Today Team Mindapples are at the Mental Health Congress, running our now-famous tree pop-up and listening to a range of specialists from the mental health care and policy communities speak about the future of the sector in the UK. Here are a few of the key points that I felt were most interesting from the plenary sessions today.
Bruce Calderwood, Director of Mental Health Policy at the Department of Health, kicked off the day with a policy overview. The Mental Health Strategy is a good document and the intention to take an integrated approach to put mental health on an equal platform with physical health is encouraging. The part that particularly interests us at Mindapples is the first objective of the strategy, “More people will have good mental health”. There is a lot in this strand, mostly focussed on supporting people to stay mentally healthy at key life stages (childhood, education, work, life, and old age). What was striking though is that there was no reference to direct mental health promotion campaigning, beyond a cursory reference to the usual “5 Ways to Wellbeing”. For the sixth objective, reducing stigma, the Department and Comic Relief have pledged over £20 million pounds to the Time to Change campaign (our clients for much of our public engagement work). I would like to see the equivalent funding committed to promoting good mental health in the wider population. I think this is the area of greatest potential impact for improving mental health in the UK, and I’d like to see it given the same level of Central Government support as other parts of the strategy.
Jenny Hyatt from Big White Wall popped up with the first question, which was about ‘e-mental health’. Do we need a strategy specifically for how digital tools can be used in mental health care? Bruce said this was an area that needs more work, and I agree. What I’d add to that is that we need to think much more broadly than simply electronic service delivery, into the role of digital in reshaping our models of care, joining up clinical and non-clinical services, and particularly in connecting people together within and outside the care system. ‘e-health’ doesn’t just have to mean transactional services.
The next panel was on healthcare service commissioning, not directly my area but it was interesting listening to the themes that emerged, particularly in the Q&As afterwards. There was a lot of talk about change, and barriers to innovation, with St Mungos making the point that if commissioners are being told specifically how to commission for care pathways, local innovation becomes very difficult. A commissioner from Croydon, now part of Mindapples amalgamated NHS partners ‘NHS South East London’ also raised concerns that the economies of scale gained from amalgamating local NHS commissioners is offset by the barriers thsi creates to localisation. The most significant point for me though was made by the ever-vigilant Michele from CoolTanArts, who pinpointed that the rhetoric around patient control and choice, so central in recovery, wasn’t being backed up with a clear plan for patient involvement and choice in the care and commissioning process. The message back, sadly, was that in a decentralised system without common commissioning pathways, service users were going to need to “stamp their feet and kick up a fuss” to be heard.
I had to skip the presentation by Peter Finn at the Audit Commission (sorry Peter) on benchmarking measurements, but I did speak to him over breakfast and he asked me what key measurement we should add to the national standards to help us measure the quality of care. My answer was locus of control, measuring how far our public services give users a sense that they are in control of their care and conditions, rather than feeling powerless in the face of external events. My reasoning for this is that an external locus of control has been linked with significant negative mental and physical health issues, whilst feeling empowered and in control of our fate is excellent for our mental health. Control is very much a subjective phenomenon, but it strikes me as very strange that no-one in our public services (and indeed in our workplaces) seems to be measuring this simple and vital factor in people’s health and wellbeing. And it would be very cheap to measure.
Ian Hulatt from the Royal College of Nursing was up next after the break, and he talked in detail about how mental health nursing has changed over the past decades. We now have a generation of nurses who were trained in a very different way from the old-fashioned, coercive world of the asylums, but mental health nursing still has an image problem, and the RCN is doing a lot of work on this. My personal experience of mental health nurses has been that they are universally very caring people who struggle every day to both care for and respect the views of some very troubled and troubling patients. It was encouraging to hear Ian talk about the importance of good health and wellbeing in the care process too, although of course crises do happen.
Some stats for you now, shared from Department of Health figures by Chris Naylor of the Kings Fund. 30% of the UK population have a long-term health condition, of whome around 30% have a mental health problem. 20% of us have mental health problems, of whom around 46% have long-term conditions. Which is a complicated way of saying that long-term conditions and mental health problems go hand-in-hand, and the cost of this ‘co-morbidity’ is huge, both in human terms to the quality of people’s lives, and also in the financial impact of increased service use and costs. Generally, for example (US data now), long-term patients with depression cost around twice as much to treat as those without depression. The Kings Fund estimates that £1 in every £8 spent on long-term conditions goes on treating related mental health issues. To be less mercenary about it, people with bipolar disorder and schizophrenia die 10-25 years earlier than the rest of the population, and far more from “unrelated” physical health conditions than from suicide. So improving the mental health of long-term conditions patients should clearly be a top priority for the NHS. Their top suggestions include adding a psychological component to existing physical care services, and improving the mental health support in Primary Care (something we’re obviously keen on given our ongoing GPs pilot work). So, if anyone out there wants to speak to us about how Mindapples might be used to support the treatment of long-term conditions, please do get in touch.
I was most encouraged by Chris’s point that, although we have physical health co-morbidity mentioned in the Mental Health Strategy, what we also need is to place mental health at the heart of our physical health strategies. I’ve met so people in the NHS and local government who are really aware that many physical health issues, particularly public health problems, are deeply connected to low-level mental health issues – and yet public health in the UK remains siloed, with “alcohol” in one corner, “obseity” in another, “smoking” over there. Recognising the common thread of mental health problems running across so many of our health and social issues feels like an obvious and overdue policy focus, so anything that places mental health promotion at the heart of policymaking for physical health gets my vote.
And on the lifestyle point, next speaker Geraldine Strathdee made an impassioned point about the patronising attitudes we take to patients around lifestyle, and that we should never prescribe medication to patients without first giving them full information about lifestyle changes and other health considerations, to help them make informed choices. As she puts it, we wouldn’t ever prescribe medication for diabetes without also talking through information on diet and nutrition. Giving patients more information and choice about taking care of their minds – nice one Geraldine, I’m a fan. And obviously I think Mindapples could have a key role to play alongside Weightwatchers, free gym passes, sports groups and other parts of the personalised care plans that assist people to get and stay well. I asked Geraldine and Chris this question: given what we know about the value of integrating mental and phyiscal health care and of patients making more informed lifestyle decisions, was there enough emphasis in current policy on education and engagement, to ensure patients and the public know what they can do to look after themselves and are educated about their health needs? Chris felt that this was absolutely central to the Government’s new strategy, because we can’t have a deregulated and decentralised market for healthcare provision without having educated and empowered ‘customers’. However, he also felt that this element had been sidelined for the timebeing because structural concerns are dominating the debate at the moment. Geraldine’s argument was actually that there isn’t enough that policymakers can do, and it’s up to the staff on the frontline to do what we know needs doing – and if we want to create a mass movement to promote this information, we absolutely can. Inspiring and pragmatic stuff, but having tried to do just that for three years now, I can tell you that a bit more support from Central Government would definitely help!
Last up was Prof Neil Greenberg from the Kings Centre for Military Health Research. The key point I took from this is that the biggest issues faced by armed forces members being referred to mental health services are “adjustment disorders” – the struggle to reintegrate back into civilian life. This issue has been well-documented, and is a perfect example of how much our mental health is a product, in part, of our relationship to society, with people struggling to adjust to what might on the surface appear to be a less traumatic and difficult situation. Our friends at Big White Wall are doing a lot to support veterans now, and I had a good discussion with someone working on this at the Department of Health about how Mindapples might get involved in supporting our armed forces to manage their mental health more effectively during and after service. So lots to think about there too.
I will be giving a talk this afternoon about positive mental health promotion and preventative care, so I’m hoping to raise some of the points above with the audience then. I’ll post a few points from the Day Two sessions tomorrow too, and in the meantime please do leave us comments if you have any thoughts on any of this. It’s the only way we’ll learn…
**Addendum: Day Two has been very clinincal so I won’t be posting a summary of all the sessions. But, we’ve just been to an excellent couple of presentations this afternoon about involving young people in creating their own mental health interventions, so here are a few extra notes from them.**
Elise Leclerc from the Mental Health Foundation’s youth projects team presented some great impact findings from their work to engage young people in the design and delivery of services. We also heard from MAC-UK about their great work with young people at risk of mental health issues and offending. Here are a few stats from their presentation:
- Serious youth violence much a public health issue as much as a justice one
- 1 in 3 young people who offend have an unmet mental health need at the time of offence
- Clinical depression is far more likely to present as aggression in young men; aggression which leads to violence
- The evidence suggests that once young people are in the justice system, their mental health needs remain unmet
Young people who are at risk of mental health issues, and of offending, often have complex, multi-level needs, and the evidence from all these presentations is that the best way to help them involves engaging them in activities and services which they have chosen and helped to create. It’s also worth saying that fear of violence contributes significantly to the anxiety levels in young people, so it isn’t so much about stopping young people from being violent, it’s about keeping them safe.
The undoubted highlight though was Stella Charman of Right Here, who is the only person I’ve heard over these past two days (apart from us) who is talking about the central value of ENGAGEMENT. They have a lot of evidence of the clinical value of engaging young people in therapeutic activities that they actually enjoy, like rockclimbing and music production. She really knew the value of understanding what people actually WANT to do, as a route to encouraging people to participate in services and seek help. Mindapples won a Cabinet Office award in early 2011 for an idea to visualise insights data about what people say THEY think is good for their health and wellbeing. There is a huge volume of insights data being collected through Mindapples site (50,000+ suggestions and counting), and from service co-design and co-delivery projects across the country. If we were selling a product like Coca Cola, we would begin by seeking to understand what consumers value and desire, and we think all this data would be incredibly useful for understanding how to commission services that will actually engage people – and yet we’ve had very little interest from public commissioners in finding out what their “consumers” actually want.
The best quote of the whole conference for me was from Stella, who summed up our attitude to mental health services in the UK. “The therapeutic value of a perfectly-planned, fully evidence-based UNATTENDED intervention is ZERO.” Exactly. Thank you, Right Here, now let’s get engagement on the policy map for 2012!