Glaring Omissions

    After months of anticipation, many health and social care
    professionals have excitedly unwrapped the government’s Choosing
    Health white paper and been unable to hide their disappointment
    with what’s inside.

    Told to expect a far-reaching reorganisation of policy that
    would place public health at the top of the political agenda, they
    have been presented with a document that is long on good intentions
    but short on concrete proposals. The document pledges £1bn to
    be spent over the next three years and a new partnership between
    the statutory, voluntary and private sectors. Yet, aside from the
    headline-grabbing plan to ban smoking in the workplace by 2008,
    much of the document seems to be stymied by a fear of being accused
    of creating a “nanny state”.

    Despite one of the largest public consultations ever undertaken,
    and more than 1,000 submissions from individuals alone, the white
    paper has left many care professionals wondering what all the fuss
    was about.

    Most crestfallen have been those working in the sexual and
    mental health fields who feel that the needs of their service users
    have been either misunderstood or ignored. Many mental health
    professionals feel that the white paper’s emphasis on lifestyle
    issues and the importance of taking personal responsibility for
    one’s own health have little relevance to those suffering mental
    health problems.

    “The public could be forgiven for thinking that Britain’s health
    problems are confined to smoking and unhealthy eating,” says
    Richard Brook, chief executive of mental health charity Mind.

    “Healthy lifestyles are important – that cannot be denied. But
    we would like to see the government recognise that improving the
    nation’s mental health is an integral part of a much bigger
    picture.”

    Angela Greatley, chief executive of the Sainsbury Centre for
    Mental Health, points out that, although an individual’s risk of
    heart disease or cancer may be influenced by his or her lifestyle
    and dietary choices, the same cannot be said for illness such as
    depression or schizophrenia.

    “Nobody chooses to have a mental health problem,” she says.
    “Mental illness cannot be prevented by promoting healthy
    lifestyles. Promoting mental well-being is about tackling the
    things that put people at risk of mental ill health and taking
    action to offer fair chances in life to those with mental health
    problems.”

    This will require more public health measures to be focused on
    the needs of people suffering mental health problems and more
    resources allocated to mental health promotion, says Greatley. “It
    is vital for our nation’s health that efforts to promote good
    mental health become a real priority for public health
    professionals, and that more resources are put into mental health
    promotion. To date, mental health promotion has been starved of
    resources and existed on a shoestring.”

    The Royal College of Psychiatrists says the white paper’s
    emphasis on self-help could lead to the impression that mental
    health is a matter of choice. This could “increase the guilt, shame
    and stigma felt by patients, carers and their families”, it
    says.

    The RCP has called for a complementary – but separate – public
    health strategy for mental health. This would include measures to
    promote mental health in the workplace, improve access to mental
    health care, increase public education on mental health issues and
    address the problems caused by the “prevailing social and economic
    climate”.

    Mental health is not totally ignored in the white paper. There
    are proposals to improve access to mental health services for
    ethnic minorities. It also pledges guidelines on the management of
    mild to moderate mental ill health in the workplace, to be in place
    by 2005, and to use the Sure Start programme to protect children
    and young people against mental health problems later in life.

    However, mental health user groups are annoyed at the lack of
    any proposals to address the specific physical health needs of
    people who use mental health services.

    “It is a scandal that mental health is not at the heart of the
    government’s public health plans,” says Rethink chief executive
    Cliff Prior. “All the available research shows that people with
    mental illness face an earlier grave because their physical health
    is often neglected. People with mental illness need extra support
    and information to ensure all their health needs are met.”

    Prior points out that problems such as obesity and smoking are
    particularly prevalent among mental health care users, yet the
    white paper offers no specific measures to address these
    problems.

    There are also concerns that the proposed smoking ban in the
    workplace could work against the needs of people being treated in
    psychiatric institutions. While it is hard to argue against a
    smoking ban on the grounds of physical health, its implications for
    mental health may not be so clear cut. It is estimated that up to
    70 per cent of people treated in psychiatric wards smoke. Many use
    cigarettes as a coping mechanism and there is even evidence that
    nicotine may help alleviate the symptoms of some brain illnesses.
    To ban smoking within psychiatric hospitals may therefore be
    counter-productive. Likewise, a smoking ban in the prison service
    may also be impractical.

    While mental health campaigners have been the most vocal in
    their criticisms of the white paper, others have voiced disquiet
    about the plans to improve sexual health, saying they fail to
    promote sex education in schools and do not go far enough.

    The white paper proposals include a new national campaign
    targeted at those at greatest risk of catching a sexually
    transmitted infection or having an unplanned pregnancy, a national
    chlamydia screening programme in place by 2007 and a pledge that by
    2008 everyone referred to a genitourinary medicine (GUM) clinic
    will be offered an appointment within 48 hours.

    What the proposals do not include, says Deborah Jack, chief
    executive of the National Aids Trust, is anything likely to meet
    the specific needs of people affected by HIV/Aids. Particular
    challenges with HIV, including stigma and discrimination are also
    not addressed, she says.

    Rod Griffiths, president of the Faculty of Public Health, says
    the white paper’s sexual health proposals should be welcomed.
    However, he questions why the public has to wait so long to see
    their benefit. He says: “The year 2008 will be too little, too
    late. The government recognises that delay in access to treatment
    has a major impact on future health and fertility. How, then, can
    they justify a four-year wait to implement its goal of 48 hours for
    a GUM appointment – a recommendation made by the health select
    committee in June 2003.”

    Serious infectious diseases, such as chlamydia and HIV, should
    be treated as emergencies and access to GUM services should be made
    available within four hours – in line with other accident and
    emergency cases, says Griffiths.

    Jan Barlow, chief executive of the Brook sexual health advisory
    service for young people, sees the white paper as a missed
    opportunity. She says: “Research shows that young people who have
    received good sex and relationships education, combined with access
    to confidential services, start having sex at a later age and are
    more likely to use contraception when they do become sexually
    active.

    “If the government is serious about bringing down rising rates
    of sexually transmitted infections and achieving a consistent drop
    in rates of teenage pregnancy, sex and relationships education must
    be made a compulsory part of the national curriculum.”

    WHAT HAPPENS NEXT:

    The public health white paper emerged from a consultation
    process that ran between 3 March and 28 June 2004.

    More than 2,500 responses were received, with individuals
    contributing more than 1,000 responses.

    The government will publish a delivery plan early next year
    outlining how each of the commitments in the white paper will be
    achieved.

     It will also establish a public health research initiative
    which will receive £10m by 2007-8 to help develop front-line
    practice.

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