Analysis used the domains from the WHO systems framework 16 as a lens through which to view data and develop themes. It also applied macro, meso and micro levels to identify barriers and facilitators. Table 2 illustrates the various themes mapping onto system domains and levels.
Table 2
Sub-themes mapping onto domains illustrating barriers and enablers at macro, meso and micro levels
WHO Systems Domain | Mapping of sub-themes | Explanation of themes and sub-themes | Macro, meso and micro Barriers | Macro, meso and micro Enablers |
Leadership and Governance | • Policy and action plans on parity • Shared decision-making | Working from National level policy to service level delivery to ensure inclusive care, addressing individual need and including families where possible, whilst incorporating parity. | Macro level Policy on PoE. Equality Legislation and Standards. | Macro level Equivalent policy priority. |
Meso Level | Meso Level |
Micro Level Lacking insight into patient and carer’s experiences of Mental Health. | Micro Level Sharing decisions with patients and carers or families where possible. |
Financing | • Funding for services • Targets and incentives. • Mental health estate | The impact of inequitable funding for mental health care and inadequate provision, which create an impact on both service providers and users. Targets and incentives should develop holistic care, but limited by their definitions. | Macro Level Inequitable funding for mental health. Little consideration concerning the complexity of mental health conditions. | Macro Level Campaigning for funding. |
Meso Level Inadequate resource allocation. Different funding models. Lack of investment in the mental health estate. Unclear targets. Targets fail to consider people with complex mental and physical health problems. | Meso Level |
Micro Level | Micro Level |
Service Delivery | • Access to quality care • Integrated care and collaboration • Informal caregiver involvement • Person-centred care | Accessibility and availability of services including issues such as acceptable waiting times, medication reviews, follow-ups and availability of a range of services. Integrated multidisciplinary teams learning from one another and working together with families of individuals to provide continuity of and person-centred pro-active care that takes into account differences in social environment and levels of available support. | Macro Level | Macro Level Equivalent clinical priority |
Meso Level Inaccessible and ‘patchy’ services. Poor consistency of service provision. Variable availability between areas and regions. Inadequate crisis care. Lack of placed based care. Long waiting lists for children’s mental health. Poor integration of teams. | Meso Level Suggested multiple access points to gain entry to services. Integrating care into the community. |
Micro Level Lack of time. | Micro Level Involving families, formal carers and individuals in the decision-making environment. Person-centred care. |
Workforce | • Education, training and continuous professional development (CPD) • Staffing numbers | Education and training for all healthcare workers to include mental health, alongside CPD for understanding the aims of the Mental Capacity Act and reinforcing insight into difference. Ensuring adequate staffing of services to ensure equitable delivery of care. | Macro Level Agreement of educational curricula without consideration of meso and micro levels. | Macro Level |
Meso Level Poor staffing levels. Workloads. Lack of focused education, training and CPD for staff enabling consideration of the holistic body. Lack of integrated mental health awareness. | Meso Level Having an understanding of the impact of the social determinants of health on patients and carers. |
Micro Level Discriminatory staff attitudes. Lack of cultural competence. Inability to engage with diversity. | Micro Level |
Information and Research | • Access to reliable data • Measurement and bench-marking • Parity in research | Access to reliable data in order to improve systems. Measurement and benchmarking for conditions to provide indicators that are more reliable. Parity in research funding to explore and improve outcomes. | Macro Level Lack of parity between physical and mental health research. Lack of reliable data. Lack of clear indicators. Measurement uncertainty for indicators. Ambiguous benchmarking. Introducing and then removing QOFs. | Macro level Equivalent research priorities for physical and mental health. Providing Quality Outcome Frameworks (QOFs). |
Technologies and Medical Products | • Choice of treatments • Shared information systems | Access to and choice of ensures equitable access to the latest evidence based treatment and products. There are also shared information systems to ensure joined-up care. Electronic records are linked and available nationally at varying levels to different professionals and primary care systems | Macro Level | Macro Level |
Meso Level Lack of accessibility for electronic records at all levels. | Meso Level |
Micro Level Patients prevented from making choices because of perceptions about their mental health status. | Micro Level Patients and carers enabled to make decisions and choices about treatment. |
Domains: Barriers and enablers of PoE at macro, meso and micro levels
Leadership and Governance
Key themes for this domain included a) policy and action plans on parity and b) shared decision-making. Policy and action plans at the macro level for parity of esteem appear to have created barriers due to a lack of clarity and definition in the ways that parity may be achieved 20, 21. Broad enablers for PoE at the macro level included “campaigning for mental health funding” (PT.19, p.3), and “making sure mental health problems have equivalent policy priority”(PT. 18, p.2), but the method of enactment of these initiatives required meso and micro level thinking. Specifically, Participants argued that setting equality standards at the macro level such as everyone having a maximum of a two-week wait prevented shared decision-making, creating barriers because it worked against people experiencing a mental health crisis, tending to treat all mental health conditions as the same with little consideration for diversity, or complexity. “Why is it that people with psychosis, or a psychotic crisis, should expect the equivalent, or parity, if you like, of access, as someone with […] cancer?”(PT.1, p.12).
Shared decision-making inevitably links to patient-centred care, and equity in this context meant having the autonomy to build a relationship and respond to a patient as a person situated in a particular psychosocial and economic environment. The majority of this activity occurred at the meso and micro level. “To understand that what generates good diabetic care, is often understanding psychological and social contexts in which people have their difficulties” (PT.1, p. 9).
Financing
Key themes for this domain included a) funding for services, b) targets and incentives and c) the mental health estate.
All participants mentioned the central role of funding; suggesting that a system was constrained by inequitable funding was both a challenge to and a manifestation of a lack of PoE. Participants perceived that moving funding around to prioritise one area over another perpetuated mental and physical health inequalities, inadvertently setting the two fields up as financial competitors rather than an integrated healthcare goal. “In a resource constrained system, if we want to give more to someone else we have to take it from one area and move it to another”(PT. 27, p. 14).
Integrated care systems occur at meso levels but remain heavly dependent on funding from the macro level, with mental health appearing secondary to physical health “there's always going to be people with what appear to be hugely significant health problems physically that “trump” mental health problems” (PT. 27, p.5). Participants mentioned further local tensions in resource allocation and funding for acute and mental health services, emanating from this inequity. “[…] each ICS (integrated care system) has a sort of capital spending limit, which has to be shared between its acute hospitals and its mental health trusts. Mental health is always a relatively small player” (PT. 6, p.4). Participants believed that this Cartesian vision of mental and physical health limited the ability to gain larger amounts of funding from the macro level.
Participants also discussed the inadequacy of mental health funding for children and adolescents, suggesting local and whole system inequalities maybe further exacerbated in some populations. “What we focus on(young people and mental health) – is so sort of underfunded and under-prioritised compared to the rest of the healthcare system” (PT.12, p.3).
Participants perceived a need for adequate resourcing at meso levels to meet policy and service targets “the need is to focus resources and provision to meet those targets. I think the challenge with it is that you have to have adequate resources to do that” (PT. 21, p. 10).
For some participants targets added a new level of complexity that risked whole system improvement. “The danger with that is we get narrowly focused on how many people are accessing psychological therapies, and a more encompassing measure looks at people who maybe don’t want to access psychological therapies, but do still want support” (PT.2, p. 12). For many participants in the current study, targets did not appear to address provision for people with complex mental and physical health problems, resulting in a lack of parity. “There are waiting time targets for psychological therapies, but it seems that not really that much is done around those people who fall through the gaps and who are too complex” (PT.2, p, 7). The complexity of conditions appeared to be an area receiving very little consideration at macro level when allocating funding.“The other big test of the complexity of parity of esteem, in a sense, is that people don't have one problem. So people don't just have a psychological difficulty, or they don't just have diabetes, they often have multiple problems”(PT. 1, p. 14). At worst, participants suggested that targets might lead to a reduction of total effort at the meso level “sometimes what happens then is people only focus on the targets, rather than the bigger picture”(PT. 5, p.8).
A considerable challenge involves clearly identifying indicators for benchmarking PoE progress “the indicators are going to act as this kind of galvanising force around an area that the targets are going to do that so you have to be very specific about what it is you want change” (PT. 8, pp.6-7).
Participants perceived that a lack of funding at the macro level affected both the physical environment of mental health services at meso level and the availability and quality of care for people with mental health problems at micro level. A lack of investment in physical infrastructure affected mental health care creating “facilities that are not fit for purpose, with people still in dormitories and wards that are not acceptable in this day and age”(PT. 6, p. 7). A concomitant impact on patient wellbeing and long-term recovery was evident.“Often in emergency departments there will be a particular area or a particular room where someone who is experiencing a mental health crisis, or presenting with a primary mental health need, will be placed. Often those places aren’t very well looked after; they’re not very welcoming, they’re not very therapeutic.”(PT. 25, p. 5).
Service Delivery
Key themes in the service delivery domain were a) Access to quality care, b) Integrated care and collaboration, c) Informal caregiver involvement and d) Person-centred care.
Macro level enablers for participants included “making sure mental health problems have equivalent clinical priority”(PT. 18, p.2).
Crisis services in particular exhibited many barriers to support and care at a meso level. “How easy it is for people with mental health problems and their families to get support when somebody’s in crisis. How responsive is that service? The answer is it isn’t” (PT 11, p.5).
Participants discussed the accessibility of formal services and the sub-optimal role that GPs may play as gatekeepers to this system “It’s no criticism of GPs, but Access Points rely heavily on people going through GPs to access the system.” (PT 3, p.5). Participants offered potential solutions such as meso level enablers involving multiple access points and better health care integration and support within communities, potentially reducing inequalities in referrals for people with mental health problems and relieving the burden on GPs by employing more community-based health care for mild to moderate conditions. “There needs to be equity of access once you pass the threshold and therein lies the problem, because access for someone with a mental health problem, even to a service which has parity of resource, has to be different to someone with a physical health problem.”(PT 27, p. 6). “[…] the positive change that needs to take place, that would improve mental health would be, better integration with the community. That actually that applies to all long-term conditions.”(PT 8, pp. 5-6).
Participant’s perceptions also focused on the importance of availability of services at meso level “The early intervention psychosis programmes are really good examples. There aren't enough of them and people can't get at them and, you know, so they're patchy, it's not uniform.”(PT. 25, p.5). Barriers to early intervention services and crisis care came up numerous times in people’s narratives across adult, child and adolescent services. Given the possible impact of early mental health difficulties across the lifecourse, participants viewed deficits in children’s care as particularly salient. “If you have a child who is anxious and depressed, to the point it's getting in the way of their development, and they are ten years old, being on a waiting list for a year, is a tenth of their lifespan that they’ve not been functioning for and they pay a very heavy developmental price.”(PT.5, p.10).
A lack of continual and follow-up support for people and their supporters when experiencing mental health crisis reinforced a lack of parity for acute and mental health service user, with caregivers seen as instrumental in negotiating access and responsiveness from mental health services. Perceived enablers at the meso level involved carers and families; “Family members are a really important part of navigating the health systems, advocating for the health systems, reminding the health systems, they alert if there's a problem going on. […].”(PT 1, p.18).
Participants discussed involving families and formal carers as facilitators for developing greater levels of acceptability. “You’ve got to start with the service users, their families and the professionals that are directly involved in the coordination and delivery of their care and support.”(PT 13, p. 14). Without the support of families and formal caregivers, professionals may struggle to deliver acceptable, effective and equitable care, but this itself raises challenges at the micro level in terms of language used, clinical culture and power differentials.
Barriers to patient-centred care involved time and pressure on services “time is an important factor because of increasing service demands and pressure on clinical services. Sadly, even with the best will, we don’t have the time to sometimes delve into a little more detail.” (PT. 24, p.5). Without the time to explore with patients and their carers important details and inclusion in the patient professional encounter then ‘no decision about me without me’ 22 (p.3) is unlikely to occur. Some participants discussed person-centred care as both a facilitator and barrier to parity. “Making sure that the patient is able to tell you more about their needs than anything else”(PT16, p.6). However, “With mental health I think everyone is a bit more fearful; they remove themselves, they maybe don’t want to enter in a discussion” (PT. 23, p.6). It would appear that for parity to occur in choice and decision-making there needs to be more training in facilitating individuals, families and carers to become part of the decision-making environment.
Workforce
Key themes for this domain were a) Education, training and continuous professional development (CPD), and b) Staffing numbers.
Participants perceived the impact of lack of funding on staffing numbers at macro level as a challenge to service delivery at the meso level“When patients come into ED, they’re often waiting for the mental health liaison team. They’re quite often short-staffed, underfunded” (PT. 23, p. 3). They felt that a lack of resources had a direct impact on staff themselves, particularly in early intervention and crisis care services, which then exerted an effect at the micro level: “the staff are under so much pressure, they have no resources and not enough staff” (PT. 22, p. 11).
“When someone’s in a mental health crisis, they should not be left to not know where to go. Or to not have support because there aren’t enough resources or the service isn’t open” (PT. 2, p. 7).
Staffing was an issue throughout participant interviews, particularly at the meso level for
The workforce is a substantial resource within the services, and arguably, it is important to keep abreast of new evidence and ensure holistic care is prominent. Some participants highlighted a siloing of education and training which focused mostly on physical health “If I'm trained as a physician I'm trained in physical health. I learn to be blind to mental health problems”(PT. 27, p.4). Cartesian duality appeared reified by education “you know we’re definitely trained in splitting people's bodies and minds.”(PT1. P, 9). This disjointed training at the meso level disabled healthcare practitioners, affecting service delivery at the micro level, because there are barriers to effective communication and asking people about their mental health. “Mental health nurses, don’t feel as confident with physical healthcare as we could, because we haven’t been trained to the level that we need. The reverse is true for acute care nurses, they don’t get any mental health training and they’re scared” (PT. 10, p. 4).
Information and Research
Key themes for this domain were; a) Access to reliable data; b) Measurement and benchmarking; and c) Parity in research.
Acknowledgement came from participants regarding the lack of parity between physical and mental health research “you’d want to see some parity in mental health research. Of course, it’s way behind other health areas.” (PT. 14, pp. 7-8). Reducing barriers at the macro level would facilitate more equitable meso level advances. Whilst broad macro level enablers for participants included “making sure mental health problems have equivalent research and funding priority”(PT. 18, p.2), more specificity was evident in some participants responses.
Participants discussed meso level barriers to accessing reliable data because of variations in coding and collecting data. “Quality of the data is still really poor and the way that different NHS trusts collect the data, there’s just a huge amount of variation. How can you assess the effectiveness of the system, the quality of care, if first of all you’re not collecting the right data?”(PT. 12, p. 14). Enablers involved standardising data aiming towards quality improvement and “really understanding the data and what you’re measuring, really understanding the change cycle that you’re implementing, and then sustainability about the metrics that you’re collecting, to measure it.” (PT. 21, p.15). Another participant suggested that there was a pressing need “to invest more time and energy and effort and research into what patient reported outcomes (PROMs) would be of value to people.” (PT. 24, p. 6).
Being able to judge the efficacy of a system and need for resources becomes challenging if the data is unreliable. It also makes requests for further resources difficult.
Within healthcare, benchmarking links to targets, incentives and metrics and usually classified into one of four categories: productivity, quality, time and cost-related. This allegedly establishes standards of excellence and improves services and quality 23. Participants perceived that benchmarking was important “how are we doing on this indicator, compared to the national average? I would do it more by bench-marking the key indicators.”(PT. 14, p. 8). This also underlined considerable operational complexity: “How you measure what the outcomes are for something like mortality? Do you then break it down for different mental health conditions?” (PT. 3, p.11).
At the meso level, participants gave positive examples of enablers such as Quality Outcomes Frameworks (QOFs) involving integrated care addressing physical and mental health. “They access a dietician, get to the optician, see the podiatrist, and go for their regular physical health checks. They should have an ECG and bloods taken at regular intervals at least once a year. People with bipolar disorder and schizophrenia should have that in general practice. There was a QoF around that, but that’s been removed” (PT.17, p.7). While participants perceived incentivising physical and mental health through the introduction of yearly health checks at the meso level as an enabler, the potential for the mis-coordination or instability of these approaches was a prominent barrier.
Technologies and Medical Products
Key themes for this domain were a) Shared information systems and b) Treatment choice.
This domain was least mentioned. Participants who did discuss PoE under this domain typically perceived barriers to care emanating from a lack of shared information systems at the meso level. This occurred primarily when they were attempting to support inpatients with mental health care. Inflexible interpretations of confidentiality and data protection appeared to present specific barriers. For example, blocking access of healthcare staff to scans and appointments sent to the patient’s home address, even though they were in-patients in a mental health unit in the same hospital grounds:
“They have a system within the main hospital where all the CT scans are reported and actually held electronically, but we don’t have access. We have tried to get access and we have failed. The radiologists are telling us, ‘we cannot give you access to the system, we cannot email you the result, and you have to physically come’. So, we have to leave our building, walk across the hospital site, go to another building and get the scan result. When my junior doctor arrived there they said, ‘oh no, we are not giving it to you’. So, they can’t email it to us, they can’t physically give it to us, they can’t put it on the system, so I’m not really sure how we’re supposed to access it.” (PT17, p.4).
Other participants discussed barriers to treatment choices resulting from perceptions around mental health at the micro level “I would always discus treatments and the choice and the availability of different treatments to a patient and, you know, involve, them […]. In mental health, for some reason, a different idea is that they can’t make that decision or they shouldn’t have that decision” (PT.23, p.9). This participant appeared to suggest that professional or institutional discrimination might result in patients with mental health problems ultimately having less choice and by implication iniquitous or sub-optimal care standards. “They’ve not had the same choice in treatment, or […] I’m not going to Steri-Strip…I’m not going to suture them because, you know, they’ve self-harmed, they’ll probably rip it out and self-harm again, so it’s not really worth it.” (PT. 22, p.3-4).