Closing the Gap?

Earlier this week, over the border in England Deputy Prime Minister Nick Clegg put his name to a new policy document titled Closing the Gap: Priorities for essential change in mental health. The foreword to this includes the line that ‘Mental health is moving up the policy agenda across government’. This is a welcome assertion. It is also one which deserves to be examined alongside evidence of recent cuts in funding and retractions in services at a time of rising demand (see here and here for my earlier posts on mental health in an era of austerity).

This is a document listing 25 areas for change in four areas: increasing access to mental health services; integrating physical and mental health care; starting early to promote mental wellbeing and prevent mental health problems; and improving the quality of life of people with mental health problems. It closes with the maxim that mental health is everybody’s business. Initial coverage in The Guardian included a fairly straightforward description of the document’s content, and particularly its promise of increased choice for people using services and the introduction of waiting time targets. In The Independent, Paul Jenkins (from the organisation Rethink Mental Illness) was more searching, contrasting Closing the Gap‘s aspiration with what we know about frontline services:

[…] historically, mental health has always had a raw deal when it comes to NHS spending and accounts for 22% of illness in this country, but only gets 11% of the NHS budget. On top of this, over the last two years, we’ve seen a 2% cut in mental health spending despite increasing demand. Services which were already struggling are being squeezed even further. So how can the Government now make real inroads into significantly improving care and introducing choice when the services simply aren’t there? People are waiting months, even years for treatment.

If politicians really want to improve the lives of people with mental illness, we need to see investment in mental health services – in the very least services should not be cut. We should also be making sure that people who are too ill to work are properly supported with the benefits there are entitled to and with services that respond when and where they are needed. And when we see an action plan, it needs to set out specific commitments on how things are going to change and by when.

Well said. Personally I am minded to think, again, about the mental health field’s wicked problems, and how large-scale policy always contains just one version of what a system’s most pressing challenges (and their solutions) might be. Closing the Gap has plenty to say on what ought to be happening at local level (better preparation of commissioners of mental health services, more mental health training for primary care workers, more psychological therapies, and so on). What it does not unequivocally say is that ‘the problem’ may also be one of underfunding relative to levels of need.

I am also reminded of how local service change in response to national policy can lead to unintended consequences (something I have written about at length here). Here’s a speculative example to illustrate this point. Typically, mental health teams have responsibilities to respond in timely fashion to new requests for help (from colleagues in primary care, for example) whilst simultaneously providing care to people already using their services. Who knows, then, what the wider system effects might be when waiting limits for mental health services are introduced next year, as Closing the Gap promises they will? At local level, will redoubled efforts to respond to new referrals mean that the delivery of ongoing care and treatment will suffer? Will NHS organisations be tempted to establish new types of service specifically to reduce waiting times? If so, how will these find their feet in systems which are already organisationally complex? None of this is to say, of course, that waiting periods are problems which do not deserve to be tackled, but it is to say that actions to address perceived deficiencies always reverberate.

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2 Responses to Closing the Gap?

  1. Peter Martin says:

    Wicked paper attached, man. I’m trying to find an intellectual to explain it all to me. I thought solutions would be quite simple. Instead, I must be the simple one!

    • benhannigan says:

      Peter, the original (and celebrated) paper is here: http://www.uctc.net/mwebber/Rittel+Webber+Dilemmas+General_Theory_of_Planning

      One of things I find most useful is the idea that everything is connected. So an apparently simple solution might, over time, be ‘felt’ in unexpected places and in unintended ways. And, thinking about it, are solutions to problems in public services ever all that ‘simple’ at all? More often than not they’re contestable. So if we want to improve mental health services, what’s to be done? Can we even agree on what ‘improve’ means? Maybe the problem is one of science, and we know too little about the biological causes of mental ill-health. Well, if that’s the formulation of the problem then a certain set of solutions must follow. Or is it that people’s distress has social causes? That leads to a further set of solutions. Or is ‘the problem’ in mental health one of stigma, negative public attitudes, inadequately trained professionals, inflexible services, poverty? Perhaps some combination of all of these, and other, things? So all pretty complex, I reckon…

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