Last week the UK government published its mental health strategy for England. It contains some good news for patients, and some not so good news. It has its critics and its supporters. Whatever your view of it, if your are involved in mental health in the UK its three simple principles are going to be important to you in the coming years.
The strategy can be found here: No health without mental health
A clear message
The first piece of good news is — the government has published a mental health strategy. That’s good because it sends a clear message to the NHS and social services that mental health is important at last.
Previously, the message has been that mental health is not very important (except for IAPT), and the result of that has been many, many mentally ill people not receiving effective treatment from the NHS and just being left ill, sometimes for decades.
The not-so-good news on this is that it’s only a government strategy, and the whole point of the wider changes to the NHS that are on the way is that it will not be driven from Whitehall by the strategies of the bureaucrats and politicians there. Instead, there will be much more freedom for GPs and NHS trusts to improve and innovate in line with local needs.
So this strategy is about allowing and encouraging much-needed improvements in the NHS, but it’s not about government taking a “we know best” stance.
Next, this is not just a Department of Health strategy, it’s a cross-government strategy. Again, that’s good news because it sends a clear message to other government departments. For example, it directly involves the Home Office and the Department of Justice on issues like domestic violence and the mental health of offenders.
The not-so-good news on this is that when you broaden your view of mental health beyond the NHS remit of treating diagnosed mental illness, you get into some areas that are very poorly defined. So this approach introduces lots of opportunities for woolly thinking.
There’s an example of this in the very first page of text in the strategy document, where the Foreword repeats the “one in four” myth about the number of people who suffer from mental illness:
At least one in four of us will experience a mental health problem
at some point in our life…
That’s an indication that the strategy has not been based on very sound advice about the realities of mental health. That statement is immediately followed by another, equally flawed:
…and around half of people with lifetime mental health problems experience their first symptoms by the age of 14. By promoting good mental health and intervening early, particularly in the crucial childhood and teenage years, we can help to prevent mental illness from developing and mitigate its effects when it does.
The plan seems to be to intervene medically in the lives of children who are not ill. Unfortunately there is no sound basis for guessing which children will eventually become ill, and even if there were, there is no known way to treat them for an illness they don’t have yet.
So although in some ways looking at mental health as a wider problem has merit, in other ways it makes the government vulnerable to unsound advice from vested interests — for example, from charities that would like more funding for their social projects, and from drug companies that would like to market more psychotropic drugs to children.
Next, and here we get down to brass tasks, the strategy is based on three simple down-to-earth principles, and all three are good news (page 3):
- putting people who use services at the heart of everything…
- focusing on measurable outcomes…
- freedom to innovate and to drive improvements…
At present, as anyone who has battled with the NHS to get effective treatment knows, ‘resources’ are at the heart of the NHS, and the managers who control those resources run the show. The stratgey aims to change that. As these changes are gradually implemented, ‘lack of resources’ will cease to be a valid excuse for failing to provide effective treatment.
Some people are worried by this, because they really believe that the NHS is short of money. However, the crucial point here is that effective treatment is cheaper than supporting someone’s illness year after year. Perhaps you think the NHS is rich, or perhaps you think the NHS is poor — whichever it is, the NHS can save money by putting the people who use its services at the heart of what they do and treating their illnesses effectively.
To make this happen, the NHS will measure outcomes. At present, the NHS is driven by process targets, like number of CBT sessions attended or number of home visits by a CPN. The more sessions attended, and the more home visits, the more points NHS managers get in their annual performance reviews.
Anyone can see that a system like that only encourages the NHS to keep people ill, keep them coming back for more CBT year after year, keep them calling the crisis team, keep the CPNs doing home visits. Measuring outcomes will change all that. The managers will score their points when patients get better and don’t need treatment any more.
The not-so-good news on this is that attitudes are very slow to change. Some NHS staff who have been trained in the old ways will never really buy in to the idea that a mental illness can be a brief interruption in an otherwise happy life. And some of those who cannot buy in to the idea will become academics responsible for training the next generation of NHS staff.
So it will take constant pressure on the NHS to make it put these principles into practice. Therefore the overall strategy for the NHS also spells out how that pressure will be applied, and I’ll return to this in my next post.
Criticism about wellbeing
A further sign of unsound advice from vested interests is the conflation in the strategy of ‘wellbeing’ with absence of mental illness. For example (page 6):
More people of all ages and backgrounds will have better wellbeing and good mental health. Fewer people will develop mental health problems – by starting well, developing well, working well, living well and ageing well.
When you delve into the causes of mental illness, patient by patient, which CBT therapists do, you never find that the illness was caused by the patient not “starting well, developing well, working well, living well”. It is just nonsense to suggest that you can prevent mental illness by well-meaning meddling to make everyone’s lives nicer in some vague way.
…usually published by organisations with vested interests in keeping their services at the forefront of social policy concern in order to maintain or improve government funding.
He further suggests that there is so much of this social policy in the strategy that it will be innefective for the people who actually need treatment:
The real tragedy is that the government’s strategy is unlikely to do anything to help those children who do need professional intervention. It is more concerned with the micro-management of behaviour, extolling both platitudes and condescension towards us all.
While I am not as pessimistic about the strategy as Ken McLaughlin, I do think that, unfortunately, these ill-advised parts of it will be used as excuses for NHS trusts to divert resources away from difficult tasks like actually treating illness, towards easy tasks like promoting happiness.
Criticism about funding
Another public critic of the mental health strategy has been Professor David Richards, an academic who advised the previous government on IAPT training. He used the publication of the strategy to criticize the present government’s approach to funding, which has always been to allow decisions about how money is spent to be made more locally.
Prof. Richards wants the government to decide centrally how money is spent on IAPT, so as to protect the revenue stream that universities enjoy from the IAPT training they provide. However, he is not regarded as an expert on funding, and he was immediately sacked from his position as a government advisor.
His sacking even woke the normally sleepy BABCP, run by Prof. Richards’ fellow academics. It issued a tedious statement making it clear that it is only interested in the money.
It is good news for patients that detailed funding decisions are no longer to be made in Whitehall. It frees local GPs and NHS trusts to find more cost-effective ways to treat people.
To train psychotherapists, for example, instead of buying costly academic training from universities, NHS trusts could save money and improve standards by setting up in-house training schemes along the lines of apprenticeships. If, in the future, you have the choice of whether to be treated by an NHS apprentice or by someone with a PhD, choose the apprentice! Psychotherapy is a practical skill.
Criticism about families
Another public critic has been the Centre for Social Justice, which claimed:
Family breakdown in all its forms is strongly associated with poor mental health in adults and children…unacknowledged in the Government’s mental health strategy launched last week.
That would be interesting if it were true, but the influence of families on mental health is widely acknowledged throughout the strategy document. To quote just one example (page 20):
A whole-family approach that addresses mental health together with other issues, such as domestic violence or alcohol misuse, has been shown to reduce the risks associated with mental health problems.
As I pointed out above, the idea that mental illness can be prevented by interfering with normal children in some way is unsound. But when a family member, whether adult or child, is diagnosed as having a mental health problem, then it can often make good sense to involve the whole family and to work with other issues that the family might have.
It seems to me that on this occasion the Centre for Social Justice’s PR people were just trying to get a headline, not making a serious point, which is a shame because the Centre’s work is generally serious and valuable.
This mental health strategy ties in closely with the overall strategy for the NHS. The big changes that you hear about in the news mostly affect managers and other bureaucrats, many of whom will have to retire or find other work, leaving the NHS more efficient.
The changes that affect patients directly will be more subtle and might take years to achieve results. In another post, I’ll examine what the coming changes in the NHS will mean in practice for patients with mental illness.