The Centre for Mental Health Services Development has surveyed senior managers of mental health services in London every year since 1996 to identify trends in their views.
This is the only study in England which examines the views of a group of managers over time. It also represents the views of managers in an area which has been the subject of considerable policy activity during the life of the study, and in a city where research has demonstrated that services are under pressure.
Respondents considered the development of community mental health teams, plus the care programme approach and assertive outreach, as priorities for implementation, and the size of the change agenda and financial restrictions as the main obstacles to service development.
The national service framework for mental health was seen as the main influence on priority setting.
Respondents were asked about problems with the development of community mental health teams.
They considered these to include professional differences between medical and social services and the effect of changes in other services.
Having the team together in one place was seen as important to effective working.Managers also considered that their workload was an obstacle to creating new services.
Several important themes emerge from the 2000 survey, when considered in combination with results from previous years.
Community mental health teams hold a central and enduring role in the mental health system for managers. Throughout the five years, developing community mental health teams has been rated as the top priority for local implementation. As these teams started to appear in London in the early 1980s and entered national policy documents in the early 1990s, this continuing focus on them may suggest that innovative practice and national policy are not necessarily easy to implement.
But it also appears that what constitutes successful implementation of these teams may be changing over time, with the criteria for success becoming harder to achieve. In the 1980s, co-location of health and social services staff was one key goal; during the 1990s, co-ordinating the care programme approach with care management within community mental health teams became an important aim; and now, integrating the management of health and social services staff who work in community mental health teams may become the objective.
In these circumstances, it is perhaps not surprising that the concept of community mental health teams is contested, and that tensions between managers and professionals (and between professionals themselves) arise.
More managers reported that they held managerial responsibility for both health and social services in 2000 than in any previous year. On the basis of the survey data, however, enhanced partnership does not appear to have improved reported levels of trust between the agencies.
The professional cultures of staff may prove more difficult to reconcile the more closely that different professions are asked to work together. This problem is perhaps symbolised by the apparent frustration of managers in social services departments with consultant psychiatrists - and is no less evident in 2000 than in 1996.
Throughout the five years, personal and organisational stability have always been seen as central to the creation of trust between agencies. It is potentially helpful, therefore, that fewer respondents reported organisational changes in the 2000 survey than in previous years.More than half the sample had not been affected by any restructuring in 2000, a much higher proportion than in 1998 and 1999.
Respondents had been working in the mental health field for an average of nine years, and in their current post for just under three. Seventeen managers described themselves as feeling very or reasonably secure in their job. Eleven felt insecure.More than half, a higher proportion than in previous years, did not envisage staying in their current job more than a year.
Such turnover could serve to create significant instability, as could the imminent introduction of primary care trusts, combined mental health and social care trusts and care trusts as providers and commissioners of mental health services. But in some cases, reported levels of trust were so low as to suggest that changes in the personnel and organisations may be beneficial to the partnership between agencies.
Also, the integration of mental health and social care provision and commissioning in these new trusts may remove at a stroke the requirement for trust between agencies. It is also difficult to believe that all of the problems that require trust between health and social care managers will be entirely resolved by such new structures.
Managers were asked what they thought was needed to increase trust between agencies.
Comments included, 'full integration, single management', 'more clarity around boundaries', 'senior-level commitment to giving people more of a joint message' and 'experienced managers and stability in organisations'.
Managers thought stability in individual posts and structures would strengthen trust between agencies. There was a feeling that with pooled budgets and joint management, trust would increase.
Finally, a large majority rated - and welcomed - the mental health national service framework as the top national policy intervention replacing Modernising Mental Health Services (Department of Health, 1998) which was top in 1999, which itself displaced The New NHS: modern, dependable (DoH, 1997) which was top in 1998.
But they were concerned about resources to deliver the policy at local level. During the interviews many managers mentioned the extra work involved in implementing the national service framework.
Managers are clearly always aware of the most recent national policy initiative; at the same time their local priority for implementation remains the same. Local priorities do not necessarily appear to be superseded by national policy. This is significant, especially given the pressure from the DoH for managers to focus during 2000 on three 'must dos' which do not include community mental health trusts.
Managers may be worried that they will be obliged to implement service models that are not perceived to reflect local needs. This suggests that there is not a simple relationship between national policy promulgation and local policy implementation, even where that policy is broadly accepted.
The research mapped the views of managers of mental health services in London during a period of sustained policy activity. Overall, government pronouncements of policy, although acknowledged, appear less influential on managers' working lives than local priorities and pressures and other factors that apparently remain constant:
organisational instability; work overload; and the level of trust between agencies attempting to collaborate. Together these consistent characteristics of managerial life serve to slow down the implementation of policy.
In this context, the perceived prescriptivity of the national service framework implementation process is perhaps understandable, as is the apparently increasing government enthusiasm for the integration of health and social care agencies.
But neither of these approaches will enable managers to avoid the enduring difficulties revealed by this study. For instance, it is becoming apparent that one of the 'must dos' - assertive outreach - may be contested as much by professionals as by community mental health teams. This research suggests that managers need time to incorporate national policy into local priorities, support in dealing with their workload, and organisational stability to foster organisational relationships.
1 Peck E, Smith H, Barker I, Henderson G. The Obstacles to and Opportunities for the Development of Mental Health Services in London: the perception of managers. In: London's Mental Health. Report to the King's Fund London Commission. King's Fund, 1997.
2 Peck E, Hills B, Secker J. Managing Mental Health Services in London. J of Mental Health 1999; 8 (6): 621-628.
3 Gulliver P, Peck E, Howell V.Mental Health: London Managers'Views 1996-1999. Br J of Health Care Management 2000, 6 (3): 101-106.