Monthly Archives: December 2012

Bree Hernandez ~ An Alarming Trend on College Campuses Around the Nation

Understanding teen stress, anxiety, and depression has been a major focus at the Institute of Mental Health blog this year. Today’s article, by American higher education expert Bree Hernandez, takes a closer look at how university students — particularly those studying at the graduate level — are impacted. Bree has made a career out of discussing the benefits of graduate education, and she is quite knowledgeable about student issues both in and outside of the classroom.

Mental Health Problems Continue to Plague Higher Education

Psychologists have increasingly noted that mental health issues among college students have been on the rise for more than a decade. While the entire college-level population is generally perceived to be at higher risk for depression, anxiety and other conditions than other adolescent or adult communities, recent data shows that occurrences are especially high among graduate students.

In 2010, the American Psychological Association (APA) reported that mental illness among college students had risen dramatically within the previous 10 years. Based on a survey of more than 3,200 American university students, 96 percent of students who visited their campus clinic for psychological treatment were diagnosed with at least one mental disorder. While cases of average depression remained the same (“relatively mild”), rates of severe depression rose seven percentage points between 1998 and 2009. Furthermore, doctors noted a steady rise in the number of students using medication to combat their mental issues. In 1998, 11 percent of students took medication for depression, anxiety, mood disorders and ADHD, among other conditions; in 2009, that number reached 24 percent. There is reason to believe it is still on the rise.

Margarita Tartakovsky, Associate Editor of PsychCentral, recently noted that graduate students are at the greatest risk of suicide. Based on a study conducted at Berkeley University, nearly half of all graduate student respondents suffered from an emotional or stress-related disorder that affected them on a daily basis. The demanding nature of graduate-level coursework – which is typically taught within a less structured environment than undergraduate studies – plays a crucial role in the mental health of grad students, Tartakovsky found. When coupled with the stress of accruing massive student debt in order to receive a master’s degree, the deck often seems stacked against the student. While 52 percent of stressed out graduate students considered receiving help from mental health assistance services, only 27 percent actually followed through.

To mitigate the negative consequences of mental health issues, many of today’s campuses provide accommodations to affected students. According to a report by the University of Washington, these accommodations may be made in regard to classroom policy (preferential seating, early availability of textbooks and syllabi), course examinations (extended time, assistive computer software) or assignments (relaxed deadlines, substitution). However, some of these accommodations may actually be doing students a disservice by customizing the academic experience to fit their specific needs. According to a report by the Jed Foundation, institutes of higher education should not “fundamentally alter” courses in order to accommodate students with mental health issues, nor should the schools incur an “undue burden” (logistical or financial) to make accommodations.

There is also a question of fairness, argues a recent report from a professor at the College of New Rochelle. “Accommodations allow students equal opportunity to participate in all aspects of college life,” the report states, “but should not provide unfair advantage over other students or fundamentally alter the nature of courses.”

Many experts today are touting low-impact strategies that students can employ as an alternative to campus-wide accommodations for individuals with mental health issues. Studies have shown that many first-year students enter university studies with pre-existing mental health conditions which have not yet been addressed, and seeking professional help prior to arriving on campus could mitigate some of the problems related to these conditions. And because many of these mental disorders are stress-related, health experts urge students to regularly exercise, get eight hours of sleep every night and refrain from frequent drinking or recreational drug abuse. And according to Psychology Today contributor Julie Hersh, all students can play a role in fighting mental health issues on campus by forming committees and support groups for affected individuals.

Students who suffer from mental health issues should not exclusively rely on counselor treatment or campus-wide accommodations in order to succeed in college. By practicing low-impact strategies like those listed above, affected men and women stand the greatest chance of completing their courses and earning a degree in spite of a debilitating mental disorder.

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Dr Rex Haigh ~ TCTC: born 22/10/12, Windsor, England

The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we’re up against, originally posted on 24 October 2012.

‘The Windsor Conference’ started in the 1970s, set in the right royal setting of Cumberland Lodge, in the gated community of extreme privilege of Windsor Great Park. Every autumn, the grand old founding fathers of the British TC movement all came to play here, every year, until 2010. With friends and colleagues from overseas, mostly the Netherlands at first; later Italians and currently Greek therapists, together with a smattering of like-minded clinicians, researchers and TC leaders from Switzerland, Germany, New Zealand, Australia, USA, India and Africa, they came along to an unbroken sequence of annual community meetings, and much besides, until last year.

Cumberland Lodge (rear)

Cumberland Lodge (rear)

What happened last year? Well, the organisation of ATC decided that it was time for a change – the most prominent reasons were that the 3-night conference, for up to 100 people in its heyday, had become too expensive for many, inaccessible to new delegates, and somewhat anachronistic and unrealistic in its expectation that all delegates must stay throughout the four leisurely days. There was a general feeling of it having become somewhat repetitive and perhaps ‘stuck’. It was therefore moved to a large and pleasant Quaker Meeting House in Birmingham in September 2011, but the membership soon made it clear that they wanted Windsor back!

So, for the 2012 event, a new three day/two night format was introduced, which had a theme of INTEGRITY – with a different sub-theme each day and various guest speakers. Delegates were able to come for one, two or three days – and were made welcome with goody bags, a very professionally produced programme, and daily large and small discussion groups.

 
 
INTRODUCING INTEGRITY
The first day was called ‘Introducing Integrity’ and it was built around the ending of two longstanding TC organisations, The Association of Therapeutic Communities (ATC – for adult TCs) and Charterhouse Group (CHG – for children’s TCs), and the merger to form a single new body ‘The Consortium of Therapeutic Communities’ (TCTC – for all types of TC).
On the shoulders of giants:
Nick Manning and Colwyn Trevarthan (front)
Rex Haigh and Gary Winship (rear)

Gary Winship – a longstanding champion of the movement – gave a spirited and funny précis of ATC’s forty years which he called ‘a cross between a love letter and a eulogy’. He peppered his talk with lively character vignettes of some of the main characters over the years, and criticised ATC for not having enough managerial ‘savvy’, and for being rather patriarchal in its choice of leaders; he acknowledged the organisation’s adaptability and relentless adherence to a radical political position, through the thick and thin of social psychiatry, Thatcherism, regulation and governance, to neoliberal economics. Richard Rollinson, with many years of CHG history, told of missed opportunities to come together sooner – and the different but oh-so parallel history of personalities and conflict, trials and tribulations in the history of the childrens’ TC organisation.

After saying goodbye to the old organisations, and a typically wonderful Cumberland Lodge lunch, the main topic for decision about the new organisation was introduced: what sort of organisation do we want TCTC to be? (TCTC2B??) Was it to have ‘more of the same’ (called the narrow focus), or was it to look to expand and cover new territory – particularly including the wider use of TC principles in different ways and settings? Almost a reprise of David Clarke’s ‘TC Proper v TC Approach’, or the more recent ‘Community of Communities’ and ‘Enabling Environments’ projects. The eight small groups, variously scattered throughout the lodge, thought about it and described a clear consensus: think wide. After having done most of the thinking, the inaugural AGM was mostly a formality; perhaps most interesting for electing six new board members, several of whom are ex-TC members.

The hour-long large group at the end of the day – now called a ‘community meeting’ – was reflective and open, if a little constipated. As its conductor, I was determined not to make any plunging interpretations and to positively nurture it as a warm and welcoming space. Indeed, nobody tried intimidating tactics of ‘Nobel Prize thinking’ (as originally described by Lionel Kreeger) – and  the Greek delegates seemed particularly appreciative of the simple opportunity to be together. When somebody thoughtfully asked them if they wanted any space at the conference to be in a Greek-speaking small group, they said that they could do that at home!  It’s widely acknowledged that being in a large group (this one was between 60 and 75) can be a weird emotional experience; I would add that it is even weirder to be conducting one.

PROMOTING INTEGRITY

The second day had three seriously impressive external speakers. The first was Professor Colwyn Trevarthan, from Edinburgh: the distinguished academic who introduced the concept of ‘primary intersubectivity’ (which impressed me first when I heard of it in my Cambridge social psychology days, and still does). With a title of ‘The Social Brain: The Healing Power of Emotions’, he put on a dazzling performance to demonstrate experimentally what we all feel and know clinically: that there is a lot more to relationships, and how important they are, than  transmitter neurochemistry, or detailed scans (even though discoveries such as mirror neurones support this), or indeed the multitude of clinical questionnaires and ‘instruments’ that we routinely use could ever meaningfully measure.

A few gems – often of linguistic precision as much as empirical fact – which caught my attention, amidst the array of sparkling jewellery:

  • “a project made propositional by their collaboration” (musical analysis of infant movements)
  • secondary intersubjectivity – from about 9 months – includes understanding the intention of the other; “sense of shared dynamic intentionality” (catch up, mentalisation!)
  • primary complex emotions = PRIDE and SHAME
  • elemental need for playfulness / fun / imagination / creativity
  • ‘Empathy’ is philologically the wrong word: sympathy is better, and mirror neurones would be more accurately described as ‘sympathy neurones’
  • ‘being human’ is more limbic and subcortical than it is cerebral…

Mark Johnson was next with a powerful service user account, ‘Reclaiming Integrity after a Destructive Childhood’. Mark is a Guardian columnist and author of the very successful book ‘Wasted’, who founded the charity and social enterprise ‘User Voice’.

After lunch, we had Leonie Cowen giving us a refreshingly clear and radical view of how commissioning should be done. If only it was!

A panel discussion to explore the detail of the issues, followed by small groups, gave ample time and space to give the ideas due reflection and digestion. ‘Fringe sessions’ followed – and Fiona and I took about a dozen delegates for a walk to the copper horse, after explaining what greencare is  and showing some pictures of our project, yurt and all, at Iver Environment Centre. Unfortunately the gate was locked just shy of the copper horse itself, because it’s rutting season for the deer – but there’s greencare for you. And of course, in the leisurely old days of the Windsor conference, a whole afternoon would be set aside for walks in the park; later to be timetabled as ‘professional networking’ to avert the gaze of sharp-eyed study leave funders. No such luxury any more – unless we repackage it as ‘greencare’!

Large group, and a splendid dinner – hijacked as a magnificent birthday party by the Bard of East Anglia. Then there was drinking, and dancing, and more. I was long in bed by then.

DEMONSTRATING INTEGRITY

We all now know so well that is does not matter a jot what good work we do, if we cannot suitably demonstrate what we do, and justify it with the sort of evidence required by the prevailing demands of the superordinate system. So – enter the TCTC research group, ably chaired by Susan Williams and presided over by Nick Manning.

They presented two streams of thought about outcomes: individual questionnaires so we can all be measuring what matters, and doing it in a way that facilitates comparison; and environment questionnaires to measure that elusive ‘atmosphere’ which is so easy to smell, but so hard to define.

The two questionnaires which came top of their Delphi exercise were:

  • CORE (34 items for well-being, symptoms, relations and risk)
  • Euroqol EQ-5D (5 items for quality of life are almost meaningless taken individually, but are very significant to health economists and QALY calculations)

So these are now going to be recommended to Community of Communities to be included in the basic service standards. Others also mentioned included the Recovery Star, HoNOS, GHQ and its derivatives, and the social functioning questionnaire.

None of the environment questionnaires examined were quite up to scratch – too old and whiskery; too long; too complicated; or not particularly relevant for TCs. The committee is therefore going to design a new one, with help by piloting it in volunteer communities. Watch this space…

Equally significant, in that ‘deep and thick’ way that only rigorous ethnography or phenomenology can do, were some of the research presentations about PhD work under way. In fact, there are currently three qualitative studies under way at Nottingham’s Institute of Mental Health – which can only serve to enrich and expand the academic base for the field.

After lunch, the demonstration of integrity took a different turn – and we all assembled in the elegant drawing room for we knew not quite what. We first heard the story of Simon Clarke, told by himself – from a hopeless and chaotic existence, through Christ Church Deal TC (CCD), to a productive high-level academic career. The next was Jonathan Walker, from an equally troubled background through CCD to a very successful career as a Liverpool campaigner and street musician: we enjoyed two lyrical and moving songs. Finally, Matthew Shipton told us of his own similar trajectory from squalor and disarray to rediscovering his own musical aptitude. Then he lifted the lid on the grand piano and simply blew everybody’s socks off (as they say) with a twenty minute rendition of an exquisitely complex Chopin rendition. Being about conflict and its resolution, he prefaced it – but so much more besides.

Bedazzled, we collected tea and wandered into our final small group sessions, before the final presentation: a presentation from a modern-day progressive catholic foundation school in Leamington Spa, called MAL-HER-JUS-TED. It was led by a passionate and forceful teacher from Chicago (echoes of the Boys Republic?), and described how they gathered information from ex-residents of young people’s TCs as part of the Lottery-funded ‘looking after other people’s children’ project run by Craig Fees at the Planned Environment Therapy Trust (PETT) in Gloucestershire.

With just half an hour’s quiet and reflective large group to finish, most seemed appreciative of being with each other – and their various contributions.

The logo of the new combined organisation

The logo of the new combined organisation

Back next year, dates booked already. By then we’ll see if this new organisation is on the tracks we hope – to say and do something really significant…

Posted by:
Dr Rex Haigh FRCPsych
www.greenshrink.blogspot.com

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A manifesto for social science research in the field of mental health – Nick Manning

Today we have a blog post from IMH Director Professor Nick Manning, with, as an introduction, some questions to think about and a link to a lecture by Professor Nikolas Rose.  Together, this post and lecture provide a ‘sociological’ view of mental health, and hopefully will provide some food for thought over the Christmas break.

Visiting this link will take you to a ‘mediasite’ presentation by Professor Nikolas Rose, entitled ‘What is mental health today?’.  Please note that viewing this video may require additional plugins on your web browser.  If you are prompted to install Microsoft Silverlight, it is safe to do so, and you will need to restart your browser for the changes to take effect.  Other lectures by Professor Rose can be found here.

Some questions to think about when watching the video, and while reading Professor Manning’s post, which follows:

1. Is there an epidemic of mental disorder?
2. Does the path to understanding mental disorder lie through the brain?
3. What is the role of diagnosis and diagnostic manuals?
4. Should we seek early diagnosis of those at risk of future mental pathology?
5. What is the place of patients, users, survivors, consumers in the mental health system?

Professor Manning’s Post

Over the last 20 years a number of critical issues have challenged the mental health field in two areas.

First, the evidence for and effectiveness of treatment has been criticised for:

  • the integrity and relevance of research (pharma company trials, for example on the effectiveness of SSRIs and atypical anti-psychotics);
  • promissory claims by genetics and biological psychiatry research, which have not revealed hoped-for breakthroughs;
  • the extent of the evidence base (RCTs, NICE, complex interventions, which have not offered strong support for singular interventions);
  • the effectiveness of new technologies (CBT, DSPD are being challenged, and the latter investment has been wound up after 10 years and £0.25 billion)

Second, there has been criticism of the care and treatment practice, such as

  • the quality of care (murders by Christopher Clunis, Michael Stone, Richard King; care home scandals such as Winterbourne View; public enquiries such as the death of David Rocky Bennett);
  • the development of European and UK mental health legislation (risk prediction is weak and hence compulsory treatment and legal advice are contested).

The pattern here is for research based on an aetiology and pathology of mental illness in terms of biological processes and structures to have made limited progress. A recent UK Medical Research Council review of mental health research in the UK concludes that “the research questions in this field have been relatively intractable” (MRC, 2010).  Genetic markers have been elusive, neuroscience has yet to show clear directions for diagnosis and treatment, psychological treatments and effective drugs have been disappointing.  Yet the biomedical model has retained its dominance, despite the limitations of pharmaceutical, genetic, neuroscientific and psychologically based interventions.

By contrast there is a body of work from social science in relation to epidemiology and therapy, which demonstrates clearly the working of social processes in the distribution and care of mental illness. For example there has been growing evidence for the last 50 years that mental illness rates are related to the social inequalities of race, gender, age, migration, and unemployment (Pilgrim and Rogers, 2009). Part of this pattern is a selection effect caused by prejudice and stigma, for which the social theory of labelling, developed in the 1960s, provides evidence and explanation (see Scheff, 1999 for a summary). But part of this is direct causation mediated through stress (see Wilkinson and Pickett 2010 for a summary). In terms of therapy there is social science evidence about the damage poor treatment environments can do (Goffman, 1991, et seq), and the consequences of social isolation under community care. There is also evidence about the way in which those treatment environments can be positive and therapeutic (Lees, 2004), and about the potential for building better supportive personal and social networks (Spencer and Pahl, 2006).

At the same time there has been a growing burden of mental distress.  Bloom, et al (2011, p.26) estimate that mental disorder is the leading global cause of all disability-adjusted life-years. Suicide is second only to traffic accidents as the cause of death among those aged 15–35 years (WHO, 2005). 75% of prisoners in the UK have a diagnosable mental disorder, with rates of psychosis in excess of 20 times the national average. Mental health problems account for 35–45% of absenteeism from work, at a cost to Europe of €136.3 billion in 2007 (ECNP, 2009; OECD, 2012). Overall costs of mental disorder in the UK have grown from £77.4 billion in 2003, to £105.2 billion in 2009 (CMH, 2010).

Such a combination of growing need and perceived problems with the effectiveness of existing healthcare is fertile ground for innovation. The response from the biomedical research community has been to repeat the pattern from 30 years ago, and make a renewed emphasis on building more biomedical and neuroscience capacity on the basis of familiar promises and prospects. For example the MRC (2010) review notes that there is “low research capacity” in the field.

However an alternative approach originating in the USA in the 1990s has grown rapidly and vocally to fill the gap. This approach is based on the concept of ‘recovery’. Recovery means the right to a life that has meaning and satisfaction as defined by the person themselves, even if their mental health problems cannot be eradicated. Recovery originated as a grass-roots movement in the USA (Davidson, Rakfeldt and Strauss, 2010). It has spread with enormous energy throughout the English-speaking world (US, NZ, Aus, UK), and is under serious discussion in Europe (Samele, 2012; WHO, 2005). It is increasingly supported by professional, third sector and activist movements, and has very recently appeared in both the latest UK Department of Health policy No health without mental health (2011) and the US Federal government’s Substance Abuse and Mental Health Administration policy (SAMHSA, 2011). For example SAMHSA defines recovery in four parts:

  • health – managing one’s disease(s) and living in a healthy way;
  • home – a stable and safe place to live;
  • purpose – meaningful daily activities, such as work, with the independence and resources to participate in society;
  • community – relationships and social networks for support, friendship, love, and hope.

The emergence of recovery originated as a social movement by those experiencing mental health difficulties, but it has since been adopted by mental health professionals, and more latterly incorporated into the policy framework of government health and social care departments. Although the SAMHSA definition is typical of the field, weaker meanings of recovery have been promoted by different professional groups as a way of accommodating their existing activities and interests, such that there are now three definitions or types of recovery used within the mental health field, ranging from weak to strong:

  • as a reduction of medical symptoms (recovery RI), frequently stressed by medical staff.
  • as the complete redefinition of the meaning of mental disorder, and the instillation of hope for a better life (recovery RIII), increasingly used by service users and their representatives.
  • as rehabilitation, mainly employment (recovery RII), often used by nursing and social care staff.

Relevance of social science

Social science has a long tradition of work in the field of mental health. The earliest work analysed the aetiology of mental illness in relation to major social patterns such as urbanisation and social inequality. At that time most mental health sufferers were placed in large hospitals, and these institutions also furnished a rich source of sociological data about the structures and dynamics of large organisations. Fundamental developments in interactionist sociology on identity, group life, power negotiations, and grounded theory were made by Goffman, Strauss and others. Labelling theory and stigmatization, developed in the work of Scheff (1999) and others, founded a research tradition that was subsequently applied to the sociology of crime, youth culture, and race. Much of this crossed to the UK to inform studies of organisations, deviancy, work, and the professions, but despite an interdisciplinary interest in resilience, wellbeing and happiness, there has been far less social science research in the mental health field in the last 20 years.

In other related areas there have been major new research avenues explored, such as the sociology of physical health and illness, and the sociology of the body.  Medical sociology is by far the biggest sub-field of any in sociology, and yet almost none of its work focusses on mental health. For example studies of doctor – patient interactions, the nature of diagnostic practices and meanings, and the anthropology of symptoms, have made major advances in our understanding, yet little of this work has crossed over into the mental health field. Some examples would be Kleinman’s (2011) work on the somatisation of human suffering, and the way in which anthropology alerts us to the cultural relativity of biomedical concepts, and Busfield’s (2011) recent argument that the diagnosis of mental illness is becoming over-extended. Of closer relevance to recovery is Crossley’s (2006) research into oppositional movements by service users and the way these are structured in common with pressure groups and political movements.

However these examples are notable exceptions in relatively quiet field. An important task therefore is to gather data on the way in which all three different definitions of recovery are used and promoted in the ‘recovery society’.  We need a detailed examination of the way in which this term has developed, the way it is being widely introduced in practice, the experiences of mental health service users, and the methodological issues involved in gathering and assessing data about it.  We should bring social science back into this field by the careful and critical investigation of recovery which is based centrally on a social aetiology, and the novel use of powerful social technologies, for example: Pahl’s work on friendship, personal communities and ‘social convoys’ (Pahl, 2000; Spencer and Pahl, 2006); Hacking’s analyses of ‘making up people’ and the ‘looping effects’ of mental disorder categories (Hacking, 2007); and research on ‘successful’ lives of both the profoundly impaired and the rich (Pascall and Hendey, 2001; Pahl, 1995).

There is today an unprecedented opportunity to re-think the nature of mental disorder, its health and social care, the experiences of those struggling with it, and the application of these findings to wider areas of long-term health conditions.

References

Bloom, D.E., et al (2011) The Global Economic Burden of Non-communicable Diseases. Geneva: WEF

Busfield, J. (2011) Mental Illness Cambridge: Polity Press.

CMH (Centre for Mental Health) (2010) The economic and social costs of mental health in 2009/10

Crossley, N. (2006) Contesting Psychiatry: Social movements in mental health London: Routledge

Davidson, L., Rakfeldt, J and Strauss, J. (2010) The roots of the recovery movement in psychiatry Wiley

DH (UK Department of Health) (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages Gateway Ref 14679, HMGov

ECNP (European College of Neuropsychopharmacology) (2009) 22nd Congress, 12 Sept, Istanbul

Goffman, E. (1991) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates Penguin.

Hacking, I. (2007) ‘Kinds of people: moving targets’ Proceedings of the British Academy 151, pp. 285-318

Kleinman, A. (2011) ‘Four social theories for global health’ The Lancet 375, 9725, pp 1518-1519

Lees, J., Manning, N., Menzies, D. and Morant, N. (2004) A Culture of Enquiry: research evidence and the therapeutic community, Jessica Kingsley Publishers

MRC (Medical Research Council) (2010) Review of Mental Health Research London: MRC

OECD (2012) Sick on the Job? Myths and Realities about Mental Health and Work.  Paris:OECD

Pahl, R.E (1995) After Success. Fin-de-Siècle Anxiety and IdentityCambridge: Polity Press

Pahl, R.E. (2000) On Friendship Cambridge: Polity Press

Pascall, G. and Hendey, N. (2001) Disability and Transition to Adulthood: Achieving independent living Brighton/York: Pavilion/Joseph Rowntree Foundation

Pilgrim, D. and Rogers, A. (2009) Sociology of Mental health and Illness Buckingham: Open University.

SAMHSA (US Federal Substance Abuse and Mental Health Administration) (2011) at  http://www.samhsa.gov/newsroom/advisories/1112223420.aspx

Samele, C. (2012)  European Profile of Prevention and Promotion of Mental Health (EuropPoPP/MH), Brussels: EU Executive Agency for Health and Consumers.

Scheff, T.J. (1999) Being Mentally Ill, A Sociological Theory New York: Aldine de Gruyter

Spencer, L. and Pahl, R. (2006) Rethinking Friendship Princeton University Press

WHO (2005) Mental health: facing the challenges, building solutions. Copenhagen: WHO

Wilkinson, R. and Pickett, K. (2010) The Spirit Level: Why Equality is Better for Everyone Penguin.

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Professor Ruth McDonald ~ Paying for Performance in the NHS – is it good for our health?

In the olden days, we used to trust public servants to do their best for the people they served. Nowadays things are a little different, especially in the NHS. Policy makers are increasingly resorting to ‘Pay for Performance’ (PfP) in an effort to drive up the quality of care delivered to patients. The Commissioning for Quality and Innovation Payment Framework, or CQUIN as it is known, makes a proportion of income conditional on the achievement of quality improvement and innovation goals. This was increased from 0.5 to 1.5% in the second year of the scheme and this year the percentage was increased to 2.5%. David Nicholson, the NHS Chief Executive said recently that he wants to see this rise to 4 or 5%, presumably due to fears that the 2.5% isn’t having the desired effect.

The question asked by a lot of people is ‘do PfP schemes work’? But this is the wrong question, since it fails to recognise that these initiatives are all different. What we need to do is to look at the features of the individual schemes – how they are designed and implemented and in what context – and assess impact to work out how and to what extent a scheme works.

Our recent evaluation of the Advancing Quality (AQ) scheme in the NHS North West found that it saved almost 900 lives. The bonus payments were a drop in the ocean compared with CQUIN, which suggests that whilst it’s helpful to offer carrots, there are other motives afoot here. Perhaps NHS staff are only too ready, willing and able to improve services, but what they need sometimes is a little help. In this case, help took a number of forms including standardised data definitions and bespoke software. But aside from these technical aspects, collaborative events brought together staff from all 24 participating organisations to share their learning and work through common problems. In addition to shared learning, the development of this AQ ‘community’ appears to have been really important in providing emotional support for what has been (make no bones about it!) a gruelling and often uphill struggle for the staff involved. As our study shows, ‘PfP’ can produce desired results, yet  what motivated the front line NHS staff in our study was not ‘rational’ calculation of efforts versus rewards, but an ability and desire to  work together in a supported way, to do what they all felt was the right thing for patients. AQ has now broadened its scope to include all of the mental health Trusts in the region so we’re watching with interest to see if the initial success can be replicated as the programme expands.

Much of the thinking on incentives has traditionally been dominated by economists who take a rather one dimensional view of human beings. And economic rationality has often been seen as contrary to emotion. But an obsession with finding the magic percentage which proves to be a tipping point is the wrong way to go here (David Nicholson, please take note). What’s needed is for policy makers and evaluators to begin to adopt a less impoverished view of human behaviour – recognising the importance of emotion in improvement initiatives would be a good place to start.

Posted by:
Professor Ruth McDonald
Chair in Health Innovation and Learning
Business School
University of Nottingham

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