Why is social care so often invisible in mental health policy?
By Mark Trewin
If you open any newspaper, TV channel or social media feed at the moment, you will see that there is a great deal of concern about our mental health services. Professional groups write letters to newspapers, MPs make passionate speeches in the commons, people who use services outline their understandable frustrations with the apparent postcode lottery across England and Wales. The Government has responded by committing a theoretical £1 billion to improve NHS mental health services, while many Clinical Commissioning Groups privately say they have no choice but to cut the budget locally. Last week, Simon Stevens expressed concern that the funding for the widely welcomed Five Year Forward View for Mental Health may be at risk.
There is something very important missing from this debate, the problems identified, and the solutions being suggested. This is the role of social care and especially local authority (LA) commissioned mental health support services. Most of the media, public, politicians and many mental health professionals assume that mental health is a 'health' and ‘illness' issue. Parity of esteem between physical and mental health is their goal. Extra funding for NHS services is the way to achieve it. Very few people ever mention the significant, underfunded, and increasingly at-risk ‘elephant’ in the room - that a substantial amount of mental health services are provided by local authorities and undertaken by the social care agencies and staff they commission.
Few people ever mention the significant ‘elephant’ in the room - that a substantial amount of mental health services are undertaken by social care agencies
I run the LA social care mental health services in Bradford and I know how vital these are to local people. Take Beth as an example. She suffered from very serious and traumatic mental health problems which eventually led her to receive an urgent assessment led by our (local authority) Approved Mental Health Professionals in an emergency out-of-hours team. She was detained to a secure hospital under section 3 of the Mental Health Act. With the right care, medication and a stable environment she began to recover and after eight months was ready to be discharged. The discharge plan led to a right to aftercare from social care and health agencies. She was allocated a social worker and received a support package under the Care Act that led to her being placed in supported housing commissioned by the Local Authority with a direct payment to help her learn the skills she needed to live independently. Eventually she attended a voluntary sector employment project funded by the LA and began the long road back to work and independence. She is just about to move into her own flat - provided by the council housing services and funded by council housing benefit. She is being supported with the help of council-funded advocacy and advice services.
In Beth's life, there is also a brilliant psychiatrist who is highly committed to a social model of care, and a very caring community nurse who sees her a lot and works alongside the local authority social care agencies. For eight months she was in an inpatient unit that really helped her.
My point here is that health and social care are intimately bound up with each other. Both have a role. Some people with mental health issues will require good health services for a small but significant amount of time. But they will also require a long time within families, communities, work and home - this is where the social model of care and support is essential. You cannot run a good mental health service and have one part of it without the other.
Some people with mental health issues will require good health services for a small but significant amount of time. But they will also require a long time within families, communities, work and home...
The problem with the current debate about mental health is that social care is invisible within it - even though it is impossible to use the Mental Health Act, Mental Capacity Act, Care Act and other legislation without local authorities, social work and social care. None of the new funding going into mental health services is allocated to LAs, which is assumed to be about elderly people. Mental health services, like everything in LAs, are subject to substantial cuts. The Sustainability and Transformation Partnerships currently redesigning health and care in every locality have a very mixed track record on involving LAs and voluntary sector organisations, and designing services with them and communities. Local authorities have the advantage of elected members who run health and wellbeing committees, and most have a senior councillor as a Mental Health Champion who can have an influential role in the local area representing mental health.
The problem with the current debate about mental health is that social care is invisible within it
A widespread assumption is that the NHS spends more on mental health than local authorities. But, if we add Social Work, residential and nursing care, substance misuse and public health budgets, housing and disability services and benefits, and commissioned services in the voluntary and private sector, the difference is small. In its brilliant publication Being Mindful of Mental Health the Local Government Association has worked out that the figures are much closer than originally thought, and highlighted that LA’s have an equal role in delivering a wide range of prevention based mental health services.
In my view, local authority social care, and the voluntary, private and not for profit sector services we commission, should be a key part of an integrated future for mental health. It can’t all be about the NHS – important though that organisation is. Social care should be working with people who use services and carers; with the police, in the community, supporting crisis services and developing new ‘asset based’ working that is about emphasising the positive skills and rights of people with mental health difficulties to take control of their own lives. In addition, the NHS needs social care to thrive. Beds can only be freed up and out of area placements reduced if people have somewhere to go and something to do on discharge from hospital.
Beds can only be freed up and out of area placements reduced if people have somewhere to go and something to do on discharge from hospital.
Despite the problems, I am optimistic. The new review of the Mental Health Act looks like it is going to take social work and social care seriously. The NHS adult mental health national team is clearly committed to working alongside local authorities. There is a new sense of enthusiasm across the country for health and care to work together and especially alongside people who rely on our services. Social work is equipping itself to ensure that a community led, social model of support survives into the future. The Approved Mental Health Professional statutory role is finally being given the serious respect it needs, and integrated health and social care commissioning is increasing.
It is time for all agencies and political parties to work together with people who use services, to design the integrated support services we will need in the future. While we do this, let’s not forget about social care!
‘Beth’ is a composite of real service users that Mark works with in Bradford
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