Yesterday I opened this blog with a reference to a paper Michael Coffey and I published in 2011. I briefly talked about ‘wicked problems’, linking back to Rittel and Webber’s original article introducing this term.

In our paper Michael and I commented on the pace of change in mental health policy and services across the UK. We were particularly interested in the years from 1997, beginning with the election of New Labour. At the start of this period there were some bold statements from members of the then-new government, including the claim that community care had ‘failed’. At the time I thought this to be far too bald and simplistic a formulation of ‘the problem’. I still do, as it happens. As a solution, more (and different types of) community mental health care became the policy prescription. It was in this context that assertive outreach teams and crisis resolution and home treatment services appeared.

What struck Michael and me was how quickly this problem/solution formulation yielded to a replacement, this time emphasising shortcomings in professional practice. Policy pronouncements in the early/mid 2000s referenced occupational boundaries as a problem. Now, eroding demarcation became a key goal of policy: and it is in this context that new ways of working emerged. This was all about redrawing divisions of labour, and I’m sure this is something I’ll return to in the future because it interests me very much.

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So, what to say in a first post? Perhaps introduce some of the ideas I’ve had the opportunity to work up in more detail in recent articles.

As a starting observation I’ve come to think of the whole business of organising and providing health (and social) care as being exceptionally complex. Hardly a novel insight, but worth pausing over awhile. Think of the problems which face policymakers and to which policy action might be directed. These do not arrive ready-packaged, but have to be named, identified and argued about. Values and politics come into play, and ‘the evidence’ for policy is likely to be incomplete and open to challenge. Problems and their solutions are also inseparable. So if ‘the problem’ facing health systems is defined as one of bloated public services inefficiency, then ‘the solution’ might be to inject some competition using market mechanisms. Readers familiar with contemporary NHS policy in England will recognise this problem/solution combo. I also recognise it from the time I worked as a community mental health nurse in east London in the early to mid-1990s. That was the era of the purchaser/provider split, and of quasi-markets. As it happens, I reject this particular inefficiency/marketisation problem/solution formulation. So just as I said above: any combo is open to contest and challenge.

This kind of thinking can be pushed a little further. For any given problem/solution combination, how might we know actions have ‘worked’? What, indeed, does it mean for a large-scale policy to ‘work’ at all given that actions and innovations which improve things in one locality might have very different effects elsewhere? And what about the unintended consequences of policy and service change? Or that realising grand aspirations often requires lots of agencies, organisations and people all having to pull together at the same time?

These are some of the reasons why many of the problems facing people who make health policy and develop services are of the ‘wicked’ variety, to use the memorable term coined by US academics Rittel and Webber in 1973. In 2011 my friend Michael Coffey (who works at Swansea University) and I published this paper in the journal Health Policy in which we employed a ‘wicked issues’ perspective to consider recent policy and service change across the UK’s system of mental health care.

In this paper Michael and I argued that different problem/solution combos have been wheeled out over the last 15 or so years, and that distinct (but overlapping) policy formulation phases can be discerned. And what did we say these phases were? I’ll blog some more on this at a later point, and see if I can create a link to an ‘author accepted manuscript’ version on Cardiff University’s ORCA repository.

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