This report results from an extensive research project examining how knowledge functions within a consultation process for a new mental health policy in Scotland. The research is part of the European Commission funded KnowandPol project which investigates knowledge in relation to health and education policies within eight European countries. The work of the Scottish Health team throughout the project focuses on mental health policy in Scotland. Our work reported here represents the first of two case studies for ‘Orientation 2’ of the project which seeks to examine the way knowledge is used and produced within the processes of a particular policy or public action.
The following questions guide the general KnowandPol research within Orientation 2:
• Where do the actors involved in the public action speak from? Where do they come from? Who do they talk to? What kind of relationships are they involved in?
• What do the actors involved know? What do they think they know? What types of categories do they use in their narratives? How do they assemble ideas, actors, devices, events, values in their story?
• What are the common stages/events emerging from the narratives?
• Why is it that such or such representation of reality comes to structure public action at a given time period in a given country/sector?
In order to explore these questions we have chosen to focus on the consultation for Towards a Mentally Flourishing Scotland (TAMFS) which was launched in October 2007. This consultation was initiated to develop the next stage of the Scottish population mental health policy - the National Programme for Improving Mental Health and Wellbeing. We chose the TAMFS consultation as a case study because the policy consultation process represents a ‘critical event’ in that it serves to strip an existing policy back, makes it justify itself and opens itself up to new discourses. It also represents the introduction of a new form of knowledge into the policy domain and permits us to visualise the way in which this knowledge flows through the policy community. It allows us to examine the knowledge used by a wide range of actors in their interaction with the policy ideas and each other. This action happens within a wide range of settings – within many different document forms, closed meetings, pubic events, 2 private discussions and emails. This allows us to visualise how knowledge differentially functions within these different practices.
The TAMFS consultation consisted in a series of events, documents and meetings which responded to a government consultation document. The key ‘public’ stages of the consultation involved a series of consultation events hosted nationally and by local authorities, health boards and NGOs and the submission of consultation response documents by individuals and organisations. The key ‘closed’ (internal government and invited) stages of the consultation involved a series of meetings by a national reference group of expert service users, practitioners and academics and of a internal government reference group, meetings between government actors and individual experts and a series of events with key stakeholder groups prior to the publication of the final policy document.
We tracked each stage of the consultation process by utilising a broad mix of data collection methods:
1. Interviews on the development of the National Programme and how the consultation document was developed.
2. Observation of a broad range of consultation events.
3. Documentary analysis of the consultation document and support documents.
4. Documentary analysis of written responses made.
5. Observation of the National Reference Group guiding the consideration of the consultation responses.
6. Interviews with those responsible for organising the consultation events and/or drafting responses.
7. Interviews with those involved in drafting the final policy and action plan.
8. Documentary analysis of the final document and other documents which informed its development.
In order to answer criticisms about the lack of a clear model of mental health being used in the work of the National Programme the TAMFS consultation document introduced a new theoretical model for public mental health based around the work of Corey Keyes and Keith Tudor. It also based itself clearly within an ‘inequalities’ framework.
We found that different actors used different forms of knowledge in very different ways at different stages of the consultation process:
Government actors set the terms of the consultation and used its involvement in order to educate the consultation ‘public’ about their agenda for mental health improvement. The knowledge government actors were presenting was validated through their reference to the work of ‘expert’ and international actors and through 3 referring to peer reviewed research and statistical evidence from the use of indicators and other measurement tools.
The Scottish Government does not create knowledge, but rather it gathered and organised it. Its involvement in the consultation was as a hand guiding the process. It directed how knowledge should be understood (in this case through the selection of appropriate theory) and what types of knowledge should be gathered (consultation events and inviting specific types of actors to contribute and through devising instruments such as indicators to support the policy implementation). In this way it set up the conditions in which knowledge could be created but did not generate its own knowledge.
Practitioners made up the vast majority of the ‘consultation public’ present at consultation events. Different practitioners were invited to present examples of ‘good practice’ at all consultation events we attended. The dialogue between practitioners within discussion groups which followed these presentations drew on the experiential knowledge of practitioners. This experience-based knowledge drawn from their work – often expressed in the form of short vignettes about their practice - was ‘traded’ in a back and forth dialogue between participants. The trading of good and bad practice allowed the boundaries of work in the area to be ‘rehearsed’. Through the processes of the consultation appropriate practices were therefore developed in relation to the new policy being discussed. This process was educational in that it taught those who would have to implement the new policy about how this might best take place. In this way the consultation process acted as a way of cementing the new policy in the minds of those who would have to do the work and ‘armed’ them with strategies for how the work of the policy could be taken forward.
Practitioner knowledge did not take the form of vignettes in the consultation responses which were submitted by mainly practice-based organisations. In the consultation response documents practitioner organisations drew to a far greater extent on ‘official’ evidence drawn from research reports, evaluations and statistics. Practice based knowledge was largely absent from the rest of the consultation process although practitioners were included in the final stakeholder discussions in order to validate the policy before it was released. We argue that this may be as a result of the particular practices surrounding different parts of the consultation process – because of conventions about their use official policy documents cannot contain the type of experiential knowledge produced and used by practitioners.
Unlike practitioners and government representatives, service users and carers did not give presentations on their experience at the consultation events but were most active as participants in discussion groups. As with practitioners, the service users and carers we observed based their knowledge on personal experience and often transmitted this knowledge through the use of small vignettes used to illustrate a point.
Service user knowledge did not ‘travel well’ through the process. Service user voices were present at the consultation events and reference group meetings but did not readily move from this context into the consultation response documents. This may be as a result of the form that service user knowledge was presented in. Like practitioner 4 knowledge personal experience is difficult to quantify and the vignettes in which service user knowledge were presented do not easily fit within some document forms.
The experts whose knowledge was included in the consultation are mostly public health specialists and academics. Academic knowledge was not prominent in the consultation events and only visualised through the presentation or citation of the work of these experts. It was more prominently used in the reference group, which included academics and was provided with papers and presentations by Keith Tudor, Phil Hanlon and Carol Tannahill. The experts present a mixture of local actors who know the Scottish ‘scene’ and international experts who provide the theoretical and epidemiological perspectives which frame the work of the National Programme. Their knowledge was used to validate the government’s agenda for mental health improvement in Scotland.
Psychiatry- an absent actor:
Psychiatrists did not participate at most of the consultation events and were not invited to do so by the government. Psychiatry has traditionally had little to do with the day to day work of public mental health, given that its focus is on the treatment of mental ill-health. Professional psychiatric knowledge challenges the mentally flourishing framework, as evidenced in the response document submitted by the Royal College of Psychiatrists, which made negative comments about the theoretical framework underpinning the TAMFS document.
Consultation as education:
Within the TAMFS consultation the purpose of creating a new policy seemed at some stages to be secondary to the purpose of ‘education’ of the policy ‘public’. Different actors used the consultation process for different educative purposes. For the government the consultation document and events also provided an opportunity for educating a captive audience about the issues and practices involved in the implementation of policy and practice for population mental health. The use of language and theory were important instruments in this work. In our discussion of practitioner knowledge we show that for organisations hosting consultation events these served the purpose of educating those working within their organisation or area about the role that they had to play in doing the work of the National Programme. This ‘education’ took place via presentations made by government, practitioners and experts. It also occurred through the back and forth dialogue of practitioners sharing good practice.
Through its educative function the consultation process worked to carve out a new space for policy action which would mean an easier transition to the new policy and a greater depth of policy awareness which would, in turn, lead to better policy implementation. In this way we can visualise the consultation process as functioning as the first stage of policy implementation. Consultation processes in themselves thus act as a macro instrument of policy.
Hierarchies of evidence – theory vs. other types of evidence:
The decision to use the theory related to its status in relation to other types of knowledge. Use of the theory was seen as a logical step for the consultation document as it provided a justification for the policy approach taken where no other evidence existed that would justify the policy. In the TAMFS consultation document theory was thus used instrumentally in place of other evidence when there were no other forms of evidence available. However, by the time that the policy and action plan came to be written other forms of knowledge had become available which were seen to challenge the ‘authority’ of the theory as evidence underpinning the work of the National Programme. The creation of new statistical and other research data on public mental health served to destabilise the dual continua theory for those developing the policy and action plan. Theory, then, was seen as important, but was ‘outclassed’ as a form of reliable policy evidence in the face of ‘data’ sourced from measures and indicators.
Language was used instrumentally by different actors throughout the consultation process where different vocabularies were used or challenged in order to make different policy arguments. Many of the arguments related to the need to develop a shared language which could convey the themes of the policy. Using a certain kind of language brings with it a certain kind of knowledge or theoretical perspective. Even in the absence of formally articulated scientific knowledge, the ’right words’ were seen by many involved in the consultation process as a key vehicle of the ’right policy. There was a frustration amongst a range of actors about the inability for a shared language to be developed that could simply express the theoretical basis underpinning the work of the National Programme. A lack of a shared language was seen to result in limited shared working around the goals of the National Programme and a failure for the message of positive mental health to spread into other fields. Language was thus viewed as an important instrument whose correct use would lead to successful policy outcomes
Our analysis pointed to a growing interest in the creation and use of statistics and, following on from this, the development of indicators for mental health policy in Scotland. This raises questions about why indicators and statistics are seen to have such utility for mental health policy. It was felt that a lack of indicators meant that particular policies and programmes could not be justified to funding bodies and agencies because their effectiveness could not be adequately gauged. Drafts of the final TAMFS Policy and Action Plan called for the development of new indicators for population mental health in addition to the newly devised Warwick Edinburgh Mental Wellbeing Scale (WEMWBS). The introduction of these new indicators extended the boundaries of the governable space yet further. Part of the utility of the development of the WEMWBS scale is that it marked out a new space as governable – that of positive mental health - and this was important when the words used to express the theory were deemed to be inadequate. Numbers were able to do what words cannot. A set of indicators becomes the shared language that everyone can use.
Conclusions about knowledge in the TAMFS consultation:
In concluding we can list some of the variables effecting the emergence of different types of knowledge within the consultation process:
Discourse practices – the type of practice in which a discourse is enacted depends on what type of knowledge is prioritised. For example, consultation events give way to embodied knowledge such as good practice or personal experience. This knowledge is not able to be contained so easily within a highly structured document such as a policy and action plan, where strict conventions govern what content is acceptable.
Individuals – what gets written down on paper in the end is determined to a certain extent by who does the writing. At each enactment of knowledge within every stage of the process different configurations of power and knowledge determine what knowledge is included. The leadership style and personal knowledge of those in leadership positions within the Mental Health Division determined what sorts of knowledge were prioritised within, for example, the discussions in the National Reference group.
Political environment – the political environment will have a ‘high order’, macro bearing on what knowledge is prioritised in the process. For example, the SNP’s prioritisation of the use of indicators through its National Performance Framework meant that indicators were more highly prized than other forms of policy instrument.
Availability of instruments – in our discussion of theory we noted that there was what could be called a ‘hierarchy of instruments’ functioning. Theory was valid evidence for policy development only when the evidence produced by a more reliable instrument such as, in this case, data from an indicator, was not available.
SMITH-MERRY Jennifer, FREEMAN Richard & STURDY Steven (2009), Towards a Mentally Flourishing Scotland: Consultation as Public Action, KNOWandPOL Report.