As the Lancet Commission on ending stigma and discrimination in mental health highlights, demonising portrayals of severe mental illness in the media can be profoundly damaging. They also distract us from a disturbing reality—the UK’s mental health services are in crisis.
The Lancet, 17/02/2024
Inflammatory narratives around the risk that people with severe mental illness pose to the public are misleading. Patients are more likely to be victims of violence than perpetrators, and homicides are extremely rare. So rare, in fact, that predicting violence becomes problematic—evidence for the predictive performance of violence risk assessment instruments is limited. Some UK mental health legislation not only lacks evidence of effectiveness—it is demonstrably ineffective. Community treatment orders, introduced in England and Wales as part of the Mental Health Act 2007, facilitate compulsory community treatment of patients. Abundant evidence has since shown that they do not reduce re-admission or bed days, most notably the OCTET trial, which “found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients’ personal liberty”.
Do decision makers care about evidence? In 2018, an Independent Review on modernising the Mental Health Act 2007 was published amid concerns about the rising rates of detention under the Act, particularly of people from minority ethnic groups. With more than 50 000 people held under the Act in 2022, the UK Government’s decision in 2023 to shelve a proposed bill reforming the Act came as a huge blow to the mental health community. Outdated legislation compounds the wealth of challenges already facing those with severe mental health conditions. People with severe mental health conditions are likely to die up to 20 years earlier than the general population and were five times more likely to die early during the COVID-19 pandemic. The UK must act to address such monumental health inequity.
WHO advocates for person-centred and rights-based approaches to mental health care, which have the potential to benefit patients and practitioners across acute, inpatient, and community settings. But such approaches are impossible with severely constrained resources. Investment alone without an evidence-led strategy is futile. Despite increased spending on mental health services, few could credibly argue that the National Health Service (NHS) Long Term Plan has met its ambition to “expand access and deliver timely, high quality mental health support by 2023/24”. The reality is excessive bureaucracy, breakdown in continuity of care, and high-throughput targets at the expense of wellbeing. Spiralling demand means that more than 1·8 million people await mental health treatment, and a chronic shortage of beds for mental health patients now sees the NHS pay £2 billion per year to private hospitals that report profit margins of up to 20%. Practitioners face the demoralising task of trying to help those for whom they have neither time nor capacity. The backbone of community mental health is the community psychiatric nurse. But mental health nursing is in crisis, with workforce shortages, misunderstandings about the role, and few opportunities for career progression. Patients often undergo a lonely and disjointed care journey, devoid of enduring empathic relationships. We have a system that incentivises indifference.
Are mental health services alone responsible for the failures in care? Years of austerity, the COVID-19 pandemic, and an economic crisis have decimated support networks, especially for some of the most vulnerable in society. Compassion from communities, and individuals, can make a huge difference—perhaps we all have some responsibility for the health of our neighbours. However, the approaching UK general election, offers a chance to hold the government to account for its part. We join the Royal College of Psychiatrists in their call for all parties to prioritise mental health in their manifestos. We need an evidence-led mental health service that we can trust to ensure that no one is left uncared for.