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The government has invested much time, money and energy reforming mental health services. But there is still a feeling among users and professionals that the reforms are to keep society safe and not to improve well-being for users, reports Mark Hunter.   

Nobody could reasonably accuse this government of ignoring mental health. After decades of under-funding and low priority, the Labour election victory in 1997 thrust mental health services into the political spotlight.

During the next four years, some 650 policy documents on mental health service delivery were published.

In 1999, mental health was granted the first National Service Framework (NSF) and a year later the NHS Plan named mental health as one of the three areas of top priority. More than £300 million has been ploughed into mental health services since 2001 and hardly a month has gone by without another major initiative being announced.

All of which, one would have thought, would have mental health professionals and service users rubbing their hands with glee. But while most would agree that health and social care for people with mental health problems has improved over the past few years, particularly in the area of acute mental illness, several major doubts remain.

Staffing problems, geographically patchy services, poor treatment for ethnic minorities and an over-emphasis on acute illness are the chief criticisms. The near universal condemnation of the draft Mental Health Bill, published in June 2002, exposed a suspicion that the reform programme is more concerned with protecting the general public from the "dangerous" mentally ill than it is with improving the quality of service.

Several recent reports suggest that the reform of mental health services has a long way to go before these suspicions will be allayed.

A survey of mental health trusts carried out last year by the Commission for Health Improvement found that while most trusts were moving in the right direction, their ability to meet the NSF targets was being hampered by "serious capacity problems in management, staffing and infrastructure". Services to ethnic minorities were poor and those service users who did not fall within the NSF's remit were in danger of being overlooked, the report warned. It stated: "The focus on adult mental health services has been at the expense of, for example, services for older people and child and adolescent mental health services."

More recently, a report from mental health charity Rethink suggested that up to 50,000 people with mental health problems are being failed by the government's reform programme because they are "too well" to qualify for support.

Missing out
Paul Corry, head of policy and campaigns at Rethink, says:"There is an emerging group of people who have missed out on the reforms. These are the people who have been in touch with mental health services for some time. They have come through their acute early crises and are now considered medically stable."

They may have problems getting their lives back on track or finding a job or a decent place to live and so tend to have a poor quality of life. "Often they are being cared for by their parents or older relatives, so there's a knock-on effect in the worry and stress caused," he adds.

Corry is concerned that the investment being made to tackle acute mental illness is often directly at the expense of those with longer term and lower grade problems.

He says that Rethink welcomes the government's reform programme as far as it goes but believes it concentrates on young people who are suffering their first bout of mental illness and on people who are in crisis.

"The new services being provided such as assertive outreach teams and crisis resolution teams are doing an excellent job but there is some evidence that other services such as day care centres are being closed in order to fund them." Staff, he adds, are moving to the newer more exciting teams, leaving the older services with severe recruitment problems.

More proposals
The Department of Health denies that its reforms are excluding any particular group and points to the mental health and social exclusion project, due to report this month, which is specifically aimed at helping reintegrate people with mental health problems back into society. A DoH spokesperson says that the project will set out a range of recommended actions across government to help ensure that people with mental health problems are not isolated from services and employment.

This, the DoH says, is in addition to the £300 million extra investment that has been put into mental health since 2001, and "sustained baseline funding helping to improve access to effective treatment and care, reduce unfair variation, raise standards, and provide quicker and more convenient services for everyone with mental health problems".

For those on the front line, however, talk of extra funding means little when faced with longstanding debts, serious staff shortages and rising prescription bills.

In a survey carried out last year by the Sainsbury Centre for Mental Health, more than half of the local implementation teams, which co-ordinate improvements to local mental health services, said financial pressures were delaying progress towards meeting key NHS Plan targets.

Many mental health trusts complained that primary care trusts were diverting much-needed extra money to other services. Social services, meanwhile, were under such pressure to tackle other issues that mental health budgets frequently lost out on funding.

The Sainsbury Centre's report also questioned whether mental health was receiving quite as much of the funding as the government has suggested. Its figures showed that English mental health services received growth money of 1.6 per cent in 2003, compared to 5 per cent for the NHS as a whole.

Jeopardise reform
And this funding gap could jeopardise the whole of the government's mental health reform programme.

"From our experience, most of what's happening in mental health services is really positive because it's about improving services, particularly community services, early intervention and, most importantly, keeping people out of hospital," says Angela Greatley, acting chief executive of the Sainsbury Centre.

Reforms are being implemented without the necessary increase in resources and staffing, she says. "So what is happening is that the new services are being set up at the expense of existing services. The new teams are poaching staff from the old teams and that leaves a big hole."

Mental health has now had four years in the spotlight, sitting alongside heart disease and cancer as a top three priority for the government. But with the new Mental Health Bill still on ice, and the reform programme stuttering in the face of staffing shortages and rising costs, it may be some time before it manages to shake off its entrenched reputation as a Cinderella service. 

Key government mental health initiatives

• October 1999 National Service Framework for Mental Health.
• November 1999 Richardson Report and green paper on reforming the Mental Health Act 1983.
• July 2000 NHS Plan.
• March 2001 National Mental Health Information Strategy launched.
• March 2001 National Service Framework for Older People published, which includes targets for mental health.
• April 2002 New Deal for Disabled People extended nationally.
• June 2002 Draft Mental Health Bill published.
• June 2002 Launch of National Institute for Mental Health in England.
• March 2003 Social Exclusion Unit project on reintegrating people with mental health problems back into society launched.
• June 2004 Social Exclusion Unit report due to be published.

A week in the life of Michael Elvin, a mental health service user

Monday
Start the week by attending the day centre. The long weekend is over. When I arrive I'm greeted by a member of staff who tells me I'm looking good and that I am a nice boy. Today I'm a "good" user. My activities include web site design on a computer, supervised by my key worker who has a qualification in health and safety. The service users hold their regular meeting in the afternoon and the manager is present. He says that I can do the minutes. When I query this, he replies saying that I'm being empowered and it is good for me. In general, I value the human interactions that remove me from the isolation of my bedsit. A cup of tea and a chat with other service users lifts me out of melancholy.

Tuesday
Another day at the day centre. I like to contribute but I find it strange when social care workers keep saying "did you do that yourself?" The comment usually follows work I have done on the computer or a letter I have written to a local newspaper. But the way to get treated well is to play the game and allow them their delusions rather than attempt to challenge them. Today another user is told to take down his poster from inside a garden shed where he works. The poster displays a picture of a bulldog, above which are the words "piss off". Apparently his sense of humour offends a member of staff. The day becomes exciting because we are told there is to be yet another trip to a shopping mall in the minibus. You get to like concrete eventually. When we arrive, some of us go to a pub for a meal.

Wednesday
I spend most of the day safely contained in my small bedsit, apart from attending a monthly appointment with my community psychiatric nurse. We discuss my care plan and the activities at the day centre. I make sure that I reciprocate her smile, otherwise it will be recorded that something is wrong with me. I know how to get the eye contact and body position right as well. Go to the chippy and buy pie and chips. I find doing my own cooking difficult and tend to burn a lot of food. Medication is my lifeline but it slows my speech and sometimes it is difficult to respond to others. When I'm alone I experience a lot of tiredness, but very little sleep. I do some meditation and listen to poetry readings. Today William Blake is my favourite. And I never miss an episode of The Archers.

Thursday
In the morning I attend a tri-monthly visit to an NHS psychiatrist. Sometimes the regularity of the meetings is increased to one every two weeks, depending on my moods. After the usual 10 minutes I leave and go on to arrive late at the day centre. I feel down. Today's visit also coincides with a six-monthly review meeting with my keyworker who writes my care plan. He likes to tell me the activities that I should be doing and if I agree with him then it's deemed that I'm improving. He always says he wants to do one-to-one with me and records it in my care plan. At the next review I intend to ask him exactly what one-to-one is. When I get home I feel exhausted. But I am the chair of a public patient forum for a mental health trust and I need to complete some paperwork on my home computer. And there are messages on my answer phone, which require immediate replies.

Friday
An independent complaints investigator visits me. I've complained about the lack of consultation on changes at the day centre, but keep getting told that it is only my opinion. The staff are allowed to give their views but other service users are considered too vulnerable to become involved. Whenever we suggest things there are always excuses. Usually there are "health and safety considerations" or "a duty to care". Nothing seems to change much, and I decide to listen to a John Lennon CD. Another long weekend advances towards me.

Stifling stigma

A new draft bill will help people with mental health problems by bringing them further within the remit of discrimination law, writes Rowena Daw from Mind.

The Disability Discri-mination Act 1995 is not a law that people with mental health problems have seen as an ally when they face discrimination. Perhaps they do not consider themselves as disabled or may be they do not wish to reveal their diagnosis. Perhaps the experience of stigma is so pervasive that they find it hard to believe that the law could reduce it. A recent report by the Legal Services Commission found that people with mental health discrimination cases were least likely to believe that the law could help them.

Potentially, the DDA is very powerful. Its coverage is broad and its definitions of discrimination helpful. A person who is sacked when they take sick leave because of depression or a student who needs extra time to complete a university course after a nervous breakdown might successfully claim protection under it.

Discrimination bill
Improvements are on the way too. From October 2004, professional bodies could be guilty of discrimination if they refuse to register a qualified person who wants to practise because they suffered from a mental illness in the past. And if the draft Disability Discrimination Bill amending the DDA is passed, someone thrown off a bus because of their "strange" behaviour, or a person who has their application to become an adoptive parent automatically rejected on the grounds of a mental health problem, might also have a viable case.

Although the number of people with mental health problems who pursue discrimination cases is increasing, few succeed. So why do they fail?

Shortcomings in the law are sometimes to blame or the medical evidence may be inadequate. Sometimes claimants withdraw because the process is too stressful. And time limits for lodging applications are also very tight - an individual has just three months in employment cases. There is no legal aid available for employment tribunals so claimants often do not have any legal representation. They can become easy prey for lawyers in court. The cost of expert witnesses can also deter people.

Daunting process
Tribunal members often seem to believe that an employee has been malingering, although why a person would willingly take powerful drugs with horrible side effects, or how a doctor could be so easily hoodwinked into prescribing them, is anyone's guess. Overall, the whole process can be pretty daunting for a person who is unwell. Yet despite all this, some cases do succeed and the level of understanding of mental health issues in the workplace and in tribunals is starting to improve.

When the draft bill to amend the DDA went before a parliamentary scrutiny committee last month, Mind pointed out that the actual definition of disability in the DDA was in itself discriminatory. This is because it describes disability as a physical or mental impairment that has a substantial long-term (ie 12 months) adverse effect on normal day-to-day activities. Such a definition of disability has complications for people with mental health problems.

First, people with a mental illness have an extra legal hurdle compared to other disabled people because they have to prove that their illness is "clinically well recognised", presumably so that they couldn't make one up.

Second, the requirement to prove that an impairment adversely affects normal day-to-day activities can be difficult for service users to satisfy. The activities listed are mostly physical, with the only one relevant to mental illness being the "ability to concentrate". Some mental illnesses such as depression affect a person's ability to communicate with others or to care for themselves. And eating disorders and schizophrenia may affect an individual's perception of reality.

Third, depression, which is the most common source of discrimination, lasts on average six months and so fails to meet the 12 month requirement.

Thankfully, the parliamentary scrutiny committee agreed with Mind and has recommended changes to the law. Hopefully, these problems will be remedied by the time the draft bill appears in parliament. Certainly in other respects there is much to welcome in it. 

Rowena Daw is head of policy development at Mind.