Last week I went to a mental health conference to join a group developing a Wellbeing Charter for people working in psychological therapies. I normally last 10 minutes in such environments before the existentials hit, but I took this occupational risk to show solidarity to the woman who coordinated the charter who I like immensely. To disguise my likely regression into a more primitive state I wore a skirt and coordinated make up rather than adopt a fur and dragging a club with my extended forearms.
Please play nicely, please, just this once.
Thirty minutes in and hair was starting to grow on my palms. Shiny young folk promoting Cognitive Behavioural Therapy apps and online courses, wellbeing at work industry reps, private contractors delivering the Work Programme and welfare assessments, private employment agencies and clinical psychologists measuring the impact of self-guided resilience manuals.
We’re not in Kansas now, Toto.
As I am about to click my heals a retired Doctor called Chris with immense humanity and an enviable capacity for building solidarity somehow manages to bundle me into a windowless room to listen to a presentation on the link between welfare and mental health. An MP on a podium apparently unencumbered by actual facts about his own government’s inability to sign off the Universal Disaster of Universal Credit and unaware that being on welfare doesn’t mean you’re not in work, as 30% of NHS workers can testify.
As the discussions start about how we are going to build support for a Wellbeing Charter I realise that, for some, this is primarily a question of learning how to present the ‘business case’ and learn the creative accounting required to match targets and outputs with actually helping people. As someone who has spent most of their working life as a trade unionist I would like to suggest that the entire experience of industrial relations is that whatever financial argument you present to protect psychological therapies actually doing it will require genuine political will on both sides. To simply adopt a business school logic creates just a fiction about ‘going forward’.
To make matters worse I’m sitting next to a rep from an online CBT provider talking about how the clinicians they employ value the flexibility of working on a zero hour contract. I stare enviously at her matching beige outfit and wonder if she can tell that my hair is matted and full of moss and twigs. It appears she has not connected the growth of ‘flexible work’ with the growing number of people working in mental health services don’t want to get out of bed in the morning because of the culture of fear they are forced to work in. Online therapy offering a narcissistic model where neither the patient nor the clinician ever has to be in contact with another troublesome human beings ever again.
I feel my toe nails start to split open my shoes and dig holes into the hotel carpet.
The debate about precarious work is a defining one in the field of employment relations, making the research link between nationally set cuts and targets, privatization of health and social care services and growth of labour outside core-public sector, the use of command and control management, work intensification and bullying cultures.
The confusion and ignorance about the employment relations system of mental health workers is very much about the continuous privatization and restructuring of the NHS and shift of commissioning powers to local level be that PCTs or CCGs. Over the last 5 years there has been a 50% increase in services provided by non-NHS providers with expenditure rising from £6.6 billion to £10 billion. There are an estimated 53,000 private contracts in the NHS with 15,000 within 211 CCGs in community health services and secondary care. An estimated 12.7% of the CCG budget is spent on specialist mental health services – and the primary problems relate to poor contract management and very low penalties for poor delivery. What we do know is that in 2014 half of the private mental health providers commissioned by NHS England to provide specialist care were not fully compliant with NHS standards.
The privatisation of the Commissioning Support Units in April 2016 set up to administer the NHS contracting process raises further concerns about the governance and monitoring those services provided by private providers (Public Accounts Committee, February 2014).
You read that correctly.
The administrators in charge of managing third party contracts will themselves be working for third parties. Yup, that’s neo-liberal economics for you old chum.
As someone who comes to mental health from industry I find the lack of knowledge about the trends in our own sector both breathtaking and frightening.
Although its possible that the third parties currently may offer a good-enough service if the experience of every other sector is anything to go by within a two year period the contracts will be downgraded to compete with ever stringent budgets. Within 5 years the clinicians and managers in these private companies that came from the public sector will have retired or moved, leaving a new generation of workers without any living memory of good clinical practice or decent work. Given that there is little to no governance of private contractors in the NHS this will happen without even the slightest fuss over patient safety.
Here’s where I’m going to say something not all that nice and potentially divisive but I think its usefully true.
In our psychoanalytically-minded society there is a growing split between the established and the disestablished. We see it every day in our services – we now need to allow ourselves to see it in our profession.
After four years of talking to mental health workers and now carrying out research into our sector I think its fair to say that we are experiencing a rise in what Sally Weintrobe calls Noah’s-ark-ism. This is the phenomena where those people who still have decent jobs – or who are safely established on pensions or private practice, leadership positions in our professional and training bodies – are protecting what they have while turning a blind eye to those of us who are very-soon-to-be-disestablished. This second tier of workers includes the Psychological Wellbeing Practitioners who provide the main bulk of IAPT services, the hundreds of honoraries working for free in the NHS, the people manning the mental health call centres, the clinicians carrying out disability welfare assessments and the ones working in social care and support services who were forced to leave their clinical jobs.
The people that think they still have a place on the ark are looking away from the horizon, and have stopped being able to look at the rest of us in the face. These are the characters who think that the words ‘surviving work’ don’t apply to them because, ahem, “Elizabeth, we actually love our work”. Well, all you’re saying there is that you don’t think that the pervasive culture of fear and bullying that most people in the NHS work under is part of your professional reality. Yet.
This dis-connect creates a professional culture in psychological therapies much like a 17th Century French Court – a preoccupation with the minutia of court procedures rather than the blood and guts of economic crisis and finding therapeutic modalities that can respond to it.
It is a growing possibility that we are within a decade of our profession dying out. As we become de-professionalised, downgraded and demoralised and our experienced leadership retired or retreated into private practice, this leaves the gates open to private providers to fill the gap, and very quickly. Going forward towards a mental health service made up of tick boxes and compulsory wellness – a ruthless regime of can-do contractors and labour agencies.
Up until recently I’ve found my place in this feudal system eating raw potatoes in the back row but last week I realised that even this position was a luxury I could no longer afford. True, its still the case that the politics suck at professional conferences and some high ranking policy folk still have a tendency to appeal to our sadistic superegos and tell us what we have a responsibility to do, for free, for them.
Our professional bodies in crisis – torn between defending the sector and their organisation which increasingly cannot happen at the same time. Our unions literally asleep at the wheel with a growing gap between the rhetoric of collectivisation and the reality of it.
If this is what going forward looks like I definitely want to go backwards.
As me and Chris sit and listen to a senior official from one of the big NHS associations bark random nonsense about evidence I realise that Anton Obholzer is sitting behind us. He’s a man mountain of epic political experience – who produced possibly the best book on work in health and social care, The Unconscious at Work. I even made my mum read it so she’d stop asking me if I’d met a nice man working in mental health. Anton is sitting with his head in his hands. I want to be sick in my own hand at what must be going through his mind as he listens to a panel of experts talk about ‘going forward’. I say a small prayer of gratitude that Anton is just there holding in his head the knowledge that there is a really important political fight to be had but that its not happening in this particular room anytime soon.
I put my psychic club down and have a little cry in public.
Then a man from Sheffield speaks up – an IAPT manager there with his team and reminds the audience of some actual facts. That he can afford to train 2-3 Psychological Wellbeing Practitioners per year to provide 80% of his service. Despite getting over 800 applicants for the training, because PWPs don’t earn enough to live on and provide care that they are not trained to deliver they leave fast. This didn’t make any difference to the young man on the podium but it made an enormous difference to those of us in the back row reminding us that it has always been the case that real politics exist between us rather than further up the food chain.
At that moment I realised that if I allow myself to become so angry and frustrated with the evident failings of the institutions of mental health then I fail myself and the people I work with. Paranoid maybe but I wonder if they want us to walk away and leave them alone. But how about we don’t? How about we actually get closer to them by turning up at the meetings, by disagreeing with them about their policies, by writing critical blogs and getting elected onto their governing bodies? How about we take the Wellbeing Charter and talk about it at work?
This, my friends, is not a silver bullet to the inherent conservatism within our organisations, but it keeps the conversation between you and me going long enough to think about the future of our profession.
The presence of Anton, Chris, Mark and Amra allowed me to take a third position on the nature of our profession, one which doesn’t end up with me walking out in a huff with fingers strategically raised.
This is what we know about as people working in mental health. That all we have is each other, right now, listening and talking long enough to see and understand reality for what it is. A relational model of solidarity where we make the best of the people around us and the bad lot we have been left with in mental health.
First published on the Surviving Work blog