Mental Health Policy for Nurses

Ian Hulatt, Ian Hulatt, Author

• Publisher: SAGE Publications Ltd
• Year: 2014
• Print ISBN: 9781446252512, 9781446252505
• eBook ISBN: 9781473905177
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Policy determines much of what nurses actually do on a daily basis, which means it is essential for nurses to engage with policy if they are to understand their own practice.  Mental health nursing in particular has been shaped by a variety of policy factors in the past fifty years. In this new textbook, edited by the mental health advisor to the Royal College of Nursing, a range of experts in their field introduce the essential elements of mental health policy to students and experienced practitioners. The book covers a broad range of areas, including settings for care and the historical context, policy affecting various diagnoses and service user groups, and how policy is translated into action.  Clinical examples are drawn on throughout, to help students think about the real-life context of what can be a difficult subject.

It will be essential reading for pre-registration mental health nursing students, and valuable to those working in practice who want to gain an understanding of policy.

1	THE HISTORY OF MENTAL HEALTH POLICY IN THE UNITED KINGDOM

Peter Nolan

Chapter Overview

In this introductory chapter to the book Professor Nolan provides an overview of mental health policy in the UK. Like any book there is a very good chance that by the time this is read there will have been further developments and occurrences of note, however, he has provided you the reader with an opportunity to see the development of policy in a broad historical sweep and with reference to social events that may well have informed the policy development. As alluded to in the introduction to this volume, policy does not occur in a vacuum.

So as you will see here there are wider social and political events and movements that can be said to have shaped the world within which you now practise. The history of policy has certain pivotal moments and in this chapter you can clearly recognise the influence of those who we would now describe as reformers: individuals who possessed a vision of how care and treatment could be improved and delivered in a more humane way. This perhaps reached its peak with the de-institutionalisation programme of the 1980s from which in some senses we are still emerging. The water towers are now few and those that remain in the midst of housing estates do so as ‘listed’ reminders of a past age.

As this book was nearing completion the NHS was still undergoing close scrutiny and this was exemplified by the Francis Report (2013) which investigated the failings of care in Mid Staffordshire. It is possible that mental health services had their ‘Francis moment’ many years ago, but there is still a need to be vigilant and also aware that the current service models provide for those in our society who number amongst the most vulnerable.

INTRODUCTION

In the second decade of the twenty-first century, policy has assumed a much greater degree of importance in the design, delivery and direction of mental health services than was previously the case. Health is now seen as a fundamental human right that is indispensable for the exercise of other human rights and every human being is entitled to attain a standard of health conducive to living a dignified life (Andersen et al., 2006; Penhale and Parker, 2007). But there are other reasons also, including an ageing population, increasing demands on mental health services, advances in medical technology, efficiency savings in the NHS, and heightened expectations on the part of patients and service users. If those responsible for the provision of health care become so preoccupied with administrative minutiae then it is possible that health-care provision could become deeply embedded in routine and unable to respond to need, with the result that it becomes little more than a mechanism for perpetuating the social, economic, and political order of an inegalitarian society (Sullivan, 1987; Goodwin et al., 1999). Addressing all of these issues requires understanding and consideration of the varying perspectives of providers, consumers and the general public. In addition, health policy must currently confront a challenging economic climate in which uncertainty is all pervading. Governments faced with rising health-care costs must seek ways of achieving higher quality and productivity without increasing expenditure (Propper, 2011). In the UK and elsewhere, policy makers are challenged by numerous questions: does competition or collaboration produce better healthcare; how can closer working relationships be brought about between providers; what should be the roles of the private and voluntary sectors; how can a strong consumer voice exist alongside, but distinct from, the regulators (Dixon, 2011).

It is apparent that, given such complex circumstances, a systematic development of mental health services and sustained improvement are unlikely to occur without a clear mental health policy. While the boundaries of health policy are regularly contested and redefined, four objectives seem to remain constant:

• Devising services which can be accessed early and easily.

• Ensuring that services are diverse and appropriate.

• Training health-care workers so they are appropriately skilled to deliver services.

• Putting in place suitable support for people recovering from mental health problems in ways that can be seen as constituting ‘recovery capital’.

This chapter offers a succinct overview of the evolution of mental health policy in the UK, briefly examining why certain policies were introduced at certain times and concluding with a discussion of the challenges that both confront those who formulate policy and those who are charged with implementing it. Although mental health policy throughout the UK is largely similar differences do occur, both with respect to content and focus, and these will be highlighted and briefly discussed towards the end of the chapter. Although few mental health nurses will be directly involved in formulating policies, all nurses – irrespective of their position or grade – have a responsibility to be informed about these and active in their implementation. The seeming indifference of nurses towards mental health policy has been due in previous decades to a perceived lack of professional autonomy that arose from an anachronistic, ‘handmaiden’ relationship with psychiatric medicine (Barker, 1989). Until recently, the work of nurses was poorly defined and largely shaped by the culture of medically-dominated institutions and the preferences of psychiatrists and managers for specific therapeutic approaches. It was inconceivable to the majority of nurses that centralised policies might impact directly on their work.

Analysts have noted that mental health-care policy has not only lagged behind other areas of health care, but also that it is one of the most neglected facets of health care worldwide. However, it would be inaccurate to assert that policies in other branches of health care always determine interventions or are always implemented homogeneously; theory is not always made incarnate (Weiss, 1995). On the contrary, argue Greenhalgh et al. (2011), most interventions – including those in mental health – are driven by hypotheses, hunches and aspirations. While policies are directed at populations, services are provided for individuals in circumstances which vary considerably. However, it is generally agreed among policy commentators that without the spur of policy to direct practice, some people with mental health problems have been poorly treated while others have received no treatment at all, and as a result, these individuals have experienced disrupted relationships, unemployment, social exclusion, and increased exposure to the criminal justice system.

Public attitudes towards mental health services have fuelled policy neglect, with attitudes based on the belief (held even by some of those who provide mental health care) that people with mental health problems could get well ‘if they really wanted to’. Ignorance impedes the development of services: mental health problems are poorly understood both by the general public and by practitioners; researchers have not illuminated sufficiently the causes of mental illness; treatments are idiosyncratic and conjectural; and few in public life champion those who suffer with mental health problems (Koffman & Fulop, 1999; Pilgrim & Rogers, 2001).

However, when prominent people have supported improvements in the quality of services they have effected change, even if not to the extent that they would have hoped for (Pilgrim & Rogers, 2001). In the 1950s in the UK, Donald Macintosh, a Conservative MP, doctor and ex-psychiatric patient, used his influence as a parliamentarian to get mental health care onto the political agenda. He highlighted the poor conditions in which the mentally ill were cared for in comparison to patients in other branches of medicine and the lack of access to effective treatments. Similarly, in the 1990s Ian McCartney, a Labour MP, spearheaded a policy review of conditions and practices in mental health, while Tessa Jowell, in the same decade, sponsored a number of private members’ bills relating to aftercare provision for service users (the latter drew on her extensive previous experience in mental health care as the Training and Education Director for MIND). Equally dedicated was former Tory Minister of Health, Virginia Bottomley, an ex-psychiatric social worker who regularly participated in debates on mental health policy and services. While the work of these few is admirable, it is also remarkable by virtue of the fact that it is confined to such a small number, given that one in five of the 650 MPs in the House of Commons has admitted to having experienced a mental health problem at some point in their lives (MIND, 2008). This almost unanimous failure on the part of MPs to advocate for the mentally ill has seriously impeded the development of services and their availability and accessibility. The UK has seen very little of the courage demonstrated by the Norwegian Prime Minister, Kjell Magne Bondevik, who developed a mental illness while in office, disclosed it, and acknowledged that it prevented him from carrying out his duties as Premier. His honesty stimulated an outpouring of sympathy and understanding from all sectors of society, and his candour was rewarded by his being re-elected with an increased majority (Knapp et al., 2007). This incident has much to say about how political leadership can be instrumental in increasing public awareness, interest and commitment.

REMIT OF MENTAL HEALTH POLICY

Carpenter (2000) states that the student of health policy should commence by focusing on the process of policy making rather than undertaking an exploration of what it was that specific policies were designed to achieve. He contends that policy is an umbrella term encompassing legislation, research, economics and politics, all of which are distilled to yield an indication of what can realistically be provided and achieved. Policy, he continues, should take into account the culture of public services and the variety of ways in which mental health services can be made available to people from a variety of cultural and social backgrounds. Mental health policy has to be to be viewed from multiple standpoints. How has policy evolved? How is it presented and what language is used to express it? What implications does it have for resources? How is it to be implemented? What recommendations, if any, are there for how it is to be evaluated? And most importantly, what are the limitations of a specific policy and to what extent does it conflict or overlap with other policies?

All policies – regardless of their intentions – constitute a discourse between the individual and the state, and although there is disagreement about the precise definition of policy it is generally agreed that it provides a vision of how a particular society would wish things to be (Andrews, 2001). Policies are essentially declarations of an intended direction of travel, and of necessity these will change over time in accordance with changing social circumstances: they are not absolute edicts meant to be adhered to regardless of circumstances, and should not appear to be unrealistically utopian in their aspirations. In contrast to the law which is mandatory, public policy is expressed in the regulations, decisions and actions of government: it does not only refer to the actions of government, but also to the intentions that determine those actions. In short, public policy consists of the political decisions that are taken in implementing programmes to achieve societal goals (McCool, 1995). Explaining why policies are necessary, Grayling (2006) states that these support human societies to evolve in a reasoned, compassionate and civilised way, while Osbourne (2008) suggests that policies should attempt to define health and highlight tried and tested strategies for its maintenance: it is thus the function of policy to state unequivocally what people should expect by way of state provision in order to be healthy. Osbourne considers that without transparency and candour, health-care providers are liable to interpret directives in different ways, giving rise to postcode lotteries which can result in both apparent and real injustices with respect to the availability of services and treatments. Mental health policy should paint a vision of what the future should look like and act as a declaration of the level of wellbeing that a government seeks to attain for the population it serves.

Osbourne also contends that in a state-run health service it is incumbent on the government to explain the political and economic ideologies that gave rise to its policies, to provide evidence of public need, and give an assurance that what is being proposed is deliverable and affordable. As the NHS is a tax-funded system and the chief means by which people take care of each other, it is – of necessity – an intensely political institution. Good health service governance requires the commitment of three key stakeholders if its implementation is to be successful, namely users, funders and workers. In formulating and implementing policy, government seeks to foster a dialogue and build consensus between professionals, service users and the public. Differences in the social and cultural context of health care in different countries or regions of the same country, in the personnel involved in delivering it, in costs, in perceived consequences for the community as a whole, and in people’s expectations inevitably result in health-care policy that is constantly changing. Providers and professionals will therefore not universally comply with policies, and these may be seen as unstable and as externally-imposed constraints which threaten professionals’ self-interest (Pilgrim & Rogers, 2001).

Behavioural economists will frequently invoke ‘nudge theory’ in examining the importance of policy, the essence of which is to persuade people of the rightness of what is being suggested (Thaler & Sunstein, 2009). Closely aligned to this is libertarian paternalism, which holds that state involvement in the welfare of citizens does not have to compromise or ignore individual autonomy. People’s choices can be steered in directions that will improve their welfare but without the coercive proscription of certain courses of action. Andrews (2001) argues that all policies, regardless of their theoretical assumptions, are no more than navigational aids and do not provide clear explanations as to how they should be implemented. While policies must be persuasive, intelligible and credible, they must also appear to be pragmatic and achievable – and above all, clearly capable of contributing to the improvement of people’s lives. To attain a high level of agreement on policy between state and public, Andrews (2001) posits certain a priori conditions: there must exist an educated population capable of critical thinking and reflection; there must also be debate and discussion that include all sections of society; and time must be set aside to allow people to explore the meaning and implications of certain courses of actions. People must be sufficiently public-spirited to see what is in the best interest of others as well as themselves. These conditions are especially relevant as those managing and delivering services come under increasing pressure to cut costs, to be more transparent, and to include members of the public in exploring how improvements could be initiated and sustained.

EVOLUTION OF MENTAL HEALTH POLICY

In his history of psychiatry, Shorter (1997) asserts that mental health policy can be related to three phases in the development of mental health services: the establishment...

Table of contents

• Cover Page
• Halftitle
• Sage
• Title
• Copyright
• Contents
• About the Editor and Contributors
• List of Acronyms
• Introduction
• 1 The history of mental health policy in the United Kingdom
• 2 The European context
• 3 Community services
• 4 Psychosis
• 5 Older people
• 6 Dementia
• 7 Personality disorder
• 8 Service user involvement
• 9 Equalities in mental health nursing
• 10 Child mental health policy in the UK
• 11 Dual diagnosis
• 12 Policy into action?
• Index