Delivering choice in mental health

The recent announcement that the principle of right of choice will be extended to people receiving care for mental health issues is a welcome one. The previous situation was at best illogical and at worst discriminatory. For the sake of argument let’s call our case study Dave.

Now Dave may have both physical and mental health problems, like many mental health service users. Since 2004, he has had a right to choice in the treatment of his physical ailments, but not his mental illness.

Making a complaint or disengaging with care has been the only way he can exercise choice, a clearly negative outcome. This situation was obviously unsustainable, and the government should be applauded for putting it right.

‘It always feels like mental health is behind the curve when it comes to the choice agenda’

People who work in mental healthcare understand the importance of choice, both in terms of the therapeutic relationship and in the exercise of autonomy. Mental health service users are no different from anyone else in that they want to be able to exercise choice. They want to be treated with respect and be supported by skilled staff to receive high-quality care. Freedom of choice is absolutely fundamental to these aspirations.

However, choice in the context of mental healthcare is far more than just a simple selection from a menu of options. For example, some service users may choose not to see a psychiatrist or accept treatment. This is where choice can come into play as the first step in collaboration between service user and service provider. It is a chance to empower the service user at an early stage, setting the tone for the whole episode of care.

Choice should reflect a whole service that encourages autonomy and dignity, not just a piecemeal approach which offers choice in some parts of the system but not others. In the words of former health minister Rosie Winterton:

“Better health care outcomes are achieved when… both patient and health professional share in making decisions about treatment and care. The quality of consent for treatment is improved, people take a more active role in managing their health and health professionals are better supported to provide a level of healthcare and choice that they can take great pride in and that people increasingly expect.”

Clinical recovery vs personal recovery

Many professionals, both in primary and mental health care, see increased choice as a challenge and I agree. Specifically, the challenge is in ensuring that there is an honest and participative therapeutic relationship with the patient. Paternalistic and ill-informed care denies choice, and if services are to ensure that choice becomes a reality they must be established in line with this basic principle.

The staff who provide services must be trained in the values that underpin choice so that services offered are person-centred and socially inclusive at their core. Patients must be given the opportunity to choose or change their psychiatrist or other mental health professional just as they choose their family doctor. This might be achieved, for example, by moving away from purely catchment area-based services.

Recent developments in mental healthcare such as the recovery approach will enhance choice. People who work in mental health services recognise that there is such a thing as “clinical recovery”, but for many who have experienced mental illness “personal recovery” is at least as relevant because this means building a meaningful life as defined by the person themselves.

So if we are to see meaningful right to choice for people with a mental health problem, it must be more than a simple selection from a directory. Services must be developed so that there is a person-centred approach that respects autonomy from the very first contact and is supported by the provision of accurate information, user-friendly documentation and information about outcomes including service user feedback.

Poor relations

It always feels like mental health is behind the curve when it comes to the choice agenda. The fact that the government’s ‘friends and family’ test will be rolled out to acute hospital inpatients and accident and emergency patients from April 2013 and only to mental health “as soon as possible after October” underlines this.

That said, the extension of right to choice is a positive step, and possibly a signal that the government is taking ‘No Health Without Mental Health’ seriously. However, this issue is too important to be implemented without using the opportunity to address the issue of what choice means in the whole context of mental healthcare.

To be successful it requires a coming together of mental health and primary care services, local authorities and patient groups. To achieve this we need to see a development of the range of services available as well as an increased investment in staff, particularly training.

There must be investment in mental health services so that they are no longer the poor relations. Only when there is equality of funding will there be equality of choice.

Dr Sean Lennon is the medical director at Manchester Mental Health and Social Care Trust.