There are important messages in the Chief Medical Officers Report on Public Mental Health that will be welcomed by many – in particular her championing of the need for further investment in mental health services, reduction of waiting times and her call for greater support for people with mental health problems to maintain their jobs. There is a good section on the work of Time to Change a BIG lottery portfolio addressing stigma delivered by MIND and Rethink with strong support for its continuation.
Inequality is in there…just.
However, this is primarily a clinical report (not surprising with approximately 90% of the authors being medics) the wider social conditions that people live in receive insufficient attention. Frankly, given the evidence that the bottom quintile are more than twice as likely to be at risk of mental illness than the top quintile this is more than a small omission – this is very poor – not good use of the evidence.
This failure to give due weight to inequality and in particular the impact of poverty, financial insecurity and indebtedness (for more on indebtedness and mental health see my earlier blog here) on mental health reinforces the focus on clinical solutions to social causes. To the credit of the authors of Chapter 7 (Stansfield, McManus, Bhui and Jones) indebtedness is mentioned in Chapter 7 where they recommend:
“evaluation of the impact of debt reduction intervention programmes is needed. The fact that, before the recession, a quarter of people with mental disorder were in debt has direct implications for effective clinical assessments and care planning as well as for awareness in debt counselling agencies, utility companies and financial organisations”
Shamefully even this recommendation does not float through to the key recommendations made by the CMO.
This is further compounded by the absence of any critique of the impact of Department of Work and Pension policies on the wellbeing of people with mental health problems.
There is one mention of Work Capability Assessments in the whole document with no comment at all on the effectiveness of this service. The current IPPR North briefing “In Safe Hands? Rethinking Employment pathways for ESA claimants with mental health problems” notes that:
“People with mental health problems, who make up 40% of those going through the WCA are being let down by a system that appears to be neither effective nor accurate in determining the appropriate level of financial or employment support for claimant with mental health problems. Equally, the system fails to provide the kind of support for claimants that is adequate or appropriate for people with mental health problems”
This briefing goes on to say that “of the 137,130 participants in the Work Programme with mental and behavioural disorders only 7,060 (5.1%) were successful in sustaining jobs.”
This is not just about stigma – this is a system that is systematically failing people with mental health problems.
Lets take it out on wellbeing
Consistent with the narrow clinical view of much of the document is an attack on the concept of wellbeing. By the way, the CMO clearly thinks that it is more important to spend pages putting the boot into wellbeing than give adequate space to inequality and mental health. The report attacks the concept of wellbeing using a report by CLES consulting and the New Economics Foundation (Big Lottery Fund National Wellbeing Evaluation: Final Report 2013) as a straw man. Frankly, I think it is unacceptable that a senior civil servant uses an official government publication to attack the authors of a report who are given no right of reply in that document.
“One of the most problematic implications of the use of grey literature is the widespread adoption of scientific-sounding statements from well funded but poor-quality studies which are based on flawed methodology. To explain our standpoint more comprehensively, we turn to a case study of a widely cited report covering aspects of well-being and mental health: (prepared by CLES Consulting and New Economics Foundation, 2013). This report offers ‘lessons for service providers, commissioners, the Big Lottery Fund and Government”
This attack is part of a broader critique of the current state of play with regard to what we mean by the term ‘wellbeing’ this leads her to conclude that:
“Well-being interventions should not be commissioned in mental health as there is insufficient evidence to support this.”
Now precisely what does the CMO mean by the above sentence?
What do you think?
Just before the summer I participated in a round table discussion on the relationship between health, wellbeing and welfare rights services. This discussion was supported by the excellent Baring Foundation and involved a range of welfare rights organisations including the Advice Services Alliance, Youth Access, the Low Commission and others.
There is a growing body of experience and evidence across a wide range of advice services of the relationship between access to advice and health and wellbeing.
I have written before about the experience of Sheffield Mental Health CAB (now part of Sheffield Citizens Advice and Law Centre) in this regard. What is clearer to me is that there is a strong relationship between increased vulnerability due to poor health and need for advice – I think the relationship is a bit like this:
The experience of MacMillan Cancer Care confirms this, in their report “Cancers Hidden Price Tag” they tell us that following a cancer diagnosis four in five people (83%) are affected and, on average are £570 a month worse off because of a cancer diagnosis with one in three people experiencing a loss in income averaging £860 a month.
Unfortunately it is still the case that many NHS commissioners are still unconvinced – they usually ask this question:
“Can you demonstrate that there is a causal link between receiving welfare rights advice and being well?”
They should actually be asking another question of course:
“What can we do to stop people with a progressive long term condition falling into poverty?”
For an eloquent and clear statement about the urgent need for reform of social welfare support see this 5 minute interview with Simon Duffy from the Centre for Welfare Reform.
What is to be done?
Despite these challenges and the continued attacks from central government on local authority funding there are some some opportunities that we need to respond to.
The Department of Health draft Care Act guidance recognises the importance of access to welfare rights and advice.
“Information and advice is fundamental to enabling people, carers and families to take control of, and make well informed choices about, their care and support and how they fund it”
The guidance notes that local authorities must ensure that information and advice services established cover more than just basic information about care and support.
The service should also address:
- prevention of care and support needs
- what to do in the event of abuse and neglect
This draft guidance combined with the focus on integration through the Better Care Fund has the potential to transform the position of welfare rights and advocacy provision in the health and social care sector.
It could help ensure that welfare rights services in particular are targetted on the most vulnerable, that their contribution to wellbeing is recognised and that the NHS understands the importance of jointly commissioning services with local government.
What do you think?
The way in which we frame our relationships determines the outcomes we will achieve.
If we invite people to answer a question they will (because they want to be helpful) attempt to help us answer it. So, consultations on services usually come up with ways in which a service might be improved rather than question whether or not the service should exist in the first place, its relative importance or its relationship with others.
The NHS has a long tradition of framing its relationship with the public in a particular way and although the language may have changed along with government policy (patients, consumers, users etc) the focus has remained the same:
“we would like to talk to you about the health services we provide”
This framing usually leads to a rather distorted view of how NHS Patient and Public Involvement perceives us – citizens.
I think there are three ways of thinking about people:
- We live – work, play, have families, learn. pay taxes and so on
- We give – we contribute to civil society – we volunteer formally and informally
- We receive – we are recipients of services – in this case health services.
I think that the NHS tends to see us like this:
This perception pushes us into being less of a person – we are instead ‘a consumer’ or ‘a patient’ and both of these roles carry with them assumptions of passivity. We receive healthcare and when our opinions are sought they are only understood to be valid within the context of our role as patients or consumers.
I think we are actually more like this:
Of course, when we become unwell the relative proportions of who we are may change – so we may be more of a patient (receiving) for a period of time.
Despite good intentions I think it is very hard for the NHS to break away from thinking in this sort of way. This leads to discussions which have increasingly diminishing returns as we try to use patient experience to help us improve services and efficiencies. This is because the discussion happens acontextually – not recognising the wider factors that impact on our lives, that have a greater effect on our health and wellbeing – employment, education, housing etc and our view of ourselves as more than a consumer or patient – a citizen.
We need to develop an ease in speaking about wellbeing if we are to move away from procuring services in silos. This means giving a greater focus to mental health and talking more about the social determinants of health.
I think that the continued survival of NHS survives increasingly relies on us moving to a dialogue which is about us as citizens and our wellbeing, the alternative is a narrow consumer dialogue – promoted by this government in particular – which drives us more quickly to increased marketisation and privatisation.
What do you think?
This is a story about some work I have been doing for the last year or so to improve the way the expertise of grass roots organisations is heard by local commissioners.
There’s nothing inherently wrong with the Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS) but the way they have been developed means that they are:
- read by few,
- provide a very high level view of need that is largely based on a set of standard national measures
- struggle to bend system priorities to complex, small and pressing issues that too often slip below the radar.
It is often the case that it is these small, complex ‘wicked’ issues that grass roots organisations are tackling on a day to day basis – and they feel frustrated that the problems they are addressing do not seem to be understood at a JSNA or JHWS level. This of course is one of the reasons why commissioning continues to favour big statutory and private organisations.
I think that one of the reasons this happens is because we fall into the trap of thinking that the JSNA process is primarily a linear one – gather up all the data, put it all in one place – a web site or a report and then analyse it.
I am not arguing against this process – its good to have a population level view - but it is not sufficient if we want a genuinely responsive, inclusive and integrated approach to local commissioning, specifically one that is able to bring issues forward that:
- Affect small populations
- Are complex – multi-causal
- Have poor incomplete data sets
- Are about power, exclusion and inequality
Many of the organisations that work in this area are voluntary and community sector ones. If you work in areas that are easily ignored with people who are unpopular with policy makers then you are likely to struggle to be heard too. Witness the Trussell Trusts exclusion by Ian Duncan Smith.
So, we need a more asset based approach. One that gives voice to these organisations, playing to their strengths and allowing them to share their analysis of the issues they are tackling. This means providing opportunities for the expertise of these organisations to play in and for the voice of the people they serve to be heard.
It also means making it worthwhile for these very pressured organisations to contribute to the process.
Rapid Intelligence Review
About a year ago I started a project to try to come up with a rapid way of trying to address this problem – this is not rocket science. Working in partnership with Involve Yorkshire and Humber and funded by what was then the Yorkshire and Humber Public Health Observatory (now Public Health England Knowledge and Intelligence Team) we devised a model based on the following principles:
- It had to make little demand on the voluntary and community sector in terms of time or resource
- It needed to be led by a VCS view of what issues we should focus on
- It had to capture a more complete story – so a mixture of qualitative and quantitative data
- It had to be cheap
- It needed to make some recommendations
The VCS in two areas (NOVA in Wakefield and Voluntary Action Sheffield) with their respective local authorities worked through the process with us. In Sheffield they identified food banks and specifically the people who use them as the priority area and in Wakefield they identified Pressured Parents.
Jake Abbas (Interim Director, PHE Northern, Knowledge and Intelligence Team) and I have written an overview report on the process which has now been published by Public Health England. This is titled:
The experience of doing the two reviews has led me to the following conclusions:
- the JSNA process cannot just be about putting all the data into one place – it must also include a continuous process of small reviews that focus on “wicked issues” and the process for determining these should be jointly agreed with local civil society organisations.
- it is important to have actions and recommendations – but for a number of these issues just using the review to create a debate at a place level is a step forward.
- we need a more inclusive view of evidence – lack of population level data or RCT evidence is not a good reason for failing to investigate a topic – its actually an abrogation of responsibility.
What do you think?
Jake and I will be sharing this work at the Local Area Research and Intelligence Association Conference this year – and hopefully at other national events – if I can get the abstracts done!
The recent BMA survey of the public health profession provides a useful insight into the current concerns of public health professionals and into the general condition of public health as a profession.
The survey is worth reading. However, I think its message is quite different to the headline statements from the Faculty of Public Health and the BMA. They have chosen to focus on two areas of loss.
Loss of Independence and Loss of Medical Professionals.
“We are particularly concerned that over half of the people surveyed say they don’t have the freedom to speak out. That freedom has saved countless lives in the past when public heath leaders have spoken out, often going against the grain of popular opinion to do so.”
“This survey confirms what our members have been telling us for several years: public health specialists are very concerned that the new public health structures in England are a risk to people’s health. We know the system is working well in some places, but the number of professionals who are considering leaving the public health profession is one of many reasons for concern.”
John Ashton President of the Faculty of Public Health
John is supported here by Penelope Toff the BMA Public Health Committee Co-Chair
“Two thirds of doctors who responded are considering leaving the specialty and more than half of medical trainees are planning to move on.”
Lets have a look at these two questions in turn.
Q – “I have the professional independence I need to speak out on public health issues”
- Agree – 49.90%
- Neutral – 23.7%
- Disagree – 26.4%
Ok, it is possible from the above data to truthfully claim that less than 50% of public health professionals believe they have the professional independence to speak out, after all the figure is .1% below 50%.
But it is equally possible to say:
“Hooray! Twice as many public health professionals feel that they have the professional independence to speak out, compared to those who do not feel they can speak out”
Indeed if we were to put aside those who were neutral we could even claim that almost 2/3 of public health professionals who have an opinion about this feel that they do have the independence to speak out.
Q – Medics – have you considered leaving the profession in the past two years?
- Yes – frequently and or seriously – 25.7%
- Yes – it has crossed my mind – 34.7%
- No – 36.3%
So from these figures Melanie says 2/3 of medics have considered leaving the profession – presumably she has added together “frequently/seriously” and “its crossed my mind”.
Of course we don’t know how many people who said ‘yes’ have actually left the service and the single largest group are those who have never thought about leaving the service.
In the last 3 years it has ‘crossed my mind’ on a number of occasions that I might go and live on a canal boat, in a remote cottage, travel round the UK in a trawler etc – I have no intention of doing any of these things. (Yes, I know that some people reading this wish very sincerely that I had taken up one of these options.)
I think it is perfectly reasonable for people to indicate that leaving the profession has ‘crossed their mind’ and for them still to be generally happy and committed to their job.
More Survey Problems
Of course the survey has no base line either – so it is hard to know what public health professionals might have said when they were based in the NHS. I can still just about remember those happy days and there were plenty of public health professionals then who felt constrained by the bureaucratic and apolitical straightjacket of the NHS.
So we do not know what the variation is between present perceptions of independence and past perceptions when public health was in the NHS. That is of course what matters.
My favourite question has to be:
Q “In my local authority, the public health grant is not seen as a resource to be raided”
This is beauty! What a loaded question! This implies that some local authorities are being run by Highwaymen or Vikings – excellent! For those of us long in tooth I remember a constant complaint in the NHS was that there was no specific public health budget allocation at all – with any funds having to be fought for and protected every year.
For a good objective account of the current state of play in public health funding read the article by Gareth Iacobucci in the BMJ. In this there is a thoughtful response by John Middleton (Vice President of the Faculty of Public Health) who notes that:
“My (council) is no different (transferring money from the public health budget), although we are taking the opportunity to remould services in a more evidence based and public health focused approach … Its not wrong to apply public health funding to other areas, but some councils have just done it very crudely”
In the same article Duncan Selbie Chief Executive of Public Health England notes that:
“I welcome local government reviewing where the money has been spent. Local government is pretty advanced in looking at outcome based commissioning and of course they will be looking for more value….. the duty is to improve the public’s health, not to provide a public health service”
What is the real issue?
I think focusing on loss of independence and funding distracts from addressing a much more important and serious issue which I would suggest is something like this:
“How to develop a strong fit for purpose public health profession that is seen as relevant and useful to local government.” Importantly it also distracts from building on some of the strengths and positives that also come through this survey.
What the survey tells us
This is a profession in transition and as the introduction to the report on the survey notes – a divided one. It seems to me that non medical public health professionals and trainees in particular are generally more positive about how they view the future.
It also seem to me that there are quite large numbers often around 30% who are undecided about the present and future prospects for public health. In some ways this is fair enough – we are only one year into this transition.
There do seem to be as many concerns about Public Health England as there are about working with Local Government.
- This is a profession in transition, the Faculty in particular has to come to terms with a changing membership that is increasingly non-medical and recognise and represent their interests more.
- Public Health is still bedding into the new structures.
- Its not just about local government – if anything there are more fundamental concerns about Public Health England
- Trainees are generally positive about their future.
- Non Medics are positive about the future
- The independence of Directors of Public Health (whatever that means) is not under threat
- It is tough in public health – but that is no different to the experience of the rest of local government and the voluntary sector – there are common causes to be made.
It is really important to be working closely with local authorities to design a profession that works for them and not to try to impose the existing model onto them. It is particularly important build on and support those in the profession who are successfully establishing credible relationship within local authorities.
What do you think?