Closing The Gap

~ Nicola Byrom

I have been passionate about mental health for years. I think our society, today, has the opportunity to see a complete revolutionary shift in attitudes to mental health. The change is vital, but is the motivation there?

Most of our society is familiar with the statistic 1 in 4. 1 in 4 adults will experience a mental health problem this year [1] . 1 in 4 is also the number of people with a mental health problem that get treatment. Yes that is right. At the Deputy Prime Minister’s conference (20th January 2014) on Closing the Gap: Priorities for essential change in mental health, Nick Clegg set out a strong agenda for reaching parity between mental and physical health. Nick argued that we cannot have a stronger economy and fairer society without tackling attitudes to mental health. The problem still seems to be – how can we achieve this. As Graham Thornicroft [2] explained at the conference, 75% of people with mental health problems do not get treatment. This is despite the fact that we know that average life expectancy is dramatically reduced for men and women living with mental health problems; cut by 20 years for men and 15 years for women [3] . Can anyone even imagine this lack of treatment for a health problem with such an enormous impact on life expectancy?

Parity between mental and physical health needs funding. That funding has to come from somewhere. A medical ethicist at the conference noted that mental health “asylums” have been closed (a good thing, we might all agree) but the transfer of services to the community was less than perfect and the Department of Health is even now continuing to cut the number of beds on mental health wards. She asked Nick Clegg if he would be happy to specify which hospitals and which acute services would be cut to fund better mental health services. Her question was not entirely sincere, but it hits the nail on the head. We need a long hard look at how funding gets shared out within the NHS between services. This perhaps seems unlikely to happen as another individual noted at the conference that in December 2013, NHS England took £150 million out of the mental health budget to cover increased staffing levels in acute services.

There may however be a positive note to this question of funding. A representative from Clinical Commissioning Groups noted that CCGs were entirely on board with the mental health agenda and recognised that better (and more) mental health services needed to be commissioned. She asked for information – noting that her CCG needed to know what services worked. If she is to commission evidence based interventions, she needs the evidence. A short answer to this was provided by Lord Layard: why aren’t we using the NICE guidelines as standard? CCGs should commission services that meet the recommendations of the NICE guidelines. A longer answer should look at how the research is funded (after all, research is the generally accepted way of finding evidence based treatment interventions). In 2008/9 the Medical Research Council in the UK spent £24 million, 3.5% of its budget on mental health research [4] .

Nick Clegg recognised that there is a major problem with the transition between CAMHS (Child & Adolescence Mental Health Services) and AMHS (Adult Mental Health Services). CAMHS usually ends at 18. This is a time of major change for young people. Many will leave home and move to university or leave school and start jobs. With these upheavals in life, young people with mental health problems have enough going on without major changes in their service provision. Nick Clegg promised better support through this transition, but does this go far enough? Young people often can’t simply transition from CAMHS to AMHS because AMHS do not offer the same services for the same mental health problems as CAMHS. It is not surprising that so many young adults fall through the gap. And when the individuals are students and are moving to a new part of the country to study, it is even more likely that they will slip off the radar and be failed by the health service during what is likely to be one of the most stressful and challenging times of their life to date.

This gap needs to be taken seriously, but the agenda set out by Nick Clegg did not mention students once. The Royal College of Psychiatrists (2011) called for National Health Service providers to ‘recognise and respond to the particular mental health needs of the student population and the difficulties that many experience in gaining equal access to services’. I asked Nick Clegg why students did not feature in the new Department of Health priorities for essential change in mental health. Nick shifted responsibility from the Department of Health to universities, noting that universities have a duty of care for their students. Nick suggested that universities should be working closely with local health services to ensure that these services are meeting the needs of students. It seems that Nick Clegg would like me to hand this question over to the Rt Hon David Willetts, Minister for Universities and Science. I agree that pressure must be put on universities to step up to the challenge of mental health, but surely the NHS has some role to play in this transition?

The Rt Hon Norman Lamb however responded to my question later in the conference. He returned to his argument that “This cliff-edge must end – proper transition plans should be put in place, and our ambition is for this to be standard practice across the NHS. There must also be effective co-ordination between CAMHS and adult services, and a commitment to ensuring that the support given is always age-appropriate.” [5] Norman recognises the challenges that students face and suggested at the conference that serious consideration should be given to extending CAMHS to 25. Here here!

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