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.

	Treatment		Cost per additional QALY
Mental illness Depression.                   .         Social anxiety disorder  Post-natal depression  Obsessive-Compulsive Disorder Physical illnessDiabetes  Asthma COPD  Cardio-vascular  Epilepsy  Arthritis	CBT v Placebo CBT v Treatment As Usual (TAU)  Interpersonal therapy v TAU CBT v TAU Metformin v Insulin Beta-agonists + Steroids v Steroids  Ditto Statins v PlaceboTopirimate v Placebo Cox-2 inhibitors v Placebo		£6,700  £9,600  £4,500 £21,000 £6,000  £11,600  £41,700  £14,000 £900  £30,000

Source:
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.