Richard Layard and colleagues have recently published a report concerning treatment of mental health in the NHS. Here is the executive summary of that report, published by the Centre for Economic Performance’s Mental Health Policy Group.
There is one massive inequality within the NHS: the way it treats mental illness as compared with physical illness. Here are six remarkable facts.
Among people under 65, nearly half of all ill health is mental illness (see Figure 1). In other words, nearly as much ill health is mental illness as all physical illnesses put together
Mental illness is generally more debilitating than most chronic physical conditions. On average, a person with depression is at least 50% more disabled than someone with angina, arthritis, asthma or diabetes. Mental pain is as real as physical pain, and it is often more severe.
Yet only a quarter of all those with mental illness are in treatment, compared with the vast majority of those with physical conditions. It is a real scandal that we have 6,000,000 people with depression or crippling anxiety conditions and 700,000 children with problem behaviours, anxiety or depression. Yet three quarters of each group get no treatment. One main reason is clear: NHS commissioners have failed to commission properly the mental health services that NICE recommend. The purpose of this paper is to mend this injustice, by pressing for quite new priorities in commissioning. This might seem the worst possible moment to do this, but that is wrong for the following reason.
More expenditure on the most common mental disorders would almost certainly cost the NHS nothing. For mental illness often increases the scale of physical illness. It can make existing physical illness worse. And it can also cause physical symptoms which cannot be medically explained at all: a half of all NHS patients referred for first consultant appointments in the acute sector have “medically unexplained symptoms”. Altogether the extra physical healthcare caused by mental illness now costs the NHS at least £10 billion. Much of this money would be better spent on psychological therapies for those people who have mental health problems on top of their physical symptoms. When people with physical symptoms receive psychological therapy, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy. So while doing the right thing on mental illness, the NHS costs itself nothing. This applies much less to most other NHS expenditures.
This is mainly because the costs of psychological therapy are low and recovery rates are high. A half of all patients with anxiety conditions will recover, mostly permanently, after ten sessions of treatment on average. And a half of those with depression will recover, with a much diminished risk of relapse. Doctors normally measure the effectiveness of a treatment by the number of people who have to be treated in order to achieve one successful outcome. For depression and anxiety the Number Needed to Treat is under 3. In the government’s Improved Access to Psychological Therapy programme, outcomes are measured more carefully than in most of the NHS, and success rates are much higher than with very many physical conditions.
Effective mental health treatment can also generate other large savings to the government, for example by increasing employment or improving the behaviour of children. As one example, the Improved Access to Psychological Therapy programme has almost certainly paid for itself through reduced disability benefits and extra tax receipts. Likewise, when children are treated for conduct disorder, the costs are almost certainly repaid in full through savings in criminal justice, education and social services.
To conclude, mental illness accounts for a massive share of the total burden of disease. Even when we include the burden of premature death mental illness accounts for 23% of the total burden of disease. Yet, despite the existence of cost-effective treatments, it receives only 13% of NHS health expenditure. The under-treatment of people with crippling mental illnesses is the most glaring case of health inequality in our country.
At least six major steps are needed.
- The government’s announced mental health policies should be implemented on the ground. For example, local Commissioners have been given £400 million in their baseline budgets for 2011-14 in order to complete the national roll-out of Improved Access to Psychological Therapy (IAPT). By 2014 this programme should be treating 900,000 people suffering from depression and anxiety, with 50% recovering. But many local commissioners are not using their budgets for the intended purpose.
- Though included in government documents, such as No health without mental health, the obligation to complete the IAPT roll-out is not included in the NHS Outcomes Framework for 2012/13 which is the crucial document for commissioners. If the government means what it says, IAPT targets should be reflected in the NHS Outcomes Framework.
- After 2014 the IAPT programme needs a further phase when it is expanded to cover people suffering from long-term conditions and medically unexplained symptoms. The Children and Young Person’s IAPT will also need to continue till 2017.
- For all this to happen, the Commissioning Board will need to nurture IAPT and make it one of its priority projects, as will Health Education, England.
- The training of GPs will also need to change and include a rotation in an IAPT or CAMHS service.
- And recruitment to psychiatry should be increased, if we are to handle properly the more complex cases of mental illness.
The need for a rethink is urgent. At present mental health care is, if anything, being cut. It should be expanded. This is a matter of fairness, to remedy a gross inequality, and it is a matter of simple economics – the net cost to the NHS would be very small. When everyone praises early intervention, it is particularly shocking that the sharpest cuts today are those affecting children.
The NHS aims to save £20 billion on existing activities in order to finance new activities required by new needs, old unmet needs, and new technology. Nowhere is the case for extra spending more strong. In mental health there is massive unmet need and there are new treatments which are only beginning to be rolled out. We appeal to commissioners to think again.
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Professor Richard Layard, the Baron Layard, is Director of the Well-Being Programme at LSE’s Centre for Economic Performance. He is a labour economist who has worked for most of his life on how to reduce unemployment and inequality. He is also one of the first economists to have worked on happiness, and his main current interest is in how better mental health could improve our social and economic life.