Too weak on inequality – Chief Medical Officer Report on Public Mental Health

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?