Coming down to earth

Understandably, considering the initial hype, many anticipated the equivalent of the Bible, guiding us with conviction and certainty into an uncertain future, addressing every eventuality. As a member of the external reference group, I remember receiving letters asking us to deal with incredibly detailed and rather peripheral points, almost deciding the colour of toilet paper on hospital wards. Sensibly, the Department of Health has resisted the challenge, although one would not have guessed so from the length of the document.

In some quarters the framework will be criticised for what it omits: a prescriptive national service model.

Instead, seven descriptive standards of good mental healthcare have been produced, addressing health promotion, primary care, specialist services, carers and suicide. Each of the standards is supported by some evidence and a series of good-practice examples.

I welcome the absence of structural imperatives such as, 'Thou shalt have a crisis team staffed by three nurses', since I never could get my head around a model of care as valid in South Devon as in West Lambeth.

Much better to insist that crisis care ought to be available for everyone.

This means, though, that much will depend on local interpretation and skills, putting at risk the idea of equality that was the original inspiration for the framework. It should be no surprise that so much emphasis is placed on the monitoring of performance indicators.

On their own, each of the standards is welcome. Most principles of good care are crammed into a small number of broad statements. It would be hard to disagree with ideas such as around-the-clock access and effective treatments.

The general validity of many standards is also their weakness.

Where does one start, and what are the absolute priorities? This is more problematic when standards are considered in combination. For example, a primary care standard tells us that any service user with a common mental health problem should be offered effective treatments, including referral to specialist services. Elsewhere it is stated that people with severe and enduring mental illness are the priority. Equity is the driving value behind the document, and rightly so.

But does this mean that some standards have priority over others?

And who will decide?

These superficially pedantic points may come to matter a lot for two reasons. One line in the document has the potential to change the culture and configuration of mental health services: the announcement that primary care trusts may in future provide mental healthcare, including local inpatient beds. In principle this could be exciting, bringing care closer to local communities. But apart from structural change possibly taking precedence over development of good care for years to come, this could set in motion unintentional consequences that might prove hard to control.

Most people in mental health will remember the constant wrangling between fundholders and specialist services about who to prioritise, and many NHS staff still bear the scars. At least budgets for specialist services were then control led by health authorities. Dominant PCTs may be less cautious, and invest a bit more of their money in safe beds for dangerous patients and counselling for the armies of worried well. A shift of a few per cent away from community services towards beds and psychotherapy will devastate community care. This has to be dealt with immediately, if only to prevent irrational fear of the unknown paralysing the workforce yet again when enthusiasm is so essential.

All this would be totally irrelevant if my second reason for concern proves unnecessary. This is the boring old one of resources. No costing has been given, but a top-of-the-head calculation suggests that an additional£1bn annually towards mental health could deliver the framework, offering counselling, access around the clock, effective treatments and additional beds. The part of the document dealing with funding is not terribly transparent, but the paragraph on the top of page four of the executive summary, implying a heavy reliance on greater cost-effectiveness, might be a pointer to the future. Of course, mental health could not absorb such amounts of money instantly, but it would set a growth target to work towards over the next decade, allowing more systematic planning of recruitment, training, research and development, clinical decision support systems and capital investment.

It is those underpinning schemes that will determine the framework's success, and the document is very aware of this. A lot of good ideas are put forward, most in the preparation stage. All are long-term, both in terms of development and impact. I hope the realisation has dawned after the 18 painful months it has taken to publish the framework, that it might take more than another 18 months to remedy everything that is wrong in mental healthcare.

It is crucial that the framework is perceived by government as the starting point of a long-distance race, not a sprint. A 10-year timeframe seems realistic, similar to that for suicide reduction.

If mental health is given similar status to waiting lists, cancer and coronary heart disease, with resources following identified need, there is hope. If it is flavour of the month, forgotten as soon as the next framework is published, or renounced when a high-profile disaster hits the front pages, it will take longer. What everyone will agree on is that the status quo is intolerable. Let's have realistic milestones, not millstones.