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Editorials

The national service framework: a scaffold for mental health

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7216.1017 (Published 16 October 1999) Cite this as: BMJ 1999;319:1017

Implementation is key to determining whether it's a support or a gallows

  1. Peter Tyrer, professor of community psychiatry
  1. Division of Neuroscience and Psychological Medicine, Imperial College School of Medicine, St Mary's Campus, Paterson Centre, London W2 1PD

    The National Service Framework for Mental Health, part of the programme to establish better quality and reduce unacceptable variations in the NHS,1 has just been published.2 This, an accompaniment to the introduction of the National Institute of Clinical Excellence (NICE), sets new standards for the delivery and monitoring of mental health services. In his introduction Frank Dobson, the secretary of state for health, claims that these national standards are founded on “a solid base of evidence” provided by the external reference group (chaired by Professor Graham Thornicroft of the Institute of Psychiatry). Mental health services have always had difficulties in setting standards, because of uncertainty over whether subjective patient oriented 3 4 or external “service” outcomes of mental illness 5 are preferable, so the framework has set itself ambitious objectives.

    Has it succeeded? The answer is the same as the response to asking whether it is wiseto plant a tree in a desert. It seems churlish to give a negative response as planting trees in deserts is a noble enterprise But, though the task is possible, its purpose is unlikely to succeed unless there is the wherewithal to nurture and sustain the tree at critical phases in its development. Similarly, this document proposes a coordinated national framework where only a few oases of excellence exist, supported more by internal forces of ramshackle intimacy than by the discipline of external standards. Examples of local excellence shine out from the framework document; but no explanation is given why they remain local, even though inquiries into these are eminently possible.6

    Standards are set in five areas: mental health promotion, primary care and access to services, effective care for those with severe mental illness, and the prevention of suicide. And out of the desert rise a set of guiding principles: to give accessible, accountable, safe, high quality, well coordinated, non-discriminatory care involving service users and carers which offers choices to all. Once the observer has decided that these principles are not just utopian he has to apply them to standards in which the “solid baseof evidence” has all the firmness of blancmange. The first standard is “to promote mental health for all and combat discrimination against individuals and groups with mental health problems.” What a standard. Even fewer could disagree with the sentiments of this than with mom and apple pie, but how is it measured and monitored?

    The authors try valiantly to give sustenance to these and some other standards that are really no more than political slogans, but they cannot win. The third standard, for example, relates to services in primary care and includes the ability “to use (the new telephone line) NHS Direct, for first level advice” on mental health problems What do the monitors do: tap the phones and listen to the advice, count the calls, or test the ability of sufferers physically to dial the correct number? No evidence is given that phoninghelp lines is of value; indeed such evidence that does exist suggests that for some groups it may do harm.7 No information is given aboutthe training and expertise of these telephone supercounsellors and how general practitioners are expected to cope with this splitting of care. In explaining the rationale for this intervention the bald statement “government commitment” suffices.

    It is only when the reference group is allowed full scope for its expertise that things improve. The proposals for a national support structure to underpin improvements are excellent. Similarly, the intention to integrate health and social services for mental health and to provide more support for carers and their needs are based on genuinely sound evidence 8 9 and deserves commendation. But even here the recommendations are infiltrated by dogma. The obsession with risk reduction despite no real evidence that it is attainable10 and slavish adherence to an ill defined interventioncalled assertive outreach with 24 hour cover despite evidence of lack of efficacy of this type of approach in the United Kingdom 11 shows that it takes little to trump evidence based medicine, despite it being at the supposed heart of clinical governance.

    Supporting the aims of clinical governance and improved quality in the NHS are possible but not helped by the overblown language of this document. Oyebode et al probably reflect mainstream mental health opinion in supporting the more modest belief that, when correctly used, the measures associated with clinical governance should “help to steer theinterests of clinicians and managers to the common end of improving clinical care.” 12 Getting more appropriate standards that are commensurate with better care rather than promoting the wish lists of focus groups will determine whether the scaffold of the national framework becomes a genuine support for healthy growth or a raised platform for the execution of hollow promises that should never have been made.

    References

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