"The difficulties in all these excellent promises are how they will be operationalised in practice. After all, we don’t have a single standard for physical health."Simon Wessley
05 December 2019
Mental health is front and centre at this election, but are the parties' promises deliverable?
SIMON WESSELY: Evidence-based policymaking is crucial to implementing and delivering mental healthcare that works
The Policy Institute is producing a series of comment pieces analysing election manifesto pledges from the different parties across a range of policy areas. Read the full series here.
It is hardly surprising, given the recent attention, that mental health would appear prominently in the manifesto of any self-respecting political party. It is hard to remember that it was not always the case. Indeed, health, let alone mental health, did not appear much during the first two decades of the NHS, when our “national religion”, as Ken Clarke described it, barely received a mention in any manifesto. In 1951, the Labour manifesto made a brief mention, saying “the NHS is the admiration of the post-war world”, the only party to comment on it at all. And that was pretty much it for the next 10 years.
Even during the 1960s and 70s, the “Health Service”, as the Conservatives continued to call it, barely makes an appearance in any manifesto. Health was a minor issue, largely restricted to promises around child and maternal care. In 1964 the Conservatives pledged that “every mother who needs to will be able to have her baby in hospital.” Paradoxically, a 21st century version might now promise the opposite.
However, by the 1980s, the NHS, as opposed to just health, became the battleground. The 1992 general election was the first time that one party would claim that “this election will decide the future of the NHS”. The Liberal Democrats announced in 2005 that “the future on the NHS is the most important issue for most voters, while the “NHS is on the ballot paper” appeared in numerous Labour manifestos right up to 2017. The Conservatives were playing catch-up until in 2010 they announced themselves as “the party of the NHS”.
However, even where the NHS was a contested territory in general elections, mental health figured not at all, perhaps as something embarrassing, and not to be discussed in public, and certainly not a vote winner.
The first appearance of mental health was in 2005, when Labour made noises about improving mental health care in primary care, and also talked about reform of the Mental Health Act. However, two of their three promises were around improving public safety rather than better care for the mentally unwell. By 2010, things changed and mental health was beginning to become a prominent issue with cross-party commitments to a massive expansion in the talking therapies – the Improving Access to Psychological Therapies programme. The Lib Dems were by now making the running, with a much longer set of promises, some of which were implemented as part of the Coalition.
By 2017, the space given to mental health across all the manifestos was larger than that devoted to any other health issue. The same is true this time round. Mental health is firmly established in the public and political agendas, although it is likely that the commitment is deeper in the former than the latter. This is partly a matter of age – millennials have much more liberal attitudes to mental health than baby boomers, and the political classes tend to be from the latter.
So, looking at the current offerings, we can see a great deal of overlap.
“Parity of esteem” provides common ground. The Liberal Democrats say they will treat mental health with the same urgency as physical health, identical to the Conservative pledge. Labour hits parity of esteem fair and square with “ensuring access to treatments is on a par with that for physical health conditions”. They also promise new “standards for mental health, enshrined in the NHS Constitution”.
The difficulties in all these excellent promises are how they will be operationalised in practice. After all, we don’t have a single standard for physical health – we know that some things need to be treated quicker than others, and also some places are better for emergencies than others. I remember when I was a junior doctor the A&E sister would come up to anyone sitting in the queue to be seen, point to the sign above the door and ask sweetly: “Are you an accident, my dear?” and if the answer was no, then continue: “Are you an emergency?”. If the response was again negative, her voice would change and she would tell them to “piss off then”. Not the greatest customer service, but she was right in that not everything in either physical or mental health is an emergency.
What we really need to make these commitments real are specific statements such as “Everyone with a first episode of psychosis should be seen within four weeks” and so on. The Greens say that everyone who needs them should have access to “evidence-based mental health therapies within 28 days”, which is a start in one sense, but a non-starter in another due to workforce issues. Saying we will treat physical and mental illness the same sounds good, but we could be treating them both equally badly and still fulfil the commitment.
The problem is that in reality physical and mental illnesses are not the same. I remember chairing a panel including the formidable Hannah Jane Parkinson, winner of numerous journalistic prizes and someone who has been under section when her bipolar disorder relapsed. A person from the audience made a statement to the effect that having a mental breakdown should be no different to having a broken arm. The audience approved, but Hannah Jane did not, and was on her feet with a vehement “I have had both, and I can tell you they are not the effing same”
“Parity of Esteem” is a general principle more than a detailed policy. It doesn’t mean that our treatments should be identical, or that we should spend exactly the same on mental as we do on physical illness. All of that would be daft. But it does mean fairness. For example, any promises to improve the estate on the physical side of the Cartesian divide should be accompanied by an equivalent commitment to the mental side. What we don’t want is, for example, the Conservatives announcing at their party conference that they would spend £4 billion on the acute hospitals, but in the same press release £70 million on mental health services. Our side of the road still awaits the promised £800 million capital investment to bring our estate up to even a tolerable standard.
“Parity of Esteem” is a general principle more than a detailed policy. It doesn’t mean that our treatments should be identical, or that we should spend exactly the same on mental as we do on physical illness.Simon Wessley
Now forgive me if I dwell a little on the reform of the Mental Health Act. That’s because I spent most of the last two years chairing the Independent Review for England and Wales. We reported in December 2018, to a favourable reception from the key stakeholders including all sides of the political spectrum, so it is good to see this consensus reflected across the manifestos. Full marks to the Liberal Democrats, who promised “full implementation” and even namechecked me. Labour promised exactly the same, albeit without the flattery. The Conservatives are slightly more elliptical, but subsequent conversations and indeed tweets confirm that the commitment given in the last Queen’s Speech to Mental Health Act reform remains in place.
All parties also agree on the need to find better ways of helping those with learning difficulties and/or autism – some of which are addressed in the Mental Health Act review, but others, probably the most important, depend on providing more and better local support and provision. Whoever wins the election should be careful not to rush on this – it took a generation to achieve the transformation of care represented by closing the asylums; it will take time to do the same for learning difficulties and autism.
Perhaps the greatest risk to reform remains the fact that the Brexit saga will continue, and I use the word “saga” in the Norse meaning of a story in which no one wins and most die. It will continue to wreak havoc with parliamentary time for a long time to come and may present barriers to the implementation of many issues in which there is consensus but not enough parliamentary time.
There are other areas of broad agreement relating to mental health. Tackling domestic violence or doing something about housing and rough sleeping cannot be faulted in all the manifestos. There is also consensus on social care – unfortunately the agreement is that it’s important and in crisis, and no one really knows what to do. Labour and the Liberal Democrats at least have a go, while the Conservatives have placed this on the “too difficult” list.
But there are differences, both in presentation and in commitments. The Conservatives have a relatively brief single section (under “We will focus on your priorities”), Labour have a longer section which includes more on the money and some good promises on eating disorders and gambling. But they also have small mental health spin-offs under “Justice” and then “Work” (a Royal Commission on workplace health including mental health and safety).
But when it comes to the space devoted to mental health, there is only one winner. Since 2010 the Lib Dems have given more prominence to mental health than anyone else, and this year was no exception. In their manifesto mental health features in the introduction, strongly under the economy, a huge chunk under “Health and Social Care” and finally a little coda under “Our Plans for a Fairer Society”. Throughout, they pay far more attention to the “wellbeing” agenda, promising a Minister for it, and echoing the lead of New Zealand. True, these are unlikely to be implemented, unless Boris or Jeremy have their “I agree with Jo” moment, which seems unlikely, but the Liberal Democrats must get credit for ambition, and I suspect imitation being the sincerest form of flattery, they may have to settle for flattery in place of power.
That’s not to say everything is of equal merit. As a King’s College London academic I am a member of the Boring Boffin club and prefer evidence to ideology every day of the week. Yes, there has been in increase in the true prevalence of mental disorders in students, but it’s nothing like as large as many media reports and off-the-cuff surveys would have you believe, and it’s not clear what the reason is. Likewise, there seems to be a mental health crisis in every single occupation going – just in the last few weeks this has been said of the entire NHS workforce, police, farmers, teachers, dentists, lawyers, students, accountants and so on. Yet population studies that include all of the above, not to mention the government’s own measures of happiness, provide a different picture.
And some of the commitments, most obviously from the Lib Dems, mainly because they include more policy on it, are less evidence-based than my Boring Boffin party would like. Better mental health education for teachers sounds good, but the evidence suggests that it improves teachers’ knowledge rather than the mental health of children. What is a statutory Student Mental Health Charter? I doubt that the so-called epidemic of mental health problems will be solved by an epidemic of counselling, and I hope that is not the intention. Indeed, much-derided social media may in practice play a more positive role by promoting social networks than any party is willing to concede.
There is a real risk of jumping to a prescription or interventions when frankly we don’t yet have a diagnosis for what has gone wrong, let alone a cause or causes. The history of mental health interventions, well-intentioned but not based on robust evidence, suggests it is sometimes easier to make things worse than better.
There is a real risk of jumping to a prescription or interventions when frankly we don’t yet have a diagnosis for what has gone wrong...The history of mental health interventions, well-intentioned but not based on robust evidence, suggests it is sometimes easier to make things worse than better.Simon Wessley
And finally, there is the workforce. Or to be more precise, where is the workforce? Mental health is a low-cost part of the NHS, because we don’t prescribe lots of budget-breaking drugs, and don’t use very expensive kit. Instead, our biggest expense is people, and there is no getting away from the fact that we don’t have enough to deal with current needs, which is one, but not the only reason, why I have expressed scepticism about whether there is a continuing need for yet more mental health awareness weeks. Most people with mental health disorders already know they have problems, and their reluctance is based more on scepticism that our existing staffing and services are adequate to help them, and owes less to stigma than some assume. Increasing awareness is no longer the key issue – increasing staffing is.
All the parties recognise that if you stimulate demand without increasing the workforce, you end up with more frustrated patients and more burnt-out staff. It is good to see all the parties recognise the mistakes made with nurses, and pledge to reintroduce bursaries for “specialist nursing” in areas of the greatest shortages (Liberal Democrats), a maintenance grant for student nurses (Conservatives) and reintroduce bursaries (Labour). After that, things become more blurred.
Here one has to feel sorry for politicians. They know that you can’t magic up 6,000 extra GPs or psychiatrists from the Job Centre, and although, for example, my college has helped turn around psychiatry recruitment, the benefits in terms of consultant numbers won’t be visible until at best the parliament after the next one.
Yes, you can recruit, Brexit permitting, compassionate people who can deliver support and comfort. Yes, you can ensure that in, for example, the workplace the person one above you in the hierarchy, whether you be a teacher, blue-light worker, doctor, nurse, soldier or whatever, has better mental health skills (notice I say skills, not knowledge). But when it comes to what we need to deliver the assessments, care and treatment, that can only come from a consultant, a clinical psychologist, or an experienced social worker or A&E nurse – and that takes time.
And time is always the commodity that is in short supply when it comes to politicians and their manifesto commitments.
Simon Wessely is Regius Professor of Psychiatry at the Institute of Psychiatry, Psychology & Neuroscience, and Director of King's Centre for Military Health Research, both at King's College London.