Foundation essay: This article on the state of mental health services is part of a series marking the launch of The Conversation in the UK. Our foundation essays are longer than our usual comment and analysis articles and take a wider look at key issues affecting society.
We’re 65 years into the NHS and mental health services are still the poor cousin in healthcare. We all - public, professionals, mental health service users - want and deserve better, but the reality is that services seem to be getting worse.
But despite recognition that physical and mental health are inextricably linked, the NHS still operates as if they were two different things.
A major report from the London School of Economics last year, written by a team of economists, doctors, psychologists and NHS managers, found that although mental illness accounted for nearly a half of all ill health experienced by people aged under 65, mental health receives only 13% of the NHS’s spend. And only a quarter of adults and children with mental health problems receive any treatment at all.
All talk, no substance
If anything, the response to people’s mental health conditions gets punier and more controlling. Services and support are deteriorating, while both the Labour party and the Coalition government compete with each other in their apparent aspirations.
Officially NHS funding is ringfenced, meaning it can’t be spent on anything else but health, but how come spending on mental services has fallen for the second year in succession – three times less in some areas than others - and is expected to fare worse in the future? For one thing local authority social care support is not ringfenced.
Talk to mental health service users and they paint a picture of less support, having to battle for what they have, charging and cuts in day services (which increases isolation), delays in getting help and tightening eligibility criteria to access local authority social care support.
Mental health services are already overstretched and many need treatment but can’t access services.
Problems of safety in services for women remain, for example the continued existence of mixed wards in in-patient psychiatric settings, which is notoriously problematic. Black and ethnic minority service users still also have inferior access to valued services and are more likely to be subject to controlling ones.
People with learning difficulties and older people continue to be poorly served by both mental health and physical care services.
Welfare and benefits reform
The damaging effects of current welfare reform policy also mean that mental health policy can no longer be considered in isolation. These reforms are increasing service users’ anxiety and insecurity, raising the risk of them losing what networks they do have. They are forced to move through arbitrary financial caps on housing benefit that bear no relation to local rents as well as losing disability and other benefits through arbitrary assessment processes.
Welfare reform has been particularly damaging to mental health service users because of the fluctuating nature of many conditions. And Work Capability Assessments, used to decide who is fit for work, have been designed in a way that can actively discriminate against mental health service users. This leaves people especially vulnerable and puts their mental health further at risk.
Ironically, as successive governments have pumped more money into the anti-stigma campaigns like Time to Change, they have ramped up the media campaign against mental health service users as benefits scroungers, increasing negative stereotypes and public hostility.
Personal health budgets
Personal health budgets, where people have more control over how and where they spend the money for their care through a voucher system, also offer some wonderful opportunities for mental health service users to get the support they want and escape the stigma of the psychiatric system. But they also run counter to the universalist principles of the NHS, held in such great store by patients and public alike.
There has been much less discussion of privatisation in the context of mental health as opposed to other NHS services, but companies like Virgin are already significantly involved in running mental health services and this is likely to have significant implications for the future. Patients on the receiving end are already expressing their anxieties about this development, particularly given their negative experiences in social care.
Recovery and ‘reablement’
Nor are bright new policy ideas necessarily working as they should. The emphasis on “recovery” was meant to improve life chances, but service users want better quality help to do this.
The associated emphasis on “reablement” has encouraged the idea of a conveyor belt of services, with support withdrawn when people are regarded as sufficiently recovered, when some need continued help to maintain their wellbeing.
The Improved Access to Psychological Therapies (IAPTs), which is meant to encourage access to talking therapies for people with common mental health issues such as anxiety and depression is a great idea. But the LSE study found that many local commissioners weren’t using the £400m government funding intended for to do this. Service users have also raised concerns that in practice IAPTs has sometimes resulted in over-mechanical, inadequately skilled and short-term help, narrowly based on Cognitive Behaviour Therapy (CBT), rather than a range of counselling services for different needs.
An emphasis on control, compulsion and detention seems to be increasing. “Disturbing levels” of physical constraint are reported as used on patients in hospitals.
Many patients are voluntary in name only, control has been extended into the community and there is increased use of community treatment orders; some service users report overly risk averse services and informal threats relating to their accommodation status or parenting rights.
Yet as one recent study shows most service users with experience of compulsory “treatment” thought it hindered rather than helped them.
At the heart of the problems in mental health policy is not just current political and economic difficulties, but the very concept of mental illness, which is still based on a narrow medical model. Service users increasingly report that they see such a model as stigmatising and unhelpful.
There is increasing interest in bio-genetic explanations and the search for genes that might be causing mental health conditions, like the so-called “schizophrenia gene”.
Yet so far this seem to offer little to help people in their daily lives. The diagnosis of schizophrenia is still widely disputed and the recent publication of DSM-5 (the Diagnostic Statistical Manual of Mental Disorders) seems only to signify increasing emphasis on converting social issues and human conditions into psychiatric disorders and private pathology.
The Hearing Voices Network and the international hearing voices movement have highlighted that there is a different and more helpful way of understanding and responding to people’s experience than reducing schizophrenia to a diagnostic category.
The medicalisation of mental health issues also seems to be unhelpfully linked with a continuing over-reliance on drug treatments. This is also associated with their increasing extension, both to children and to older people, including those living with dementia, as a means of control.
Traditional approaches not working
Traditional approaches to mental health are clearly not working. At the same time, there are some solutions. These crucially rest on developing more social-based approaches that help people hold on to and build new relationships, gain skills and confidence, and extend their opportunities - and linked with this, involving service users and their organisations much more fully throughout the process.
Governments have made rhetorical commitments to user involvement in mental health since the 1990s, but these have generally translated poorly into practice. Service users continue to highlight the importance of advocacy and increased control over their lives. They value support from other service users – true peer support – as well as user-led services developed by people with shared understanding and experience.
Sadly the user-led organisations that provide the basis for such policy are now increasingly insecure and under-funded, despite past commitments from governments to support the development of a national network of such local resources.
But regardless of the present longstanding negatives, an alternative future does beckon for mental health services and their users, or “psychiatric system survivors” as many actually prefer to call themselves. But it won’t be achieved just by injecting more money – however much that is needed - or offering more of the same.
What is required is a fundamental culture change. This means a culture that involves and and listens to service users as a central core, and which uses and encourages their strengths rather than constantly emphasising their pathology and weaknesses. Ironically, the government is now talking up such “co-production” across social policies. But let’s hope this is more than some of the rhetoric we’ve heard.