During the general election, the key parties committed to making changes in relation to mental health, ranging from additional investment in frontline staff and training, to increased access to talking therapies and a particular focus on children and young people. Aside from the moral case, this makes good economic sense.
As RSA research conducted in 2015 shows, the potential benefits of improving mental health care are huge. We found that not only are people with mental health illnesses a third less likely to be in employment, but they are also anywhere between 10% and 45% less likely to receive physical health checks on things like blood pressure, cholesterol and cervical cancer. This failure to meet basic needs at the primary care level is contributing to the elevated mortality of people with mental health illnesses, who die 10–15 years younger than average.
The RSA’s work on public services and mental health suggests that we need a combination of clear central political leadership — around parity of esteem between mental and physical health — alongside greater local decision making, capable of drawing together agencies to meet people’s multiple needs, innovating and engaging communities. Yet, the UK remains one of the most centralised political economies in the world, so while health services are increasingly commissioned at a local level, the priorities continue to be set by the centre, where mental health policy falls unfavourably between the Department of Health, Department for Education and the NHS.
Both Labour and the Conservatives have committed themselves to supporting further devolution, with the latter’s manifesto describing the UK’s approach as one that tends to “devolve and forget” and pledging to be more “supportive” — read interventionist. This is a potentially contradictory stance mirroring Labour’s lack of detail on whether it wants to stall or accelerate city-region devolution. Indeed an important question now is exactly how the new government makes these changes, and what purpose power transfers will serve.
Catalyst for reform
While mental health interventions might cost more money in the short term, long-term savings arise elsewhere. Nationally, up to 25% of police time is spent on issues that stem from mental illness and the costs to the taxpayer across the public sector are significant. The new government needs to ensure that devolved regions that have the ability to innovate in areas of education and health, truly grasp the issue of parity and its cost effectiveness.
One area where greater localism offers opportunities to improve outcomes is our country’s prison system, which holds many people with acute needs. According to the Prison Reform Trust, 26% of women and 16% of men said they had received treatment for a mental health problem in the year before custody. Currently, the health needs of this population reflect the lack of investment in community-based support, and the prison reform agenda — which gives governors a role in co-commissioning health services — is a welcome step.
More broadly, the devolution process is already bringing about a significant disruption to the norm. In April 2016 Greater Manchester’s landmark devolution deal brought together all £6bn of health and social care spending under the new directly elected mayor, Andy Burnham, who has called for a new integrated health and care service. This provides a chance to drive and test service re-design and ensure that it is fully aligned with the rhetoric of parity of esteem.
Mayoralties that can rise above technocratic localism provide an opportunity to set a clear vision at the regional level. These kinds of approaches enable the regional authority to cross the complex divide between NHS England commissioned services (which provide primary care for prisons), local authorities (which provide substance misuse support) and clinical commissioning groups (which provide services for prisoners managed by probation).
“The potential benefits of improving mental health care are huge”
And as a new crop of city leaders settle into their jobs, it is not just in Manchester that opportunities lie. In Bristol, Mayor Marvin Rees has created the City Office, which brings together organisations from across sectors to address key issues and go beyond formal powers to ‘knock heads together’ in order to improve public services. Starting with a focus on rough sleeping, the model could also be used to improve mental health services that are letting thousands of people down, though this highlights the risk that devolution can be dependent on the individual priorities of politicians.
However, alongside service improvement, greater devolution can also be a vehicle for a higher profile ‘hearts and minds’ approach to mental health. Both Greater London and the West Midlands have expressed interest in the ‘Thrive’ approach developed in New York City. This blends public health and acute mental health provision — which, surprisingly, is very rare — while providing skills and training across institutions so that public servants understand how to signpost and direct support to those most in need, including providing emergency accommodation for people in crisis.
Leaders such as detective chief inspector Sean Russell, who has been seconded in to lead the West Midlands Mental Health Commission, embody the opportunity provided by region-led working, making way for greater co-commissioning between West Midlands Police and mental health and social care. He is overseeing delivery of a plan to reduce suicides and stem the flow of people with mental health problems into the criminal justice system through staff training and early interventions. The Commission, which estimates that the annual cost of mental ill health is in the region of £12.6bn, has helped to embed a new child and adolescent mental health service and up-skill the region’s teachers and support staff so that they are mental health first-aid trained. The RSA is actively working with Russell across seven schools within the RSA Academies, which are aiming to embed a ‘whole school’ approach to supporting young people with mental ill health.
The challenge now is how we mainstream these kinds of approaches and scale up action. Whatever the ‘new’ devolution agenda looks like in the coming years, we will need to revisit old debates about local variations, skills and investment. Amongst this, there is a need to exploit the political consensus that effective public services need to see parity of esteem of mental and physical health, and to drive place-based policies that seek to achieve this.