Monday 11 October 2010

Mental Health Services and the "Big Society"

I had been contemplating the future of mental health services when I bumped into Peter Hain MP who knows Hafal well (our HQ is in his constituency). He seems reasonably chipper after losing the election for the shadow cabinet then getting back in anyway (still as shadow Secretary of State for Wales) on one of the wild-cards available to new leader Ed Miliband. He asks how things are and I say it's still mainly business as usual until the squeeze starts in earnest in April (as would have happened in some manner whoever was in power). We discuss the Tories' Big Society idea and I agree that it better not just mean the likes of Hafal delivering required services without the necessary resources.

Driving home I hear a torrid Question Time on Radio 4 with in-your-face historian David Starkey backing the Big Society concept, contrasting the Edmund Burke-style, bottom-up, self-help, "British" approach to social development with the "French Revolutionary", top-down, tax-driven model. Put like that the "Big Society" sounds like a good thing but Burke and his friends saw a much lesser role for the state than would be the consensus today (see Rowlandson's Burkian cartoon above which includes equality as an undesirable goal). The QT panel also identifies the problem of the voluntary sector having in large part become the vassals of the state, relying on statutory commissioning (guilty as charged to a significant extent, I'm afraid).

Interestingly there are varying noises from the Third Sector. NCVO complains about depressing times ahead while the Association of Chief Executives of Voluntary Organisations (of which I am a passive member) has been engaging enthusiastically though not unconditionally with the Big Society idea under the leadership of Stephen Bubb, a controversial but effective figure. Stephen's excellent paper on the function of the voluntary sector in the context of the Big Society can be seen here - required reading for anybody concerned with this issue.

President Kennedy is remembered for his own take on the Big Society, advising "Ask not what your country can do for you; ask what you can do for your country". But isn't it paradoxical for the government to ask us to take up certain responsibilities outside the government's agenda? That is a matter for us and there is a risk that we might be less responsive or even bloody-minded if cajoled by politicians to do our bit. Would JFK's words have been forgotten if he had served his time and American citizens had carried on doing just as much voluntary work as they felt like doing?

And what of mental health services? There has been a consensus since before Burke's time that there is a duty for the state to assist people with a serious mental illness (even if that used to mean the Poor Law, primitive asylums or the Workhouse - and, much earlier, Welsh "post-tribal" law codified by Hywel Dda exempted people with a mental illness from contributing to compensation). In more recent times (arguably only in the last 40 years) it has been accepted that people with lower level mental health problems should also be assisted, mainly through Primary Care. We certainly need to insist that the government continues to discharge its responsibilities for citizens experiencing problems at these levels, though they would do well to consider further commissioning of the voluntary and private sectors to deliver services on a test of best quality and value.

But what about the mental well-being of all citizens? We all at least occasionally have significantly troubled thoughts (and I don't just mean unhappiness brought on proportionately by life events). Arguably only about 20% of us (not including me!) are relatively untroubled by at least mild neuroses. Does the state have a role in addressing these matters? Those who manage mental health services increasingly believe so and I agree just to the extent that (i) the state needs to consider the effect of those policies and services for which it has responsibility on citizens' mental well-being and (ii) there is a case to be made to educate citizens about how to protect their own mental health and to help those around them who have problems. However, overwhelmingly these are matters not for government but for individuals, families and society at large.

Citizens should anyway be sceptical about the ability of the mental health establishment (and I include the Third Sector in this) to advise them on how to lead their lives. Such advice is often inappropriate because it finds unnecessary and unhelpful new language for issues which people could address more effectively on their own terms; alternatively the advice can be risibly patronising and obvious, for example letting people know that a walk in the countryside can promote a "sense of well-being" (indeed, and bears sh*t there too, I understand).