Working in Mental Health

Practice and Policy in a Changing Environment

Peter Phillips, Tom Sandford, Claire Johnston

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136324802
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

A paradigm shift in the ways in which mental health services are delivered is happening—both for service users and for professional mental healthcare workers. The landscape is being changed by a more influential service user movement, a range of new community-based mental healthcare programmes delivered by an increasing plurality of providers, and new mental health policy and legislation.

Written by a team of experienced authors and drawing on their expertise in policy and clinical leadership, Working in Mental Health: Practice and Policy in a Changing Environment explains how mental health services staff can operate and contribute in this new environment. Divided into three parts, the first focuses on the socio-political environment, incorporating service user perspectives. The second section looks at current themes and ways of working in mental health. It includes chapters on recovery, the IAPT programme, and mental healthcare for specific vulnerable populations. The final part explores new and future challenges, such as changing professional roles and commissioning services. The book focuses throughout on the importance of public health approaches to mental healthcare.

This important text will be of interest to all those studying and working in mental healthcare, whether from a nursing, medical, social work or allied health background.

Part I

Mental Health Care and the Socio-Political Environment

1

UK Mental Health Policy Development

A Framework for Meaningful Change

Andrew McCulloch and Simon Lawton-Smith

This chapter seeks to give an overview of English mental health policy over the last few decades, focusing particularly on the period 1997 to the present day, and on future challenges. It will also seek to explain what mental health policy is, and to give a little of the history before 1997. The aim is to draw out the key components for those actually involved in or affected by mental health policy and practice.

What is Mental Health Policy?

Policy itself is often misunderstood. Koontz and Weihrich usefully define it as ‘General statements or understandings which guide thinking on decision making’ (Koontz and Weihrich, 1988). As such it breaks down into primary and secondary legislation (law), explicit administrative policy (e.g. published Government statements) and unwritten policy (e.g. verbal briefings by Ministers and civil servants to, for example, senior health service managers). At the coalface policy is only one factor in decision making and often a secondary one to clinical or resource issues (Muijen and McCulloch, 2009).

National mental health policy per se is specific to mental health, e.g. mental health legislation or a mental health white paper. However, mental health services and mentally ill people are of course impacted by generic policies on health, welfare, housing and others and these impacts are often more important than that of specialist policy. This must always be borne in mind when considering mental health policy. Each part of the UK has its own mental health policies although there is some sharing of legislation to which Scotland is an exception and Northern Ireland is becoming so. It is too complicated within a short chapter to deal with UK mental health policy so we have focused on England. It is generally, however, considered that Scotland is in advance of England in its development of public mental health and perhaps legislation (for example, Scottish mental health legislation on compulsory treatment takes account of a person’s capacity to make decisions about their own care; English legislation does not). In England service development has been very much to the fore.

Mental Health Policy Until 1979

Modern mental health policy started with the introduction of legislation to control the governance of lunatic asylums in early Victorian times and has evolved from there. After the First World War more modern approaches such as psychotherapy started to evolve and after the Second World War charitable and local authority mental health services, mainly asylum based, were mostly incorporated into the NHS. These started to decline in size in the 1950s and this policy direction was explicitly acknowledged in Enoch Powell’s ‘water tower’ speech in the 1960s. Almost all of the old asylums are now closed, depending on how closure is defined. During the 1970s more detailed and explicit mental health policies began to emerge dealing with the establishment of acute psychiatric units in general hospitals and the beginnings of community care. However, many would argue that during the initial period of the decline of asylums the needs of people with severe and enduring mental illness, especially those with deteriorating conditions, were not well addressed in policy perhaps because there was an assumption that some of these conditions were caused by institutionalisation.

Mental Health Policy from 1979 to 1997

Mental health policy during the Conservative administration of this period was primarily about the process of discovering the consequences of the closure of the old asylums. In 1983 an excellent new Mental Health Act was introduced that consisted essentially of a substantial update of the landmark 1959 Act. Reforms included the creation of a Mental Health Act Commission to defend the rights of detained patients.

In the latter part of the 1980s it became increasingly clear that the model of providing care via hospital beds and undifferentiated community services would not succeed in meeting the needs of a core group of people with severe and enduring mental illness. Much of policy from this point on was about addressing the needs of this group and responding to inquiries into homicides by people with severe mental illness (McCulloch and Parker, 2004). The inquiry into the killing of a social worker by a patient at Bexley Hospital (Sharon Campbell) was one such event that led to the introduction of obligatory care planning for people requiring secondary mental health care. Other changes included the introduction of supervision registers, conditional discharge and compulsory inquiries into serious incidents. This created a new risk management industry, some of it perhaps beneficial and some certainly not.

Alongside this, however, there was also a healthy emphasis on public mental health in documents such as the Health of the Nation mental illness key area, and also on developing services for groups such as children and homeless people. Some of this activity set the scene for the major development programme that was introduced under Labour.

Policy under New Labour

The National Service Framework

When the National Service Framework for Mental Health (NSFMH) (Department of Health, 1999) was launched, the Sainsbury Centre for Mental Health commented: ‘For the first time, Government has set out a comprehensive agenda for mental health services which acknowledges that the whole system of mental health care must be made to work if we are to succeed in modernising care’ (Sainsbury Centre for Mental Health, 1999).

Whilst the NSFMH was radically new in terms of its comprehensiveness and ambition it can be located within a general attempt to develop health care policy on a more comprehensive, evidence-based way (McCulloch, Glover and St John, 2003) – although it should be noted that the NSFMH was for adults of working age, and that standards for the mental health of older people was covered in the NSF for older people (2001) and for children in the NSF for children and young people (2004).

The NSFMH set out seven ‘standards’, which are really key areas for service and practice development, and these are summarised in Box 1.1.

Inevitably with such a comprehensive document there were some confusions and contradictions and there was a subsequent debate about differing emphases on safety and compulsion as opposed to care and choice, for example. However, there seem to be six readily definable core aims that can be deduced from the document (McCulloch, Glover and St John, 2003).

1. Modernising primary, secondary and tertiary mental health care.
2. Improving public mental health.
3. Reducing suicide.
4. Improving public safety.
5. Improving the quality of care.
6. Improving support for carers.

Of these, 1, 4 and 5 were given the most emphasis in words and actions.

Box 1.1 The National Service Framework for Mental Health standards

Standard 1 aims to ensure health and social services promote mental health and reduce the discrimination and social exclusion associated with mental health problems.

Health and social services should:

• promote mental health for all, working with individuals and communities;
• combat discrimination against individuals and groups with mental health problems, and promote their social inclusion.

Standards 2 and 3 aim to deliver better primary mental health care, and to ensure consistent advice and help for people with mental health needs, including primary care services for individuals with severe mental illness.

Any service user who contacts their primary health care team with a common mental health problem should:

• have their mental health needs identified and assessed;
• be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it.

Any individual with a common mental health problem should:

• be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care;
• be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines or to local services.

Standards 4 and 5 aim to ensure: that each person with severe mental illness receives the range of mental health services they need; that crises are anticipated or prevented where possible; prompt and effective help if a crisis does occur; and timely access to an appropriate and safe mental health place or hospital bed, including a secure bed, as close to home as possible.

All mental health service users on CPA (Care Programme Approach) should:

• receive care that optimizes engagement, anticipates or prevents a crisis, and reduces risk;
• have a copy of a written care plan that:
  1. includes the action to be taken in a crisis by the service user, their carer and their care coordinator
  2. advises their GP how they should respond if the service user needs additional help,
  3. is regularly reviewed by their care coordinator,
  4. is able to access services 24 hours a day, 365 days a year.

Each service user who is assessed as requiring a period of care away from their home should have:

• timely access to an appropriate hospital bed or place that is:
  1. in the least restrictive environment consistent with the need to protect them and the public,
  2. as close to home as possible;
• a copy of a written care plan agreed on discharge that sets out the care and rehabilitation to be provided, identifies the care coordinator, and specifies the action to be taken in a crisis.

Standard 6 aims to ensure health and social services assess the needs of carers who provide regular and substantial care for those with severe mental illness, and provide care to meet their needs.

All individuals who provide regular and substantial care for a person on CPA should:

• have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis;
• have their own written care plan that is given to them and implemented in discussion with them.

Standard 7 aims to ensure that health and social services play their full part in the achievement of the target set in a previous public health white paper to reduce the suicide rate by at least one fifth by 2010.

The NHS Plan

The year after the NSFMH was published the NHS Plan (Department of Health, 2000) put in place the targets and money that made parts of the NSFMH a reality – specifically improvements in forensic services and intensive community care teams. Three critical targets were the focus of much management action within mental health services:

• 50 early intervention teams to be in place by 2004
• 335 crisis resolution teams by 2004
• 220 assertive outreach teams by 2003.

Implementation of the NSFMH and NHS Plan/Achievements

Supporters of mental health policy during the New Labour years tend to focus on seven key areas of achievement:

1. The reform of community care to provide a much more intensive and comprehensive service.
2. Reductions in suicide rates nationally.
3. Large investment in mental health services of perhaps £2bn in real terms and staffing increases averaging about one third.
4. Improvements in inpatient care with around 70 per cent of patients in private rooms.
5. Increased use of new drugs and therapies including psychotherapy.
6. High patient satisfaction.
7. Investment in older people’s and children’s services (via the two further NSFs mentioned above).

A specific analysis by NSF standard tends to show a more mixed picture. In relation to Standard 1 (Promotion and Prevention) there are very few achievements and no evidence of improved public mental health. Indeed there has been a significant deterioration of the mental health of middle-aged women as shown by epidemiological surveys. Dementia is also increasing in line with demography. Child mental health problems have remained steady at the high levels of 1990s. More recently, and subsequent to the life of the NSFMH, we are seeing more debt-related and stress problems caused by the economic environment. This poor progress is reflected by very low levels of investment in public mental health (between 2000 and 2009 only around 0.1 per cent of annual NHS mental health spend was spent on mental health promotion, the subject of Standard One). Arguably other Ministries such as Education have invested more in emotional well-being than Health.

In terms of Standards 2 and 3 (Primary Mental Health Care) there have been some ad hoc improvements, but these are hard to measure. General Practitioners (GPs) use interventions other than medication sporadically although many wish to do so. A policy of expansion of psychological therapy provision was fought for long and hard by mental health charities and professional bodies. Some initial progress has been made with extra ring-fenced funding, but in many parts of the country there is still a struggle to establish adequate and effective psychological therapy services.

The greatest achievements seem to be in relation to Standards 4 and 5 (Secondary Care), which appears to have improved in both quality and quantity and is regarded as being amongst the best in the world for a public sector mental health service. However, large resources are being spent on secure care and some inpatient care without clear outcomes. Services are still not fully user or recovery oriented although some good progress has been made.

In relation to Standard 6 (Carers) little was achieved except to introduce carers’ assessments and there is little value in assessment in isolation. On Standard 7, suicide rates have been reduced and a good strategy (refreshed in 2011) was put in place, although a causal link between the two is hard to prove.

Overall, it appears that major progress was made in mental health service development during the New Labour years but with a number of key deficits:

• There were and are no plans to deal with ineffective services such as unfocused day care and counselling. Inpatient care also lacks an absolute evidence base but progress has been made to reform this.
• Secure settings and prisons seem to be used as modern asylums at huge financial and human cost.
• Services remain poorer for young adults, older people and people from ethnic minorities.
• As stated above, there is a dearth of investment in promotion and prevention.
• Services are still too medically focused and too downstream with not enough early intervention – housing and employment support services for example.
• Mental health workforce planning has created a model that is arguably still too top heavy and lacking integration, for example between psychology and other services.
• Stakeholder input into policy has been poor but input into many local services has improved.
• There is no clear hierarchy of priorities, giving the impression that policy is unachievable.

The Policy Challenges under the Coalition Government

This leaves us, therefore, with a number of serious challenges ahead, both in terms of establishing policies that will provide a framework for tackling these deficits, and in turning policy into everyday practice that is truly patient-centred, recovery-based and integrated, in terms of primary and secondary mental health services and support across different agencies such as housing, criminal justice and social care.

The New Mental Health Strategy

The Coalition Gover...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• List of contributors
• Acknowledgements
• Foreword
• PART I : Mental health care and the socio-political environment
• PART II : Characteristics of new mental health services
• PART III : The new territory
• Index