For at least a decade, health policymakers across developed countries have worshipped at the altar of “value.” Rather than paying for activity, purchasers should define the desired outcomes for particular health services—rehabilitation after a hip operation or effective management of a chronic condition—and reward providers for delivering these outcomes as efficiently as possible.
But what do we do if there is no broad agreement on the outcomes a particular group of services should deliver? Under these circumstances, will the definition and pursuit of specific health outcomes provide valuable professional discipline? Or will it cause mistrust and division?
Mental health is one area where consensus is hard to find. There is fierce disagreement on the benefits of established forms of treatment. Service users describe themselves as survivors—not of illness—but the institutions supposed to help them. Many turn to organisations that operate as an alternative to traditional health services. There is a perception that, despite the best efforts of many staff, traditional services are failing on matters of fundamental importance.
The King’s Fund’s recent paper on outcomes in mental health, commissioned by Janssen, considers the outcomes currently prioritised by mental health services. In clinical services, the focus is on managing the signs and symptoms of mental health conditions such as anxiety or depression and people’s ability to cope with daily life. In social services, the focus is on developing the resources and capabilities people need to recover and live independent lives. For example, do people have a job or other form of meaningful activity, safe and secure housing, and a strong support network? These are all vitally important things. And yet this narrow focus seems profoundly problematic.
At NAVIGO, a social enterprise in Grimsby, we were shown around by a service user, Maria, who is now a volunteer. Maria had “selective mutism”—she didn’t talk—during her childhood and a large part of her adult life. She told us about her childhood with a mother with post-natal depression who was unable to show warmth or talk to her, the sexual abuse she suffered at school, and terrifying experiences in locked mental health services. She also explained how, in NAVIGO’s therapeutic community, she was able to make sense of what had happened to her, recognise the cycles of her illness, and reconnect with her family. When she stopped talking, we were all in tears.
If I am rushed to hospital with trauma after a car accident, I am, and those caring for me are, likely to have a clear set of shared objectives. The order of priorities is self-evident. In the care of people with mental health problems, and perhaps people with other chronic conditions, things feel very different. Even a brief discussion with Maria reminds us of the profoundly personal nature of mental illness. While she might share a diagnosis with others, Maria’s experience of mental illness, her understanding of her condition, her healing journey and her aspirations for the future are unique.
The roles of public services in supporting people with mental health problems are also surely equally complex. In moments of crisis, people turn to services not just for a diagnosis, medical treatment or social support, but for sanctuary, to alleviate symptoms of illness, to help make sense of what has happened to them. They look for support in grieving, in recovering their voice, in rekindling hope. They look to services to address the stigma that comes with a mental health diagnosis, to let them know that just because they have reached rock bottom, they are still fully human, and perhaps for many other important things besides.
If service users are angry, it is surely in part because traditional services—incited by commissioners and trapped within a narrow definition of the outcomes that matter—are prioritising the technical and clinical aspects of care to the detriment of these “humanitarian” aspects of care.
Ben Collins is projects director at The King’s Fund and author of Outcomes for mental health services: what really matters?: https://www.kingsfund.org.uk/publications/outcomes-mental-health-services