Besides 'clinical governance', something called 'primary mental health care' (whose definition differed from site to site) emerged from the data as a second related 'object' or complex intervention which was also to be implemented. We therefore treat them together when comparing them with the two sets of organisational conditions which the NPM framework assumes promote normalisation.
Skill set workability
a) Creating 'primary mental health care'
In policy terms the notion of 'primary mental health care' had emerged against a background and skill set in which secondary care norms and modes of operation dominated the consciousness and practice of mental health care and everyday clinical practice . There was considerable variation in the extent to which general practitioners felt able or prepared to work with people with mental health problems and probably a greater variation in threshold for referral  for mental ill-health than for any other presenting health problem:
'they may be a perfectly competent GP but they just haven't got that level of training to know that, okay, that person may calm down if you just spend a bit longer with them, they maybe haven't got that level of skill, maybe they're frightened, may be they just don't want to do it, it's a mixture of things. Its often a feeling of I can't cope with this because mental health problems, a lot of them are very messy, they're not clear-cut.' (Site F PCT mental health lead (GP))
So it is not surprising that our informants reported a gap in service provision, a 'grey area' between what was provided for people with mental health problems in general practice, and by Community Mental Health Teams in mental health trusts which have, in recent years, focussed much more on 'severe and enduring mental illness':
'So we have a cohort of patients- service users who are too severe for the counselling service, don't meet the criteria for the CMHT specialist services and GPs are finding they don't quite know what to do with these patients...So some of our GPs have had training and they're very interested and they can do short-term interventions but the vast majority of GPs out there wouldn't have a clue.' [Site H mental health lead PCT (commissioner)]
How sites were responding to this problem seemed to depend on a number of factors. Dissatisfaction expressed by the GPs about 'the number of patients who were either, if you like, bounced back from secondary care, or, simply just not taken on by secondary care at all' [Site E combined PCT/Mental Health Trust mental health manager] was clearly an important factor, as was the discontent caused by service inequities across the PCT. But the nature of the response and the sense of ownership of this problem to challenge working practices within primary care itself rather than the practices of the specialist mental health sector varied from site to site. It seemed either to depend historically on the presence of key actors in primary care, or within the mental health trust, who had interest in developing something that they called 'primary care mental health services' or the way in which the service had been historically configured.
At PCT level, some actors emerged as both formal and informal leaders in commissioning mental health services, particularly where they shared a common provider mental health trust and had managed to maintain some continuity of senior staff:
Mental health lead 1: 'I think just by sheer default we will almost be the leaders at this stage because we seem slightly more organised, which I hesitate to say.'
Mental health lead 2: 'Yes. I mean I wouldn't say that [co-provided PCTs]would agree that we were leading the process... what I would say to you is that the continuity of [site J]enables the corporateness to be able to be developed and maintained.' (Site J)
However, the PCT-level commissioners did not necessarily perceive that they had to possess any 'expert knowledge' to become involved in decision making about mental health care:
'Oh mental health's a learning curve..... I mean I've been in health since 1990 and it's been in primary care finance you know initially... But I asked to do mental health about a year ago as a development issue and I'm just, I'm falling in love with the subject you know, I think it's really, really interesting.' [Site H mental health lead 2001]
This interviewee had moved on again by the time of our final interviews in 2003–4. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, or actors with the power and/or skills to set about realising or executing it, there was a sense of confusion and lack of direction.
b) Under-defined roles
Some breaking down of barriers between primary and specialist care had been achieved in all sites with the production of joint guidelines for common mental health problems such as anxiety and depression specified by the NSF as 'must do's'. It was generally viewed as a success if they had been distributed:
' there's this sort of glossy package if you will, and that should have gone to all the GPs ... certainly I've got a copy, the teams have got copies of them as well, so as far as I was aware that's been circulated.' [Site F service manager mental health trust]
But there was recognition that distribution did not equate with implementation:
'...actually knowing whether the protocols are being followed and practices used, whether they're helpful, I mean the whole evaluation is going to be a nightmare. I have to say that. I acknowledge it's going to be a nightmare. I've chosen not to jump in ...as yet.' [Site B mental health lead commissioner)]
The actors in 'clinical governance' however had little shared knowledge or understanding of their role in improving the quality of mental health care within the PCTs. So far as monitoring the quality of care was concerned, either they perceived mental health data as being collectable, but only at a basic level, because of its poor quality and inherent complexity, or beyond their remit.
'I don't think Mental Health is as easy to do as Coronary Heart Disease, we have approached it in terms of developing care pathways, and we have a Mental Health Lead as we have a CHD [coronary heart disease] Lead, so we do work in reaching the targets for the NSF and we have .. organised auditing, it seems to have a lower profile, yeah.
A: Perhaps because it feels not a life and death situation, it could be...
A: ... it could possibly be, off the top of my head, umm we've certainly got clinicians out there who are very interested in it, that's excellent and we know that standards are improving because of that, at least it... people are more informed about it, that might be a better way of doing that,..... it could well be that there's a lot going on and it's just not an area that I've got involved with .. highly; I know that we get our regular reports on the NSF and that we're meeting our targets there, I know that we've got future developments coming in through our local delivery plan which is about enhancing Mental Health, so I'm confident that there's work going on and some good stuff but, I couldn't write an essay on it.' [Site H clinical governance lead]
This was not a job that she perceived as being allocated for her to do or that she possessed the skills to perform. However this quote also raises the point that mental health issues are not perceived here as 'life or death' situations. Given the potential for both harm to self and others, an agenda which has been powerful in the development of the 'public safety' agenda in mental health policy, mental health problems clearly are, if not commonly, potentially matters of life and death. Rather, her remarks suggest that she -and possibly other key actors in the organisation – attached relatively low urgency or importance to issues of quality of mental health care. The only data that was routinely utilized in primary care organisation for the purposes of governance was the (relatively easily collected in UK primary care) prescribing data which was subject to scrutiny by the prescribing advisors at the Primary Care Trusts (see below).
c) GPs: discretion versus normalisation
We did not collect data from doctors (other than mental health leads) or patients, but the relative importance attributed to primary mental health care within hierarchies of knowledge and practice was apparent:
'what we did recently was a training needs analysis and the data that was pulled off from there, I don't think it even mentioned Mental Health... Mental Health came about eighth, most of them were about .. neurological conditions, that GPs felt unfamiliar with.' [Site H Clinical Governance Lead]
Sometimes the problem seemed to extend further- to any work involving people with mental health problems even if it was physical health care. At site J there had been discussion about implementation of the NICE guidelines for Schizophrenia:
"GPs say well, you know, 'do physical health checks on people with schizophrenia' ... we haven't got the capacity to do that, if they're in secondary services....
Q: Did that surprise you?
A: Not in the slightest." [Site J mental health trust manager]
GPs and other primary care staff, at all of the sites we visited, were able to exercise a considerable amount of discretion as to whether they engaged in clinical governance activities that related to mental health or not. It was perceived as something that they did not have to do and might not necessarily choose to do given the option. For them, there appeared still to be a failure of normalisation of mental health care in routine primary care. In that case, the creation of 'primary mental health care' within a primary care organisation will challenge basic assumptions about how professionals within the system should relate to each other (relational integration) but also how doctors and patients should negotiate the management of mental health care within the wide range of problems that might be encountered in the primary care consultation (interactional workability).
GPs often have low expectations about whether it is possible for they themselves to intervene effectively with mental health problems [20, 21]. Paradoxically, they can be remarkably positive about the impact of counselling despite having limited knowledge of the training and supervision arrangements which are necessary for the safe employment of counsellors in primary care . This apparent conflict is probably best understood in terms of the desire of many GPs (particularly those with a limited knowledge or interest in mental health) to pass these problems onto another professional, perhaps with an assumption that, if nothing much seems to have a positive impact for people with mental health problems, then nothing much can do any harm? Whatever the beliefs or assumptions of the GPs, we certainly identified a clear preference for the 'referral' route the management of mental health problems which meant GPs neither needed to see themselves as, nor act as, the key actors in mental health. Rather they considered that through the mechanism of referral, the major responsibility lay within the secondary care sector, although the threshold for referral undoubtedly varies between doctors . This lack of ownership not only contributed to the failure of implementation of 'clinical governance' in relation to mental health but also to the problematic progress in the construction of 'primary mental health care' within the organisations and in its normalisation. Insofar as the skill-set workability of mental health care was implicitly considered at all, its skill-set workability was implicitly rated low by GPs.
d) Polar experiences of skill set workability
Two contrasting levels of skill set workability were instantiated by the introduction of graduate mental health workers and by prescribing. The problematic implementation of new primary care mental health workers called 'graduate mental health workers' over the last five years in England  highlighted the different responses, and sometimes resistance, to the normalisation of a new working practice when the ownership of knowledge, work-flows and inter-professional relationships were already unclear even before the new workers were introduced to the system . An opposite example was that the monitoring and standardisation of prescribing practice proved relatively easy to achieve. The requisite data were already collected in detail from pharmacists for re-imbursement purposes, and included data on drugs used for mental health care. By the time of this study it was already established routine practice for these data to be fed back to PCTs, to the collective body of GPs within the PCT, and to the individual prescribers. (This also represents a high level of relational integration.) In all sites, each prescriber knows how to identify his or her own prescribing patterns and compare them with local averages. In some (not all) study sites, the data were not even anonymised, so that each prescriber could also know who was adopting which prescribing patterns. It was a relatively straightforward step to make prescribing reviews a routine and central clinical governance activity.
a) Change, fragmentation, re-integration
The most striking feature of the organisations that we studied was their persistent instability of organisational structures, identity, personnel and strategic direction. The last five years have seen major, barely interrupted changes in the configuration of health authorities and trusts in England. This meant that some of the emerging organisations that we visited in 2000 were, by 2003–4, part of larger new PCTs serving more than twice the original population. Ostensibly these mergers were aimed at increasing efficiency and improving integration, although such centralisation of purpose has sometimes proved difficult to achieve in practice . The three PCTs that directly provided mental health care had remained relatively unchanged during 2000–2003 but the configuration of the mental health provider trusts for the other sites had changed radically. Across the sites as a whole, few of the people that we interviewed in 2003–4 were the same as in 2000 even though in 2003–4 we interviewed people who held the same, or nearest equivalent, roles to our 2000 interviewees. These changes impeded the contextual integration of clinical governance, and the NSF, in primary mental health care.
b) Targets, tick-boxes- and a policy vacuum
In 2000 we found that there was general optimism about the National Service Framework (NSF) and the impact that it might have:
'So far we are pleased that the way forward has been dictated by the National Service Framework....the NSF has given at least a benchmark to various statutory authorities that they've got to deliver and it is prescriptive and it is quite clear what we need to do.' (Site K)
However it soon became apparent that there was a lack of specificity in the NSF about the nature of 'primary mental health care' to be commissioned, compounded in the NHS Plan  despite the inclusion of several specific targets for specialist mental health services:
'In terms of specifically primary care I would...say we haven't done as much as we might have liked, because the priorities around the NSF milestones have been the assertive outreach and crisis resolution which are more at the end of the severe and enduring end of things.... you can also say, to be brutally honest about it, that the key things that matter are the, the targets, and, you know, you could sort of say the rest, you could if you were really hard-nosed, say "Well, you know, if this doesn't meet the target, let's just forget about it.' (Site C PCT mental health lead)
When the NSF arrived in 1999, primary care organisations were clearly at different levels of preparedness to implement it. For some, the NSF acted as a challenge to act and reinforce an ongoing creative process of negotiation between actors about the formal knowledge and practice of something called 'primary mental health care'. However, for others, where such conversations had not yet begun, or were stalled, progress was much slower.
'Mental health' seemed to be something that the PCT mental health lead did only in terms of 'developing services', often with no specific way of ensuring that they were either based on best evidence or evaluated as an integral part of the commissioning and/or development process. This fits with the view of mental health service development as 'an image of heroic pirates resourcefully bending the rules'  (p.68). The disconnection between the formal managerial 'commissioning' view and the actual work going into developing the service through informal networks in the organisation was most striking at site F:
'I certainly found coming in as mental health lead I sort of didn't quite know what the joint commissioning team were doing, I knew they were doing lots of stuff but it didn't feel connected at all...I've tried to draw people in before, people would perhaps come to a meeting or two but because it wasn't their main remit and in a sense it wasn't someone with sufficient seniority really to get in there and make sure its included in the strategic thinking of the PCT.' [site F mental health lead (GP)]
c) Gaps between primary and secondary care
Paradoxically, where the PCT itself provided integrated primary care and mental health services (3 sites) there seemed little sense that 'mental health care' should be owned by or fostered within the primary care wing of the organisation, indicating an apparent absence of actual integration of working practices within these organisations. In one of these PCTs there was not even regular primary care input into the Local Implementation Team, the local group tasked with steering implementation of the NSF 'I'll be honest I've never thought of inviting the Primary Care Commissioning Manager.' [Site G combined PCT/Mental Health Trust mental health lead]
Despite the key position of mental health trusts there was remarkably little joint activity that could be construed as clinical governance across the interface between primary and secondary mental health care other than infrequent joint educational or liaison events. More intensive links were a minority and tended to be focussed around a particular project or 'piece of work' like the development of a protocol. There was limited recognition that such activities might, like service development, be considered to be the part of the ongoing work of clinical governance of mental health care.