Are we nearly there yet?
Can mental health policy ever deliver its objectives?
Published by Helen Johnson on Monday, August 15, 2011
This was the bold claim made by the Secretary of State, Andrew Lansley MP, in the Coalition Government’s mental health strategy paper, No Health, Without Mental Health (NHWMH) published in February 2011. The ambition of this latest strategy is to mainstream mental health provision and care and achieve “parity of esteem”2 with physical health. Pressure is now being placed on the Department of Health by mental health managers, namely Steve Shrubb, director of Mental Health Network3, to clarify how NHWMH will be implemented. In the two years since our last article4 on mental health policy, much has changed in politics. The Labour party suffered its worst electoral defeat since 1983 and the first full coalition government since 1945 was formed between the Conservative and Liberal Democrat parties. Given Lansley’s bold claim, it seems appropriate to review whether recent developments in mental health policy have been similarly momentous over that period.
Since July 2010, a series of papers have been published by the Department of Health (DH) under the guidance of Lansley, designed to reform the NHS and “liberate” it from Whitehall control. At the time of writing, the Health and Social Care Bill has just concluded its second Commons Committee stage following recommendations from the NHS Future Forum, and the political battle for the title of “defender of the NHS” rages on. The fierce debate over the principles of healthcare and who should provide it has overshadowed the details of how each White Paper of the last nine months will impact the different sectors within it. The organisational and structural reforms have already started, but mental health care provision, in particular, seems to have slipped down the agenda. There are questions that few seem to be asking: can and will the Coalition succeed in its aim of establishing mental health as an equal to physical health? Is this the right objective? How does this strategy differ from the many others that have come before? These are difficult times for the public sector and this Government has set itself a challenge that would be difficult even in affluent times. After years of successive Government strategies prioritising mental health, the most pertinent question right now must surely be – “are we nearly there yet?”
At the time of our last article, the successor strategy to the National Service Framework for Mental Health5 was eagerly awaited. In December 2009, the DH, under the previous Labour Government, published New Horizons: A shared vision for mental health6. It laid out the Government’s strategy for the coming years with the then Health Secretary, Andy Burnham MP writing “for the first time, it recognises mental health and wellbeing not just as a health concern, but as a major social issue demanding action across all parts of Government” – not dissimilar to the claim made last year by Lansley. New Horizons, which was broadly welcomed by stakeholders, did not claim to be all new and shiny. Instead, it sought to “build on recent achievements, [while] helping to prevent mental health problems from developing in the first place.”7
Section 3 of New Horizons: “Cross-government Actions on Key Themes and Across the Life Course” listed no less than 120 actions. Many of these read more like pledges or aspirations – in many cases, there was no clear measurement of success linked to the actions or definitive outcomes. It contained pledges from a wide range of Government departments, including the Ministry of Justice, the Department of Work and Pensions and the Department for Children, Schools and Families (now Department for Education).
“An Atlas for Mental Well-being in England will be developed and published in spring 2010. This will contain relevant information to support local commissioners in both urban and rural areas.”8
Spring 2010 was also the anticipated time of the General Election. A cynic might suggest that this “Atlas” was never intended for nationwide implementation as, by this time, many within the Labour Parliamentary Party were beginning to fear they might lose the election.
“Publication of a violence and abuse prevention framework in spring 2010. This will engage a number of government departments and provide evidence to address violence and abuse, which are key factors for poor mental health.”
Again, this framework was due to be published around the same time as the election, and was intended to engage “a number of government departments” and “provide evidence”. Again, this action – together with so many of the strategy’s other pledges – would not be implemented prior to Purdah.
At the time of New Horizons’ publication, many of the key stakeholders pointed out that the strategy was “without targets or funding commitment9”. Paul Corry, Director of Public Affairs at Rethink writing in the Guardian blog “Joe Public” called New Horizons:
“…an inspiring strategy that’s full of hope for people with severe mental illness. Yet once again, I’m at a loss as to where the cash is going to spring from to finance the grandiose expectations.”10
Overall, the reaction to the strategy was very positive, but tinged with concern, given the wider economic situation and a looming General Election. Perhaps even more worrying – in the context of the strategy being carried forward after the election – was the admission from Professor Louis Appleby, National Director for Mental Health in England, that were was little evidence on how much money the policies would save. As the main political parties geared up for the election, strategies that offered no clear savings or outcomes were no longer a priority.
In March 2010, the DH released Confident Communities, Brighter Futures: A Framework for Developing Wellbeing11. With the country and the press in full electioneering mode, this Framework attracted little attention. Speaking at the Framework’s launch, Dr Andrew McCulloch of The Future Vision Coalition warned:
“This could be the beginning of another revolution in public mental health or it could all fade into the background and will do without that wider commitment. The challenge now is to develop a comprehensive public mental health strategy and to embed this within public health, where it belongs.”12
Dr McCulloch’s words echo what was being said only three months earlier at the New Horizons launch. It is unfortunate and almost certainly frustrating for those working in the mental health sector, that this strategy was launched so close to an election that would see the Government ejected from office only six weeks after its publication.
In May 2010, the Conservative and Liberal Democrat parties came together to form a coalition. They thrashed out a “Coalition Agreement” that was intended to set key markers of what they hoped to achieve over the next Parliament and to be an amalgamation of their respective election manifestos. It is worth reminding ourselves of the original Coalition Agreement pledges that related to mental health. There are four parts that are related (see box):
Considering that less than a year later this Government committed itself to making mental health a priority, it is surprising it gets so little attention in the Agreement. Admittedly, talking therapies are acknowledged as falling under the Public Health remit, although the stated aim to “reduce long-term costs for the NHS” hardly demonstrates a deep understanding of the wider health, personal, societal and economic benefits that can be achieved from general good mental health.
In July 2010, the Coalition published the White Paper Equity and Excellence: Liberating the NHS13 which provided an over-arching strategy for how the Government intended to reform the NHS. It states that the criteria used for the NHS Outcomes Framework will ensure that they “do not exclude outcomes for key groups or services…such as mental health”. It lays out the Government’s intention to build on the work done by its predecessors in Payment by Results (PbR), by implementing a set of currencies for adult mental health services for use from 2012/13 and develops currencies for child and adolescent services. This White Paper also claims the Government will ensure “coherent and coordinated local commissioning strategies across all three services” which includes mental health. All of these commitments are still broad, with little sense of timeline, however, towards the end of the paper it does list April 2011 at the time they intend people to have a “choice of provider in some [my emphasis] mental health services”.
Published in November 2010, Healthy Lives, Healthy People14 outlined the Government’s plans to revolutionise public health and reform the NHS. This White Paper also announced that the DH would be publishing a new mental health strategy in 2011. Unlike the July 2010 White Paper, Equity and Excellence: Liberating the NHS15, the importance of mental health to wider public health is woven throughout Healthy Lives, Healthy People, and the importance of mental health across age groups and to wider wellbeing is also highlighted. This could be taken as an example of how thinking had developed since the Coalition Agreement.
By the time of the publication of the mental health strategy, No Health, Without Mental Health in February 2011, the storm around the wider NHS reforms and the Health and Social Care Bill was already raging.
At the launch of the strategy, Lansley proclaimed:
“For the first time, people of all ages with mental health problems will be able to receive personalised care to reflect their own needs. The NHS will also no longer focus its attention on treatment alone – but will move towards early intervention and prevention to deliver outcomes for patients which are amongst the best in the world.”16
Despite Lansley’s claims, there are striking resemblances between NHWMH and New Horizons and very little that is truly “new”. On the one hand, this gives an encouraging message about the importance of policy continuity – no mean feat, given the change of colour of Government from red to blue and yellow. However, it hardly supports Lansley’s claim that this strategy is “for the first time”.
The strategy has been broadly welcomed – indeed, there is very little in the six core objectives that the mental health community would want to disagree with – but very similar concerns have been expressed to those expressed when New Horizons was published eighteen months ago.
To some, the strategy is big on vision, but light on definitive outcomes and implementation. Money and resources remain a concern. The UK Council for Psychotherapy expressed doubts over the £400 million funding, questioning whether it was actually “new money”17. The Mental Health Foundation noted:
“…it is noticeable that there are few solid financial commitments made…Previous strategies, for example, have pledged to tackle stigma and discrimination, but we are yet to see evidence that this commitment has been successfully acted on.”18
So, what is actually new? The Mental Health Foundation’s response to the 2011 strategy welcomes the fact that “for the first time, medically unexplained symptoms (MUS) are specially mentioned as an issue that will need tackling from a mental health perspective.”19 However, MUS are specifically mentioned in New Horizons as well. In fact, there are whole sections of both New Horizons and NHWMH that are almost identical. For example:
The new Ministerial Advisory Group for inequalities and mental health, involving external stakeholders and chaired by the Minister of State for Care Services, will advise on strategies and monitor progress. (p70)
We will also establish a Mental Health Strategy Ministerial Advisory Group of key stakeholders, including people with mental health problems and carers, to work in partnership to realise this strategy’s aim to improve mental health outcomes for people of all ages. (p15)
The development of Payment by Results for mental health has the potential to improve services (p77)
Better information, particularly in relation to quality and outcome measurement, will be vital for effective commissioning. For most services, this might well entail developing systems to ensure the appropriate collection of HoNOS scores for patients on the new Care Programme Approach, particularly as the evolution of Payment by Results in mental health is likely to depend on assessments that incorporate HoNOS. (p80)
The Government is developing a system of Payment by Results for adult mental health services (p54)
The NHS information architecture is being developed to support better routine outcome measurement across all mental health services. The use of the HoNOS is becoming widespread. This is a widely-accepted outcome measure for severe mental illness collected through the Mental Health Minimum Dataset and is being used in the roll-out of Payment by results in mental health. (p48)
Only a national and local cross-government approach working with local government, in partnership with the third sector, communities and individuals, will achieve the changes that will reduce the burden of mental illness and unlock the benefits of well-being and mental health for the whole population.(p9)
This mental health outcomes strategy sets out how actions across government will help to deliver better mental health outcomes. It is more than a service improvement plan; it seeks to promote a transformation in public attitudes towards mental health. (p12)
Tackling stigma and discrimination is one of the main priority areas for many respondents and there is strong support for maintaining and developing campaigns. (p17)
We all need to take responsibility for caring for our own mental health and that of others, and to challenge the blight of stigma and discrimination. (p5)
In some respects, it is unsurprising that there are so many similarities between the two strategies; given the two were published less than two years apart, policy in this area is unlikely to have changed radically and continuity is to be welcomed. It does, however, raise an important question: for all the well meaning words in these strategies to what extent, if at all, are the policy objectives ever actually achieved? Are the same ideas just being recycled and repackaged for each “new” strategy, but without clearly-defined, robust outcomes and a measurement and evaluation mechanism included to find out how, if at all, the strategy is being implemented “on the ground”?
Improving mental health has been a “priority” of UK Government for years, with strategy after strategy eloquently explaining ways in which the population’s mental health will become just as important as its physical health. Herein lies the problem. No government would announce a new strategy designed to tackle the nation’s “physical health” in a single policy document. Strategies, targets, initiatives and outcomes are developed for specific areas of physical health, whether that is cancer, diabetes, obesity etc. Could it be that in order to successfully improve the overall mental health of the population, government needs to stop thinking about such a broad and complex area of health in terms of a single, homogenous issue and instead think about how to address the specific and very different needs of people with dementia, schizophrenia, depression, social exclusion, anxiety or bipolar disorder?
According to the Office of National Statistics (ONS) 2000 survey, mixed anxiety and depression is experienced by 9.2 per cent of adults in Britain20, whereas the ONS suggests a per year prevalence rate of around 5 per 1000 of the population (0.5 per cent) for schizophrenia21. Surely, it would be more effective to tackle these two different mental health disorders with separate strategies that reflect their prevalence in the overall population and their particular needs, and do the same with the other areas of mental health? If specific strategies could be designed with specific outcomes, then resources could be more targeted and enable more accurate measure of outcomes.
If this Government is serious about putting mental health at the centre of the nation’s wider health, it may need to reconsider how it gets there and whether it should be doing the driving at all. To that extent, simply rehashing the strategies of previous Governments may not be the right approach after all. Given the call for localism in public health and mental health having “equal weight as physical health”, then surely a national, centrally-driven strategy cannot suffice? For an area of health that is so complex it seems impossible that one strategy – however visionary and aspirational – can hope to address everything. To avoid repeating the same journey again and again, perhaps this Government should use the pause of the wider NHS reforms to rethink the route for mental health policy.