Richard Smith: Mental health—has the tide finally turned?

richard_smith_2014When I spoke to this group four years ago about mental health services all was doom and gloom, but now I feel optimistic. This is how Paul Farmer, chief executive officer of MIND, began his talk this week to the Cambridge Health Network. Despite about three quarters of patients with mental health problems still not getting the full package of care that would help them, Farmer has grounds for optimism.

Public attitudes to mental health are changing, with more people talking about their problems and stigma falling. Realistic stories in the media are outnumbering “mad axeman on the loose” stories, and following changes in the public and media attitudes politicians have made commitments to improving mental health and increased funding.

Farmer chaired a task force that produced 58 recommendations for improving mental health, and the government accepted all of them. Some 20 000 people engaged with the task force, and its recommendations covered providing high quality care seven days a week, integrating mental and physical health services, and prevention.

The task force emphasised the importance for services of all ages, and a questioner in the audience pointed out that mental health problems account for 20% of the cost of services for those under 30 and are the biggest cause of lost life years and lost employment days. At the moment only 28% of young people with mental health problems get all the evidence based interventions that would help them, and the target is to increase this to 35% for 2021. Such gaps would not be tolerated for physical disease.

Farmer argued that breaking down the barriers between physical and mental health services is key to improving both. Patients with severe mental illness have a life expectancy 15-20 years less than the average, and a high proportion of patients with long term physical conditions have mental health problems that complicate their condition and impede treatment. We British are unusual in how much we separate body and mind, said Geraldine Strathdee, former National Director for Mental Health. British acute hospitals are alone in the developing world, she said, in not including departments of psychological medicine. Some 70% of patients in liver units are there because of addiction to alcohol, and intensive care units have many patients whose physical problems originated with mental health problems.

Mental health services have, pointed out Strathdee, achieved much of what acute hospitals need to achieve: they have shifted resources from hospitals to the community, dramatically reducing the number of beds; they have built relationships with charities and the private sector; they have worked closely with social care; they have involved users in all decisions about services; and they have encouraged self and family care, partly through default in that services have not been available. There seems to be lots of scope for leaders of mental health services to help the leaders of acute trusts develop services in the community and reduce hospital beds.

But the shift of resources from acute hospitals to mental health and community services will not happen, warned Stuart Bell, chief executive of Oxford Health NHS Foundation Trust, while we have a health payment system that pays for hospital bed days rather than outcomes that matter to patients. Some clinical commissioning groups would like to shift resources from acute trusts but know that arbitration will force them to pay for hospital bed days. Bell wants the payment and arbitration systems changed but concedes that that would lead to “howls of protest” from acute trusts.

Farmer’s optimism for mental health services is further supported by the plans for mental health in the Five Year Forward View and the granularity of the implementation plan. It’s the first time that there has been such a plan for mental health, and it is backed by a target that all patients with a mental health crisis must be seen within four hours. Both Farmer and Strathdee welcomed the use of indicators within mental health and the appearance soon of a dashboard that will allow the monitoring of mental health services. They will show huge variation in services, variations that would cause an outcry in, for example, cancer services. Farmer argued that data on outcomes in mental health services should be published.

All three speakers recognised that these developments will not bring parity with services for those with physical problems, and the financial crisis in the NHS may mean that this may not be the moment for a revolution in mental health. But widespread recognition of the interdependence of physical and mental health services and an understanding that more investment in mental health services could relieve pressure on acute hospitals could mean that financial pressures will support mental health services catching up with physical services. What happens with the sustainability and transformation plans currently being drawn up by all health systems will show just how serious the NHS is at improving mental health services.

Richard Smith was the editor of The BMJ until 2004. 

Competing interests: None declared.

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