The problem with tackling health inequalities experienced by the severely mentally ill population, as part of a fundamentally unhealthy society.
Last year I attended a council run workshop on health inequalities experienced by those with mental health issues. It is abundantly clear that these inequalities are most evident for people with severe mental ill health. Public Health England (PHE) in their NHS Long Term Plan (2018)
describe ‘severe mental illness’ (SMI) as referring to “people with psychological problems that are often so debilitating that their ability to engage in functional and occupational activities is severely impaired.” It cites bipolar disorder and schizophrenia as examples. It is fair to say, however, that other mental illnesses can fit this description: when I was personally diagnosed with OCD as a teenager, I was an in patient, albeit voluntary, and the doctors did not think I would ever be able to hold down a job. However for the purposes of this article (and the fact that the data used in it describes SMI as primarily bipolar disorder and schizophrenia), the above PHE definition is assumed.
PHE and the
Scottish Government (2017) tend to see health inequalities as binary; there is mental health, and then there is physical health. And the two are not necessarily seen as interacting; that is to say the idea is that you can be very physically healthy but have very poor mental health, or vice versa, and the two are not at all interrelated. However it’s well known that stress and anxiety can have physical effects on the body, and given most people with SMI suffer extreme stress and anxiety because of their conditions, the mere fact that they have the condition is going to affect their mental health. In reality the different aspects of one’s overall health, which encompasses (in simplistic terms) social, environmental, psychological, physical/biological and spiritual factors, interact and cannot exist dependently of one another. This is something that these reports seem to somewhat overlook.
The Scottish Government states that: “It is unacceptable that people with severe and enduring mental illness may have their lives shortened by 15 to 20 years because of physical ill-health”. Their document then goes on to list ways to ensure that people with SMI have the same access and rights to physical health checks and are helped with things like stopping smoking, as does the PHE report. This is no surprise; as PHE
states, “people aged under-75 in contact with mental health services in England have death rates that are 5 times higher for liver disease, 4.7 times higher for respiratory disease, 3.3 times higher for cardiovascular disease, and 2 times higher for cancer” (full data in links to report). Interestingly, the side effects of medication are included in the factors which can cause physical health inequalities for both documents. It’s recognised that regular health checks are necessary, which one would hope would include blood tests to ensure everything is working healthily and as normal. Drugs and alcohol misuse/dual diagnosis are also mentioned as factors, and the Scottish Government report even cites ‘diagnostic overshadowing’ as a factor, that is, mistaking a physical health problem for a mental health one.
The Scottish Government states that, “There must be actions that improve the physical health of people with mental health problems and that improve the mental health of people with physical health problems”. It then goes on to say “There should be holistic services around the individual.” It all comes down to the definition of ‘holistic’, clearly. A truly holistic model would surely be built around the idea that mental health and physical health are not separate entities.
But perhaps this is too cynical an analysis. The fact that a holistic model is even being considered for health treatment is an improvement. Environmental factors are cited as an influence in the prevalence of mental illness, by the PHE report, and also by
Public Health Scotland (2019). While PHS acknowledges that political priorities are also a factor, PHE does not, which is unsurprising really, given how UK government policies are arguably responsible for the worsening of mental illness symptoms in the population, and the creation of mental health problems in the first place.
Words are all very well as regards the recommendations for improving the physical health of people with SMI. It’s another thing putting them into practice. For a start, regular scheduled physical health checks of those with SMI are not necessarily happening despite their mention in these reports. In the real world, it seems that it takes
financial incentives to ensure that these take place, rather than genuine care and concern, as once these incentives are removed, so are the checks. Medication is still not acknowledged by GPs and other doctors as a cause of various ailments, and diagnostic overshadowing is a problem. The PHE report states that identification of risk factors for cardiovascular diseases has improved, possibly due to a higher rate of physical health checks, but treatment rates have not. It does not explain or suggest why this is, but this may be related to why the desire to do the checks has dropped, along with the fact that if people are not being checked, they are not adding to waiting lists and statistics on health inequalities in the SMI population might show less disparity in some areas. Very cynical, but statistics are everything for governments.
The drive to stop people from smoking is also an interesting question. Smoking, while generally agreed to be bad for one’s physical health, is often seen as a way of relieving stress and anxiety or even clarifying thought processes for people with SMI. It’s a well known coping mechanism for many sufferers I know, and it would be problematic for them to reduce or even stop their smoking habits. Where clinicians only see bad in smoking, and are less aware of the perceived benefits of the practice, service users often see a lifeline. As someone who has never smoked, I cannot personally endorse it as a form of coping, but for others it would be traumatic to even consider giving up. And is smoking ultimately any worse than taking a high dose of antipsychotic medication which can cause obesity, heart disease and diabetes, to name but a few physical health problems? Together of course they will increase the risk of developing such conditions, but given the seeming mental health benefits of smoking, it seems unlikely that this policy target will have much success. A point worth making here is that psychiatric wards were some of the last places for indoor smoking bans to be enforced. This can either be read as an acknowledgement of the benefits of smoking cited by service users of tobacco use, or difficulties in implementing the policy; or it could be that the mentally ill are not seen as a priority population in the drive to improve public health.
Of course it’s worth pointing out that as anything which has a negative effect on your physical health has a negative effect on your general health, both smoking and medication are also bad in some way for your mental health. This might seem paradoxical to anyone who is sold on the benefits of psychiatric drugs, or thinks that smoking is overall a good thing when the pros and cons are weighed up. Addictions/Dependencies in general are not good for anyone. Anything which encourages overeating of sugary foods (such as antipsychotics) is also not good for one’s overall health. This is one reason why a truly holistic health service would possibly find the use of medication problematic or would certainly be more likely to see it as a last resort, rather than a first point of call. But given the drugs industry has such a hold over the medical profession, such a service is a long way off, if ever possible.
The socioeconomic system we live in has created many inequalities, and indeed poverty and social deprivation are cited as causes of worse health outcomes for people with SMI; and of course SMI diagnoses are higher amongst poorer populations. As neoliberal capitalism places a lot of importance on having a paid job, it is inevitable that both governments cite getting those with SMI back into employment as a potential goal. NHS England
claims that “A major factor in maintaining good mental health is stable employment.” It cites no research or evidence for this when making this claim, which is interesting, but not entirely surprising, especially regarding those with SMI. There is a disparity between the definition of SMI used in the earlier PHE
document, which states that SMI itself severely impairs one’s ability to “engage in functional and occupational activities”, and the idea that anyone suffering from it should be expected to work. I know when I have been really unwell with psychosis, there is no way I can do any job in an adequate or organised manner, if at all. And in this socioeconomic system, almost all jobs have an element of stress inducing activities; the push to do things immediately and efficiently like a machine at all times is stressful for a start, and given most employers’ attitudes towards SMI even if someone is fit to do a job, it’s unlikely they will be successful in attaining it if they are honest. And if you are not honest, and you fall ill, this opens another can of worms. The nature of some SMIs also means having ‘good’ days and ‘bad’ days, where getting out of bed can sometimes be more than one feels capable of. No employer will take on someone who they will just see as unreliable, lazy and feckless, when in fact they are suffering from severe mental health problems.
These reports also feature a myriad of other strategies to tackle health inequalities and the reader can explore them at their leisure. The reason I haven’t gone into every detail of what they are proposing is because they are just words. There is a lot more in these strategies and proposals that can be criticised. It would be great if in the real world they were truly tackled and the proposals all carried out, but the real world is one which encourages inequality of all kinds, and sees inequality as a natural and fair process. For capitalist political parties and governments to genuinely try and address any kind of inequality, would be to go against the system and their policies itself, as they would need to be compatible with such a system. SMI is undoubtedly exacerbated by this system, and while it may not be the system alone that leads to it, there will always be more of it in a highly unequal and competitive society driven by selfishness and a lack of community, and compassion for others. Any policies aimed at reducing inequalities are more mitigating or compensating acts. They can’t fully address what is ingrained in society.
One could go through every proposal and assess its chances of succeeding or even being implemented. As someone who has given up on expecting political solutions to improve anything in this world, it feels like a pointless exercise. And with the advent of Covid 19, and the current situation around the virus, it just seems even less likely that any of these strategies will be enacted. For a start, any mental health services which do exist have been stripped back as staff are enlisted to help with fighting Covid 19. Many services are now not running as a result of it. The only thing which can be guaranteed is more of a reliance on digital technologies in delivering support to people, as the PHE
NHS Long Term Plan cites in later chapters. If anything we are heading for more disconnection and less real life interaction, and more sedentary behaviour, which of course is not good for anyone’s health. Despite the rhetoric that ‘mental health is key’ during the Covid 19 lockdown, in practice this is not the case at all. People feel abandoned and at a time when mh services are understaffed, and the virus is leading to twice as many deaths in psychiatric wards than on average, these long term proposals will be at best ‘put on ice’, and at worst, completely shelved. The NHS, which politicians of all stripes are always keen to claim they cherish and will always protect, is on its last legs in many ways, as was quite likely intended by the UK government.
Operation Cygnus predicted that a pandemic situation such as the current coronavirus emergency would cripple the public health service, and given no pre-emptive measures were put in place to prepare for such a crisis, it appears that it isn’t quite as treasured as the Tory party would have us believe. This is no surprise given the party’s
links to private healthcare interests. However a report revealed by the Scottish Government
shows failings in NHS Scotland regarding pandemic preparation, and the SNP also have lesser but previous
form for privatising services. The shrinking or even end of public healthcare is a complete game changer, and we cannot know exactly what form if any these pledges will take under such conditions, which now seem inevitable.
PHE claims that for the SMI population “The underlying reasons for poorer health are not yet fully understood.” Perhaps there are clues in their disjointed analyses of mental and physical health, and the fact we live in an inherently unequal society which is bad for your general wellbeing. All the talk, from making services more ‘holistic’, and joining up the dots with regards to organisations that can help, to addressing poverty and exclusion, cannot succeed with the current mindset, and a system which is uniquely setting these public bodies up to fail by making any kind of equality impossible by its very existence. And as this system is global, it makes any attempt at replacing it with something which makes progress around this area possible much more unlikely. Something governments need to remember is this: actions speak louder than words. We await their next move with interest.
Thanks to snowstorm for inspiring the subject of the blog and providing some of the links.