The NHS at 75: Mental health services in the NHS

5 July 2023
By Andy Bell

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Today the NHS marks its landmark 75th birthday. Three-quarters of a century ago, Aneurin Bevan’s vision became a reality: health care in the UK was made available free at the point of use, funded by general taxation, bringing together general practice, hospitals, community health care and more for everyone at every stage of life.

From day one, mental health services were part of the picture – albeit a not very prominent part (then and now). As we celebrate the NHS’s birthday, it’s an opportune time to ask what it’s meant for mental health care in the UK, and what needs to happen next.

There are lots of positives. Thanks to the NHS, most mental health care in the UK is available without charge, according to need: no small achievement in itself. Thanks to the NHS, the asylums and long-stay hospitals that characterised mental health care in 1948 were all closed, systematically, to be replaced with a mixture of community and inpatient services, for both adults and children. More recently, thanks to the NHS, some talking therapies are now available in every area of England for people with depression and anxiety. We take these things for granted at our peril.

But there are negatives we have to talk about, too. Mental health care, whatever the rhetoric, has never been on a par with physical health care at any point in the last 75 years. They have been underfunded, undervalued, and unable to reach the majority of people with a mental health difficulty. The asylums may be gone, but too many people find themselves in hospitals for too long – sometimes in facilities that are not fit for purpose, and far away from home.

Long waiting lists, high service thresholds, and support that’s poorly adapted to many people’s needs are not an inevitable result of a publicly funded health care system. (And insurance-based systems are, if anything, less able to meet people’s mental health needs fairly and efficiently.) But they have become features of a system that marginalises mental health care and puts up too readily with inadequate provision and premises.

Some of the weaknesses in our system can be traced back to the beginning of the NHS. The failure of that, and every successive, Government to prioritise social care means that an important part of every mental health service has been poorly resourced. The NHS and social services should be equal partners in mental health care, but they have never been resourced equitably, and the gap has grown during the last ten years of austerity in local government funding.

Likewise, it took the NHS 60 years to accept that psychological therapies should be a standard part of its offer. Thankfully, that changed in 2008, but the NHS still has a lot of catching up to do, leaving many people seeking psychological support from charities or private therapy (if they can afford it).

Other fault lines have emerged over the NHS’s history, often due to mental health services being overlooked in wider health policymaking and planning. The failure to put in place comprehensive access and waiting time standards for mental health services on a par with those for elective surgery, for example, mean long waits and inadequate provision are tolerated far more than in other parts of the system. Dilapidated and outdated hospital facilities are still too commonplace, yet the current New Hospitals Programme still shortchanges mental health services with a miserly proportion of the NHS’s capital funding.

The NHS’s anniversary is shared with the arrival of the Empire Windrush in the UK. Throughout its 75 years in operation, the NHS has relied on immigration and on minoritised communities to staff its services. Yet structural racism continues to constrain the NHS’s ability to offer truly equitable health care, or safe working conditions for many of its staff. In mental health services, racial injustice manifests starkly in Black people’s experiences of oppression, coercion and inadequate care. Promises from successive governments and NHS leaders to address these inequities have produced few tangible results to date.

The shortcomings of the NHS are not unique to our health and care system, and nor are they inherent in it. As the NHS Long Term Plan has demonstrated since 2019, it is possible to expand mental health care provision and build up the workforce, even in the most inauspicious circumstances. Previous expansion and reform programmes have also demonstrated the benefits of a national health care service in enabling large-scale change to take place – from the closure of the asylums to the 1999 National Service Framework for Mental Health. A clear policy direction, backed up with investment and sustained commitment, can make a real difference as a direct result of the way the NHS is funded and structured.

It’s unlikely perhaps that mental health services will feature prominently in celebrations of the NHS’s 75th birthday – they haven’t in previous anniversaries. But they deserve to share equally in the limelight today – literally, to have parity of esteem. They are just as important as every other part of the NHS, and it’s time they were valued equally and treated fairly.

There’s a lot of work to do to realise Bevan’s promises about the NHS when it comes to mental health care. While people with a mental illness have a 20-year shorter life expectancy than average. While Black people are four times more likely to be sectioned than white people. While both children and adults are sent far from home to a hospital bed or made to wait for hours in emergency departments for urgent care.

That we have had 75 years of the NHS is well worth recognising as one of this nation’s proudest achievements. We would be a lot worse off without it. Its founding principles remain as relevant today as they were in 1948. We also know that it could be better, and we will continue to work with the NHS to improve mental health support for everyone who needs it. But we join with it today to celebrate 75 years of tax-funded health care for us all.

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