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Abstract
Mental health services continues to be a high priority for healthcare and social service systems. Funding structures within community mental health settings have shown to impact service providers’ behaviour and practices. Additionally, stakeholder engagement is suggested as an important mechanism to achieving the intended goals. However, the literature on community mental health funding reform and associated outcomes is inconsistent and there are no consistent best practices for stakeholder engagement in such efforts.
Objectives This study sought to understand how stakeholder engagement impacts outcomes when there is a change in public funding within community mental health settings.
Design A realist synthesis approach was used to address the research question to fully understand the role of stakeholder engagement as a mechanism in achieving outcomes (system and service user) in the context of community mental health service reform. An iterative process was used to identify programme theories and context–mechanism–outcome configurations within the literature.
Results Findings highlight that in the absence of stakeholder engagement, funding changes may lead to negative outcomes. When stakeholders were engaged in some form, funding changes were more often associated with positive outcomes. Stakeholder engagement is multifaceted and requires considerable time and investment to support achieving intended outcomes when funding changes are implemented.
Conclusions To support successful transformation of community mental health programmes, it is important that stakeholders are meaningfully engaged during funding allocation changes. Stakeholder engagement may entail connecting around a shared purpose, individual participation and meaningful interactions and dialogue.
- MENTAL HEALTH
- HEALTH ECONOMICS
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Health economics
Data availability statement
Data are available on reasonable request. Data extraction tables available on request from the authors.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study used a highly iterative process, guided by literature review, author reflection and stakeholder consultation, to develop and test the theory that stakeholder engagement is an important mechanism that can positively influence outcomes within community mental health settings, when changes are made to funding.
An established conceptual stakeholder engagement framework, grounded in evidence, was used to draw out components of engagement from the literature.
These findings should be viewed with some level of caution as the engagement components presented in the literature may have been overstated or understated given the availability of evidence on this mechanism in published research, and authors of included articles may had different interpretations of engagement.
Introduction
Addressing mental health needs remains a significant priority in today’s health and social care systems. Over many decades, countries in the developed world have focused on transitioning mental healthcare to the community, in the hopes of both reducing expensive hospital based care and improving the quality of life for users of mental health services.1–3 Subsequently, there has been an increasing shift in funding of community mental health services.4 Existing literature on community mental health funding underscores a variety of funding approaches, including pay by results, activity-based funding, managed care, fee-for-service, carve out or capitated funding models, to name a few.5 The problem for researchers is that mental health funding has been inconsistently defined, operationalised and evaluated.6
In practice, funders of community mental health services are interested in creating efficient funding approaches.3 Within public funding formulas, and impacted by the presence of competing political agendas, it is not uncommon for funders to shift or make changes to funding approaches.7 Changes in the funding amount, reallocation from a different funding stream or changes to a funding model are common ‘change in funding’ approaches observed in practice. Little is understood about how these shifts impact service delivery, organisational structures and service outcomes.8 A better understanding of how mental health funding changes impact desired outcomes can inform the planning and management of health services.8 9 In general, the link between funding approaches and outcomes has been poorly described in the literature.10 This is true of both service user outcomes as well as system-level outcomes.
The objective of this research was to explore the unique relationship between change in funding and outcomes within community mental health settings. Given the present state of the evidence, and variations in funding approaches and outcomes reporting, a meta-analysis approach was deemed unproductive. However, a realist synthesis was identified as an ideal method to explore the linkages between change in funding, influential mechanisms and outcomes within community mental health settings.
Methods
A realist synthesis is used when a researcher seeks to understand ‘what works, how, in what circumstances and to what extent?’,11 and is considered an ideal evaluation for community programmes that tend to have variable outcomes.12 The process of completing a realist synthesis is about drawing out context–mechanisms–outcomes (CMO) relationships from existing literature and synthesising the results into CMO configurations that present causal relationships.13 The unique feature of a realist synthesis, compared with other knowledge syntheses, is the consideration of mechanisms. Mechanisms are often ‘hidden’ features13 but can produce outcomes when influenced by variations in context.14
A realist approach is grounded in realism and supports an approach to ‘untangling the complexity of real-life implementation’15 of programmes. The methodological guidelines for theory-driven realist synthesis studies, RAMESES protocol,16 and the Key Steps in Realist Review,11 were used to guide the approach in this study. Specifically, these steps are: step 1—clarify the scope, step 2—search for evidence, step 3—appraise primary studies and extract data, step 4—synthesise evidence and draw conclusions and step—disseminate, implement and evaluate.11
Step 1: clarify the scope
Through an initial search of key literature, an iterative process was used to clarify the research question, relevant constructs and theories to be tested. The context of interest was change in public funding within community mental health settings. Public funding models were chosen, as it is most relevant to community mental health settings and permitted a focused exploration.
A realist synthesis methodology was embraced due to the high variable and low consistency in how outcomes are measured and reported in practice and research.17 Such variation on measurement and reporting led to a wide view of outcomes, including system level, service delivery or service user health and well-being outcomes. Specifically, we approached this synthesis with the view that potential outcomes of interest could include service access improvements, service delivery model enhancements, system cost efficiencies, health or well-being service user outcomes or service user satisfaction scores.
Mechanism: stakeholder engagement
The community mental health literature highlights that funding can influence community mental health service provider practices, and that this subsequently can influence outcomes.8 18 For example, researchers have reported that when new funding approaches support innovative service delivery models, service providers take steps to create ‘whatever it takes’ partnerships,19 ‘wrap around’ service planning20 or cost-effective treatment approaches.21 Conversely, the literature suggests that changes in funding can have negative effects when stakeholders do not feel committed to the model proposed or engaged in the change process. For example, when organisations perceive that funding is insufficient for the needs of service users, this can create programme instability and limited collaboration with other service agencies22 or lead to hiring less qualified staff.23 These findings led us to appreciate that stakeholder engagement may be a mechanism of interest. Specifically, understanding how changes in community mental health funding with and without stakeholder engagement can impact outcomes seemed a worthy line of inquiry. Other mechanisms that were considered included organisational training, culture and leadership, however, stakeholder engagement arose as the most promising mechanism for this realist review.
The concept of stakeholder engagement has been of increasing interest among researchers, funders and policy makers, as successful system transformation and improved financial performance have been demonstrated when healthcare professionals are engaged.24 25 Despite the growing interest in and perceived importance of stakeholder engagement, there is currently no single widely accepted definition of engagement or agreed on engagement process.
Norris et al sought to conceptualise stakeholder engagement in the context of healthcare improvement initiatives. Specifically, the researchers interviewed a variety of stakeholders and arrived at a conceptual model of engagement highlighting three major components: individual participation, connecting around a purpose and meaningful interactions and dialogue.24 Within each of these components, there are strategies that further inform and describe stakeholder engagement. Norris’ model presents an interesting foundation on which to examine how the mechanism of stakeholder engagement impacts outcomes during funding allocation changes in community mental health settings. This conceptual model formulated the theoretical backdrop for creation of research question and middle range theory, as well us the structure for data collection and analyses. Further details of how this model was applied can be found in results.
Research question
With context, mechanism and outcomes defined, and an associated guiding conceptual framework identified, clarity for the research question arose. Specifically, this realist literature synthesis sought to address ‘How does stakeholder engagement impact outcomes when there is a change in public funding within community mental health settings?’
Middle-range theory
Jagosh et al defined the term middle-range theory as ‘an implicit or explicit explanatory theory that can be used to assess programmes or interventions’.26 An iterative process was used to formulate the middle-range theory. Specifically, this involved preliminary review of the literature, reviewing the conceptual model of engagement, considering the definitions of the context, mechanisms and outcomes, dialogue with other researchers who specialise in realist synthesis reviews and consultation with community mental health agency leaders to determine the appropriateness of the topic and focus.
Through this exploration and clarification, the theory for validation in this study emerged as changes in funding can lead to successful outcomes when stakeholder engagement is present. Additionally, the reverse theory is that changes in funding without engagement are linked to less successful outcomes.
Step 2: search for evidence
The search strategy, search term development and searching activities were completed with support from a research librarian. Specifically, the initial search terms used a variety of economic and funding terms, mental health and mental illness terms, service provision terms and outcome terms (online supplemental appendix A). An initial list of search terms was created by analysing the MeSH headings that were applied to the literature when clarifying the scope. The PubMed identifier for each article was placed into the Yale MeSH Analyzer. This helped generate a working list of appropriate search terms, which were modified iteratively until it was found that the search terms were targeting the intended articles for consideration.
Supplemental material
Patient and public involvement
Additionally, an external stakeholder, who is responsible for managing teams of community mental health service providers and understands the complex link between funding, service provider practices and outcomes was consulted. This individual reviewed the search terms and provided feedback to ensure search terms were inclusive of today’s common practices. No patients were involved in this study.
With the search terms identified, the following databases were searched: MEDLINE, CINAHL, EMBASE and Scopus. Handsearching also occurred if an article was identified within one of the selected articles that was thought to contribute to the CMO considerations.
Step 3: appraise primary studies and extract data
The compiled list of searched articles was downloaded into Covidence.27 Following this, title and abstract screening and full-text screening were conducted by two reviewers to limit reviewer bias. Articles were included if they focused on community mental health funding changes, were published after 1998 and if they addressed and informed the CMO configurations. Twenty years of publications were thought to support the formulation of a modern day finding. Articles were rejected if they were problem focused only, had insufficient stakeholder considerations (mechanism) or if there was insufficient data for the opinions generated. Discrepancies were discussed until agreement was achieved.
Pawson et al shared that the approach to appraising quality in a realist synthesis involves evaluating relevance and rigour. Although traditional evidence synthesis protocols may exclude articles that are deemed as weaker evidence or poorer study designs, a realist approach may include articles if they help inform the CMO configurations. For example, it is not uncommon to include editorials in a realist synthesis of the literature support the consideration of the mechanisms in this context. Specifically, the articles may be viewed as demonstrating a ‘thick’ relationship between the CMO,28 even if the study design is viewed as lower in quality.29 Thick concepts are understood to be characterised as ‘involving intentional and purposive detail which help us to understand those activities,’ while thin concepts are less evaluable and more loosely defined.30 In the realm of realist syntheses, classifying literature as ‘thick’ is seen to include articles that ‘offer greater explanatory insights into the factors shaping implementation processes’ and identifying mechanism and contextual processes,31 where ‘thin’ literature is perceived as articles ‘where discerning a programme theory would be problematic’.28
The chosen articles were numbered to create consistency within the data extraction tables. Data from each article were extracted related to the specific change in funding reported (context), the stakeholder engagement process (mechanism) and specific outcomes of the programme. Initial extraction tables captured all relevant data in regards to context, mechanism and outcomes.
Step 4: synthesise evidence and draw conclusions
Once all data were extracted, Pawson et al’s approach was used to guide the data synthesis process. Data tables were reviewed by the research team and the findings condensed into preliminary themes. The themes were discussed and analysed to identify chains of inference.15 The data were then synthesised to test and refine the middle range theory. The conceptual model of stakeholder engagement24 provided the framework for this theory testing. Next, efforts were made to identify data that contradicted the middle range theories or or evidence to generate new insights. Lastly, the research team discussed the findings to allow for a presentation of conclusions based on the context, mechanisms and outcome configurations.
Step 5: disseminate, implement and evaluate
The final step in a realist synthesis seeks to test out the conclusions and recommendations with key stakeholders as well as in practice. The same external stakeholder who provided consultation on the search terms was engaged in this discussion.
Results
The search strategy identified an initial N=4671 articles for consideration. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA chart figure 1) identifies the number of articles that were searched and removed at each step of the search process. Once consensus was reached for article inclusion, N=30 articles remained for data extraction. The articles were from countries around the world: 60% were from the USA (N=18); 17% were from England or other European countries (N=5); 17% were from Canada (N=5); and 7% were from Australia (N=2). Included studies represent a breadth of qualitative and quantitative, editorial, randomised controlled trial (RCT) and case study designs.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. CMO, context–mechanism–outcome.
With respect to outcomes, online supplemental table 1 provides the details about outcomes and outcome types represented in the articles. Access to care (34%) was the most referenced outcome, and service model development or enhancement (21%) was the second most discussed outcome. Others outcomes reported included quality of care (15%), staff workload (13%), service user outcomes (9%), cost-effectiveness (6%) and collaboration (3%). As some articles mentioned more than one outcome, there are more outcome types reported than articles cited.
Supplemental material
Change in funding
All included studies highlighted some form of change in funding, such as an increase in funding, a decrease in funding, a reallocation of funding from one funding stream to another or a change in the funding model (online supplemental table 1). Some studies compared two different funding models when a new funding amount, model or approach was trialled within the same system. Additionally, some changes occurred within the context of programmatic changes. Three of the articles reported on traditional RCT studies that compared two funding models to determine differences in outcomes. For example, Alterman et al32 compared two groups: one with fee for service funding against managed care and capitated funding models.
Stakeholder engagement
The main components within Norris et al’s stakeholder engagement conceptual model are individual participation, connecting around a purpose and meaningful Interactions and dialogue. These concepts provided the foundation for data extraction of stakeholder engagement mechanisms. Most included articles commented on some level of stakeholder engagement, however there were a few articles (N=4) describing that stakeholder engagement was lacking. As can be observed in online supplemental table 2, the authors commonly reflected on individual participation and connecting around a purpose and related subthemes, while meaningful interactions and dialogue was the least described mechanism in this literature.
Supplemental material
Individual participation
The first broad them in the concept of stakeholder engagement is individual participation; with subthemes of ‘active’, ‘willing’, ‘committed’ and ‘varying levels’.18 As an illustrative example of individual participation, George et al discussed the implementation of Assertive Community Treatment programmes in Ontario, Canada over a 6-year period. While the authors discussed many aspects of engagement, one of the features that they highlighted as key to successful implementation was the establishment of a technical advisory panel that comprised ‘team leaders, psychiatrists, peer support workers, family organisations, consumers, the Ontario Office of the Patient Advocate and senior ministry staff’.33 The inclusion of perspectives from diverse stakeholders ensured engagement through individual participation from individuals at all levels of the system and all stakeholder groups.33
Connecting around a purpose
The second broad theme in the concept of stakeholder engagement is Connecting Around A Purpose; with sub themes of ‘voice at the table’, ‘interesting and relevant problem’ and ‘shared vision and decision making’.18 An example drawn from the literature of ‘voice at the table’ is when all stakeholders could participate in discussions about how the community mental health system is structured and funded. This construct was therefore viewed at a system wide, structural frame of reference. On the other hand, other elements within this broad theme, such as addressing an ‘interesting and relevant problem’ and ‘shared vision and decision making’18 were interpreted as relevant to the consideration and development of care pathways and/or service delivery models.
An example of how connecting around an ‘interesting and relevant problem’ was represented within the articles is the implementation of a community of practice (CoP) of service provider stakeholders. One group of authors discussed how a CoP of service providers was formed during the At Home/Chez Soi Housing First research demonstration project in Canada.34 One of the key items that the authors highlighted was that the CoP supported service provider engagement and helped inform frontline service delivery, including the consistent use of best practices within the programme.
Alternatively, another group of researchers discussed how the state of Oregon transitioned to a managed care model for Medicaid-funded substance use treatment.35 The authors emphasised that improved access and quality of care and decreased costs were observed when treatment providers had a ‘voice at the table’ through hosting of ‘regional meetings of treatment providers across the state to provide information about the transition and to allow treatment providers to share their experiences, troubleshoot and share data’.35
Meaningful interaction and dialogue
The third broad theme of Norris et al’s conceptual model of stakeholder engagement is Meaningful Interaction and Dialogue, which include the subthemes of ‘two-way contribution’, ‘communication’, ‘an invitation early in the process’, ‘listening and understanding’ and ‘respect and sincerity’.18 While it is not difficult to understand why these are essential components of successful engagement, this broader construct was less evident in the literature. Mechanisms can often be hidden in the literature,13 and meaningful interaction and dialogue was the most difficult to detect within the articles examined. While funders may allow for the creation of processes that ensure all stakeholders have an opportunity to engage in ‘two-way contribution’, it is not discussed or described at great length within the literature. It may be considered implicit, and therefore, authors may not find it necessary to mention or capture sentiments that participants ‘felt heard and considered’. That said, this does appear in the literature in some articles and sometimes quite directly.
For example, one study examined what happened to community mental health services when a federally funded initiative came to an end.36 Specifically, in the USA, a federally funded project called Access to Community Care and Effective Services and Supports (ACCESS) intended to foster partnerships between service providers who supported populations experiencing homelessness, serious mental health and substance use conditions. This funding envelope was established for a period of 5 years and there was concern that these initiatives would discontinue when federal funding ended. However, the researchers found that during the 5-year funding period, significant stakeholder engagement led to collaborative identification of other funding opportunities to support sustainability. The authors discussed that right from the start of the 5-year demonstration project, ACCESS-funded sites were encouraged to ‘develop strategies to continue ACCESS services with local and/or state monies’, which reflects an ‘invitation early in the process’. The authors discussed the presence of ‘two-way contribution’ and ‘communication’ at multiple points in the article and their findings highlighted that obtaining ‘local buy-in’ was a critical component to ensuring continuation of projects after the completion of federal funding.36 While the authors did not say explicitly that participants felt that ‘sincere and genuine’ communication was occurring, they did discuss that policy makers ‘went to bat for continued funding’ and that programme managers were focused on sharing the successful results of the programme to potential new funders.36
CMO synthesis and configuration
The data extracted were simplified by the stakeholder engagement constructs from the conceptual model to allow for CMO synthesis and configuration. As online supplemental table 2 reflects, and in line with the guiding middle range theory, it appears that when funding changes are made without stakeholder engagement, it can lead to undesirable or negative outcomes. This was represented in 13% (N=4) of the articles. Similarly, when stakeholder engagement of various types was present in the context of a funding change, this supported positive outcomes for 63% (N=19) or mixed outcomes for 23% (N=7) of the articles. What is also clear from this synthesis is that outcomes are rarely directly impacted by the type of funding change being implemented. Regardless of funding increase, decrease or reallocation, the funding change did not appear to be the driving factor impacting outcomes. On the other hand, the synthesis appeared to suggest that when stakeholder engagement was present during a funding change, it more likely supported a positive outcome. These findings endorse the proposed theory in regarding to funding changes, stakeholder engagement and outcomes.
With the middle-range theory supported through this synthesis process, efforts were made to understand if further connections could be drawn that link specific components of engagement to funding changes and outcomes. Specifically, articles with thick relationships between the context, mechanism and outcomes were further considered. Thick concepts are understood to be characterised as ‘involving intentional and purposive detail which help us to understand those activities,’ while thin concepts are less evaluable and more loosely defined.30 Essentially, we understood the thick articles as more strongly addressing our line of inquiry.
As can be seen in online supplemental table 2, while all N=30 articles contributed to the CMO configuration, there are N=14 articles that included thick description of relationships. It was found that N=10 articles had positive and mixed outcomes, and these articles reported high levels of stakeholder engagement with all three components of the conceptual model of engagement present. In the N=4 articles that highlighted lack of stakeholder engagement, authors reported negative outcomes. Based on the synthesis of studies with the thickest description of CMO relationships, it appears that all the components of engagement need to be present for successful outcomes to be observed. For example, individual participation alone does not reflect sufficient stakeholder engagement, nor is just the presence of meaningful communication.
Further to these findings, the articles with thick CMO relationships highlighted many consistent practical considerations. Training and technical support of service providers was often reported as an essential stakeholder engagement activity.33 34 37 When described as a successful engagement strategy, it was rarely spoken of as a single directional engagement between providers and funders, but instead as a mutual approach to building competency, shared vision and supportive communities of practice. In addition a clear understanding of expectations and outcomes by all stakeholders, with flexibility to accommodate individual client needs, was an important component of successful system transformation.35 36 38 Furthermore, political support and championing was frequently mentioned as a practical and necessary approach to ensuring continued funding allocation.34 36 39
There are a few other noteworthy themes that arose from the articles, whether categorised as thick or thin in the CMO configurations. The first theme that arose was that change takes a substantial investment. Many authors noted that with changes in funding, meaningful engagement and realising positive outcomes take significant time.20 33–35 39–42 This presents a new contextual factor that was not initially theorised, that implementing a change in funding takes significant time, resources and commitment. It was recommended that health and social systems have sound change principles in place to support positive outcomes when changes to funding are implemented.34
Further to this, some authors emphasised that there needs to be varying levels of individual participation. It was noted that engagement cannot be an only top down or bottom up process36 43 44 and that stakeholders at all levels are required to see optimal engagement.19 41 Two authors commented that engagement needs to extend to service users, highlighting that currently service users are not engaged enough in policy development45 and that to truly understand service users’ needs and preferences, they need to be involved in discussions about funding and service delivery.46
Finally, many authors noted that engagement cannot be siloed among stakeholders from one system alone. When changes to funding and services are made to one system, it can create a ‘bottleneck’ in other parts of the system, thus decreasing efficiencies and leading to negative results for service users and that system.40 42 47 It was further reinforced that bringing together stakeholders from multiple levels and systems takes significant effort, work and time, which further highlights that stakeholder engagement is complex and takes extensive planning and resources to lead to positive system level and service user health and wellness outcomes.
The results of the CMO configurations were shared with the same external stakeholder who provided consultation on the search strategy. This individual stated that while it is recognised that stakeholder engagement is important, and that many service agencies work closely with the funders when changes are made, in practice there is rarely extra time and resources in the system to support proper stakeholder engagement from front-line service delivery providers and service users.
Discussion
This realist synthesis contributed to the theory that when funding changes are made within community mental health service settings, stakeholder engagement is an important mechanism that may positively influence outcomes. The concept of stakeholder engagement is not new, attracting increasing attention from funders, policy makers, health professionals and researchers in recent years. Although there is no widely agreed on definition or method of stakeholder engagement,24 a growing body of knowledge highlights that stakeholder engagement can influence-system improvement, adoption of evidence-based practices and improved quality of care for service users.48 This realist synthesis has highlighted that within community mental health settings, stakeholder engagement is an influential construct, similar to other other healthcare or social services arenas. Funding decision-makers may not automatically or routinely engage stakeholders from the mental health service sector and adjoining systems; however, these findings suggest that implementation of intentional and thoughtful stakeholder engagement may support positive outcomes when a change in funding level or model occurs. Furthermore, stakeholder engagement needs to be multifaceted and include components of individual participation, connecting around a purpose and meaningful interactions and dialogue of multiple stakeholder groups. This emphasises the importance of dedicated funding and resources for training, ensuring clarity of expectations for all stakeholder groups and creating space for all stakeholders to participate in planning as essential activities for ensuring positive outcomes when funding changes occur.
Although this realist synthesis commenced with an initial view that stakeholder groups include service users, the literature on change in funding for community mental health services has been largely silent on evaluations, processes or best practices for including the voice of service users in the planning process for funding changes or funding allocations. Engagement of service user groups and their families are considered constructive collective governance strategies,49 however, future research is required as to how to do this in a meaningful way.
While the results of this study show that funding can be decreased and positive outcomes can still be actualised, this theory can only hold to a point. Specifically, negative system level and service user outcomes can result if the funding is decreased so drastically that service providers can no longer provide adequate care22 and already underserviced service users go without care.50 That is, sufficient funding will always be required to provide care to vulnerable service users of community mental health services.
The conclusions reached from this realist synthesis were formulated from a wide and diverse group of articles. While the chains of inference were detected, caution should be applied when comparing editorials and case studies with RCTs. The final cautious reflection from this realist synthesis is that when we study change in funding within a controlled research study, a heightened level of engagement may naturally occur. This is a necessary step to ensuring rigour within study methods. Four of the articles in this realist synthesis discussed substantial stakeholder engagement to ensure service providers were knowledgeable and trained to provide the interventions in question.36 50–52 The present review did not follow programmes from initiation through spread and scale and cannot confirm findings are representative of larger populations or geographies than those included in the original studies.
Mental health reform remains a high priority public health policy issue,3 with many stakeholders advocating for changes to mental health funding models and allocations. The evidence continues to highlight that funding models influence service provider practices, and that stakeholder engagement can influence outcomes when change in funding occurs. While stakeholder engagement is a valuable activity, in practice funding and time to allow for meaningful engagement at all levels can be limited. An important reflection for service planners and funders is to consider adequate funding for stakeholder engagement activities when funding changes are made. Building in processes to allow for stakeholders at all levels to have a ‘voice at the table’, engage in ‘meaningful interactions’ and assist in ‘solving a common problem’ are important tasks to support more successful individual, programme and system-level outcomes.
Strengths and limitations of this study
This realist synthesis embraced a highly iterative process, guided by literature review, author reflection and stakeholder consultation, which is thought to have strengthened the theory development and CMO considerations presented in this paper.
As with all evidence synthesis approaches, slightly different search terms may have identified different articles, which may have changed the final conclusions. While this realist synthesis suggested some important CMO synergies, the findings are completely predicated on pulling data from articles written by authors who have their own biases and may or may not have discussed all stakeholder engagement or other mechanistic components. Furthermore, some stakeholder engagement components may have been over or understated, and the analysis was limited to what information on mechanisms was available within the articles. Additionally, inclusion bias may have favoured articles where funders deemed stakeholder engagement as a higher priority, thus inflating the conclusions.
Lastly, we sought the guidance of a community mental health stakeholder, who could have influenced the search and conclusion. A larger consultation could have supported different conclusions. Every effort was made to use an iterative and conscientious approach; however, researcher biases about search term creation, article inclusion and exclusion, data extraction and data analysis may have influenced each step of the process.
Conclusions
This realist synthesis took an international and macro level view of what happens when there is a change to public funding allocation models in community mental health. This study highlights that the mechanism of stakeholder engagement is powerful, and not to be overlooked in the context of funding changes. In the presence of high-quality stakeholder engagement, positive system and service user outcomes can be more likely when funding changes occur.
Data availability statement
Data are available on reasonable request. Data extraction tables available on request from the authors.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Mental health services continues to be a high priority for health care and social service systems. Funding structures within community mental health settings have shown to impact service providers’ behavior and practices. Additionally, stakeholder engagement is suggested as an important mechanism to achieving the intended goals. However, the literature on community mental health funding reform and associated outcomes is inconsistent and there are no consistent best practices for stakeholder engagement in such efforts.
Twitter @wwodchis
Contributors AD, VS, KND, WPW and MK contributed to the study conception and design. Material preparation, data collection and analysis were performed by AD. The first draft of the manuscript was written by AD and VS, KND, WPW and MK commented on previous versions of the manuscript. AD, VS, KND, WPW and MK read and approved the final manuscript. AD is overall content guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.