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How do we begin to fix the mental health crisis?

Saturday 27 July 2019

This was the question we investigated at a pair of recent ThinkIns. Here are the key points of the discussion, as well our thoughts on where we’ll head next

It feels a bit like staring at the Matterhorn: a challenge so daunting, so huge, so compelling that it is hard to feel equipped to begin tackling it. But the two ThinkIns we’ve had on mental health – one this week, one a couple of weeks ago – showed us where our first toe-holds on the issue might be, and where the routes might go after that.

And we do intend to follow those routes. Starting with Lucy McDonald’s recent essay about services for children, Tortoise has already opened a Case File on mental health, which we will fill out with more journalism in the months ahead. We’ll be holding more ThinkIns on the subject, too. We’d appreciate as much involvement from our members as possible, whether you’ve suffered from mental health problems, know someone who has, or not.

The dining room of the NHS Lavender Walk Adolescent Psychiatric Unit, which provides specialist services for for young people with mental health difficulties, aged between 13 and 18 years

Our first two ThinkIns were helped by many valuable contributions. Guest experts included: Stevie Spring, the Chairman of Mind; Luciana Berger, the independent MP and mental health campaigner; and Dr Lisa Cameron, an MP who has worked as a psychologist. Our members and visitors brought their own stories, which were searing as well as insightful.

One question wove itself throughout the second ThinkIn, in particular: is it fair to call the situation a crisis? The consensus response: yes. What other name would fit? We heard personal testimony of lives that had been deeply affected, even ended, by mental health problems. We heard about a still-ingrained reluctance to open up to friends about it. We heard of people seeking their own, damaging solutions to mental health difficulties because orthodox help is not available.

Not, in fact, a single crisis but multiple crises: one that involves young people whose mental health is deteriorating; one that denies adequate resources and leaves parity of esteem between mental and physical health a distant dream; one that requires young people to make not one but two suicide attempts before they’re deemed sufficiently at risk to qualify for proper treatment. How do we move all this from the “important box to the urgent box” if we don’t attach the right label?

The main lounge of the NHS Lavender Walk Adolescent Psychiatric Unit

We bumped into a paradox. It’s not useful to think about the spectrum of mental health issues, from wellbeing to crisis, as a single block; it’s essential to think about the system as whole. Without that system-wide view, one branch of government will do accidental harm to health in pursuit of some other aim. Poor housing, poor choices in school, poorly-run workplaces, poor decisions about benefits: all are capable of affecting wellbeing and the prospect of recovery.

And we have to remember the kaleidoscope of provision. This is by no means a conversation only about Britain’s National Health Service, nor indeed just about Britain. It encompasses peer support, social prescribing, early intervention and crisis treatment. It involves friends and family, third sector organisations and private providers. Continuity of care across that spectrum is a challenge, but the ThinkIns could not have been clearer about the importance of rising to it.

There were moments of real optimism in our conversation; companies that encourage their employees to talk openly and honestly, a sense of a stigma finally easing. We could have talked for many hours, not one, and over the coming months we will talk for many hours at other ThinkIns.

Bedrooms for new in-patients at the NHS Lavender Walk Adolescent Psychiatric Unit

What next?

Some areas that we’ll want to explore further:

Gaps. Perhaps it’s inevitable that, in an area as broad as this, there’ll be gaps. But some seemed too important to ignore, including: the gap between provision of services for physical and mental health; the gaps in provision that result in children being sent from Cornwall to Sheffield for in-patient treatment; and the gaps in continuity that mean patients have to re-live traumatic episodes multiple times, simply because their notes have not kept up with them as they move around the system.

Perverse incentives. Any under-funded service is at risk of triaging by the severity of illness. But we heard something different: about a process that can encourage people who are sick to become worse in order to access treatment.

We also heard about the incentive to keep quiet. It makes no sense to deter anyone from seeking treatment early for fear of what it will mean for their job or their family.

The classrooms at the Lavender Walk Adolescent Psychiatric Unit

Targets. NHS targets for treatments of physical health have driven huge change. A similar approach to mental health could do likewise. It might also have the effect of hard-wiring a commitment to proper funding of mental health for years to come, whoever is in charge. Governments find it hard to remove entitlements once they’re laid down.

Any targets would have to include users’ experience as well as deadlines for access to services. Being treated quickly but badly is not a good outcome.

A mental health “duty”. A fascinating thought. The Equality Act has had massive consequences for the rights of individuals and groups across a broad front. A duty to consider the impact on mental health of any proposed change, from education to workplace to welfare, would be difficult to frame but might be profound.