Consultancies and Government in mental health: The Flawed Business Model

I believe the business model around consultancies and mental health (and possibly broader social policy) design is rigged against the community who is meant to benefit from that policy.

Having worked with many consultancies, I observe that while some consultancies are values-driven and work in solidarity with community, many others are well-branded profit machines. Individuals and organisations need to reflect, but it is important for us as a community to reflect on the broader business models that are incentivised by this approach.

This is what I think we can do as a community to address it.

The context

There are multiple converging trends emerging in mental health policy.

Demands for co-design

First, there is an increasing demand that people with lived experience – consumers of mental health services in the first instance and families, carers and supporters secondly – have a more meaningful say in the policies that affect them. In many respects this leads to calls for ‘co-designed’ or ‘co-produced’ mental health policy, or frameworks developed and led by people with lived experience.

Under resourced government

Secondly, governments are lacking the human resources – due to a stripping back of the public sector at the same time that there are increasing demands on it – and therefore relying on the use of consultancies to assist in this process. The Victorian Government has spent $671 million on consultants in the last five years.

Branding for co-design

Thirdly, those consultancies therefore need to appear to be able to deliver on the expectation of co-designed or co-produced mental health policy. They are more able to fashion themselves in this respect because they can be more targeted with the brand development/image management than a government, by having fewer tasks and constituencies, and less visible power (which grants the appearance of being more collaborative rather than dominating, which a government can resemble).

The problem

This convergence is creating a whole range of problems. These include:

• Faux-design – consultancies are reflecting rhetoric of co-design and co-production, without meeting the accepted standards of those methodologies from the communities impacted. Read more from Jo ?? Szczepańska .
• Poor or status-quo policy – these poor design processes result in either worse, or at best, status-quo maintaining mental health policy, at a time where the need and demand for change is urgent and enormous.
• Misuse of tax-payer money – often the use of consultants is a way to mask government debt, but masking doesn’t change the reality: we are paying for bad or unhelpful policy.
• Public service hollowing – the reliance on consultants, if unchecked and uncritically used, can white-ant the public sector, which then loses further capacity and in turn relies more on consultants. This creates what many call a ‘shadow government’. It’s a vicious cycle.

• Undermining responsible government – the notion of responsible government is that Ministers and governments are responsible for how they exercise their functions. But if the faux design is done by consultancies, the government becomes one-step removed which can limit the accountability on them.

Broadly this all creates an unhealthy set of incentives whereby consultancies do what they think will get them a pipeline of contracts, even if that comes at the expense of people with lived experience. It also means the radical potential of co-design and co-production is lost, reform is delayed, and we lose another generation to failed mental health reform. Instead, consumers and survivors, and families, carers, supporters and kin are tasked with repeating the same messages over and over again where they gain little in their lives while profit grows among consultancies. Profits and wages rest on this current operating model.

Something needs to change.

The opportunities and draft solutions

There are several ways that we as community members – in particular those with lived experience – can support change. With the unhealth business model and incentives between government and private sector actors, the reality is that the responsibility to prompt change requires this. The solutions lie not in making micro or minimal changes, but rather to change the political and business incentives to be more aligned to our needs. In broader regulation and governance scholarship and evidence, solutions are found in an active civil society (e.g. community) that intervene to break negative cycles. So while the task is big, I believe there are clear tasks we can get on with.

Some things that we could do:

• Become familiar with true co-design – we should all be aware of and demand true co-design. Looking at the available resources on co-design and co-production (and see this Kickstarter from Jo River ), this gives primacy not just to the tools – e.g. sticky notes, journey mapping, prototyping and so on – but rather on power and decision-making. We should be clear and demand decision-making power if those terms are to be used (and they should be!).
• Obtain evidence of poor work – if you believe that you have been part of a faux design process, seek to gain evidence of that and document where it doesn’t meet our standards of co-design or co-production. If that information can’t be shared or isn’t public available, learn (it’s not that hard) how to do your own freedom of information request to government about reports and documents by private consultancies on their co-design processes.
• Use the media – this is a hot political topic at the moment, which means it is newsworthy. That won’t always be the case. News cycles move fast. If you have tried to resolve issues with a consultancy and they haven’t acted in good faith, consider providing evidence of the issues to the media.
• Act in coordination – de-centring oneself and acting in solidarity is critical to systemic change. Act in coordination with other community members who may have experienced faux design. The more cross-community support and volume of voices, the stronger your story and the greater your likelihood of pressuring a change in the political and business incentives.

To me,? this broadly coalesces into a strategy for a project – led by a coalition of individuals and organisations – to obtain information on poor performance, develop a report and single out the best and poorest performers, and to release this report via the media with recommendations for consultancies and government. Doing this extracts a commercial cost for the use of faux design and a political cost for either inappropriately contracting out or doing so knowing that it will result in faux design.

Importantly, this needs to be generative too. We need to re-establish an image of what an effective market and public service would look like in service of the kind of mental health reform we want. These are complex but urgent conversations.

Undertaking these strategies I believe is a start.

What do you reckon about this plan? Would you add, subtract or change anything?