Co-production in Coercive Environments Seminar Summary by Harminder Kaur

Co-production in Coercive Environments Seminar

The seminar ‘Co-production in Coercive Environments’, which took place on 6th July 2017 at the University of Huddersfield, was the sixth seminar of seven in the ERSC Seminar Series ‘Re-imagining Professionalism in Mental Health: Towards Co-production’. About 35 delegates attended, these being  a mixture of researchers, academics, professionals, carers, and service users. Appropriately, the seminar took place in co-production week which was organised by The Social Care Institute of Excellence (SCIE) to celebrate the benefits of co-production and share good practice.

 

The seminar day consisted of an introduction by Dr Christine Rhodes of the University of Huddersfield and Dr Pamela Fisher of Leeds Beckett University. There was then a keynote talk by Professor David Pilgrim, followed by a talk from social worker and PhD student Charlotte Scott. After lunch the room was divided into smaller groups for an activity co-produced by service users, carers, staff from the University of Huddersfield, and external partners. Information and videos of the talks will be available on the web at https://coproductionblog.wordpress.com/

 

The appropriate definition of co-production was a topic of discussion and debate at the seminar. Roughly speaking, however, the term ‘co-production’ refers to service users and professionals working in a genuinely collaborative way in relation to some project, which might be provision of services, research, public involvement and campaigning, or any other matter of shared interest or concern.

 

Introduction

 

Christine Rhodes and Pamela Fisher opened the seminar and stated that the ultimate aim when working with ‘involuntary’ service users is co-production, if this is at all possible. They pointed out that there is no single agreed definition of ‘co-production’ and indicated the risk that the term might be misused.

 

Pamela Fisher gave an introduction to the topic. She made an interesting connection between postcolonial theory and co-production arguing that there needs to be a ‘decolonisation’ of knowledge. She argued that service user perspectives are often not taken seriously as legitimate forms of knowledge.

 

She proposed that co-production is about authentic power-sharing and requires a fundamental democratising of relationships; it is connected to wider questions of citizenship and is associated with significant challenges. She ended by emphasising that it is important not only that service users should be heard, but also that their voices should carry the power to effect real changes.

 

Professor David Pilgrim, ‘Co-production of Mental Health Services: The Art of the Impossible?’

 

David Pilgrim argued persuasively that true co-production in involuntary settings is impossible. He made his case in a clear, step by step fashion. Although involuntary services could be ‘humanised’ or ‘softened’, it was his contention that this would not be ‘co-production’.

 

He drew attention to something that many people in secure services are affected by, but rarely speak about, namely the ‘peculiarities’ of mental health services and mental health law. Looked at afresh, he argued, it is extraordinary that people are detained, often against their will, for periods of up to six months, without trial. In any other context, he said, the State would be accused of false imprisonment and possibly assault. He also contended that the act of detaining a service user under the Mental Health Act (MHA) is less about protecting or enhancing mental health, and more about removing people exhibiting deviant or transgressive behaviour from society. He said that this may or may not be a bad thing, but called for more honesty about what was being done, to whom, and for what reason.

 

He set out four characteristics that in combination define co-production:

 

  • The citizenship of non-professionals is respected and enhanced.
  • Citizens and professionals are mutually dependent.
  • Both parties are agreed to be rational moral agents.
  • Citizens and professionals have a common agenda.

 

He proceeded to argue that none of these four necessary features of co-production could be achieved under the conditions of enforced psychiatric treatment. This is because:

 

  • Enforced psychiatric detention and treatment diminish citizenship rather than enhancing it.
  • Mental health professionals and service users are not mutually dependent. Service users in detention are heavily dependent on professionals, but professionals are only dependent on service users in the sense that they need jobs and salaries, and not in any wider sense.
  • Service users who have been detained under the MHA are presumed not to possess rationality and moral agency.
  • Professionals and mental health service users do not have a shared agenda in involuntary settings. The interests of the patients are sacrificed in the interests of those who are not patients.

 

David Pilgrim pointed out the interesting fact that whereas poor people under-utilise healthcare in general, this is not the case in involuntary mental healthcare where poor people are over-represented. He also touched on the inequalities present in mental health services in regard to race. He argued that mental health law should be abolished and a form of ‘dangerousness act’ should replace it.

 

While David Pilgrim’s position was clearly stated and well argued, I disagree with his perspective on the MHA. As a service user who has been detained under the MHA a number of times, my view is that when employed well, the MHA protects vulnerable people from danger and risk of exploitation. While I agree that MHA legislation is distinctive and ‘peculiar’, I would put forward the argument that mental distress, specifically psychosis, is itself both distinctive and ‘peculiar’, and that the legislation cannot be properly assessed without acknowledging this. I did not get much of a sense of what a ‘dangerousness act’ would entail, but I would be very worried about any dismantling of the Mental Health Act. Home treatment sounds benign, but in reality it is about a lack of funding and it can put an unbearable strain on service users and carers.

 

During the discussion that followed David Pilgrim’s paper, a carer made the important point that she found the talk pessimistic and passionately argued for hope for change in services. This led to a discussion about whether co-production is a product or a process. Pamela Fisher wondered whether it was something you could work towards, a journey rather than simply a destination.

 

Charlotte Scott, ‘Power Sharing within Coercive Environments’

 

Charlotte Scott is a social worker with a background in community Mental Health. She is also an Approved Mental Health Practioner (AMHP). She is in the final stages of a PhD looking at how AMHPs make decisions during MHA assessments, drawing on service users’ views of these assessments.

 

Like David Pilgrim, Charlotte Scott drew attention to the extraordinary and unique situation whereby the MHA could deprive someone of their liberty. She argued that detention under the MHA produces a highly coercive environment and that co-production in this setting is not achievable.

 

Charlotte provided a very helpful overview of a MHA assessment. While for service users this might begin with a knock at the door, for AMHPs there would have been prior behind the scenes discussion. She referred to something known as the ‘dominant narrative’. I took this to be the predominating professionally-produced account of the service user’s episode which can help build up and shape a sense of what is going on for the service user, but which can also get in the way of listening to what the service user is actually saying.

 

Charlotte explained that she is interested in looking at how AMHPs could empower service users, promote rights, and work in the least restrictive way, specifically during a MHA assessment. In particular she is interested in how service users’ voices can be heard. Indeed, she pointed out that the guiding principles of the Mental Health Act code of practice set out that,

 

“Patients should be fully involved in decisions about care, support and treatment. The views of families, carers and others where appropriate should be fully considered when taking decisions. Where decisions are taken that are contradictory to views expressed, professionals should explain the reasons for this.”

 

Charlotte Scott stated that these guiding principles are all very well, but she said that what matters is how they are translated into practice. In her sample (which she acknowledged may be biased because practitioners willing to be observed may be more likely to be less coercive, and to adhere more closely to the guiding principles) she found that there was a will to find the least restrictive option. She suggested that there was a “stillness to listen” and a desire to advocate for the individual person being assessed; but she noted that there was also a sense that by the point of referral for a MHA assessment other options had usually already been explored.

 

Although co-production in a MHA assessment was felt to be impossible, Charlotte Scott did point out some things that could help mitigate the effects of the power imbalance. These include creating an environment that is more conducive to involving the person being assessed, ensuring that the individual being assessed has time to pack, time to phone people they need to, and has money in their pocket, and also a consideration of the impact of the means of transport, for example being aware of the stigma of having an ambulance or police car on a quiet cul de sac. In addition she stressed the relevance of advance directives. These might set out what the individual would prefer to be called, what language they would like used to describe what’s going on, and jointly agreed circumstances in which intervention would be necessary.

 

Charlotte Scott’s talk was followed by discussion. Questions arose around how she had got ethical approval to observe MHA assessments. She explained that she had worked with a service user group from the outset to shape the study and was guided by them. Another point that arose was made by a carer who was surprised to see the guiding principles of the MHA assessment, as she had never been consulted during the MHA assessment of her sons.

 

‘Team Huddersfield’

 

The small group discussion which then took place, ‘Team Hudd’, was co-produced by service users, carers, and staff from the University of Huddersfield and external partners. At the table where I was sitting there were approximately six delegates, a facilitator and a Trust service user who also had experience of being a carer. The facilitator asked the service user questions which related to the power imbalance he had experienced in mental health services and his experience of coercion. The service user spoke about being a service user, and also being a carer to his mother who had experienced mental health problems. His mother had been given Risperidone for long periods of time without review and this had had a bad effect on her. The group discussed this situation. Each table then fed back key points to the group as a whole.

 

Finally, there was a discussion initiated by a delegate called Jacqui Dyer focussing on the Conservative Party’s plan to re-write the Mental Health Act. Some discussion took place, and it was suggested that Jacqui should set out her initial thoughts and the opinions of people in the room in a blog.

 

The seminar day was fascinating and by the end there was a real buzz of energy and excitement in the room. The talks were high quality and the general feeling was that although co-production is not possible in coercive environments, this need not stop stakeholders from aspiring and working towards it and making significant changes.

 

Harminder Kaur

 

 

Seminar 4: Contemporary Developments in Mental Health Policy and Commissioning Seminar Notes

Reimagining professionalism in mental health: towards co-production

Seminar 4: Contemporary Developments in Mental Health Policy and Commissioning: a help and/or hindrance to power-sharing

Hosted by the International Centre for Mental Health Social Researchesrc-big-logo

University of York, Friday 28 October

Many thanks to all the people who participated at seminar 4. Very lively and productive debates!

Below we have provided some written notes on the presentations, discussions and your concluding thoughts from seminar four.

The powerpoint presentations will be available on the blog shortly, and the ‘talking head’ videos and short videos of excerpts of presentations will be made available on the blog in due course, as will Adam’s poem. Please be reassured that if you have been filmed as a presenter or ‘talking head’, you will be able to see the video and decide whether or not you wish it to be made available on the blog.

Seminar 5 Reconciling regulatory knowledge with co-production will be on 3 March 2017 at the same venue (Research Centre for the Social Sciences, University of York).

 ESRC Co-production https://coproductionblog.wordpress.com/

Follow on twitter@ https://twitter.com/ESRCcopro

Best regards,

Martin & Pamela

 Anne Rogers: Commissioning of self-management support

There are social and economic drivers of meeting mental health needs – education, employment, housing and criminal justice services have to respond to the well-established impact of not being in work due to mental health problems. How does commissioning and mental health policy respond to this? There is a recognition that improvements are required, but there are many priorities for investment. Some commissioners have taken a more integrated, social approach such as in Nottingham which includes advocacy, open door project and other socially-oriented services. However, the hidden impact of bureaucracy prioritisation of risk management remains the ‘elephant in the room’.

There is a tension between local aspirations and those identified by NHS England for empowering people. There is a need to focus more on early strategic planning of lay involvement to provide an avenue for genuine engagement of individuals and communities in a meaningful way. A capability approach is required which focuses on what an individual values and can achieve.

Commissioning needs to be re-oriented towards understanding and enhancing the power of social networks. There is good evidence that behaviours within networks as a collective phenomena reinforce ‘unhealthy’ behaviours, but can be used positively for behavioural change. Self-management of our health and mental health involves weak ties within our networks (connections to people within communities such as shop keepers, taxi drivers, postman/woman). The power of these weak ties is under-estimated. In addition, there is evidence that participation in community organisations is associated with better physical and mental health, particularly among people on low incomes who are more physically active.

There has been a rise in non-medical aspects in NHS commissioning in mental health. For example, pets are valued for companionship and social engagement, but they are not routinely included on mental health care plans. There is good evidence that they support people’s well-being, but there are few opportunities for personal commissioning of pets.

Mapping social networks provides a positive disruption to what people focus on in their daily lives. Externalising away from the self is very valued. When people see their network they can see how they can mobilise it, or identify gaps to enhance their connectivity. Genie is a method of visualising networks and connecting people with local resources. It requires some resources locally to keep it up to date and live, but is a useful tool for people to use to enhance connectivity within local areas.

Karen Newbigging: Co-production in commissioning: Are we there yet?

The commissioning cycle is a process which involves assessing needs and assets; planning, which involves engaging with all sectors of the local population; securing provision of services through contracting and monitoring the services through measurement of outcomes. In reality, it is often more messy than this. What is crucial, though, is involving local communities in the process to ensure local needs are met.

Involved in commissioning for mental health, there are 209 Clinical Commissioning Groups, 152 Local Authorities, individuals with health and social care personal budgets and NHS England who commissioned specialised services. Commissioning is diverse, but social movements, activism and collective advocacy are important in the commissioning process.

Co-production in commissioning is an equal partnership throughout the commissioning cycle. It is a form of deliberative democracy and should be values-driven. It requires a move to asset-based approaches and a shift to a social model, which values the importance of social context, individual values and preferences. Decision-making should be transparent and accountable.

In practice, this requires:

  • Getting the foundations in place with proper resourcing and support
  • Framing the questions differently
  • Defining outcomes to commission against (‘I statements’)
  • Using a range of methods to co-design and co-assess services
  • Working with voluntary and community groups to engage seldom-heard groups
  • Confronting the ‘D’ (decommissioning) question

Where are local commissioners on the co-production journey? Looking at Arnstein’s ladder of participation, the impressions in the room are that commissioners are generally not. However, Lambeth Collaborative; UK’s first Mental Health Parliament in Sandwell; Making a Difference (MAD) Alliance in North West London; and Newcastle social prescribing scheme were cited as good examples.

Commissioners view commissioning as a rational process and emphasise getting the right structure and processes. Providers see it as a ‘fine-tuning’ process to get their services right or as a way of exerting leverage on commissioners. Service users and the public see the process as being a wide spectrum of activities ranging from direct involvement in care to more strategic purposes.

What do commissioners need to do to support co-production? Some of Karen’s suggestions:

  • do it together – deliberate purpose and methods
  • attend to organisational culture and build capacity for co-production
  • invest in and support user groups / patient forums / voluntary sector to build capacity
  • tolerance of ambiguity and understand and use a plurality of methods and approaches to engage all sections of the population
  • deliberate the limits – are there any?
  • build co-production into contracts
  • share and learn from successes and challenges

Joseph Alderdice & Danielle Barnes: From the street to the strategy

Joe introduced the Leeds Mental Health Strategic Partnership which includes the NHS, local authority and voluntary sector. This includes 150 people with lived experience and many identities, such as networkers, activists, artists, poets, peer supporters and researchers. Lived experience is essential to co-produced commissioning. In reality, this means connecting as humans not just in the boardroom but beyond this. Meeting in community cafes or neutral spaces helps to see commissioners as fellow human beings.

Based on shared values, it is possible to define priorities and competencies, and design and deliver training. “Community development is about working with people to find solutions, support them and then get out of the way”.

What’s in it for people who engage in the commissioning process. Reciprocity is really important – people must get something out of it rather than just contributing to it. Peer support is an important component of this, but also is validation of their perspective. Co-producing system change is like turning around an old ship getting blown away in the wind. We need to harness individual energies, but support them through the process.

It is difficult to influence change across whole systems where some people are very distant from co-produced activities or do not draw upon lived experience.

How genuine is co-production? Are the ideas / plans already in the heads of commissioners? How does co-production influence this?

In conversation with Danielle Barnes, Joe discusses the (West Yorkshire Finding Independence) WY-FI project which involves people who have lived experience of mental health issues, substance use issues, offending or homelessness. This includes peer mentoring. Co-production is about finding the problems and developing the solutions together. WF-FI project is an example of meeting people where they are rather than expecting them to ‘come in’ and receive a service. Trust and reciprocity are key to this process.

Where do we go from here? What can we take away from today?
Take co-production beyond this forum It’s all in the language, we’re all people! The term service user perpetuates traditional (not co-productive) services
Need to move beyond principles and work out more detailed strategies for co-production. ‘The devil is in the detail’ A buzz and sense of excitement that should enable us to spread the word – maybe even into ‘hostile’ territory…
Develop master class on co-production for commissioners. Karen Newbigging may have resources available Think about the financial implications of participation in co-production, especially for people with mental distress
Build alliances across stakeholder groups  
Shift focus from ‘mental’ health to optimal health. Question mental/physical health divide  

Seminar 4: Co-Production in mental health policy & commissioning

Seminar 4 entitled Contemporary developments in mental health policy and commissioning: a help and/or hindrance to co-production and power-sharing will take place at the University of York on the 28 October 2016. 

REGISTER HERE

We warmly invite you to participate in the 4th seminar which focuses on co-production in mental health policy and commissioning. The aim is to encourage debate across boundaries between service users/survivors and carers, academics, and professionals from voluntary and public organisations.

To make enquiries or to apply for a travel bursary (available to service users, carers, and professionals in voluntary organisations), please email esrc-co@leeds.ac.uk

For more details on the seminar, please contact the principal investigator Pamela Fisher (pamela.l.fisher@leedsbeckett.ac.uk)

 

The programme

9.30 – Registration (with tea and coffee available)

10.00 – Opening with Martin Webber and Pamela Fisher

10.30 – Keynote by Anne Rogers, Professor of Health Systems and Implementation, University of Southampton ‘Commissioning of self-management support: an exploration of commissioner aspirations and processes in the context of moving towards co-produced and socially connected interventions’

11.15 – Discussion of arising themes (with tea and coffee available)

11.45 – Presentation by Karen Newbigging, Senior Lecturer in Health Policy and Management at the Health Services Management Centre, University of Birmingham. ‘Co-commissioning: Are we there yet?’

12.30 – LUNCH

1.30 – Joseph Alderdice and Danielle Barnes will present and lead around table discussion. Joseph (formerly of Involving People) is the Development and Engagement Lead for West Yorkshire Finding Independence (WY-FI). Danielle, originally part of a group of experts by experience, is one of WY-FI’s Engagement and Co-Production Workers. ‘From the street to the strategy: Co-producing system change in the real world’

3.00 – Tea and coffee and identification of the main points arising from presentations and discussions

3.30 – Adam Montgomery is a Dual Diagnosis Peer Support Development & Group Worker employed by Leeds Mind. However, it will be in his capacity as a spoken work artist and poet that Adam will close the seminar.

3.45 – Additional networking opportunity