State Sponsored Gaslighting

For those of us with a memory last week’s news about improving mental health services was an exercise in state-sponsored gaslighting. 

The first item on radio-good-news concerned a consultation by NICE – the National Institute for Health and Care Excellence – about treatment for depression. The aim of NICE’s proposed changes in guidelines for treatment of depression is a good one. Reduce reliance on medication to treat depression, revive the call for therapies. 

What on earth could be your problem Surviving Work? Those negative thoughts and behaviours troubling you again?

NICE determines what counts as mental health treatment within the NHS. If it recognises the evidence base for a treatment, it recommends it and then the clinicians further down the commissioning food chain can buy it using public money. Their dominant mental health model is IAPT - Increased Access to Psychological Therapies - so that kind of says something about what counts as evidence and the level of genuine consultation that takes place within NICE. 

At the risk of being frog marched off to the optimism theme park for a round of behavioural activation I do have a problem with this. Firstly, NICE’s guidelines take it as self-evident two key assumptions: the efficacy of the IAPT model and the financial logic that underpins it. I won’t bang on about this because it’s been said. 

Possibly even more worrying, not once does it mention the rapid digitalization of mental health services in and out of IAPT and the interrelated strategy of degradation of the clinical provision they list in their guidelines. Even if you believed the evidence for NICE recommended  treatments (most of it based on 2015 research in the early years of uberisation) in the real world its not actually what most people are offered. In the brave new world of AI and Chatbots the proposed guidance, peppered with sadistic reference to patient choice and joint decision making on treatment plans, paints a fantasy world that hasn’t existed for over a decade since IAPT was introduced. 

An actual fact to back this up, the IAPT model defines therapy as anything more than two sessions (thanks to @brazendale5 for bringing this to my attention). The more critical political economy minds in the room might even think that IAPT was set up precisely to address the financial crisis at the expense of the clinical crisis and that of the clinicians within it. It’s no surprise then that medication became the only prescribable offering available to GPs in a context of the uberisation of services. 

Life is always about the alternatives and this guidance ducks the real mental health crisis where there are none in the NHS.

Just as I was mindfully catching my breath another item came on the radio and along with it my first  political panic attack of the day. Jeremy Hunt, all frontline-doing-it-from-the-back-benches-outrage reminds the universe that there is no workforce planning in health and social care and as a result we can’t implement our targets. He proposes another potentially reasonable call for the requirement on the NHS to do annual reviews of its workforce strategy. 

Sounds great doesn’t it, but that dear reader is just state sponsored gaslighting. 

Hunt was the author of an important and devastating policy document 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 proposed 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 proposed that a substantial number of these new positions - 11,000 - will be clinical, including those in regulated professions, 8000 were to be made up of nonclinical associate roles and others by non-waged peer support. In other words, 50 per cent of mental health roles were openly planned to be non-clinical. This expansion of non-clinical roles was, 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. 

Since nobody actually collects data on the mental health workforce lord only knows where we got with this strategy but what we do know is that it brought into reality a mental health strategy fundamentally underpinned by the downgrading of jobs in the sector. As if written in red crayon, it sticks its fingers up at good jobs and quality care in mental health. 

Mental health policies, all positivity jazz hands but paying no attention to the reality of low/no wages and actual jobs have created a legitimacy vacuum within services.  And to say otherwise just reminds us why we used to call Jeremy Hunt by another name. 

There is growing consensus that the only way out of the mental health crisis is to look at the reality of mental health services, including 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.

And for those of you with a memory of what therapy can be submit your comments to NICE by the 12 January 2022 here.