When Napoleon was asked what he wanted in his marshals he answered “to be lucky”. He would have been pleased with Theresa May. A year ago, David Cameron gave a good speech on mental health – I know, I was there. But hardly anyone else does, because he chose the morning that David Bowie died. There was zero coverage. May chose a day in which, for some reason, Donald Trump said nothing, and the only other news was the London tube strike, and thus dominated the airwaves. Even the strike worked in her favour – more people were at home twiddling their thumbs with nothing better to do than watch the news.
A Prime Ministerial speech is important. It sets a tone. The political and civil service bandwidth for AOTB (Anything Other Than Brexit) is going to be narrow for years to come, so knowing what Downing Street is keen on really matters. And there is no going back from this – May meant what she said on her first day in office – she wants to see a transformation in how we approach mental health. So we must applaud the fact the speech happened at all.
But what about the content? Again, there was much to like. There was a spirited defence of the importance of social networks and social cohesion for mental wellbeing. Nothing that we would not agree with, and perhaps a little dig at the first woman Prime Minister, who famously – or infamously – claimed there was no such thing as society. In our world there most definitely is.
We heard a lot about the early years – again, little we have not been saying ourselves, but still very welcome. There was a commitment to ending using police cells as a place of ‘safety’ for mentally ill adolescents. We at The Royal College of Psychiatrists have been pushing for this for some time. There will be more mental health education for teachers – Mental Health First Aid will be rolled out across the sector. My alter ego, The Boring Boffin, might point out that the best trial of this showed that it did improve teachers’ knowledge of mental health, but had little impact on the children. However, this is probably the occasion to keep Boring Boffin in the kennel.
And to be fair, the pre-speech briefings did include the word ‘trials’. Boring Boffin worked hard to get that – not ‘pilots’, still less ‘evaluations’, but ‘trials’. Well-meaning interventions, especially with children, can do harm as well as good. It is our role, as a calm but authoritative voice, to point this out. Where we have evidence – as in parenting programmes to reduce behavioural difficulties in children – we will shout this from the roof tops. But the only way we can find out what works and build our evidence-base is through trials. There is no other way of assessing the balance between benefit and harm.
But we don’t need more trials to know that Prime Ministerial support for putting mental health services into A&E is a good thing. A&E services will always see those with drug, alcohol, deliberate self-harm, comorbidity and so on. And they will also always see those with serious mental health problems who have developed acute physical health issues. And so they will always need us.
Digital is all the rage, so not surprising that a lot was made of this. From our perspective it was good to see that six mental health trusts will be designated as ‘Digital Exemplars’, which comes with £5 million in extra funding, after competition. I say good, because that would not have happened without our strenuous interventions when it became clear from the first announcement that mental health trusts were not originally included in the scheme.
As ever, what was not said was as important as what was said. We tried to get more in about the workforce – this wasn’t successful, but back chat indicated that our hope that the commitment to provide up to 1,500 extra places for medical students will include measures to ensure that they don’t all want to be surgeons (of which we need fewer, not more, in the future), but GPs and psychiatrists (of which we definitely need more) will be heeded soon. In addition, 1,700 new therapists were promised for CAMHS services – but not the 350 CAMHS psychiatrists that ourselves and HEE have indicated are needed.
Nor did we get the PM backing to end out-of-area placements for adults. We created the Crisp Commission soon after I took office, and were pleased when NHS England accepted its findings and recommendations, but not the deadline we had proposed to this practice finally outlawed. We had hoped the PM might advance this, but she remained silent.
But we return, as we must, to money. The PM promised some: as far as I can gather, the only truly new money was £15 million allocated for out-of-hospital crisis care, such as mental health cafes. Some previous commitments were repeated – liaison and court diversion schemes to keep people out of the criminal justice system being extended across the country. I thought that was already happening, but having the PM repeat it does no harm. Ditto the extra investment for A&E liaison psychiatry services. So in the end, there was little to add to the Five year forward view for mental health. This work, chaired by Paul Farmer and in which we played a prominent part has now been accepted by Simon Stevens and now the PM.
But overall, the picture is gloomy. Between 2010 and 2015 funding to mental health trusts went down by more than 8%. Not up, down. Since 2010, we have lost more than 2,000 beds in England alone. But demand has risen – referrals to community mental health teams have gone up by 20%. So has there been a concomitant increase in staff? Don’t hold your breath – that went down by 5%. Meanwhile, you probably have seen the coverage of the 50% rise in mental health attendances at A&E over the same period – with a particularly worrying increase in children. Some, but not all, of this is due to better coding, but clearly the underlying trend is not good.
And looming over it all remains the fact that sightings of the large sums (now we are talking not a few million, but more than a billion) promised by George Osborne before he was defenestrated as Chancellor remain as elusive as sightings of the Loch Ness Monster or the Beast of Dartmoor. Confirmed sightings continue to be of small kittens rather than the sabre-toothed tiger-sized felines that we were promised. Certainly eating disorder and perinatal services are benefitting, which is great, but the radical transformation that the speech promised remain to be delivered.
We at the RCPsych are responding, helped it must be said by the new NHS England ‘dashboards’, which give at least some evidence of what clinical commissioning groups (CCGs) are actually spending on mental health. Before Christmas, we had a blitz on CCGs that made Scrooge look like the Bill Gates Foundation when it came to funding CAMHS services. Armed with the data, we targeted local MPs and media in a bid to name and shame errant performers, this being almost the only weapon we have in the post-Lansley/Health and Social Care Act era. Expect a lot more of the same as we get down to looking at numbers of Out of Area Transfers, or who is honouring the expected 1.5% mental health uplift.
But I am afraid that, from talking to medical and finance directors up and down the land we know that the famine continues and the broad sunlit uplands remain a distant prospect. We are not alone in this – as I write you cannot help but notice the tension between Number 10 and Simon Stevens about the overall level of NHS spending – who promised what and where is it? Stevens seems to have the facts on his side, but this is now about politics, and where this will end we can’t say. I hope that it will settle, because Stevens has been a good friend to mental health – it is where he started his career – and it is also hard to see anyone who would want to do his job, let alone do it better than he does.
So where does that leave us? I don’t think I can improve on this week’s (January 14) Economist – “The Prime Minister makes a big speech but signs a small cheque”. Big speeches are good, big cheques even better.
Professor Sir Simon Wessely is president of the Royal College of Psychiatrists