In sickness and in health

I want to respond to a number of assertions made in the article ‘In Sickness and in Health’ in issue six of Enterprising by Karen Reissman, a community psychiatric nurse for Manchester Mental Health and Social Care Trust and a Unison representative. Karen does not mention the team I manage, N’gage Assertive Outreach Service, by name in any of the quotes attributed to her. However, it would be clear to anyone familiar with mental health services in the city that it is our service she is referring to as an example of why the voluntary sector should not be involved in running mainstream mental health services.

The first point to make is that Karen’s information about the service is out of date. HARP approached her employer, Manchester Mental Health and Social Care Trust in 2006 with a proposal for developing a partnership approach to running assertive outreach based on the ‘recovery focused assertive outreach’ model. This involves practitioners from voluntary and statutory sector agencies working together in a single service setting to provide a comprehensive service that incorporates the strengths, skills and specialisms of both sectors. The Trust were very keen on our proposal – as were the mental health commissioners, who earlier this year awarded the partnership between the two organisations the tender to deliver the service for a minimum of the next three years.

The basis for Karen’s hostility seems to be a conflation of the voluntary and private sectors. On one level, this is understandable in that government also does this – often referring an overarching ‘independent sector’ and failing to differentiate between two very different sets of organisations. However, it also appears that in the absence of any private sector organisations running community mental health services in Manchester (they tend to go for the hospital and residential sector where there is more opportunity for profit), the voluntary sector becomes Karen’s favourite whipping boy: almost as the ‘soft face’ of privatisation. It would appear to be a case of ‘if it doesn’t look like us it must be our enemy.’ We, on the other hand, would argue that voluntary sector involvement in running services is NOT privatisation. There is no profit making motive. There are no shareholders. There is no change to who ‘owns’ the services. The service is still free at the point of delivery and aimed at those who need it most. BUPA, we are not.

In her quotes in the article itself, Karen makes a number of inaccurate and misleading statements about our service which we strongly believe cannot go unchallenged. Quotes from ‘In Sickness and in Health’ are shown in italics.

She worries that voluntary sector and social enterprise organisations can win tenders through cutting costs, and this can mean lower standards of care and poorer conditions for workers on the mental health front line.

For services such as assertive outreach, the indicative amount available to deliver the service is usually included in the tender application pack. Applying to run a service such as assertive outreach is about far more than the financial considerations – 75% of the application is, crucially, about providing evidence to demonstrate that you have the skills, qualities, attributes, policies and procedures and track record to delivery the service effectively. Interestingly, when it came to the financial side of our application to run the assertive outreach service, it was our statutory partner rather than HARP who was keen to keen the proposed costings as low as possible. HARP, on the other hand, in common with moast of the voluntary sector, are fully committed to the principle of full cost recovery for any service it tenders for.

“One of Manchester’s current assertive outreach teams is voluntary sector. One of the main things this has meant is that experienced NHS staff have been replaced with inexperienced staff,” she explains. “This is partly because the voluntary sector organisation pays less, and because staff moving to it lose their NHS or local authority pensions.

For six years, Manchester’s only assertive outreach team has been a voluntary sector led partnership with the Mental Health and Social Care Trust. No NHS staff were replaced, because prior to HARP running assertive outreach there was no such service in Manchester. Assertive outreach was introduced to the UK by Tulip, a voluntary sector agency based in West London. Whilst most subsequent teams have been solely statuary, this is a reflection of the lack of vision and creativity of commissioners rather than because the service’s natural home is within the NHS. Indeed, it can be argued that with its emphasis on engagement, social inclusion and collaborative working – all core voluntary sector attributes – there are pressing reasons for the voluntary sector to be involved with assertive outreach.

There exists a myth that Karen repeats that all skilled, experienced and effective mental health workers are essentially to be found within the NHS. This is deeply insulting to the many skilled practitioners working in voluntary and community organisations up and down the country. Contrary to her assertion, this service has workers with up to 20 years experience in mental health – many, but not all of whom previously worked in the statutory sector. Whilst HARP cannot match the NHS pension – very few employers can – our staff are well paid. Social workers are on comparable salaries to their statutory counterparts, unqualified staff (support workers, social inclusion workers, etc) are better paid, and only our nurses are less well paid than psychiatric nurses in the NHS. This is partly why, in the expanded service, nurses still employed by the NHS but managed by HARP will be working on the teams.

The other point about working for the voluntary sector is that it is not just about pay and conditions: in a good voluntary sector organisation, staff are listened to and valued, their ideas and contributions are taken seriously and they are allowed to use their creativity and their full potential. I worked in the statutory sector in Local Government for over a decade before moving to the voluntary sector and I cannot even begin to compare the two. I may not have such a good pension as I would have done if I’d have stayed with my old employer, but the quality of my working life has improved by leaps and bounds.

“Experienced staff are likely to be older and therefore more concerned about their pensions, so they are very unlikely to want to move to new social enterprise sector organisations. This means that some of the most severely mentally ill people in the area are being cared for by people who themselves are newly qualified or in some cases trained in-house.”

The first part of this statement is as sweeping and meaningless as it would be if we were to say “Older staff are time-serving jobsworths who are set in their ways, resistant to change and unwilling to embrace new ideas and ways of working.” This is a grossly unfair and untrue generalisation – as is Karen’s point. Some of our best workers – those who are keenest about life-long learning and continuing professional development, who have the best rapport with service users and are our most skilled practitioners – are in their thirties, and by Karen’s standard should probably be written off as inexperienced. On occasion, HARP – like the Trust or any other employer – has taken on newly qualified staff. After all, they are the experienced staff of tomorrow. I have really struggled to understand how having some relatively inexperienced staff working alongside more experienced colleagues is problematic or makes the voluntary sector any different from any other sector. Interestingly, on the assertive outreach service we run, all the staff are between their early thirties and mid fifties, with most being over forty: hardly a service made up of inexperienced staff! In any case, experience needs to be set alongside knowledge, skills, dedication and decent values, which we have in abundance.

In addition to their qualifications and to training provided by outside agencies, we provide or purchase some training in-house. Purchased training has included, for example, sending four team members on post graduate courses in psychosocial interventions; sending four unqualified team members to train as social workers with the Open University, sending three team members on a post graduate dual diagnosis course, sending two team members on nurse prescribing courses. None of this should be used against the voluntary sector, as Karen has tried to do. Rather it reflects well on HARP’s commitment to staff development and I would imagine compares very favourably to a typical statutory team. ‘In house’ training has been about arranging for trainers to come to us rather than sending two or three team members on external courses. So for example, we’ve have in house training from the Dual Diagnosis Service on motivational interviewing and the cycle of change, from Shelter on homelessness law, from HARP Advice Team on Disability Living Allowance and so on. We’ve also had regular team clinical supervision that has included a teaching element. Again, none of these things reflect badly on HARP, but rather are something we are pleased to tell people about.

In conclusion, we are immensely proud of the services we run and of the dedicated, hard working and skilled staff we employ to deliver those services. We believe that innovative and dynamic partnerships between the voluntary and statutory sectors are an important part of the future of the mental health economy in the UK. It’s now time to get beyond the ‘either/or’ debates about who should run services and look at how different organisations in different sectors can bring together a range of skills and expertise for the benefit of our service users. Neither the voluntary nor statutory sectors have the monopoly on good practice but both sectors have much they can teach each other.