This year’s World Mental Health Day is about investment in mental health – a fitting but challenging message for governments and communities around the world who face the human and societal repercussions of economic downturn and its associated austerity measures.
One in four will experience mental health illness in their lifetime, and last week the CIPD published research showing that stress is now the most common cause of long-term sickness absence for both manual and non-manual employees. Mind’s It’s time to act on mental health at work campaign challenges employers to introduce supportive policies and practices for a more productive workforce. A seemingly tough sell in the boardroom, policy makers have also been slow to respond to the increasing demand for mental health services and support. The Coalition has attempted to redress mental health’s ‘cinderella’ status through the swift publication of No health without mental health,the second outcomes strategy to be developed after cancer.
The aims of the strategy are to intervene early to promote good mental health, challenge the stigma associated with mental illness, and improve the outcomes of people with mental health problems through faster access to high quality services. Today Minister of State for Health, Paul Burstow MP may feel at ease explaining the cornerstone of the Government’s approach – an investment of £400 million over the next four years to make choice of psychological therapies available to all those who need it, and £16m on tackling stigma and discrimination through the Time to Changecampaign – but what lies beneath the headline friendly funding pledges?
Improving Access to Psychological Therapies (IAPT) was launched under the Labour administration and uses interventions approved by NICE to treat people with depression and anxiety, including computerised cognitive behavioural therapy like Beating the Blues. IAPT has all the hallmarks of an initiative that deserves investment – timely services provided early to prevent escalation of mental health conditions and manage symptoms in communities rather than in expensive acute settings. Widespread roll-out proved challenging perhaps (Burstow will hope) due to insufficient prioritisation and funding.
Commissioners should take heed of the recent IAPT impact report from the NHS Information Centre which showed significant variation in the recovery rate for patients receiving counselling interventions. Despite the important contribution of talking therapies, there is a bigger picture, and commissioners will need to ensure that services are attuned to the breadth of individual needs within the local population. The outcomes strategy itself is short on detail about specialist provision, and could say more about the role of psychological, psychiatric and pharmacological interventions that form part of a complete package of care and support. Rethink’s recent relaunch as Rethink Mental Illness reflects the need to differentiate more clearly about mental health and ensure that specialist services for people with complex mental illness are both safeguarded and enhanced as the reforms – and cuts – play out.
The NHS reform agenda creates other opportunities to prioritise the needs of people with serious mental illness. A number of mental health conditions including schizophrenia and bi-polar disorder are included within the library of topics to be developed as quality standards. Meanwhile the national outcomes frameworks recognise the heightened risk of physical ill health caused by mental illness through the measurement of premature deaths (domain one in the NHS Outcomes Framework and smoking rates (domain four in the Public Health Outcomes Framework consultation paper)
Beyond the levers for quality improvement that affect the behaviour of commissioners and providers, how will the demand-side drivers work for people with mental health problems? The ‘no decision about me, without me’ reform mantra has already begun to feel tired, and is yet to be tried out in the context of the NHS changes. In doing so, there will be difficult questions about how choice can be made meaningful for people with a mental illness.
It is a common criticism of the reforms that choice will exist only for those who are informed, assertive and engaged enough to exercise it. As someone who has accessed mental health services on behalf of a friend, patience and tenacity were essential – both in getting a referral and timely follow-up appointments, and in providing encouragement and support to a reluctant user of services. Mental illness by its very nature is not always conducive to self-help, and additional support and understanding is often required to bring a better way of life within reach.
This is an important lesson for user involvement. Patients need to be well-supported to enable shared decision-making. This requires cultural change within NHS services, but also time, patience, and effective advocacy at every step. Meanwhile commissioners must look to draw on the insights and experiences of mental health service users as a priority, facilitated by mental health charities– another practical example of the growing demands on the Big Society.
Mental health needs reach into all corners of public service provision – health, public health, housing, education, welfare, criminal justice, and social care. Hopes are pinned on local authorities and Health and Wellbeing Boards to identify local needs and to stimulate an integrated commissioning response that satisfies the needs of people with, or at risk of, mental health illness, and realises savings beyond organisational boundaries. Our recent research shows varying degrees of preparedness for this task. There is no doubt that mental illness presents a major test of the reforms – marked improvements in the outcomes and experiences of people with mental health issues will be an important measure of their success.