Through a glass darkly – inequalities, public health and NHS data on mental health
The NHS 5 Year Forward View gives a clear call for a re-balanced approach to prevention, clinical services, and community support and notes how important this is to help us tackle health inequalities and poor mental health.
But….those of those who are involved locally know that its all very well having the analysis and the aspiration – translating this into action is something else.
I want to focus on how our use of data shapes our approach to mental health and how this determines what we commission and provide – I think that this tends to leads us in one direction only – towards clinical solutions for social problems. We can see this in the report of the Independent Task Force on Mental Health to the NHS in England – although it recognises poverty as a significant driver for poor mental health its focus on inequalities is almost exclusively on ensuring equal access to clinical services – not on the social circumstances in which people with mental health problems live..
Lets look at the national data – because these set the tone for how we use data locally.
Problem One
The Public Health England Public Health Profiles do include mental health indicators – but they only have two. These are for quite specific issues – incidence of suicide and deaths from drug misuse. There is nothing on broader issues such as anxiety and depression.
Problem Two
We know about the relationship between poor mental health – anxiety, depression and inequalities but most of the measures that pick up on inequality in the Public Health Profiles do so at a county/borough/city level – so the extent of inequality is masked by those who are better off.
Problem Three
There are more detailed mental health indicators that are produced by Public Health England. Two that are particularly helpful are the Common Mental Health Disorders and the Severe Mental Illness Profiles.
There is a tremendous amount of detail in both of these – with an overwhelming emphasis on data from statutory clinical health services. However once again they fail to locate the incidence of anxiety and depression within the wider socio-economic context of a particular district. There is a section on ‘Risk Factors’ which is deprivation related. But I think that the scale of the issue here is masked by a wider population effect.
Problem Four
As I have said almost all the data in the mental health datasets looks at the performance of the Health and Care mental health system. This means that there is a constant pull back towards clinical interventions.
Yet as the APHO 2007 report “indications of public health in the english regions 7 mental health” notes we need to focus on the needs of those who experience inequality most – this means focussing on:
- Housing Insecurity
- Problematic Debt
- Low wage and insecure employment
- Take up of welfare rights support
- Social Isolation
While some of this data sit in a background document to the Mental Health profiles (cmhd indicator list v5 march-2016) each indicator is presented in isolation and so does not give a coherent picture of the negative social factors that people with mental health problems experience.
This failure to present a coherent narrative about the relationship between mental health and inequality means that local health and care systems lack the evidence that will help them make the significant changes that are needed to rebalance services to focus more on prevention and community support.
What needs to happen
- PHE and NHS England need to start to produce a data set that describes the scale of the risk factors that are faced by populations of people with poor mental health AND data sets that focus on the risk factors faced by people in the bottom 20% of the population by income – compared to those in the top 20%
- More work needs to be done to bring key voluntary sector data into these profiles. There is plenty of data out there – for example voluntary sector and social landlords have good data on housing insecurity, Citizens Advice and Stepchange have excellent data on incidence of indebtedness and so on.
The recent report “The Missing Link” from the Money and Mental Health Policy Institute notes that:
“The IAPT recovery rate for people experiencing both depression and financial difficulty is likely to be just 22%, compared to 55% for people without financial difficulties. For anxiety, the IAPT recovery rate is likely to be just 38% among those with financial difficulties, while over half of patients without financial difficulties recover through IAPT.
We found that an intervention on financial difficulty boosts the likelihood of recovery for an individual with depression and financial difficulties from 22% to 48% and for an individual with anxiety and financial difficulties the likelihood of recovery increases from 38% to 50%.
What do you think?
What this shows is that “mental health” is increasingly taken to mean “any unpleasant feeling”, such as sadness (depression) or fear (anxiety), whilst simultaneously decontextualizing it. So, once the context is considered, the feelings become meaningful, i.e. anxiety about life-destroying poverty with structural barriers in place that virtually guarantee life-long harm. Similarly with sadness – add in context and what looks like a “mental health problem”, becomes entirely understandable within the context, as does the outcome connected to the help offered.
It is indeed difficult to imagine how much worse the impact of structural inequality on communities needs to get before we see data – and the action that needs to follow it on this, converging with MH data. In truth though, this is as much, or more, about the time (dis) honoured tradition of MH services being called upon to be the repository for the too contentious outcomes of a failed politics. We need a response in MH that resists this and the endless creep of ordinary life pathologisation that accompanies it.
Question: how do we know that the policy makers, researchers and government officials have good mental health? If you have been inside the mental health system you will have a radically different view of the question. It is the dark glasses that become removed. https://woodenhenkblog.com/tag/twin-towers/
Firstly I think you’re spot on but the issues you raise are ‘political’. They presuppose a genuine desire to address the issue. I don’t believe that exists.
The solutions require a joined up approach which won’t happen in a fragmented system. What is being measured and acted upon is what has been made important by the inability/unwillingness to measure and act upon what would provide the data to really support and frame solutions to the problem. Suffice to say, really addressing these issues requires political will and I’m not seeing that.
Thanks for the comment Nathan – I agree the issues are ‘political’ however, I think that there is sufficient flex in big systems like Public Health England or NHS England to allow decision makers there to at least start to identify some of the dissonances in the current approach and to invest in agencies (outside government) that will bring a degree of challenge.
Therefore we should have expectations with regard to the role those clinicians and policy makers in bureaucracies should play.
For example look at the the role that Simon Stevens is playing at the moment to advocate for more funding for the NHS. Pragmatically, I suppose I just want to validate and encourage challenge in the system – in reality much of this comes from external players like the voluntary and charitable sector (Money and Mental Health Policy Unit, Joseph Rowntree, Resolution Foundation etc). However, I also know that there are many officers often at a middle management level who are looking for evidence and alliances to progress the agenda we are talking about.
Its a long term game!
All the best – Mark
I hope you’re right Mark about those in the system(s) being willing and able to contribute to the long term process you refer to. It does seem to be a case of organisations linked to but outside of the system collecting robust and rigorous evidence as several have done with Universal Credit. It is interesting (well that’s one word for it) just how evidence proof so many people actually are! I appreciate it’s a long game, the problem is so many suffer during the process and in the long run well, we are all dead. To end on a more positive note, persistence often wins out 🙂