An innovative approach to mental health support

James_Morris_MPby James Morris MP

As chair of the All-Party Parliamentary Group on Mental Health, I am always pleased to hear about promising new ways of helping people who have previously missed out on effective treatment and support.

A group of GPs in the City of London and Hackney have taken an innovative response to the needs of people whose mental health problems are more complex than their doctor can manage alone yet who don’t qualify for specialist services. The Primary Care Psychotherapy Consultation Service (PCPCS) is run by the Tavistock and Portman NHS Foundation Trust. It offers hope to people who would otherwise get bounced around the NHS without adequate care and support, such as people with medically unexplained symptoms, those with personality disorder and those with complex mental health problems. This ground-breaking service offers a range of therapies, close to people’s homes, often in their own GP surgeries, not a one-size-fits-all service in a remote clinic.

complex_needsCentre for Mental Health has evaluated the PCPCS and shown that it has changed people’s lives. And it shows that the service offers good value for public money – not just by improving the health of people with complex needs but by taking pressure off primary care services and local hospitals.

Many of the patients supported by the PCPCS have multiple mental and physical health problems at the same time, coupled in some cases with a history of social difficulties, isolation, neglect and trauma. Because of this complexity, patients supported by the PCPCS do not fit neatly into any single diagnostic category and by the same token their needs do not map readily on to existing structures of service provision. They are unlikely to be well supported by local IAPT services, which are mainly set up to deal with relatively straightforward cases of anxiety and depression.

The Centre’s report shows that by offering a broad range of therapies, tailored to each person, and by advising GPs on how to manage complexity, services like the PCPCS can help to extend psychological therapy provision in the NHS and improve mental health support in GP surgeries.

I am delighted to see that the NHS is taking an innovative approach to improving mental health support, achieving better care cost-effectively, and making a real difference to people’s lives. The PCPCS demonstrates to the whole system what can be achieved by opening up the NHS to high quality psychological support to people who too often get nothing. I hope it will inspire many more NHS commissioners to innovate locally and improve mental health care for all who need it.

Helping young people out of offending

by Junior Smart

Junior Smart, Founder of St Giles Trust’s SOS Project which supports young people to exit gangs and serious youth violence, explains how young people become trapped in gangs and what can be done to support them.

Barely a week goes by in the capital without the distressing news of a stabbing or shooting. Behind the headlines, real lives are affected – mothers grieving for lost sons, girlfriends robbed of future partners, children left without their young father.  And there is a complex web of reasons as to why another often innocent young person has become yet another tragic statistic.

Gangs and serious youth violence thrive when there are no strong motivations in alternative directions.  A young person growing up in a deprived community with no advantages and opportunities will often then try to make their own.  And it is this vacuum that those at the top of gangs – the elders – seek to exploit.

Fear and manipulation pervade gangs and are central to the way they thrive.   It starts through persuading a vulnerable, isolated young man with no positive male role model in his life that he can make get cash and girls through carrying drugs and weapons for the top man on the estate.  Once he’s done a few runs, suck him in further with offers of promotion through the gang ‘ranks’ if he takes bigger risks.  Tell him you love him and that if he loves you back he’ll go even further.  Then threaten him and his family if he tries to break free.

A recent evaluation into St Giles Trust’s SOS Project analysed the practical, behavioural and emotional needs of a sample of young clients who were all caught up in gang crime.

Alongside practical issues such as housing, employment and finances were insights into their emotional and behavioural state.  54.4% showed signs of having suffered emotional and sexual abuse, 37% showed signs of stress and instability, 16.8% showed psychological problems and 14% reported self harm and suicidal thoughts.

This is a classic chicken and egg scenario – was a vulnerable young person already suffering from abuse and trauma deliberately targeted by a gang or did their abusive experiences in gang life cause these needs?  In truth, it is probably a mix of both.   However, such needs make the young people extremely distrustful of statutory services, reluctant to engage with support and unable to cry for help.

This is where we firmly believe SOS’s approach of using professionally trained, reformed ex-offenders who have direct experience of the issues the young people are facing is so crucial.  They have the power to reach the most heavily disengaged, needy, chaotic young people that are probably causing the most damage to others, their communities and themselves.  Because they have been in the same boat, they know how to reach out and handhold them out of this destructive cycle.

The same evaluation asked the clients what they thought had helped them.  87% felt that the SOS Project had changed their attitude to offending and 73% said that they felt it was important that their caseworkers were ex-offenders, because they could relate to them and felt inspired to change.

In essence, SOS creates a positive ripple effect to tackle the negative ripple created by gang crime.  By turning it on its head, we can change the hearts and minds of a few young people which will impact well beyond those individuals.  The means safer communities, less young lives destroyed by gangs and fewer future victims caught up in their often deadly vortex.

The SOS project and others are included as examples of good practice in Centre for Mental Health’s new briefing paper on Young adults in transition.

How mental ill health affects the economy

helenaBy Helena Brice

Last week the Organisation for Economic Co-operation and Development (OECD) released an in-depth report Mental Health and Work United Kingdom looking at how mental health affects the UK economy. The report recognises that mental ill health is a major problem for social and labour market policy and that it is a problem creating significant costs for people, employers and the economy.

The report notes that the UK is among the most advanced countries in terms of awareness about costs of mental illness for society as a whole, as well as the benefits employment brings for a person’s mental health.

Centre for Mental Health has helped shape thinking in this crucial area. We have released numerous papers looking at the economic impact of mental ill health on the workforce. In 2007, we estimated that mental ill health costs UK business nearly £26 billion each year. The OECD paper estimates that the cost to Britain as a whole was some £70 billion.

The OECD paper draws attention to shortcomings in the way we support people with mental health problems to get and keep paid work. We hope the Government will consider the report’s recommendations in full and build a more effective system of health and employment support for people who are out of work and have mental health difficutlies.

An encouraging aspect of the report is that many of the recommendation are in the process of being implemented.

This includes a proposal to improve employment support and access to psychological therapies for those with a common mental health problem who are out of work. This was pledged by the government in its Mental Health Action Plan released last month. The new Health and Work Advisory Service can also help to support more people who are off sick to get back into work rather than losing their jobs. A further challenge remains, however, about how to support people when they are first unwell, often long before they take time off sick, to help them to get access to treatment more quickly and prevent a protracted period of sickness absence.

The OECD’s report also recommends that GPs knowledge of mental health and work issues needs to be improved as they play a key role in both the health and benefit systems. The majority of people with a mental health problem will not see mental health services and will instead be looked after by their GP. A proposal from the Royal College of GPs for family doctors to get a year’s extra training, including a greater focus on mental health, could help to improve this. But it is also crucial that GPs are given up-to-date information about the help that’s available for people now, such as Access to Work funding for ‘reasonable adjustments’ at work.

A step towards closing the gap

helenaBy Helena Brice

Recently government published an action plan: ‘Closing the gap: Priorities for essential change in mental health’, building on the 2011 strategy paper ‘No Health without Mental Health’, which set out how to improve the mental health and wellbeing. The strategy aimed to put mental health on a par with physical health (parity of esteem) and to tackle negative outcomes. Lots of positive work has happened since the strategy was published, but there is a lot more still to do and hopefully this action plan will spur the relevant bodies back into action.There are key roles for all government departments as well as local authorities. The Health and Social Care Act 2012 enshrined parity of esteem in law and that esteem is now in the action plan. The Welfare Reform Act 2012 also has had major implications for people with mental health problems.

‘Closing the gap’ lists 25 areas where people can expect to see, and experience, the fastest changes. These fall under the following five headlines:

  1. Increasing access to mental health services.
  2. Improving the quality of mental health services.
  3. Integrating physical and mental health care.
  4. Starting early to promote mental wellbeing and prevent mental health problems.
  5. Improving the quality of life of people with mental health problems.

1.   Increasing access to mental health services

People have to wait too long for treatment but access to services is a very important step towards recovery. We therefore fully support the commitment to introduce clear standards for access and waiting times by 2015 but they need to apply to children and young people as well as adults. To monitor that this is taking effect in child and adolescent mental health services (CAMHS), the government must collect the appropriate data.

As the Bradley Commission’s first briefing paper explored, Black and minority ethnic (BME) communities are still a group less likely to access mental health services and, when they do, it’s often through less mainstream routes, such as community organisations or liaison and diversion services. It is fantastic to see in the action plan that the government is committed to working with the Race Equality Foundation and other stakeholders to understand why BME communities find it so hard to access services.

2.   Improving the quality of mental health services

Quality of mental health services is a huge issue; unlike in physical health services the friends and family test has not been in place. This means that mental health services have not been under the same obligation as physical health services to improve. Information about public attitudes to the quality of services has not been collected and services can’t find out what works and what doesn’t work. We welcome that from the end of December 2014, the friends and family test will be used in all mental health care settings including for children and young people.

3. Integrating physical and mental health care

If the health care system is going to become more efficient, it is vital that mental health and physical health are integrated. Although there was a clear objective in the strategy that more people with mental health problems would have good physical health, this has still not been realised.

If mental health and physical health are better integrated it will have a number of positive outcomes, not only leading to better health but also to savings for the NHS. A great example of such integration is psychiatric liaison services. They provide mental health care to people being treated for physical health conditions in general hospitals and were found by the Centre to save an average hospital £5 million a year. Centre research has also calculated that between 12% and 18% of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – this equates to roughly £10 billion in England each year.

Accordingly, it is very good to see that the government has asked Health Education England to develop training programmes for healthcare employers on mental health problems and how they may affect their staff.

4.   Starting early to promote mental wellbeing and prevent mental health problems

The government has acknowledged that half of people with lifetime mental health problems first experience symptoms by the age of 14. One in ten children aged between 5 and 16 has a mental health problem, the most common of which is conduct disorder. At its most severe, conduct disorder affects 5% of children but many more will suffer from early behavioural problems that will have serious consequences. If these early behavioural problems are not dealt with, the children affected are twice as likely to leave school with no qualifications, three times more likely to become a teenage parent, six times more likely to die before age 30 and 20 times more likely to end up in prison.

The action plan commits to support schools to identify mental health problems sooner. This is very encouraging, but more needs to be done.

Too often teachers don’t know the symptoms of mental health problems in children and, if they do, are not sure where to refer them. The Centre recently published a series of tailored briefings aimed at different professionals that may come in to contact with children who have the signs of conduct disorder. One of them is specifically for those working in schools.

We know that targeted parenting programmes are effective and cost effective, for severe behavioural problems. The cost of these interventions is more than covered by subsequent savings in public spending. Parenting programmes need to be easily accessible to those parents who need it, but we know that this is not currently the case.

5.   Improving the quality of life of people with mental health problems

Mental health lags behind many other conditions on the information front. Cancer has a long established National Cancer Intelligence Network and there is also a Child and Maternal Health Intelligence Network. Public Health England and NHS England are currently establishing the Mental Health Intelligence Network (MHIN). This network will bring together comprehensive information about mental health and wellbeing to provide a greater insight into common mental health problems, how they vary with age, and what the make-up of different areas is in relation to mental health problems.

The information will help health and wellbeing boards and clinical commissioning groups commission the most appropriate services for their areas. It will also help better inform the government of what works. Practical and substantive change cannot be made without this information.

In recent years there has been a central government cut back on collection of data, hopefully the MHIN will help buck this trend. It is encouraging to see that the government is pushing for greater information sharing. Integration can only truly happen if the information is shared, however we must make sure that the correct information is shared. Information is vital to drive change and to influence policy.

Why this document is good

This paper re-asserts who in the health and social care world are responsible for what in mental health. It is brilliant news that the government is planning on measuring their progress against the priority activities described in the document and that they will report back next year. This means that we should be able to see where improvements are really being made and where work stills need to be done.

The false economy of cuts to crisis care

 seandugganBy Sean Duggan

Just weeks after exposing pressures on acute beds in mental health services, Community Care and BBC News have today given the clearest warning yet about the extent and impact of spending cuts in community teams across England. Its survey, based on exhaustive searching of board reports from mental health trusts, indicates that services are experiencing significant real terms cuts and in many cases being forced to reduce capacity in community teams, including crisis resolution and home treatment.

This is extremely worrying news. Crisis teams were a major and vital component of the National Service Framework for Mental Health, with a good evidence base for their effectiveness when implemented properly. Cutting back on the edges of such services can easily undermine them, reducing their ability to offer the support people need when they need it. And with police stations still too often used as ‘places of safety’ and growing pressure on A&E units, salami slicing mental health crisis care appears to be a serious false economy.

The NHS is of course facing an unprecedented financial challenge and local government is having to make bigger sacrifices still. And the way mental health services are paid for, especially for children, still makes them much more vulnerable to short-term cuts than many other health services. Commissioners and providers of mental health care alike are then left with major dilemmas when told they must make cuts. Too often, the most vulnerable services are those that intervene early, that support recovery and that respond to the distinctive needs of the most marginalised in society. Cutting back on these services can be disastrous, storing up bigger problems as people’s needs escalate, placing yet more pressure on higher cost inpatient services.

The government and NHS England alike have pledged to place mental health on a par with physical health and to work to close the gaps between them. Today’s survey is a timely and sobering reminder of how big a challenge that is. We need urgent action to ensure that spending on mental health care is protected and that money is directed towards services that promote wellbeing, support recovery and integrate physical and mental health care. We need to reinstate or replace the national survey of investment in mental health services and extend it to children’s services. And we need to support commissioners in the NHS and local authorities to reinvest in the most effective interventions and protect those that already offer good value for money.

Knocking mental health stigma for six

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By Andy Bell and Helena Brice

The breaking sports news on Monday morning was that that the England cricketer Jonathan Trott was immediately leaving the Ashes Tour in Australia due to a stress-related illness.

Trott is one of a growing number of notable sportsmen and women who have been open about experiencing mental health problems, including Marcus Trescothick, who later spoke movingly of his depression, Ian Thorpe, Clarke Carlisle, Dame Kelly Holmes and Gemma Spofforth.

Mental ill health can affect anyone regardless of their job, gender, background or social standing. It affects one in four adults and one in ten children every year, most commonly as depression or anxiety.

The recent Channel 4 series Bedlam and BBC Three’s Don’t Call Me Crazy demonstrated to wide audiences that mental health problems can affect absolutely anyone and that the impact mental illness can have on our lives varies enormously from person to person. But a consistent message from people living with mental illness is the devastating impact of stigma and discrimination. They can stop people from talking with family, friends and colleagues about their mental health and prevent people from seeking help from their doctor or their employer when they become unwell. Some three-quarters of people with depression and anxiety get no treatment at all and many more do not seek help until they reach a crisis. In the meantime, many lose their jobs and experience difficulties in their relationships – making it even harder to recover.

Time to Change, a joint initiative by Mind and Rethink Mental illness, has been working to end stigma around mental health since 2007. A recent study of the impact of Time to Change so far has found that public attitudes towards people with mental health problems have improved and that people with mental health conditions are experiencing less discrimination in their everyday lives. But this is a task that will take a generation and it needs to be sustained for some time.

Last year, for the first time ever, four members of parliament spoke openly about their experiences of mental ill health. The same year saw legislation to banish the last vestiges of outright discrimination against people with a mental illness, for example in relation to jury service.

We are making real progress towards a future in which a person who experiences mental ill health can speak openly about it, can get help they need in a timely manner, and will be treated with the same respect at work, at school and indeed in the media as someone experiencing a physical illness. The media response to Jonathan Trott leaving an Ashes tour has been far more sympathetic and understanding than that given to Marcus Trescothick seven years ago. If we can just accept that mental ill health is a normal part of life and ensure that those who experience it get the right support to help them to recover, we will truly build a better society for everyone.

Follow @Andy__Bell__ and @Hel_B on Twitter

A louder voice for mental health

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By Andy Bell

AndyBell

This week, five MPs have marked Parliament Week by writing blogs for Centre for Mental Health on the importance of a range of mental health issues in their constituencies. The five MPs come from three different political parties and from different parts of the country. They are united, however, by a common understanding of the importance of mental health in their constituencies and the need for greater attention both locally and nationally to the needs of people living with a mental health condition.

A few years ago, it was a rare occurrence indeed for mental health issues to be talked about in parliament. Few members of parliament felt compelled to champion mental health issues or raise concerns about the needs of people with mental health problems. When mental health issues did receive political attention, it was often only because of concerns about risk and violence that often exacerbated stigma rather than reducing it.

In the last two years, by contrast, mental health has been debated in parliament on numerous occasions, on a range of different topics. Some MPs have talked about their own experiences of mental ill health for the very first time. And last year parliament legislated to outlaw the last vestiges of discriminatory legislation against people with mental health problems such as the bar on jury service or sitting as an MP.

This begs two important questions. Why has this dramatic change happened? And what difference will it make to people’s lives?

The reasons for this change are many and varied. The Time to Change anti-stigma campaign and the willingness of people such as Stephen Fry, Ruby Wax and Alastair Campbell to talk about their experiences of mental ill health have created a new openness that did not exist even five years ago. More MPs are also now telling us that mental health issues are prominent in their constituency surgeries and the letters they receive – that more people are talking to them about mental health concerns and seeking support for their causes. A combination of encouragement and pressure from constituents to engage more positively with any issue can greatly enhance its importance to MPs.

The difference it will make is harder still to gauge. But signs of progress are evident. With more MPs talking about mental health and championing specific mental health issues, ministers and shadow ministers are raising their game on mental health, too. The government’s commitment to ‘parity of esteem’ for mental health has been made far easier by the universal support it receives from Westminster and this is beginning to change the way policy is made.

Too often, mental health has been an afterthought for policymakers – now it is very clearly being considered when policy is made, and not just in health but in other areas that affect people with mental health conditions. We have a long way to go before we can say with certainty that mental health issues are getting the consideration they deserve from across government and public services, but we are making progress.

And we are also beginning to see mental health issues growing in their prominence in local politics. A growing number of councils now have member champions for mental health through the mental health challenge. Some have used their new public health responsibilities to develop local mental health strategies that seek to improve wellbeing for all and to support people with mental health conditions more effectively. And it is local people talking about mental health issues to councillors that has provided the biggest impetus behind this increased interest in what councils can do to help make their lives better.

The blogs we have published this Parliament Week show how far we have come in raising the political profile of mental health. We know there is much more to do to translate this attention into action that will make a difference to people’s lives. But by building on the support we have and by encouraging MPs, councillors and other in elected office to take mental health issues seriously we can ensure that the voices of people who live with mental ill health are always heard, never ignored and consistently heeded.

Andy Bell is deputy chief executive at Centre for Mental Health.

Follow Andy on Twitter @Andy__Bell__