Back in what now seems like a curiously quaint era for UK civil democracy, the Scottish Independence referendum was the once-in-a-generation opportunity for a group of people to take back control™ of their own political destiny. Despite what must have been a significant series of exchanges on either side of the divide, the one I most remember was the comedian Frankie Boyle expressing surprise that one of the politicians involved was so animated about independence since his obvious poor lifestyle and health meant that he wouldn’t be around long to reap the benefits of independence. So much so that Boyle remarked in a typically bleak (and funny) aside that ‘my hamster is choosing suits for his funeral’.
I was reminded of Frankie Boyle’s hamster a few weeks back at the release of the NHS long-term plan for the next ten years. To illustrate my point, consider the last 10 years of the NHS. We’ve seen the implementation of a staggeringly poor attempt to fast-forward marketisation in the NHS via Lansley’s NHS reorganisation the Health and Social Care Act (2012) (so big you could see it from space). While newly formed CCG’s were trying to make sense of how to administer an £80bn budget, they were landed with another reorganisation (one that you couldn’t see from space – the 2014 Five Year Forward View).
Here, the rougher edges of the Health and Social Care Act (that is to say, all of the them) were to be smoothed out by a nationwide series of sustainability and transformation plans (STPs) which had the none-too-timid ambition of delivering integrated health and social care by making CCG’s and local authorities start working together to plan, commission and deliver health and social care services.
Don’t forget the Nicholson challenge, where Lord Nicholson challenged the NHS not to fall apart while the government took £20bn out of it’s coffers and then, through STPs, we got the Cameron/Osborne/Hunt/Ming the Merciless challenge of revolutionising health integration while losing another £22bn. During this time we had a coalition government, a Conservative majority government, and a hung parliament with a Conservative minority government propped up by renowned Ulster charmers, the DUP.
And, via Brexit, an almost complete collapse of the everyday working of parliament.
Actually, that’s just 7 years- so we may have three more years of the Brexit immolation carnival after which point the NHS could have its HQ is Texas, with a new logo replete with an added cowboy hat and 1 in 6 citizens having no access to health insurance. Or not, of course.
In this context, it seems like an exercise in astronomical optimism to be able to set out a series of long term objectives and expect that they may even in the most remote sense actually come true.
All this said, I’ve decided to metaphorically leave Frankie’s hamster checking out a burgundy crushed velvet number in the mirror in anticipation of the imminent death of the NHS ten year plan and I’ve interacted with it as if the political world would sufficiently pause it’s recent breakneck febrility to allow for any of this stuff to actually happen.
It is impossible in a 1,200 word blog to do justice to a 135 page document that covers ‘a new service model for the 21st century’ (Frankie’s hamster’s ears have pricked up again), health inequalities (again), people gaining more control over their own health and personalised care (again), digital enablement (again) a comprehensive new workforce implementation plan (that’s four in a row, they win a speedboat), and so on and so forth.
So instead I’ve cheated a little and just focussed on what it says about mental health and inequalities. First, the good news. Someone in government has come to revolutionary conclusion that having 60% of children with mental health problems unable to receive any kind of support might not be an optimal way of supporting the next generation. Hence the announcement of an increase in funding for children and young people’s mental health and an increase in spending on mental health care generally.
Stating “we will increase funding for community care by £4.5bn”, can be read as a sheepish apology note for the loss of 60p out of every £1 since 2010 that the Government had provided for Local Authority services. There is also an increase in post-crisis support for families and staff bereaved by suicide, mental health transport vehicles and a progressive openness to the use of sanctuaries, safe havens and crisis cafes to be expanded as more suitable alternatives to accident and emergencies.
There’s the mixed news- the expansion of the ‘world leading IAPT’ service that not everyone would agree is world-leading, a commitment to help 380,000 more get therapy for depression and anxiety by 23/24, which would be great if the answer to the question of why 380,000 people need therapy in the first place for depression and anxiety wasn’t so badly fluffed. And this neatly leads us on to the pronouncements on health inequalities.
Like a drunken darts player who keeps missing the board and mumbling swear words on his way to the loo, NHS leaders once again show their world-leading expertise in misunderstanding and misrecognising the entanglements between social and income inequalities and mental distress. For the ten year plan, overcoming health inequalities still seems to include a forensically narrow ‘focus on smoking, alcohol, air pollution and type II diabetes™’. The dogged refusal, even in an era of cut and shut health and social care integration, to recognise the broad social drivers of mental distress is stubborn to the point of oddness. You would imagine that, like a child pinning a tail on the donkey, NHS mandarins would eventually fluke a focus on poverty, income inequality, hunger, housing, domestic violence, personal debt and discrimination.
Let’s take housing as an example although we could have chosen any number of social and economic inequalities. Rough sleeping has increased 169% since 2010 and the average life expectancy of homeless people is now only 47 years old.
Just last week we heard that many people around the country continue to languish on Local Authority housing waiting lists due to the shortage of affordable, fit-for-habitation properties. More than 40% of council houses sold under ‘Right to Buy’ are now privately rented with tens of millions of pounds being paid by (catastrophically broke) Local Authorities to rent former council homes in order to house growing numbers of homeless families.
Some councils have bought back their former homes at more than six times the amount they sold them for and hundreds of private landlords now own five or more right-to-buy properties. Councils have spent £22m a year on renting back properties they once owned to use as temporary accommodation and one in seven UK private tenants pays more than half income in rent.
Why does this matter?
It matters because, like other social inequalities, housing and mental health are often linked. Being homeless or having problems in your home can make your mental health worse. Whether that’s the stress of keeping up with exorbitant repayments, being homeless or fear of losing your home, stress and anxiety of living somewhere that feels unsafe, uncomfortable or insecure, or physical health problems associated with damp, mould, and dirt. Or maybe being affected by the benefit cap or the bedroom tax.
Housing stressors like overcrowding, dampness, hazards, difficulty with heating the home and type of tenure independently predict limiting long-standing illness, including mental distress. Area characteristics, internal housing conditions and housing tenure, all have independent effects on health and repossession is associated with an increased risk of common mental illness. Finally, attempts to improve housing and neighbourhood conditions are seen as upstream interventions with the potential to tackle health inequalities. This was highlighted in the WHO report on the Commission for Social Determinants of Health (2008).
Despite the huge growth in evidence in the way that health inequalities are driven by the impacts of multiple social and economic influences like housing, we still see a relentlessly unambitious focussing on ‘smoking, alcohol consumption and Type II diabetes’.
Of course, in the end, it’s probably not really worth getting excited about these continuing gaps in the mental health literacy of the Department of health. As Frankie’s hamster is only too well aware, none of this will probably matter anyway.