Not for the first time, I’ve attempted to produce some cumulative insights from the past and present mental health research studies I’ve had the opportunity to work on. These include my PhD investigation into work and roles in community mental health care, my post-doctoral study of crisis services, and more recent projects which Alan Simpson, Michael Coffey or I have led on.
The prompt, on this occasion, has been the chance to give a presentation at a School of Healthcare Sciences research seminar taking place this afternoon. For anyone interested, here is the PowerPoint I used. I opened with some general comments on the need for mental health research, and on the funding landscape. I then had some things to say about theory, design and methods. Many of the individual slides have hyperlinks to green open access publications:
The much-trailed higher education Green Paper appeared last week. For the full document, the place to go is here and for a Times Higher summary the link is here. Immediately worth bearing in mind is that higher education in the UK is a matter for devolved government, meaning that most of what the Green Paper says relates to English universities. I say ‘most’ because, as is noted towards the beginning of the document, the Research Councils (like the MRC and the ESRC) have UK-wide remits, whilst the REF and the various editions of the RAE preceding it were carried out on a four-country basis. It would also be naive in the extreme to suggest that universities and policymakers here in Wales can ignore the England-only bits of what the Green Paper has to say; for a nice piece on the Green Paper and devolution, follow this link. And, for an insight into work ongoing in Wales on matters higher education-related, here’s a link to a current review of funding arrangements.
Fulfilling our potential: teaching excellence, social mobility and student choice, to give the Green Paper its full title, proposes plenty of change. It also leaves much of the detail unfilled, and (in at least one analysis) contributes to an emerging higher education policy framework which is both vague and contradictory. One idea is for the Higher Education Funding Council for England and the Office for Fair Access to combine functions within a new Office for Students. Plans for a Teaching Excellence Framework are outlined, along with variable rates of tuition fees. Ahead of the publication of the document there was some talk that REF2014 might have been the last of its kind. What the Green Paper actually says (briefly) is that dual support for research should remain, and that some version of the research excellence framework should continue and be used as the basis for the allocation of government block funding. The next REF, it is suggested, will take place by 2021. But there is obviously more to follow in this context, with sections in the document referring to the administrative burden and cost of the REF and the possible use of metrics to ‘refresh’ quality assessments in between full cycles of peer review. There is also the small matter of having to determine, if the Higher Education Funding Council for England disappears, which body should in the future assume the task of allocating quality-related funding to English universities.
Meanwhile, the sole nurse to get a mention in the Green Paper and its surrounding commentary is Sir Paul Nurse, Nobel Laureate, President of the Royal Society and chair of the review into the UK’s research councils. Nurses, of the type of which I am one, have to look elsewhere for the specifics on possible future arrangements for the organisation and funding of health care professional education and for debates in this area.
Today’s Guardian interview with Professor Simon Wessely, President of the Royal College of Psychiatrists, reveals how large the mental health care and treatment gap has become. Professor Wessely draws comparisons between mental health and cancer services, saying:
“People are still routinely waiting for – well, we don’t really know, but certainly more than 18 weeks, possibly up to two years, for their treatment and that is routine in some parts of the country. Some children aren’t getting any treatment at all – literally none. That’s what’s happening. So although we have the aspiration, the gap is now so big and yet there is no more money,” he said.
Wessely said there would be a public outcry if those who went without treatment were cancer patients rather than people with mental health problems. Imagine, he told the Guardian, the reaction if he gave a talk that began: “‘So, we have a problem in cancer service at the moment. Only 30% of people with cancer are getting treatment, so 70% of them don’t get any treatment for their cancer at all and it’s not even recognised.”
NHS England places considerable emphasis on ‘parity of esteem‘, with the Improving Access to Psychological Therapies (IAPT) programme intended to be a one, key, part of making this happen. Evidence like Simon Wessely’s, combined with (for example) BBC/Community Care investigatory evidence of cuts in services, points to a chasm between the stated intention and the frontline reality.
This lack of parity extends to research. Within the last week or so the Liberal Democrats made a promise to include in their general election manifesto a commitment to increase mental health research funding by £50m each year. It has often struck me how poorly funded mental health research is. Mental health researchers can apply for support to bodies like the NIHR and NISCHR, and many do with some success (see all my previous posts on this site relating to COCAPP, RiSC and Plan4Recovery, for example). But unlike most other areas of health care the mental health field has no large-scale, dedicated, charitable research funding. Mental Health Research UK was founded in 2008 as (it says on its website) the UK’s first charity devoted specifically to raising funds to support research into the causes and treatments of mental illness. And that’s about it, I think: unless someone is able to tell me differently?
For the second time in two months the BBC and Community Care have collaborated to establish the extent of funding cuts to mental health services in England. Freedom of Information requests were sent to 51 NHS trusts, of whom 43 responded. Summaries of this investigation, and headline findings, can be found on the BBC website here and on the Community Care website here. Community Care says:
Data returned by over two-thirds of the mental health trusts, obtained in two separate Freedom of Information requests, showed that:
- Overall trust budgets for 2013/14 had shrunk by 2.3% in real terms from 2011/12. Ten out of 13 trusts that provided forecast budgets for 2014/15 are projecting further cuts next year.
- Budgets for ‘crisis resolution teams’ fell 1.7% in real terms compared to 2011/12 while the average monthly referrals to these teams rose 16%. The teams provide intensive home treatment in a bid to prevent acutely unwell people being hospitalised.
- Budgets for community mental health teams flatlined in real terms but referrals rose 13.3%. These services provide ongoing support in a bid to prevent people’s mental health deteriorating to crisis point.
Community Care also lists 10 ways this underfunding is damaging care.
This is also the month that a special, free-to-download, ‘impact of austerity’ edition of Mental Health Nursing journal has appeared. In an email forwarded to all members of Mental Health Nurse Academics UK by Steve Hemingway (who is both an MHNA member and a member of the MHN editorial board), Dave Munday at Unite the Union (which publishes the journal) says:
This month the Mental Health Nursing journal is focused on austerity and mental health. I hope you’ll agree with me that this is a vitally important topic that not only every mental health nurse should know about, but every citizen. We hope that the journal will help to trigger some thoughts and debates that you can have locally in your workplaces but also outside of work. To this end we’re making the journal free to access even if you’re not a MHNA member or MHN subscriber.
Last week I drafted a short, commentary-type, paper for a special edition of Mental Health Nursing which will be focusing on practice and services during a time of austerity. Some years ago I was on the editorial board of MHN. I’m pleased to learn that having disappeared from the library shelves in favour of becoming an online journal (available only to members of Unite the Union) it has made a return in traditional paper form. I’ve been sent a stack of copies, which I’ll be distributing to students.
Anyway: no sooner had I completed my draft and sent it onwards than yesterday’s big health and social care story broke. Under the banner England’s mental health services ‘in crisis’ the BBC ran a report drawing on a joint investigation conducted with Community Care magazine. The headlines were sobering, suggesting over 1,500 mental health hospital beds being lost since April 2011. These bald figures were illustrated with personal stories, revealing people needing crisis admission being transferred to wherever beds could be found around the country, and wards running at over 100% occupancy.
This is very bad news, and suggests a shrinkage back to the way things last were in the early to mid 1990s. In writing my paper for MHN I fished out my copy of this article by David McDaid and Martin Knapp, in which the point is made that at times of economic hardship demand for mental health care increases. And yet, as we are finding, services are actually retracting as austerity bites.
The formal academic year for students of the health professions (and therefore for their teachers, too) tends to be on the long side. Whilst many UK university students will have ended their studies until the autumn there are plenty of nurses, midwives and others with work to do before they can knock off for the summer. In September I’ll be working with pre-registration, second year, students of mental health nursing in a module assessed through the critiquing of published research. Before then I have a short, intensive, module to lead which is part of the taught component within the School’s professional doctorate.
This doctoral level module is all about ‘complexity’ and ‘systems’ and starts next month, and today I’ve been putting the finishing touches to some of the materials I’ll be using. As befits the student group and their thesis-producing aspirations I have opted to draw heavily on colleagues’ and my research experiences as far as is possible. I’m also hoping to foster a spirit of studying and learning together, and want to avoid being didactic.
Elsewhere today, in addition to research project-related work, I have had the opportunity to be part of a panel considering applications for RCN Foundation bursaries. There were some strong candidates, and well done to all who are about to get letters confirming their success. Others will be invited to interview (which I personally am unable to take part in). My commiserations, too, to those dropping out at this stage. I know how it feels to apply for support and not to get it, but there are always other opportunities. As I once heard someone, somewhere, say: if you’re not getting funding bids rejected you’re not applying enough!
Writing for The Guardian’s Healthcare Professionals Network this week, David Brindle reports that spending on mental health care in England has fallen for the second year in a row. He references unpublished figures disclosed last week to the House of Commons Health Committee, along with the 2011-12 National Survey of Investment in Adult Mental Health Services which appeared last August, and from which I have clipped these first two headline findings:
The key figure here is the bit I have circled in red: that, in real terms, investment in mental health services in England in 2011-12 reduced by 1%. Last summer The Guardian reported the publication of this finding under the banner of mental health spending having fallen for the first time in 10 years, and if I am understanding David Brindle’s latest article correctly evidence of further cuts has been gathered since. Elsewhere in this piece Dr Hugh Griffiths, the Department of Health’s National Clinical Director for Mental Health, is quoted as having told the Health Committee last week of being ‘disturbed’ by reports of cutbacks to services in some English regions.
Meanwhile, via this piece in The Telegraph I see that the former coalition government Care Minister and LibDem MP Paul Burstow is heading up an independent Mental Health Commission with the liberal think-tank CentreForum. The Commission’s task is to ‘examine the state of mental health care provision in England’. This is a task made all the more urgent in the light of the finding, also contained in last August’s National Survey, of a £29.3 million reduction in investment in crisis resolution, assertive outreach and early intervention services.
All this paints a very bleak picture indeed. Reductions in funding and in services threaten to roll back the investments made in dedicated mental health care in the years following the publication, in England in 1999, of the National Service Framework for Mental Health. New Labour acted at tremendous speed in prioritising the mental health field. When in government Labour took action to develop community care through the creation of new types of services. It changed the law, put resources into improving access to psychological therapies and rewrote professional role boundaries. Some of the specifics were contentious, sure, but I for one did not doubt that the challenges of improving mental health and developing services were finally being taken seriously. In fact, Michael Coffey and I wrote about this period of policymaking in our wicked problems paper (which can be downloaded here). In this we urged careful consideration of the cumulative impact of policy actions, and the perils of trying to change everything in a complex system of health and social care all at the same time. But needless to say we made no case for cuts, which is what is evidently taking place around large parts of the country now.
As it happens, I can’t immediately find a Welsh equivalent for the Department of Health’s National Survey for England. If it’s out there, perhaps someone can point me in the right direction? It would be good to know the trends for investment in mental health services here in Wales. More generally, now I come to think of it, I want to learn more of the prospects for the future of the mental health system in this part of the UK now that the Welsh Government
has a new Health Minister
in Professor Mark Drakeford
. The Minister is a Cardiff University Professor of Social Policy and Applied Social Sciences
, and it will be interesting to see how future policy and services shape up under his direction.