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Tuesday 19 February 2013

Mental Health Planning: A Script for Failure

Planning documents in my collection.
Lots of writing, little change.

Let me declare my bias right at the outset:  I don’t believe in mental health planning.

To be more precise, I don’t believe that mental health planning usually has any significant impact on mental health services. In fact, I think that real change happens seldom enough that it wouldn’t be too far out of line to call most mental health planning fraudulent.

I’ve been in practice for many years, and I have seen many mental health planning reports released in that time. I watched enough of these processes at a distance in my early career that I swore never to become involved in them.

And then at one point the subject was so close to my clinical interests, and the prospects for systemic change seemed so bright, that I convinced myself that “this time for sure” things would go well. Of course, this is precisely how everyone gets involved in these things, and of course the project went exactly the same way all the others do.

There’s a reticence among professionals to talk about this issue. Part of the problem is the faint hope that someday a planning project will come along with ironclad guarantees and a genuine chance of having an impact on services – and if you have blabbed about how little you think of the planning biz you probably won’t be asked to take part.

Another sticking point is the fear that anything you might say will be ignored anyway because people will think you are just burned out or disgruntled that people didn’t pay attention to your own grandiose ideas.

I have no plans to take part in future planning efforts, and most of my disappointment has to do with the fate of planning efforts in which I was not involved, so I don’t really have any reason to hold back. My rant on the subject has gotten loose on various occasions, so let’s keep a leash on it and discuss just three points: the sequence of planning, the types of benefits, and the motive for planning.

The sequence of planning

The first time I watched as a colleague became involved in a mental health plan, the sequence of events seemed so nonsensical that I assumed it would never be replicated. Since then I’ve noticed that it is almost invariant.

  1. The government of the day, often in response to tragedy or harsh criticism, announces an overhaul of some aspect of the system. Rather than an overhaul, what they actually mean is a mental health planning effort. Often a delivery date for the new plan is mentioned.
  2. The excitement (and news coverage) of the announcement having past, the urgency to get started fades. A long search for the individuals to carry out the planning project ensues. Once they are found, the government delays while it works out the “terms of reference” for the effort.
  3. The supposed start date for the project passes without anything happening.
  4. Once one-third to two-thirds of the planning period have passed, tension rises between contractees and the ministry and the funds are finally released so that the team can get started. The end date is not shifted, however, so that the plan will inevitably be a rush job.
  5. The plan invariably calls for “all stakeholders” to be consulted, meaning that any consensus on specific actions – or any ranking of their importance – is impossible to achieve. Whether this is an intentional or unintentional effect is open to question.
  6. The planning team asks for an extension so that the planning term is as long as originally projected before the government delayed the process. This request is denied.
  7. A report is hastily rushed into print. It is a work of graphic art, with ample real-world quotes and case examples. But the actual recommendations are phrased in such vague terms as to be meaningless (and certainly toothless).
  8. The government greets the completion of the report with enthusiasm and a congratulatory media event, often timed to coincide with a major conference to ensure a large audience for the television cameras.
  9. Time passes. The planners and stakeholders hear nothing about the report. Little evidence can be found that anyone has read it. The funding covered only the planning effort, not systemic change, so there are no resources to put the recommendations into place.
  10. Several years later, another crisis or bout of criticism arises. Rather than dusting off the now-hard-to-find report, the government announces a new planning initiative. If anyone recalls or asks about the recently-completed plan, it is pointed out that the earlier plan was based on old data and the state of affairs that existed perhaps five years ago. What is really needed is a new report based on current conditions.
  11. Repeat steps 2 through 10. 

Two types of benefit

The cynical perspective I’ve outlined above implies that little gets done as a result of these reports. But whenever these efforts are discussed, funders and planners alike go to great pains to describe the tremendous progress that has been made. Unless you listen closely, it can sound as though the original problem has now been solved.

But the progress is always described in the same terms. A jurisdiction-wide consultation has been achieved. All stakeholders have been consulted. Quality assurance subcommittees have been struck. Knowledge exchange has been promoted. A comprehensive listing of services has been developed. It all sounds great, except none of it seems to relate to the actual services being provided to people with mental health issues.

I remember sitting in one of these meetings listening to a self-congratulatory provincial health minister rhyming off the sparkling achievements of one of these projects. Perhaps I’d had too much coffee (or not enough), but I found myself getting more and more angry. I had a suggestion to make, but inhibition (and a secret fear that I must, must, must, be missing something of significance – the emperor cannot possibly be this naked) prevented me.

The thought that occurred to me at the time, and that still strikes me as a good idea, was to divide all outcomes into two categories.

  • Category A would consist of committees struck, shiny publications printed, discussions held, recommendations made, hotel banquet lunches eaten, and so on.
  • Category B would consist of concrete changes that actually alter a real service being provided to any user of the mental health system that increases the quality of their experience in any way whatsoever.

When I read mental health documents, I’m always on the lookout for Category B items. Unfortunately, I seldom find any. Of course, there’s an easy defense for this point: “This is only a plan. Of course it hasn’t been put into action yet, but it WILL.  REALLY.”

So my second thought is that the media opportunity should be saved. Don’t hold the announcement and get your picture in the newspaper when the report is written and handed over. Keep quiet about it. And invite the photographers only when you can announce that a concrete change has actually benefitted a real human being.

An impractical idea, that one. It would mean:

  1. Ministers would seldom get their pictures in the paper, and
  2. Funding for mental health planning would evaporate, because the main benefit of these projects appears to be to get the minister’s picture in the paper.

What’s the motive?

Why do mental health plans exist? And why aren’t they more effective or useful?

Actually, I’ve come to believe that the second question above contains a false premise. In fact, mental health plans are extremely effective and useful. But the effect sought is not the one announced.

Mental health planning is, most often, a money saving exercise. True, it seldom leads to improvements in service. But perhaps that is precisely the point.

Planning is cheaper than service improvement.

Mental health plans cost anywhere from $100,000 to $2 million. Although that can sound like a lot of money, in fact it is unbelievably cheap relative to the cost of upgrading mental health services.

When someone calls the quality of your mental health service into question, one option is to upgrade the service. Another is to set aside an impressive-sounding quantity of money and hire national experts in the subject to design your upgrade.

The planning effort will take a minimum of three years from start to finish. During that time, if anyone asks about your service you can say, “I’m glad you asked. In fact, we have an extensive planning program taking place as we speak.” When the report actually comes out, you can get lots of press and you can word your announcement in such a way that it sounds like you have actually done something.

For the next year, you can respond to inquiries by saying “We have a newly minted plan in hand, and we are examining the way forward based firmly upon the recommendations therein.” In the second year after delivery it’s best to lay low and keep your mouth shut as much as possible. But in the third year following the report, you can start talking about the necessity of a new look at the problem.

And you never have to upgrade a mental health service. Ever.

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