Mark Brown (@markoneinfour) tries to collect together some of the questions and worries for mental health as a sector and for those that experience mental health difficulties posed by June 23rd’s EU referendum vote.
On 24th of June 2016, a narrow majority of people in the UK voted to leave the European Union in a national referendum. As I write this on Sunday afternoon it is not clear exactly what the next immediate steps are for the UK. It isn’t clear what Bexit as a policy, if indeed it becomes a policy, will mean for mental health as an area of activity and for people with mental health difficulties as a whole.
The first rule of mental health is that it always falls low down in the pile of funding priorities. Political reality defines whether mental health is a funding priority. If something else more pressing comes along; mental health falls off the bottom of the list. And that list in the UK just grew incredibly long. Whether you are pro-bexit or anti-brexit; it is impossible to deny that the UK has had in the space of 48 hours the greatest single change of political priorities since the beginning of World War II. As yet, there is little-to-no specific expert opinion about the effect that this change might have upon the lives of people with mental health difficulties, so I’m doing my best to cobble together some thoughts.
The first is that it is unlikely, no matter how hard we hope, that voting for leave will give us an immediate end to austerity. Benefits, affordable housing and other social protections will not see a rush of funding. In fact, little will change immediately.
As such, the following aren’t so much predictions as reasons why people might be worried or questions that are currently in need of answers. The answers will not be forthcoming immediately.
There are three real tracks of reality here. The first track is everyday experience. The on the ground reality is that, practically not much has changed since 10pm on Thursday the 23rd of June when the polls closed in the EU referendum. The buses are still running. Food is still the same price in the shops. No part of any government policy or british or scottish law has changed. If you’d avoided the papers and had a long weekend on the sofa watching Netflix in your pyjamas with your phone off it wouldn’t be immediately apparent that anything much had happened. We haven’t left the European Union yet.
The second track is what we can predict will happen to government; organisations; bodies; services and circumstances.
The third track is perception and what people believe will happen. The first manifestation of this is the volatility of financial markets. Money people don’t like uncertainty; and from the point that the referendum was called in the favour of Leave; the status quo was upended. Something had changed; even if its practical effects were not yet clear. Until it’s clear; things will be financially unstable for the country as a whole. The resignation of Prime Minister David Cameron on the morning of June 25th underlined this: whatever happens next it’ll be different.
If there was anyone waiting for business in mental health to return to normal anytime soon: it won’t. There isn’t a new normal yet.
The National Health Service
Whether we like it or not, many of us with mental health difficulties find the NHS is something upon which a degree of our wellbeing is dependent.
At present the leaders of the Leave campaign are desperately backpeddling from the claim that the disputed £350m the UK sends to the EU would be saved and spent on the NHS instead.
Despite the claim featuring prominently in the campaign, including on the side of a massive bus, it’s currently being discussed as a mistake or a misunderstanding.
I’ve not come across (yet) anything on the potential effects on the health services of Wales, Scotland and Northern Ireland but am happy to add if you get in touch in the comments.
The Health Service Journal were quick off the mark in looking at the potential effect of Brexit on NHS in England. The single biggest risk to the NHS is recession. If the UK does not successful steer its way through the choppy waters post Brexit, the something will have to go. The current government has been committed to moving to a budget surplus by 2019-20, which was looking dicey anyway. Any big drop in tax income would would blow that out of the water further meaning that the NHS will either need to provide less things or people will need to pay more taxes; the taxes option being pretty impossible if there are overall fewer people making enough money in work to pay those taxes.
The shorter term view from the HSJ is that even prior to the leave vote the NHS didn’t have enough money. On the immediate risk, HSJ quotes Chris Hopson of NHS Providers: “We would expect there to be a debate among system leaders about whether more needs to be done in 2016-17 to offset the risk that comes from choppier economic times. But our members would argue that they are already doing everything they can and if more money is taken out consequences will inevitably follow in service and staffing levels.” In other words; the riskier the present seems the more likely it is that NHS providers will cut what they can now to try to keep something in the bank for later. The instability in government; and potential increased volatility of the House of Commons makes the present seem riskier.
Dave West, writing for HSJ, notes that: “Jennifer Dixon, Health Foundation chief executive, warned that a vacuum of political oversight in coming months – along with the likely departure of patient safety champion Jeremy Hunt from the health brief – meant more risks may be taken with the quality of care.” NHS England was already facing a new settlement being drawn up from Government, as the NHS had collectively been given a deal where more money has been awarded upfront on the understanding that savings would be made. Those savings haven’t been made and prior to Brexit, the NHS was worried about having to try to find savings from its staff bill.
The worry is, then, that the NHS will be told to make savings on top of savings. Given the resignation of David Cameron as PM and the potential for a General Election to be called, it isn’t clear who will be in government beyond October when David Cameron’s successor will have been chosen by his party and what their attitude toward the NHS will be.
A further pressure would be the potential departure of NHS staff from EU countries, as noted by HSJ journalist Shaun Lintern. This would not only depend on changes to law, but to the also on the extent to which people feel welcome in this country.
Historically, mental health has not fared well in the NHS and it’s probably unlikely that any future leader of the Conservative Party will look so favourably upon mental health, given the possible upheaval in other areas of policy. Looking forward in 2017, the future is, as yet, unwritten.
The voluntary sector, unless it is involved in direct humanitarian crisis, generally needs a degree of stability to flourish. The voluntary sector in mental health in England and Wales has claimed a number of wins in the last five years such as the funding of national anti-stigma Time to Change and the prominence of mental health in David Cameron’s now dead in the water Life Chances strategy. The recommendations of the much trumpeted, oft-delayed Mental Health Taskforce The Five Year Forward View on Mental Health, the first independent mental health strategy headed by the voluntary sector which reported finally in February this year will now probably turn out differently. The next five years does not now look like it did when the Taskforce began drafting and redrafting.
Given the great potential changes underway, it’s fair to say that the voluntary sector in mental health is going to find it more difficult to get the ear of decisions makers. And more difficult to get people and funders to open their wallets, if indeed those wallets contain anything but pennies.
The voluntary sector as we currently know it is a direct product of the New Labour years between 1997 and 2008. During those years the voluntary sector grew, in part due to New Labour’s discomfort with being seen to spend too heavily on public services apart from the NHS. The NHS, in turn, looked toward funding voluntary sector mental health services as an add-on to their core business of treatment. Similarly, local authorities answered calls from community members for additional social care-ish services and funded some mental health related organisations and services via block grants.
As such, the voluntary sector in mental health grew but remained dependent on public sector money. The donor base, that is how much money mental health charities can raise from members of the public and companies giving voluntarily, remains low in mental health and is skewed very strongly toward the largest mental health organisations.
Grants were available from a number of grant making bodies and grant funders, with some funds made available from government for particular initiatives or schemes.
From 2008 onward, all of these streams of funds began to constrict. Not uniformly across the country or across all activities. The NHS and local authorities began to spend less on the funding of mental health related activities. Central government began to spend less. There was a kind of firesale where money was ‘got out of the door’ before it disappeared.
The 2010 general election ushered in a five year period of austerity spending policy. Money that was once there was no longer there, apt as a mirror of the financial crisis of 2007/2008 where this was literally the overnight reality as markets dipped and debt went toxic.
The voluntary sector in mental health was slow to wake up to this; focusing on keeping its head down and waiting for the money to come back. This, it seemed, was a policy change, a slowing of a general upward curve in the funds available for mental health-related work. Soon, business as usual would be resumed.
Except it wasn’t. The financial crash wiped a lot of money out; including money that charitable funders has invested in stocks, shares and other financial vehicles. The NHS reorganisation created by the cul de sac of the Health and Social Care Act 2013 and various decisions made about funding to Local Authorities meant that the squeeze continued. As satellites of the NHS and local authorities, with few avenues open to them smaller mental health charities began to collapse, larger ones tried to reconfigure to deliver what low level services were currently being put out to tender and the largest ones consolidated their positions as service providers.
The events of the last few days have the potential to shake up this situation even further. The politicians that were available for meetings and launches will probably be otherwise engaged. It’s not clear whether the opposition Labour party will even have the role of shadow minister for mental health, a role at time of writing occupied by Luciana Berger.
Writing for Civil Society on Friday 24th, David Ainsworth set out the stark challenge for charitable funding in wake of a full brexit: “The charity sector receives over £200m a year in grants from the European Union, and it seems unlikely that the UK government – free of an obligation to distribute this money – will continue to hand out this money. Given the lack of enthusiasm in government for grant funding – the minister for civil society himself suggested that grants were “unsustainable” – this money is unlikely to be replaced.” Whether much of that money is money at risk in mental health I’m not able to establish with what I have to hand; so it may be that this has little direct effect on mental health organisations but may have a large effect on people’s mental health through loss of other services.
Even starker was his warning about the effect of the drop in sterling and the possibility of recession on the money grant making bodies would have available to make grants. There have not been huge grants to mental health over the last five years; but funders have been there. Says Ainsworth: “Each year, charitable foundations make grants of about £2.5bn to the sector – as well as considerably more outside it – and the vast majority of this relies on income from £123bn of investment assets.
“At least, it was £123bn yesterday. The charity sector holds about half its assets in the UK stock market, and has therefore probably lost about £5bn since six o’clock this morning.
“A significant chunk of the money distributed by grant-givers comes from capital appreciation – the fact that shares go up in value faster than the economy as a whole. Unless there is a recovery over the next few months, there will be no capital appreciation to speak of this year, and grant-giving could be heavily affected.”
Who is allowed to provide services has been governed by EU procurement law (or ‘EU red tape’ depending on your preference). Some mental health organisations have increasingly become service providers to the NHS or to Local Authorities, in part due to the lack of available charitable funds or direct donations. If the UK actually formally exits the EU one potential change an exit might bring is a change in how services are contracted. Says a sector source: “many mental healthier services are being commissioned and retendered to deliver the ambitions of the Five Year Forward View on Mental Health. These contracts (because of their size) would be under EU procurement rules, which in some areas have prevented smaller, organisations led by lived experiences from being a lead partner in the contract. Leaving the EU might mean that we could diversify the provision within the local health economies. Alternatively a response might be bigger contracts for independent providers (but under domestic competition rules rather than governed by EU procurement). With the removal of state aid rules we could see greater investment by the state to continue support the ailing and underfunded mental health system or alternatively leave its survival to market conditions”
Writing for the voluntary sector as whole, Sir Stuart Etherington of the National Council for Voluntary Organisations said on Friday 24th: “We are just recovering from the previous economic crisis. Further years of economic difficulty would scarcely seem like a change to young people who have known nothing else. But they would mean more years of struggling to fulfil our organisations’ complete potential to do good, more years of seeing people struggle in the face of hardship. We can only hope for skilled and thoughtful leadership in the coming weeks and months in order to avoid the worst of the financial predictions.”
It can only be hoped that the mental health voluntary sector itself will generate such thoughtful leadership at this difficult time.
Crossing over to an extent with the story of the NHS and of the voluntary sector, social care is a far more fragmented area which some of us with mental health difficulties are lucky enough from which to still benefit.
Community Care’s Andy McNicoll writing on Friday 24th surveyed the main challenges ahead. On funding he points to the warnings of the Remain campaign prior to the vote: “During the campaign, chancellor George Osborne said he would have to slash public spending and put up taxes in order to plug a £30bn “black hole” if the UK voted to leave. Speaking alongside his predecessor Alistair Darling, Osborne said £15bn would have to come from cuts. Spending on local government could be reduced by 5% and the ring-fenced NHS budget cut, the pair warned.”
McNicoll also points to the fact that at current estimates over 80,000 people from other EU countries are currently employed in social care, about 6% of the overall workforce. While nothing legally has yet changed, as with the NHS, it will depend on current and upcoming events as to whether those people feel secure enough on the UK to remain.
The same concerns about funding and political priority remain; especially coming at a point where health and social care are meant to be moving closer to integration across England.
As to where this leaves conversations about personal budgets, access to advocacy and mental health social work is not yet clear. Funding remains a strong concern in the advent of a further recession.
Given how diverse the activity is that falls under the heading of social care; it’s going to take people much cleverer than me to capture the full range of issues as they relate to both Brexit and mental health.
I’ve not got to hand details of how much of the mental health related research in the UK derives from the EU, but it’s clear that the relations between EU membership and research is more complex than just funds; relating as it does to the ability of researchers to move freely across Europe and to collaborate. A worry is that UK research organisations will experience a ‘brain drain’ as people leave what may feel like a less hospitable country or that those born in the UK will look to move to EU countries if it looks like the UK will enter more challenging times.
[UPDATE 15.00 28th June: After a bit of asking about, a sector source suggested that the answer to this question is not clear cut. The second highest contribution after germany from Horizon 2020, the EU Framework Programme for Research and Innovation. According to the Association of Medical Research Charities the UK: "UK charity-supported researchers received over £260 million in further funding from the European Union, covering disease areas from arthritis to Parkinson’s disease in the period from 1st January 2012 – 31st December 2014."
My source suggests that if the weighting of funding toward mental health for EU funded work follows the pattern in the UK, 6 to 7% of those funds will have been used in mental health related research carried out by charities. My source also said it'll probably be a while before anyone is quite able to put a figure to the possible loss of funds to mental health-related research. But as mental health research is chronically underfunded already; it's unlikely that any variety of Brexit will lead to more; especially not in light of the potential effect on charitable funders noted above.]
Change and wellbeing
For some the Leave verdict was a blessed, long hoped for relief. For others it’s been accepted with trepidation and worry. Those who are happy about the result will be no less immune than those who voted for the alternative. For many people in the UK who were born in other EU countries it has cast a long shadow over their feelings of comfort and confidence about their lives in the UK. As we work through the potential paths forward from the vote and the implications of various courses of action it becomes clearer and clearer that what this all means is change whether we like it or not and whether we wanted it or not.
People with mental health difficulties are not generally well disposed toward change and uncertainty.
We also know that financial hardship, the experience of racism and that lack of security in our lives tends to exacerbate our mental health difficulties. We also know that people with mental health difficulties tend to end up experiencing more the effects of wider economic and social changes as we tend to be more vulnerable to changes in public policy, changes in the labour market and changes to the availability of social supports and social protections.
We also know that how people feel about their lives and their futures interacts with mental health in ways too numerous to mention. For a number of with mental health difficulties the last six years of austerity has felt like a collision between a worsening practical reality and a dimming belief in the future.
We don’t know how the majority of people who experience mental health difficulties voted in the referendum but we do know that a continued perception of chaos and uncertainty will not make people rest more easily in their beds; especially if this perception is backed up by increasing practical results of the referendum decision that do not directly benefit them.
Almost certainly people of other EU nationalities currently living and working in the UK will not be feeling comforted by the result. Nor will those who worry for the effect of general economic upheaval on services, benefits, jobs. Also, arguably, those who voted for Brexit may well find that the things they felt they were promised by the campaign are longer in arriving than they hoped.
If there’s one concrete fear that I have for mental health it’s that, despite all of our protestations, mental health will be at the back of the queue for the duration of the settling of the Brexit question. Something that might take years.
Whatever happens, we need to find ways to keep ‘buggering on’. This may be easier said than done, especially if there is a vacuum at the top. We all hope that people from different sides of the vote will be able to pull together within families, communities and other places to get on with life. At the time of writing this does not appear to be a process that will be led by Westminster; at least not until it actually becomes clear who is actually in control and who isn’t. Add to this the potential for, hopefully isolated, racist attacks emboldened by the overall turn against the EU and it seems that discord may be the order of the day for at least the immediate future.
Which will do no one’s nerves any good.
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter.