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Urban Suffering Studies Center



What is different in Mental Heath

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John Jenkins


International conference

Milan Italy 13-14 December 2007

Mental Health Policy and Development in the UK – 1975-2007

The way in which society chose to deal with people with mental health problems, out of sight, out of mind in isolated institutions dominated the care and treatment of these people for 200 years. These institutions grew in scale and were exported from Britain and France to every where in the world. This growth peaked in the mid 1950's when there occurred a gradual reduction in the number of people that were incarcerated in them. At this time there was a shift in attitudes concerning how society should care for the mentally ill. The concept of care in the community has its foundations at this time. We have been trying since then to change the system of mental health care in a number of ways. These include:

- National Policy and Legislation

1. 1975 Mental Health Policy, "Better Services For the Mentally Ill" This was the first Policy to set out a vision for community mental health and signaled the gradual closure of the institutions in the UK. It was far sighted in the detailed services that were envisaged to replace the institutions over a long time span, 25 years. This has its roots in the philosophy of civil libertarians like Enoch Powell who claimed that psychiatric hospitals were in fact prisons.

2. 1959 Mental Health Act, made informal admission the usual method of admission

3. 1983 Mental Health Act. This set out the legislation to protect the rights of people with mental health problems. It also defined the circumstance in whish people could be compulsory detained in psychiatric hospitals and nursing homes and a system to protect them against wrongful admission and treatments.

4. Community Care Act (1990) This Act required social services to provide social care for people with mental health problems and that everyone should be assessed.

5. National Service Framework for Mental Health (1999) This was a ten year program of reform built around standards of reform: - Mental health promotion - Access to services - Effective service models in secondary and primary care - Carer support - Suicide prevention

6. Mental Health National Plan (2000) This identified mental health development as one of the key priorities for the government. The main aim was to strengthen community care by developing functional specialized community teams. - Crisis resolution (home treatment) teams providing care and treatment at home to educe admissions and prevent relapse. 343 across England are in place caring for 100,000 people. - Assertive outreach teams providing intensive support to people most at risk of falling out of services. Focusing on a recovery approach to their care.252 of these teams supporting 21,000 people is in place across all of England. - Early intervention teams providing for the early detection, rapid assessment and treatment of young people at risk of developing a sever mental illness. There are 118 of these supporting 12,000 people and operating in most places in England.

Investment Between 2001 and 2005 spending by health and social services on mental increased by 1 billion pounds.

7. Mental Health and Social Exclusion (2004). This highlighted the social exclusion experience of people with mental health problems: - 24 % of people with long term problems are in paid work. - 84 % of people with mental health problems feel isolated from society compared to 29 % of the general population. - A person with schizophrenia can expect to live 10 years less a member of the general public. - 83 % of people felt that stigma and discrimination was the main problem that the faced in leading a quality life.

8. Health, Work and Well Being - DWP/DOH (2005) A joint charter to improve the working conditions for people in the work place through improved occupational health.

9. Our Health, Our Care This set out how people could have more choice and say about what they thought they needed in social and health care.

10. Developing a recovery culture A recovery culture is one that supports each person to take responsibility for their own well being and for their positive role in their pathway to recovery and thus their key role in the community. It also outlines the responsibilities and circumstances that mental health organizations have to adopt to enable service users to fulfill this role.

11. Mental Health Bill (2007) This Bill has attracted much protest from professionals and users which resulted in the amendment of the 1983 Act instead of replacing it by a new Act. The definition of mental disorder is broadened and the categories of mental disorder are abolished. The criterion for detention becomes appropriate treatment. It introduces supervised community treatment orders.

- Good Practice, New Models

Innovative new services developed by professionals and managers working in the provision of services. These include community mental health centers, acute inpatient units in general hospital, day care services, work schemes, Home treatment. Assertive outreach teams, recovery workers, primary care therapists. Self help support, recovery workers, hearing voices groups and consultants, self harm self help and consultants. Computerized e-learning technology e.g. CBT.

London Examples:

- The user movement.

These movements have groan from young fledglings in the 1960's in the USA and Europe to strong well structured organizations operating in many countries in the world. These maximize the use of the expertise of those that have the condition, provide a self help philosophy and support, provide advocacy and are able to play a key role in the design and development of services.

- Carer organizations All over the world relatives of a person with mental health problems have come together to advocate for improved treatment, care and services. They also act as important support and information groups. They have been successful in many places to help to transform the mental health system.

Mental health in large cities The development of community based care services to replace the remote and large institutions of the 19th Century means that the vast majority of people with serious mental health now live within their own community. However, although they may be residing there too often they remain apart from them, living, working and spending leisure time in specialized mental health facilities. Such segregation limits both the opportunities available to people who experience mental health problems but also the wider communities understanding of them and their needs. This problem is particularly manifest in large cities. Efforts and resources need to be directed at enabling inclusion rather than exclusion. The specialized mental health (at worst mental illness service) is sometimes promoting dependency and exclusion. The social determinates of health and mental and physical well being in cities place people in a venerable situation for developing mental health problems. Across the developed world rates of mental illness are raising and the problem of high need are particularly severe in large global metropolises. Strategic thinking about finding solutions to the complexity and scale of need must be based on partnerships Mental health, illness and wellbeing are not solely health issues. A mental health community strategy must involve as partners the wider health sector, social care, education, housing, employment criminal justice system, voluntary and community organizations and businesses.


London's Mental Health Services

London is the largest city in Europe with a population of 7.43 million people (2004). 350.000 people leave and enter London each year. The ethnic minority population grew by 54% between 1991 and 2001. London and its population are unique in the UK. London has a rich, ethnically diverse population with over 300 spoken languages and large populations of refugees and asylum seekers. There are pockets of great social deprivation with some of the most deprived communities in the UK with high homelessness rates and unemployment rates. Social deprivation and homelessness are associated with increased risk of mental illness. Employment acts as a protector in relation to people's mental health and as a means to promote their recovery. London's population is relatively young compared to the rest of the UK. Mental health in young people has consequences for their development and brings educational, social, health and economic difficulties for them in later life. Another difficulty is the very mobile nature of Londoners which bring problems in providing a seamless service. A paradox inherent in the character of London as a major world city is that is very strengths are also the source of its weaknesses. It is a city that excels in the industries of the mind; finance and business, academia and research, media and the arts, government and politics. At the same time the conditions that support that flourishing - the pace of life, the diversity, and the stresses of urban living, pose some of the greatest challenges to maintaining well being. London lives by its wits and so it must take care of them, just as much in good and appropriate mental health care as in education. Over a million people in London have mental health problems. In 2003 there were over 26,000 inpatient admissions for London residents and 455,000 outpatient appointments. Compared to England this is higher. London has a higher number of inpatient beds per 100,000 of the population than England, 86 compared with 65 beds per 100,000 in 2003. Deprivation in some London boroughs is closely linked to the use of inpatient beds. London has a higher percentage of inpatients with psychotic disorders (schizophrenia schizotypal, and delusional disorders) (23%) compared to England (14%). The quality of inpatient care is variable, not always receiving adequate investment. There is an overrepresentation of people from black groups in inpatient mental health and forensic services. A recent study of first episode Psychosis showed that diagnosis of psychosis among African/Caribbean and Black Africans were four or five times higher than amongst white British people. London has a consistently higher use of forensic beds than the rest of England, 20% of all medium and low secure inpatient beds across England are for London residents and 30% of all patients in the 3 secure hospitals are from London. There are plans to increase the London beds by 50%. The spectrum of community services has been expanding over the last few years. In March 2004 there were 139 community mental health teams, with a total caseload of over 36,000 people. There were also 43 assertive outreach teams and 31 crisis resolution teams. The prevalence of people with a dual diagnosis (mental health and drug or alcohol problems) is higher in London than the rest of the UK. One study has suggested that up to half of people in acute wards were also substance misusers London has a large concentration o people in contact with criminal justice system with 8 prisons. A high proportion of people in contact with the criminal justice system have serious mental health problems. It has been estimated that 70% of prisoners have two or more mental health problems (Prison Reform Trust). It is estimated that 90% of people with mental health problems are cared for entirely by primary care services. However pressure on primary care services and the closure of some GP lists present access barriers, particularly for vulnerable groups.

London's NHS structures and systems are complex, with 31 primary care NHS trusts and 10 NHS Mental Health Care Trusts. These work with 31 boroughs in Greater London. A recent report by the GLA described London's mental health services as a "maze" and difficult to navigate for service users. The shortage of affordable housing and high rates of homelessness in London put pressure on mental health services which seriously delays discharge.

There are a number of features about the population of London that make the mental health needs of its population very different to the rest of England. Among the most important differences are •A very high refugee population. Around a quarter of a million refugees live in London accounting for between three to four per cent of the population. In Inner London boroughs this figure rises to six to eight per cent. Refugees are likely to be over-represented among users of mental health services. Ealing, which is estimated to have a refugee population of between 3.9–4.5 per cent, reported that the percentage of service users that are refugees is between six to ten per cent. Hillingdon, which is estimated to have a refugee population of 1.7 per cent, reported that refugees account for three to five per cent of service users.

•A large black and minority ethnic community. The 2001 census estimates that 29 per cent of the population is from an ethnic minority. Minority communities face barriers in accessing mental health services either for language reasons or for cultural reasons. They also have a significantly different profile in terms of admissions to hospital.

•The population of London is much younger than the population of the rest of the UK with almost two thirds of the population aged under 45 and a quarter aged under 30. This is reflected in the make-up of London’s patient population. The age profile of in-patients in London mental health wards has more patients in the 15–44 age group and fewer in the over 75s. The mental health problems of younger people differ from those of older people with higher levels of psychotic disorders.

•London has many of the most deprived parts of the UK. Of the fifteen most deprived constituencies in England, 11 are in London.

The pattern of admissions among London in-patients from more deprived areas shows a greater proportion being admitted for psychotic conditions and disorders due to drugs and alcohol. The reverse is true for the proportion of admissions for dementia, learning disability, and affective disorders, which decreases in areas with greater deprivation.

These differences in admissions affect the overall make up of London’s mental health services users. The patient mix is noticeably different from the rest of England with higher proportions of admissions for psychotic illness (23 per cent of inpatient admissions in London compared to 14 per cent elsewhere). Table 1 Percentage of inpatients by diagnosis group Diagnosis group London Rest Dementia 8% 12% Disorders due to other psychoactive substance 5% 4% Disorders due to use of alcohol 17% 16% Mental retardation [learning disability] 7% 10% Mood [affective] disorders 23% 23% Neurotic, stress-related, and somatoform 5% 8% disorders Other mental and behavioural disorders 12% 13% Schizophrenia, schizotypal, and delusional 23% 14% disorders 100% 100%


In addition there are a number of other factors that affect demand on mental health services in London including very high levels of homelessness and greater numbers of single households than the rest of England. Both are associated with higher levels of mental illness. In addition, both homeless people and those living alone require higher levels of support.

- Primary care and mental health services The importance of primary care in the treatment of mental illness is well documented. Among the key statistics are:

•One third of GP consultations are for mental health problems.

•90 per cent of people with mental health problems are treated in primary care.

•One third of people with serious mental illness are treated in primary care.

There is also substantial evidence that primary care practitioners often fail to deal appropriately with mental illness. In particular it has been shown that GPs fail to correctly diagnose more than half of all cases of depression. Interviews conducted with mental health commissioners from Primary Care Trusts (PCTs) across London accord with this evidence. There was widespread concern that primary care services in mental health were weak. When asked about where there were gaps in mental health services most PCT representatives mentioned primary care. Specific weaknesses mentioned by PCTs were: •lack of effective assessment skills in primary care •lack of capacity in primary care •lack of knowledge of secondary care services •lack of access to psychological therapies •GPs ‘not sufficiently interested’ in mental health


Many PCTs feel that there is an over-emphasis on the treatment of the severely mentally ill as opposed to moderately ill and that this worked to the detriment of primary care services.

- Variations in secondary care mental health services There are large variations in the level of resources available to mental health services in different boroughs. These variations are not easily explained by variations in need. We looked at ten indicators of the level of resources going into mental health services in different London boroughs/PCTs. The indicators were selected on the basis of being the most reliable data available and included staffing levels, bed levels and spending. We compared services by PCT area since Mental Health Trusts are paid for services, and account for their services, on a PCT area basis. We then scored PCTs according to the comparative level of resources and identified the top and bottom quartiles. Table 2 High and low resourced services High-resourced Low-resourced (Top quartile) (Bottom quartile) City & Hackney Barking & Dagenham Kensington & Chelsea Barnet Lambeth Ealing Redbridge Enfield Southwark Merton Waltham Forest Newham Westminster Sutton


The high-resourced group shows a number of differences in the quality of services provided which are likely to result in better patient satisfaction and better patient outcomes. These include the following factors: •High-resourced areas reported lower than average waiting times for assessment with most conducting urgent assessments within 48 hours and standard assessments within three weeks. The longest waiting times reported were up to ten weeks for a standard assessment. High-resourced areas had better accommodation on inpatient wards with most wards having single room accommodation. High-resourced areas were also more likely to have separate day facilities for men and women and single sex wards.

•Pressure on beds means that often people requiring inpatient treatment for mental health problems cannot be accommodated in a hospital close to their home. High-resourced boroughs were less likely to admit inpatients to Trusts that do not cover the borough. They had an average of 12 per cent of patients accommodated by trusts outside the borough, compared to over a quarter of patients in low-resourced areas. Intermediate resourced areas lay between the two with an average of 18 per cent.

•Community services were also more likely to be in place, with most of the high-resourced group having home treatment teams while none of the low-resourced group did. Home treatment teams aim to provide a high level of treatment in the patient’s own home equivalent to the level of treatment they might receive on an inpatient ward enabling the patient to avoid admission to hospital. Assertive outreach teams were in place in most areas. However better resourced areas had more teams. The teams were also more likely to include dual-diagnosis workers.

•High-resourced boroughs had more rehabilitation schemes and more employment schemes, resulting in higher numbers of weekly attendances at employment schemes.

•The high-resourced group was more likely to include complementary therapies as part of their service. The use of complementary therapies in the treatment of mental illness is advocated by a number of patient groups and there is, in some cases, evidence of efficacy. High-resourced areas were more likely to provide exercise, massage, aromatherapy, acupuncture and yoga.

•There was less variation between high- and low-resourced groups on official performance measures such as the percentage of service users given a review within seven days of discharge and the percentage of readmissions that occurred within 90 days of discharge. This perhaps reflects the fact that all areas are under equal pressure to meet these targets regardless of resources.

Greater resources were to some degree associated with higher levels of deprivation. The high-resourced areas tended to be inner-city areas that have traditionally had more severe mental health problems.

- Psychological therapies Mental Health Trusts were asked about a range of psychological therapies, which have been acknowledged by the National Health Service as having good clinical evidence of efficacy. MHTs said they offered most therapies in a secondary care setting for most PCTs. Family therapy was less likely to be offered as was Cognitive Behavioural Therapy (CBT) for severe mental illnesses. We also asked MHTs to estimate the number of eligible patients that actually received these treatments. Estimates were made for only seven boroughs. Answers for CBT for anxiety and depression ranged between 75 per cent and ten per cent. Answers regarding family therapy for schizophrenia ranged from 50 per cent to five per cent. The figures show an acknowledgement that in many areas there is not sufficient provision of these therapies to meet need. In some cases the under provision is thought to be dramatic with only a minority of eligible patients receiving therapy. The two therapies identified as having greatest under-provision were family therapy for schizophrenia and CBT for people with delusions and hallucinations. Access to psychological therapies in primary care is limited in some areas.

- Engaging ethnic minorities Representatives from 15 PCTs and chief executives of all 11 MHTs were asked about groups excluded from access to mental health services. Black and minority ethnic communities, refugees and asylum seekers and people who do not speak English were cited most commonly as likely to be excluded from services. It is estimated from 350,000 to 420,000 of the population in London are asylum seekers or refugees. Ealing PCT estimates that up to ten per cent of people accessing mental health services are refugees and asylum seekers. There are particular difficulties for refugees and asylum seekers in being able to access translators. All boroughs said that they were committed in principal to the provision of translators. However one third said that in practice they faced difficulties achieving this because there simply wasn’t the capacity available. The pressing need for language support and information provision was identified as a key area in the survey. In particular, the responses indicated the need for a more comprehensive language support service. In view of the fact that language barriers were regarded as one of the major hurdles to people accessing mental health services it is surprising that only around one half of borough services provide written information in other languages. In many cases the range of information supplied is very limited, for example, covering just the patient’s rights under the Mental Health Act. Table 3 The percentage of PCTs that provide particular information services Information services % Aim to provide interpreting as matter of policy 100 Have difficulty accessing interpreters 35 Provide information in other languages 48

There is a very wide range of outreach programmes organised by MHTs across London (see full report Appendix D). Some Trusts are more active than others in setting up targeted outreach programmes – for example, Central and North West London, Barnet, Enfield and Haringey and South London and Maudsley. In total there are over 20 separate outreach programmes for minority ethnic groups with service for black men and Asian women being most common. While the organisation of these services at a local level allows engagement with local community groups and appropriate tailoring of services. Some areas had made cultural and spiritual awareness an important feature of their service and received recognition for their work. In particular the Sainsbury Centre for Mental Health has cited Newham as an example of good practice in this regard. Comparing the ethnic make-up of inpatients with the ethnic make-up of the borough, well-documented differences appear with the black population over-represented and the Asian population under-represented fairly consistently across all boroughs. There is a closer match between patient numbers and staff numbers by ethnicity than between patients and the population as a whole. Breakdowns of staff by ethnicity were available from seven PCTs. While levels of black staff were in line with the levels of black patients overall, staff tended to be black African while patients were more likely to be black Caribbean. Asians were generally over-represented in the staff population, compared to the patient population. The issue for many Trusts was not simply to ensure that staff make-up reflected the patient profile, but also to ensure that staff from minority ethnic groups reached senior roles within the organization. Monitoring of staff showed that people from minority ethnic groups were consistently less likely to reach senior positions.

- Services for women There are a number of examples of exceptionally good levels of service for women with mental health problems. Camden & Islington fund a national beacon service called Drayton Park, an eight-bedded crisis home for women with mental health problems who need to be in a women only service. It provides 24 hours, 7 days per week care. Croydon also funds an eight-bedded women only, women-staffed crisis house. However, the standards of service in general mental health inpatient wards vary significantly. For example: •Hillingdon. All service users have single rooms with en-suite bathroom facilities, which are zoned into male or female areas with separate sitting room areas.

•Redbridge. Wards have female and male bedroom wings, with single rooms for all services users and separate female-only sitting rooms on all wards.

•Greenwich. All patients have their own room along separate male and female corridors, with communal eating and living areas.

•Enfield. None of the wards are single sex and none of the wards have single rooms; although there are separate sleeping areas for men and women, none of the wards have separate day facilities.

In several areas there are no specific mother and baby units. For example, Barnet, Enfield and Haringey Mental Health Trust has no units but is considering developing one due to increased demand. Oxleas Mental Health Trust refers patients to South London and Maudsley NHS Trust.

Financial and staffing pressures Recruiting and retaining staff was commonly cited by MHTs as being a hindrance to meeting NSF targets. This has two results – first, a direct impact on the quality of services due to unfilled posts, and second, an impact on budgets due to the high cost of employing agency staff to cover vacancies. The cost of agency staff can have a ruinous effect on staffing budgets. In some cases, over half the relevant budget is spent on agency staff adding as much as 100 per cent to the total staff costs. Department of Health figures for September 2001 show London as having significantly higher vacancy rates for community psychiatric nurses (five per cent) compared to the rest of England (one per cent) and even higher rates for other psychiatric nurses (seven per cent) compared to the rest of the country (four per cent). Key issues mentioned by PCTs as putting pressure on budgets were: •past deficits and the fact that funding for new targets does not take into account the current budget position •insufficient acknowledgement in funding formulas for the problems faced in London including high levels of deprivation and increasing number of patients with dual diagnosis •rising costs of private sector care.

In some cases, competing priorities in the acute sector have resulted in earmarked funds for mental health being diverted into acute services.

Transforming London's Mental Health

London' mental health services have achieved major advances in the last 20 years. Bed numbers in the large psychiatric hospitals have reduced substantially, cost effectiveness has improved, more people are receiving care and support in community settings. London has shown the way in learning about developing home treatment, assertive outreach and early intervention services in complex urban settings, of involving service users as partners in service delivery and developing effective interventions. However challenges clearly exist, in particular there are wide variations across London and there is a shortage of work opportunities and training of skills, affordable housing and supportive accommodation. Historically higher levels of funding for mental health services in more deprived areas have produced significantly better quality services in some areas, such as Lambeth and Westminster, however other areas such as Newham are greatly under-resourced. Some boroughs with historically under-funded mental health services could benefit from stronger ring-fencing of new money to rebalance spending. Commissioners of mental health services in London could benefit from greater support and development of commissioning skills in primary care services. This will become increasingly important as primary care becomes more of a focus for targets in service improvement.

There is a need for the development of a comprehensive language support strategy in London. This would enable people who are currently excluded to better access mental health services. More work is also necessary to identify the extent to which faith communities support people with mental health problems; and also the extent to which faith organisations and statutory sector providers can work together to help meet people’s mental health needs. It is important that directors and senior managers demonstrate a commitment to proactively target and progress the development of black and minority ethnic staff. This will require systematic training programmes to tackle the ‘glass ceiling’, which exists within organisations. A more comprehensive approach to developing services across health and social care is needed. This will help to overcome the ad hoc service delivery which currently exists, and help to reduce the wide variation in service provision between boroughs. Increased investment in psychological therapies in primary care is needed to make access universal. Access is arbitrary to a large degree and determined by factors such as the structure of local services and the level of interest of the GP. Increased investment in psychological services would also be required to provide a service adequate to meet the patient needs. A systematic approach to women only services, based on identified need, is required. A pan-London strategy to improve staff retention rates – particularly for inpatient psychiatric nurses – would, if successful, have a significant impact, on the money available for delivery of mental health services.

The mental health NHS Trusts have identified six strategic objectives for the next few years:

1. Further development and expansion of early intervention services. To promote mental health and wellbeing and provide effective preventative strategies to help those at risk of developing serious mental health problems in early life.

2. A clear pathway of care. To provide a continuity care system between primary, secondary and tertiary services.

3. Promoting recovery approaches and social inclusion. To adopt evidence based approaches to help people on their recovery journey. To combat socially exclusive attitudes and practices.

4. Local treatment within the community. To refocus the work of CMHT's and provide more care at home based services.

5. A new strategy for inpatient care. To rethink the purpose, function, quality and structure of acute inpatient services.

6. Working with those most at risk. To develop effective service models for offenders, dual diagnosis users and others.

A "Whole Life Whole Systems" approach.

The overall objective in order for users to have a meaningful whole life is to adopt a whole systems approach in the design and development of a community mental health system. The main indicators for developing this whole system approach include:

1. Situational analysis. Information gathering on the needs, characteristics and numbers of people using the services in all organizations.

2. Development of community organization partnerships. To bring together organizations that provide local health services, education, housing, employment opportunities, etc to find a common purpose that is shared by all for the benefit of the community as a whole; to improve the wellbeing of citizens in a given local community.

3. Supporting users with a Personal Recovery and Development Program. This is to train mental health professional of how to work with service users for them to build partnerships and to discover the whole person in themselves and to move forward in their life.

4. Knowledge of community systems, good practice services nationally and internationally. Networking with people and organization internationally to improve information and people exchange and research opportunities for new solutions. Mental health in inner large cities collaboration and twinning initiatives.

Over the last 20 years much has been achieved in moving away from the isolated institutions of the 19th century to a more community focused service. As can been seen there has been an array and abundance of policy and legislation that together sets a clear strategic direction. Some of the individual policies, their objectives and services have been implemented; however there has been major difficulty in bringing together all the policy intentions and implementing these in a cohesive and holistic way at local level. The next big challenge and need for a clear vision is to work with and build a community system with local community organizations to meet the broad and diverse needs of service users. This is particularly important in the ever changing mosaic of life in large cities cross the world. Skills and technologies in community development work in a whole system context is required and to move away from mental health professionals looking inwards within and trapped in a mental illness service that has the danger of perpetuating institutional thought and practice, not giving opportunity to improve the social inclusion for users. A suggestion could be to develop a "Twinning Collaboration" between a few major cities in Europe to exchange good practices, develop new initiatives, provide action research to overcome the many challenges that exist, using the "Whole Life Whole System" approach.


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