Mental Health in 2014 – Uncertain steps towards the Promised Land
For those of us who are engaged with the mental health agenda these are uncertain times. In some senses there are grounds for optimism, given what seems to be a genuine sea change in public attitudes towards mental health. At the same time, a growing incidence of mental health problems in the wake of economic distress and the financial pressure on services has meant that the experience of those living with mental health problems is in many cases worse than it was 5 years ago. As a result “parity of esteem” for mental health, a concept which I think is a worthy and meaningful ambition is on danger of being discredited by the extent of the gap between aspiration and reality. A number of events from 2014 highlight the position
First the good news. In the years I had the privilege of leading one of the partner organisations in Time to Change I could sense a real change in the public dialogue about attitudes towards mental health problems. This year there was some unambiguous evidence to back up that feeling with the publication in the autumn of the results of the Department of Health’s routine survey into attitudes towards mental health. It confirmed an overall improvement in attitudes of 6.4% since Time to Change started in 2007 and a leap of 2.8% in the last year (2012/3), the greatest improvement seen in a single year. This translates into greater willingness to engage with people with mental health problems whether as colleagues at work, neighbours or friends. It should be remembered that for most of the time since this survey first started in the 1990s attitudes were either stuck at the same level of in some cases even getting worse.
One caveat to this generally positive story about improving attitudes rests with the NHS which itself may still be one of the most intransient sources of stigma towards people with mental health problems. There are, at the heart of this, major issues about the training of health care professionals and the gaps around knowledge of mental health which exist for many practitioners who work in physical health care. The healthcare system succeeds in operating a system of apartheid between mental and physical care which ill serves patients. This is an urgent priority which needs addressing. As small but import at first step it’s been good to hear about the success of schemes to increase the proportion of Foundation Year medical students who do a placement in psychiatry.
Improving attitudes can be measured in social surveys but they also manifest itself themselves in public narratives and shared stories. Undoubtedly the largest mental health story of the year was the tragic suicide of Robin Williams. With some exceptions, its coverage represented a mature reaction not just to the actor’s death but to the mental health problems he had experienced in his lifetime and which many others, without his celebrity status, share.
Changing attitudes is crucial to delivering progress. Fear and stigma have held back the prospects of those affected by mental illness either by leading to direct discrimination or in a more insidious way by facilitating a culture of self-stigma. One of the things which has undoubtedly changed in the last 5 years has been the confidence of the mental health lobby to challenge negative attitudes with social media being a powerful catalyst for this change.
Improving attitudes also help open up the public debate. For years the mental health lobby has had a smaller “voice” than it deserves given the number of individuals and families affected and the economic impact of mental illness. This is beginning to change. When Nick Clegg made the announcement of mental health waiting times the centre piece of his party conference speech in October some commentators accused him of “chasing votes”. Nothing could be a better tribute to people affected by mental health problems than for them to be taken seriously as an interest group whose votes were worth courting.
That announcement was important in other respects. At last there was a concrete commitment to do something to create some genuine equality for people with mental health conditions. Access is not the only important aspect of care but it can be a lifesaver, as people who have experienced a first episode of psychosis will attest to. Since the announcement there have been arguments about the money but there is some hope that this offers an appropriate mechanism to drive new investment into mental health services.
There are plenty of pressing priorities waiting for it. No mental health story this year has been more poignant than that of young people detained in police cells or sent to the other end of the country because of the absence of an appropriate inpatient bed in their locality. Rightly these stories have created an outrage and there has been action in terms of investment in new provision and the establishment of a Children and Young People’s Mental Health Taskforce. However there is a still a sense that had the sentence started with a “young person with cancer” the reaction might have been even stronger.
At the end of the day the biggest story for mental health in 2014 continues to be that of the tension between increasing demand and declining investment. Mental health was always likely to come out of austerity badly. The history shows a regular pattern of increasing levels of mental health problems in times of economic hardship and uncertainty, exacerbated by cuts in social care, housing and by the impact of changes to the welfare system. Suicide rates have been showing an increase, despite some good preventative work. Colleagues in some other London Trusts report a doubling in demand for crisis services in recent years.
Resources in mental health services have not kept up with this extra demand in the system, indeed they may have gone backwards. A welcome injunction in this year’s NHS planning guidance stresses the importance of commissioners increasing real terms investment in mental health in 2015/6. I hope this is the case.
So we stand on the cusp of 2015, with some optimism about improving public attitudes but with considerable anxiety about resources and the pressures on services. With the state of the public finances there is no easy answer through this conundrum but it will be crucial that politicians are brave enough to recognise the reality of the injustice at the heart of our health service. On May 7th we all have the chance to encourage them.