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Earlier this year, the first ever cross-government mental health strategy was launched, laying out plans for the future of mental health care in England (1). The Government has recognised the crucial fact that mental health is not simply a Department of Health issue in isolation, but that mental health affects every area of a person’s life and impacts upon their ability to play an active role in society. The strategy, however, is woolly, uncosted and lacks an implementation plan. The overarching theme of the strategy represents a misguided, somewhat soft-headed, utopianism focused on wellbeing and mental good health, as though there was a direct connection between a happy society and reduction in serious mental illness. But there is not. Events and circumstances, often unavoidable, play a significant part in the origins of serious disorders but only a part, and often a very small part. This personal perspective article criticises the Government for failing to focus on the profound level of unmet service needs of people with serious mental illness. The NHS and local authorities need a strategy that aims to change for the better the lives of people with serious enduring mental illness and their families, not a recipe book for improving national wellbeing.

The broader public health issue of the mental wellbeing of individuals and society and the aim to intervene to prevent the experience of distress are of course legitimate national strategic objectives. It is undoubtedly true that the toll of emotional human misery and minor psychiatric morbidity costs England £105 billion every year and that this burden spreads beyond health services to education, employers, the social security benefits system, housing, the criminal justice system, and to families and communities (2). National wellbeing should influence our approach to economics and it is entirely legitimate to try to intervene to promote good mental wellbeing. But I have grave doubts whether this should be the target of a mental health document that will largely be read by health and social care providers.

The strategy includes a renewed commitment to the widespread availability of psychological therapies and, in particular, extends access to these therapies to children and to young people. There has long been a need to improve access to psychological therapies for those with serious ongoing mental ill health, who tend to get medications and little else but there is almost no evidence that wholesale availability of taking treatments to the wider population will alleviate the nation’s problems. The campaigning journalist Marjorie Wallace from the families organisation, SANE rightly complains that this ‘therapy for the nation’ strategy is being touted as a panacea for the whole spectrum of mental health conditions, but is being launched against a background of active planning to save £20bn from the NHS, with Local Authorities shamelessly slashing and burning community services for people with mental health problems. The SANE articulates the complaints of many local voluntary organisations that worryingly disturbed people are being turned away from help, especially from in-patient care, when they feel desperate or they and their families have reached crisis point. Mental Health Services are still not always getting it right for seriously ill people and their families and we need a strategy that does.

The public health outcomes framework in this document seems to me mostly aspirational wishful thinking. It includes everything from reducing re-offending and self-harm all the way through to access to green spaces and, I quote, ‘improving social connectedness’, whatever that is….a Facebook account for all? Aspirational and idealistic but this has nothing to do with mental ill health realities. The prevention strategy focuses heavily on early interventions with children and young people. What we do know from the US and our experience in the UK is that social interventions that make a difference to the mental wellbeing of children and young people have to be comprehensive, very focused, usually costly and require major changes in the way services are organised. Successful pilot schemes have been exceptionally difficult to migrate internationally and replicate on a large national scale while maintaining fidelity to the original model. The Government’s own accompanying policy document ‘Mental Health Promotion and Mental Illness Prevention: the Economic Case’ is eloquent about the possible savings in economic terms and about the reduction of harm and distress, if the proposed interventions should work, but the editors also introduce a cautionary note in the preamble about the lack of data and on the difficulties of the economic modelling (3). The editors emphasise that, the fact that there was inadequate evidence to model some of these interventions, does not necessarily mean that they are not cost-effective, merely that the evidence was lacking. It is not an encouraging document when read in its entirety.

It is a waste of time to do a little bit of intervention with individuals and families and yet there is a real danger that, that is what we will do when resources are tight. Let us examine, for example, the practicalities of intervening to prevent maternal depression. There is modest evidence for the efficacy of preventive interventions; home visiting, parenting programmes and peer support; refocused Sure Start children’s centres; parent support advisers working with school staff and local services to help families to overcome the problems they face. Then, there are other family support workers, such as health visitors or early year’s outreach workers, a veritable army of helpers and workers of one sort or another. Then, there are approaches such as, the Family Nurse Partnership Programme, which works intensively with the most disadvantaged young families with complex, interlinked problems aimed at interrupting the trans-generational cycle of poor health (4). There is positive evidence for the latter’s efficacy from Colorado and the UK too and at least the Government is committed to rigorous evaluation. The Government has pledged to increase the health visitor workforce by a further 4,200 posts refocusing health visitors on maternal and infant mental health. But the overall evidence for the efficacy of health visitors in improving child health has been slight in the past. The NICE report based on an earlier Health Development Agency’s review of the evidence did not give much comfort in the area of home visiting and has recently been withdrawn from the NICE website while the guidance ‘is reviewed by Ministers’. The research base is small scale and modest; some of it is encouraging but not sufficient to justify millions of pounds worth of investments in expanding the army yet further.

To support these and other programmes, the Government has introduced a new area-based Early Intervention Grant (EIG) that will bring together funding for a number of early intervention and preventative services, including Sure Start children’s centres (5). In these straightened times, it remains unlikely that there will be huge amounts to implement these programmes effectively across the country. The current reality is that funding for intervention programmes in England, such as teenage pregnancy and youth crime support, is to be cut. While the new single grant gives local authorities, greater flexibility to spend on local priorities, and that is surely sensible, the overall amount that will be allocated through EIG will be nearly 11% lower in 2011–2012 than the aggregated funding for 2010–2011 with a further major drop in the following year. An extra £400 million advertised by the Department of Health for psychological therapies is simply a ‘notional sum’ identified in the baseline funding of the NHS. It seems highly unlikely that it will be spent in the suggested fashion, given the context of the £20 billion cost improvements in the NHS and I would be sympathetic to commissioners, who felt that there were better evidence-based interventions to purchase in mental health.

A mental health strategy should focus primarily on those with the most severe disorders whose lives are so often wrecked by the misery of mental illness. It has to be fit for the purpose of being translated into measurable outcomes for the Commissioning Board and turned easily into commissioning intentions by GP consortia. At present, GPs lack confidence in commissioning mental health services. The charity Rethink survey in last year found that whereas three quarters of GPs say, they feel confident to take responsibility for diabetes and asthma services, fewer than a third (31%) felt the same for mental health services (6). The GPs will need change for the better in specialist services. But they need a small number of clear measurable outcomes to work with. The Mental Health network of the NHS Confederation has done some good work in collaboration with the pathfinder consortia but this has now to be generalised nationwide. We need a costed, detailed strategy built around realistic measurable outcomes for the morbidity and mortality of our most difficult and distressed patients.

References

  1. Top of page
  2. Disclosures
  3. References
  • 1
    HMG/DH. No Health without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. London. 2 February 2011. Gateway reference: 14679.
  • 2
    Sainsbury Centre for Mental Health. The Economic and Social Costs of Mental Illness. 2003. Policy paper: 3.
  • 3
    Knapp M, McDaid D, Parsonage M, eds. ‘Mental Health Promotion and Mental Illness Prevention: the Economic Case. Department of Health, London. 2011. Gateway reference: 15972.
  • 4
    Department of Health. The Family Nurse Partnership Programme. 2009. Gateway reference: 14671
  • 5
    Department of Education. Early Intervention Grant Determination 2011–12 [No31/1879]. 2011.
  • 6
    White Paper to Hand Mental Health Commissioning to Gps, but Most Don't Have Necessary Expertise. http://www.rethink.org/how_we_can_help/news_-and_media/index.html (accessed July 2010).