This position paper examines evidence from service-user originated mental health reforms including recovery, direct payments and service user participation to assess the challenges and possibilities for co-production in mainstream mental health services, including the NHS

Carr, S.

English

Middlesex University Research Repository

3/9/2017 Can Co­production Really Transform UK Mental Health Services? ­ Mad In Americahttps://www.madinamerica.com/2016/08/can­co­production­really­transform­uk­mental­health­services/ 1/3Can Co­production Really Transform UK Mental Health Services?If you can’t quite get a grip on co-production, you’re not alone. Much of the literature dating back as far as 1984 suggests that it’s somethingof a greased pig and that efforts to define it end up like a policy pig scramble. Is it democratic citizen involvement public services? Is itindividual, ‘responsibilised’ health and social care consumerism? Is it power shifting to communities through participatory governance? Someauthors have said that ‘neither on the level of interactions between organisations nor on the level of servicing users, has co-production a fixedmeaning’ and others have noted its ‘excessive elasticity.’ Perhaps it’s the ultimate post-modern policy concept. But can it work for mentalhealth?In 2000 the American law academic and social justice activist, Edgar Cahn, wrote a book called ‘No More Throwaway People: The Co-productionImperative’ in which he set out perhaps the clearest and most radical set of proposals for the ‘co-production’ of public services. Under the NewLabour government, his co-production theories became very influential for UK health and social care policy, including mental health.Cahn’s conceptualisation of ‘co-production’ seems to make a lot of sense to mental health service users and survivors, and often appears to beconsistent with many service user and survivor movement values. It’s about social justice, ‘the transformation of power and control’ and givingequal status to service user and survivor knowledge and expertise. It means shifting relationships between professionals and service users andtheir communities from ‘one of subordination and dependency to parity, mutuality and reciprocity.’ Cahn acknowledges that the process won’tbe easy and may involve ‘hellraising’ and disruption as an integral part of power realignment and change processes.User Participation on Anabolic Steroids?If this type of co-production is like service user participation on anabolic steroids, for mental health what’s not to like? Politicians and centralgovernment policy makers in the UK were certainly keen, (although possibly less keen on actually directly co-producing policy with service usersand their organisations). Influenced by Cahn, left-leaning think tanks such as the New Economics Foundation, Compass, and Nesta took up theco-production cause, redefined it and actively influenced New Labour health and social care policy.The term began to proliferate in UK national social care and mental health ‘transformation’ policy documentation, firstly in 2008’s ‘PuttingPeople First,’ which boldy proclaimed that it ‘seeks to be the first public service reform programme which is co-produced, co-developed, co-evaluated and recognises that real change will only be achieved through the participation of users and carers at every stage.’ Eight years later,the NHS Five Year Forward View for Mental Health recommends co-production as a treatment for a critically (f)ailing system.But, as with its modernising big sister ‘personalization,’ and its revolutionary cousin, ‘recovery,’ there are serious questions to be asked aboutthe realities of implementing a radical type of ‘transformative’ co-production in mainstream UK mental health services. Cahn’s co-productionconcept means fundamental policy reform that relocates power to mental health service users, survivors, their organisations and communities.But how possible is this in a medicalised system that is riven with vast and varied inequalities, engrained stigma and has a history of strictpower and role relations?The Fate of RevolutionsThe dominant medical psychiatric paradigm appears to pose a fundamental challenge to achieving co-production in mainstream mental healthservices. People with mental health problems in UK are subject to compulsion and containment under the Mental Health Act. How then can theassets, expertise and knowledge of service users and survivors be regarded as equal and valuable when, as Peter Beresford has observed, ‘theirprocessing in the psychiatric system is related not only to them being seen as defective, but also frequently dissident, non-conformist anddifferent in their values’?By  Sarah Carr, PhDAugust 29, 2016“Every revolution evaporates and leaves behind Only the slime of a new bureaucracy”— Franz Kafka3/9/2017 Can Co­production Really Transform UK Mental Health Services? ­ Mad In Americahttps://www.madinamerica.com/2016/08/can­co­production­really­transform­uk­mental­health­services/ 2/3In order to understand what the prospects are for co-production to transform mainstream UK mental health services, it may be sensible to lookat the fate of revolutionary mental health reform ideas originating with the service user and survivor movement. This is what a smallcollaborative working group of mental health service users, survivors, carers, practitioners, researchers and policy workers did recently for aposition paper asking questions about co-production in mainstream UK mental health services.The group looked at evidence on what has happened to user-defined empowerment, personal recovery, user participation and choice andcontrol through direct payments once they were implemented into the mainstream. They found that their potential to transform the mentalhealth system was significantly limited by the legacy of old institutional cultures and control mechanisms. This was often through limitations onservice users exercising their agency and power and through the maintenance of professional or service influence and power. Institutionalcontrol also affected the way practitioners were able to work equally and collaboratively with service users.The Legacy of the Old InstitutionsThe overview of evidence on the introduction of personal recovery, user participation, direct payments and user-defined empowerment showedthat there are several specific challenges for achieving transformative co-production in current mainstream NHS mental health servicesassociated with the legacy of the old institutions. Many of these are bad for staff and general quality of care and support too. They were:Institutional resistance to change: Often traditional systems and practices remained the same, or with superficial or short-term changes. Inthe case of direct payments or personal recovery, evidence showed that co-option and control are at play, where clinical and organisationalgoals drive the agenda. Because they can pose a collective challenge and alternative power base, service user and survivor organisations werenot always welcomed in mainstream mental health service user participation and support provision initiatives.Restrictive administrative procedure and professional practice: People were still being judged by their diagnosis, psychiatric history oradministrative categories in any initiatives aimed at increasing influence, choice and control. This power dynamic is maintained by medicaland professional role dominance. However, the medical model, professional role rigidity and risk aversity are also bad for staff who areexpected to work in co-production with service users as equals.Avoidance of challenge, confrontation or emotional expression: Service users may initially want to tell uncomfortable stories inparticipation forums, make criticisms of services or practice, express anger about bad experiences or want to take control of their ownrecovery or care and support plan. However, within mental health system participation initiatives this can result in the exercise ofprofessional control, the marginalisation and pathologisation of service user voices or the translation or modification of those voices byprofessionals, all of which represent aspects of institutional control.The demand to conform by institutional rules and cultural norms: Service users who are invited into service spaces to participate indecision-making or in their own support or recovery planning are often expected to obey certain institutional rules and cultural norms aboutbehaviour, choices and use of language. This can mean they are expected to remain in an ‘obedient patient’ type role in order to beaccepted. Revolutionary concepts like recovery and direct payments can be co-opted and transformed into part of standard administrative ordecision-making procedure.Dismantling InstitutionsFrom the evidence examined, it seems that there is a risk of co-production being absorbed into and defined by a mainstream mental healthsystem that has the characteristics of the institution and becoming part of institutionally or professionally defined procedure. However, EdgarCahn’s original revolutionary idea of transformative co-production was about dismantling institutions, changing their cultures and practices andrebalancing power.His foundational view of co-production is about social justice and inclusion, with the fundamental conviction that there should be no‘throwaway people’ because everyone has assets, knowledge, strengths and contributions to make. It is about disrupting traditional fixed rolesand power relations between professionals and service users and should not be determined by what the institution or organisation wants.Depending on the context co-production may be collaborative, but it may also be confrontational. It may result in small but significant changesto individual relationships between practitioners and service users, or it may mean larger service or system reforms. Radical change in mentalhealth through transformative co-production can mean that ‘hell-raising’ and challenge can be a necessary part of the process.Is it the complex legacy of the institution that we need to address for co-production in the mainstream UK mental health system as it appears tohave been a barrier to all previous attempts by service users and survivors to revolutionise their support and improve their lives. Perhaps, asMary O’Hagan has observed, it is time for mainstream mental health services to finally ‘see how their well-funded services run by expertssqueeze the resourcefulness out of mad people, their families and their communities,’ if co-production is to fulfil its revolutionary potential.* * * * *3/9/2017 Can Co­production Really Transform UK Mental Health Services? ­ Mad In Americahttps://www.madinamerica.com/2016/08/can­co­production­really­transform­uk­mental­health­services/ 3/3$ 20.00$10.00 $20.00 $50.00 Give a Custom AmountSupport MIAEnjoyed what you just read? Consider a donation to help us continue to produce content, provide up­to­date research news, offercontinuing education courses, and continue building a community for exploring alternatives to the current paradigm of mental health.All donations are tax deductible. Make this Donation MonthlyDonate NowSarah Carr, PhDDr Sarah Carr is Associate Professor of Mental Health Research at Middlesex University London, and Vice­Chair of the National Survivor User Network (NSUN),England.

Can co-production really transform UK mental health services?

https://repository.mdx.ac.uk/download/39b3c30490f2edb79dc145bb48c52873d66aae72764e8401f6df35dd9ee5da09/157679/Can%20Co-production%20Really%20Transform%20UK%20Mental%20Health%20Services_%20-%20Mad%20In%20America.pdf

Can co-production really transform UK mental health services?

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