Beyond The Ballot is The Huffington Post UK's alternative take on the General Election, taking on the issues too awkward for Westminster. It focuses on the unanswered questions around internet freedom, mental health and housing. Election news, blogs, polls and predictions are combined with in-depth coverage of our three issues including roundtable debates, MP interviews and analysis.
The three main parties have all mentioned mental health far more in their manifestos than they did in 2010, and a change in attitudes has been palpable. The government has given funding to The Time For Change campaign to fight stigma, and in this parliament, MPs have even come out about their own mental health issues. But according to a panel of experts and campaigners assembled for a Huffington Post UK roundtable debate on the future of mental health policy in Britain, there's still been far too much "talk" and not enough action.
Contributors to the roundtable have claimed the current pigeonholing of people as having either a physical or mental condition, is creating a notion of treatment that is biased against mental health, and what is actually needed, is a holistic approach to care of both.
And the panel, which included The Centre for Mental Health’s Andy Bell and Mind’s parliamentary manager Louise Rubin, said spending more and better on mental health did not have to mean spending less on physical health.
The panel also included two people with personal experiences of mental health in very different ways. Marcia Rigg’s whose brother Sean Rigg suffered from schizophrenia and died in police custody in 2008. Before his detention by the police, he had already been failed by other parts of the system. Marcia Rigg now campaigns for reform with her Sean Rigg Justice & Change Campaign. Shalini Bhalla was diagnosed with depression and sought treatment at The Priory. She teaches mindfulness and speaks about her own experience and recovery.
During our discussion, the panel recommended:
- A more holistic approach: Physical and mental health should not be treated or thought of separately, as one can cause the other and health services are too quick to designate people as physically or mentally unwell
- Targets: There needs to be more accountability for delivering mental health services as the current setup lacks targets on wellbeing and local agencies can ignore national calls for more focus on the issue
- Leadership from national government and the media: While there had been progress in ending stigma around mental health but events, education is needed within the schooling system to end the mental health stereotypes 'embedded in our culture'
- A national plan: Establish a strategy on wellbeing and prevention of mental health conditions
- Legislation: Changes to the law so that children cannot be held in police cells after being detained under the Mental Health Act
Why bringing mental health and physical health together would benefit both
Rubin said the last five years had seen “a lot of positive police announcements but not much action on the ground”. Politicians appear to have woken up to the fact there could be votes in talking about mental health. The manifestos of the three main parties, published after our roundtable, all discuss mental health. In particular, they all pledge to expand the availability of talking therapy, something people with long memories will remember them pledging in their manifestos in 2010. Pledging to expand something in a manifesto inevitably triggers questions about where the money would come from, especially in this economy. But Bell, from the Centre for Mental Health, said dividing physical and mental health into two areas was a false economy.
“Reinvesting money in mental health doesn't mean taking money away from physical health,” he said. “A great example is lots of hospitals now have liaison mental health teams, they provide support in any part of the hospital - people coming into A&E who clearly have a mental health need, somebody in a bed who's experiencing poor mental health as well as whatever condition they're in the hospital for.
"Research has shown that those services improve people's experience of the health care system as a whole and allow the hospital to reduce the number of beds because people are not being admitted so often from A&E and they go home quicker, which is what most of us want to do. So actually you improve people's health overall by taking a more holistic approach. You save money.”
Rubin said the separation had “really dire consequences” on the physical health of people of people diagnosed with mental health conditions. She said: “One of the most shocking statistics that's out there is that people with mental health problems can expect to die on average up to 20 years earlier than people without and that's because we're not looking after their physical health.
“They’re told: 'These are the mental health specialists, this is the mental health building, don't worry about the fact you smoke and your medication causing you to put on weight, don't worry about the possible cancer side-effects, and so on, we'll just look at your mental health'. That needs to stop. People are whole people.”
Bhalla described how a loved one was recently diagnosed with cancer and, while he received “brilliant” support for his physical needs, none of the surgeons or nurses asked how it was making him feel or how the family was coping. “Nobody ever asked that proactively. That's such a small thing, that doesn't cost money. A nurse just needs to know to ask that question,” he says.
Bell said the problem goes both ways - saying there was a “curse of low expectation” in which people presumed those with mental problems would inevitably by physically unwell.
“People with severe mental illness have very, very poor support for their physical health programme. Smoking cessation support [should be] offered more proactively with people living with schizophrenia and bi-polar disorder, for example,” he said. “So it's not just simply a case of taking money out of one bit of the system and putting it another. It's about using our money better and within mental health we have to spend our money better.”
This is easier said than done. Under the last government, the NHS went through a drastic reorganisation. Going through another one would be daunting. But, Bell said the financial benefits are obvious with around 13% of the overall NHS budget going on mental health and another 13% going on extra physical health care for people with long-term conditions, such as diabetes, “whose poor mental health is affecting their physical health very seriously”.
“So actually by reinvesting in some mental health support for those groups of people that are currently experiencing poor physical and mental health we can make the system work better as a whole and improve people's lived markedly,” he added.
What would parity of esteem actually look like?
The panel said the ultimate goal for mental health reformers is parity of esteem. When asked by HuffPost UK what the next government most needed to commit to, Tory backbencher and mental health reform advocate Sarah Wollaston said 'parity of esteem', without hesitating. The Tory manifesto this year seems to think it has already been achieved, saying: “We have legislated to ensure that mental and physical health conditions are given equal priority.”
This parity of esteem was enshrined in the Health and Social Care Act, the legislation that fundamentally reorganised the NHS under this government. But, as Sarah Wollaston told HuffPost UK, this has yet to be realised on the ground.
Bell said the reorganisation of the NHS had actually meant less was being spent on mental health. “The government said it wanted local clinical commissioning groups, the people now responsible for most NHS funding, to treat mental health services more fairly, and on the whole, most clinical commissioning groups (CCGs) did exactly the opposite and took money out, particularly in some of the most important areas like children,” he said.
For Bhalla, parity of esteem means a change of the type that physical diseases, such as breast cancer, underwent. “Nobody used to talk about it before, now people are talking about it, the funding is there for it, they raise a lot of money for it. The numbers [of people dying] have really, really dropped,” she said.
“It's something a lot people can get over, because the treatment is there. The research is there, the money's behind it. If we could have something similar with mental health issues, that's what I'd be looking at...that's where I'd see parity of esteem.”
The panel also pointed out that the NHS constitution does not explicitly give patients a right to psychological therapy, though it does give the right to “drugs and treatments” approved by the National Institute For Health And Care Intelligence (NICE). Rubin said: “NHS constitution quite a good place to start with this. If we all know what we can expect and there's a constitutional backing for that. That would help. To be fair to the current government, some of that work has started.”
The ‘extraordinary’ lack of accountability within mental health
The panel discussed two different types of accountability that were missing from mental health: Culpability for when the systems fails fatally, and what standards local mental health services should meet.
Bell said the “extraordinary” lack of accountability was reflected by the CCGs cutting their spending on mental health without sanction from central government. He also claimed there was now less accountability with schools.
He said: “We know that schools are desperate to support mental health better and they know they're not good. But one of the requirements previously that Ofsted looked at to see how schools were supporting wellbeing was taken away... If we're serious about creating fairness for mental health, and fairer life chances, actually a little bit of accountability would go quite a long way.
He added: “I think we fundamentally lack a way of ensuring a way that decisions are made on the ground that reflects some of the good policies, we've developed."
Rigg’s brother Sean died at Brixton Police Station after prolonged restraint by police. After repeated investigations, which saw the police watchdog accused of making many blunders, no officer involved was prosecuted.
She sees a lack of accountability for those who die while in mental health care or state custody. “For instance, if somebody died in psychiatric unit. There's not an independent body to investigate what happened there. It's all done in-house. That can create all sorts of problems, where there's cover up and certain documents go missing, because it does happen, there needs to be transparency and independent people monitoring all the stake agencies to see exactly what's happening,” she said.
The charity Inquest, which campaigns for the families of people who die in state custody, released a report earlier this year that called for such a body. It said: “Independent investigations of deaths in mental health settings may well have resource implications. However, if this reform were to lead to safer practice and fewer deaths, it would be a price worth paying.”
Rigg added: “They're an independent charity that looks at these deaths. They've shown the patterns that happen, it's not isolated. The patterns are re-occurring, time and time again for decades so, where actually are the resources going? Where is the funding going?”
How do we overcome the stigma that sits at the heart of the 'contradiction' in our views on mental health?
Days before the roundtable took place, Germanwings flight 9525 crashed in the French alps, killing 150 people. Co-pilot Andreas Lubitz was blamed for deliberately bringing the plane down and was reported to have been suffering from depression. We saw a raft of headlines that demonised the illness.
Bell says there has been progress in overcoming stigma. A poll for HuffPost UK found 84% of Britons regard depression as an illness needing treatment like any other. But Bell said the Germanwings crash showed how the progress fighting stigma could be pushed back. “I think what we've seen recently is you can make lots of bits and pieces and progress but then you can pushed back very suddenly by something terrible happening.”
Bhalla called out the press for “sensational headlines”, saying: “It was really important that charities like Mind came out with statements saying ‘actually you can't oversimplify issues like depression and mental health issues’. [The press should] stop writing these sensationalist headlines because, all you're doing is further stigmatising this whole issue. The media need to take some responsibility. It's all about selling newspapers to them but they're playing with people's lives.”
Rubin said this tweet that “crystalised the contradiction” in our views on mental health and how it affects people in the workplace.
She said: “The headlines in relation to the Germanwings story, where he [the pilot] had depression, 'why on earth was he allowed to work?' When you compared that to some of the headlines about benefits claimants, 'Of course they can work, they're scroungers, they're lazy,' there's such a contradiction there.
“People have just mixed views about depression and mental health problems and what it means. I think that comes down to a real lack of understanding and perhaps a willingness on the part of the media to fuel that, to sell papers.”
She praised the government for helping fund the Time For Change anti-stigma campaign run by Mind and another charity Rethink Mental Illness. She said it had been “fantastically successful about opening up the conversation”. The campaign conducts an annual survey of attitudes to mental health and claims to have seen significant increases in people saying they would ‘work with someone with a mental health problem’ (an increase from 69% to 76% in one year) and ‘continue a relationship with a friend who had a mental health problem’ (up from 82% to 88% in the same period. But the Department for Health funding ran out at the end of March. One of Mind’s general election campaign requests is for the the government to resume it.
“Changing attitudes the work of a generation, when you look at other attitudes that we've managed to change, towards sexuality or women, it doesn't happen overnight,” Rubin said. “We've seen the numbers of people who are willing to come out just go through the roof in that time.
“It's quite a straightforward message. You don't need to be an expert to talk about mental health. But you can ask people how they're doing. When they come back don't shy away from asking them, ask them how they are.”
Bell said national government had to “lead from the front” on fighting stigma and fight the “drip-drip-drip demonisation” of the mentally ill. “I hope we see the next government avoiding the temptation to demean and belittle people, receiving benefits for example and people who have depression who are unable to work.”
He also said schools needed to be given a different approach to mental health to help fight the stigma in the minds of the young. “I think takes a lot of work because we have to not go back on these easy prejudices that are embedded in our culture,” he added. “It's not easy and it will take ages but I think what we've seen recently is you can make lots of bits and pieces and progress but then you can pushed back very suddenly by something terrible happening. We just need to be sure we're not letting those thing that push us back, beat us, we just need to keep going.”
Can we expect people on the frontline to recognise every mental health condition?
When Sean Rigg was picked up by the police in 2008, the warning signs about his health were not picked up on by officers.
The case illustrates a recurring pattern - mental health conditions can be either unnoticed or misunderstood by those trying to deal with or help the individual. People with mental health issues can enter the public sector at different levels - those in crisis can be picked up by paramedics or the police who have never met them and may not realise what is wrong.
Marcia Rigg said a big obstacle to caring for her brother was confidentiality. He would leave the country without telling relatives and be picked up the authorities abroad, who knew nothing about his medical history. The mental health team did not tell the families about his movements or whether he was taking medication.
"Not being able to interact properly with the mental health care team... their stance was that each person has the right to their information being kept confidential unless given consent, which I completely understand," she said. "But with a person with mental health what happens when they don't have the capacity to make that judgement themselves? It's absolutely vital that the carers and families are completely involved in the mental health care."
She added: "If Sean was not taking his medication, which is something that's a re-occurring aspect of mental health... because of side effects, because they're trying to ween themselves off. Sean had a pattern...the mental health team wouldn't contact the family to say 'I don't think Sean's taking his medication. Could you encourage him?' There's always trust in a family... That was something they wouldn't have thought."
But with the sheer breadth of conditions, can we expect every person with a professional duty of care to others to recognise when someone is mentally ill?
Bhalla said it might be too much to expect them all to have comprehensive knowledge of mental health, but "some understanding and some training" was not a big ask.
She said: "Look at any workplace, you always have a first aid person and they're trained to look at physical issues that can come up if somebody collapses. So why not have that same kind of training for mental health issues. You have dedicated people who have got that training, and there is that training out there, it's just that not many employers know about it. Starting with small steps like that is going to make a big difference, not detailed but at least they have to have an understanding in how to deal with it."
Bell pointed to research the Centre For Mental Health had conducted with the London School of Economics on womens' mental health during pregnancy, which highlighted the extent to which women went to hide any symptoms of depression and the "shocking" lack of confidence doctors and nurses had in dealing with it. It estimated perinatal mental health cost the British economy around £8 billion a year.
"Teachers, are not trained in child development, a minority of GPs get training as part of their basic training, I think we can go an enormous way by improving the quality of education we give to people in frontline professional roles, ensuring they really understand it from the people with lived experience," he said.
"Because you can't see what's happening in the mind, that makes it harder for people and I think people start to handle these illnesses with kid gloves, they don't want to talk about it, because they're so scared of offending. But actually, some people just want you to ask the questions, if you know the questions to ask and get that information out, that's really important.
"We're still talking about them separately and I think we should be a lot further down the line."
Bell added that, however well trained police officers become, children with mental health issues should not be detained and held in police cells.
"There were some good proposals quite recently to outlaw children being placed in police cells as a place of safety... I think it's really important that, whoever's in government, implements that and makes that change," he added.
Rubin said the disparity between how much we esteem physical and mental health was a key factor in why people with mental health issues can enter public sector care in such different ways, often while in crisis. She discussed a man whom Mind has worked whose experience showed the contrast.
"When he had a heart attack, he phoned an ambulance, which was there, within four to five minutes, he was given all the treatment he needed, he was in hospital the next day, scanned and so on. But when he felt suicidal and he tried to get help, he was told 'can you call back tomorrow? The teams are busy at the moment’. That difference in the way people are treated that leads to these situations where people are forced to be picked up by the police or other services," she said.
"If we were to intervene much earlier and treat a mental health crisis as we treat a physical health crisis... I think that's the heart of the issue."
The recommendations:
- A more holistic approach: Physical and mental health should not be treated or thought of separately, as one can cause the other and health services are too quick to designate people as physically or mentally unwell
- Targets: There needs to be more accountability for delivering mental health services as the current setup lacks targets on wellbeing and local agencies can ignore national calls for more focus on the issue
- Leadership from national government and the media: While there had been progress in ending stigma around mental health but events, education is needed within the schooling system to end the mental health stereotypes 'embedded in our culture'
- A national plan: Establish a strategy on wellbeing and prevention of mental health conditions
- Legislation: Changes to the law so that children cannot be held in police cells after being detained under the Mental Health Act
MIND THE GAP:
Sarah Wollaston Says The Tories Should 'Scotch The Myth' They Don't Care About Mental Health
What We Need Is a Culture Change in Attitudes Towards Mental Health, Marcia Rigg Blogs
NHS 'Not Prepared' To Deal With Depression, Vast Majority Of MPs Say
It's Time To Shout About Mental Health - Alastair Campbell Blogs For Beyond The Ballot
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