Upon being asked to pass comment upon the Mental Health taskforce report, the temptation was to be a smart aleck and attempt a literary critique: While parts engage the reader, the characterisation is shallow, the tone inconsistent and the plotlines hackneyed…(etc). Such a glib approach runs the risk of undermining the seriousness of the subject of mental health (though there is some truth in those points) and is henceforth abandoned, but it led to a minor, but perhaps revealing insight to the document.
Ordinarily these sorts of reports carry a full list of contributors and collaborating agencies, a page full of logos (and pat straplines), and so forth but this one does not. Despite stressing how independent it is (even having independent in its name and repeatedly in press releases), it adopts the stylings and format of NHS England, and it’s possible that this has seeped into its substance. It follows in the wake of previous much-heralded documents like “New Horizons” and “No Health without Mental Health”, which one naively might have imagined would have obviated the need for a taskforce to be summoned.
The independent taskforce was originally asked in 2015 to develop a five-year strategy for mental health in England. What it has produced is more akin to a strategy for the mental health bits of the NHS, which is not quite the same thing.
The NHS may be the star around which orbits everything that wears the formal badge of mental health, but it’s not the whole solar system, let alone the universe. The tenor is very much on doing more of what the NHS likes doing and not enough consideration of what the NHS should (and shouldn’t) be doing.
Looking at the document as a whole, there is a considerable amount to praise, particularly its succinct capture of many of the problems and issues besetting mental health service users, those experiencing distress, services and the people who work in them. Oh, and carers. That sentence is a little tongue-in-cheek, because it’s a too-familiar formulation, one whereby carers are added on as some kind of appendix, and to be fair the report goes some way to acknowledging this shortcoming.
And yet…it’s all about the NHS and nobody else: to take but one example, the peer support bits, on a second reading could be taken solely to mean in-house, NHS (compromised?) peer support, and there’s nothing about user-run/user-led stuff really. Innovation (and peer support) can be said chiefly to come originally from outside the NHS through activists and from the voluntary sector, both of whom get short shrift in the document. Social determinants get name-checked but with no real, broad, consideration; given that it’s meant to be a cross-cutting interdepartmental initiative it lets the likes of theDepartment for Work and Pensions and Department for Communities and Local Government off very lightly indeed, putting mental health in a neo-medical place.
Speaking of which, allied to this is the curious and largely unchallenged emphasis on integration, particularly between health and social care, whereby social care is seen as just the thing to prop up the NHS. This ignores the fact that social care is even more beleaguered, even more financially stricken than the NHS (some councils fear not even being able to meet their basic statutory duties by 2018), and just as significantly suborns the social care model to a medical way of working. Of course one idea is that the NHS becomes more socially-minded, less medicalised, but a narrow medical mode is cheaper…Putting it bluntly, while integration is something many have argued for, for 50 odd years, it’s undo-able for several reasons (cost-shunting, and universal provision vs. means-testing).
If you were to start from scratch, a comprehensive health and social care service is what you’d construct, but we’re not starting from there, and many fear a levelling down between health and social care. That is to say, means-testing brought into the NHS, universal provision to go out of the window, and many being left without a service at all until at death’s door (i.e. critical need FACS equivalent in health), when it may well be too late.
The document has lots and lots on values, and their importance (and values are indeed important). However, there’s not enough defining what the values are: are we talking Mother Teresa values, Grant Shapps values or Sepp Blatter values? And whose values prevail? This is borne out by the insistence on employment as a health outcome, which offers up easy meat for the managerialist technocrat, and runs the risk of being used in ways that damage many vulnerable people: there’s a very real likelihood (already evident in some rhetoric) of a “work is good for mental health” assumption holding sway.
Look properly into the evidence, and not the glib summaries and the picture is more complicated. Put baldly, “good” work (rewarding, stable and accommodating) is good for one’s mental health (and very much to be encouraged). “Bad” work (low status, low pay, no security) is bad for one’s mental health. “Bad” work is one of the biggest causes of mental health related contacts with the NHS. The Taskforce report recognises this, but presents its case in a way that could be seized upon in a reductive fashion that would be at best disingenuous, at worst actively harmful.
We hear an awful lot these days about moving upstream, and the drive towards preventative work and that with young people. These themes permeate the whole report. While this is certainly not an ignoble aim, and makes longer-term sense, great care must be taken, especially in a period of very limited resources, not to rob Peter to pay Paul, or to continue the riverine metaphor, not to abandon those who are already downstream, or who keep falling back into the water.
A parallel can be drawn with the first wave implementation of IAPT where there was great scope for gaming the system, achieving marvellous looking outputs for “recovery” by focusing on the not-very-unwell, those who’d soon get better anyhow without any intervention, and essentially jettisoning the principle of targeting resources at the neediest.
We know the arguments that prevention is better than “cure” and theoretically will save money, but in practice there is growing evidence that moving upstream simply exposes greater, hitherto unknown, demand, demand at a far lower order of severity, but a high number of individuals.
Meet that “surprise” extra demand from the already stretched resources and the corollary is that those downstream suffer. An over-emphasis on that elastic and much-debated term “recovery” is evident, and this could be said at be to the cost of those for whom maintenance might be a better term. “Recovery” does imply cure, or more cynically, the cessation of use of services.
This is a little unfortunate, given that substantial mention is also made of (physical health) Long Term Conditions (LTCs) and their impact upon mental well-being. This leads to the question of when is a mental health problem a long term condition, and when is it something from which one can recover or even something that is preventable by the heroic inputs of services? The Taskforce is notably light on ideas about quality of life for people who won’t ‘get better’ but might have better lives.
Great attention has to be paid to the mental health ecosystem, which faces two (related) threats: the ever-larger big charities and providers who have an increasingly corporatised approach, and the trend when calling for innovation and good practice to demand uniformity/repeatability/scalability.
This actually contradicts the drive for personalisation or bespoke approaches, and will ultimately have a stultifying effect: without variation, without difference, there can be little room for future innovation. Logically, this should lead to a duty upon both commissioners and the large organisations to look out for the continued existence of the small fry (which is also what most, if not all user-led organisations might be deemed). They represent the best, most flexible, responsive and appropriate way of meeting niche needs and the specific requirements of certain demographic groups, of certain geographical localities, of certain diagnoses, far better than the leviathan, homogenised, over-standardised usual suspects, who will talk of their responsiveness yet still enforce rigid, stiflingly uniform organisational standards across the board.
This omission makes it hard to place complete faith in the Taskforce report, as it assumes that those agencies that have been least innovative to date will suddenly be able and willing to do things differently.
It may be somewhat galling reading for those who’ve used services over a long period, from whose ranks, incidentally, have come most of those activists and small organisation workers who’ve originated the best new ideas: an appropriation by the big boys of some of their initiatives (possibly without the correct accompanying ethos…) alongside a downplaying, verging on a disregard, for their personal needs. That’s probably overstating things, but without any express statements about securing the viability of small organisations, it’s easy to see why mistrust may exist.
How to conclude? It’s a Taskforce report, after all, not as independent as maybe it presents itself, and not as binding or authoritative as some have taken it as being. It’s praiseworthy in places, vexingly vague in others, with multiple sins of omission. It seems to have led to a Governmental response so rapid that one might almost think it was synchronised.
That response has been politically astute, but opaque about monies, which are new and which not, and where they shall come from, all with a disappointing distant approach to accountability and implementation. Exactly who will have what to spend, if anything, who’s aligned to this and who’s going to check on progress is unclear.
By the time we have clarity on all this, it’ll most likely be time for the next system-changing, transformative publication.