Tuesday, 18 March 2014

Why no scandal?

An interesting two tweets in my twitter timeline caught my eye today:

@AlexBThomson: Can you imagine any specialty other than #psychiatry which would use "risk of dying" as the primary criterion for seeing/treating patients?

@AlexBThomson: If "risk of dying" were the main criterion for all health services, there would be no ophthalmology, no dermatology, no hip replacements etc

They got me thinking (which I guess is entirely the point of twitter in its purest form).

I have heard too many tales of people being denied help in a crisis, simply because they hadn't yet made firm suicide plans.  People who have had to push and push on every possible door to access even the most basic of healthcare.  People who have literally begged for help, but were told they were not yet eligible.  Even having recurring thoughts of dying, or wanting to die, was not enough to persuade health care providers to intervene and refer to a suitable crisis service.  If you are mentally ill, and seeking medical help, often the most you can hope for is a prescription and possibly a place on a talking therapy waiting list.  

And even in a suicide crisis, quite often the "mental health service" turns out to be the local police force, using Mental Health Act powers. 

Why? Why do we accept this as a way of managing illness?  Do people still believe that mental illness is a modern phenomenon, used to avoid the stresses of life?  Or that it is some kind of lifestyle choice?  Does an illness really need to be life threatening in order to be taken seriously?  After all, as @AlexBThomson pointed out on twitter, many non life threatening conditions are routinely treated by the NHS - from cataract removal to bunions.

In most other illness groups, emphasis amongst service providers is on early diagnosis and treatment.  In cancer, for example, huge gains have been made in survival rates by catching tumours early and treating appropriately.  In other areas, we educate and implement public health programs.  Doctors are rewarded for monitoring and treating the health of higher risk groups (e.g. Blood pressure and cholesterol monitoring of older or more overweight patients).  Scientists, epidemiologists, health economists and doctors have shown that early treatment and prevention saves both lives and money.  

The government - the ultimate commissioner of health services in this country - decides which treatments are covered by the NHS and which are not.  It is guided by the National Institute of Health and Clinical Excellence (NICE).  NICE guidelines, across all medical disciplines, tend to recommend any treatment or intervention which costs less than around £30,000 per quality-adjusted life year (QALY).  Treatments which are cheap to produce (few overheads, low staffing requirements, easily replicable) and highly effective (prolonging life, increasing quality of life) are dutifully recommended to NHS commissioners.

With this definition of "commisionable" treatment, it is easy to understand why mental health interventions might fall through the cracks in the system.  Capturing (in £ terms) the uplift in quality of life from (say) a course of Cognitive Behavioural Therapy is bloody hard.  How do you value the ability to leave your house?  The desire to play with your children?  The feeling that you no longer want to disappear?  And most mental health services require skilled practitioners and intensive treatments in order to have lasting impact.

But even with these difficulties, researchers have consistently shown that common mental health interventions are cost effective. So it seems that even with the emerging evidence, commissioners are still not funding the services they should.



Cost per additional QALY
Mental illness
Depression.                   .        
Social anxiety disorder 
Post-natal depression 
Obsessive-Compulsive Disorder
Physical illnessDiabetes 

CBT v Placebo
CBT v Treatment As Usual (TAU) 
Interpersonal therapy v TAU

Metformin v Insulin
Beta-agonists + Steroids v Steroids 
Statins v PlaceboTopirimate v Placebo
Cox-2 inhibitors v Placebo


Centre for Economic Performance http://cep.lse.ac.uk/pubs/download/special/cepsp26.pdf

The government (and politicians across the spectrum) have recently made promises that mental health should be given "parity of esteem" with physical health.  So it is strange that the proportion of NHS funding for mental health (13%) is still no where near it's proportion of the whole disease burden (28%). Especially when cost effective (and life saving) treatments are known to exist.  In fact, these very same politicians are now introducing cuts to vital mental health services, in order to minimise the risk of another "Mid Staffs" hospital scandal.  

This news on the 12th of March prompted a vociferous response from mental health charities, as well as an important petition.

But aside from within the mental health industry, there has been no wider uproar.  There should be.  I don't know how to end this post.  It's not over, that is for sure.  More soon. 


  1. I fully agree that more needs to be done about the issues surrounding mental health. This is a great post, I'll be sure to read what else you have to say on the matter.

    1. Thanks Emma - yes there will be more on this soon... Lots more! ;). I'm hoping to do some work with MH charities who are actively campaigning on this, maybe put my old health economics skills to some use...

  2. Mental health is a sensitive issue but an issue nonetheless and the sooner the government tackle it the more people will be save.

    A thought provoking post.


    1. Thanks for popping over pixie dust.. Yes the govt really does have the possibility of saving lives - I hope it takes action!

  3. I totally agree with you. I can only base it on my own personal experience of a different subject but similar situation. I couldn't prove that my ex was a risk to my daughter because nothing had actually happened - I needed to have stayed for something to have happened to have proved this! Somehow these professions have got it so wrong. Thank you for linking to PoCoLo x

    1. Thanks so much for commenting Vicky. So sorry to hear social/police service have similar - equally dangerous - issues. Worrying!

  4. I agree with you too. TBH I find reading the financial cost benefit analysis (I don't know what else to call it) rather grim...guess I am an idealist. I suspect, however, that part of the "problem" is that you can't point to a measurable (in the hard quantifiable narrow sense) of the relationship between therapy and suicide prevention. For me, the issue is deeper than that. It's about what makes us truly human.


    1. Hi Sarah, thanks so much for your thoughts. I completely agree - putting a financial analysis on people's lives is horrible, but sadly a necessity in this world of limited resources and competing health demands. I will keeping fighting for mental health in this fight, while also hoping upon hope that the NHS is cherished and funded adequately. X

  5. It's sad isn't it? My care was so great once I reached the level where I was 'a danger to myself or others' but help prior could have possibly prevented that and thus saved the thousands it cost the nhs for me to be in MBU for 3 months