Good mental health underpins our capacity to live well. Effective mental health support is vital when we’re struggling, but access is not guaranteed and treatments often aren’t informed by quality evidence. People’s experiences of poor or inadequate support, disjointed services, and stigma are driven by wider system issues. These can include chronic underfunding, human resource shortages, fragmented delivery models, and limited implementation of ‘what works’ in mental health policy and practice.
COVID-19 has made things worse. We’ve all experienced the daily trauma of rising death tolls coupled with financial challenges, school closures, and lockdown after lockdown. Mental health conditions have been called the ‘second pandemic’ with rates of depression and anxiety having grown 28% and 26% respectively. The burden of COVID-19 and its attendant mental health challenges is also most acutely felt by those who are already vulnerable.
Reform is therefore the need of the hour, and ambitious reform efforts are already underway in some systems. But this isn’t just a question of developing policies and plans. We know from our own experience in service delivery and policy reform that transformation is hard. Despite the best efforts of dedicated people, changes in complex, multi-layered systems often don’t result in improved outcomes for those accessing programs and services. Mis-implementation (when things that work don’t get taken up – or things that don’t work take hold) is very common.
This is where implementation science comes in. The field offers policymakers and practitioners evidence-backed, accessible methods and approaches that help navigate system complexity as they drive change. What’s more, approaches rooted in the discipline have already delivered substantial, sustained impact in mental health systems reform globally. Implementation science is a rich resource for reformers in mental health systems. It is central to reform efforts and vastly increases the likelihood of successfully achieving and sustaining intended transformation.
Nine lessons from our implementation science partnership work that can support change agendas:
1. Centre communities and service users in reform
It’s no secret that user voice is important. But there is still a significant gap between acknowledging that we should engage those with lived experience in reform and doing it – the actual work can be hard, messy, and uncomfortable; people and their needs are complex. Ongoing participation and collaboration with those for whom the system and services exist is essential to sustainable reform. Meaningful involvement promotes empowerment and equity, recovery, improved health and wellbeing, better service quality, enhanced accessibility and acceptability of services, and greater satisfaction with these services. This can help to ensure that equity is at the heart of reform and that interventions and reforms are adapted to local needs and strengths. One of our collaborators, Dr Richie Poulton, has said that the key to good implementation is to ‘listen at the feet of the community’, and we couldn’t agree more.
2. Context is king
We see again and again that there is no ‘one size fits all’ approach to facilitating change in complex systems. Context includes the interplay of people, organisations, and systems and how these variables affect how change occurs. Change processes always take place with a degree of unpredictability, meaning that people and systems must remain adaptive and responsive. Mapping and understanding context, building culture and expectations around reform, and engaging key stakeholders can enable reformers to systematically address the major contextual factors affecting their efforts.
3. We all have a role in transformation
Reform needs to leverage all of our strengths and efforts. Designated leadership provides a clear vision and direction for intended changes, but more informal roles help to distribute leadership among those involved in reform. This helps to define a balance of accountability and build strong structures of shared responsibilities.
4. Things change, and we need to change with them
Change is a constant in mental health agencies, organisations, and systems. Against this backdrop, how do we ensure the services being delivered are still high quality and appropriate through change cycles? To avoid a mismatch over time, we recommend using continuous quality improvement (CQI) approaches. CQI depends on three essential components: (1) designing with local conditions in mind, (2) systematic data-guided activities, and (3) iterative development and testing.
5. Purposeful and ongoing engagement is vital
Communication that facilitates engagement amongst people affected by reforms – from service users to partner agencies and clinicians – is central to effective transformation but often neglected or seen as a bolt-on. Communications should be planned, targeted, purposeful, and ongoing in order that stakeholders remain engaged and understand how the transformation will take place, owning and developing the role they play in the process. Time spent nurturing engagement and developing solid communication plans that reflect various stakeholder needs is vital; paying up front here pays off.
6. Promote a culture of continuous collaborative learning to support change
We work with many skilled, dedicated people at many levels of mental health systems. Reform efforts are about enabling all of these people – clinicians, system leaders, social workers, and others – to start rowing in a new direction – and they’re often also about ‘rebuilding the boat’ as it sails. Building on motivation to engage within an environment that offers opportunities for behaviour change is essential to optimise learning for those who drive and sustain system reforms. Learning new behaviours and competencies is a continuous, long-term process that needs to be integrated into the realities of workplaces and the wider system.
7. Build implementation capacity
Implementation science has a body of literature that captures the known, learnable skills that are important for the design, preparation, implementation, and sustainment of transformational change. These might be different than the skill sets that already exist within the system, but they can be developed. Cultivating a workforce that is aware of and actively works to address cultural bias and social inequity in research practice and translation is important for mental health reformers seeking to improve outcomes for marginalised communities, for example.
Beyond building team skills, there are ways to build capacity at the organisational and cross-agency level for reform work:
- Improvement teams can operate as groups that are collectively accountable – assisting existing formal leadership structures;
- Engagement of intermediary organisations with implementation science expertise; and
- Inter-agency collaborations that work across levels of the system to integrate and promote reform.
8. Reform is a journey, not a destination
Implementation is not a linear process. Real-world transformation is always dynamic and involves continuously assessing changes; constantly learning and problem-solving; and regularly adapting and tailoring. Implementation needs to become part of the system, with continuous monitoring and adjustment to respond to changes and emerging requirements.
9. Good governance will support your efforts and safeguard your reforms
Governance structures that are clear and jointly owned can help with overcoming some of the challenges inherent in collaboration for systems change. Plans, expectations, and responsibilities across the system can be clarified and supported by governance measures including:
- Ensuring representation, participation, and consensus-oriented decision making across partnerships
- Co-developing a well-articulated, joint vision
- Co-developing frameworks that monitor performance and progress and allow for context
- Facilitating a culture of openness and transparency, ensuring clarity around accountability, and ensuring that decisions can be critically reviewed and contested
- Applying principles of fairness and accountability in all aspects of governance
The pandemic has given rise to new issues that will need to be addressed in reform efforts. How, for example, do people get equitable access to quality mental health information and support when they’re locked down? What are the mental health effects of pandemic policies? And how can we design emergency public health policy to take care of population physical and mental health?
It is vital that we keep these and other questions central in the active, staged, and planned approaches that support the creation of capacity that mental health systems require over time. This will ensure access is addressed and the system continuously adopts, adapts, and ultimately sustains the effective services required to improve the lives of those who are vulnerable.