Mind The Gap – Mental Health and the NHS

Guest Blog by Stuart Carroll, Senior Health Economist and Epidemiologist

“Mind the gap” is a warning sign synonymous with the London Underground.  Narrow platforms, hustle and bustle, rush hour pandemonium, Londoners jockeying for positions like horses in the Grand National is the “every man for themselves” scene when travelling on the tube. A scene that is invariably more chaotic than Claude Shannon’s theory of entropy.

As recent analysis has shown, this same warning sign confers equivalent applicability in parts of the NHS as worryingly exemplified by the widening gap and deterioration in the provision and delivery of mental healthcare services across England.  A gap policy-makers have neglected to keep in mind.

Reports of patients travelling horrendously long distances to seek critical emergency care combined with inadequate and underfunded services highlight the extremity of a problem that has now become entrenched and institutionalised.  This sad and unacceptable fact has been acknowledged by Norman Lamb, the Care and Support Minister.  It has also been a prominent area of contention promulgated by Ed Miliband during heated exchanges at PMQs, albeit given Labour’s doubtful record over 13 years of government that is a bit like the Hunchback of Notre-Dame telling someone to sit up straight.

How and why has the NHS failed to be the progressive and comprehensive service its raison d’être demands it to be when it comes to mental health?   Although there are multi-faceted reasons, there are arguably three key contributory factors.

First, there is the problem of priority.  It is axiomatic, or at least it should be, that changing culture and perceptions, which in turn help to shape priorities and mould policy imperatives, is a non-trivial business.  The uncomfortable truth is that politicians have been allowed to preside over an NHS where mental health has been marginalised, side-lined and operated like a “Cinderella service”.  In short, it has not been viewed as a “Champions League” priority, which has been reinforced by society’s proclivity to tuck the issue underneath the national carpet.  Like all health and social issues, removing the taboo around mental health is key and, although significant progress has been made compared to previous generations not least because of the excellent work of charities such as MIND and SANE combined with better education and shifting societal attitudes, there is still a long way to go.

Second, there is the problem of context and equivalence.  Although mawkishly over-medicalising mental health problems and conflating with every day stresses and strains is invidious and unhelpful, getting people talking about the issue more openly and frankly is important for improving patient health outcomes, but also for galvanising political pressure and awareness to put mental health on the same map as other disease areas.  Until a majority of people feel able and comfortable talking about mental health problems whether that be with friends, family, employers and doctors, and without fear of being discriminated against or being treated differently, this problem will persist.  An example of this is within the work setting.  Someone with a heart condition or a broken leg would, in most cases, have relatively few qualms about notifying their employer of restrictive ill-health.  Someone with debilitating depression is less likely to be forthcoming instead hiding and masking the problem often with adroit application.  Awareness of mental health, and the private hell many people go through, still has some way to go, as does cultivating an open and secure environment to do so.  This is key for political pressure and action.

Moreover, although the media has adopted a more responsible agenda on mental health in the last decade or so, problems still persist around understanding and perspective.  We still live in a society where ludicrous and misplaced throwaway remarks such as “what does that person have to be depressed about” or “stop being soft and pull yourself together” can be cynically heard, which only serve to subliminally, sometimes overtly, reinforce regressive attitudes towards mental health and discourage people from talking about their suffering.  Of course, any such perspective fundamentally fails to understand that mental health problems are not simply a function of an individual’s circumstances, status or wealth, but are often a consequence of factors that on a clinical, genetic and psychological level are decidedly more complicated.  Asking why someone is depressed would be a bit like asking Usain Bolt why he did not run the 100 metres when carrying a serious hamstring injury.  This lack of equivalence obviates necessary understanding and the broader perspective central to improving societal awareness.

Third, there is the issue of measurement.  The same levels of performance management required for physical conditions, such as the NHS 18 week maximum target for waiting times, do not apply to mental health.  This is an outrageous reality, pungent of a rotten status quo, that the current Government and future administrations must be impelled to reverse.  Cynical voices might say that any such change would be tantamount to special pleading, but that would be wildly incorrect.  The antithesis is true.  Ensuring equity across NHS performance management and target metrics is seminal to creating a level playing field to drive up standards and foster a culture dedicated to improving patient care.  It is also fundamental to the principles of a service striving to be a universal, comprehensive and free at the point of delivery healthcare system.

Against the backdrop of increased incidence and prevalence of mental health problems (empirical evidence continues to suggest that one in four people suffer from some type of mental health problem), the health economic imperative is also vital to the future sustainability of the NHS and the wellbeing of our wider society.  If we do not properly invest in mental health services, including better preventative and management strategies to tackle its root causes and subsequent afflictions, the cost burden never mind the human suffering will be incalculably high.  For all these reasons, our politicians should act now to reverse this worrying legacy of inadequacy and tokenism.  After all, a bit like the tube, gaps should always be minded.  In the case of mental health, this is an action point our policy-makers would do well to remember.