A report on London’s mental health suggests that collaborative leadership is at the heart of future transformation. Helen Gilburt explains
With its history of radical transformation and a model of care based predominately in the community, there is significant interest in mental health as a model for transforming acute care. Yet as our previous report Service Transformation: Lessons from Mental Health highlighted, this journey has been neither linear, nor smooth. Indeed, the pressures that mental health providers currently face and the criticisms of current services suggest that this journey is still not complete.
‘The absence of trust and sharing of expertise limits the ability to commission mental health appropriately’
Prompted by the London Mental Health Trust Chief Executives Group, we set out to explore what a vision for transforming mental health in the capital might look like and how it could be achieved.
At the heart of this was a process of stakeholder engagement that sought to capture the unique perspectives of the multiple groups involved in providing mental health services, as well as the people delivering and using those services.
What emerged was consensus on the vision, but a lack of agreement about how to bring it to fruition. Our recent report Transforming Mental Health: A Plan of Action for London outlines this vision and unpicks the main barriers to delivering it. It provides an important source of learning for those involved in mental health, not only in London but across the country.
A brief review shows that many of the problems mental health services face today are not new. Most of these problems cannot be tackled in isolation – implementing change typically requires a systemic approach with joined up working between multiple stakeholders.
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The array of different stakeholders in mental health makes this particularly challenging, but a number of other issues compound the situation. Some stakeholders have fundamentally different agendas: prioritisation of personalisation and independence in social care does not always sit comfortably with the more medically focused approaches of health services, for example.
The dispersed and uneven pattern of power and responsibility between NHS and non-NHS providers, and between NHS providers in different parts of the health system create tensions that present a major barrier to collaboration. These problems are exacerbated by funding inequalities which create the impression that those involved are more focused on territorial battles than improving the outcomes of patients in their care.
This often results in a discourse of non-constructive communication between stakeholders. Our engagement process prompted a number of heated debates about where responsibility lies, who should take what action and whose role it is to lead transformation.
‘The absence of trust and sharing of expertise will limit people’s ability to commission mental health appropriate’
While these conversations resonate strongly within each group, they were often underpinned by a lack of shared knowledge about their respective agendas, what each party does well, and the potential access to skills and resources that different stakeholders provide.
Much of the criticism for the lack of progress in improving outcomes has landed at the door of commissioners. Prior to the Health and Social Care Act 2012, commissioners already faced strong criticism for their lack of expertise and interest in mental health.
However, with increasing pressure to move away from using block contracts to commission mental health services, their role is likely to increase. So, the absence of trust and sharing of expertise is likely to continue to limit their ability to commission mental health appropriately, let alone deliver the kind of transformation required.
It is not wrong to say that overall outcomes for people with mental health problems are:
- disproportionately poor compared to those with physical health conditions;
- engagement with staff, services users and carers remains marginal; and
- efforts to prevent people from developing mental health problems have been limited.
While much of the focus has been on the lack of funding, too little has been done to challenge those involved on these issues.
However, this should also not be read as if nothing is being achieved in mental health. There are a number of examples of high quality services and innovative practice, but they tend to sit in isolation, either geographically or within individual sectors of provision, rather than acting as exemplars to drive change at scale.
Delivering on this requires far more than dissemination of good practice, but a fundamental transformation of mental health provision to develop and embed solutions more systemically.
Transformation is not an alien concept to stakeholders in the mental health system. Many are likely to have experienced the implementation of the National Service Framework less than a decade ago. The national policy focus on integrated care also provides a catalyst for encouraging collaboration.
Bringing stakeholders together and developing a collaborative approach requires collective leadership based on a cultural shift from leadership focused on the role of individual organisations or groups in implementing change, to a focus on the role they can play in supporting collaboration and building shared agendas.
Establishing “constellations of leadership”, in which responsibilities for change are shared among different stakeholder groups, has been shown to be instrumental in the wider transformation of services.
The Crisis Care Concordat represents an important step towards this with over 22 organisations signing up to an agreement on standards of care for people experiencing a crisis. Meanwhile, partnerships such as The Collaborative in south east London is putting this into practice on the ground, bringing commissioners, providers and the local community together to build a vision of health and social care based on local need.
‘It’s time for the sector to lead the way to ensure stakeholders work together to deliver a system fit for the future’
Collaboration can also be supported through the use of innovative contracting models such as lead provider and alliance contracting alongside the use of a national tariff system similar to that used in acute services. Bringing together individual stakeholders within a geographical region, including clinical commissioning groups and local authorities, should also be encouraged to share expertise and resources and enable change at scale.
Achieving change on the scale needed also requires infrastructure to support it. Academic health science centres, networks and Collaboration for Leadership in Applied Health Research and Care networks could play a vital role in bringing local stakeholders together and facilitating change.
However, they need to be sufficiently focused to ensure learning is shared effectively across their geographical regions, as well as engaging in their core research functions.
For change to result in improved outcomes - and be able to hold commissioners and providers to account for this - requires examples of what good looks like and the data to support this.
Although some of this can be achieved through contracting and commissioner-provider agreements, national leadership will be important to identify models of care and tackle variations in practice.
In the spotlight
There is a tendency to dwell on the “Cinderella story” of mental health. Not only does this have limited resonance with those stakeholders outside the sector that are facing clinical and financial pressures of their own, it does a great disservice to what has already been achieved and the vast expertise of those involved.
‘There is no end of enthusiasm and passion for improving practice’
Over the past year, mental health has risen up the agenda. The chief medical officer’s annual report focused on public mental health, while the Liberal Democrats have committed to putting mental health “on the front page” of their election manifesto. These are all encouraging signs that the commitment to put mental health on par with physical health has shifted attentionon to the sector.
While our report contains some hard truths, engagement with stakeholders demonstrated no end of enthusiasm and passion for improving practice. As the rest of the NHS looks to mental health for guidance on transformation, it is time for the sector to lead the way in ensuring that all stakeholders are working together to deliver a system fit for the future.
Helen Gilburt is a fellow at the King’s Fund, with a special focus on mental health