Tag: government

Closing the Gap?

Earlier this week, over the border in England Deputy Prime Minister Nick Clegg put his name to a new policy document titled Closing the Gap: Priorities for essential change in mental health. The foreword to this includes the line that ‘Mental health is moving up the policy agenda across government’. This is a welcome assertion. It is also one which deserves to be examined alongside evidence of recent cuts in funding and retractions in services at a time of rising demand (see here and here for my earlier posts on mental health in an era of austerity).

This is a document listing 25 areas for change in four areas: increasing access to mental health services; integrating physical and mental health care; starting early to promote mental wellbeing and prevent mental health problems; and improving the quality of life of people with mental health problems. It closes with the maxim that mental health is everybody’s business. Initial coverage in The Guardian included a fairly straightforward description of the document’s content, and particularly its promise of increased choice for people using services and the introduction of waiting time targets. In The Independent, Paul Jenkins (from the organisation Rethink Mental Illness) was more searching, contrasting Closing the Gap‘s aspiration with what we know about frontline services:

[…] historically, mental health has always had a raw deal when it comes to NHS spending and accounts for 22% of illness in this country, but only gets 11% of the NHS budget. On top of this, over the last two years, we’ve seen a 2% cut in mental health spending despite increasing demand. Services which were already struggling are being squeezed even further. So how can the Government now make real inroads into significantly improving care and introducing choice when the services simply aren’t there? People are waiting months, even years for treatment.

If politicians really want to improve the lives of people with mental illness, we need to see investment in mental health services – in the very least services should not be cut. We should also be making sure that people who are too ill to work are properly supported with the benefits there are entitled to and with services that respond when and where they are needed. And when we see an action plan, it needs to set out specific commitments on how things are going to change and by when.

Well said. Personally I am minded to think, again, about the mental health field’s wicked problems, and how large-scale policy always contains just one version of what a system’s most pressing challenges (and their solutions) might be. Closing the Gap has plenty to say on what ought to be happening at local level (better preparation of commissioners of mental health services, more mental health training for primary care workers, more psychological therapies, and so on). What it does not unequivocally say is that ‘the problem’ may also be one of underfunding relative to levels of need.

I am also reminded of how local service change in response to national policy can lead to unintended consequences (something I have written about at length here). Here’s a speculative example to illustrate this point. Typically, mental health teams have responsibilities to respond in timely fashion to new requests for help (from colleagues in primary care, for example) whilst simultaneously providing care to people already using their services. Who knows, then, what the wider system effects might be when waiting limits for mental health services are introduced next year, as Closing the Gap promises they will? At local level, will redoubled efforts to respond to new referrals mean that the delivery of ongoing care and treatment will suffer? Will NHS organisations be tempted to establish new types of service specifically to reduce waiting times? If so, how will these find their feet in systems which are already organisationally complex? None of this is to say, of course, that waiting periods are problems which do not deserve to be tackled, but it is to say that actions to address perceived deficiencies always reverberate.

Disinvesting in mental health?

National Survey of Investment 2011-12Writing 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:

National Survey of Investment 2011-12b

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.