Large-scale Sustainable Change
Examining the impact on local service delivery: Formulating, implementing and enacting national policies across NHS Scotland
What we know
Child and Adolescent Mental Health Services (CAMHS) are designed to diagnose and treat child and adolescent mental health problems that require specialist treatment and interventions. Over recent years, services in Scotland have come under increasing pressure and scrutiny – due to a sharp rise in referrals to CAMHS and increasing waiting lists. Leaving an unacceptable number of families struggling to obtain timely, high-quality, effective and evidence-based care.
The Scottish Government’s Mental Health Strategy 2017-2027 promotes the need for mental health and wellbeing services to work together, with a greater focus on early intervention and prevention. Following the publication of the Strategy, a number of national audits and reports were published (by public and third sector organisations) that led to the establishment of a national Children & Young People’s Mental Health Task Force to address the need to improve CAMHS access, waiting times and outcomes.
The recommendations that followed highlighted the critical need to transform services, emphasising the importance of early intervention, prevention and improved collaboration between mental health providers. In order to deliver treatment and recovery-oriented service models through a whole-system approach between voluntary and statutory providers that are comprehensive, sustainable, and community based.
Over a 2-year period, several national reports were published, making recommendations to improve CAMHS. What all these policies and reviews, had in common is the urgent need to transform services. However, what was less clear, is how the formulation of goals and objectives of fast-changing national policies will provide the implementation structures necessary to support the transformation and reconfiguration of existing services.
The aim of this project is to understand and explore how these national mental health policies were formulated (at macro-level), implemented (through meso-level organisations) and enacted locally (at micro level) within CAMHS. This was undertaken by interrogating the multiple layers of variation and interactions that take place when policy attempts to become practice in the context of local transformation and reconfiguration of services.
What this research explored
This study was based on a triangulation of qualitative methods, involving 16 semi structured individual interviews and four focus groups. Informants were selected through purposeful sampling to ensure representation from organisations, groups and perspectives from across all system levels:
- Macro level - seven interviews with national policy makers and commissioners from across Scottish Government Mental Health Directorate, responsible for monitoring performance and setting the national direction for improvements within mental health and beyond.
- Meso level - nine interviews with stakeholders representing statutory and voluntary sector organisations, with a strategic role in either developing/advising on mental health policy priorities or supporting the implementation of policies at local level.
- Micro level - four focus group interviews were conducted with multi-disciplinary CAMHS teams who provide a range of outpatient and inpatient care at secondary and tertiary levels. These participants had significant experience of delivering clinical care within the context of driving service improvements.
What this study adds
This study demonstrates the importance of understanding the complex and dynamic interactions between policy makers (macro) and ‘national implementers’ (meso) and CAMHS (micro), in order to optimise the implementation of government policies within service delivery contexts.
The key findings (from all system levels), indicated insufficient linkage between the formulation, implementation and enactment level of policies and highlighted that there was inadequate understanding of the complementary roles played by stakeholders at the different levels, and a lack of awareness of how one level might influence the other levels systemically. This was demonstrated through several emergent themes:
- Macro-level: Ambiguous macro-level policy formulation related to a poor understanding of the initial problem; insufficient knowledge of the implementation context; unclear, overlapping and even contradictory goals; poor quality evidence; and an absence of political consultation and uneven participation in the policy debate.
- Meso-level: Cluttered landscape of meso-level national organisations supporting policy implementation. Although support from these organisations was welcomed; often this resulted in siloed, differing approaches to implementation support, creating either gaps or producing waste due to overlapping responsibilities and remits.
- Micro-level: Low levels of investment in mental health services and an unequal allocation to CAMHS was perceived as having a negative impact on service capacity to maintain current standards of care whilst re-designing and delivering transformational service improvements.
Barriers to local policy implementation stemmed from the interpretation of the large number of ambiguous and overlapping policies and implementation support from a wide range of national organisations with differing approaches. Reported unintended consequences of these issues was low morale and transformation fatigue, in teams charged with implementing the policy objectives.
Benefits and impact
It is well established that putting a policy on paper does not ensure it will be embraced or followed as written. The findings from this study offer an opportunity to articulate approaches to optimise the translation of government policies to deliver improvements in service delivery which can be generalisable beyond mental health services.
Data analysis identified three fundamental elements for policy formulation:
- local knowledge;
- a deep understanding of stakeholders’ perspectives;
- production of robust evidence-based implementation statements, with clear expectations on deliverables that remove ambiguity.
These elements will ensure policies are developed, accurately reflecting the contexts in which they will be implemented, enabling local adoption within the fidelity of the policy objectives.
Policy implementation can be enhanced by taking a whole system approach to engagement through a wide range of clinical networks and implementation agencies to enable an effective flow of information and deliver a co-ordinated approach to implementation. Bringing together multiple organisations behind a unified agenda enables implementation to be tailored to local contexts and negates the impact of a cluttered landscape of support. This alignment needs to be reflected in the policy and governance levers to support cross-fertilisation and consistent policy messaging and support and Government has a role to play in drawing agencies together in order to avoid duplication between agencies to clarify lines of responsibility.
For health policies to be effective in practice, they need to be communicated and translated at strategic and operational levels, to be integrated into clinical practice. There is little empirical evidence from this study whether this happens and, if it does, there are important unintended consequences that needs to be accounted for and eventually overcome. All such approaches would require close liaison with, and an understanding of, the position of the front-line practitioners delivering change locally and tailoring of central recommendation to better understand what works for whom and in what circumstances.
Future research must be encouraged to create a comprehensive understanding of policies directives, and enhance the evidence for effective policy formulation, implementation and enactment, in Scotland and beyond. This type of enquiry will ultimately lead to more consistent service delivery approaches and improved health and wellbeing outcomes through unified health improvement agendas.
The project was funded by the Carnegie Trust and led by Dr Madalina Toma, supported by staff from the School of Health Sciences at Dundee University.
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