Table 2 Themes mapping onto domains illustrating barriers and enablers at macro, meso and micro levels

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.

Policy on PoE.

Equality Legislation and Standards.

Equivalent policy priority.

Lacking insight into patient and carer’s experiences of Mental Health

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.

Inequitable funding for mental health.

Little consideration concerning the complexity of mental health conditions.

Campaigning for funding.

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.

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

Equivalent clinical priority

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.

Suggested multiple access points to gain entry to servicesIntegrating care into the community

Lack of time.

Involving families, formal carers and individuals in the decision-making environmentPerson-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

Agreement of educational curricula without consideration of meso and micro levels.

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.

Having an understanding of the impact of the social determinants of health on patients and carers

Discriminatory staff attitudes.Lack of cultural competence.Inability to engage with diversity.

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

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.

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

Lack of accessibility for electronic records at all levels.

Patients prevented from making choices because of perceptions about their mental health status.

Patients and carers enabled to make decisions and choices about treatment.