Choice: wake up and smell the coffee!: INVITED COMMENTARY ON... CHOICE IN MENTAL HEALTH

The ‘choice agenda’ reflects a key element of themodernisation of public services. There are many conceptualand practical difficulties with the implementation of choicewithin mental health services, but these are not in any wayunique to this client group. Professionals will have to adaptto the new world that will encompass a plurality of paradigmsof care and service providers.

Few people working within the public services in the UK canbe unaware of the ‘choice agenda’ that dominatescontemporary government policy for healthcare, social care andeducation. As Valsraj & Gardner (2007, this issue) state,the aim is to create a ‘patient-led NHS’. This isto involve a paradigm shift that professionals no longer ‘doto’ but ‘work with’ patients (also known inmental health services as clients, users and survivors) andtheir carers.

As Valsraj & Gardner rather neatly put it, the mechanismsthat have been put into place in the acute health sector toenhance patient choice rest ‘on the twin pillars of competitionand plurality of provision’. Thus local health economiesare required, under ‘choose and book’ (Department of Health, 2004),to ensure that at the point of referral for elective care generalpractitioners offer the patient a range of providers; therehave been specific financial incentives for the developmentof private-sector healthcare provision contracted to undertakeNHS work; and, under payment by results, money for service provisionfollows the patient. Direct payments and personalised budgetsare supposed to produce analogous choice-enhancing changes inthe social care system.

Payment by results is yet to be extended into mental healthcare,partly because of the extreme technical difficulty of developingappropriate tariffs that can remunerate providers for the workthey actually do. A hip replacement is a hip replacement; theinputs required to undertake the procedure successfully andthe care pathway can be generally agreed. The limited numberof factors that might influence outcome and costs are relativelyeasily modelled. Contrast this with the ‘package of care’to be offered to someone with schizophrenia, which will or shouldbe highly variable, depending on patient and carer need (andwill fluctuate over time).

The jury is out about the success of these choice-based reforms,although one cannot help but notice that their introductionoccurred just before a significant loss of public confidencein the NHS and an unprecedented financial crisis that is affectingmental health trusts, even when they have been historicallyin financial balance. Paradoxically, investment in healthcareis at an all-time high and, despite public concerns, objectivemeasures of performance show evidence of improvement.

Is mental healthcare different?

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Is mental healthcare different?

Valsraj & Gardner argue that choice in mental healthcareshould be seen and understood as in some way different fromchoice in other spheres of public service. They describe mentalhealth services as ‘complex and highly individualised’.This complexity is not, however, unique. Meeting the healthand social care needs of a person disabled by rheumatoid arthritis,suffering from a rare tumour or with severe Parkinson’sdisease is quite complex and requires an individualised approachto the treatment and care plan. Most of the money spent in healthand social care goes on the support of elderly people, who tendnot to have problems that are neatly compartmentalised.

In fact the ethical basis underlying mental healthcare is nodifferent from that underlying physical healthcare. To takean example, consent to mental health treatment is defined inthe code of practice to the Mental Health Act 1983 (Department of Health, 1999:15.13) as:

‘The voluntary and continuing permission of the patientto receive a particular treatment, based on an adequate knowledgeof the purpose, nature, likely effects and risks of that treatmentincluding the likelihood of its success and any alternativesto it’.

Note the word ‘alternatives’. This definition isbased on the key ethical principle that all health and socialcare providers should be seeking to maximise the autonomy oftheir patients.

Mental health professionals have therefore long been requiredto offer patients (service users, survivors) choices and thisrequirement has been further underlined in the guidelines publishedby the National Institute for Health and Clinical Excellence(NICE) (see, for example, the schizophrenia guidelines; NICE, 2002).What is unique in mental healthcare, of course, is the routineuse of compulsory treatment and other coercive practices. Giventhe current ‘risk agenda’, coercion is set to increase,as we see in the introduction of ‘supervised communitytreatment’ (Department of Health, 2006): psychiatric patientsare to be encouraged to exercise choice, but with firm limitsif they are deemed to present risks.

Myths and truths about choice

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Myths and truths about...

In Box 1 of their article, Valsraj & Gardner identify some‘myths’ about choice. Some of their ‘myths’are actually truths. There is good evidence from the socialpsychology of choice that too much choice makes us unhappy (Bate & Robert, 2005).This is one of the reasons why, despite massive improvementsin the standard of living in the West in the past 50 years,levels of happiness in society have not increased correspondingly(Layard, 2005). It is a matter of record that one element ofthe choice agenda is funding for independent-sector providersthat will offer competition to the hitherto monolithic NHS,and the logic of Valsraj & Gardner’s argument suggeststhat this is no bad thing. (We know that independent-sectorproviders are very interested in running the psychological treatmentcentres that were advocated by Layard (2006).) It must be thecase that choice has little meaning in a situation where thereis no spare capacity. The introduction of payment by resultshas indeed resulted in destabilisation of mental health serviceseven before it has actually applied to them.

To be fair, some of their ‘truths’ are true. Thereis much to applaud in the sentiments expressed in the ‘choicechecklist’ (Care Services Improvement Partnership, 2005),which offers an overview of interesting local projects (includingthose described by Valsraj & Gardner) and I would urge interestedreaders to go to the primary source. Rehabilitation practitionershave long been supporting their patients/clients to make lifechoices in ways that are completely compatible with the newlyfashionable recovery paradigm (Roberts & Wolfson, 2004),which conceptually underlies much of the contemporary choiceagenda in mental health. Improving choice can have surprisingeffects: there is, for example, evidence that encouraging peopleto set out their choices for how they should be supported duringrelapse episodes results in fewer subsequent compulsory admissions(Henderson et al, 2004).

Conclusions

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Conclusions

In the current climate it would be impossible to stand againstsuch a self-evident good as choice, but we do need to understandthe implications of the choice agenda. It is quite clear thatin future health and social care providers will be operatingin a marketplace. There will be competition for funds, for patientswho will follow the funds and for ideas about how best to tacklethe problems that mental health services are there to address.Like their colleagues in the USA, mental health professionalsin the UK will need to learn marketing and customer skills ifthey are to be successful in attracting patients in the bravenew world. If they don’t attract patients they can’thelp them.

Declaration of interest

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Declaration of interest

None – other than a slightly old-fashioned fondness forthe values of the pre-modernisation NHS.

Footnotes

See pp. 60–67, this issue.

Discussed on pp. 3–6 and 7–9, this issue. Ed.

References

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