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

Abstract

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.