I am currently reading Donald Trump’s The Art of the Deal. I know what you’re thinking, but please hear me out. Whether we like it or not, we live in the world of Trump. Becoming President of the United States was quite a deal. The book gives his top tips for success in deal making – think big, use your leverage, get the word out, and deliver the goods. Themes that wouldn’t look out of place on a strategy plan to elevate mental health onto the same platform as physical health.
That’s not to suggest that progress hasn’t been made, because it has. That the Prime Minister dedicated almost an entire speech to mental health is proof enough and those of us who are closely involved with politicians and policy makers are justifiably proud of the inroads made. The speech may not have delivered the policy punch we would have liked – inevitably, these things never do – but it did put mental health squarely under the public’s nose and gives anyone interested in the subject an important tool to leverage action from the government.
There’s a lot of talk about mental health, but people on the ground who see little or slow progress or even reductions in services can often view pronouncements as ‘fake news’. Psychiatrists have been pursuing the introduction of integrated services for years, so the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, published yesterday [January 26] is very welcome. It is the clearest evidence yet that physical and mental health equality can save lives. The report confirms what we already know – that patients with a physical illness who also happen to have a mental illness are more likely receive poor care in general hospitals that do not have integrated physical and mental healthcare services.
Perhaps more importantly, someone who is not a mental health professional led the report. Why is this significant? It is one thing for those of us in the thick of it to bang on about integrating services but it is quite another when others start to do the same.
As healthcare professionals, we work hard for our patients. We want them to recover and receive the best care possible. Despite the stories that end up in the press, most people are cared for to the highest standards. But what is frustrating is knowing that it could be even better if we changed our systems and attitudes. It’s not just psychiatrists who understand the importance of mental health. Nurses working in specialist areas also acknowledge the need to be more adept at recognising when they should bring in a mental health specialist to assess a patient being treated for a physical health issue.
The NCEPOD report recommends that “all hospital staff who have interaction with patients, including clinical, clerical and security staff, should receive training in mental health conditions in general hospitals. Training should be developed and offered across the entire career pathway from undergraduate to workplace-based continued professional development.” This recommendation has the power to break down the barriers that currently exist between medical and non-medical staff – if it’s implemented. The pessimist in me inevitably sees this report relegated to the forget-me-drawer. Let’s hope that’s not the case.
So, let’s take some of Trump’s key steps:
The mental health world has been blighted by a collective learned helplessness. This has stopped us insisting on what is needed. The Adult Psychiatric Morbidity Survey (2014) suggested that only a third of people who require and would benefit from evidence-based mental health interventions actually receive them.
The current target for access to psychological therapies is only for 25%. The Five Year Forward View for Mental Health aims for only a third of children and young people to get treatments by 2021. The suicide prevention target is a reduction of 10% over 5 years. This would still leave suicide as the leading cause of death for men aged 15-49. The amount of money allocated to suicide prevention (£25 million over 5 years) amounts to 10p per person per year.
Aiming high? More like a limbo dance. Who, if not we are better placed to demand more? We should be aiming to ensure that every person who needs help, be it for a physical or mental health condition, gets it. We should be aiming to make sure that all children and young people have access to mental health services. We know that those who access treatment early are more likely to have better outcomes later in life. We should not accept that 10p per person a year is the right amount to spend to reduce the numbers of those who attempt suicide. Such aims in a target-led system may make the number crunchers uncomfortable but settling for such a low success rate should make policy-makers even less so.
Use your leverage
The mental health world has huge leverage considering that 1 in 3 of us will experience a mental health problem at some point in our life. We are voters and can influence politics, the organisations we work in and the communities we live in. We will continue to struggle to seek the equality of stature that mental health deserves until recognising it is just as normal as recognising physical health.
There are untapped opportunities in relation to work and mental illness. We know that mental health problems are the leading cause of absence from work. But it is only recently that companies like BT have decided to focus on mental health in the workplace. They understand that this is not only something they should do but that it is good for their business.
Get the word out
This has been a major area of success in the last 5 years. We should applaud people like former NHS director and registered mental health nurse Mandy Stevens who bravely posted an article on LinkedIn about how she suddenly became a patient on a mental health ward. It doesn’t get more real than that. Stories like hers, told warts and all, have the power to chip away at the stigma that has held back real reform in this important and growing area of healthcare.
That’s not to say that reform hasn’t been happening. The Time to Change campaign has brought about modest but significant changes in attitude to mental illness in recent years.
At the 2015 General Election, all the major political parties had significant sections on mental health in their manifestos. Who would have thought that on the steps of Downing Street on July 13, 2016, Theresa May would have talked about mental health, about stigma and that there is “not enough help to hand”? Her predecessor, David Cameron, spoke about suicide on January 11, 2016 and George Osborne was the first to highlight mental health in a Chancellor’s Autumn Statement on November 25, 2015.
Now the Duke and Duchess of Cambridge and Prince Harry are urging the nation to start a conversation about mental health in their work on their ‘Heads Together’ campaign. So it would appear that everybody’s talking about mental health, which has to be a good thing. The problem is that in people’s everyday lives this can still be a struggle.
Deliver the goods
This is the nub of the issue. Few seriously doubt the sincerity of our leaders in wanting to improve outcomes for people with mental health problems. Whatever happens at the centre, as things trickle down through the system, mental health seems to lose out. For example, data analysis of the Mental Health Five Year Forward View Dashboard by the Royal College of Psychiatrists in November 2016 indicated that in spite of the push on improving child and adolescent mental health services (CAMHS) there was a huge disparity between clinical commissioning group (CCG) spend. Some reported they planned to spend as little as £2 per head on CAMHS.
The good news is that the Dashboard also indicated that 78% of trusts met the mental health investment standard. The bad news is that the remaining 22% (46 trusts) did not. Roll on more pressure on CCGs to put their mental health funding into mental health services.
So how are we doing? There are some encouraging signs but could do much better. Is there cause for optimism? Absolutely. Is there opportunity? Most definitely. Whatever the battles, triumphs and disappointments, we must keep positive and press ahead to turn perceived ‘fake news’ into headline news.
Dr Adrian James is registrar of the Royal College of Psychiatrists.