When Napoleon was asked what he wanted in his Marshalls
he answered “to be lucky”.
He would have been pleased with Theresa May. A year ago David
Cameron gave a good speech on mental health - I know, I was there.
But hardly anyone else does, because he chose the morning that
David Bowie died. There was zero coverage.
Theresa May chose a day in which for some reason Donald Trump
said nothing and the only other news was the London tube strike and
so she dominated the airwaves. Even the strike worked in her favour
- more people at home twiddling their thumbs with nothing better to
do than follow the news.
A Prime Ministerial speech is important. It sets a tone. The
political and civil service bandwidth for AOTB (Anything Other Than
Brexit) is going to be narrow for years to come, so knowing what
Downing Street is keen on really matters.
And there is no going back from this - Theresa May meant what
she said on her first day in office – she wants to see a
transformation in how we approach mental health. So we must applaud
the fact that the speech happened at all.
But what about the content? Again, there was much to like. There
was a spirited defence of the importance of social networks and
social cohesion for mental wellbeing. Nothing that we would not
agree with and perhaps a little dig at the first woman Prime
Minister, who famously or infamously claimed there was no such
thing as society. In our world there most definitely is.
We heard a lot about the early years - again, little we have not
been saying ourselves, but still very welcome.
There was a commitment to ending using police cells as a place
of “safety” for mentally ill adolescents. We have been pushing for
this for some time. There will be more mental health education for
teachers - Mental Health First Aid will be rolled out across the
My alter ego, The Boring Boffin, might point out that the best
trial of this showed that it did improve teachers’ knowledge of
mental health, but had little impact on the children. However, this
is probably the occasion to keep Boring Boffin in the kennel.
And to be fair, the pre-speech briefings (I will riff on the
subject of what really goes on before, during and after a political
speech in a later blog) did include the word “trials”. Boring
Boffin worked hard to get that - not “pilots”, still less
“evaluations”, but “trials”. Well meaning interventions, especially
with children, can do harm as well as good.
It is our role as a calm but authoritative voice, to point this
out. Where we have evidence - as in parenting programmes to reduce
behavioural difficulties in children - we will shout this from the
rooftops. But the only way we can find out what works and build our
evidence-base, is through trials. There is no other way of
assessing the balance between benefit and harm.
But we don’t need more trials to know that Prime Ministerial
support for putting mental health services into A & E is a good
thing. A & E services will always be seeing those with drug,
alcohol, deliberate self-harm, comorbidity and so on. And they will
also always have to see those with serious mental health problems
who have developed acute physical health care issues. And so they
will always need us.
Digital is all the rage, so not surprising that a lot was made
of this. From our perspective it was good to see that six mental
health trusts will be designated as “Digital Exemplars”, which
comes with £5 million in extra funding, after competition.
I say good, because that would not have happened without our
strenuous interventions when it became clear from the first
announcement that mental health trusts were not originally included
in the scheme.
As ever, what was not said was as important as what was said. We
tried to get more in about the workforce - this wasn’t successful,
but back chat indicated that our hope that the commitment to
provide up to 1,500 extra places for medical students will include
measures to ensure that they don’t all want to be surgeons (of
which we need fewer, not more, in the future), but GPs and
psychiatrists (of which we definitely need more) will be heeded
soon. 1,700 new therapists were promised for CAMHS services - but
not the 350 CAMHS psychiatrists that both ourselves and HEE have
indicated are needed.
Nor did we get the PM backing to end out of area placements for
adults. We created the Crisp Commission soon after I took office
and were pleased when NHSE accepted its findings and
recommendations, but not the deadline we had proposed to this
practice finally outlawed. We had hoped the PM might advance this,
but she remained silent.
But we return, as we almost must, to the money. The PM promised
some – as far as I can gather, the only truly new money was £15
million allocated for out of hospital crisis care, such as mental
Some previous commitments were repeated - liaison and court
diversion schemes to keep people out of the criminal justice system
being extended across the country. I actually thought that was
already happening, but having the PM repeat it does no harm. Ditto
the extra investment for A & E liaison psychiatry services.
But overall the picture is gloomy. Between 2010 and 2015 funding
to the mental health trusts went down by over 8%. Not up, down.
Since 2010 we have lost more than 2000 beds in England alone. But
demand has risen - referrals to community mental health teams have
gone up by 20%. So has there been a concomitant increase in
Don’t hold your breath - that went down by 5%. Meanwhile, you
probably have seen the coverage of the 50% rise in mental health
attendances at A & E over the same period - with a particularly
worrying increase in children. Some, but not all, of this is due to
better coding, but clearly the underlying trend is not good.
And looming over it all remains the fact that sightings of the
large sums (now we are talking not a few million, but over a
billion) promised by George Osborne before he was defenestrated,
remains as elusive as sightings of the Loch Ness Monster or the
Beast of Dartmoor.
Confirmed sightings of the money continue to be of small kittens
rather than the Sabre Toothed Tiger sized felines that we were
promised. Certainly eating disorder and perinatal services are
benefiting, which is great, but the radical transformation that the
speech promises remain to be delivered.
We are responding, helped it must be said by the new NHSE
“dashboards” - which give at least some evidence of what CCGs are
actually spending on mental health. Before Christmas we had a blitz
on CCGs that made Scrooge look like the Bill Gates Foundation when
it came to funding CAMHS services.
Armed with the data, we targeted local MPs and media, in a bid
to name and shame errant performers, this being almost the only
weapon we have in the post Lansley/Health and Social Care Act era.
Expect a lot more of the same as we get down to looking at numbers
of Out of Area Transfers (OATS), or who is honouring the expected
1.5% mental health uplift.
But I am afraid talking to Medical and Finance Directors up and
down the land, we know that the famine continues and the broad
sunlit uplands remain a distant prospect. We are not alone in this
– as I write you cannot help but notice the tension between Number
10 and Simon Stevens about the overall level of NHS spending - who
promised what and where is it?
Simon seems to have the facts on his side, but this is now about
politics and where this will end we can’t say. I hope that it will
settle, because Simon Stevens has been a good friend to mental
health (it is where he started his career) and it is also hard to
see anyone who would want to do his job, let alone do it better
than he does.
So where does that leave us? I don’t think I can improve on this
week’s (Jan 14) Economist – “The Prime Minister makes a big speech
but signs a small cheque”. Big speeches are good, cheques would be
Professor Sir Simon Wessely
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