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 Research
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/
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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