Comment / Investing in dignity

The theme of dignity runs throughout Sir Simon Wessely’s 2018 review of the Mental Health Act 1983. The review recognised the importance of acknowledging the experiences of those detained under the act, who felt stripped of their dignity and self-respect. And it underlined that dignity is not just desirable, but essential to wellbeing and health, reducing the risk of future admissions.

If dignity means that what a person has to say is important, then the recent mental health white paper goes some way to recognising that allowing a person to retain their dignity is essential.

Over the next three months, the government is consulting on a wide range of changes to the act. The consultation has been delayed by Covid-19, but the pandemic has already accelerated some of the changes called for in the review. It has certainly further highlighted the importance of improving mental health services and the impact that racial and cultural inequalities can have for those who need support.

The review developed four principles that are at the centre of the government’s proposed reforms. The principle of choice and autonomy ensures that a person’s views and choices are respected. The powers of the act should be used in the least restrictive way. There needs to be a therapeutic benefit to the intervention to allow people to get better and be discharged. And patients must be viewed as individuals and treated as such.

Dignity will not be delivered by any single change. Some of the changes will be cultural, but better facilities and an expanded and enhanced workforce will also play a part.

Some of the changes needed are already underway. The NHS long term plan sets out the intention to further personalise care and many areas already offer fantastic, personalised care to those in receipt of mental health services. For those in receipt of section 117 aftercare, after they have been detained under the act, there is already a legal right to have a personal health budget.

The expansion of crisis services is another example and the NHS people plan promises to increase and improve the mental health workforce. In terms of facilities, funding has already been identified to remove dormitories from the mental health estate.

But the white paper goes further. It commits to tackling the backlog maintenance for the mental health estate, although the funding to do so is not identified. It also sets out a new duty on the NHS, specifically clinical commissioning groups, and local authorities to ensure that there is an adequate supply of community services for people with a learning disability or autism. The proposals recognise that this may lead to additional funding requirements although there is only a commitment to assess the implications for local government in this respect.  

If assessment and detention under the mental health act is to be the last resort, then the continued investment in mental health services is essential. The Health Infrastructure Plan included plans to build 40 new hospitals, two of which were for mental health. Alongside the white paper, the government has announced that bids will be invited for a further eight schemes, some of which will be for mental health and will be in addition to the existing committed funding of £400m to improve the mental health estate.

As the country enters a period of anticipated prolonged recession, committing funding to support further investment in mental health improvements is a big ask. The government anticipates that the cost of the additional workforce required to enact the reforms to the mental health act is likely to be £200m to £400m a year.

There is the ongoing question of where those staff are going to come from for a sector that often struggles to recruit. And, within the text of the proposals that highlight that this will be presented ‘when Parliamentary time allows’, is the following sentence – ‘the proposals set out in this white paper are subject to future funding decisions, including at spending review 2021’.

The core principles of the proposed reforms are indisputable. We all hope to retain our dignity at the times when we are most vulnerable and in need of support. But at a time when all sectors of our economy need support, are these sweeping reforms something that the government can fully commit to?