An exploration of primary care policy and practice for reducing inequalities in mental health

Mental health problems in individuals and in the Scottish population are less well defined by routine data and diagnostic criteria than are physical health problems, but they have similar relationships with social gradients. Primary care in Scotland in recent years has been given an emphasis on health inequalities and on prevention and is also expected to provide frontline services and ongoing support to patients with mental health problems. Addressing health inequalities and inequalities in mental health are thought to require action on social circumstances as well as on biological conditions. However, the health service works within an established biomedical culture influenced by the strong medical workforce system and the broader political emphasis on accelerated economic growth. Policies express a general expectation that all public sector services have addressing health inequalities built in to their functions, but there is evidence to suggest that primary care has not yet found its place in meeting this expectation. To date there have been few concrete proposals for action and no guidelines for primary care to address health inequalities. The study set out to identify the contribution that primary care can make to reducing and preventing inequalities in mental health. Interpretive policy analysis was used as the framework for the study. In contrast to traditional policy analyses, which take an objective approach to comparing policy interventions, interpretive policy analysis can help to synthesise perspectives or reframe debates. It regards stakeholders’ interpretations of policy as drivers for change on the ground rather than the policies themselves. Stakeholders are described as being within three “communities of meaning” of policymakers, implementing agencies and service users, and each grouping can have several internal communities making different interpretations of the same policy. There were four communities of meaning relevant to this study: policymakers; primary care strategic staff; primary care and mental health frontline professionals; and services a patient might encounter. The policymakers’ perspectives on health inequalities and inequalities in mental health were drawn from an appraisal of nine health and social policies current at the time of the main study period (2002 – 2006). The other three communities were identified within one Community Health Partnership in the West of Scotland. Data were collected using document analyses, observation of a primary care mental health needs assessment and interviews with 21 frontline primary care and mental health professional staff from 14 disciplines. Identification of the services a patient might expect in relation to inequalities in mental health was elicited through frontline professionals’ responses to a vignette. All nine policy documents in the appraisal included aims to tackle some aspects of health inequalities, but inequalities in mental health were barely mentioned. The documents presented a disjointed picture of definitions for inequalities that lacked a clear overall interpretation of inequalities in health. They also proposed actions which often did not flow from the definitions and clouded the identification of expectations on primary care for addressing inequalities in mental health. For example, documents suggested that poverty, area deprivation and other social circumstances were linked with health inequalities, but the emphasis for action was skewed towards individual lifestyles and organisational change. The confused policy picture was mirrored by similar disjunctions between definitions and actions among strategic and frontline professional staff. In addition, there were clear differences between definitions identified in policy documents and those given by professionals, suggesting that frontline professional staff appeared to draw information about mental health and inequalities from public media and practice experience rather than from research and policy. Observation of a mental health needs assessment included an appraisal of the local strategic context and additional interviews with key senior staff. The observation found that inequalities were not considered for action in the mental health needs assessment nor in most of the other local strategic processes. This was despite some key strategic staff’s individual perspectives that social inequalities can impact on mental health, and despite information about local social and mental health inequalities being made available. The observation concluded that the culture of the organisation was not conducive to tackling inequalities in mental health. Frontline and strategic staff were generally unclear about identifying a patient’s social circumstances which might put them at most at risk of developing mental health problems. Although some frontline professionals linked mental health and social inequalities in defining health inequalities, most were unlikely to intervene on addressing a patient’s social circumstances. While frontline professionals and strategic staff almost universally defined health inequalities as differential access to services, few indicated that they would take action to ensure access, for example, following a patient’s non-attendance. The culture of the observed primary care organisation was not conducive to driving change on inequalities in mental health, and its contribution to reducing and preventing inequalities in mental health is at an early stage. Interpretive policy analysis identified disjunction and gaps in understanding and leadership to address inequalities in mental health at policy, planning and practice levels, but also identified potential areas for development. The study concluded that some of the building blocks are already in place for the primary care organisation to respond to policy leadership on inequalities in mental health should that time come