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Re-allocating the money: who should lead on reforming mental health?


The focus on delivering improvements in mental health care is currently dominated by how funding is allocated. But in the midst of the debate, little thought has been given to who should receive this money, and importantly how this could lead to reforming the system. Is it really a case of robbing Peter to pay Paul, or could we all benefit by sharing a little more?

Last week saw speakers at The King’s Fund’s mental health conference tackle some of the opportunities and challenges around improving outcomes for people with mental health problems. Underpinning many of the presentations was the importance of leadership and collaboration in delivering effective care; whether this was police taking the lead in developing effective care pathways for people in a crisis; or economists and providers working to establish the effectiveness of interventions. But, what could this teach us about system transformation for the future?

At the moment, the mental health system benefits from strong and consistent leadership from local mental health trusts. Their expertise in delivering care for people with mental health problems, supported by block contracting, has contributed to their dominance in service provision. However, this may have come at a price. Most trusts offer little in the way of choice for service users seeking to take greater control over their health, while their focus on acute care and limited interface with primary care limits their contribution to supporting greater moves towards the prevention of mental illness.

Indications are that the mental health service system would benefit from more diverse leadership, and there are many organisations capable of taking up this challenge. Housing services, for example, have been identified as a key element in mental health care and many specialist housing providers have developed expertise in supporting people with long-term mental health problems as well as having access to resources not available to most trusts. To involve alternative providers could put forward the case for procurement by competition, with commissioners using their knowledge and understanding of the needs of the population to identify the provider best placed to deliver. This approach would, to some extent, reflect the original vision of the NHS reforms.

In practice, we are currently far from being able to implement this in mental health services. Many commissioners are relatively new to their job and there is a lack mental health expertise. The NHS England commissioning for mental health programme seeks to address this, but it is likely to take time to deliver the level of skills required.  Furthermore, while some sectors have the capability to take a lead role, others do not. Primary care has been identified as a focal point for future mental health provision, but general practice resources are stretched to the limit and questions remain around general practitioners’ skills and knowledge of mental health.

Across all approaches to improving outcomes is an emphasis on placing individuals and individual organisations, whether commissioners or providers, at the forefront of transformation. Yet, while replacing leadership from a single sector with leadership from several sectors could drive change in the short-term, it often pits different providers and sectors against each other whilst excluding others, and as a result can lead to further fragmentation.

The limitations of the current and proposed models of leadership have not gone unnoticed, and while many organisations continue to pursue an agenda of asserting their position, a minority have begun to think differently and explore new ways of working. From alliance commissioning, to the development of learning sets and use of collaborative frameworks, the key to these new approaches is that they involve collaboration. Bringing parties together enables participants to benefit from the unique skills, knowledge, roles and resources of different groups, and while this presents risks in terms of sharing information and power, the risks are shared while maximising the opportunity to use resources more effectively to improve outcomes. Importantly, these new ways of working facilitate the chance to ensure all parties are at the table, expanding the remit to public health and social care, and offering an opportunity to move from consultation to co-production with service users.

Perhaps in an era defined by the fragmentation of physical and mental health services, low resources and competition, it is poetic justice that a model of leadership is emerging which challenges traditional approaches, capitalises on the considerable diversity, experience and skills in the mental health sector and brings people and organisations together with a common goal of designing a service system fit for the needs of the future population.