Where the wicked problems are: The case of mental health
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
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