V – so how is the mental health work going? We haven’t heard about that for a while.

A –  Well, OK.  Perhaps not as much happening across the strands of work as I’d ideally like and maybe the statutory bodies doing things themselves, ignoring the group.  But the main thing I wanted to focus on this time, was a review of supporting people in crisis.

V – OK, go on.

A – This all started with service users raising concerns about the support they get when ‘in crisis’, particularly getting a satisfactory response from the mental health trust’s crisis team.  So, about a year ago, it was agreed there should be a review, kicking it off at one of a regular series of meetings between service users and professionals in March 2018.

V – right, I remember now, you mentioned this in a blog in July? [link]

A – that’s right.  It seemed, at the July meeting of the group, as if the service user meeting and the report on it were being taken as the end of the matter without a review.

V – but wasn’t it going to be discussed again at the following meeting?

A – yes, the one in September, to which I presented a paper setting out the case for a review and suggesting how it should be done.

M – no doubt everyone could see you were completely right as usual so they just agreed to everything?

A – well, no.  The idea of a review wasn’t rejected but practical difficulties were raised.  Who would drive and project manage the review; how could you get senior buy-in to it; and what area should it cover, that of the Health and Wellbeing Board (the local authority area) or the whole county which the trust covers.

V – Important issues, but presumably not insurmountable.  Did they discuss how to overcome them?

A – no, we ran out of time and it was agreed to escalate it to the steering group for the Health and Wellbeing Board.  That was September.  There was a report back from the steering group at the November meeting.

M – and?  We’re all ears.

A – The objections that had been raised before weren’t mentioned.  Instead, there was a concern expressed that the scope was too wide: that examples of crisis from the service user meeting went from not having enough milk to potential suicide.  You see, the service user meeting had asked people what they meant by crisis, at various levels from mild to extreme.  However, the reference to milk wasn’t in the final report, so presumably this was something the person had remembered from the event itself (so presumably a salient part of their take on the topic).

M – but it’s a fair point isn’t it?  Crisis can mean lots of things and you couldn’t deal with all of that in a review.

A – you could draft the scope in terms of people in such a state of crisis that they call the crisis line, police or other public agency or commit serious harm to themselves or others.  If a seemingly minor matter quickly escalates, then it may be important to understand such situations, to find ways of dealing with them, such as through peer support and voluntary organisations.

V – so where does it stand now?  Is the review going ahead or not?

A – they’ve taken it away to have another look.  Anyway, I’m sorry to have taken so long describing the situation.  I really wanted to talk about some of the issues arising out of it, in terms of what it means for partnership working.

M – oh no, this isn’t what you were going on about before is it, the difference between ‘collectivities’ as entities and ‘shifting coalitions’?

A – well, yes, I’m afraid that is sort of part of it.

V – come back and sit down, Mal, let’s give him another chance.

A – OK.  Well, first of all, part of what happened can be explained by ‘shifting coalitions’ – there were different sets of people at each meeting.  They would each hold their own mental representation of the situation – the salient facts and judgements on them.  A sub set of these would be aired at each meeting (not everyone gets chance to say everything they might want) leading to a judgement at that time.  So you get variation: discussions and decisions veer one way then another depending who’s there and which voices get heard.  The alternative would be to have more of a collective mental landscape.

M – except in this case wasn’t it pretty constant – a constant push back against the idea of a review?

A – well yes, I did wonder if this was all just an ongoing attempt to kick it into the long grass.  But there was variation in the arguments used, so the ‘shifting coalitions’ idea is still relevant.

Which brings me to the second way of looking at the committee, or partnership, as an entity or collective.  To some extent, the committee had to take account of its previous discussions and decisions.  Not that it was unable to change them, but it would be a decision to change, rather than treating each issue at each meeting as if nothing had been decided before.  (Although it is possible, on occasion, to forget or ignore what has gone before).  So in a sense, the committee as a whole has a view, independent to some extent from the particular coalition view at any one time.

M – all very fascinating in terms of some sort of arcane theory, but has this any relevance at all for real people in the real world?

A – Well yes, a couple of things occurred to me.  While variation isn’t inherently bad, you need to make the most of it.  So, if different views are expressed, you need to ensure they are taken into account but within a coherent approach, the ‘committee view’.

V – this is still sounding rather theoretical.  Any practical applications?

A – Well, there are implications for recording of discussions and decisions and for the decision making process itself.

If you have different people at different meetings, you need to make sure the discussions are very well recorded and minuted.

M – and don’t tell me, the people you have just aren’t up to the standard it would be if you were doing it.

A – not at all, they were excellent.  So I accept that suggests it isn’t enough to have well recorded meetings.  I still think it’s important, though, so people can follow, and revisit if necessary, the threads for how they got here.

The other thing is about decision making.  This is another whole subject in itself, but here are a couple of issues.  Often there isn’t full participation in a decision (for instance, the chair assumes the conversation is going a particular way, even if not all views have been expressed).  Also, the various arguments are not always marshalled and set alongside each other to be fully taken into account in decision making.  So, for instance, a simple chart with pros and cons plus other implications and comments could be helpful.

If you don’t have a written, systematic approach, the risk is that you rely on a selection of people’s shifting perceptions; what they happen to consider most salient at any one time, their particular, possibly idiosyncratic views and judgements.

M – All very nice, theory-boy, but who’s going to produce all those decision diagrams for all the many decisions a committee takes?

A – fair point.  But if a committee has, say, three or four projects or issues over a period of a year or two, isn’t the broad way forward on each of those worthy of some systematic, in-depth decision making on the basis of facts and evidence?

V – so let me get this straight.  You seem to be saying that it’s better if the committee or partnership can act as a collectivity or entity, rather than a ‘shifting coalition’.  But to help it do that it needs to be better at coming to a collective view and recording how it arrived at that view.  It can then use that to more consistently navigate the waters as it goes forward.

M – lord help us, you’re sounding just like him now!

V – just reflecting back, not necessarily how I would have put it.  Is that broadly right though Ade?

A – Yes, I suppose so.  This isn’t a totally well-thought out theory; it’s just trying to make some sense of recent experience in more general terms, that could then be applied to other situations.

I mean, I suppose there could be an argument that if the collectivity isn’t as good at something as some sub-set of it (it’s less than the sum of its parts), you might as well let a few individuals just get on with it.

M – Never mind the variation you get from ‘shifting coalitions’ – you manage to get that much variation from just within yourself, in the course of one discussion.

V – on which point, I think we better leave it.  If not any definitive conclusions, at least some food for thought.