Mind the Gap in Public Health White Paper

The government wants the NHS to be a national ‘health’ service not an ‘illness service’. But will the war on fat and fags, promised in the recent Public Health White Paper extend to an attack on poor mental health outcomes? Simon Lawton Smith says that mental health professionals will have to remind service commissioners and planners about their responsibilities

Maybe, after a hard day’s work in the community or on the ward, you collapse at home with a newspaper or in front of the TV. If so, you cannot have failed to notice that over the past few months, obesity, smoking and exercise have been hot topics. A combination of fast food, fags, too little exercise and incautious sexual activity fuelled by binge drinking is creating a nightmare scenario in which the NHS will buckle under the weight of illness caused by this reckless and feckless lifestyle.

Faced by this, the Government has issued its weighty Public Health White Paper, Choosing Health (DH, 2004). This set out its plans to improve ‘the opportunities, support and information people need to enable them to choose health’. The main spotlights in the 207 page document focussed on obesity, smoking, and lack of exercise. In doing so, it targeted the ‘big killers’ of cancer and heart disease, two of the Government’s three clinical priorities.

What was much less clear, and hardly touched on in the media coverage, was how the White Paper would address the third clinical priority – mental health. This may be because it is only on page 131 that you find the welcome assertion that Transforming the NHS from a sickness service to a health service is not just a matter of promoting physical health. Understanding how everyone in the NHS can promote mental well-being is equally important’.

Another problem is that the Paper focuses heavily on helping people to change their lifestyles – eat better, exercise more, stop smoking. But, by and large, mental illness is not a lifestyle choice.

Before looking at the Paper in more detail, it is worth reminding ourselves about the scope of problems related to mental health. An estimated one adult in six in the UK aged between 16 and 64 suffers from some form of mental illness, mainly anxiety and depressive episodes. One in four of us will experience some sort of mental illness at some time in their lives. One child in ten between the ages of five and 15 suffers from a mental disorder. Around 4,500 people take their own life in England every year. Some 30% of all GPs’ consultation time is spent on patients with mental health problems. Half a million people with work-related stress mean 13.5 million lost working days. Nearly 870,000 adults on incapacity benefit cite mental ill health as their primary condition.

A reader of this article is also likely to know that pressures on front-line mental health staff are greater than ever. Many of the old securities and received wisdom about how to provide services have had their foundations shaken, if not actually uprooted, over the past few years.

The biggest change, though it has been with us awhile, came with the move towards caring for mentally ill people in the community, liberating tens of thousands of people from a life of institutionalisation to one in which they can, with the right support, play an active role in their local communities.

Treatment for people with mental illness has made great advances in recent years. There are better drugs, but also an increasing acceptance that while medication has a vital role to play, it is only one of a range of interventions that should be offered to people. Health minister Stephen Ladyman indicated in November 2004 that it was his ambition that the NHS and social care should offer to patients a whole spectrum of activities stretching from t’ai chi to mountain climbing, to driving go-karts, to swimming and ballroom dancing.

We have patient-centred models of care, Experts by Experience and the wider Patient and Public Involvement agenda. More recently, the mantra has been one of ‘personalised’ services. Staff can no longer work to a ‘one size fits all’ model.

On top of all these changes, Health Secretary John Reid has made clear that NHS staff can no longer expect to work within closed areas of professional competence: ‘I want to commend the widespread development of new roles and new ways of working across the NHS, the diversity and flexibility of our staff and the move away from professional demarcations to team working based on patient needs’ (DH, 2003).

Despite the missed opportunity in the White Paper to send out a clarion call for mental health, it does contain some useful initiatives. Mental health in the workplace is featured, along with better support for people with mental health problems in accessing employment. At a time when there are increasing numbers of children and young adults being diagnosed with mental disorders, there is a welcome emphasis on the emotional well-being of children. And the links between poor physical health and poor mental health are noted, with some promising work on new models of physical healthcare for people with mental health problems.

There are two new groups of people who could, in theory, make an impact on improving the mental health of local communities. The first are called ‘health champions’, existing individuals drawn from a range of organisations and sectors ‘with experience, enthusiasm and often skills in promoting health and community engagement’. These individuals ‘will be able to offer short-term consultancy support to local councils and community partnerships to share good practice and assist them in developing local action for health’. Clearly such a network of individuals could, and should, contain many from the mental health field.

The Big Idea, though, comes in the form of new ‘health trainers’. These will be drawn from local communities, and will ‘understand the day-to-day concerns and experiences for the people they are supporting on health’. They will also be ‘friendly, approachable, understanding and supportive’ and will get NHS training and accreditation and support people in making healthy choices, as well as acting as referral points to other services.

Disappointingly, there is no requirement set out in the White Paper for mental health to be a core skill for health trainers, though that may follow. Nor is it made clear where health trainers might stand on the shifting sands of community mental health teams, graduate workers in primary care, practice counsellors, gateway workers, community development workers and Support, Time and Recovery workers (not forgetting the 3,000 new community matrons promised by 2008 to provide personalised case management for people with long-term conditions, including mental health problems).

All of a sudden it’s starting to look a very crowded field out there. The Paper does not specify future numbers of health trainers, but says that ‘everyone’ will have access to their support. In England, that means they will, in theory at any rate, provide support to some 50 million people – much as GPs do.

It’s not clear what workload they will be expected to cope with, or how hands-on they will be. Should each session with a health trainer take around 40 minutes, a trainer might fulfil maybe 40 sessions a week – let’s say around 1,800 sessions a year. Even assuming no-one returns for a second session (unlikely), that means we need around 28,000 health trainers – not dissimilar to the number of GPs, which is around 32,500.

That’s some 90 per primary care trust. Crucially, though, the Paper does point out that support from a healthcare trainer is only there ‘if people want it’. I suspect the Department of Health envisages a considerably lower figure, based on only a small percentage of the population seeking advice.

Two final questions. First, will the White Paper bring resources into mental health? The amounts of NHS and local authority expenditure in England on mental health services added up to 3,489 million in 2002/03 for adults of working age. Yet within this, spending on mental health promotion was only 0.1% (SCMH, 2003). With its focus on obesity, smoking and exercise, there is little in the Paper that suggests a shift of resources into public health mental health.

Second, will the Paper lead to more commissioning of mental health promotion and prevention services? It makes clear that it is up to local Primary Care Trusts (PCTs), working in partnership with other local organisations, to decide on public health priorities and targets. The influential Wanless Report on public health (Wanless, 2004) also pointed out that much of the public health workload will fall on PCTs.

However we know (London’s State of Mind, King’s Fund, 2003) that PCTs can be weak commissioners in respect of mental health. Mental health promotion, in London at any rate, is poorly resourced and generally had a low profile. Projects are often commissioned on a short-term basis, which made sustaining action difficult. On the whole, mental health promotion remains a peripheral concern to statutory agencies. The voluntary and community sectors have a crucial role but their capacity is underdeveloped.

The White Paper isn’t all gloom and doom for mental health, but local mental health workers are going to have to do a major lobbying job on service planners and commissioners if its stated aim of improving the mental health of the nation is to become a reality.

Simon L\awton Smith is mental health policy officer at the King’s Fund

John Reid has made clear that NHS staff can no longer expect to work within closed areas of professional competence: ‘I want to commend the widespread development of new roles and new ways of working across the NHS, the diversity and flexibility of our staff and the move away from professional demarcations to team working based on patient needs’ (DH, 2003)

On the whole, mental health promotion remains a peripheral concern to statutory agencies. The voluntary and community sectors have a crucial role but their capacity is under-developed

Another problem Is that the Paper focuses heavily on helping people to change their lifestyles – eat better, exercise more, stop smoking. But, by and large, mental illness is not a lifestyle choice

References

Department of Health (2003) More staff, working differently the NHS Workforce in England. London, DH

Department of Health (2004) Choosing health: making healthy choices easier. London, DH

King’s Fund (2003) London’s State of Mind

Sainsbury Centre for Mental Health (2003) Money for Mental Health. SCMH

Wanless D (2004) securing Good Health for the Whole Population. London, DH

Copyright Community Psychiatric Nurses Association Mar 2005