Professionalism, Evidence and Power: Key Themes Influencing the Management of a Mental Health Programme in the National Health Service in England

This thesis critically examines a national programme in mental health which has been driven by the implementation of National Institute of Health and Clinical Excellence (NICE) guidance. Assumptions which underpin research method, drawn from the natural sciences, are critiqued in terms of their adequacy in accounting for human relating and expert therapeutic practice. The work of Dreyfus and Dreyfus (1986) is problematized in how they account for proficiency and expertise as intuition and the leap that they make from calculative to deliberative rationality. An alternative source of understanding, based on non-linear causality and complex responsive processes, is developed, building on the work of Stacey (2001, 2005, 2007). The ineffability of expert practice (or clinical judgement) is contrasted with competence based, rule governed practice, which necessarily underpins the early stages of learning. It is argued that because research practices undertaken in randomised controlled trials (RCTs) must be describable, measurable and focussed on predictable outcomes, then these cannot account for expert practice, therefore the assertion that the Improving Access to Psychological Therapies programme (IAPT) is wholly based on research based, evidence based therapies, cannot be substantiated. The work explores professionalism and specifically considers the role of psychiatrists, psychologists and psychological therapists in mental health and in increasing access to psychological therapies. The role of managers and managerialism are explored, specifically how the NHS has sought to manage 3 professional staff and multi-disciplinary teams in adopting corporate and new ways of working (NWW). This includes the importance of and difficulty in countering professional identity using competence based approaches. The performance management processes in the NHS are recognised as an equally relevant source of evidence (to that of NICE), despite there being a poor (traditional) evidence base for it (Stacey, 2010; Seddon, 2008). Power relating in human relationships is identified as immanent, using the context of a management group, and it is argued that Foucault’s concept of disciplinary power (1994) can account for what is considered to be knowledge and truth, drawing on specialist expertise based on science and research, with a forceful potential for rendering others silent as well as pervasively self-silencing, in processes of inclusion and exclusion (Elias, 1978). It is argued that these on-going processes of relating influence policy decisions at national and local levels and how these policies are implemented in practice. The inevitability of unpredictable outcomes is highlighted, despite strong centralised programme management along with the provision of an explicit blueprint for implementation

New ways of working in acute inpatient care: a case for change

This position paper focuses on the current tensions and challenges of aligning inpatient care with innovations in mental health services. It argues that a cultural shift is required within inpatient services. Obstacles to change including traditional perceptions of the role and responsibilities of the psychiatrist are discussed. The paper urges all staff working in acute care to reflect on the service that they provide, and to consider how the adoption of new ways of working might revolutionise the organisational culture. This cultural shift offers inpatient staff the opportunity to fully utilise their expertise. New ways of working may be perceived as a threat to existing roles and responsibilities or as an exciting opportunity for professional development with increased job satisfaction. Above all, the move to new ways of working, which is gathering pace throughout the UK, could offer service users1 a quality of care that meets their needs and expectations

New Ways of Working in Acute Care: A Case for Change

This position paper focuses on the current tensions and challenges of aligning inpatient care with innovations in mental health services. It argues that a cultural shift is required within inpatient services. Obstacles to change including traditional perceptions of the role and responsibilities of the psychiatrist are discussed. The paper urges all staff working in acute care to reflect on the service that they provide, and to consider how the adoption of new ways of working might revolutionise the organisational culture. This cultural shift offers inpatient staff the opportunity to fully utilise their expertise. New ways of working may be perceived as a threat to existing roles and responsibilities or as an exciting opportunity for professional development with increased job satisfaction. Above all, the move to new ways of working, which is gathering pace throughout the UK, could offer service users a quality of care that meets their needs and expectations

PET/CT targeted tissue sampling reveals virus specific dIgA can alter the distribution and localization of HIV after rectal exposure.

Human immunodeficiency virus (HIV) vaccines have not been successful in clinical trials. Dimeric IgA (dIgA) in the form of secretory IgA is the most abundant antibody class in mucosal tissues, making dIgA a prime candidate for potential HIV vaccines. We coupled Positron Emission Tomography (PET) imaging and fluorescent microscopy of 64Cu-labeled, photoactivatable-GFP HIV (PA-GFP-BaL) and fluorescently labeled dIgA to determine how dIgA antibodies influence virus interaction with mucosal barriers and viral penetration in colorectal tissue. Our results show that HIV virions rapidly disseminate throughout the colon two hours after exposure. The presence of dIgA resulted in an increase in virions and penetration depth in the transverse colon. Moreover, virions were found in the mesenteric lymph nodes two hours after viral exposure, and the presence of dIgA led to an increase in virions in mesenteric lymph nodes. Taken together, these technologies enable in vivo and in situ visualization of antibody-virus interactions and detailed investigations of early events in HIV infection