Handing out balloons
This blog is the first part of a larger article published in Soundings Futures in 2019 about the mental health crisis and developing a political response to it. To read the full article click here.
The mental health landscape
Getting a clear picture on the state of mental services can be difficult, as there are some apparent paradoxes in the public mental health research - which in themselves raise important questions about how mental health is measured, and the need to contextualise and analyse data. Indeed, approaches to data collection, and the way data is used, are a central part of the debate.
Information on the demand for mental health services is patchy, but it has been estimated that the demand for mental health services will have gone up by two million by 2030 - in addition to the 1.8 million people currently accessing services in 2015/16. The government’s ONS Wellbeing measurement, however, reports a steady increase in wellbeing - but this data cuts against most other indices of mental health, including the rise in suicides, and the growing research that links socioeconomic inequalities to health inequalities. According to the Darzi Review of Health and Care, there has been an increase in mental health problems in the UK, particularly among children, where an estimated one in five experience mental health problems. Pockets of chronic un-care have also emerged in relation to Child and Adolescent Mental Health Services (CAMHS), and acute and postnatal mental health services.
The total amount spent on mental health is unknown. Most public funding is directed at NHS England, which then allocates funding to Clinical Commissioning Groups. The Sustainability and Transformation Fund - now the Provider Sustainability Fund - was established in 2016 to provide £1.8 billion additional funding for NHS services, as a government response to public concerns about the under-funding of services. But it is estimated that it has only contributed a 1.4 per cent budget increase to mental health trusts. One difficulty in estimating amounts spent on mental health is that there is very limited information or monitoring of the private providers commissioned by Clinical Commissioning Groups - estimated at 15,000 contracts in 2015 - and directly by GP surgeries.
This article concludes with a discussion on how to challenge the current system. One way is to campaign for an inclusive inquiry into the IAPT model and the nature of the ‘evidence base’ for mental health services (an inquiry that would not be led by the organisations and bodies with a vested interest in delivering services). Another is to find ways of campaigning more broadly for better mental health provision. I therefore also discuss the potential for developing a new negotiating platform to address workforce issues in the service, including wages, working conditions and standards of care needed for a quality mental health service. Again, the proposal is to establish a body that is not populated by employers’ organisations or private providers, but by the professional, trade union, service-user and political networks that have an interest in mobilising mental health workers to defend services.
IAPT is also a central part of the political crisis that is emerging for mental health services as a result of its positioning as a key component within the government’s austerity programme and its plans for changes to welfare benefits. There has been a merging of mental health services with the DWP’s programme of welfare reform, as outlined in the DWP’s 2017 green paper Improving Lives: the Future of Work, Health and Disability, and the establishment of the Work and Health Programme, which has replaced the Work Programme.
For the first time, health and unemployment services in the UK have been explicitly linked. The adoption of the IAPT model has been central to these plans, since it is cheap to administer, and people who are ‘cured’ are then disqualified from benefits based on the state of their mental health. This is in part a response to a growth in the proportion of Employment Support Allowance (ESA) claimants (the benefit that replaced incapacity benefits) who experience mental health problems. This rose from 37.3 per cent in 2010 to 49.3 in 2016, when ESA claimants numbered 1,178564. A primary target for reducing the benefit bill is to ensure the return to work of people living with mental health problems.
In order to implement this reform (which is also closely associated with the introduction of universal credit), the DWP and Department of Health created a series of ‘pilot’ programmes and partnerships between Jobcentre Plus, Work Programme and IAPT services. In 2014, the introduction of Jobcentre staff and employment support workers into IAPT services took place, and there was an initial pilot programme to introduce IAPT services into Job Centres. This was met with strong rejection from mental health activists, despite the initial engagement of five of the large psychotherapeutic professional bodies in establishing this new area of work. The programme has nevertheless been rolled out regionally, and has involved the carrying out of ‘wellbeing’ workshops for claimants, and ‘psychoeducation’ group-work to encourage job applications and skills to secure employment.
At the core of this policy is the introduction of the new ‘fitness for work’ welfare assessment process (where fitness for work, rather than extent of disability, is measured). The process targets claimants with Personal Independence Plans (PIP), or who receive Employment Support Allowance or disability living allowance. This has resulted in a dramatic decline - by an estimated number of 2 million claimants - for these schemes since austerity measures were introduced in 2008 - either through claimants being declared fit-for-work or through claims being withdrawn.
It is very clearly understood by claimants who have ‘volunteered’ for these programmes that the way it links work and mental health raises ethical concerns about confidentiality, the therapeutic relationship and professional conduct. And one of the implications for mental health workers of this re-orientation of mental health services has been that it has created a significant credibility risk for the sector and for the people working within it; The deployment of the IAPT model as part of a strategy for delivering welfare cuts has raised profound ethical and professional concerns for workers.
Indeed, one result of the entanglement of mental health with welfare reform designed to exclude people from benefits, and the weakness of the IAPT model, has been that, despite the acknowledged attack on mental health services from a decade of austerity, there is an ambivalence within the service about government attempts to increase mental health funding by rolling out the current IAPT model. For many people working in and accessing these services, IAPT is considered a threat rather than an expansion of decent care. All this raises a profound question about what kind of services should we should be spending money on.
A further strategic objective of IAPT has been that is an enabler of the opening up of the mental health sector to private, third sector and non-clinical providers. This is partly because it paves the way towards a downgrading of clinical roles and jobs across the mental health sector. The delivery of the new welfare programmes has been carried out almost exclusively by large private contractors, including Maximus and Atos, and the majority of assessments have been carried out by staff who are not clinically trained. The ‘new’ mental health jobs created in these programmes do not require clinicians, and the whole process therefore represents a clear move towards generic and non-clinical jobs in the sector. The manualised and online nature of much of IAPT’s interventions also opens the door to digital providers. Much is now being made of digital healthcare, including grand claims for digiceuticals and the use of App technologies to measure health levels, including mental health; and these have been supported by successive health ministries. The benefits of this tech ‘alternative’ to complex long-term treatments provided by clinicians are clearly empirically exaggerated, but they are heavily supported by the normative logic of austerity on which decisions about mental health are actually based. .
Despite a number of mental health inquiries and workforce reviews, there has yet to be any genuine engagement with the emerging crisis in the sector. It may be that one explanation as to why the expansion of IAPT services has not been subject to public inquiry is the vested interests of the individuals and organisations involved in all the reviews (for a selection see below). Given the almost universal criticism of the direction of mental health services on the part of clinicians and service users, the question has to be asked: who benefits from the uncritical continuation and expansion of the IAPT model?
The policy framework
One striking characteristic of the mental health sector is the limitations of the policy frameworks within which it operates. Current policy for mental health is primarily expressed in The Five Year Forward View for Mental Health (FYFVMH), produced in 2016 by the Mental Health Taskforce (led by Paul Farmer, CEO of Mind, the largest mental health charity in the UK). As with many mental health policy documents, the principles behind it are relatively progressive. It has a psychosocial understanding of mental illness, and is supportive of co-production with services users, patient-centred services, collaborative approaches and workforce planning. But it pays no attention to the major barriers to providing good care. And it takes as self-evident two key assumptions: the efficacy of the IAPT model and the financial logic that underpins it. This means that, although the report recognises the deficit in reliable data, and the complexities of addressing mental health through coordinated health, housing and welfare systems, it nevertheless accepts the financial logic of expanding mental health services to facilitate the DWP’s welfare reforms. Furthermore, as part of this financial logic, it proposes the rolling out of performance-related pay on the basis of outcomes - presumably based on recovery targets and getting patients off benefits - while leaving the actual workforce crisis untouched.
The FYFVMH implementation plan, produced in 2018, nods towards improving the data behind a new mental health workforce development strategy by setting up the Mental Health Services data set, but this only serves to further expose the weakness of the NHS’s existing workforce strategy. The proposed expansion of services relies on systemic de-professionalisation. Although it acknowledges staff shortages and a failure to recruit the next generation of clinicians into clinical training, it does not address the growing gap between training and professional registration requirements, or the clinical requirements of jobs in mental health. To add insult to injury, the report proposes to address the wellbeing of mental health staff through a ‘lite’ programme of stress management, phone therapy and mindfulness.
A second important policy document is Stepping forward to 2020/21: The mental health workforce plan for England, published quietly in July 2017 before the summer break, and with no debate or consultation. It is unclear what, if any, consultation over this document took place, and the strategy contains some important omissions on implementation. It seductively proposes 21,000 new mental health posts by 2021, to cover the 10 per cent staffing shortage being experienced across the sector, which is particularly acute in nursing and psychiatry. However, although it proposes that a substantial number of these new positions - 11,000 - will be clinical, including those in regulated professions, 8000 will be made up of non-clinical associate roles and others by non-waged peer support. In other words, 50 per cent of future roles will be non-clinical. This expansion of non-clinical roles is, in part, justified as an ‘alignment’ of job functions with the new model of short term, non-clinical mental health interventions being introduced through IAPT, and the wellbeing programmes being introduced in primary care. This means that the implementation of the government’s mental health strategy is fundamentally underpinned by the downgrading of jobs in the sector.
The Lord Darzi Report, produced in 2018, also looks at mental health provision. It accepts the growth of inequalities as an important contextualising factor, and acknowledges Marmot’s social health agenda, but again fails to address the real barriers to improving mental health levels in the UK. As with all previous policy documents and reviews, the ‘quality’ of IAPT services and recovery rates is not questioned. Indeed the report absurdly claims that mental health services have improved in quality since the introduction of IAPT. The report also pushes for the opening up of the mental health market in response to the ‘over-regulation’ within the sector, a claim that has been strongly contested in relation to private providers - who are not routinely monitored. The panel responsible for producing this report included representatives of Gilead Sciences (a private biopharma company) and Siemens Healthcare.
Thriving at Work: The Stevenson/Farmer review is a high-profile report on the growing wellbeing at work industry, regarded as an increasingly important part of the wider mental health field. The review outlines a set of core standards for wellbeing at work that represent an uncontested and research-based set of recommendations, including better people management, ‘good’ working conditions, mental health awareness and support. However the review suffers from a politically naive formulation of ‘good’ work, and is not informed by any of the employment relations research about institutional models; it is apparently unaware of problems such as the growth of precarious work, and maintains the assumption that any work is good for you. It is overwhelmingly based on the financial rationale of reducing sickness absence. Its proposed model of wellbeing at work is painfully uncritical of the current dominant mental health model - which, like IAPT, focuses on individual cognitions and behaviours; and it uncritically accepts employers’ programmes for managing wellbeing, particularly mindfulness programmes, whose impact has been highly contested. This is a policy without a hope of changing existing practice. It should be noted that Mind’s Paul Farmer was also co-author of this report, and that MIND is emerging as a major provider of wellbeing services, both within the DWP but also commercially in relation to workplace wellbeing programmes.
The conservatism of the professional framework
In stark contrast to the competitive world of new public management, the major professional and training bodies have acted as a conservative force in their role of maintaining the current system of training and professional registration within the sector. There continues to be an over-supply of psychological and psychotherapeutic training, and the number of people being trained in long-term mental health qualifications has no apparent relationship to the availability of paid employment. Within mental health services approximately 45 per cent of workers will come from a mental health nursing background, but many will also have undertaken Continuing Professional Development and further training, often in counselling and psychodynamic trainings. The vast majority of psychotherapeutic trainings are self-funded, as, increasingly, are clinical psychology trainings. Despite the decline in decent jobs, the training industry continues to be robust, and it is increasingly directed towards attracting international students, and promoting a model of post-qualification working life in private practice.
The work of the child psychotherapists offers one exception to this professional landscape: some years ago they managed to secure NHS recognition and funding for their training. Although the number of trainees in the UK remains small, at around thirty students per year (mainly trained through the Tavistock and Portman clinic and the Northern School of Child and Adolescent Psychotherapy), most trainees go into CAMHS, although some will now find work in schools. Currently, clinical roles in CAMHS are likely to be held by trained child psychotherapists, but as the funding stream is cut it is likely that these roles will be downgraded, as in adult services.
The gap between institutional training and support and the real needs of graduates in securing full-time and paid employment remains large. Universities providing clinical training have not explicitly addressed the decline in employability in the mental health sector; while the independent training bodies have not addressed the decline in UK students who can afford lengthy trainings involving years of unwaged work (apart from in the marketing of courses to international students or offering specialist and CPD courses). Moreover, critical debates about the downgrading of work and the lack of paid work are not encouraged within these institutions, for fear of raising systemic and potentially unsolvable problems within the training model.
The professional and training bodies continue to offer the same model of professional training and development that has essentially been in place for the last twenty years. The issue of the costs of training, and the levels of honorary work involved in completing training and professional registration, is, however, the subject of an emerging internal debate, and some bodies, such as the UK Council for Psychotherapy and British Association for Counselling and Psychotherapy, are attempting to develop policies around unwaged work. However, there is no radical agenda for change in response to the widespread downgrading of mental health jobs. Professional bodies attempt to contain debates within professional silos, and are reluctant to take a broader perspective on jobs in the mental health sector as a whole. Students consistently demand greater preparation for waged work and support in finding clients in private practice from these bodies, but, as with other insecure sectors - such as the creative industries - the realities of working life are not fully addressed at an institutional level. The realities of securing paid employment with potential for progression and setting up in private practice - the main alternative to waged work - are only superficially addressed during training. This helps to obscure the financial reality that, for newly qualified mental health workers, self-employment offers a bleak prospect for earning a living wage.
This absence of action on the part of the psychological and psychotherapeutic professional bodies is related to the internal tension between their roles: they function both as regulators and gatekeepers of mental health work and as membership organisations to defend workers’ interests. None so far has taken a lead in coordinating the many organisations involved in representing mental health workers to establish a platform to negotiate wages and working conditions more broadly across the sector. Further, they have not attempted to challenge the IAPT model, but instead signed a profoundly ill-advised memorandum of understanding with the DWP about the introduction of psychological therapies into job centres. This has subsequently been buried, but it has added a further significant disincentive for them to open up a debate with their members about therapeutic modalities. Within most of these organisations there exist outspoken individuals and networks that make important challenges to their institutions; and there is a growing acceptance by members that the protection of their professions will involve opening up to difficult debates about money and jobs. Although this dissent is patchy, there is potential here for the professional bodies to contribute towards reform in the sector.
The organising challenge ahead
Our research raises a number of questions about how we might influence the way mental health services are delivered in the future. How do mental health workers get to the point of organised industrial activity - a point from where they can make demands about wages and working conditions across the mental health sector? How do we open up a debate within the sector about the political project ahead for defending quality mental health services, and how can we start to organise around this agenda?
Firstly, on a policy level, mental health services deserve a public inquiry into the current regime of performance management and the IAPT model - to be run by a group of people who are not financially invested in the outcome, with genuine experience of IAPT from client and clinician perspectives. There is an emerging leadership in the campaign against the IAPT model and the co-option of therapies to deliver welfare cuts - which, unsurprisingly, is led by disability and mental health service user networks. The most radical challenge to the current mental health system has not come from workers or their collective institutions, but rather from disability and mental health networks such as DPAC, NSUN, Recovery in the Bin and the Mental Health Resistance Network. These networks are uniquely placed to provide data and information about what is happening to service users, particularly those on benefits, as well as a critical perspective on the IAPT model. They also do not have financial interests in the outcome of this inquiry.
Secondly, there is a need for the development of a new network of interested parties (including trade unions, alternative networks and those professional bodies that have an interest in political action) that can start to research and debate the workforce crisis in mental health services, and work towards creating a platform for negotiation on wages and working conditions in the sector. Many organisations and activists are involved in this data collection, and in raising concerns within the sector. If pooled this work could be developed to help create a platform for national engagement on the key workforce issues.
It is striking that the representative bodies for mental health workers - the professional bodies and mainstream trade unions - have not taken the lead in As a result self-organised groups such as Counsellors Together UK, the Psychotherapy & Counselling Union and the Alliance for Counsellors and Psychotherapists, and networks such as Partners for Counselling and Psychotherapy are beginning to drive the organising work we have been describing. New groups will emerge as the crisis deepens.
Whatever constellation of organisations and networks emerges, or puts itself forward to join this platform, there will also be a need to supplement its work with expertise from employment relations and academic fields. As the fallout from the poorly negotiated 2019 nurses’ pay deal shows, any credible platform has to have the expertise to develop a negotiating strategy that can improve rather than compound existing workforce issues.
Without thinking this clearly about the future of mental health services we are just handing out balloons.
To access our surveys results about mental health services go here www.thefutureoftherapy.org