Understanding mental health systems and services

Working in collaboration with colleagues across the UK, including with people who have directly used services, researchers in the School of Healthcare Sciences at Cardiff University study mental health systems.

Our projects investigate the organisation and delivery of health and social care, the work that professionals and others do, and the experiences and views of people living with mental health difficulties.

This research often involves the use of in-depth qualitative methods (such as long, semi-structured, interviews), either alone or in combination with quantitative methods (such as questionnaires). Underpinning this programme of research is the idea that in order for policymakers, managers and practitioners to improve services it is first necessary to understand them.

Why are health and social care systems complex?

A starting point for research of this type is the observation that health and social care systems are complex. This is so for a number of reasons:

Responsibilities for care and treatment are often shared between different organisations: NHS health boards and trusts, local authorities, charities, private sector providers. This can complicate integrated provision.
Face-to-face caring work (particularly for people with long-term conditions) is typically done by people from a range of occupational groups: doctors, nurses, allied health professionals, social workers, paraprofessional and support staff. Within and across each of these groups members possess varying constellations of knowledge and skill, contributing to an intricate division of labour and creating opportunities for differences to emerge surrounding the goals of service provision.

Work is also done by people who are not paid for what they do. These include those living with illness, along with family members and lay carers. They are engaged in work whenever negotiations take place with paid practitioners on what therapies and treatments should be followed, and whenever they actively participate in plans of care.

The mental health system

The UK’s mental health system has evolved over many decades, and is complex in exactly the ways described above. For many years organised mental health care exclusively meant care in large psychiatric hospitals. Large numbers of these were built from the second half of the nineteenth century onwards, at their height housing many thousands of inpatients. Cardiff’s Whitchurch Hospital is a good example. This opened in 1908, and until closing to inpatients in spring 2016 lay at the heart of mental health services for the people of the Welsh capital.

What was once an entirely hospital-based system has changed beyond recognition. Care nowadays is provided through networks of services and staff located in community and hospital settings, with the community components assuming steadily increasing prominence.

Explicit policies driving community mental health care have been in place since at least the early 1960s, with early landmarks including the Hospital Plan of 1962 and the White Paper Better Services for the Mentally Ill in 1975. Interprofessional community mental health teams, bringing together practitioners serving the needs of people living within defined localities, became the dominant model for organising specialist care and treatment from the middle of the 1970s onwards. For long periods in the second half of the twentieth century the mental health system was not a priority for policy attention and service improvement, and failed to attract the resources necessary to fully support its historic shift towards community care.

This relative lack of attention began to change in the middle of the 1990s, with the mental health system finally moving closer to the centre stage. In response to criticisms of underfunding and underperformance, new types of community team were set up. Important examples included services providing crisis resolution and home treatment for people who might otherwise have been admitted to hospital, along with early intervention services for people experiencing a first episode of a major mental illness and assertive outreach for people with long-term, disabling, problems.

New roles for professionals were created, and investments made in new primary care-based services and interventions for people with depression, anxiety and other commonly experienced mental health problems.

In an era of devolution, mental health services across the countries of the UK began to take shape in different ways. In Wales (but only here) a law was passed mandating for primary mental health care, along with statutory care coordination and care and treatment planning for people in receipt of secondary mental health care. Most recently of all, services face being reshaped in an era of austerity with evidence emerging of long-awaited investments in England being withdrawn and of services retracting.

Researching the mental health system

Mental health systems research in the School of Healthcare Sciences takes place against this general backdrop of complexity and change. Past studies have investigated the work and roles of community practitioners, and the convoluted journeys taken by people living with mental health difficulties as they cross from primary to secondary care and from home to hospital, and as they move from one type of specialist service to another.

Projects have employed action research to introduce triage as a way of managing demand for community child and adolescent mental health services. More recent and ongoing projects (involving collaborations with colleagues in Swansea University, City University London, the University of Manchester, in the NHS and with people with experience of using mental health services) are investigating the less obvious risks to young people in mental health hospital, care planning and care coordination in both community and hospital mental health services and social care approaches to recovery from mental illness.

Our aim is to produce useful new knowledge which makes a difference, and can be drawn on to inform decisions on how services are planned, organised and delivered. Check back on this blog for future news on research in these and related areas.

Dr Ben Hannigan is a Reader in Mental Health Nursing in the School of Healthcare Sciences at Cardiff University. He blogs at benhannigan.com and tweets at @benhannigan