In her first director's blog, our co-founder and managing director, Vikki Price, tells us about how intelligence-led approaches came to be a central focus in Peer Hub's thinking about transformational change in mental health services.
It's an understatement to say I had some thinking to do when I decided to set up Peer Hub CIC. I’ve spent an awful lot of time over the past few years working closely with people with lived experience of mental health problems and listening to the challenges they experience in accessing good care. I’ve also reflected a lot on my own experiences of mental health care and working in an NHS Trust. I wanted to provide valuable and meaningful training and consultancy to improve people’s experiences of care, and also staff’s confidence and experience of work. Listening to strategic leaders across organisations, one of the most common questions that I have heard is ‘how?’ – How do I implement trauma informed approaches? How do I implement peer support? How we do coproduction and involvement better?
There is a real desire for some quick, clarifying answers about how to get from A (business as usual) to B (new approaches). I found this interesting, because leaders already have access to all the information they need to do this stuff, they just need to know how to wade through everything out there, figure out what they need to know and how to then use that knowledge effectively in strategic planning and decision making.
Thus, the Peer Hub CIC training and consultancy service was born with a focus on intelligence-led approaches. Why? Because intelligence-led approaches are a framework for how to use what you know, and this seems to be the missing link in strategic development. On 15th February 2021, Peer Hub CIC will be officially launching. But before then, I’d like to introduce what intelligence-led approaches meant to me and how I believe they can enable and streamline the implementation of all the other important things in mental health care today.
My experience of intelligence-led approaches
Before moving to the mental health sector, I started my career working in justice and law enforcement. I was lucky that during the 9 years I worked in policing, there was a commitment to and focus on intelligence-led policing and innovation in crime analysis. I learned so much through the ups and downs of my role as an intelligence analyst, and when leading a team of analysts, researchers and information officers as a senior analyst. The main thing I learned was the importance of knowing the strategic operating environment, and making strategic decisions with a good idea of what you know, what you don’t know and what you need to know, and often: what you really don’t need to know!
I’ve noticed that strategic direction in mental health can be a bit woolly, both centrally from NHS England and Improvement, and locally in terms of what to prioritise and how. That doesn’t mean that there aren’t strategic plans in health, it’s just that they’re not communicated in a way that is clear and accessible, and they don’t seem to have much impact on the ground. And, perhaps most confusing for me, there’s no real direction and accountability about what needs to be better understood in mental health to execute those strategic priorities, or direct expectation of actions for frontline staff in relation to them.
Also, everything seems to be a strategic priority (crisis care, child to adult service transitions, trauma informed approaches, peer support, evidence based practice, psychological therapies, prescribing etc etc). The result of that is that everyone seems to be doing their own thing. Implementing a strategic programme feels a bit like herding cats that are all chasing mice, where all the mice are equally as valuable as anything I have to offer in the grand scheme of things.
Policing isn’t perfect, that I will say. There are mistakes made that raise fair concerns for the public, and we’ve seen that really quite powerfully over the last year with the Black Lives Matter movement. But largely, law enforcement agencies aim to be clear about what they’re doing and why, and lead their strategic activity through intelligence gathering, analysis and intelligence-led decision making. This means there’s a continuous cycle of actionable information moving throughout the organisation. While it’s a question for leadership about how to reliably get people to do what they’re supposed to be doing, my experience of policing was that I knew what I supposed to be doing most of the time.
Setting clear strategic priorities is to key to framing the work and expectations of front-line staff. For example, the national strategic priorities set by the Home Office for the National Crime Agency clearly direct where their areas of focus should be:
Reduce the number of victims of exploitation: this includes Child Sexual Abuse and Exploitation, Modern Slavery and Human trafficking and Organised Immigration Crime
Reduce the impact of Serious Organised Crime on Communities: the main threats are firearms and drugs
Reduce the harm to individuals, the UK Economy and Institutions from economic crime – the main threats under this includes money laundering, fraud, and cybercrime.
Strategic expectations for areas of focus in mental health seem significantly less clear. What are the priorities for NHS England for mental health? Do you know? I can find plenty of documents from the Five Year Forward View, to the NHS Ten Year Plan, the Community Mental Health Framework – exec summaries, implementation frameworks, review. But, frankly, there are so many things that mental health services are trying to do, it’s really difficult to tell what is the most important thing, and where resources are best allocated. It’s even more difficult for front line workers to tell what the best outcome is in any decision they make, even down to the basic questions of how to best deal with significant risk.
From my personal and professional experiences of mental health services, I feel that using an intelligence led approach could really help co-ordinate strategic activity to support the work of front line workers, and improve the experiences of service users. So, in this, my first director’s blog for Peer Hub CIC, I’m going to lay out a quick overview of intelligence-led approaches. In my next blog, I’ll publish an example of an intelligence-led strategy for suicide prevention, to put the theory into practical context. Hopefully, by outlining key elements and translating the theory into practice, I can demonstrate why Peer Hub CIC is centring intelligence-led decision making in our training and consultancy services, and the value this can offer for mental health providers.
Where did intelligence-led approaches come from?
Intelligence-led policing evolved from mistakes, not successes. It emerged from picking up the pieces after tragedies which, on reflection, turned out to be preventable if only decision makers had known then what they know now. But importantly, intelligence-led policing evolved from the fact that that decision makers could have known then what they know now, if they had taken time to look in the right places. In most cases, the information they needed was already within their organisation, or even right under their noses.
Intelligence-led approaches were driven by two main failures in law enforcement and military intelligence processes: failure to use critical information to inform action because they didn’t know they had it; and acting inappropriately on information because the personal assumptions and biases of decision makers led to information being misunderstood, overlooked or misused. Major events that caused law enforcement and intelligence agencies to reconsider their approaches and reform their use of intelligence during the development of intelligence-led policing included:
The gaps in intelligence processes leading up to the terror attacks in the US on 9/11 (2001) and in the UK on 7/7 (2005)
The failure of agencies to share information that led to the murders of Holly Wells and Jessica Chapman in Soham, Cambridgeshire (2002)
The failure to verify the intelligence picture that led to the invasion of Iraq by the UK and the US (2003)
The death of Peter Connelly (Baby P) due to failures in systems to protect vulnerable children in London (2007)
The killers of Stephen Lawrence going unprosecuted in the 1990s due to institutional racism and police corruption (and enquiries and investigations in 1999, 2006, 2013 and 2014)
The intelligence that Jimmy Saville was sexually abusing children, that was not believed and/or acted on when he was alive, leading to the posthumous revelation of over 300 victims of sexual predation after this death (2012)
All of these events may have been prevented by acting on information and intelligence already held by agencies. Intelligence-led approaches grew from failures to identify the important information that preceded terrible events, and the flaws in human logic that led to actions or inaction that led to appalling, irreversible harm. They come from the learning that human beings are fundamentally flawed in the way they value and interpret information and when decisions and action are vital to prevent harm, robust processes need to be in place to ensure the information acted on is solid. To ensure the right action is taken, there needs to be an ability to counteract innate beliefs, assumptions and biases that skew the understanding of what is known and what is likely to be true. This is particularly true of strategy, when decisions affect the practices across an organisation for long periods. But crucially, also, in communicating strategy, which should affect the thousands of decisions made in large organisations by staff on the ground, every day.
Obviously, policing practices have a strong focus on enforcement, and mental health practices are much more focussed on care. Whilst the fundamental purposes underpinning policing and mental health might differ, both police officers and mental health practitioners have powers of detention, responsibilities around human rights and responsibilities for preventing serious harm. So, just putting aside for a moment some of the ideological differences that can arise across both criminal justice and mental health sectors, what value might an intelligence-led approach offer mental health providers?
What are intelligence-led approaches?
Intelligence-led approaches are systemic processes that enable decision makers in organisations to assess the information they have, direct the collection of information they need and analyse information to make informed decisions and then effectively communicate them. The UK has a National Intelligence Model and a National Decision Making model that guide police activity in how intelligence should move around an organisation to inform decision making at all levels. The benefit of an intelligence-led approach is that it is an informed approach, and it can reduce the likelihood of unintentional error. This is something I believe might really make difference around reducing iatrogenic harm in mental health services, among other things.
What’s the difference between intelligence-led and evidenced-based?
The developments in Evidence Based Policing support police decision makers to identify the action they can take which is most likely to be effective. However, without understanding the context of taking action, even evidence based practice is likely to have limited results. In a nutshell, from the orientation of problem solving: you can’t effectively apply evidence based practice without first knowing the problem you are trying to solve. Intelligence-led approaches are the means by which to understand the problem.
Intelligence led policing is putting the horse before the cart because your problem is moving the cart. Or closing the stable door before the horse bolts, because the problem is a bolting horse. It’s knowing the problem, so that you can then decide how to solve it: whether you’re a strategic manager, or a front-line worker. So, if the problem is iatrogenic harm, we need to know what that can look like before we can take evidence-based action to avoid it. Or if the problem is suicide rates, we know enough about suicide to be able to take action to reduce its rate. The knowing, then the action: the intelligence, then the practice.
Intelligence-led strategy and policy making
Strategy and policy are the means by which organisations identify what they are going to do and how they are going to do it. Strategy lays out the long term aims and the plan to reach them. Policy draws the lines around action that can be taken – whether that’s due to legislation, regulation or the values of an organisation. Intelligence-led strategy and policy, then, means getting the information needed to strategic decision makers and policy writers to ensure strategy and policy are based on reliable and valid information. It also means that where there are gaps in understanding, the strategy can seek to address these gaps, review them and amend as needed. An intelligence model also includes how this is communicated to ensure everyone knows what the strategy and policies are, and so they can be used in staff’s day to day work.
There are obvious questions in the transferability of intelligence-led strategy from policing to mental health. Particularly, there are ethical considerations about the boundaries of intelligence-led approaches, which information should be accessible to mental health services in making decisions, and who should direct mental health strategy when there is such debate about what is helpful or harmful. In my next blog, I’ll show how intelligence-led approaches can be implemented in strategy with a case study on suicide prevention. I’ll address some of the potential issues with practical application moving from criminal justice to mental services, and I’ll also highlight how taking a trauma informed approach to strategy development leads to a trauma informed approach in front line working.
But for now, at the very least, I hope I’ve opened your curiosity to the potential of this way of working. Hopefully, also, we can start a conversation about how what we know affects how we act, and different experiences of people across different roles.