Is that all there is? – Five Year Forward View for Mental Health
When a system is under pressure a natural tendency is to focus inward at precisely the time it needs to be looking outwards. So its not surprising that this report focusses almost exclusively on the NHS.
The Independent Mental Health Taskforce to the NHS in England report is a determined attempt to raise the profile of mental health services and in particular contribute to action that drives parity of esteem for mental health.
The foreword says:
“we have placed a particular focus on tackling inequalities. Mental health problems disproportionately affect people living in poverty, those who are unemployed and who already face discrimination. For too many, especially black, Asian and minority ethnic people, their first experience of mental health care comes when they are detained under the Mental Health Act, often with police involvement, followed by a long stay in hospital. To truly address this, we have to tackle inequalities at local and national level. ”
The problem is when I look through the report I cannot find this ‘particular focus’.
Inequality
The report does say that inequality is a major cause of poor mental health:
- People with mental health problems are overrepresented in high turnover, low pay and often part time or temporary work.
- Children from low income families are are 3 times more likely to be at risk.
- Children living in poor housing have increased chances of experiencing stress, anxiety and depression
- People in marginalised groups are at greater risk – especially people from black and minority ethnic communities
- As many as nine out of ten people in prison have a mental health, drug or alcohol problem
System Failure
The report does make the case for system failure:
- Three quarters of people with mental health problems receive no support at all
- There is wide variation in access to services such as IAPT – with waits of 6 to 124 days
- 20% of people on the Care Programme Approach have not had a formal review in the previous 12 months
- Mental Health accounts for 23% of all NHS activity but spending on secondary mental health services is equivalent to just half of this.
An argument for funding for NHS providers
The recommendations largely miss out on the root causes of inequality and primary prevention and instead focus on the system at the end of the line – the NHS – social care is poorly represented in the report.
There are almost 60 recommendations. With the majority concerned with local operational matters – how services are delivered, yet the report speaks primarily to NHSE rather than local health and care systems.
I am not saying that this huge wodge of recommendations are bad – but I think the commission ended up not seeing the wood for the trees – it has produced a plan that is about operational change rather than system transformation.
Missing the point
Inequality – The report is unclear about inequality – there is no challenge to how government policy risks exacerbating inequality. Although many of the examples it gives in the introduction are about how societal inequality increases the likelihood of poor mental health. The few actions that explicitly reference inequalities focus on the unequal way in which people who have mental health problems are treated and how some groups of people with mental health problems such as some minority ethnic communities and people who have been in prison are not treated equally.
Community – Locally the role of community organisations, social prescribing etc is increasingly understood yet the VCS barely scrapes into the report – I spotted one explicit reference with regard to navigators. It is unfortunate that the important contribution that local Healthwatch are increasingly making as positive disruptors in local systems is not affirmed. If there is one area of social policy that needs strong ongoing disruption it is mental health. The need for public and user experience is briefly recognised but needs to be much stronger if real and sustainable change is to occur.
Social Determinants – When the social determinants of health are mentioned it is only within the context of secondary prevention – supported housing and employment support. Of course this is important but we know that the NHS and Social Care are increasingly being used to pick up the fall out from wider government policy attacks on the vulnerable – particularly with regard to changes in the benefit system and housing provision. There is no mention of the prevalence of indebtedness among people with a psychosis despite the strong evidence base to support this.
Money – Others are more expert than me here – but I am not convinced that the £1bn asked for and apparently promised by the Government is close to being sufficient. Tactically the report should at least have called for more funding than it thought the government was likely to give!
What next
- Local Health and Care systems must ensure that the recommendations and focus of this report are understood to be only a small part of the discussion they need to have locally. It is crucial that the role of Housing Providers, Citizens as advocates, Social Care, Employment Support, Access to Education and communities themselves is also included.
- There remains an urgent need for a more holistic mental health strategy that recognises the crucial role of the social determinants of health
What do you think?
I want to disagree but can’t. Arguments spot on. System failure and the drivers of inequalities in mental health untouched. Indebtedness and mental health also noted. Damn but you are so right. Damn but we are failing so many people in the name of austerity.
Spot on Mark – in my view one of your most apposite blogs ever – the pity is that we have been shooting at these same barn doors for years. As Simon Rippon and I reiterated in ‘Head, hands and heart’ “Poor mental wellbeing is both a cause and a consequence of inequality and health inequity.
The report recognises the causal/consequential links between mental health/wellbeing and physical health. But this is nothing new – this ground that has been well covered by Lynne Friedli and many others over the years.
As you state, the real problem is that the recommendations nearly all suggest action through existing systems and organisations. The very ones that have created these problems in the first place. To rush for an Einstein quote as I am won’t to do: “We can’t solve problems by using the same kind of thinking we used when we created them.”
None of the organisations listed in the recommendations, both local and national, were set up, or have a remit for ‘system transformation’. As you correctly observe Mark, their remit, perhaps their obsession, is with piecemeal and unconnected operational change.
Fundamentally the problem is that the majority think that the NHS is, in essence, a ‘good thing’ perhaps even ‘the best thing.’ As Nigel Lawson famously wrote in 1993 “The National Health Service is the closest thing the English have to a religion, with those who practise in it regarding themselves as a priesthood. This made it quite extraordinarily difficult to reform.” (and who would have thought I’d ever quote Nigel Lawson to back up my point)
In challenging this and calling for ‘system transformation’ I suggest that we are not shooting at barn doors but banging our heads on a brick wall.
Oww!