Elsevier

Health Policy

Volume 101, Issue 3, August 2011, Pages 220-227
Health Policy

Where the wicked problems are: The case of mental health

https://doi.org/10.1016/j.healthpol.2010.11.002Get rights and content

Abstract

Objective

To use system ideas and the concept of ‘wicked problems’ to frame examination of a decade-and-a-half of UK mental health policy.

Methods

Theoretically informed policy analysis.

Results

Modern health care is complex, and mental health care particularly so. In the UK the mental health system has also become a policymaking priority. Features of this system mean that many of the problems policymakers face are of the ‘wicked’ variety. Wicked problems are resistant. Problem formulations and their solutions are contestable. Solutions which have ‘worked’ in one setting may not ‘work’ in another, and evidence to guide change is open to challenge. Actions trigger waves with widespread system consequences. In the case of the UK's mental health field significant shifts have taken place in formulations of ‘the problem’ to which actions have been directed. These have included assessments of community care failure, formulations emphasising problems with the professions and, most recently, the need for action to promote mental health and wellbeing.

Conclusions

In their efforts to secure improvement in a neglected field UK policymakers have unleashed a torrent of top-down actions. Attention needs to be paid to constructing strong, system-wide, partnerships and to examining the cumulative impact of policy actions.

Introduction

We show in this paper how ideas emphasising the interconnections within complex systems and the concept of ‘wicked problems’ can be combined to improve understanding of the challenges of public services policy and delivery, including in the arena of health care. We then use these ideas to underpin examination of a decade-and-a-half of activity in the United Kingdom's (UK's) mental health field. This is an area which emerged as a policy priority in the mid-1990s, and which has since been the subject of sustained attention. Mental health, however, is a disputed field. Following a brief chronological narrative of recent mental health policy we trace how changes in focus reveal important shifts in formulations of ‘the problem’ to which attention has been directed. Fast-moving policy action and service developments in areas as complex as this also bring the potential to trigger profound, cumulative, consequences. In interconnected systems these can emerge in unpredictable ways, and have lasting effects. We consider the implications of this observation for the mental health field, before drawing some wider lessons for policymakers and scholars not primarily interested in mental health per se.

Section snippets

System complexity and wicked problems

The framework we propose is founded on a critique of approaches to public policymaking and implementation that are based on assumptions of order, cause-and-effect and the uncritical use of ‘best practice’ examples. Chapman writes how these traditional models are reflected in certain types of language [1]:

A conversation with a civil servant, politician or senior public sector manager will yield a large number of phrases based upon the notion that government and organisations are machine-like:

Comprehending the mental health field

In using these ideas to frame analysis of the mental health field we observe, first, how the system which has evolved across the countries of the UK shares many of the general qualities (such as a fragmentation of agency and professional responsibilities) which contribute to the complexity found in other health and social care arenas. Mental health, however, is a particularly untamed field, characterised by singular historical and contemporary features which make it more complex still [14]. The

Surveying the territory: understanding recent mental health policy

Against this complex background, and following years of relative neglect, in the UK an unprecedented explosion of mental health policy activism began in the mid-1990s [28]. For many working in this area or receiving care the start of the deluge was welcomed as evidence that government was preparing to finally rid mental health of its ‘Cinderella service’ status [29]. The extent of the subsequent ‘initiativitis’ still came as a surprise to some, however [30]. Having trawled the Department of

On problems with problem formulation and waves of consequences

The broad turns in problem formulation and policy action we identify in this brief synopsis exemplify how problem identification and solution in complex systems are actively created in particular contexts, and remain open to challenge. Concern over homicides committed by people with mental illness living in the community [51] combined with fears from within the system that services were over-stretched and under-funded help explain why community care emerged as a candidate for early policy

Conclusion

The ideas we have drawn on in this paper are gaining ground. Chapman writes of the need for government to ‘think differently’ [1], and evidence is emerging across a whole range of public policy arenas of a growing appreciation of complexity and the relative intractability of wicked problems. Notable recent examples include analyses in the fields of health inequalities [67], [68], [69], the environment [70], sports development [71], higher education [72], and crime [73]. In the context of public

References (78)

  • B. Hudson et al.

    In pursuit of inter-agency collaboration in the public sector: what is the contribution of theory and research?

    Public Management

    (1999)
  • B. Hudson et al.

    The NHS and social care: the final countdown?

    Policy and Politics

    (2002)
  • D. Allen et al.

    Making connections: healthcare as a case study in the social organisation of work

    Sociology of Health and Illness

    (2005)
  • H.W.J. Rittel et al.

    Dilemmas in a general theory of planning

    Policy Sciences

    (1973)
  • C. Clothier et al.

    The Allitt inquiry: independent inquiry relating to deaths and injuries on the children's ward at Grantham and Kesteven General Hospital during the period February to April 1991

    (1994)
  • The Shipman Inquiry....
  • R. Srinivasan

    Swine flu: is panic the key to successful modern health policy?

    Journal of the Royal Society of Medicine

    (2010)
  • B. Hannigan et al.

    Complexity and change in the United Kingdom's system of mental health care

    Social Theory & Health

    (2006)
  • A. Rogers et al.

    Mental health policy in Britain

    (2001)
  • Hannigan B, Allen D. Giving a fig about roles: policy, context and work in community mental health care. Journal of...
  • N. Craddock et al.

    Wake-up call for British psychiatry

    British Journal of Psychiatry

    (2008)
  • D. Pilgrim et al.

    Survival and its discontents: the case of British psychiatry

    Sociology of Health and Illness

    (2009)
  • V. Coppock et al.

    Critical perspectives on mental health

    (2000)
  • M. Coffey et al.

    You don’t talk about voices’: voice hearers and community mental health nurses talk about responses to voice hearing experiences

    Journal of Clinical Nursing

    (2008)
  • L. Prior

    The social organization of mental illness

    (1993)
  • N. Crossley

    Contesting psychiatry: social movements in mental health

    (2006)
  • K. Woodbridge et al.

    Whose values? A workbook for values-based practice in mental health care

    (2004)
  • S.B. Guze

    Biological psychiatry: is there any other kind?

    Psychological Medicine

    (1989)
  • G. Thornicroft

    Shunned: discrimination against people with mental illness

    (2006)
  • A. Molodynski et al.

    Coercion and compulsion in community mental health care

    British Medical Bulletin

    (2010)
  • H. Lester et al.

    Mental health policy and practice

    (2010)
  • J. Boardman et al.

    Delivering the government's mental health policies

    (2007)
  • P. 6 et al.

    New Labour's modernization in the public sector: a neo-Durkheimian approach and the case of mental health services

    Public Administration

    (2004)
  • J. Boardman

    New services for old: an overview of mental health policy

  • National Assembly for Wales

    Adult mental health services for Wales: equity, empowerment, effectiveness, efficiency

    (2001)
  • Welsh Assembly Government

    Raising the standard: the revised adult mental health national service framework and an action plan for Wales

    (2005)
  • Scottish Executive

    Delivering for mental health

    (2006)
  • Department of Health Social Services and Public Safety

    Mental health service framework: project initiation document

    (2007)
  • J. Dunning

    Care services minister outlines revised mental health strategy. Paul Burstow outlines link between poor mental health and poverty

    Community Care

    (2010)
  • View full text