Mark Brown examines the reasons why we accept the idea that there is no money for mental health services and asks what happens when we move from ‘Why? No money’ to ‘Why no money?’
If there’s one thing many of us ‘know’ about mental health is that there is never enough money to provide support for people to maintain it. Mental health is the ‘Cinderella Service’ people say and we all nod. ‘It’s true, isn’t it?’ we say and then get on with trying to cope with whatever deficiency in the support or services. But why do we accept there’s no money?
It’s possible to find money in government if the will is there. Health secretary Jeremy Hunt announced in June 2014 an extra £250million for elective surgery to clear a backlog of operations over the summer months to reduce waiting times. A vote winner; but also proof that there is money that can be found if a need to is recognised
Lack of funding for mental health is not a natural fact. Lack of money for mental health is a result of decisions made by people. Decisions about what receives funding and what does not are made by people, not abstract forces like institutional bias or lack of parity of esteem. Governments make decisions, people in organs of government make decision, voters make decisions about for whom they cast their vote. Rhetorical abstractions move us further from analysing why money does not flow.
Crisis? What Crisis?
The run up to a general election is a funny time. All of the voices of sectional interests who have remained quiet for the length of the government so far suddenly find their voice. There is a ratcheting up of coverage of problems and perceived problems; bodies and organisations that have notably avoided public tussles find new stridency in their criticism of elements of government policy on which they had been surprisingly quiet in recent memory.
Whichever party or parties are in government, the temperature of debate always rises in the year running up to an election. So it is in mental health. There has been a hum of news stories, increasing in pitch, signifying an ever growing sense of crisis. Pulse reported that in their survey of GPs a fifth claimed to have “seen patients come to harm as they were unable to access appropriate support from their community mental health teams, with some patients committing suicide, being sectioned or admitted as a result”; and that “More than eight out of ten GPs saying their local community mental health service could not cope with its caseload”. (worth noting that committing suicide is the incorrect term for UK as suicide is no longer a crime, but you know what they mean). Labour’s shadow public health minister Luciana Berger used Freedom of Information (FOI) requests to Clinical Commissioning Groups to find out that, according to The Guardian’s reporting of the story, “72 of the 142 (67%) which responded spend less than 10% of their budget on mental health services.” . The Royal College of Psychiatrists announced in June “mental health services were approaching a “tipping point” due to lack of beds. Add to this increasing pressure from NGOs and third sector organisations over the effect of benefits reform and you have quite a stew of mental health discontent. Something has to change, the ‘official’ voices say at a point where, almost as if they’d planned it, there is strong possibility of policy change via democratic vote.
The elements of the press interested in mental health have consistently covered mental health stories, of course, but even they are sensing that in a post-Health and Social Care Act world mental health is one of the elements of social provision that is suffering disproportionately. The Guardian and the Sunday Express have kept up a notable stream of stories covering the failings of our current mental health settlement. In May 2014 Andy McNicoll (@andymcnicoll) of Community Care Magazine wrote a magestic post picking away at why the problems in mental health persist. This built upon October 2013’s collaboration between Community Care and BBC News who worked together on a series of FOI requests to NHS mental health trusts that found a 9% reduction in available mental health beds since the year 2011/2012. Health Service Journal’s Shaun Lintern (@shaunlintern) has expressed similar enthusiasm for getting to the bottom of what’s up with mental health.
So, at a basic level, we know things aren’t quite where they should be. As everyone always points out; if this were any other national service it would be a national scandal. So why isn’t it?
The cinderella service cop out
If there’s one thing that people know if they know that there is a challenge in providing mental health services it’s that mental health is the ‘Cinderella service’. Poor old mental health: when her sisters cancer, or dementia, or maternity or Accident and Emergency get whisked off to the funding ball she has to remain at home cleaning the hearth and peeling the spuds. Mental health – always the bridesmaid, never the bride. What does that mean, though? To describe mental health as a cinderella service is presented as some great insight. People will nod in approval of the grasp that the utterer has of the dire challenges we face. They, the listener will think, they really understand the challenge we face.
The problem is that ‘Cinderella Service’ is not an analysis of the problem but merely a description. It in essence says ‘there is no money for mental health because there is no money for mental health’. It is deployed as an answer to the questions ‘why can’t we have more of X in mental health?’ and ‘Why doesn’t Y work in mental health?’
Writing for Liberal Democrat Voice, Minister of State for Care and Support Norman Lamb acknowledged the cliche replacing it with a seemingly more concrete concept: “It’s a bit of a cliché to say that mental health is the Cinderella service of the NHS but it’s essentially true. There is a real institutional bias against mental health. It loses out financially when budgets are tight for local commissioners and significant advances on choice and access for patients introduced by the Labour Government left out mental health.”
In the manner of many pseudo-profundities ‘cinderella service’ is a metaphor which merely restates the initial premise in more poetic terms, obscuring the fact that it fails to move the inquiry any closer to any concrete answer. It’s a rhetorical device to obscure uncomfortable truths and to abstract analysis from the real questions. It makes the answer to any question about failings within mental health ‘because there’s no money.’
But that isn’t an answer it’s a statement of the situation. Similarly, the idea parity of esteem (an idea that features large in rhetoric but currently features three priority areas: Improving Access to Psychological Therapies for people with anxiety and depression; improving diagnosis and support for people with dementias; and improving awareness and focus on the duties within the Mental Capacity Act) is an abstraction suitable to mandate on behalf of but very difficult to grasp day-to-day.
The current priority areas for parity of esteem also confirm the feelings of many people with enduring, more severe mental health difficulties that there is no commitment to ongoing support, never mind commitment to increasing the wellbeing of those with conditions other than anxiety and depression related disorders.
Even a commitment to mandating maximum waiting times and access standards for psychological treatments only covers a tiny element of the needs of people with mental health difficulties. It does not, for example, cover social care support or other services. It also introduces the perverse incentive well known to rail companies when fines exist for late running trains: you will accrue less fines if you cancel in advance services you know will be late running, meaning that while you provide no service to the passenger you do not affect your record of trains in service that arrive on time.
From ‘Why? No money.’ to ‘Why no money?’
It’s notable that a search of Closing the gap: priorities for essential change in mental health published by the Department of Health in January 2014 and detailing their short to medium terms aspirations for mental health in England, reveals eleven mentions of ‘funding’: none of them relating to new funding available to commissioners to pay for services. The strategy stresses the need for change and better use of what’s there. It’s unclear what framework will achieve that strategy
It isn’t, however, often that easy to work out what actually is there in terms of funds and investment that can be used better. The final official compilation of overall national spending on adult mental health available is the 2011/12 National Survey of Investment in Adult Mental Health Services published in March 2013 published by The Department of Health. The data for 2012/13 may be available if pieced together from different sources, but the FOI requests from which current stories of crisis are built may indicate otherwise.
It is possible to pull rabbits out of hats. The art of the Chancellor of the Exchequer on Budget day is doing just that. As are most cabinet ministers close to election time. If we are always happy to accept that the reason for our failure in mental health is that there’s no money, we’re avoiding asking why there’s no money. Instead of ‘Why? No money’ we need to be asking ‘Why no money?’
In 2013 The World Health Organisation (WHO) published Investing in mental health: Evidence for action, an excellent paper which in their own description examines: “potential reasons for apparent contradiction between cherished human values and observed social actions.” The paper examines the case for governments across the world to invest in mental health by acting upon avoidable risks, providing essential care and enforcing fundamental rights. It also examines why governments do not make these investments despite convincing evidence to encourage them. As the report has it; there are a “number of barriers that continue to influence collective values and decision-making – including negative cultural attitudes towards mental illness and a predominant emphasis on the creation or retention of wealth (rather than the promotion of societal well-being).”
It’s worth looking at what WHO regards the justification for state intervention in mental health. The UK, even with our currently falling level of investment, still has one of the best funded systems of social support for people with mental health difficulties in the world. The report states: “ there is ample international evidence that mental disorders are disproportionately present among the poor, either as a result of a drift by those with mental health problems towards more socially disadvantaged circumstances (due to impaired levels of psychological or social functioning) or because of greater exposure to adverse life events among the poor.”
The WHO feel there are a number of key actions, not limited to treatment, requiring state intervention to promote mental health:
provide better information, awareness and education about mental health and illness;
provide better (and more) health and social care services for currently underserved populations with unmet needs;
provide better social and financial protection for persons with mental disorders, particularly those in socially disadvantaged groups;
provide better legislative protection and social support for persons, families and communities adversely affected by mental disorders.
Recognising global variation in methods of government, The WHO says: “The exact nature of these collective actions or responses (e.g. the extent to which governments actually offer social protection) will vary according to prevailing notions of social choice in a country and the existing health system structures and constraints. In other words, governments do not need to pay the entire mental health budget or provide all services themselves (a nongovernmental or private entity may also contribute), but governments do have an obligation to ensure that appropriate institutional, legal, financing and service arrangements are put in place to protect human rights and to address the mental health needs of the population.”
Democratic governments maintain their position by remaining popular. UK government maintains its ability to make things happen by gaining the support of the electorate and by gaining agreement of elected representatives to make, amend or remove laws; set taxes; and decide budgets. Centrally controlled spending can be centrally controlled. Devolved spending, such as spending within the current NHS and Local Government budgets can be mandated or incentivised.
The discussion of barriers to investment within the WHO report is not extensive but suggests that one of the reasons why governments do not invest in mental health is because there is always something more important to spend money on.
From a policy perspective mental health difficulties are not leading causes of mortality in populations. In other words people do not usually die from mental health difficulties in large, definite numbers in a way that pricks the public conscience and the ways in which mental health difficulty and other problems which may result from them interact is obscured. If someone loses their job as a result of a mental health difficulty and becomes homeless that is seen as a housing problem. If someone with mental health difficulties becomes involved in crime this becomes a criminal justice problem. If you don’t meet people’s mental health needs they drift into other services and thus out of the mental health budget entirely and as such the investment in mental health can always be put off to address the more direct demands placed by reactive services. In this way reactive spending always trumps other forms of spending. This is particularly problematic in mental health as reactive spending is often a response to people’s needs after their wellbeing has been destroyed, undermined or otherwise lost to them.
The WHO paper also suggests that while governments may be fully aware of the individual and community costs of unmet mental health need, they are also aware that to pay for meeting that need would mean removing funds from another potentially more valued activity. So, in essence, the decision is made to underfund mental health on the basis that other areas of spending are considered to be more important either to government or to voters. In essence, the moving of funds from one or more things to mental health is considered to be too much of an electoral risk. In the UK at present, for example, it has been argued that the decision to attempt to cut spending on social security benefits and reduce government spending has been at the cost of the mental health and wellbeing of many people involved in the claiming or receipt of those benefits. (see Royal College of Psychiatrists statement for one amongst many.)
The WHO also identify the fact that “persons with a wide range of health conditions currently lack access to appropriate health care” as a potential barrier to greater investment in public mental health. In other words: why should mental health come top of the list when there are a number of other competing claims on public funds? Governments, and commissioners in turn, choose where to direct their funds based on evaluating competing demands.
Further to that the WHO suggest that negative perceptions of mental illness (stigma) influences decisions as well as “Low expressed demand/advocacy for better services”. There is, in other words, a lack of political will and political pressure to spend on mental health other than in the ways already decided upon.
While England is is investing historically unprecedented yet still modest amounts of funds in combating mental health stigma its arguable that this is not creating a demand for better services. While it is true that there has been a recognition of underfunding, there has yet to be a clear, strong, coherent and attractive vision for where the lives of people with mental health difficulties should be in the UK.
While it would not be true to say that lip service alone is being paid to the challenges of mental health, it is true to say that the decision to invest has not taken place during the course of the current Parliament. The work of mandating and setting policy in process has occurred, but there has not been the political will to move significant funds into improving the lives of people with mental health difficulties or even to return existing services to previous levels.
Scarcity thinking or ‘can I have the crumbs from your table’?
Ultimately, the widely held belief that we can’t have more, better and more diverse mental health supports and services because there just isn’t enough money to go around is both a result and a cause of our inability to believe it can be otherwise. Eldar Shafir speaks about scarcity and its effect on our decision making. When we feel there is not enough of something we need, we become preoccupied with how we’ll manage to get through situations where we might need it. When we are hungry all we can think about is food. When we don’t have enough money to live on, we can’t do much else but worry about the fact that we don’t know how we’ll make it to the end of the week. Mental health as an area of human endeavour is rife with scarcity thinking; with every service, every professional worrying about how they’ll make ends meet or continue to deliver what they can with ever decreasing resources. This uses up any energy and any space to ask questions about the future or to really consider the direction in which services and support are travelling. It makes us in mental health hugely grateful and excited about even the smallest morsel of succour or sustenance at the same times as we know that it will plug the hole for minutes at best.
Mental health is slowly starving. It make bad decisions when every service or sector fights to fill its own belly first. And perhaps it always will until we are prepared to move from dumb acceptance of talk of cinderella services and ‘more for less’ and actually ask the question: Why has the decision been made not to spend on better mental health for all and who made it?
And then, if the scarcity can end for more than a fleeting moment we could, maybe, begin to ask: ‘How should we spend money for better mental health?’
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter