Purchasing, providing and participating in mental health services

Abstract

This thesis examines the implications of the changes introduced by the NHS and Community Care Act 1990 for mental health services. It focuses on two main issues. Firstly, the impact on mental health services of the 'market' system of purchasers and providers introduced by the 1990 Act. Second.ly, the extent to which the 1990 changes had led to any increase in user participation and involvement in the planning and delivery of psychiatric services. Analysis of the existing theoretical literature found that there had been little research which focused on the specific implications of health care 'markets' for mental health services. In addition, much of the work on the development of psychiatry had not focused on the role of the local context in influencing the nature of mental health service provision. In this thesis these issues are explored through a case study of the mental health services of one English county. Semistructured, qualitative interviews were und.ertaken with managers, professionals and individuals in purchaser, provider and voluntary sector organisations. People using community mental health services in the county were also interviewed. This contrasts with many previous studies which have tended to concentrate exclusively on users of in-patient services. The study found that local circumstances played a significant role in the relationships between those purchasing, providing and participating in mental health services. The imminent closure of a large Victorian psychiatric hospital and the uncertainty about which services would replace it had been a source of tension between the newly formed purchaser and provider organisations in the county under study. The lack of any strong existing groups in the local area representing users of mental health services was also significant. It meant that increased user participation in the county after the 1990 Act was reliant on initiatives by managers and professionals rather than organised pressure from user groups and users themselves. The variety of different local mental health agencies purchasing and providing mental health services in the county called for a degree of cooperation between organisations which conflicted with the competition encouraged by the 'market' system introduced by the 1990 Act. The focus, first, on psychiatric services in the examination of 'markets' and, second, the importance of the local context in mental health service development provides the basis for the study's contribution to theoretical and policy debates both about the 1990 Act and psychiatric services in general.