Centre for Mental Health
Realising a better future
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Mental Health:
challenges for a new Parliament
May 2010
One in six of us experience a mental health problem at any one time. It is one of the biggest public health issues we face. It affects every aspect of policy making in the areas that matter most to people: jobs, the economy, families, welfare, the NHS and crime. And mental health problems carry a significant cost, in human and monetary terms, which will increase in the future unless we all take steps to address it.
The health costs of mental distress
- At least a third of GP consultations involve mental health issues, mostly depression and anxiety.
- The NHS spends £3 billion a year treating people with 'medically unexplained symptoms' which have an underlying mental health cause.
- People with depression are twice as likely to have a stroke and four times as likely to have a heart attack.
We recognise that these are straitened times. The eight priorities we have identified are not a shopping list of demands. They represent a call to re-balance public spending and take action that is affordable, practical and based on good evidence.
Doing the right thing, and doing it early, improves people's lives and saves money. Too often public services fail people, young and old, with mental health conditions. Problems get worse and more time and money are spent later 'in the system' to help people get back on their feet. So while intensive support services should always be available for those who need them, it is possible to reduce demand and distress by getting to grips with mental ill health much earlier and by targeting services much better.
1. Intervene early
One child in 10 in the UK has a clinically diagnosable mental health problem. Conduct problems are the most common. A child's life chances are reduced dramatically if problems like conduct disorder and failure in school are not picked up at an early stage. Some 80% of crime is committed by people who had conduct problems as a child.
Simple, cost effective parenting interventions, from before birth to early childhood, can break the link between early conduct problems and later offending. We need to build on primary care services, Sure Start Children's Centres, targeted mental health in schools and other innovative schemes to ensure that the families of children at risk of lifelong mental ill health are offered effective and non-stigmatising parenting support, and engage those who are most likely to be missed.
from the Programme for Government, May 2010
Investing at the earliest opportunity gives the greatest chance of preventing crime, improving life chances and protecting communities. A group parenting scheme costs just £900 per child while intensive support for families at high risk costs £4,000. By contrast, the lifetime costs of offending for a child with conduct disorder are 40 times higher, at £160,000. Parenting support thus represents excellent value for money and should be a major priority for public health policy with both immediate and longer term benefits.
2. Keep children out of custody
Children and young people in custody have high levels of mental ill health and of communication and learning difficulties. Three-quarters will go on to offend again, yet services find it very difficult to offer effective help to these young people and their families.
We need to identify young people with vulnerabilities at the point of arrest and take prompt action to help. And we need better partnerships between health, children's and youth justice services to offer the right support, wherever possible away from custody.
The minority with the most complex problems and the highest risks need access to specialist services such as secure residential therapeutic facilities with good quality discharge and step down care to facilitate progress.
For those with mental health needs who do, as a last resort, go into custody, effective and speedy support on release is vital. Many young people don't get the intensity and continuity of support they need with the result that they have high chances of reoffending and cycle in and out of a system not designed to address their needs.
3. Divert to save
from the Programme for Government, May 2010
The majority of people in prison, and at least half of those in Probation services, have significant mental health problems. We need to identify those people when they enter the criminal justice system and direct them to an appropriate mental health service.
For long-term prisoners with the most severe mental health problems, admission to hospital may be the best form of diversion. But for the vast majority, diversion is best achieved away from custody altogether.
It is especially important to divert people from short prison sentences. Two-thirds of prisoners serve sentences of less than 12 months. Yet a short spell in prison makes already disadvantaged people more disadvantaged, with poorer health, and increases their likelihood of reoffending. Few receive mental health care or effective help for substance problems in prison, and many are released with minimal support in the community.
For women, the benefits of diversion are even greater. Women offenders are often sole care givers of children and many of their children get taken into care. Women account for 6% of the prison population but some 46% of incidents of self harm.
4. Address multiple needs
Offenders and ex offenders often have a combination of mental ill health, learning disabilities and drug and alcohol problems. For many, a chaotic lifestyle, rough sleeping, physical health problems and unemployment make recovery and resettlement difficult.
Health and substance use services are rarely designed to deal with multiple problems. Too many people find themselves 'bounced' between services. Offending and reoffending are often the costs of these unmet needs. We need to develop effective incentives for public, private and voluntary sector services to offer support together and across organisational boundaries.
5. Reform forensic services
from the Programme for Government, May 2010
There are 4,500 medium and high secure hospital beds in England, costing almost £1 billion a year. By comparison an estimated 8,000 prisoners have a severe mental illness, many of whom are never diverted from prison. When they do take place, transfers between prison and hospital can be slow – often lasting for several weeks – even though most such prisoners are acutely unwell.
Lengths of stay in medium and high secure beds are long, often spanning years at a time, in stark comparison to other psychiatric inpatient services. This 'bed blocking' is one of the main barriers to speeding up transfers from prison. Improvements need to be made to tackle these blockages, including more efficient assessments and better step-down and community services to which to discharge people who no longer need to be in medium secure beds.
A medium secure bed costs £180,000 per year. A high secure bed costs £300,000 per year. Prison costs up to £40,000 per prisoner per year.
6. Improve employment support
The cycle of low expectations and under-employment for people receiving treatment from mental health services must come to an end under this Government. Wasting talent and money is in no one's interest. People using mental health services have the lowest rate of employment of any group of disabled people, at just 20%. Yet 80% would like to do at least some paid work.
With the right help, many people can achieve and sustain their employment goals. There is a very effective way of supporting people with severe or enduring mental health problems into paid work, known as individual placement and support (IPS). It emphasises rapid placement into paid work with on-the-job support instead of keeping people in training or sheltered work. More than half of people receiving IPS services get some paid work and one-third go on to be regular workers. IPS costs only a third of current day and vocational service provision. Yet it is rarely used in English mental health services.
There is evidence that employment speeds up recovery from mental ill health and that for those who become regular workers it will lead to significant savings in health care costs.
The Government should ensure that effectively supporting people into employment is a priority for mental health services, and that any 'payment by results' system in the NHS includes sustained work as an outcome.
7. Reform welfare to work
from the Programme for Government, May 2010
Unemployment is as bad for health as smoking or obesity and it particularly damages mental health. Over one million people on incapacity benefits, and many more on Jobseekers Allowance, have significant mental health problems. The longer a person has been unemployed, the harder it is to help them get back to work. Just four weeks of sickness absence can be a critical turning point. So any back to work programme needs to be equipped to handle mental health issues and work closely with the NHS.
Increasing numbers of people with mental health problems are now being transferred to Jobseekers Allowance. The consequent reduction in income and the threat of sanctions can increase anxiety and may as a knock on effect increase health care costs.
Jobcentre Plus advisers need to be able to respond effectively to people with mental health needs. They need to know that benefit sanctions do not have the desired effect on people with mental health problems and that training and volunteering simply to keep benefits is a waste of everyone's time and money.
Work Programme providers will need to work with specialist providers of support for people with mental health problems if they are truly to provide sustainable outcomes for the 'hardest to help' and those farthest from the labour market. Standards for all Work Programme contractors should specify minimum service standards and training/competencies for front line staff including and especially in working with people with mental health conditions.
And the Access to Work scheme should be extended proactively to jobseekers with mental health problems. Less than 1% of the scheme's budget is currently spent on mental health. 'Passporting' Access to Work so that applicants can guarantee funding to a prospective employer could make all the difference.
from the Programme for Government, May 2010
8. Help people stay in work
Mental health is the predominant public health issue of the working age population, and as such warrants attention and action even, perhaps especially, in difficult economic circumstances.
Mental ill health at work costs UK business £26 billion a year, or £1,000 for every worker. Supporting people at risk of falling out of the workforce in the first place is key to prevent later loss and cost.
First responses to people starting to experience mental health difficulties, for example from their GP, should include their employment needs: making use of the new 'fit note' for example. Psychological therapies need to be offered alongside employment support, without which they will not keep people in their jobs.
from the Programme for Government, May 2010
"We will ensure greater access to talking therapies to reduce long-term costs for the NHS." (p.28)
A Future Vision for Mental Health
The Centre is a member of the Future Vision Coalition, which calls on government to promote good mental health and improve mental health services. It argues for a cross-government strategy to prevent mental ill health and promote wellbeing.
And it says that mental health services should be focused on helping people to achieve recovery on their own terms with a better balance of power between services and those who use them.
For more information, visit www.futurevisionformentalhealth.org.uk.
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