These are a few thoughts about equality and diversity in mental health – maybe I should have phrased that ‘lack of equality and diversity in mental health.’
I get incredibly angry about the refusal of the medical profession in general, and psychiatrists in particular, to become involved in anything that is seen to be political. Obviously the glaring exception to that is the NHA party, which is fielding candidates at the forthcoming European elections, and intends to fight a large number of seats at the 2015 general election. They are fighting on the single (and vitally important) issue of the survival of the NHS as a state funded, state run comprehensive healthcare system for the people of this country. However, that is rather different from what I’m talking about.
Firstly, chronic illness, reduced/ unemployment, reduced social status, reduced income/ increased dependency on benefits, and increased incidence of relationship breakdown, all go hand in hand. This, to my mind, makes care of people with chronic illnesses a medico-political issue. The doctors and other healthcare workers responsible for health of these patients (I use the term for convenience but accept that many prefer service user or client) cannot ignore the impact of socioeconomic influences on health. Doctors should not shirk their responsibility to become involved, to fight for decent housing, decent employment rights and so on. Nor should this be deemed a primary care responsibility by secondary care doctors who feel that it is ‘nothing to do with me’. The paediatric respiratory physician is wasting his/her training, the government’s resources, and the time and cost to the mother who is bringing her child to the clinic, if there is not strong, vociferous and continued agitation to move the family from damp, insanitary bed and breakfast accommodation.
Secondly, all of the above obtains equally for those with mental health problems. We also know that those with chronic mental health problems are significantly more likely to have chronic physical illness than those without mental illness. As I mentioned in the linked extract, there is marked inequality of esteem between chronic physical and chronic mental illness (with the possible exception of chronic pain, but I would argue that the vast majority of patients with complex chronic pain have a chronic mental health problem anyway). Patients with cancer diagnoses, especially if young, are invariably labelled ‘brave’, ‘fighting to the end’, ‘raising awareness’, ‘helping others even if unable to help themselves’ etc. Now I am certainly not in the business of creating hierarchies of wellness/ illness, or of those more or less deserving of sympathy. There was an unpleasant example of this in the recent ill-thought-out pancreatic cancer campaign that appeared to label breast cancer sufferers as ‘lucky’.
My point is that cancer is universally perceived to be ‘real’, and those who are diagnosed with it as unfortunate ‘victims’ who had the misfortune to get cancer. Even those whose life choices can be shown to knowingly contribute to their risk receive non-judgemental sympathy. Various cancer charities (pancreatic cancer notwithstanding) are well supported, and have contributed hugely to the ongoing research into causes and treatments. They, together with related pressure groups, have influenced government policy, sometimes in the face of conflicting and disputed research evidence. The breast screening campaign and the use of herceptin are good examples.
The picture for mental illness is rather different.Using data from the Guardian I have tried to find the biggest medical charities (by total annual donation including legacies).
Six have incomes of over £100m:Cancer Research easily tops the lot at £515m, followed by the British Heart Foundation at £214m, MacMillan and Marie Curie at £134m & £131m, and SCOPE with £102m. The biggest mental health related charity is MENCAP at £194m, but I think many people see mental handicap from the perspective of Downs syndrome, which comes into the category of ‘real’ (and from birth) illness.
The only mental health charity to make it to the top 1000 is MIND, £31m. I searched various websites and discovered that under ‘schizophrenia’ is listed a charity called Mental Health Matters, which must be doing a better job of raising its profile with others than with me because its annual income is £13.6m. In comparison Bipolar UK records £0.74m, and the Depression Alliance £0.47m.
These figures surely illustrate the problem graphically – there are numerous animal sanctuaries and charities in the top 1000, and of course well funded organisations from the arts (again I hasten to add that I wouldn’t want to take money from the arts – I think more should be given centrally), not to speak of independent schools and numerous religious establishments.
So I do feel that healthcare professionals really need to help people with mental health diagnoses (and of course, like me, sometimes the healthcare professional is also a patient) – we need a collaborative approach to deal with the negative publicity that goes with mental health diagnoses. It just isn’t fair to leave it all to the celebrities – particularly if we then accuse the very same celebrities of not ‘really’ being bipolar/ depressed or whatever. People like Alastair Campbell have done a lot, but I suspect that he is such a divisive figure that a cohort of society dismiss everything that he says as a matter of principle!
Doctors could do so much more. GPs see a huge amount of mental ill health in their surgeries; they are increasingly expected to see and manage more and more severe illness in primary care as secondary care resources become stretched beyond their limits. How is it possible to talk about your mental health to a GP who can give you ten minutes if you are lucky? Many GPs will offer double appointments to some patients if arranged in advance, but we all know that the most urgent need doesn’t arise in conveniently diarised slots several weeks hence. You are luckier still if you can develop a genuine trusting relationship with your GP and then see the same GP every time.
Where are the GPs standing up and shouting for more time to see unwell patients? When do we see them making it clear that people with depression are just as unwell and deserving of their full attention as people with heart disease? Even at the level of the Royal Colleges (from which many doctors feel totally disenfranchised) I have not seen the RCGP really emphasising how they cannot fulfill their obligations to their mental health patients under the current system. I occasionally fantasise about what would happen if every doctor who saw a patient with significant mental health problems, but didn’t have the time or resources to treat them properly, wrote to the GMC and said that they were in breach of the guidelines for the duties of a good doctor.
What if all psychiatrists did the same? Many good psychiatrists have left the NHS completely, and I owe my life to one such, but this means that many of the most able, charismatic and enthusiastic psychiatrists are no longer available to fight for NHS services.
Many people, especially mental health patients, have criticised psychiatry, and the medical models of psychiatry of the past 50 years. My criticism is much more about politics than medicine. Relationships help people with lifelong illnesses lead good productive lives. That means relationships with your doctors, relationships with your family and friends, relationships with your immediate society as well as the larger society of the country in which we live.Developing relationships of any sort takes time above all else. Trust is fundamental, and it can’t be expedited.
Good medicine and good health are shared responsibilities. They don’t rest with doctors or other healthcare workers, politicians or policy makers, employers or educationalists, patients and their families. Good health results from a collaborative effort involving all of the above, the individual and the wider society.