Our Chief Exec, Dr. Simon Newitt, wrote this piece recently on the state of mental health care for young people in 2015.
An abridged version of this piece was featured on the Huffington Post – you can read that here.
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It’s encouraging to hear leading politicians now talk and pledge openly about mental healthcare. In the last year or so, the state of our services – particularly for children and young people – has slowly, grudgingly, risen up the political agenda. It’s a scandal that it has taken near systemic collapse to achieve this, but when even Minister of State for Care and Support Norman Lamb is able to conclude that children’s mental health services “are not fit for purpose” (after three years under his watch) it is clear we’re about to hit bottom. Maybe we already have.
Multiple investigations and reviews have found the same failings, which might reasonably be summarised as the predictable result of chronic long term underinvestment in the face of growing demand and complexity (have a read of last years Centre For Social Justice report and the recently concluded enquiry by the House of Commons Health Committee if you want to understand quite how bad things have got).
Last summer the government established a task force to look at the way in which child and adolescent mental health services are commissioned, but a quick glance at a few headlines will tell you what’s going on.
Despite the fact mental health issues represent about a third of our overall burden of dis-ease in the UK and cost us over £100 billion a year; spending on services represents only 13% of the total NHS budget (NHS England, 2014), with 67% of Clinical Commissioning Groups spending less than 10% of their budget in this way. Worse, given half of all adult mental health problems (excluding dementia) start before age 15 and three quarters by age 18, it’s hard to understand why only 6% of these already limited monies go toward child and adolescent mental health. These are services which have also had to manage cuts of £50 million since 2010. Finally, it’s worth noting that funding for mental health research represents a mere 5% of overall health research spending (Mental Health Foundation, 2013).
It is this basic poverty of resources and new learning from which all other challenges flow; both for young people who experience unbearably long waits for limited treatment options, and for services with diminished budgets trying to manage the increasing demand for them. The outcomes for individuals and families that need mental health services as well as for those working to provide them are entirely predictable. Imagine for one moment if we resourced physical healthcare to the same extent and with the same lack of interest in new or better treatments.
Fifty years ago a group of far-sighted individuals in Bristol had an idea called Off the Record that remains relevant and urgent to this time. It was – and remains – the idea that young people have need of support that is accessible to them independently of adult permission, judgment or referral. Support that is culturally bespoke and sensitive to the particular challenges – biological, social and existential – that this phase of life brings. Support that does not label or pass judgment on the individual in order to exclude or admit them into the service. And support that recognises ‘being a young person’ is a social construct that has evolved socially and economically to last a decade or so longer than it did even half a century ago.
Good ideas endure, and though there have been changes to the way we do things at Off the Record (Bristol), at heart these have always been with the aim of preserving and improving the basic idea of free, self-referral support that is integrated, confidential and available until your twenty sixth birthday. Increasingly though, we find ourselves struggling to hold onto these ideals. Not for want of money or will, but because we are being overwhelmed by the number of young people unable to access other parts of the mental health system. It’s one thing to make a service available to anyone who wants it, quite another to then offer anything responsive and meaningful when so many do because
Why is demand and complexity rising? Actually this is probably the more interesting and important question, and it is staggering that the data to venture an answer is so limited. What is real are the increasing numbers of at risk young people coming through our door at Off the Record. Much too frequently for comfort, they are fresh from the accident and emergency room and the assessments and intake of statutory mental health colleagues, whose highly pressurised caseloads mean only the most acutely complex and unwell young people now meet the threshold for their services. This presents us with a basic challenge of demand and supply, one compounded by the fact some of that demand needs urgent attention of a kind we are not – up to now – used to offering to such an extent.
The simple answer to this pressure would be to introduce our own exclusion criteria. To limit demand by only accepting a narrow band of presentations or ‘wellness’ that is a good fit for our service. But that would mean turning away those most in need since Off the Record is an idea and service based on early intervention, not crisis management or long term support. It would mean mirroring other parts of a failing and often abusive system and abandoning the essence of what Off the Record is and the reason it’s different from other mental health provision locally. This cannot be the right way forward, but not taking it means we must walk a more challenging path. Instead we must try to embrace risk, view it as an opportunity to learn and to do more and do it better, improving and widening our offer to local young people. It’s difficult work in an under resourced system that will take time (and yes, human error) to get right.
In one other very important sense mental health is not equivalent to physical health. For despite the medical language that defines the field, there remain no objective scientific tests to determine the existence of particular mental illnesses. The process of classification and diagnosis, assessment and risk management remains one of personal judgment. Young people present their emotional and psychological worlds in idiosyncratic ways that are sensitive to both the meaning they give their mental health and the uneven distribution of power in society and among individuals – including health professionals. Objectivity is a myth, and risk and human error are inherent, dynamic and situational. To work with this uncertainty and live by your judgment and the consequences of your decision making in such a broken system is both brave and, frankly, heroic.
Which is why, if you work in the field and this pressurised context, the woefully simplistic and reductive narrative around mental health in the media is so frustrating. The preoccupation with dangerousness only reinforces the societal stigma that surrounds psychological and emotional suffering, and the individualisation and reification of ‘illness’ obscures the structural bases of suffering. Meanwhile the language and culture of blame when things go wrong actively undermines the work of mental health professionals. To have the systemic context of human suffering as well as the reality of under resourced, under researched and over stretched services reduced to one of personal failure does nothing but create more stressed, defensive professionals and even poorer services; even if we can and must acknowledge that services do let people down.
There’s no magic wand for someone experiencing a mental health difficulty save timely access to appropriately resourced services. In an ideal world these would also be co-designed by those that need them and based on a rich and dynamic tradition and programme of psychosocial research. And since we lack the political introspection to ask more profound questions about the health of our increasingly unequal socio-economic world and the aetiology of mental ill health more specifically, this basic issue of resources seems to me the most urgent place for our politicians to fix their gaze.
If we are going to continue to organise our society in such a way as to make the incidence of poor mental health more likely, then we can’t ignore the human and financial cost of not providing adequate public services to mitigate the consequences of this. In anticipation of the predictable groans about austerity, deficits, and doing more with less – an unprecedented upward re-distribution of wealth has taken place since 2008; I humbly suggest that the arithmetic is simple.
Dr. Simon Newitt
Chief Executive
Off the Record (Bristol)
Off the Record (Bristol) is currently celebrating its 50th anniversary year supporting young people in Bristol.
Follow Off the Record on Twitter: @otrbristol