read newspapers for the news (just for the gossip and, of course, profiles of authors). The best filter to know if the news matters is if you hear it in cafes, restaurants... or (again) parties”. Nassim Nicholas Taleb, Professor of Risk Engineering at New York University.

I like Taleb’s writing. ‘Maddeningly wise’ is how one reviewer proclaimed the Black Swan author’s recent short book The Bed of Procrustes. I therefore thought I would put his quip about news to the test. I used to be a news junkie; twenty four hour rolling news was made for me. But it is both so time-consuming, especially when so much isn’t actual ‘news’ (facts, whatever they are) but speculation and analysis, and so subject to editorial control in terms of what is deemed ‘newsworthy’. I decided that what I needed was another editorial filter, someone or something to cut out all the rubbish to allow me to peruse only the need-to-know (as Taleb says, assessing what news “matters”). Don’t worry, I’m not going all Chomsky ‘propaganda model’ on you at this point; read on.

And then I alighted on Twitter, something I had previously dismissed as a vanity project for media darlings. Using Twitter I now let the news ‘find’ me; if it is big enough I will hear about it through other users (the ‘cloud’ or ‘crowd’ sourcing approach as some see it). Of course this depends on using the right filters ie trustworthy sources as a kind of editorial control. It works though. I think I have saved myself at least an hour a day.

As a clinician I could be similarly overwhelmed with new information such as academic updates and clinical developments from journals. Having filters to control the information flow (other than a ‘head in the sand’ approach) has become a facet of professional development but who has the time to set these up and maintain them? In addition many clinicians now work in a portfolio style, across systems and sites with limited opportunities to meet up in the traditional lunchtime academic update format. To counter these problems there is a burgeoning industry of companies as well as some in-house health organisations promising and sometime providing knowledge management, access to the best evidence and ‘what your colleagues are reading’ type indicators. The holy grail is the provision of filtered ‘best’ knowledge (such as NICE guidelines, systematic reviews or even your local Trust’s policies) to the fingertips of both clinicians and patients, either as for example integrated clinical decision support tools in electronic patient records or at least having clinical knowledge resources in one easily accessible place, not dispersed across random intranet sites.

One idea we have thought about at the Institute of Mental Health in Nottingham is to have a ‘one stop’ website[1] capturing the ‘need-to-know’ information for our local mental health clinicians. It acts partly as a portal (read ‘filter’) to other sources, a quick way of on-line browsing of your usual sources (such as journals), as well as informing clinicians about other areas of indirect interest such as research or recent local talks or seminars. Ideally it offers macro and micro level learning, major updates but with local significance. Twitter increasingly has a role in this, often as re-tweets ie re-directed messages for rapid access to clinical and academic updates. What will make this initiative work though is the clinicians themselves, helping to identify the right filters, trustworthy sources to determine what matters to them and their patients. The clothes horse has been assembled; it just needs dressing. Over to you…..

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“Teenagers have it so easy nowadays”– I’ve heard this quote used frequently by adults to their stressed teenagers, telling them to make the most of the youth they have before life gets difficult, but there are becoming more and more reasons for me to disagree with this statement. The expectations that come with a 17 year old adolescent are growing rapidly from their parents, schools, friends and society itself.  The pressure to be “perfect” can be too much for some people, leading to depressionwhich can bring on further difficulties such as eating disorders and self-harm. A Healthline report states, “Treatment is important because teens with untreated depression are more likely to have social and school problems, abuse drugs and alcohol, become parents at a young age, and go on to experience adult depression and possibly suicide.”  But with the all-too obvious stigma that comes with a diagnosis of depression, can we really judge their reluctance? So, as an 18 year old myself, what do I class as perfection? Perfect grades, a perfectly set out future, perfect hair and the perfect body? These are all pressures that young adults have to face every day, in debatably the hardest time in their life as it is^.  But is the pressure any worse now that it was 30 years ago, or is it just much more publicised?

Personally, I think a lot of the pressure is to be placed with social networking and blogging sites such as Facebook, Twitter, Tumblr and many more, which have only become widely available in recent years. A study by Cyber Sentinel and published in The Daily Telegraph shows that the average teenagers spends 31 hours per week on the internet, spending a large proportion of these hours trawling through these social networking websites and looking up topics brought about by current pressures, such as cosmetic surgery, diet planning and weight loss methods. The models shown on such websites represent a figure and lifestyle that makes young adults believe that is what they must look like in order to be successful, and when so much time is being spent looking at them, it’s not surprising that image becomes transfixed in their mind. In a study by Stirling University in 2009, one in five school children said the internet, including social networking sites, influenced their decision to self-harm, a figure I find very believable.

But what can be done to help? Should parents be limiting internet access to their children, or is it up to someone else to notice the pressure piling up before it become too much? In my opinion, teenagers are the most unlikely age group to admit they think there’s something wrong with them, for fears of being judged further. So what can be done to stop them going to drastic measures to become “perfect”?

Chloe Hill Intern, Institute of Mental Health

[caption id="attachment_541" align="aligncenter" width="251"] Just a hole?

[caption id="" align="aligncenter" width="256"] No - the beginnings of something!

A massive hole was dug, the foundations have been poured, the metal supports are in place and Ekkehard is in Italy carving. He has started a blog to chart the progress of the work.  It's hard to believe that this drab little bit of grass  will soon host a 6 tonne marble sculpture.

[caption id="" align="alignleft" width="254"] 3D Model of the sculpture

Since my last post pre-cutting of the ten tonne block of Carrara marble has been completed. There are 2 stages of cutting, one involves a straight cut with a wire diamond cutter, the second one uses a robotic arm that pre-cuts the shape based upon a further rendition of the sculpture design. This model was 3D scanned and used for the pre-cutting in the Petacchi quarry. Ekkehard has since started the fine carving.   [caption id="attachment_544" align="alignright" width="300"] Sample of the marble for the sculpture

Ekkehard sent me this rather beautiful turned piece of marble from the block he purchased for the sculpture. It sits on the table in my office and has been admired and stroked by lots of visitors.  Two weeks ago the members of the 'Thursday group' came to visit the building. They are a group of people with experience of mental health problems who meet each week to make art and to visit galleries and other cultural venues. I showed them around the building and updated them on the progress of the sculpture. They'll be doing marble carving with Ekkehard after the sculpture is finished. It seems he's made a rather good impression on members of the group and they are very excited to be working with him. The Thursday group will be curating a space in the building that I've dubbed the secret corridor. More on that plus news from Petacchi quarry soon.

At the start of this new academic year, the Institute of Mental Health Blog editorial team is hoping to recruit new post writers and editors. To date, the IMH Blog has had 4,683 online visits from across 56 countries! Previous posts have explored myriad topics including: artwork and mental health; chronic pain; patient involvement; therapeutic communities; health economics/profit; prison mental health. The IMH Blog is a forum to encourage dialog about issues related to mental health broadly defined. Our aim is to capture the variety of interest and expertise that is reflected in the Institute’s diverse membership body. All interested parties are very welcome to contribute. We encourage posts from carers, service users, clinicians, academics, allied health professionals, commissioners, etc. You can write just one post, or many. We look forward to hearing from you. If you have any queries, please contact: This email address is being protected from spambots. You need JavaScript enabled to view it.

Please find below the third post from the IMH staff member Debbie Butler, Patient and Public Involvement Coordinator:

It seems a while since I wrote on the IMH blog; life hasn’t stopped though by any means. It has been quite an adventure these last few weeks with a lovely cruise around France and Spain, a mini stroke, and lots of family stuff; I feel I could go on forever.

However, working life at the NIHR Mental Health Research Network, here at the IMH, hasn’t stopped either. I am working hard with colleagues to establish a new Research Group in the North of Nottinghamshire at the Rosewood Involvement centre. Our first meeting is on the 22^nd of October 2012. Although, working in the North of Notts. seems a million miles away for me, as I don’t drive and the only way I know how to get up there takes the longest time in the history of the world. (Not really, it just feels like a long travelling time). Nevertheless, it promises to be an exciting new research venture.

Let me see what else we have been doing here at the IMH MHRN. Well, we still hold our monthly patient and public Involvement group for those of you involved in research, as we are a group of service users and carers who wish to be further involved in the research process. We have many varied skills and are willing to help in any way we can. In addition, we look for individuals or teams to come and talk to the group about their research, as we can answer most questions regarding service user and carer involvement. Last week saw us completing registration of our group members with the Involvement department and this will aid us in our ability to participate in the 'nitty-gritty' finer aspects of research. Furthermore, the group met last week and discussed Industry-based research studies and also agreed to look at writing a bid to our co-ordinating centre to establish a checking system for research ethics of such Industry studies. Have yet to speak to them about how this will work, but at least it would be something to aim for.

Can I just ask if anyone would like to join our group please? Or would like to ask the group about a project they wish to undertake? If so, please contact me and we can arrange for you to attend one of our groups. I am currently looking at speakers for next year and would be happy to accommodate those of you who are interested in either attending as a group member of as an individual speaker. Thanks.

Take care for now, Debbie.

Recent conferences, Q&A of paper presentations, and even my NHS REC meeting have recently made me question the impact of social research within mental health and the ‘so what?’ factor of non-clinical studies.  We live and work in an evidence-based system whereby the expectation is that results are observable, measurable, quantifiable and replicable.  Hence studies that value the lived experience of participants, and look for meaning rather than outcomes, can struggle to maintain a sense of validity and reliability within mental health research.

However, there is much that value-based research can offer.  As Larsen (2007) points out, evidenced-based studies that examine therapeutic intervention has a propensity to create the “black box” effect.  The research may show whether outcomes have been achieved, but it cannot address exactly how they were met.  Furthermore, these studies cannot say why these outcomes matter and who they matter to.  This omission is fairly significant given the discrepancies between provider and patient expectations.  Gilburt, Rose and Slade (2008:8) argue that ‘[d]ivisions in the views of patients and professionals in terms of what variables and themes are important mean that the resulting studies may be a poor representation of the user perspective’. Furthermore, evidence-based research ignores personal agency and creativity as it requires that support be routinised according to a set of rational mechanisms that are universally applied (Haigh, 2005).  From this perspective, individuals need only respond to a prescribed agenda of recovery rather than find meaning from their own unique experiences (Rose, 1999).  Thus in order to avoid prioritising “what works” over “what matters” (Haigh, 2005), we need studies that emphasise participants’ experiences of mental health and the outcomes that are important to them.

But there is an even greater ‘so what?’ question that value-based researchers within mental health must address.  Even if we can convince our audiences that value-based research is meaningful and needed, what do we actually do with it?  The conclusion section of many journal articles advocating the prioritisation of participant experiences usually end by saying something along the lines of, “the evidence-base should be expanded”, and/or, “what matters to participants should inform clinical practice and guide policy making”.  Whilst I wholeheartedly agree, I also cannot help but notice that they do not offer any suggestions on how to do this.

Given the evidence-based system that relies on outcomes that are deemed to be achievable and measurable, the direct impact of value-based research is not always obvious.  However it is well worth considering the practical implications of how exploring participant perspectives and highlighting lived experiences can have a real-world impact within mental health.

Posted by:
Jenelle Clarke
ESRC PhD Student (Sociology)
E: This email address is being protected from spambots. You need JavaScript enabled to view it.
References:
Gilburt, H., Rose, D. and Slade, M. (2008) The Importance of relationships in mental health care: a qualitative study of service users’ experiences of psychiatric hospital admission in the UK. BMC Health Services Research 8(92).  Available online: http://www.biomedcentral.com/1472-6963/8/92.

Haigh, R. (2005) The Trouble with Modernisation: we need better relationships, not policies and procedures. Mental Health Review Journal 10(3): pp.3-7.

Larsen, J.A. (2007) Understanding a Complex Intervention: Person-centred ethnography in early psychosis. Journal of Mental Health 16(3): pp.333-345.

Rose, N. (1999) Governing the Soul: the shaping of the private self. London: Free Association Books.

In this post Melanie Jordan from the IMH introduces two contemporary art ventures with mental health themes that may perhaps be of interest to IMH members. A BBC News photography article and a Nottingham Contemporary exhibit and talk.

1.

In this ‘BBC News In Pictures’ article Picturing Mental Health published on September the 12^th  (http://www.bbc.co.uk/news/in-pictures-19555676) Phil Coomes explores mental health via the work of photographers Marwah Al-Mugait and Michael McGuinness. It is noted this subject is ‘notoriously difficult to photograph without resorting to cliché and intrusion’, nevertheless ‘photography can be a tool to discover and an extra sensory experience’. Bipoloar disorder is explored via compelling pictures by Marwah Al-Mugait alongside discussion of intrusion and the notions of trust, understanding, and collaborative work with patients. The role of Birmingham and Solihull Mental Health Foundation Trust is then documented by Michael McGuinness. ‘Having been granted access Michael immersed himself in the Trust's work and the subject of mental health.’ Many weeks were spent working with the Trust. The work tackles issues of stigma and captures the lives of staff and service users. This article and its photographs are available online:http://www.bbc.co.uk/news/in-pictures-19555676.

2.

Kubin’s (1877–1959) work is exhibited currently at Nottingham Contemporary (until September the 30^th). A Nottingham Contemporary (http://nottinghamcontemporary.org/) event at 7pm on September the 20^th may be of interest:

A (free) talk by art historian and curator Gemma Blackshaw, who will discuss the work of Kubin in light of the 'Madness & Modernity' exhibition she curated at the Wellcome Collection (London, 2009) and the Wien Museum (Vienna, 2010). Book online: http://nottinghamcontemporary.org/event/gemma-blackshaw.

‘Haunting drawings of death, trauma and fantastical creatures inhabiting imaginary worlds sprung from Alfred Kubin’s pen at the beginning of the 20th century … Kubin never recovered from a deeply troubled childhood, losing his mother at a young age. Following a failed suicide attempt at the age of nineteen and a complete nervous breakdown at twenty, Kubin was sent to Munich to study at the art academy. This was where he finally found an outlet’ (http://nottinghamcontemporary.org/art/alfred-kubin).

This week we have a reblog from Lucy Series, who writes a really excellent blog here.  You can read the post in it's original format here.

'Far from providing a plethora of small-scale, responsive, customer-focused services which the privatizers and marketers promised (see Drakeford, 2000 for a more extended discussion), the residential care market has displayed far more traditional tendencies to monopoly and standardization. The future of private provision is set to be one of large-scale warehousing, physically located on far fewer premises and offering little by way of choice.'

When I attended a BIHR run event on human rights in healthcare in 2010, Nigel Thompson - head of human rights and equality at CQC - expressed concern that large care providers could undermine the diversity offered by micro-providers, and questioned how CQC could protect that diversity.  I don't know that any answers are forthcoming yet.  Last year the National Development Team for Inclusion (NDTi) produced a fantastic report examining the root causes of why large, expensive private sector hospitals for people with learning disabilities continue to exist, when they secure such poor outcomes and are a discredited model of care.  The answer in one word: capitalism.  Most private providers are financed by debt. Banks must be satisfied that services are financially viable. Hospitals are easy to conceptualise with 'safe predictions of profit', whereas 'alternative service models more in line with the Mansell Report ...consisting of preventative services, sessional input and flexible contracts for support ...are more complex to cost and predict.' Consequently, 'At a time when banks are less willing to lend, and are looking for greater security from companies, a move towards untried (in business terms) models that have no recognised framework for costing and predicting profitability will be attractive to neither the provider nor the bank.'  The report concluded that only with concerted state action could services in line with the Mansell report be developed.

When care services are contracted out to the independent sector, there is a loss of transparency and accountability as key modern democratic instruments such as the Freedom of Information Act 2000 and the Human Rights Act 1998 lose their traction (yes yes, the HRA applies to care homes when people are placed under the National Assistance Act, but there are plenty of other statutes a person might receive independent sector services under, and not all services are care homes).  Revolting reverse auctions used by local authorities to secure the cheapest contractor for services drive down price at the cost of quality, and will favour providers who can operate narrower profit margins due to economies of scale.  Meanwhile commissioning authorities can distance themselves from tumbling care standards as they have merely 'purchased' the care, rather than delivered abusive and neglectful services themselves.  Rather than engage in the slow, hard and costly work of improving services, they can just shop elsewhere.  Staff typically have better working conditions in the public sector, although to my mind the issues around low pay and working conditions which plague the care sector should be addressed for everybody working anywhere.  And paradoxically, although privatisation was supposed to result in greater choice and freedoms of which services a person used, this very choice and freedom can threaten the economic viability of services themselves.  In relation to the supposed 'freedom of choice' users of supported living services are meant to enjoy over who supports then, the Voluntary Organisations Disability Group and Anthony Collins Solicitors writes (pdf):

'...CQC’s primary concern is to ensure people have freedom over their choice of care provider ...Providers [of supported living services] are left unable to link any ‘care’ services to the location of the person which prevents them from being able to plan the totality of services required in an economically viable way. This does not help to deliver this type of accommodation in the volume people need...Significant tensions exist between the rights of the individual to self determination and choice, the financial constraints on the cost of care and the regulatory framework.'

In essence, although the ideals underpinning the privatisation of care turned in no small part on freedom of choice, this turned out not to suit providers all too well as they suffered the resultant market instabilities.  That market failure might be a bigger problem in care than, say, discontinuing a line of baked beans, was evident from the panic that ensued when Southern Cross was folding, and nobody was sure week on week who - if anyone - would be supporting residents of Southern Cross care homes.

But to say that capitalism and marketisation is problematic for social care, and to say the state must take action to override the tendencies of free markets in social care to result in uncertainties, monopolies and 'care as storage' is not quite the same as saying that state run services are always better.  Would it be too easy and trite to point out that scandals in Cornwall, Sutton and Merton, the Royal Sussex County Hospital, not to mention Mid Staffordshire were all NHS run services?  I was set to thinking about this yesterday by a column written in the Telegraph by Dr Max Pemberton, entitled 'Winterbourne View: The problem with all care homes', with the byline 'Many people with severe disabilities should be cared for within the NHS, rather than in private facilities'.  Pemberton appears to be under the impression that Winterbourne View was a care home, when in fact it was a hospital.  This has been a pretty common theme in media coverage of the scandal, but in this context it's quite an important confusion as the argument he appears to be making is that Winterbourne View was caused by the care in the community reforms of the 1990's:

People with severe disabilities, such as those at Winterbourne View, would have previously been cared for in large NHS asylums. However, in the Nineties, with the widespread closure of these, the residents were moved out and cared for by the NHS in the community. While some were able to live independently with NHS mental health service input, some were too disabled and required 24-hour care. These people fell awkwardly between the criteria for NHS care and for personal care, and ultimately their welfare was placed in the hands of social services, despite them having severe and complex medical problems.

Legislation such as the 1990 National Health Service and Community Care Act, as well as the Supporting People initiative, enabled private agencies to develop and provide specialised housing. The result of this is that too many people with severe and complex needs, who were once looked after by medical staff in institutions, are now at the mercy of unqualified staff in the private sector. The issue is not just that there is abuse taking place in some of these homes, but that the level of care that residents receive in all of these homes is substandard because the staff are not medically qualified or trained to the standard expected on NHS wards.

There are several points about this argument.  Firstly, it appears (to me) to be endorsing a very medicalised view of what kind of care adults with learning disabilities should be receiving, which sits in tension with the arguments advanced by leading learning disability experts and charities that:

There is no place for specialist hospitals in the care of people with learning disabilities (outside of serious forensic issues). There is clear evidence that such hospitals provide poor outcomes, often at very high cost, and that there are better, alternative ways of supporting people that have behaviour labelled as ‘challenging’. There is a place for a small number of local assessment and treatment beds, integrated with other local community services.

These charities aren't arguing for people to be moved into NHS run hospitals, they're arguing for people to be moved out of healthcare services altogether - into community services.  To be fair to Pemberton, however, he does argue 'I wouldn’t advocate returning to the days of large institutions and asylums', but he does seem to be advocating for care services run on a healthcare model.  Secondly, it seems to be linking the abuse at Winterbourne View to the fact the services were not run by the state.  I'm probably going to lose a few friends by what I'm going to write next, but I think it's problematic to argue that the state always provides better services.  I don't mean to come over all Philip Blonde about this, but the fact is that there are many excellent and innovative forms of care that are being developed - with (hopefully) support from local authorities and the state - in the independent sector.  For example, most micro-providers - which can have excellent outcomes - are in the independent sector (see Community Catalysts); Shared Lives schemes can have excellent outcomes, and they can also be in the independent sector (although some are run by local authorities).

Pemberton's article sent me scurrying away to look up some research I did in the twilight days of the CQC using care standards ratings.  Using their old search engine (have I whinged yet about how much better it was than their new search engine?), you were able to search for the number of registered providers of different types of care (e.g. care homes, domicilliary care), of different target users (e.g. learning disabilities, 'old age', dementia, etc), and of different provider type (e.g. voluntary sector, private sector, council run, NHS).  Now, CQC did release some data back in 2011 which showed that council care was better than private sector care, but the data I unpicked showed a slightly more complex picture.

For each type of service provider (e.g. NHS, local authority, voluntary/charity or private - meaning 'for profit') I calculated the proportion of services receiving CQC ratings of 0 (poor), 1 (adequate), 2 (good) or 3 (excellent).  I broke this down by type of care being provided.  I also looked at the proportion of services offered by each type of provider.  The charts below reflect what I found.  These data were collected in April 2010.  I have shared a copy of the spreadsheet with the data in full here, which you are very welcome to use as you see fit although please note the Creative Commons license this blog is published under.  I apologise that the graphs don't quite fit on the page, but it's probably better to be able to read the text than look pretty!

Domiciliary care services
The largest proportion of domiciliary care is provided by for-profit ('private') providers, followed by local authority, then voluntary/charity, and then a small proportion of NHS providers.
 Care homes  

For dementia, again we see that the private sector has the largest proportion of 'poor' services, followed by voluntary/charity then the local authority.  The voluntary/charity sector offers the largest proportion of 'excellent' services, followed by the NHS, followed by local authorities with the private sector coming last.  Once again, however, the NHS data should be treated with caution as it only reflects a sample size of 10.
For adults with learning disabilities, the private sector had the largest proportion of 'poor' services, and the local authority the least.  The voluntary/charity sector offered the highest proportion of 'excellent' services, followed by the local authority, followed by the private sector - with the NHS offering the smallest proportion of 'excellent' care homes for people with learning disabilities (there were 157 NHS care homes for this sample).  The NHS did offer the highest proportion of 'good' care homes for adults with learning disabilities, but in terms of services rated higher than 'adequate' it only equalled the private sector and was outcompeted by both the voluntary/charity sector and the local authority services.
  Discussion These data are two years out of date now, but they do suggest that it is not an easy generalisation to make that the state offers better quality care than the independent sector.  Digging deeper into the data, there are many occasions when the voluntary/charity sector performs better, and - for care homes for adults with learning disabilities at least - the NHS doesn't seem to excel.  It might stick in your throat to acknowledge this, but the voluntary/charity sector would not be offering these kinds of care services were it not for the 'privatisation' of social care which allowed services to be commissioned from independent providers.  One pattern does stand out in these data though, that the for-profit private sector, which holds the largest share of the market, is consistently the worst.  It offers the most poor services, and the fewest excellent services.  The state isn't always better, but profit usually makes it worse.

The IMH Blog is pleased to announce The Consortium for Therapeutic Communities' (TCTC's) upcoming Annual International Conference taking place 22-24 October 2012.  This year’s conference theme is Delivering Integrity and it will focus on evidence based practice, value for money and sustainable outcomes.

2012 marks a significant year for therapeutic communities (TCs) with the 40th anniversary and re-launch of the Association of Therapeutic Communities (ATC) into the newly formed TCTC.  TCs are defined as ‘psychodynamically informed planned social environments’ (Boyling, 2011:152) and found in a variety of sectors including children and young people, prisons, addictions, personality disorder and learning disabilities.  Despite some excellent and notable examples of TC research (including, but not limited to, Rapoport, 1960; Bloor et al, 1988; Dolan et al, 1996; Rawlings, 1998; Lees et al, 1999; Chiesa and Fonagy, 2000; Freestone, 2005; Freestone et al, 2006) TCs have a ‘mixed record’ of conducting research, whether qualitative or quantitative (Morant and Manning, 2005:230).  In recent years, more is being done to demonstrate clinical effectiveness as funding becomes linked to evidence based research.  Yet applying outcome based studies in TCs is difficult as TC intervention is holistic and not easily broken down into separate observable components which can be measured quantitatively (unlike pharmacological studies for example).  Thus using the RCT methodology favoured by commissioners and funding bodies is often a challenge for TCs.  In addition, finding common outcomes across TCs can be hard due to the diversity of communities themselves and because what constitutes an outcome can vary widely.  Of course TCs are not alone in this as the same could also be said of other psychotherapeutic approaches,  particularly those styles of therapy (e.g. psychodynamic) which also do not lend themselves easily to RCT methodology.  However in the midst of continued challenges to secure funding, the question of how to show that TCs deliver integrity in therapeutic interventions becomes a central issue.

In particular the upcoming conference will explore:

• how to develop specialist therapeutic practice
• the latest developments in research and evidence
• key messages for commissioners and purchasers
• experience of large and small groups as method

The conference will be of interest to all those working in, supporting, commissioning or purchasing therapeutic services in the following sectors:

• children & young people
• personality disorders
• mental health
• addictions
• learning disabilities

Location
Cumberland Lodge, Windsor Great Park

Prices
TCTC Members (full) £495Non--‐members (full) £555(*£100 discount on shared accommodation)TCTC Members (day 1 or 3) £95
Non--‐members (day 1 or 3) £115
TCTC Members (day 2) £145
Non--‐members (day 2) £165

To book a place, please contact TCTC:
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TCTC Conference Flyer 2012 (PDF)

References:
Bloor, M., McKeganey, N. and Fonkert, D. (1988) One Foot in Eden: a sociological study of the range of therapeutic community practice.London: Routledge.

Boyling, E. (2011) Being Able to Learn: researching the history of a therapeutic community. Social History of Medicine 24(1): pp.151-158.

Chiesa, M. and Fonagy, P. (2000) Cassel Personality Disorder Study: methodology and treatment effects. British Journal of Psychiatry 176(5): pp.485-491.

Dolan, B., Warren, F., Menzies, D., and Norton, K. (1996) Cost Off-Set Following Specialist Treatment of Severe Personality Disorder. Psychiatric Bulletin20(7): pp.413-17.

Freestone, M., Lees, J., Evans, C., and Manning, N. (2006) Histories of Trauma in Client Members of Therapeutic Communities. Therapeutic Communities 27(3): pp.387-409.

Freestone, M. (2005) Overview of an Ethnographic Study of the UK DSPD Pilot Units. Therapeutic Communities 26(4):pp. 449-464.

Lees, J., Manning, N., and Rawlings, B. (1999) Therapeutic Community Effectiveness: a systematic international review of therapeutic community treatment for people with
personality disorder and mentally disordered offenders. CRD Report 17, York: NHS Centre for Review and Dissemination, University of York.

Morant, N. and Manning, N. (2005) Principles and Practices in Therapeutic Community Research. Therapeutic Communities 26(3): pp.227-243.

Rapoport, R. N. (1960) Community as Doctor. London: Tavistock Publications.

Rawlings, B. (1998) The Therapeutic Community in the Prison: problems in maintaining therapeutic integrity. Therapeutic Communities 19(4): pp.281-294.

Chris Sampson ~ Considering Time Perception

Chris works in the IMH building for the NIHR CLAHRC and runs The Academic Health Economists' Blog: http://aheblog.com/.

In economic evaluations in health, time matters. More time in a bad health state is necessarily worse (or no better) than a smaller amount of time in said health state. Likewise, the value of an intervention increases with the duration of benefit. The standard QALY framework takes this into account. Furthermore, time preferences matter. Economists deal with this in a present value framework; discounting future costs and benefits. But there is another aspect of time which is not taken into account; time perception. Issues surrounding our perceptions of time recently appeared in the usual pop science outlets following the release of Claudia Hammond’s new book ‘Time Warped‘. As medical, neurological and psychological understandings of time perception improve, is it time economists weighed in?

Economists have considered the effects upon time perception of things like ‘awe‘ and the cognitive resource demands of tasks, while others have investigated the interaction between time preferences and time perceptions. It seems none have investigated the implications for an area in which time perceptions might play their most important role; health.

Why might it matter?

Time is an abstract idea, but economists rarely treat it as such. This means that people’s perceptions of time are overlooked. This may be a reasonable approach if we are working at the mean and people’s perceptions of time are consistent across health states. But what if they aren’t? Consider a basic illustrative QALY example:

• Scenario A: 2 weeks in 0.8 health, followed by 2 weeks in full health
• Scenario B: 1 week in 0.6 health, followed by 3 weeks in full health

Clearly these scenarios give the same QALY result. If one perceives time to pass more slowly in a worse health state then we might be able to add to the scenarios that in ‘A’ the first 2 weeks “feels like 3 weeks”, while in ‘B’ the first week “feels like 2 weeks”. If we were to weight the QALY values in these periods according to perceived time we would have a preference for scenario A. With these re-weightings, 2 weeks of 0.8 in scenario A would become equivalent to 2 weeks of 0.53, while 1 week of 0.6 in scenario B would become equivalent to 1 week of 0.3; increasing the difference between the two health states.

Applications

We all experience fluctuations in our own time perception. Time flies when we’re having fun. It might fly when we’re healthy too. It may be the case that a general and testable model of time perception exists in health. The most likely relationship seems to be that being in poorer health would be associated with a perception of time moving more slowly. There may also be differences in time perception between different groups of people (men and women, children and the elderly) that we may or may not want to adjust for. Some interesting implications of time perceptions for the burden of waiting times have already been identified.

Particular health conditions can affect an individual’s perception of time, and this is where the consideration of time perceptions could be crucial. Children with ADHD, for example, have been shown to perceive time in very different ways to those without ADHD. Likewise, cancer patients with evidence of disease have been found to perceive time as progressing more slowly, compared with those without. If a condition causes individuals to perceive time to move more slowly in a consistent and measurable way, then specific rules could be established to assign greater weight to treatments for said condition.

Implications

The relationships above are all testable and quantifiable. Time perceptions can be easily tested by denying well and unwell patients access to a clock and calendar, and then asking them about the ways in which they perceived their time in these states. It is important to note that during these times our perception of time may be affected by other things; whether we are confined to a hospital bed, stuck in the office or asleep at home. All of these things could be controlled for in an experiment.

The real question is whether or not we (the public) want to take this into account or not. If the public’s stated preferences do not reflect the effects of time perception then should we artificially weight their preferences to do so? The issue seems analogous to that of adaptation (to which time perceptions would no doubt be subject!). Public valuations of the effects of time perceptions could be captured with the usual time trade-off, standard gamble or discrete choice experiment techniques. One difficulty would be in ensuring that there is no double-counting. It seems likely that this would not apply in the specific applications, where the general public’s valuations would not consider ADHD’s effects on time perception, for example. However, it seems possible (likely, even) that the general public would consider time perception effects associated with being generally unwell.

Perceptions of time have been discussed in economic and health economic literature in respect to experienced utility and biases of memory in retrospective valuations. There has been little contribution to theories about individuals’ present time perception. I believe it may be time for these ideas to be explored further, particularly in relation to specific health conditions, and applied to preferences and expected utility in health.

How do you see time perceptions influencing quality of life? To what extent do you think differences in time perception either could or should influence health care decision making? Please comment below.

As a clinical psychologist working in chronic pain (CP), the question I get asked most by lay people (apart from whether I am reading their mind) is why bother? The thinking is usually this: pain is a physical experience that results from an injury of some sort, which surely requires a physical (usually medical) remedy. The implication from this, of course, is that I’m a psychologist and so I deal with ‘mental’, and not physical, experience. And as pain is clearly a physical experience, what am I doing in pain?

This form of thinking, which the philosopher John Searle called ‘residual dualism’ (Searle, 1984), is perhaps understandable in non-professional people, especially since such dualisms permeate many aspects of Western culture. However, such ontological faux pas are less forgivable with experienced medical professionals who perhaps should know better. The amount of times I have been asked by medics whether this patient’s pain is “all in their head”, or if I can please tell them whether their pain is “psychological” or “physical”. As if these things are mutually exclusive! Sometimes archaic, cod-Freudian gems are wheeled out for effect: a patient is described as having “psychogenic” pain or being a “somatizer”.

Unfortunately, these statements quoted above betray a fundamental misunderstanding about the nature of body/brain perception. Pain is a complex experience that involves a dynamic interplay between physiological, emotional and psychological (cognitive) elements. Theories based on experimental neuroscience see CP as a failure of the brain and nervous system to regulate pain signals from previously damaged pain areas. Pain can thus be likened to a faulty alarm system that has not been switched off, even though the initial emergency has passed (see Weich & Tracy, 2009). Psychological factors such as heightened pain expectation, experiential avoidance, trauma, mood disorders and stress are crucial factors maintaining this alarm system (Gatchel et al., 2007). As the International Association for the Study of Pain have pointed out, “[pain] is unquestionably a sensation in a part or parts of the body but it is also always unpleasant and therefore also an emotional experience [emphasis added]” (Merskey, 1986, p. 1, as cited in Gatchel et al., 2007). The pain experience is integrative: you simply cannot separate the “physical” from the “psychological”. It is phenomenological nonsense.

Suffering with a pain condition can be a horrible experience. CP disrupts vocational/educational functioning, relationships, sexual functioning, interests/hobbies and overall quality of life. It is very common for people to have repeat hospital appointments with different departments, have to undergo multiple scans/investigations/medication etc. which usually leads to inclusive diagnosis and/or treatment. Often they have to battle with stigma from family, friends, wider society and even within the medical professions. They are often accused of making it up, exaggerating their symptoms or malingering. Not surprisingly given all of this, mood problems in people with CP are common (Gatchel et al., 2007).

Medical systems perpetuate this process with the notion of a catch-all diagnosis and binary, either/or dichotomous evaluations. A careful balance has to be struck with patients between gently pointing out the importance of psychological factors, without reinforcing earlier messages that they are making it up or it is all “in the mind”. This can be a liberating message for patients that can help people finally move on with their life. Isn’t it time for our medical systems to do the same thing?

Posted by: Dr Simon Clarke Clinical Research Psychologist (Physical Health Speciality) University Of Nottingham and Nottinghamshire Healthcare NHS Trust

References: Gatchel et al. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133, 581-624.

Merskey, H. (1986). International association for the study of pain: Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain, 3(Suppl.), 1–226.

Searle, John. (1984). Minds, Brains and Science: The 1984 Reith Lectures. Harvard University Press.

Wiech, Katja, and Irene Tracey. (2009). “The Influence of Negative Emotions on Pain: Behavioral Effects and Neural Mechanisms.” NeuroImage 47, no. 3,  987–994.

 

Deborah Kitson, CEO, Ann Craft Trust, University of Nottingham Link to UoN press release: http://www.nottingham.ac.uk/news/pressreleases/2012/august/will-we-learn-from-the-winterbourne-view-findings.aspx A leading national charity committed to safeguarding disabled children and vulnerable adults from abuse says it hoped that lessons can be learned from the cases of abuse uncovered at Winterbourne View.

Responding to the serious case review, commissioned by South Gloucestershire’s Safeguarding Adults Board and published today, the Ann Craft Trust says although the findings are ‘sadly predictable’ it hopes it will result in safer services for vulnerable adults living in residential services across the country.

Deborah Kitson, Chief Executive of the Ann Craft Trust which is based at The University of Nottingham, said: “Poor management, lack of training, service users and staff not being listened to — these are all common themes that we have got too used to hearing about.

“Put these issues alongside staff who have little respect for the people they are supporting and who achieve some misguided sense of satisfaction and enjoyment from taunting vulnerable adults and you will always have the potential for very serious abuse.

“A member of staff raised the issue at Winterbourne a number of times both within the organisation and to the Care Quality Commission but still nothing happened resulting in the abuse continuing over a long time. Did anybody encourage the people who were living there to complain and to voice their concerns? And most crucially would anybody have listened if they had? Vulnerable adults, those with mental health needs and learning disabilities often rely on those supporting them to raise concerns on their behalf. We have to make sure that when they do their concerns are acted upon promptly and that the abuse is stopped.”

The Ann Craft Trust has completed research looking at whistleblowing in learning disability services and found that the experience for many had been traumatic. Many were not believed, were blamed for criticising services and were labelled as troublemakers — most worryingly many said that they would not do it again.

Deborah Kitson added: “This serious case review may be sadly predictable but it needs to be read and lessons need to be learned. It is not rocket science — this is about ensuring that we value and respect people, that we listen to concerns when they are raised and that we have processes in place that ensure that appropriate action is taken to stop abuse when it does occur.”

The Ann Craft Trust works with staff in the statutory, independent and voluntary sectors to protect people with learning disabilities who may be at risk from abuse. It also provides training regarding sex education for people with learning disabilities. www.anncrafttrust.org    

The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we're up against, originally posted on 17 June 2012 entitled 'Has CBT killed the human spirit?'.
Much as psychoanalysis set the cultural tone for our understanding and conduct of relationships for most of the twentieth century, cognitive behavioural therapy (CBT) has been leading us into a much less forgiving place for the last twenty years or so.

[caption id="attachment_404" align="aligncenter" width="300"] CBT Circle


In the world of psychotherapy, CBT has numerous siblings and cousins: most with three letter abbreviations to make a multiflavoured soup of ‘alphabetti spaghetti therapies’. Two flavours of the month are Dialectical Behaviour Therapy (DBT)  and Menatlisation Based Therapy (MBT). DBT, with its trendy 'mindfulness' plus new age and hippy edge, give its authoritarianism a warm fuzzy feeling; mentalisation has considerable weight of respectability afforded to it by years of attachment research in the experimental psychology departments of prominent universities – and charismatic professors with superstar status to market it. There are many other manualised and packaged 'new therapies', easily findable with your favourite search engine. But my overwhelming feeling is that they are all missing the point, and engaged in a pointless horse race with celebrity status prizes for the academics who reduce the interventions to dumbed-down therapy cookbooks, and then make sure everybody is following the recipes with multivariate statistical analyses backed up by powerful regulators like NICE. To me, this all seems like a very elaborate, somewhat sinister and ruthlessly inexorable way of taking the essential human qualities of the therapeutic relationship out of the picture.

[caption id="attachment_405" align="aligncenter" width="300"] Mandala

Well what a week. There has been progress with the MHRN Industry Group of service users and carers. This group has met twice now and are preparing to meet again in a few weeks.  The MHRN are pushing for more recruitment to these types of studies and although it is very complicated, we were privileged to have a good few people attend our first couple of meetings and give positive comments on being involved. The next meeting is the subsequent step where we discuss as a group the way forward and look at where we can get involved in the different studies. Personally I find it quite a difficult subject to understand but I am sure I will get there. (Perseverance is the key.) How can we as a small cog in such a massive, global enterprise make our way into what seems a very closed shop when often, so I have been informed that the large organisations that develop these studies have never ever involved the public and users of the medication that they produce. More positive things have happened within the MHRN - we seem to be ironing out difficulties which moving into the new building have bought about.

Another positive for me this week has been on a personal basis really and a big boost to my self-esteem. I have been asked by various members of IMH staff about patient involvement and have been glad to help. Thank you to those who have asked and if I can be of any help to others please let me know. My experience within the Trust has been over a good few years and I have met a quite a lot of individuals from doing this. My mum always asks me if there is anyone I don’t know. It’s not unusual for me to go out without seeing anyone from work or the classical music scene.  Keep fingers crossed for me, I am seeing a new singing teacher today based at the Uni.

Patient and Public Involvement for the MHRN took a great boost on Friday 27^th July as I went to the Rosewood involvement centre up in Ollerton to talk to their Friday Group about the MHRN and can I say, I came home feeling like I was walking on air.  The Friday group is a well attended group of service users and carers who get together for support and encouragement to each other and to hear about different things going on in the Trust and outside. The Rosewood centre is the sister Involvement centre to the one at Duncan Macmillan house and is a very thriving place to go. They even have their own belly dancing troop. There was so much enthusiasm from the entire group to listen, ask questions and equally wanting to become involved it was just astounding. Can I post a great big thank you to them all. I have so many contacts to make and friendships to develop, it was extraordinary.  The MHRN as an organisation is obliged to involve service users and my job is to co-ordinate the involvement and recruitment to different research studies. The boost from attending the Rosewood centre was that we could form a group in the North Nottinghamshire area and help researchers who can sometimes be Nottingham centric develop studies in the north of the county. I am sure the group would be very useful. The wealth of experience is an added bonus to anyone in the field of research.

I was one of the first service users to be employed by the Trust way back in 1999 (I think it was then). And have seen a tremendous development in this area. I cannot thank all my friends and colleagues enough for their hard work in developing Involvement. It started off with one young man called Liam O’Neil who sadly is no longer with us but his name is kept alive with one of the Trusts OSCARS bearing his name, and has developed into quite a large staff team.  Liam was a service user who I met when I was a volunteer at the Nottingham Advocacy group; he was quite a cautious man but was very vocal and knowledgeable around involvement of service users in any aspect of their care and the organisation of the Trust. Liam worked on his own to begin with to set up the involvement department in the Trust until a manager was appointed then things seem to go all out to what we have today, two Involvement centres.

Posted by:
Debbie Butler
Patient and Public Involvement Coordinator
NHIR Mental Health Research Network
Mental Health Research Network
East Midlands Hub

Suicide is a complex issue that touches many lives, and is the concern of a range of social and health-care professionals. It is also an important public health problem, being the “tenth leading cause of death worldwide” (Windfuhr & Kapur 2011: 28). While suicide is strongly related to poor mental health; it is widely understood that suicide often occurs in the absence of a psychiatric diagnosis. Although psychiatry and related mental health professionals have an important role to play in suicide prevention, the complexity of suicide necessitates the involvement of multi-disciplinary researchers and practitioners.

Published last year, Understanding Suicide: A Sociological Autopsy (Fincham, Langer, Scourfield & Shiner 2011) presents research from a broadly sociological (though incorporating other social scientific approaches) investigation of 100 suicide case files from a coroner’s office. The study incorporated both qualitative and quantitative analysis of the files, in an adaption of the more well established psychological autopsy approach to studying suicide. The research findings illuminate important, but often overlooked, social factors relating to suicide:

1. That the group of people most at risk of suicide are men in mid-life.
Fincham et al combine a quantitative analysis of the 100 case files they studied, with official statistics on suicide rates. Through this, they highlight that suicide rates for men peak between the ages of 35 and 45, with suicide being a relatively rare occurrence among young men. However, many suicide prevention programmes have focused on reducing suicide among young men. This reflects an increase in the suicide rate among young men; but obscures the fact that the men in mid-life complete suicide in greater numbers. Fincham et al’s analysis examines the ways that age and stage of life might be implicated in suicides. In particular, they highlight the varying strength and importance of social relationships and social bonds in youth, mid-life and old-age.

2. The importance social relationships in understanding suicide.
A commonly held understanding of suicide is that it is related to social isolation – leading from Emile Durkheim’s pioneering work on the sociology of suicide, which argued that social isolation increased the chances of suicide. However, Fincham et al argue that social relationships – or more accurately, unravelling social relationships - might be a more appropriate way of explaining suicide. Their research found that the deceased in the case files had often recently experienced a break-up in a relationship or had lost contact with their children. This approach to understanding suicide provides one way of explaining the connection between suicide and unemployment, with work being an important source of social relationships – particularly for men, particularly men in mid-life. A related finding was that suicide can be seen as a way of trying to work on social relationships. Analysis of the suicide notes included in just under half of the case files studied suggested that the notes were often used to attempt to heal, create, or sever social ties. Fincham et al suggest that “[r]ather than seeing death as the end … suicide notes can be a means to continue or even to initiate relationships through which agency can be exerted” (p. 89)

3. The role of gender in understanding suicide.
In an earlier paper, Jonathan Scourfield (2005) highlighted the importance of gender in seeking to better understand suicide. Scourfield’s approach emphasised the problematic way in which much previous research on suicide had addressed gender: that is in a rather straightforward way, looking at ‘males’ and ‘females’ as two separate, largely similar groups. In Understanding Suicide, a more nuanced gendered analysis is presented. This takes account of the importance of differences within men and women, rather than focusing on the differences between men and women. Thus, in Understanding Suicide, greater attention is paid to the complex interactions between gender, life stage, and employment, family-life, and intimate relationships.

Each of the above points serves to improve our understandings of why people die by suicide. By examining the role of life-stage, social relationships and gender on individual suicides, Fincham et al propose novel ways of explaining why certain groups of people are more vulnerable to suicide. Additionally, their approach further confirms the usefulness of qualitative approaches to researching suicide. Perhaps most importantly, Understanding Suicide demonstrates the need for wide-ranging approaches to suicide prevention, which incorporate social interventions alongside medical and psychological treatment (p. 185).

This blog draws on an earlier review, published in Network, the magazine of the British Sociological Association (Chandler, 2012).

Posted by:
Dr Amy Chandler
Research Fellow
Centre for Research on Families and Relationships University of Edinburgh

Chandler, A. (2012), 'Understanding Suicide: A Sociological Autopsy, by Ben Fincham, Susanne Langer, Jonathan Scourfield and Michael Shiner, Book Review', Network, 111, 37.

Fincham, B., Langer, S., Scourfield, J. and Shiner, M. (2011), Understanding Suicide: A Sociological Autopsy, London, Palgrave Macmillan.

Scourfield, J. (2005), 'Suicidal Masculinities', Sociological Research Online, 10, 2.

Windfuhr, K. and Kapur, N. (2011), 'International Perspectives on the Epidemiology and Aetiology of Suicide and Self-Harm', in O'Connor, R.C., Platt, S. and Gordon, J. (eds.), International Handbook of Suicide Prevention: Research, Policy and Practice, Chichester, Wiley-Blackwell.

 

An update on the IMH's sculpture from Victoria Tischler the Institute’s arts co-ordinator :

We've now commissioned Ekkehard Altenburger to create a sculpture for the building. See an image of his initial design and concept here http://www.institutemh.org.uk/-about-us-/art-at-the-institute and examples of his work here http://www.altenburger.co.uk/. 

Ekkehard will be sourcing marble in the North of Italy next week and he will be working there over the summer to create the piece which will weigh over 6 tonnes when completed. It will be transported directly to the IMH via road and sea in late October ready for its unveiling in November. He will hold a number of sculpting workshops with service users in the Autumn, using pieces of marble cut from the block he creates the main sculpture from.

Ekkehard visited the site recently and he and I were joined by Richard Wigginton (University Estates) and Tim Harris (project manager) to discuss logistics. Part of this meeting involved half an hour standing in the rain getting very soggy feet whilst deliberating exactly where the sculpture will be sited, X marks the spot! The Estates office will soon begin to prepare the site by pouring the concrete foundation which will be allowed time to 'settle' before the giant marble piece comes to stay - all the way from Italy to Nottingham.

Do mental disorders excuse people from responsibility when they harm others? It’s easy to feel trapped between two extremes. Either people with mental disorders aren’t responsible because they lack control, in which case we need to help them, not blame them. Or they are responsible because they do have control, in which case we should blame them, not help them. I think we need to escape this trap and that philosophical reflection on real clinical practice with patients with personality disorder can help us do so.

I began life as an analytic philosopher at the University of Oxford but for the last five years I’ve worked at the Oxfordshire Complex Needs Service, a Therapeutic Community (TC) for people with personality disorder. When I first started working clinically, I was struck by the stance adopted towards TC members who hurt others. I call this stance, ‘Responsibility without Blame’. Both in theory and in practice, this stance requires separating our concepts of responsibility and blame much more sharply than as a society we typically do.

As a philosopher, my research aims to do just this. My view is that responsibility is fundamentally about a person’s own capacity for agency. To be responsible is to have control over your behaviour, in which case you can be held accountable, as well as supported to do things differently.  Blame, in contrast, is about how we respond when a person is responsible for harm. We blame someone when, in addition to asking someone to answer for their behaviour and to change, we also do things like retaliate and reject them, judge them or write them off, and feel all sorts of hostile emotions, like hate, anger, disgust, scorn, and contempt. Blame gets in the way of people’s motivation to change. Responsibility and accountability, in contrast, are central to it.

As a society, we should learn from clinical practice. Control comes in degrees, and no doubt all of us, not just people with mental disorders, sometimes don’t have enough control to be responsible for what we do. But when someone is responsible, we can’t help them if we deny their agency. For people can only work to change what they can control. We need to be real about when people have control and so are responsible and accountable for harm. But we can do this with concern and compassion, not with blame. 

I’m currently trying to take the clinical stance of Responsibility without Blame into the criminal law. One of my projects is the development of a Responsibility without Blame training for prison officers, in conjunction with the KUF programme at the Institute of Mental Health, as part of a joint Department of Health and Ministry of Justice initiative to increase awareness of personality disorder and create a more psychologically informed environment within prisons. If you want to read more about this and other aspects of my research, you can access information and articles on my webpage http://www.philosophy.ox.ac.uk/members/research_staff/hanna_pickard as well as listening to the podcast above.

To hear a Philosophy Bites [http://www.philosophybites.com/] podcast with Hanna on this topic, click here [http://llnw.libsyn.com/p/9/1/1/9117f1dac5d99c98/Hanna_Pickard_on_Responsibility_and_Personality_Disorder.mp3?s=1342277553&e=1342279353&c_id=4681789&h=4fda6a9e4646a75c85d044dfaa967ddd].

All comments very welcome!

Dr Pritpal S. Tamber ~ Evidence and the real world

Re-posted from: http://www.optimisingclinicalknowledge.com/evidence-and-the-real-world/ There is a lot of angst around why research evidence takes so long to penetrate routine clinical practice. My view is that it’s a miracle that any of it makes it into practice at all because research-derived information is very much the square peg to clinical practice’s round hole.

The gold standard of experimental clinical research is the randomised, controlled trial (RCT), a study design created to make the research environment look nothing like the real world of the non-compliant, socially-complicated and co-morbid. You likely know all this otherwise you wouldn’t be reading a blog (first) posted on bmj.com but in my experience few do. My favourite example of this blissful ignorance was in a meeting with someone from the Department of Health of England who insisted that the company I was representing had to do what they asked “because it was based on a randomised trial”. That was the full extent of her rationale. I couldn’t help thinking about where my taxes were going.

The limitations of trials are brilliantly laid out in a 2009 article by Shaun Treweek and Merrick Zwarenstein entitled, Making trials matter. They discuss the tension between ensuring the trial is methodologically robust (internally valid) and of value in the real world (applicability). “An internally valid trial,” they believe, “that has poor applicability… is a lost opportunity to influence clinical practice and healthcare delivery”.

Despite all this, being able to cite published research has a significant influence on clinicians. A friend of mine performs market research for pharmaceutical companies. He’s stood on the anonymous side of a double-sided mirror and watched doctors leaf through marketing material. He says that without fail the presence of a citation to an RCT gets their attention and approval, and is the most likely thing to influence their behaviour.

There’s something crazy about a world in which we know research-derived information bears little resemblance to the real world and yet we continue to generate and cite it to influence behaviour.

There are some big hitters out there trying to get people to see the world as it is, including none other than the Chair of NICE, Michael Rawlins. In his Harveian Oration of 2008 he said: “Randomised controlled trials, long regarded as the ‘gold standard’ of evidence, have been put on an undeserved pedestal… Observational studies are also useful and, with care in the interpretation of the results, can provide an important source of evidence”. I understand he reiterated that point in a lecture to the Office of Health Economics.

The pharmaceutical industry has tried to show leadership in this arena by generating information more closely associated with real-life practice. They call it real world data. Although they still have to generate the usual kind of evidence to illustrate efficacy and safety they’ve recognised that real world data “increasingly plays an important role in ensuring that medicines are accepted by national policy makers and are adopted into practice”.

We often need small children (or Hans Christian Anderson) to point out what’s crazy in this world but luckily for the egos in healthcare we have Richard Bohmer. In his succinct Perspective in the New England Journal of Medicine he describes the four habits of high-value healthcare organisations. The third and fourth are measurement and self-study. In essence, they collect and analyse real world data – round pegs for round holes.

I was lucky enough to hear Bohmer give a presentation and when asked what one thing all organisations need to start doing tomorrow to improve care he said they should start collecting local performance data that local clinicians could identify with and believe in. His view was that research evidence, although important, emerges too slowly and is too abstract to keep up with the demands of real-life practice. Rather than evidence-based medicine, he said, we need to embrace evidence-capturing medicine.

I’m with Treweek, Zwarenstein, Rawlins and Bohmer; how about you?

Competing interests: I helped launch the journal in which Shaun Treweek and Merrick Zwarenstein’s article was published, although I had nothing to do with its peer review, acceptance and publication.

This blog has been co-posted on bmj.com/blogs.

Dr Pritpal S. Tamber ~ Doctors only trust doctors

Re-posted from: http://www.optimisingclinicalknowledge.com/doctors-only-trust-doctors/#more-175 I’m petrified.

I’ve been invited to participate in the Institute of Medicine‘s Roundtable on value- and science-driven health care. The focus of the all-day meeting is “continuous learning and the digital infrastructure for informed clinical decisions“, and the bit that I’m expected to speak about are the “functional needs for digital information at the point of care”.

What’s scaring me is that I want to tell them that “functional” needs are not what health leaders should be focussing on. I want to tell them that what really matters is getting doctors to trust information, and, although how the information functions is part of it, it’s only a small part of it.

In my experience, doctors only trust doctors when it comes to clinical matters. That’s the first and most important rule. It’s so important, in fact, that I am going to ask you to read it again: doctors only trust doctors.

I’ve met many non-doctors that hate that rule. They hate it so much they pretend it’s not there. I’ve watched health managers, IT experts and policy-makers all fool themselves into thinking they can influence what doctors do. They rarely – if ever – can.

Anyway, based on that rule, there are a bunch of sub-rules.

When I was a medical house officer it was clear that the gastroenterology registrar trusted other physicians before he trusted surgeons. This made all the sense in the world when you consider how many patients with “negative laparotomies” he was asked to see. When I was a surgical house officer, the nephrologists trusted the vascular surgeons because they worked closely to create anastomoses in patients in need of dialysis. They probably also trusted the transplant surgeons for much the same reason.

So the first sub-rule is that different specialists have different levels of trust for other specialists.

There are now about 180 guidance producers in the world. In my experience, Americans like to think that non-Americans want to practice like them but they’re wrong – although not always. For instance, in England I’ve come across respiratory physicians who will only follow guidance produced by the British Thoracic Society, as opposed to guidance from the American Thoracic Society; meanwhile cardiologists have tended to be more welcoming of guidance produced by the American Heart Association.

So the second sub-rule is that you have to understand what sources of information different specialists trust.

I’ve been involved in trying to convert content created for English clinical practice to Danish clinical practice. The English content was based on the regional biases of English doctors. I spent three days in Copenhagen meeting with a variety of doctors to understand their preferences and was quite surprised by how different they were to those of doctors in England. For instance, some American guidance producers were barely recognised by the Danes, while they put great stock in European guidance producers that were never mentioned by doctors in England.

So the third sub-rule is that clinicians in different countries display different levels of trust for the same sources of information.

One thing I did not test when I was in Copenhagen is whether the same specialty biases exist in Denmark as they do in England. I hypothesise that they do, but my experience has told me time again not to presume. For instance, a friend of mine is a “physical medicine” doctor in Belgrade. From what I understand she is a cross between a senior physiotherapist and a sports medicine physician but, unless the specialty has been introduced in the last few years, I don’t believe we have such specialists in England. The existence of this “new” specialty likely influences the complex dynamic of trust between specialties.

Doctors – like all people – are also more trusting of people facing the same issues as them. For instance, general practitioners in tough, urban environments more keenly seek out the views of other general practitioners working in the same kind of environment. There is an instinctive logic to this.

So the fourth sub-rule is that doctors trust other doctors dealing with similar issues.

All of these sub-rules matter because knowledge nerds like me have learnt that creating standard forms of information rarely influences doctors’ behaviour. You have to tailor the information to the biases of the specialist. The point is made rather spectacularly by England’s National Institute of Health and Clinical Excellence (NICE); despite creating globally-revered, high-quality guidance, very little of it penetrates clinical practice. The problem is so glaring that the recent government strategy for health innovation seemed more about getting NICE guidance actually used than catalysing and distributing great new ideas.

Information needs to be endorsed by doctors – or clinical bodies – that doctors trust. Achieving this requires understanding the complex interplay of the sub-rules above. It’s only if you get this right does it matter how the information “functions” at the point of care. Indeed, if you get the trust right, the function needn’t be perfect; but well-functioning content that’s not trusted is a waste of everyone’s time and energy.

I’m going to tell the IOM all this. What are the odds they’ll ever invite me back?

This blog was first posted on bmj.com. This blog has been co-posted on bmj.com/blogs.