Theresa May’s mental health reform speech on Monday was the first time I’ve heard her say more than a soundbite, and also the first time I’ve heard her talk about anything other than Brexit, so I wasn’t sure what to expect.
At the opening of her speech, I wanted to support her. I wanted to believe she would say something genuinely meaningful and compassionate. I also hoped (perhaps naively) that she would make reference to the effect of austerity upon mental health. May is in a good place to acknowledge the negative impact of previous political choices, after all. While she is maintaining many of those choices, she didn’t instigate them. She has mostly inherited the bad decisions made by others, most obviously David Cameron, becoming essentially the country’s largest-scale supply teacher.
Initially, her opening discussion of the overt and covert injustices present today were impactful, leaving her actual reform strategies as arguably the weakest element of her speech. Similarly, while her view on reducing stigma (below) says all the “right” things, it does so without providing anything tangible or practical, or any awareness of where the Government themselves have been guilty of removing that attention and treatment.
This is an historic opportunity to right a wrong, and give people deserving of compassion and support the attention and treatment they deserve. And for all of us to change the way we view mental illness so that striving to improve mental wellbeing is seen as just as natural, positive and good as striving to improve our physical wellbeing.
So, on to her eight key points. (Exact wording taken from this BBC article).
- Every secondary school to be offered mental health first aid training – which teaches people how to identify symptoms and help people who may be developing a mental health issue.
This sounds mutually beneficial on the surface- certainly, no-one would argue for the opposite. Also, the training workshops would be run by Mental Health First Aid England, who are experienced trainers in this area, so information quality shouldn’t be an issue. Instead, the problems with this concept will arise after teachers notice issues. If a secondary school teacher takes the workshop, and as a result begins to worry about some of their students, what happens next?
Noticing when students are beginning to struggle should be paramount in preventing their issues from developing further. But when everywhere children could be referred to is already at capacity, what good can a teacher do? According to the NSPCC in 2015, 21% of children referred to CAHMS (Child and Adolescent Mental Health Services) across 35 different Mental Health Trusts were turned away. Six of these trusts shared data about children whose difficulties came from known abuse, and 1/6 of these children were rejected from treatment.
When there is no structure in place for early intervention, or even on-time intervention, what can early identification actually achieve?
- Trials on strengthening links between schools and NHS specialist staff, including a review of children and adolescent services across the country.
In theory, this could be valuable, as easier contact between schools and support staff directly helps in two ways. Firstly, there are situations where parents cannot easily seek help for their child- for example, if a language barrier made it difficult for parents to communicate with medical or support organisations, or if cultural/personal unfamiliarity about mental health meant parents did not know how to ask for support. In this case, schools can mediate between mental health services and the family to better communicate what kind of support the child needs.
Secondly, some children will need support because of their family situation. They may have parents who teach them that asking for help is shameful, or who have led the children to believe their feelings are their own weakness. For children in these situations, their school can already act as a refuge from home. So the option for people within schools to contact specialists themselves creates chances for children in unsafe family situations to be supported more safely.
However, CAMHS is already overstretched and undersupported, with waiting lists of up to 200 days in some areas of the UK (this data is from a report by the Children’s Commissioner). Also, CAMHS support will be partly determined by where students live as some areas of the country stop CAMHS support at 16 years old and others at 18, while Adult Mental Health Services always begin at 18. So some schools will have no accessible services for students in Year 11 and Sixth Form- how does that information fit with the theorised links between specialists and schools? (That’s without mentioning the issue of transition between Child and Adult services, which is itself an issue in mental health support).
- By 2021, no child will be sent away from their local area to receive treatment for mental health issues.
An important goal. But without any increase in funding or resources, and without any (known) plans to build new treatment facilities or extend existing ones, how is this possible?
- Appointing mental health campaigner Lord Stevenson and Paul Farmer, chief executive of the charity Mind, to carry out a review on improving support in the workplace.
This one looks promising. Lord Stevenson has a history of supporting mental health causes, helping to found MQ, a charity supporting research into mental health. He was also involved with the Mental Health Discrimination Act of 2013, which made discrimination or job loss on the grounds of mental health illegal in more situations.Paul Farmer is also chair of both the NHS England Mental Health Taskforce, and the Association of Chief Executives of Voluntary Organisations. In theory, this background of both an understanding of the NHS process and an understanding of workplace management and social enterprises means he is one of the best-placed people to lead this review.
- Employers and organisations will be given additional training in supporting staff who need to take time off.
A history of mental health issues used to be a known barrier to finding and keeping employment- in a 1995 study only 27% of employers would regularly (more than “occasionally”) hire someone currently experiencing depression, while 23% of employers would “sometimes” dismiss an employee after finding out they had an undeclared mental illness. The Equality Act of 2010 should prevent this from happening now, and situations have improved in regards to legal protection for employees. However, more subtle forms of inequality and access barriers still exist, often through unfamiliarity and misinformation rather than deliberate prejudice.Training organisations so they know how to identify when something is wrong and how to support employees, both in taking time off work and in gradually returning to work, is a valuable way to help safeguard employees. But with little information about what is meant by training, and who in a company will receive the training, all that can be said so far is “wait and see”.
- More focus on community care such as crisis cafes and local clinics, with an extra £15m towards this, and less emphasis on patients visiting GPs and A&E.
See point #3.
Community care has the potential to offer long-term and integrated support. But when local services receive budget cut after budget cut, people in need have to rely on GPs and A&E. So this goal is meaningless without committing to not only one-off funds for community centres but also legal and practical contact and support for them.
- The reallocation of £67.7m, mostly from the existing NHS digitisation fund, for online services, such as allowing symptom checks before getting a face-to-face appointment.
Online access to NHS services is perhaps most valuable when applied to mental health conditions, as mental health issues can make phoning up for appointments and remembering appointment times more difficult than usual. But the story of previous and current NHS digitisation attempts is a long and rather winding one filled with reversals, amendments and issues. Also, how does taking money away from the NHS digitising fund to create another digital service work? Surely that will add to the existing fragmentation between services?
- A review of the “health debt form”, under which patients are charged up to £300 by a GP for documentation to prove to debt collectors they have mental health issues.
Firstly, I can’t actually find anyone using the £300 figure- from what I can find on the original research, the maximum amount charged appeared to be £150. However, that’s less relevant than there being a charge in the first place, so let’s ignore the numbers for now to look at why there is a cost. These forms- known fully as Debt and Mental Health Evidence forms- are not statutory (legally required) documents. They are jointly developed and maintained by the Royal College of Psychiatrists and the Money Advice Liason Group rather than any Government department. As a result, they are not part of the NHS’s contract with GPs. GPs can therefore choose to charge patients for completing these forms, in the same vein as countersigning passport applications or writing specific reports.
Policy group Money and Mental Health are the main drivers of this point. In Spring 2016 1/3 of patients they surveyed needed to pay their GP to fill in the forms. In response they created #Stopthecharge; a campaign to reclassify the forms as charge-exempt, in line with similar documents such as “fit notes” or the forms which relieve people with certain conditions from paying council tax.
The good news here is that Money and Mental Health (alongside the Department of Health) will be carrying out this planned review of health debt forms. This suggests a removal of fees or reclassification of forms is likely, though also dependent on the NHS.
So we’ve actually found something both highly feasible and beneficial… at the bottom of the list.
Conclusions (for now)
Most of the eight reform points are flawed for the same two reasons. Either they promise to support a service or idea without providing any resources for that support or any explanation of where those resources will come from, or they rely on already-stretched services taking on extra responsibilities. Viewing the points this way, it’s easy to see the majority of this talk being forgotten about or quickly amended (with the definite exception of in-school training, which is due to roll out this year).
For points which centre on reviews, there is also the question of how much will have changed politically by the time reviews are carried out. Alongside this is the usual concern that the ideas suggested in a review, however good they are, do not always get implemented.
For now, I’m in two minds about May’s speech. I’m glad she discussed mental health, because at least she’s created a foundation to build future plans on. But at the same time, most of the points proposed require resources she has not yet committed to and may not commit to in future. Further, I’d argue that making any real change in mental health support requires repairing the damage already carried out to support organisations and medical care, rather than just adding new burdens upon them.