Targeting in Mental Health Services

A Multi-disciplinary Challenge

Lesley Cotterill, Wally Barr

• Publisher: Taylor & Francis
• Year: 2019
• Print ISBN: 9781138724136
• eBook ISBN: 9781351755634
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

This title was first published in 2000: This work has its origins in a three-year research project initially entitled, "Do SEMI Registers Make a Difference?" and known, for short, as the SEMI Register Project. The research project was designed to monitor and evaluate the introduction of registers for people with severe and enduring mental illness (SEMI) in general practices across the Wirral. In the context of this discussion, and within the framework of the mental health and social care reforms currently being introduced, key issues in the targeting agenda include: definitional issues surrounding the term "SEMI"; practical and methodological concerns about how people with SEMI are to be identified and targeted; interface issues relating to multi-disciplinary working between primary and secondary care; issues concerning the evidence-base for risk management policies and strategies; the role of training in effective targeting; reflection on the potential consequences of targeting policies and initiatives; and the meaningful involvement of service users from all sections of society.

Part 1
Setting the Scene

Introduction

This book has its origins in a three-year research project initially entitled 'Do SEMI Registers Make a Difference?' and known, for short, as the SEMI Registers Project. The research project was designed to monitor and evaluate the introduction of registers for people with severe and enduring mental illness (SEMI) in general practices across the Wirral. The project was action-oriented, with feedback channelled through an Advisory Group. The first phase of the project involved monitoring the implementation process. The second phase, from which the project got its name, involved an evaluation of the extent to which introducing these registers made a positive difference to the quality of care and quality of life experienced by people with SEMI who were included on these registers.

The plan to introduce SEMI registers, the SEMI Registers Initiative, was part of Wirral's Mental Health Strategy. The decision to have the SEMI Registers project run in parallel to the initiative was taken forward by Ann Hoskins, then Director of Public Health in the Wirral, who wrote the first draft of the proposal for research funding. Then, the editors of this book became involved in the further development of the proposal, and subsequently became the research team based at the Health and Community Care Research Unit, University of Liverpool.

At the start of the research project, we traced the idea of targeting people with SEMI in policy and practice, and began to reflect on the utility of the idea, how this goal might best be achieved, and the sorts of concerns associated with it. We began to ask ourselves questions about targeting that we regarded as pre-requisites to the targeting agenda. These questions included: How is the term 'severe and enduring mental illness' to be defined? By what method are people with SEMI to be identified and targeted? With what are they to be targeted, and by whom? Most importantly, what is the expected effect of such targeting, and what will be the outcomes in the short, medium and long-term? How will such initiatives be evaluated, and from whose perspective? What are the associated problems, or unintended consequences? And so the list went on. Our involvement in the SEMI Registers Project gave us the chance to explore these questions and gain some insight into the extent to which they were being addressed in one particular study. This book gives another opportunity to develop and extend these lines of inquiry. As the research project progressed, the preliminary findings from the first phase of the project alerted us to the corollary of issues surrounding the notion of targeting, in the context of setting up SEMI registers. These issues include the social, ethical, political, sociological, legal and practical dimensions of the enterprise. Consideration of these issues highlighted the need for conceptual analysis, policy evaluation and theory building in this area. Our personal experience of the research process underlined the appropriateness of the action-oriented approach, and raised our awareness of the local political context within which the Registers Initiative was being introduced. At national level, the social and political context is now dominated by the government's mental health modernisation agenda.

Reviewing the literature for the SEMI Registers project revealed that, since their inception, community mental health nurses (CPNs) were expected to cater for many of the needs of people with SEMI. Despite this intention, successive research projects (with some exceptions) reported that this was not happening in many areas. In contrast, people with less severe mental health problems, dubbed 'the worried well', were found to be filling CPN case loads, with little time, and some suggested little enthusiasm, left for working with people with SEMI. In the 1990s, the trends towards developing a primary care-led NHS influenced the tendency for CPNs to become 'attached to', or located within, GP surgeries. This shift in location increasingly resulted in CPNs becoming more greatly involved in counselling and other activities appropriate for the needs of many of the people with mental health problems presenting in primary care settings. During the same period, the well-publicised series of incidents involving people with SEMI in acts of violence led to rising public concern, and highlighted the failures in care experienced by people with SEMI. The government's pressing need to be seen to act in response to this state of affairs resulted in the introduction of a variety of policy developments and initiatives designed to 'close the gap' in the 'net of care'. Some have argued that these developments (e.g. Supervision Registers and the power of supervised discharge) heralded the beginning of a more coercive, socially controlling era in mental health care. Indeed, prior to the introduction of several measures and initiatives during the early 1990s, academics and practitioners alike declared key components of the government's plan to be flawed. This was a cause of some concern, given that such measures were intended to effectively manage the risk posed by some people with SEMI in the community.

More recently, the New Labour administration has announced its health and social care modernisation programme and, within that, the proposed mental health reforms. Implementation is currently ongoing. The mental health reforms have the backing of extra funding, a commitment to improve quality and raise standards, and to deliver comprehensive mental health services that are informed by research evidence and best practice. These changes are to be monitored by new structures to deliver effective performance assessment and management. Alongside quality improvement, safety is now the main priority in mental health services, and targeting people with SEMI for specialist intervention is a cornerstone of the strategy to achieve this goal. The continuation of the trend in targeting people with SEMI for specialist intervention has the support of a national service framework and proposed changes to mental health legislation.

In the context of this discussion, and within the framework of the mental health and social care reforms currently being introduced, key issues in the targeting agenda include:

• definitional issues surrounding the term 'SEMI';
• practical and methodological concerns about how people with SEMI are to be identified and targeted;
• interface issues relating to multi-disciplinary working between primary and secondary care;
• issues concerning the evidence-base for risk management policies and strategies;
• the role of training in effective targeting;
• reflection on the potential consequences of targeting policies and initiatives; and,
• the meaningful involvement of service users from all sections of society.

Additionally, the policy directive to target people with SEMI warrants further scrutiny in order to 'unpack' some of the implicit assumptions by which it is under-pinned. According to the received wisdom of successive administrations, the strategy appears to be a rational approach: scarce resources should be targeted on people with the greatest needs. This has face validity in terms of the drive towards improving efficiency and cost-effectiveness within public services. However, the implicit assumptions that require serious consideration include the notions that:

• people with SEMI can be accurately and consistently identified;
• people with SEMI have the greatest mental health needs;
• meeting those needs will roughly equate with effective risk management;
• resources are scarce and finite; and,
• the strategy does not have any negative, unintended consequences.

These issues and assumptions are examined further in this book and serve as unifying themes for the contributed chapters. In some chapters, a particular issue may be the focus of a piece of research, or an initiative. In others, one or more issues are examined from different perspectives.

The contributors to this edited collection are drawn from different disciplinary, professional and practice backgrounds, bringing the benefit of their insights and experience to bear on the challenge presented by the mental health policy directive to target people with SEMI. The backgrounds of the authors, therefore, reflect the multi-disciplinary nature of the challenge before them, of working in partnership to deliver the government's promise of 'safe, sound and supportive' mental health services.

The book is divided into four sections. The first section, 'Setting the Scene', is comprised of three very different types of chapter, each of which begins the process of sketching-in the background for what is to follow.Chapter 1, by Lesley Cotterill and Wally Barr provides a descriptive account of the policy framework for the modernisation of mental health services. In this chapter, mental health policy is located in the context of the wider health and social care modernisation programme because of the common structures relating to quality improvement, the shift towards a primary care-led NHS, the public health agenda, and the focus on partnership working. In addition, the chapter traces the emergence of the trend towards targeting people with SEMI in policy and practice over the last decade. The chapter ends with some brief comments about the government's prioritisation of safety in its mental health reforms, and the tension this poses for the stated commitment to reducing discrimination.

In chapter 2, Maggie Clifton and David Duffy address the theme of safety in mental health services through the recommendations of mental health inquiry reports. They begin with a brief critique of the inquiry system before presenting the findings of a research project that collated and analysed the recommendations contained in 42 mental health inquiry reports published in the 1990s. In view of the priority the government attaches to improving safety and quality in its mental health services, this important piece of work represents an obvious starting point in understanding the failures of the past, and a means to prevent similar failures in the future. However, despite the status attached to these inquiries and, with one or two exceptions, this type of analysis has been largely absent from the academic and practitioner literature. This omission is wasteful of public resources in that it precludes effective dissemination of such recommendations to inform policy and practice.

The final chapter in this section, by William Spence, presents a medical sociological analysis of the phenomenon of targeting people with 'serious mental illness'. In this chapter, William focuses on the role of language in shaping our understanding of psychiatric terminology, and applies the concept of 'moral panic' to the directive to target people with this identifier for specialist intervention. This chapter is intended to provoke thought about the received wisdom and taken-for-granted assumptions that form the staple diet of much of the policy, and some of the practice, relating to people with SEMI. Whilst the 'medical model' has different connotations for different people, the reality of much funded research is that it is dominated by this broad world-view. However, by virtue of its place within the opening section, this chapter challenges the orthodoxy of the medical model of 'severe mental illness', and serves as something of an 'antidote' to the implicit assumptions that some of the remaining chapters may be accused of containing. In addition, the chapter also challenges the political motive behind the public safety orientation of mental health policy and, to that extent, counters the tendency of the chapter on the policy context to present an 'evolutionary account' of policy formation.

In section two, a selection of opinion-based chapters written from different stakeholder perspectives is presented. No claims are made for this being comprehensive in terms of the coverage of key stakeholder perspectives. Furthermore, the chapters make no pretensions to be the perspective of psychiatrists or of social services staff, and so on. As their titles imply, they represent 'a' perspective written from a particular vantage-point in the mental health and social care system. The authors creatively reflect on their personal and professional experience to begin the process of thinking through the import of the targeting directive, and focusing on key issues to be addressed in the im...

Table of contents

• Cover
• Half Title
• Dedication
• Title
• Copyright
• Contents
• List of Figures
• List of Tables
• List of Contributors
• PART 1: SETTING THE SCENE
• PART 2: PERSPECTIVES ON TARGETING
• PART 3: RESEARCH STUDIES IN TARGETING
• PART 4: TARGETING INITIATIVES