By Dr Karen Newbigging
Like politicians before her, Theresa May recently announced that mental health will be a priority, referring to “mental illness as a burning injustice”. Whilst this focus on mental health and framing in terms of social justice is welcomed by all those who are concerned about the low priority often afforded to mental health, there are questions about whether such warm words will be translated into any real step-change.
The first test of this is surely the publication of 44 Sustainability and Transformation Plans (STPs). Announced in 2016, STPs are five year plans to cover all aspects of NHS funding and are also supposed to foster better integration with social care.
In this viewpoint, I identify five tests as a basis for analysing the STPs to assess the chances of Theresa May’s expressed commitment to mental health being translated into practice. The first test is whether mental health is even identified as a priority within the plans and whether such a statement of priority is clearly translated into achievable action. Mental health can be an afterthought for a hard-pressed NHS, responding to increasing pressures and austerity measures. Indeed, concerns were raised last year about the sustainability element of STP funding being largely apportioned to the acute sector. A good STP will treat physical and mental health even handedly; make the links between physical and mental health; set out clear goals for the transformation of the mental health system across the age range, and make it clear how this will be implemented.
Whilst there are performance indicators for mental health, investment and development support will be required to support the changes that are needed and this is the second test for the STP plans. The thorny question of investment was largely missing from Theresa May’s announcement, and this has been a major focus for criticism of her announcement. This omission needs to be set in a context of chronic under-investment in the mental health system, with a reduction of 8.25% in mental health funding during the course of the last parliament.
Furthermore, although mental health accounts for about 23% of the disease burden for the NHS, it only receives 11% of the NHS budget. This will inevitably challenge STPs to deliver the required changes. If mental health is truly a priority and is to be afforded the parity of esteem with physical health that has been consistently called for, there has to be fairness and comparable levels of investment between the two. Entrenched prejudice associated with mental health, typically a soft target for cuts, is likely to make this an unlikely scenario. Indeed an FOI request in 2016 found that 57% of CCGs plan to reduce their spending on mental health in 2016/17 compared to 2015/16.
The third test is the extent to which STPs approach the transformation of mental health in systemic terms, recognising the wide range of social and economic factors that shape people’s lives and their mental wellbeing. The STPs should foreground collaboration between agencies - these differing patterns of relationships will therefore need to be grounded in a shared understanding of mental health and the factors that influence wellbeing. The Prime Minister’s framing in terms of social injustice is helpful here - demanding an explicit recognition of the role that social and economic factors play, the inequalities in terms of timely access to appropriate support and the impact mental health has on people’s lives.
Evidence is building of the negative impact of austerity on psychological welfare , unsurprisingly hitting people in socio-economically deprived communities the hardest. Organisations within STPs need to be aware of these links and identify the investment and action needed to address them in order to truly deliver social justice. As well as national and local political action to address social disadvantage, this will require the collaboration of a broad range of partners. This is highly likely to be adversely affected by broader social policy and disinvestment in other parts of the mental health system. For example, a recent assessment of mental health in the West Midlands Combined Authority has highlighted how austerity measures, particularly those being taken by local authorities, are undermining public health, the capacity to sustain preventative measures and leading to drastic reductions in funding for the voluntary sector, which play a vital role in providing peer support and access to services for communities that are otherwise underserved and at risk of further marginalisation.
The extent to which STPs can rise to this challenge, protect and develop these services and avoid a retreat into the constricted domain of NHS services, remains to be seen. Organisations coming together as a system through devolution, however, as exemplified by the launch of an action plan for the West Midlands Combined Authority, present an opportunity for STPs to work collaboratively with partners as a whole system.
The fourth test, and one which speaks to the broader ambition of current health and social care policy, is to consider the extent to which STPs are focused on prevention and early intervention. The best place to start with prevention is with children and young people, as intervention in the early years has been shown to reduce mental health problems in adulthood and can save money. Investing in perinatal mental health, strengthening parenting in the early years, working with partners to identify and respond to children exposed to adverse childhood events (ACEs), and focusing on school environments as highlighted by Theresa May, are all important strands of a prevention strategy and have benefits wider than mental health. Primary care is a key player here and central to both prevention and early intervention. Therefore, the extent to which STPS have involved primary care colleagues and factored in their role in the whole system is another key indicator of a systemic and strategic approach to transformation.
The final test is about the process of developing the STPs and the extent to which collaboration, and critically co-production with people experiencing mental distress, families and communities, has taken place. The unseemly haste with which STPs had to be produced means that this is only likely to have happened where existing infrastructure and relationships are in place. For many the mental health system requires a fundamental rethink and the knowledge and experience of local people with experience of poor mental health is critical to this process if and a fundamental requisite for social justice. For this to be meaningful, STPs have to engage with the diversity of their local populations as the risks for poor mental health are unevenly distributed.
Any STP that uncritically focuses on a narrow approach to implementing evidence, makes a token nod to collaboration, ignores the local social context or is narrowly focused on further reducing investment in mental health does so at the peril of its local population and will fundamentally fail the test of promoting social justice promised by Theresa May.
Dr Karen Newbigging is a Senior Lecturer in Healthcare Policy and Management, University of Birmingham.