It is a pleasure to be with you in York today.
I wanted to come to your conference for three reasons: because you asked me, and in Opposition you don’t take that for granted; secondly, because as the Healthcare Commission reported, Mental Health Trusts offer some of the consistently highest standards of management in the NHS, and, thirdly, because on your shoulders will fall some of the most serious consequences of our present economic crisis, and I want to tell you how I believe Government should help.
Barely a day goes by where we do not hear of thousands of jobs being shed in firms across the country. That means the livelihoods of thousands of families destroyed. The security of thousands of homes at risk. The self-respect of thousands of people dashed. Economic crises mean human catastrophes. It is vital that we see past the economics of the days that we’re living in, and see the human misery that is the end result. Mental illness is one of the greatest causes of misery in our society. It is possible to be physically ill, but still be generally happy. It is very hard to be happy and to be mentally ill. So there can be no fundamental wellbeing without good mental health. Perhaps the ultimate "no fault" illness – it can affect any one of us at any time, however talented, fortunate or careful. Just as the recession we are now facing is no respecter of social groups, mental health also touches individuals and families across Britain indiscriminately.
My concern is the health of the nation. It is vital that the effects on mental wellbeing of unemployment do not routinely become the cause of long-term mental illness. In just the last year, 89,000 people claiming unemployment benefit became unfit for work because they had developed a mental illness and moved onto incapacity benefit, where their chances of moving back to work are far slimmer. We don’t yet know how long recession will last, or how deep it will be. But with unemployment at an 11-year high and an expected 2 million people out of work by the New Year, we can expect a sharp increase in these problems. As people everywhere face unprecedented levels of stress, and the demand on services increases, it is more vital than ever that the Government act now to stop a financial crisis becoming a mental health disaster.
In 2000, Alan Milburn warned the NHS that it was in the ‘last chance saloon’. He announced that his vision for change would centre on a complete overhaul of mental health services. He promised us a ‘safe, sound, supportive mental health system.’ Yet the legacy of this overhaul is that mental health wards have become ‘tougher and scarier’ places under the Labour Government, according to the Mental Health Act Commission. Over the past 10 years, the use of inpatient mental hospitals has increased, but the number of psychiatric beds in England has fallen. The recently elected President of the Royal College of Psychiatrists admitted that the state of some wards is so dire that he would not let his own family use them – and he conceded that worse is to come.
I and my colleagues secured major changes to the Mental Health Act. The Government repeatedly promised that the introduction of Community Treatment Orders would not be used as an excuse for further reductions in in-patient accommodation. It had better not be. We don’t have to agree entirely with Dinesh’s characterisation to know that we must do better. That is why I have announced our intention to offer capital funding support for more single rooms on mental health wards, to bring down the rise of assaults.
The legislative format for compulsion in relation to mental illness has been one of the less impressive tales of policy making and service provision of the last 11 years—and there is some competition on that score. In reality, the only real ‘overhaul’ turned out to be the overhaul of individual liberties as the Government established a legal framework to bring people under compulsion. The recently enacted Mental Health Act is one of the only things that we have to show for the Government’s efforts: after a so-called blue paper, a Green Paper, a White Paper, an expert committee report, a draft Bill in 2002 and 2004 and a subsequent Joint Committee on the Draft Mental Health Bill report, eventually Ministers acknowledged that their proposals were unworkable and moved to an amending piece of legislation.
I think they hoped that this laborious process and statements of priority, such as those contained in the national service framework in 1999, would cover up for the lack of policy and practical support for mental health services: there has been no debate in Government time on the Floor of the House on mental health services during eleven years of Labour rule, the level of resources going to mental health services have not kept pace with the increase in resources provided to the rest of the NHS, and mental health patients don’t have the same assurance of access to services that other patients enjoy.
We welcome what progress has been made since 1999. The roll-out of crisis resolution teams, early intervention and assertive outreach have been significant innovations. But on so many counts – resources, waiting times, quality assurance mechanisms and health outcomes – mental health services still do not get the priority that the depth of suffering demands.
I know that we can and must do better. Today, I want to highlight five key objectives that I see for the future stewardship of mental health services.
1) Firstly, we will enable patients to access treatments that work. The main reason for the slow progress to date is the lack of priority that the Government has given to mental health. If you're referred for psychological 'talking' therapies for a condition like depression or schizophrenia you may well wait 6 months. Some people wait up to two years. And, in the same way that physical conditions get worse when not treated, a mental health condition will also deteriorate.
The case for talking therapies and CBT is proven: allowing unemployed people to access cognitive behavioural therapy can double the rate at which they are able to re-enter work. NICE has been recommending psychological therapies for people with a range of mental illnesses for years – but reports show that 86% of people with schizophrenia aren't getting this treatment.
We must be clear that psychological therapies are not a one-size-fits-all solution, but we do know that for many people they are clinically effective, and that they reduce costs in the long-term. Yet they continue to be overlooked. The current time-scale for the Government to act upon urgent recommendations about the need to roll-out CBT - issued by their own ‘happiness tsar’ Richard Layard in 2004 - is at least six years.
They were warned in 2004 that we need 10 000 extra therapists giving evidence-based psychological treatment, a doubling in the number of psychiatrists within ten years, and for all new psychiatrists to be trained in CBT. Only in 2010 or 2011 can we expect to have 3,600 extra cognitive therapists, focused on only 20 out of 152 Primary Care Trusts, and I know that there is real concern and good evidence that this will only happen as a result of budgets for in-patient and acute care being raided.
The story is the same when it comes to employment advisers in GP surgeries. Ministers announced in 2004 that they would physically locate employment advisers in GP surgeries. Despite numerous reviews and pilot projects confirming that this is essential to improve mental well-being, the Government are still dithering. Now, with the numbers of unemployed at record levels, none of the infrastructure is in place to provide this vital service when it is most needed.
Time and again, they have mistaken reviews and pilot projects for substantive progress, and forced sufferers to wait years for the treatment that the Government knew was necessary all along. Now, as the economic slump begins to affect everyone and everything, many more people are at risk because of the Government’s failure to prioritise these vital services during the good years.
Researchers have studied the experiences of those who have lived through previous recessions, and found that the number of mental illnesses and suicides surged as the psychological effects of unemployment, repossession, and the fear of both, touched whole families and communities. Unemployment was also estimated to be associated with a doubling of the suicide rate in one study. Based on this research we have calculated that we could see a 26% rise in the number of people suffering mental health disorders by 2010 as a consequence of the recession. This could mean 1.5 million more people seeking help for mental health problems in England alone.
There are immediate steps that can be taken. The Government should give priority access to new and clinically-effective psychological therapies to the unemployed – those who desperately need it at this time - by redistributing the promised funding and therapists fairly across the country and to refocus the help towards unemployed people as a priority. The Government must also act now to establish links between Jobcentres, GPs surgeries and back-to-work programmes to give sufferers the best possible chances of recovery in these difficult times.
2) Secondly, we will ensure that our constant goal, focus and preoccupation matches that of patients and their families everywhere – that is, the outcome of their treatment. Neither regulation, legislation nor resources have proved to be sufficient tools for Government to provide clinically effective treatments that are geared towards recovery.
It is time for a new approach. We will stop the health department endlessly measuring input and processes, and concentrate on outcomes. We will divert the £billions that have been spent over the last five years on pursuing targets to improving patient outcomes. The Department of Health have paid lip-service to developing measures for mental health outcomes – in 2006 they announced the launch of National Outcomes Measurement Project that would result in standardised outcome measures for mental health. Unsurprisingly, more than two years later we have heard nothing else; as with anti-stigma campaigns, it is actually third sector organisations and the Scottish Government who are setting the agenda on this count.
I am not pretending it is easy to develop outcomes measures for mental health illnesses. A radiographer can conduct an x-ray to see whether a tumour has been reduced. A dietician can look at the scales to determine whether a patient remains obese. Well-being is much more difficult to quantify. But this is a challenge that we will not shy away from. People with mental health problems currently have the lowest employment rate of any disabled group. We must do better. Because whether or not a mentally ill has moved from dependence to independence, whether they can manage their own finances, whether they return to employment, whether they maintain long-term relationships, whether there are any repeated suicide attempts – these are the things that matter to patients and their families.
One of the most important outcomes for those who suffer from mental health illness is whether they are able to return to work. The Government’s own evaluations show welfare-to-work programmes do not have anything like the focus needed to help unemployed people with mental health problems, despite the striking correlation between these conditions. We are looking at as many as 1.5 million extra people in England alone suffering from anxiety, depression and other mental health disorders by 2010 as a direct result of a massive leap in unemployment. That could mean an extra 1.5 million families and communities touched by the misery of mental health illness.
Yet perversely, current rules prevent some of the best quality mental health provision available, provided by Foundation Trusts, from helping tackle unemployment by providing their services to welfare-to-work providers and employers trying to manage workplace sickness. So this arbitrary rule acts as a direct obstacle to patient recovery, restricting the supply of expert services that could help tackle and prevent mental ill-health. With one hand the Government issues directives and agendas on health and wellness, yet with the other they strip these trusts of the autonomy to respond to this agenda by providing vital services. We will scrap this bureaucratic rule and we will set providers free to concentrate on getting people back into work.
Mental health is more than the absence of symptoms of mental illness. It is a sense of well-being and effective functioning as an individual in a community. So we will enable payment for performance, based on the delivery of mental health outcomes determined in a Quality and Outcomes Framework which, instead of measuring processes and input will incorporate a much greater emphasis on the actual outcomes for patients, including patient self-reported outcomes relating to general well-being. We will insist that people with mental health problems receive the same level of treatment for their physical health needs as others by assessing and recording the outcomes of this care through the QOF. Government will only succeed in empowering individuals to take control of building a meaningful life for themselves when we gear the service towards this outcome.
3) Thirdly, we will seek to give mental health patients more control over their healthcare. Currently, a quarter are not involved in deciding their care plan. Nearly a third of those who did not receive any counselling said they would have liked to. The Government have virtually given up on direct payments for mental health patients. For these patients, giving them control – which is often exactly what they feel and fear that they lack - is a vital tool towards recovery and an aid to self-awareness. Involvement is crucial: patients who have chosen a specific pathway of care will be likely to comply with the various steps along that pathway. This is an area where we can do better if the Government could only learn to relinquish top-down command and control.
We will bring mental health into the mainstream so that GPs have greater access to mental health budgets for their patients and more responsibility for seeing the whole of the mental health patient pathway, rather than their being, as at present, more or less forced to abdicate responsibility and hand it over to mental health trusts. A Conservative Government will put our money where our mouth is – we will devolve the decisions and move the money as close to the patient as possible. So we will give people a choice of GP. We will allow patients to choose, in consultation with their GP, where they get their secondary care. And we will ensure that hospitals and clinics and other care providers are paid according to the results they achieve.
Practice-based commissioning can never respond directly to the needs and wishes of patients unless GPs are responsible for real budgets. GPs cannot meaningfully deliver the choice in treatment which people need unless we extend the tariff into mental health, to enable commissioning to drive payment by results, reflecting the cost and complexity of mental health care. We have had promise after promise about this from the Department of Health for years now – I have submitted a series of Parliamentary questions to the Minister to try to pin them down on when we can expect this - and all we get is a series of interim reviews. If we are serious about making our service patient-centred we will listen to their preferences and put money and choice at their disposal.
4) Fourthly, we will be proactive, not reactive. Mental illness is itself the cause of substantial physical ill-health. Those with mental health problems have higher rates of obesity, smoking, heart disease, high blood pressure, respiratory disease, diabetes, and strokes. The economic costs of mental ill-health have been estimated at £77 billion per year in England – more than the total costs associated with crime. The CBI estimate the output lost from time-off due to depression, anxiety and stress is around £4 billion a year. So it is in everyone’s interest to tackle this deeply entrenched social problem.
There is a deep unease about what could be called social breakdown, which goes far beyond a lack of income and often describes people who live in highly concentrated communities, experiencing multiple and complex challenges that serve to lock them and their children into a cycle of under-achievement, poverty and unhappiness. The United Kingdom recently came bottom of a league table of 21 rich countries in a UNICEF study of child well-being. A further report has shown that one in four teenagers suffer symptoms of depression. A whole generation has been characterised as the ‘IPOD’ generation – ‘Insecure, Pressurised, Over-taxed and Debt-ridden’. We have one of the worst drug problems in Europe, and one of the highest rates of family breakdown in Europe.
There is a wealth of evidence that shows that family breakdown, serious personal debt, drug and alcohol addiction, failed education, worklessness, dependency and mental health are deeply inter connected. The majority of people suffering from mental health illnesses have experienced more than one of these problems.
The Government’s mental health strategy is severely hampered by their refusal to recognise the inter-relatedness of these deep-rooted, societal contributors. Family breakdown is a precursor to poor mental health, but debt is a significant driver of family breakdown. Similarly, high levels of failed education contribute to worklessness and dependency, which often lead to ill- mental health. For too long now, politicians have settled for piecemeal responses to social problems, reacting to profound fractures in society and human wellbeing with short term policy solutions. That is why they have only succeeded in fire-fighting a phenomenon which has both cause and effect in wider social breakdown.
So it is time to recognise that mental health is not exclusively a health department or health and social service issue. I agree entirely with Professor Sir Michael Marmot when he said recently that success in this area is ‘not a lever that the Secretary of State for Health has in his hands, but it is a lever that Government has in its hands.’ It is because the Government have designated the problem as a narrow medical issue that their response has been to focus on the elimination of symptoms, rather than the vital outcome of recovery. The sustainability of the NHS and the well-being of the population depend on the achievement of far greater success in mental health than has been seen over the last decade. David Cameron has made it clear on a number of occasions that the renewal of the NHS is our number one priority, and that the building of stronger families and a stronger society is our overall mission.
That is why we will have a Secretary of State for Public Health. I will be directly responsible for a cross-government strategy on mental health, actively co-ordinated across departments and with a champion at Cabinet level. We will also implement a new structure for public health, which would enable local directors of public health – jointly appointed by, and accountable to, PCTs and local authorities, with the power to allocate independent, ring-fenced budgets – to determine how funding for preventative health services would be spent. These directors of public health would be better placed to make effective interventions across the health, local government, education and social housing sectors to promote mental well-being in individuals, families and communities. Prevention is still better than cure.
Finally, we will invest to save. All the evidence suggests that the most cost effective way of improving well-being is through early intervention. In the United States they have found that for every dollar invested in the first three years of a child’s life, there is up to a seventeen-fold return through the reduced costs of healthcare, increased employment and reduced crime. So we will not hide in the political comfort zone of moral neutrality. We will not shy away from tackling the underlying drivers of mental health illnesses, rather than merely treating the consequences of a problem. Instead of a short-term, reactive approach to mental health illnesses, we will focus on early intervention that will improve the long-term well being of everyone.
That’s why we want to scrap Labour’s plans for a new army of untrained Sure Start outreach workers so we can have over 4,000 extra health visitors and guarantees of family visits before and after your child is born. We will provide vulnerable families with a lifeline at a critical stage of development to promote the lifelong emotional health of infants. We believe that in these times of stress and anxiety, the family is still the best welfare system there is, and we are determined to back it.
It is because we are committed to early intervention that we have also launched a ‘Responsibility Deal’ for public health - a Conservative response to challenges such as mental health illness which we know can’t be solved by regulation and legislation alone. It’s a partnership between Government and business that balances proportionate regulation with corporate responsibility. We will empower companies to maintain a healthy work force, and empower the work force to maintain good mental health by using the local networks of business organisations to establish ‘Health at Work’ schemes.
In the last year alone, around 141,000 people claimed incapacity benefit for mental ill-health who had been in work or on sick pay immediately prior to their claim. Government research shows 69 per cent of these people had no access to occupational health services through their employer. By allowing employers to access occupational health services through Foundation Trusts, we will provide a major boost to promoting better in-work mental health support. We will also support an ‘Investor in Health’ accreditation scheme alongside ‘Investors in People’. For businesses who meet this standard, we will prioritise the availability of services, including cognitive behavioural therapy and occupational therapy.
Conclusion
Mental illness is a central healthcare issue. The WHO said that depression is a more disabling condition than angina, arthritis, asthma and diabetes. Yet too often, not least because of the stigma and discrimination which bedevils debate on mental health, these people do not agitate. That is why your work - and that of patient representative groups – in providing a voice for the voiceless remains so vital. Now, in difficult economic times, as countless more people face the misery of mental health illness, your energy, enthusiasm and expertise are more vital than ever in securing recovery and well-being for patients with mental health illnesses.
But where you have provided that voice, the onus is now on the Government to respond. I mentioned earlier the stark warning that studies of previous recessions issued about the impact on mental health. An equally relevant caution that researchers issued concerned the failure of Governments at the time to acknowledge and act upon the social impact of recession. In the midst of serious discussions over unemployment figures, fiscal stimulus packages and interest rate cuts, we can not allow the Government to lose sight of the most pressing consequence of the current problems – human misery.
Mental health illness is the forgotten face of this recession. Dithering and denial are wasting precious time that should be spent developing survival strategies for individuals, businesses and communities. Now is the time to bring priority access to new, clinically-effective therapies to those threatened by unemployment, and to bring forward legislation to scrap the bureaucratic rule that prevents Trusts from supplying the best possible treatments to both unemployed people and at-risk employees.
Mental health is not just a matter of private misfortune; its pernicious effects reach to families, communities, society and the economy - so it must become a matter of pressing, public concern. Now, more than ever, those who do not agitate on their own behalf need to know that Government can see past the financial facts and figures to the human misery that is the end result. Now is the time to give the mounting numbers facing unemployment and mental health illness the care that their suffering demands.