Mental health in the United Kingdom
Mental health in the United Kingdom involves state, private and community sector intervention in mental health issues. One of the first countries to build asylums, the United Kingdom was also one of the first countries to turn away from them as the primary mode of treatment for the mentally ill. It was Enoch Powell in 1961, then Minister of Health, who led the shift towards Care in the Community, the British version of deinstitutionalisation. The majority of mental health care is now provided by the National Health Service, assisted by the private and the voluntary sectors.
According to an investigation in 2018, the NHS is struggling to cope with rising demand for mental health care, with a shortage of beds, patients facing long delays in accessing treatment, and receiving inadequate care when they do. Areas of concern include support for pregnant women and new mothers; depression, anxiety and suicidal thoughts in school-age children and adolescents; and the use of restraints on mental health patients.
The Madhouses Act 1774 was the first legislation in the United Kingdom addressing mental health. Privately funded lunatic asylums were widely established during the nineteenth century. The County Asylums Act 1808 permitted, but did not compel, Justices of the Peace to provide establishments for the care of "pauper lunatics", so that they could be removed from workhouses and prisons. The Lunacy Act 1845 established the Board of Commissioners in Lunacy. Justices were forced to build lunatic asylums financed by the local rates.
In 1859, there were about 36,000 people classified as lunatics in all forms of care in England and Wales. About 31,000 were classed as paupers and 5,000 were private patients. Over 17,000 of the paupers were in county asylums or on contract in licensed houses, about 7,000 were in workhouses, while a similar number were living 'with friends or elsewhere'. Ten per cent of workhouse infirmaries provided separate insane wards. The Lunacy Act 1862 permitted voluntary admission. Any person who had been a patient in any type of mental hospital during the previous five years could enter a licensed house as a voluntary boarder. The Lunacy Commissioners could remove lunatics from workhouses to county asylums, and the harmless chronic insane could be moved from the overcrowded asylums to the workhouses.
The Metropolitan Asylums Board, established by the Metropolitan Poor Act 1867 built two large asylums for London, Leavesden Mental Hospital and Caterham Asylum. They were built to similar designs by the same architect and each was intended to accommodate 1560 patients in six three-storey blocks for 860 females and five blocks for 700 males. They were both extended by around 500 places within five years. In 1870 there were about 46,500 poor law mental health cases: 25,500 in county asylums, 1,500 in registered establishments, 11,500 in workhouses and the remainder boarded out with relatives. In 1876, there were nearly 65,000 people classified as mentally disordered in England and Wales. It is not clear that there was actually an increase in the prevalence of mental illness.
From around 1870 there were moves to separate what were then called idiot children from adults. Darenth School for 500 children with learning disabilities was opened by the Metropolitan Asylums Board in 1878 and a separate institution next to the school, with accommodation for 1,000 adults, was opened in 1880.
The Lunacy Act 1890 placed an obligation on local authorities to maintain institutions for the mentally ill. By 1938 131,000 patients were in local authority mental hospitals in England and Wales, and 13,000 in District Asylums in Scotland, where there were also seven Royal Mental Asylums. Mental hospitals were overcrowded and understaffed.
Mental health services were not integrated with physical health services when the NHS was established in 1948. Shortages of money, staff and buildings continued. Confederation of Health Service Employees organised an overtime ban in 1956, the first national industrial action in the NHS. Iain Macleod increased capital spending from 1954, hoping to increase bed numbers by 2,800. Rising numbers of patients, especially the elderly, caused a shift in policy away from institutions and towards day centres and community care.
In 1961 Enoch Powell, then Minister of Health, made his Water Tower Speech. He said "in fifteen years time there may well be needed not more than half as many places in hospitals for mental illness as there are today". This marked a shift towards Care in the Community, the British version of deinstitutionalisation, which was given further impetus by a series of scandals over long-stay hospitals from 1968 onwards.
Incidence of mental health problems
Most mental health problems are not easily defined. The American Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems are most generally used. According to Mind about 25% of the adult population will experience a mental health problem each year.
In 2014 the Adult Psychiatric Morbidity Survey reported that 17% of those surveyed in England met the criteria for a common mental disorder and about 37% of those were accessing mental health treatment. Those more severely affected were more likely to be accessing services. In 2017 a survey found that 65% of Britons have experienced a mental health problem, with 26% having had a panic attack and 42% saying they had suffered from depression.
Pregnant women and new mothers who develop mental health problems get inadequate help from the NHS and how much help they get is subject to a postcode lottery. Some take their own lives; suicide is the most common cause of death among mothers who gave birth within the previous year. The NHS considers that up to 20% of the 775,000 women who give birth annually have a mental health problem connected with carrying a child or giving birth. This includes anxiety disorders, depression and psychotic illnesses such as bipolar disorder and schizophrenia. According to Claire Murdoch, NHS England's national mental health director, “As recently as 2014, only 3% of the country had good access to perinatal mental health care...".
Agnes Hann of the National Childbirth Trust said, "These findings are shocking, and mean that thousands of women experiencing potentially serious perinatal mental health problems are not getting the support they need. Perinatal mental illness can have a severe and long-term impact on mothers, babies and families. In extreme circumstances, it can result in tragedy – suicide is a leading cause of maternal death." From roughly 10% to 20% of women giving birth experience some type of mental illness such as anxiety and depression or more complex problems like PTSD and psychosis. With about 665,000 births a year in England 66,500–133,000 women a year develop illnesses. In 2016, 13,000 women were treated by perinatal teams while 800 became inpatients. This means the majority were untreated.
Benefit cuts and sanctions "are having a toxic impact on mental health" according to the UK Council for Psychotherapy. Rates of severe anxiety and depression among unemployed people increased from 10.1% in June 2013 to 15.2% in March 2017. In the general population the increase was from 3.4% to 4.1%.
On 5 March 2018, it was reported that "hundreds of mental health patients died after NHS care failures". The report found "271 highly vulnerable patients died between 2012 and 2017 after 706 failings by health bodies". Many of these patients took their own lives. The investigation found that the NHS is struggling to cope with rising demand for mental health care, as well as patients facing long delays in accessing treatment and receiving inadequate care when they do. "NHS providers, mental health organisations and charities have warned that NHS services have too few staff". "There are 6,000 fewer mental health nurses in England than in 2010". There was found to have been multiple notices of inadequate supervision of those with a clear suicide risk, NHS staff ignoring families fears of the suicide risk of a loved one and dozens of cases of staff making mistakes with patients medication or failing to properly assess a patients suicide risk.
Anxiety, depression and suicidal thoughts among children and adolescents are increasing but only half get the treatment they need. Consultant clinical psychologist, Dr. Nihara Krause said, "Schools face huge challenges in dealing with mental health issues in their students, and teachers are on the front line. They witness first-hand the devastating impact of pressures such as exam anxiety, bullying, and family problems. The consequences of these problems are serious, often life-threatening, and teachers are desperate to help. Yet at a time when the need for preventative, early intervention and specialist services are soaring, schools are finding it increasingly difficult to provide the help their pupils need. There's an urgent need for better support mechanisms in schools, as well as decent funding for the range of mental health services children and young people need." At least one in ten children are believed to have a psychiatric problem. Just 25% of children with mental health conditions get treatment. A child and adolescent mental health service (Camhs) worker said, "My experience in the past eight to 10 years has been a real deterioration in children and adolescents' ability to access services - the thresholds have changed considerably." At least one and a half million children under age 18 live in areas without 24/7 mental health crisis care. Research by the Education Policy Institute suggests referrals to child and adolescent mental health services rose 26% in the five years to 2018. Eating disorders causing weight loss less than 15% from the ideal weight do not get referrals despite National Institute for Health and Care Excellence guidelines that they should.
Poor mental health at work affects half of employees. Fewer than 1 in 5 employers offer mental health training to managers.
From 2010 to 2016, 224 inpatients at English psychiatric institutions died of self-inflicted injuries of whom 134 were men and 90 women. The overall figure seems to be falling. Though men are usually at greater risk of suicide, in 2015, for the first time, twenty women killed themselves compared to fifteen men, and in 2016 the figures were ten women and six men. Campaigners have described women's mental health care by the NHS as "not fit for purpose". Katharine Sacks-Jones of Agenda, which campaigns over risks to women and girls, said, "It is appalling that we are seeing so many self-inflicted deaths of women and girls detained under the Mental Health Act. Many will have been detained precisely because they were at risk to themselves, yet the Mental Health Act is not keeping them safe and is failing to support and protect them. NHS care of women with serious psychological or psychiatric problems needs to take much greater account of the fact that many female patients have suffered violence or abuse. The reality is that the conditions under which the Mental Health Act are enforced are not fit for purpose for women and girls". Coroners found at least 271 mental health patients in England and Wales died from 2012 to 2017, sometimes following multiple failings by NHS staff and organisations. This included mental health trusts, GP surgeries and ambulance services. Nearly one in six involved lack of staff, beds or treatment that a patient needed. Deborah Coles of INQUEST, called for mandatory independent investigations into deaths in places where there is mental health care. Coles said, "Our casework bears witness to the escalating rise on the number of highly vulnerable women and girls dying in places where they should be safe. Critical to this is the need for greater oversight, accountability and learning. The lack of an independent investigation system for deaths in mental health settings, unlike that for deaths in police or prison custody, undermines this necessary scrutiny."
Mental health treatment
Improved mental health funding enables people with mental health problems to become more productive workers. Patients diagnosed for the first time with psychosis are too frequently not getting the full recommended care package. Norman Lamb, Liberal Democrat Spokesperson for Health, said, "The impact on peoples' lives of not making this investment is profound. You are left with – potentially – a miserable life, a life on benefits, a life with difficult relationships. And yet if we make that investment, we can transform lives." Understaffing in psychiatric hospitals sometimes leads to avoidable deaths. Coroners issued legal warnings respecting 271 deaths of psychiatric patients that happened in England and Wales from 2012 to 2017 after treatment failings. At least 154 vulnerable patients with eating disorders, mostly women with some teenagers, needed to travel hundreds of miles away from homes to get inpatient treatment in Glasgow and Edinburgh, which cost the NHS millions of pounds per year. Mental health experts were alarmed and held severe shortage of both beds and specialist staff in mental health facilities responsible. Provision of talking therapies is subject to a postcode lottery. In some cases this method of treatment is prompt, in others there are delays of up to four months.
During the six years up to early 2018 in England and Wales 271 psychiatric patients died following failings in their NHS care. Paul Farmer of Mind stated, "When a coroner identifies failings, the NHS needs to respond by urgently addressing any concerns raised and make sure that lessons are learned, not just on one ward or in one trust, but across NHS mental health services. We also need greater clarity when it comes to accountability – it is not clear at the moment who is responsible for making sure that the improvements called for in [Prevention of Future Deaths Notices] are carried out."
Children and adolescent services
Barnardo's claims the government plans for children's therapy are too little too late. According to Barnardo's, children in mental health crisis need to see a therapist within days rather than within a month as the government promises. Further, the proposed plans will not reach more than a quarter of children for years. Matt Blow of YoungMinds said, "In many areas it is desperately hard for young people to get the support they need, Every day the charity's helpline hears from parents who have been waiting months for an appointment for their child and have nowhere to turn. Sometimes their children have started to self-harm, become suicidal or dropped out of school during the wait."
Young English people with eating disorders are sent to Scotland because the services they need are not available locally. Being away from friends and family compromises their recovery.
There are concerns that not enough is being done to support people at risk of suicide. 1,039 children and adolescents in England were admitted to beds away from home in 2017-18, many had to travel over 100 miles from home. Many had complex mental health issues frequently involving a risk of self-harm or suicide, like severe depression, eating disorders, psychosis and personality disorders.
In 2017-18 at least 539 children assessed as needing Tier 3 child and adolescent mental health services care waited more than a year to start treatment, according to a Health Service Journal survey which elicited reports from 33 out of the 50 mental health trusts. 99% of UK family doctor fear youngsters under 18 will be harmed through long delays to see a specialist and rationing of vital care.
Women's Mental Health
In 2017, a Women's Mental Health Taskforce co-chaired by Health Minister Jackie Doyle-Price MP and Katharine Sacks-Jones (Chief Executive, Agenda) was formed.  The Taskforce was established to address the differences in mental health needs and experiences between women and men. Some gender-specific needs and challenges for women includes: their experiences of mental health services, their roles as mothers and carers, their experiences of gender-based violence and trauma, multiple needs (other challenges faced alongside poor mental health), high prevalence in other mental ill health (i.e. Eating disorders, self-harm and suicide). 
A final Women's Mental Health Taskforce report was published on the 19 December 2018 as a summary of future strategic priorities and a call to action for stakeholders across the health care system. One main message of the report was to promote the principle of trauma- and gender-informed mental health care. The report also includes quoted statements from women's with lived experiences. 
The King's Fund found that 40% of English Mental Health Trusts experienced budget cuts in 2015–16. Money promised for children's mental health services is not reaching frontline services and instead is being used to offset cuts elsewhere. According to the Education Policy Institute 'Independent Commission on Children and Young People's Mental Health', young people still struggle to get psychiatric help. 23% of children and young people referred to mental health services are turned away due to "high thresholds" to access services. A report claimed, "something has to go drastically wrong before some services will intervene". In some areas services are so stretched that children only get help if they are suicidal or seriously self harming. Barnardos is not bidding to provide some services because with the limited funding available they do not believe they can provide a safe service. The number of psychiatrists available to treat children and young people with mental health needs is falling despite rising demand. Patient care is being delayed or limited because staffing numbers have not kept up with growing demand, which experts connect to academic pressures, social media and other issues. Some children's treatment is delayed up to 18 months. Dr Bernadka Dubicka of the Royal College of Psychiatrists stated, “With the country facing a crisis in children’s mental health, we need a big expansion of the number of doctors … It is deeply frustrating that the number of child and adolescent psychiatrists is falling.” Plans to change mental health care for young people will come too late for the present generation.
The numbers attending A&E due to psychiatric problems rose by 50% between 2011 and 2016 and reached 165,000 in that year. Patients are suffering psychiatric crises due to lack of earlier intervention. It is suspected[by whom?] that yet more psychiatric cases are recorded as something else like self-harm or attempted suicide. Some trusts claim that 10% of A&E cases are psychiatric. Patients attending A&E due to psychiatric problems have not benefited from early intervention due to years of underfunding. Young people do not get early help and problems escalate.
There are calls for increased provision of in patient psychiatric services and community psychiatric services because otherwise patients will be failed, sometimes with tragic results. A&E is stressful and far from ideal for people in a mental health crisis but many patients in mental distress, some suicidal, have nowhere else to go. Some mental health services have increased but many have been cut. Forty per cent of mental health trusts have seen their budget reduced. Marjorie Wallace of mental health charity Sane, said "cuts to services across the country continue and people seeking help are still being failed".
In Birmingham, the Forward Thinking Birmingham consortium was selected to deliver a new combined mental health service for people aged 0–25 across the city from October 2015. The 5-year contract had an annual value of £23.7 million. It will result in the mental health trust losing £14.2m a year. An independent impact assessment recommended delayed implementation and "bridging funding" of at least £1.5m to enable the safe transition of some adult services. The joint commissioning board for the three Birmingham and Solihull clinical commissioning groups agreed in June 2017 to spend an additional £8.1 million over two years to ease pressure on adult mental health beds after an independent report produced by Mental Health Strategies had "unearthed unsafe clinical practice due to a shortfall in bedded capacity". The contract provided 28 inpatient mental health beds for young adults but the service consistently had about 51 inpatients.
Mental health problems among university students have been increasing. Suicides among university students have increased. There is need for better joined up care between GP's at their parents' home where students are during vacations and university provision away from home. Waiting times before students can access mental health care are long.
The Tory manifesto for the 2017 general election promised to provide £1 billion extra cash by 2021 for mental health in England, to scrap the Mental Health Act 1983 and to introduce a new Mental Health Treatment Bill. In July 2017, Jeremy Hunt announced plans to create 21,000 new NHS posts. Two thousand additional nurses, consultants and therapist posts are to be created in Child and Adolescent Mental Health Services, and 2,900 additional therapists in adult talking services, with 4,800 extra nurses and therapists in crisis care settings. Javed Khan, chief executive of Barnardo's, said, "The response is insufficient, it's not broad enough, there is limited financial detail. It talks about rolling out a number of initiatives in a number of areas but funding is only secured to these areas until 2023. The prime minister has talked about this issue as a burning injustice but we don't think the action is matching the rhetoric."
Large numbers of psychiatric patients are sent out of the area where they live for treatment. In January 2018, 700 patients were sent out of their area and in February that year 650 patients received inpatient treatment outside their area. There are doubts[by whom?] if a target to end the practise by 2020 will be met. Health care professionals frequently spend hours looking for a place with a bed for a patient, preventing them from tending to other patients. Also, treatment away from family, friends and social contacts isolates patients and makes them less likely to recover. The King's Fund stated, "A lack of available beds is leading to high numbers of out-of-area placements for inpatients. Out-of-area placements are costly, have a detrimental impact on the experience of patients and are associated with an increased risk of suicide." Mental health beds in England have declined by 30% since 2009. Beds for patients with some of the most serious illnesses which include psychosis, serious depression with suicidal feelings and eating disorders, have fallen from 26,448 in 2009 to 18,082 in the first quarter of 2018. The number of mental health nurses working in the NHS fell from 46,155 to 39,358 and the number of doctors in specialist psychiatry training fell from 3,187 in 2009 to 2,588 in the first quarter of 2018. Psychiatrists and therapists are leaving the NHS while the numbers needing help are increasing.
The police are increasingly having to deal with mental health issues because the mental health services do not do enough according to Her Majesty's Inspectorate of Constabulary and Fire and Rescue Service. This takes police resources away from fighting crime. Merseyside police reckons 25% of its police time is spent dealing with mental health problems, and Lancashire police reckons that 20,000 hours of police time, out of 70,000 hours yearly is spent working on mental health problems. Police are forced to keep vulnerable psychiatrically ill patients in police cells for the patients' safety, which leaves some patients feeling like criminals.
Medical restraints in the UK
The Millfields Charter is an online charter which promotes an end to the teaching of any prone (face-down) restraint holds to frontline healthcare staff. In June 2013 the UK government announced that it was considering a ban on the use of face-down restraint in English mental health hospitals.
Face-down restraints are used more often on women and girls than on men. 51 out of 58 mental health trusts use restraints unnecessarily when other techniques would work. Organisations opposed to restraints include Mind and Rethink Mental Illness. YoungMinds and Agenda claim restraints are "frightening and humiliating" and "re-traumatise" patients, especially women and girls who have previously been victims of physical and/or sexual abuse.
The charities[which?] sent an open letter to health secretary, Jeremy Hunt showing evidence from 'Agenda, the alliance for women and girls at risk', revealing that patients are routinely restrained in some mental health units while other units use non-physical ways to calm patients or stop self-harm. According to the letter, over half of women with psychiatric problems have suffered abuse, restraint can cause physical harm, can frighten and humiliate the victim. Restraint, especially face-down restraint can re-traumatise patients who previously suffered violence and abuse. "Mental health units are meant to be caring, therapeutic environments, for people feeling at their most vulnerable, not places where physical force is routine."
Government guidelines state that face-down restraint should not be used at all and other types of physical restraint are only for last resort. Research by Agenda found one fifth of female patients in mental health units had suffered physical restraint. Some trusts averaged over twelve face-down restraints per female patient. Over 6% of women, close to 2,000, were restrained face-down in total more than 4,000 times. The figures vary widely between regions.
Some trusts hardly use restraints, others use them routinely. A woman patient[who?] was in several hospitals and units at times for a decade with mental health issues. She said in some units she suffered restraints two or three times daily. Katharine Sacks-Jones, director of Agenda, maintains trusts use restraint when alternatives would work. Sacks-Jones maintains that women in her group speak to repeatedly describe face-down restraint as a traumatic experience. On occasions, male nurses have used it when a woman did not want her medication. "If you are a woman who has been sexually or physically abused – and mental health problems in women often have close links to violence and abuse – then a safer environment has to be just that: safe and not a re-traumatising experience. ... Face-down restraint hurts, it is dangerous, and there are some big questions around why it is used more on women than men."
The use of restraints in UK psychiatric facilities is increasing. In 2016–17 there was the largest number of injuries ever; 3,652 patients were injured by being restrained, data from 48 of England's 56 mental health trusts reveals. Critics say restraints are potentially traumatic even life-threatening for patients. Norman Lamb said, "Whilst this dramatic increase may be partly explained by improved reporting, the scale of injuries is horrifying. This is also, no doubt, in part due to the stress that many trusts are under, with bed occupancy close to 100% and often relying on agency staff. This amounts to a serious and unacceptable breach of people's human rights. What is most shocking is that some of those against whom restraint is used have suffered abuse in their lives. For them, restraint amounts to an assault, which can be frightening and can completely undermine trust." The most injuries happened at Southern Health (534 cases), Merseycare (493) and South London and the Maudsley (255). Restraints were used 97,000 times in 2016–17. some trusts have greatly reduced the number of restraints used. Thirteen per cent of trusts have no restraint policy though 2014 government guidance asked all mental health care providers to draw one up. Staff as well as patients need to be protected and standards of training particularly in de-escalation techniques need improvement.
The police use stun guns on psychiatric patients including teenagers though this use is controversial and can be life-threatening. Gracie Bradley of Liberty said, “Given the pain, distress and serious health consequences electro-shock weapons can cause, it’s difficult to see how using them on vulnerable people seeking treatment in mental health hospitals could ever be appropriate or justified. [Stun guns] can and do kill, which is why they were initially restricted to use by firearms officers – but mission creep has seen them deployed well beyond that.” Norman Lamb said the UN defines stun gun use as potentially torture. “It’s seen as a way of avoiding force but this is not a risk-free option and it is particularly shocking when [stun guns] are used against teenagers.”
NHS Improvement began plans to help trusts in England integrate mental and physical health care in June 2017. Claire Murdoch said that more than 10,000 staff would be required to deliver the promised service improvements.
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