A behaviour change programme minus the behaviour change: What happens when health services are run as businesses?
In austere times, outsourcing health services to private providers is becoming more common. To ensure service-users aren’t short changed and public spending isn’t wasted, commissioners need to take a much more hands-on approach
Changing eating habits is often an element of a behaviour change programme
Recently, I spent a period working as a clinical psychologist in a health and well-being service, commissioned by a local authority in response to the UK’s obesity rate. The service is run by a small private organisation and was set up to promote healthy lifestyle behaviours. One of its aims is to support people to achieve a healthy weight to reduce the risk of preventable weight-related diseases and the human and economic costs associated with these. It does this with programmes designed to change people’s behaviours around food and eating and increase their physical activity.
Aspects of the service were very encouraging. The team deployed creative ways of engaging local communities, statutory services and charities, ensuring a steady stream of suitable people referred to the service. It had established a strong presence in the community by taking part in health and wellbeing campaigns. The programmes were delivered by an enthusiastic though overstretched team that strongly abided by the “code” of the healthy lifestyle behaviours they promoted. A particularly exciting aspect of the service was that commissioners had recognised the role psychological and psychosocial factors play in the development and maintenance of obesity and behaviour change – hence the opening for a psychologist. I was excited to get stuck into my role, supporting this already vibrant service by integrating psychological theory and practice into the service delivery.
Alas, my enthusiasm was short-lived. As I gained insights into how the service functioned, a nagging sense of unease took hold. A feeling, I now think, that stemmed from a tension created by the outsourcing of public services to private providers. It is hard to believe that the consequences of this tension are limited to this particular service - after all, in current economic times, this model of service procurement is becoming the norm. In fact, while writing this article, I had numerous conversations with colleagues working within the public and education sectors who found my experiences resonated with their own. This further convinced me to share my experiences as I hope they will stir up a further discussion.
The UK government's ‘Prevent’ policy has put counter-terrorism on the agenda for social workers and health practitioners but what are the ethical implications for the services and the impact on the people they serve?
Since the London tube bombings in 2005, counter-terrorism policy in the UK has extended into many areas of daily life. Introduced in 2006, the UK government’s Prevent strategy has put staff in areas such as local government, health and education on the front lines of domestic security and even border control, making them responsible for identifying and reporting those they consider at risk from ‘radicalisation’.
The extension of counter-terrorism to the safeguarding of vulnerable individuals such as children is unique to Britain and the ethical dilemmas it poses for professionals who work with communities rendered suspect by Prevent are only beginning to be explored.
In 2016 a UN special rapporteur criticised Prevent on grounds that the government’s definition of domestic extremism was too broad, noting concerns about “the program being implemented in a way that translates simply into crude racial, ideological, cultural and religious profiling, with consequent effects on the right to freedom of association of some groups.” Muslim groups and charities including Amnesty International and the Muslim Council of Britain have raised concerns that the policy creates division and resentment.
Anxieties about terrorism can lead to a climate of fear in which vaguely defined ‘security risks’ can become pretexts for political repression, greater government intervention in daily life and even deprivation of the rights and protections afforded by citizenship. The introduction of pre-emptive ‘risk work’, analogous to duties performed by the security services, into health and social care settings may adversely impact communication between service users and professionals and deter help-seeking – especially in scenarios where children may be removed from their parents' care.
Researchers in health and social care have begun to assess the implementation of Prevent to ask whether Muslim groups are right to see the policy as discriminatory. Questions include the impact of pre-existing biases among professionals on referrals and over the validity of the ‘conveyor belt’ model of radicalisation – a key premise of the policy which places 'moderate' religious and political beliefs and behaviours on a continuum leading to 'extreme' beliefs and potentially violent acts.
On 22nd January 2019 the government announced an independent review of the Prevent strategy, raising the possibility that the policy may be reformed. However, security minister Ben Wallace has sounded a defensive note, demanding "solid evidence" that Prevent is in fact discriminatory and accusing the policy’s critics of using "distortion and spin" to raise concerns over its effects.
In such a highly contested and politicised area, concerns about national security are sometimes invoked in a way that shuts down debate. Is it possible for health and social care professionals to stand in solidarity with service users who feel victimised in this climate? Given that Prevent remains a statutory duty as part of safeguarding, how can professionals think through the ethical and professional dilemmas it raises when working with families from communities that feel unfairly targeted? Even if the policy ends, what can we learn from the issues and debates prompted by its implementation?
If you are a health or social care professional interested in knowing more, come to the joint BASW (British Association of Social Workers) London and MedAct event on Thursday 21st March. Advocacy groups, social workers and academics will present some of their findings on the above topics and MedAct will facilitate a discussion and workshop:
PSC is a network of people interested in applying psychology to generate social and political action. You don't have to be a member of PSC to contribute to the blog