Equity and excellence in liberating mental health commissioning

Citation

Hardy, S. (2011), "Equity and excellence in liberating mental health commissioning", Journal of Public Mental Health, Vol. 10 No. 2. https://doi.org/10.1108/jpmh.2011.55610baa.002

Equity and excellence in liberating mental health commissioning

Article Type: Guest editorial From: Journal of Public Mental Health, Volume 10, Issue 2

Introduction

The White Paper, Equity and Excellence: Liberating the NHS (12 July 2010) outlines radical reform to how the National Health Service (NHS) will be organised. The Secretary of State describes his vision for the NHS as “driven by clinicians and patient choice”. The government aims for a health service that places service users at the centre and who’s needs are best met by enabling clinicians to determine care pathways and, in the case of GPs, to commission services. GP consortia are to hold the majority of the NHS budget and, therefore, commission mental health services on behalf of their patients. GP consortia will have a high-level of autonomy, more responsibility and accountability over commissioning budgets than ever before.

These changes mean that GP consortia will need to work with all clinical professionals, including mental health nurses, to design services that are easily accessible, effective and efficient while at the same time, improving the mental health of the local population. Mental health nurses, therefore, have a vital contribution to make to all aspects of the commissioning process. For example, at an individual level supporting people accessing and commissioning personalised services and at a population level, assessing local need, strategic planning and designing high-quality services.

Although thought to be controversial these political changes provide mental health nurses with opportunities to provide better health care, deliver value for money and improve mental health, not only for individuals but for local communities. However, in order for this to happen mental health nurses not only need to know about government policy but engage with it by taking a more active role in getting involved, both in working with GPs in the new commissioning arrangements and in the public health agenda.

The importance of engaging in policy development and implementation

The authors undertook a revision and update of the Chief Nursing Officer’s review of mental health nursing (2006) which included reviewing documents published in the last four years that influenced the shaping of:

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  mental health service delivery;

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  service user opinion on areas of improvement; and

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  mental health nursing role change and workforce challenges.

A review of published literature revealed that between November 2006 and April 2010, the previous government published three White Papers, six Acts of Parliament and produced over 140 mental health-related consultation documents, implementation guides and good practice examples. There have also been 310 Department of Health publications relating specifically to mental health, all of which are available via the Department of Health’s web site.

In addition, during this time period, the National Institute for Health and Clinical Excellence has produced national guidance on 53 mental health-related topics. There have been over 14 policy publications from the Sainsbury Centre for Mental Health. The Royal College of Psychiatrists web site identified three position papers, nine occasional papers and 24 college reports, all offering “easy access” to evidence-based information and guidance for improving the quality and experience of people engaged with mental health care. This is to name but a few of the organisations offering comment on political issues and priorities for mental health. All of these reports are again readily available via the respective organisations’ web sites.

However, when undertaking a more focused search of published literature on how these documents influence nursing practice and service delivery changes, it was less obvious what process mental health nurses use to engage with policy and other national guidance documents. What is evident when reviewing published papers is that there is often at least one paragraph allocated in a paper to outlining the political context within which the work, project or innovation has taken place. However, very few papers take this further by outlining how the policy had informed or led to practice innovation and change. Most often policy was set out as supportive evidence, to ensure the activity was seen as relevant to contemporary practice agendas.

Below is a table that identifies the number of documents revealed from an online database search that specifically related to policy being used to inform or influence practice changes. As can be seen below, only one paper was identified under the search term of “policy impact” and zero papers identified from a combination of search of terms “mental health policy” and “mental health nursing” and “practice innovation” (Table I).

Table I Number of items identified under themed search terms plus final MESH search

The challenge of change: efficiency, integration and inclusion

In the current financial climate, we must ensure more efficient care-pathways and provide sustainable quality care. There have been calls to ensure mental health remains a top priority. Siva (2009, p. 1230) claims “expert” clinicians are concerned that mental health may well fall lower down the political priority agenda in the current financial climate, particularly as there is evidence that during economic difficulties the need for mental health care will undoubtedly increase; people responding to the stress of unemployment, reduction in wages alongside increased cost of living are all known factors that precipitate psychological distress:

We are particularly concerned that in the face of upcoming public spending cuts, mental health will be the first to be slashed, as at the present time, a person with mental health has 10 times less spent on them than someone with cancer […] it is easier to cut mental health because there is still stigma associated with mental health and people would rather close their eyes to mental health.

In the light of such criticisms, it is reassuring that the government is clear about its intention to put mental health on the same footing as physical health. Mainstreaming mental health into the wider public and social health arena will not only enable people with mental health problems to access the care that meets their particular needs but will give prominence to all those social, environmental and economic factors that have an adverse effect on peoples’ mental health and wellbeing. Stigma, prejudice and ill informed assumptions are still evident in the way, people are treated when they enter general health and social care settings. Although further work is needed to enable integration, inclusion and an interconnected service approach to an individual’s recovery when planning and commissioning mental health services, a broad perspective may enable other adverse factors to be taken into account.

The introduction of crisis resolution and home treatment teams has resulted in fewer service users needing hospital admission. Service users also prefer to be treated at home. However, an estimated £900 million is being spent on traditional adult mental health inpatient stays, and many services are finding increased demand for highly distressed acute admissions that is an expensive treatment route and not always favoured by individuals and their families.

Innovating mental health care

Much has been done to improve inpatient care since it was highlighted as a major recommendation of the Chief Nursing Officer’s review of mental health nursing in 2006. Nevertheless, it is still possible for some health economies to improve the efficiency of the acute care pathway, including reducing variation in the use of adult inpatient beds, reducing length of stay and improving discharge arrangements. Mental health nurses have a major role to play in all these processes, as well as determining the effectiveness of the therapeutic activities and interventions that assist in peoples’ recovery and measurable health outcomes.

The potential to be innovators and collaborators of health care is available for mental health nurses. This may require educating, influencing and promoting the value of mental health nursing to those GP consortia, who may not be so well informed. Through good quality information we can demonstrate that nurses have made considerable progress on what matters to service users. We know that together with other multidisciplinary staff, effective nurses have a positive effect improving health outcomes for service users. But is there enough evidence to support the need or financial value of a therapeutic alliance that allows a nurse to “be there”, working in partnership with the service user in ways to aid recovery in a meaningful way? Will it be enough to argue that nurses provide personalised nursing care over the entire 24 hours period? At the very least the need to demonstrate nursing care that keeps service users safe from avoidable harm and in a working alliance or therapeutic relationship that can lead to better measurable health outcomes is and remains essential.

At a time when nurse education is moving to graduate status, the time is ripe for a revised nursing curriculum that enables a flexible and career progressive study pathway that works in close alignment to the changing demands of a new and “liberated” NHS (DH, 2010). The risk, however, is if nursing restricts itself to the individual clinical aspects of mental health problems that we will miss the opportunity to have greater influence at a wider community or population level with its associated possibilities for public health interventions.

The potential to purchase a time-boundaries clinical intervention as a mental health-based treatment will be an attractive route for GP consortia. Whereas, many mental health nurses are well placed to provide much needed evidence-based clinical interventions, many more will need a broader base of professional skills in order to provide practical assistance, problem solving, emotional support, preventative interventions and health promotion strategies that are more difficult to time limit.

Time for change

It is imperative for mental health nurses to respond and engage with policy in a way that will indeed “liberate” the talent and potential impact a mental health nurse can have on people’s wellbeing. Mental health nurses’ work is to improve peoples’ mental health, deliver measurable improvements to the mental health and wellbeing of individuals and society generally. They will also need to realise the enormous contribution they can make in the area of prevention, early intervention and strategic public health initiatives. What remains crucial is for nurses to articulate their contribution to health care and the very real, tangible benefits they bring to the recovery of individuals and the public’s health and wellbeing.

Key activity for mental health nursing of the future is about integrating and working collaboratively with many different agencies, including non-health sectors and the wider population, as mental health moves rapidly into the public health arena. Mental health nurses will have to wrestle with the double challenge of providing individual and group interventions alongside engaging in the public health agenda. They will have to contribute to reducing health inequalities and variability in service provision by improving accessibility to services and targeting those groups who are at higher risk of mental health problems. Nurses will have to play their part in engaging in community health and wellness activities, such as promoting wellbeing of those who become unemployed, alcohol reduction programmes, suicide prevention for vulnerable groups, stress management at work and early intervention and targeted support and building resilience for children and young people, to name but a few of the challenges.

Ahead is a period of ambitious change. The challenges are to see things through a different lens: to shift our thinking and activities from individual care to community-wide problems while bearing in mind the time-scale required to demonstrate the effects of policy change and evaluating the effects at a societal level over generations. Whether or not we are prepared to meet these challenges there is no doubt that mental health is now firmly in the public health arena, and is coming to a GP Consortium near you.

Corresponding author

Sally Hardy can be contacted at: Sally.Hardy.1@city.ac.uk

Sally Hardy, Ben ThomasSally Hardy is based at City University London, London, UK. Ben Thomas is based at Department of Health, London, UK.