Let's ensure preventative services aren't harmful themselves

According to a paper published in the Lancet Psychiatry today, the implementation of nine public mental health interventions could save the country £45 billion. The paper, “The economic case for improved coverage of public mental health interventions”, by Jonathan Campion and Martin Knapp has been endorsed by the Royal College of Psychiatrists.  

"While nipping problems in the bud might make perfect population sense it avoids the question of whether that particular bud wishes to be nipped."

The recommended interventions are based around a mixture of screening and measurable programmes targeted at particular groups of people. The paper costs up the savings to the public purse over time of these interventions:

• £4,147m after 5 years from school-based social and emotional learning programmes to prevent conduct disorder for a one year cohort of 10 year olds
• £9,726m from school-based interventions to reduce bullying for all 5-18 year olds
• £386m from parenting interventions for parents of a one year cohort of 5 year olds with conduct disorder
• £4,518m after 2 years from workplace screening and early treatment of depression and anxiety disorder for all employees  
• £568m after one year and £1,040m after 5 years from suicide awareness training for all GPs in England
• £62m after one year and £477m after 10 years from early intervention for all adults developing psychosis in a year
• £457m after one year and £1,693m after 7 years from primary care-based screening and brief intervention for all hazardous and harmful/mild dependent drinkers
• £310m after 3 years to the health sector from Cognitive Behavioural Therapy (CBT) for all adults with schizophrenia in previous year
• £18,864m after one year to employers from provision of a simple set of interventions to promote wellbeing of all employees

It’s hard to argue that work to reduce bullying and develop emotional learning in schools would be an awful thing: such harmful experiences can blight a lifetime. Similarly, increasing funding of Early Intervention in first episode Psychosis, so that this first bewildering and confusing experience does not derail a person’s life forever would be welcome and valuable. Suicide related training for GPs would be welcomed by many, as may a set of prescribed wellbeing interventions at work.

More problematic are the interventions based on screening and specifically targeting those ‘with a problem’.  Workplace screening for depression and anxiety, and primary care screening for problem drinking might, for some, have an unpleasant air of ‘doing to’ not ‘doing with’. While nipping problems in the bud might make perfect population sense it avoids the question of whether that particular bud wishes to be nipped.

Ill-feeling 

In endorsing the recommendations, Prof Wendy Burn claimed: “while these interventions are focused on mental health... They will help reduce crime and improve education, while also supporting people to find and remain in employment, thus further improving our economy.” This positioning may ring alarm bells for those who have been watching closely the drift of public policy over the last decade. Similarly, the rolling out of CBT to all people with a diagnosis of schizophrenia risks replicating the ill-feeling some with long term mental health needs feel toward the overall Improving Access to Psychological Therapies programme. The status of IAPT and CBT as the 'only game in town' has led some to feel that CBT has become a substitute for other forms of talking therapy and support. Where this is the only option, people feel the only power they have is to vote with your feet and become non-compliant and drop out.

The suggestion of targeted parenting interventions for the families of those considered to have conduct disorder have unpleasant overtones of the Troubled Families programme, the first iteration of which was judged “no discernible" effect on unemployment, truancy or criminality in an evaluation leaked to the BBC.

"It’s hard to argue that work to reduce bullying and develop emotional learning in schools would be an awful thing: such harmful experiences can blight a lifetime."

Championing such proposed ‘big’ programmes makes sense as an attempt to refocus the debate on public mental health back into rigid national programmes overseen by mental health professionals and also as a shot across the bows of Public Health England’s Prevention concordat for better mental health published in August this year.  The resources within the prevention concordat, in the main developed with The Mental Health Foundation and The Faculty of Public Health, focus on mental wellbeing and primary prevention of mental illness and provide data and guidance to local authorities intended to help local decision making.

The recommendations themselves date back to 2011 under the coalition government, when they were published in a paper that was released in the wake of the mental health strategy No Health Without Mental Health. This was before bodies such as Public Health England, Clinical Commissioning Groups and Health and Wellbeing Boards came into existence and before the responsibility for public health was transferred to local authorities.   

Individual versus population arguments

The targeted programmes versus population wellbeing approach is a battle that has a tumultuous recent history if you know where to look. In her annual report in 2013, published in 2014, Chief Medical Officer Sally Davies stated her emphatic opposition to the funding of mental wellbeing as an element of public mental health stating she refused to take a ‘leap of faith’ and recommend wellbeing programmes without evidence to support them.  Her one page summary of recommendations states: “ It is important that strategies to prevent and treat mental illness in the population are not supplanted by a myopic focus on ‘well-being’. The evidence-based specific interventions recommended by her report were, in the main, the same as those championed by the Campion and Knapp paper.  Supporters of a wellbeing approach would claim that public mental health and wellbeing approaches have not yet had time to build their evidence base.

An analysis of local authority spending on public health by the King’s Fund in September 2017 found the proportion of public health budgets allocated to public mental health is around 1.6 per cent for 2017/18. Writing for The King’s Fund, Chris Naylor notes “In some local authorities, planned spending on public mental health fell between 2016/17 and 2017/18 as a proportion of total public health expenditure. As 2017/18 has seen the first planned reduction in overall public health budgets since local authorities took on these responsibilities, this means that in some areas public mental health is getting a smaller slice of a shrinking pie.”

It is certain that public mental health is not where it needs to be, and that its current home with local authorities and Clinical Commissioning Groups may not last the course. It’s also clear, when existing bodies aren’t sure what to do to address public mental health they are more likely to do nothing and spend the money on something else.  Whether you feel the Royal College of Psychiatry are correct in trying to return the debate to where it was seven years ago will depend in part on whether you trust in the potential of massive national programmes undertaken by central edict and in part on how you think it might feel to be on the receiving end of one.

Mark Brown is former editor of One in Four magazine, created for and by people with mental health needs. Twitter: @MarkOneinFour