Mental Health Policy and Practice

Jon Glasby, Jerry Tew

• Editorial: Bloomsbury Academic
• Año: 2015
• ISBN:
  9781350313125
• Edición: 3
• Categoría: Sozialwissenschaften
• Categoría: Sozialarbeit

This highly regarded book offers a clear and considered guide to modern mental health policy and practice.Building on the success of previous editions, this third edition provides:
- An up-to-date overview of the changes to mental health policy and practice as they apply to a broad range of mental health services, from primary care and forensic mental health issues
- A focus on mental health specific issues in the context of broader health and social care reforms, including the reform of primary care, the impact of austerity and the personalisation agenda
- A greater exploration of what interagency working means: it goes beyond issues with health and social services and explores the everyday services that are essential to everyone
- A range of case studies, reflection and analyses, followed by engaging exercises and suggestions for further reading This book is designed for students of social work, social policy, nursing and health taking courses on mental health policy and practice. It also serves as an important update for practitioners in the field. New to this Edition:
- Highlights key changes and developments for today's students and practitioners
- Explores the implications for future practice

1	Introduction

In this chapter we discuss:

• The importance of partnership between health and social care.
• What we mean by mental health.
• The impact of mental illness.
• Different ways of thinking about mental illness.
• The incidence and prevalence of mental illness.

This revised and updated book is designed as an introduction to mental health policy and practice in the United Kingdom (UK) for students as well as for qualified practitioners, their managers and policy makers. That a third edition is needed so rapidly reflects the rate of change in mental health policy and practice across the four countries of the UK, with an increased degree of diversity as devolved administrations have had the opportunity to set their own policy directions. Our focus is on policy and practice relating to a range of mental health difficulties – including both more common difficulties (such as anxiety or depression) and those that may be seen as more serious and disabling (such as to psychosis) – but generally excluding neuro-degenerative conditions such as dementia which have tended to be dealt with somewhat separately in terms of policy and service provision. We will also consider the emphasis on the promotion of mental health and mental well-being that has become more prominent in mental health policy over recent years.

While mental health has acquired greater policy prominence over time, and a range of new service models and initiatives have been put in place, much remains to do in terms of:

• Developing better primary care-led and community-based models of service provision.
• Continuing to improve specialist mental health services and promoting a more personalised, recovery-oriented approach.
• Reducing stigma and promoting inclusion.
• Balancing concerns about risk and safety with increasing expectations around service user choice, control and self-management.
• Moving away from a focus on the needs of people in crisis to promote positive mental health for all.

It is these issues (although with some significant differences in emphasis), that are setting the context and agenda for policy development across the countries of the UK. However, in all UK countries, after a period of substantial growth in funding between 2000 and 2010, any desire to improve mental health services has now to be envisioned within a challenging financial context in which substantial savings are being required within the National Health Service (NHS) and, often to an even greater extent, within local authority social care services.

In seeking to understand the directions of (and contradictions within) current policy, we also aim to provide some historical perspective – exploring how thinking and practice has continued to evolve over time, and what may have been the more or less obvious drivers for such developments.

Now published as part of a broader series on interagency working for different user groups, this book does not just focus on a particular professional or organisational perspective – but on a wider whole systems approach. However, within this ‘whole system’, our focus is primarily on specialist mental health and social care services – although we recognise that people with mental health problems are also affected by (and concerned with) the everyday services and supports that are so essential to all of us (for example, housing, employment, income, education, family, neighbourhoods, transport, leisure and community safety) – and we try to reflect this wherever possible.

The importance of health and social care partnerships

Part of the difficulty in providing a holistic response to people with mental health problems derives from the structural barriers built into our welfare state (see Glasby and Dickinson, 2014, for further discussion). This is true across a range of different agencies – but is particularly the case with regard to the relationship between health and social care. Traditionally, the post-war welfare state is based on the assumption that it is possible to distinguish between people who are sick (health needs) and those who are merely frail or disabled (social care needs). This was enshrined in two pieces of 1940s legislation (the NHS Act 1946 and the National Assistance Act 1948) and continues to form the basis of service provision in the early twenty-first century (Glasby and Littlechild, 2004; Glasby, 2012). As a result, two separate systems have developed, each with different ways of working, different structures and different priorities (see Box 1.1). Even in Northern Ireland, where health and social services have been formally integrated, front-line professional practice can still feel very divided (see, for example, Heenan and Birrell, 2006, 2009).

In response, governments have explored different ways to promote more joined-up services and to provide a more efficient and coordinated response to people with complex needs. Over time, responses have ranged from the Joint Consultative Committees, joint care planning teams and joint finance initiatives of the 1960s and 1970s to attempts to ensure greater coordination with mechanisms such as care management and the Care Programme Approach in the 1990s. More recently, we have seen a plethora of approaches, including the creation of pooled budgets between the NHS and local government, the promotion of joint commissioning, integrated provider organisations, senior joint appointments, joint assessments of local need, the creation of multidisciplinary teams at local level and greater emphasis on information sharing, a single point of access, single assessment and the co-location of different professional groups (see Glasby and Dickinson, 2014, for an overview). Arising out of this partnership agenda, different health and social care professions reading this book will increasingly be working in interprofessional settings and/or integrated organisations, working with a wider range of colleagues from different professional and organisational backgrounds. While this has long been recognised in mental health, it has sometimes seemed a slower process in other settings – and there still remains much to be done even in mental health to ensure people using services receive a holistic and fully coordinated response.

Box 1.1

The health and social care divide

Key features of social care include:

• councillors democratically elected at a local level;
• local government is overseen and monitored by the Department for Communities and Local Government (although the Department of Health has a significant role in the oversight and monitoring of social care);
• subject to means testing and charges;
• based on specific geographical areas;
• traditional focus on social factors contributing to individual situations and on choice/empowerment; and
• strong emphasis on social sciences.

Key features of NHS care include:

• non-executive directors appointed by central government;
• overseen and monitored by the DH;
• free at the point of delivery;
• boundaries are based on GP practice registration;
• traditional emphasis on the individual and on medical cure; and
• strong emphasis on science.

What do we mean by mental health?

According to the World Health Organization (WHO) (2001), mental health is more than simply an absence of symptoms of mental distress – it involves a positive sense of well-being and an ability to lead a full and productive life. Everyone has mental health needs, whether or not they have a diagnosis of mental illness. Positive mental health includes the ability to understand and make sense of our surroundings, to cope with change and to connect with other people. When mentally well, we are aware of and have control over different strands of our life; we have the will to live life to its full potential; things make sense to us. Mental health is increasingly recognised as an essential component of our general health as exemplified in the key strategy documents such as Towards a Mentally Flourishing Scotland (Scottish Government, 2009b) and No Health without Mental Health (HM Government, 2011).

Mental well-being

In policy terms, the concept of mental well-being has assumed increasing prominence in recent years, particularly in Scotland, but also in England under the coalition government. Although this concept is subject to different interpretations, it is generally accepted that well-being comprises two key aspects (Ryan and Deci,2001):

1. Positive thoughts and feelings. This is the subjective or ‘hedonic’ aspect of well-being. This has been popularised as ‘happiness’ (Layard, 2006), drawing on the ideas of positive psychology (Seligman, 1991) – but also encompasses other aspects of subjective experience such as sense of belonging and having meaning and purpose in life.
2. Flourishing and active engagement in life. This is the objective or ‘eudemonic’ aspect of well-being. It is predicated on the capacity to exercise agency and choice, and has been described as ‘a dynamic state in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community’ (Foresight Programme, 2008: 10).

Although they are related concepts, well-being is not the same as ‘quality of life’ which primarily focuses on the circumstances in which people live, rather than on how they respond to those circumstances. Research suggests that well-being is not the ‘opposite’ of mental disorder: some people with ongoing ‘symptoms’ manage to achieve high levels of well-being while others do not (Weich et al., 2011), and this may be seen as a critical issue in terms of judging the effectiveness of service provision.

Well-being is seen to be achieved through a combination of personal and social factors – and may be enhanced through policies and practices which:

• enhance people’s ability to be in control of their lives;
• increase resilience and community assets; and
• facilitate participation and promote inclusion (National Mental Health Development Unit, 2010).

Although the idea of well-being has been applied at the individual level, it may also be used at the level of social groups, such as families or communities, to describe the degree to which these may or may not be flourishing and be experienced positively.

What do we mean by mental ill-health?

Mental ill-health covers a spectrum from psychosis through to more everyday experiences such as anxiety or depression. It has been understood and defined in many different ways, and meanings have changed across time, and are influenced by geography, discipline and personal perspective.A lawyer will have one definition, a psychiatrist another, a service user another still.

The legal definition under the English Mental Health Act 2007 is ‘any disorder or disability of the mind’ with similarly broad definitions in the corresponding legislation across the countries of the UK. Psychiatry most commonly conceptualises mental distress in terms of specific mental illnesses, such as schizophrenia, with precise diagnostic criteria. Psychology tends towards the idea of a formulation that describes a person’s experiences and behaviours as phenomena in their own right, rather than necessarily as symptoms of an underlying illness. Social work is most concerned with the relationship between people’s mental experiences and their wider life circumstances – including factors such as disadvantage, stigma and discrimination.

Providing something of an antidote to professional debates, the writings of people who have experienced mental distress first-hand are invaluable in providing an insight that neither romanticises nor underestimates the meaning, effects and consequences of mental ill-health. William Styron (2001: 46–7) described his depression as:

a storm of murk … near paralysis, psychic energies throttle back close to zero. Ultimately the body is affected and feels sapped, drained … I began to conceive that my mind itself was like one of those outmoded small town telephone exchanges, being gradually inundated by flood waters: one by one, the normal circuits began to drown, causing some of the functions of the body and nearly all those of instincts and intellect to slowly disconnect.

Users’ experience and writings can, however, also demonstrate the ways in which people find valu...