Last week I was fortunate to spend the morning with a mix of policymakers and practice leaders in mental health. We spent some time thinking about how out of hospital mental health care should integrate into the ‘new models’ set out in the NHS Five Year Forward View being developed across England.

The people in the room had very different day jobs: leading clinical teams, commissioning services, and working in local government, versus navigating the jungle of central bodies, ministers and critical spending review discussions.

People’s backgrounds became clear when they spoke about improving services. Policymakers were concerned with improving mental health data, changing payment systems, and access standards for evidence-based services. People closer to practice spoke about changing local culture around who is eligible to receive services, the difficulties of finding funding for double running, and the importance of peer support. There was passion to improve services on all sides of the room, as well as valid concerns and priorities. But sometimes the worlds of policy and practice seemed to be talking a very different language.

Talking about new models of care – changing the way organisations are set up to deliver care in different ways – caused challenges all round. Care models are the fashionable mainstream policy of the moment, and this difference possibly illustrates the differences between mental health and physical health thinking.

Mental health trusts don’t necessarily fit easily into the new care models. Much of their care is already out of hospital, and issues concerning them are different: reversing the trend of ever raising thresholds for care and rebuilding services for children and young people. The majority of people with a mental health problem never get near a mental health trust – so new models of care need to build capacity for high quality support for mental health problems within primary care (rather than focus on integrating existing capacity), including making further progress on access to psychological therapies.

Do differences in perspective between policymakers and local leaders matter? The answer of course is ‘it depends’.

On the one hand, differences are necessary. We are all creatures of the systems we inhabit, and need different sets of language to thrive in them. In government people working in mental health making the case for investment need to evidence change for investment provided (needing data) and convince others they have the ‘levers’ to make this happen (requiring national initiatives). Equally, a local leader is not going to be interested in national efforts to collect and publish data she already has access to, and will have her own priorities for improvements.

On the other hand, if differences in perspective mean efforts are not aligned or policy is disconnected then this is a waste of effort and resources. If, for instance, the overarching barrier to improving mental health services is the local attitudes of leaders to risk then all the transparency and targets in the world will do little – and will distract locally from the changes that matter (for more on when targets can be used effectively, see our new report).

The best policy is made when it addresses the issues at the heart of the matter, and resonates with people’s motivation locally. This requires:

  • an understanding of what is happening locally and the pressures services face,
  • knowing the likely impact of the different measures available to drive change through policy, and
  • building a consensus between policymakers, professionals and people using services as to the way forward.

Creating this set of factors is not an easy task, but we believe it starts with conversations. Conversations between those delivering services, those using them, and those advocating for them and shaping them nationally. And not separate conversations – but one discussion encompassing all those with a stake in services.

Reflecting on our mental health and new models conversation, the aspect that has stayed with me is not the differences between people but the similarities. Everyone there was passionate about making services the best they could be: and agreed this meant supporting people to be hopeful. And, despite the differences between policy and frontline professionals, this feels like a fairly hopeful place to start a conversation.


Felicity Dormon is Senior Policy Fellow at the Health Foundation.

Follow her on Twitter @FelicityTHF.


Graham Mellors

I agree that energy should be focussed on building MH capacity in primary care. I would make the same point about voluntary sector orgs, both in terms of the direct support they provide to people, and their role in building 'community capacity/resilience' more generally.

David Oliver

An excellent, lucid blog Felicity. Thank you. What you say about mental health could apply equally to other areas of healthcare whether urgent care, integrated care for older people, intermediate care services outside hospital or end of life care as well as more joined up primary care for people with long term conditions.

I have been fortunate in having a career that has spanned front line service provision. I have had year round responsibility for 24-28 bedded ward, regular on calls in ED/AMU etc and led local service developments, but also worked in the DH as an NCD an as a Medical Society President and as a Kings Fund fellow so i have been part of the policy world and commentariat and enjoyed both

I don't doubt, as you say in your blog that those in the policy roles are sincere and committed but my observation having straddled both is that too many decisions are being taken by people with no recent (or any) experience of the realities of frontline services, the pressures, the expectations of the public the morale of staff etc. They also often have scant regard for empirical peer reviewed research evidence or the amount of time it really takes to deliver and evaluate change. (Timescales being governed by political imperatives or system pressures not by realistic expectation).

And policy folk instead of applying service models also shown to work at scale (doing more of the same but doing it better or more systematically) are drawn like Magpies to the magical baubles of big blue sky thinking.

Finally, they grossly overestimate the importance of financial instruments and incentives to the health and social care staff who will be delivering the change

The most successful change has been clinically owned and driven with bottom up initiatives shown to work and then backed by some kind of national support to roll out, rarely imposed from above.

We would be better off allowing services and systems and initiatives to mature and critically, to ensure that people in policy and leadership roles are steeped in or continue to be involved in or are frequently shadowing coalface practitioners

David Oliver

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