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Fund Life
Not services: Reforming Mental Health




    Dr Simon Duffy ■ The Centre for Welfare Reform ■ Pavilion
    Conference, Leeds ■ 6th December 2012 ■
The Centre for Welfare Reform

• Welfare state is good - it is
  just designed wrong.
• Move away from meritocratic
  thinking, instead value
  human diversity & equality
• New thinking must promote
  justice, citizenship, family &
  community.
• Innovate to build practical
  alternatives
You can call anything a ‘reform’
but it doesn’t make it so.

Government’s welfare reforms
are not reforms but cuts.
Key points

1.Mental health is ripe for reform
2.Our context is changing radically
3.Personalisation & PBR opens doors
4.But real change will be from people
1. Mental health system is crazy
Fund life: a perspective

• Funding for mental health services is
   currently invested in the wrong things
• Improving mental health has more to do with
   citizenship and community than with services
• Current systems of funding and
   commissioning have made no difference
• Personalisation and greater community-focus
   could change that
• Peer support will change that
These findings [better long-term outcomes for schizophrenia in
developing countries] still generate some professional contention
and disbelief, as they challenge outdated assumptions that
generally people do not recover from schizophrenia and that
outcomes for western treatments and rehabilitation must be
superior. However, these results have proven to be remarkably
robust, on the basis of international replications and 15-25 year
follow-up studies. Explanations for this phenomenon are still at
the hypothesis level, but include:

1. greater inclusion or retained social integration in the
community in developing countries, so that the person retains a
role or status in the society

2. involvement in traditional healing rituals, reaffirming
community inclusion and solidarity

3. availability of a valued work role that can be adapted to a
lower level of functioning

4. availability of an extended kinship or communal network,
so that family tension and burden are diffused, and there is often
less negatively 'expressed emotion' in the family
Dr Alan Rosen from Destigmatising day-to-day practices: What Can Developed
Countries learn from Developing Countries? World Psychiatry 2006, 5: 21-24
Of 44 women working with WomenCentre:
Managing a serious health condition                    64%
Finding a safer place to live                          27%
Living with childhood abuse                            51%
Didn’t finish their education                          76%
Recent experience of domestic violence                 85%
Fractured family (for those with young families)       66%
Children experienced abuse (for those with children)   55%
Living with a severe level of mental illness           55%
Living with some mental illness                        91%
History of drug or alcohol misuse                      52%
Victim of crime                                        41%
Perpetrator of crimes                                  39%
Worried by debt or lack of money                       65%
Lots of services, no support
Our hypothesis
Poor mental health is a function of real poverty




Multiple reinforcing erosion of personal resilience
Service label      N Urgent problem N            Real need        N

Victim of domestic
                     55 Debt               50 Better self-esteem    64
violence
                                              To overcome past
Mentally Ill         39 Housing            48                       54
                                              trauma
                                              To manage
Criminal             35 Benefits            46                       51
                                              current trauma
                                              To stop being
Poor Mother          33 Health             37                       50
                                              bullied

Misuses Alcohol      24 Rent               32 Guidance              50

                        Criminal Justice
Uses Drugs           22                    24 Relationship skills   45
                        Advocate

Violent              19 Dentistry          8   Mothering skills     26
Chronic Health
                     16 Others             3   Others               1
Condition
Our proper focus should be
real wealth and the human spirit
2. It’s enough to make you mad
Some big growth and some big cuts




[Source: HM Treasury, 2010 October Spending Review]
Biggest growth is in central spending
Big cuts to benefits and social care
•   End of Disability Living Allowance
•   Cuts in Housing Benefit & Council Tax benefit
•   Reductions in Access to Work
•   Reduced eligibility for ESA
•   Increasingly intrusive testing by ATOS
•   Introduction of Universal Credit
•   Benefits reindexed to increase poverty
•   End of Independent Living Fund
•   Increased eligibility for social care
•   Increasing bureaucracy in social care
•   Reducing budget levels in social care
•   Return people to institutions and care homes
•   Increasing social care charges
•   Increased taxes, e.g. VAT, Council tax
•   and many, many other measures
What will be impact?
Mental health will deteriorate as



1.Inequality will increase

2.Stigmatisation will increase

3.Real poverty will increase
Income inequality correlated with mental illness
Some of this may be caused by practical aspects of
poverty, e.g. debt:

45% of people in debt have mental health problems
compared to 14% of people who are not in debt

Developing unmanageable debt is associated with
an 8.4% risk of developing a mental health
problem compared to 6.3% for people without
financial problems (i.e. a third higher)

Relative risks for people in debt: alcoholism (2x),
drug addiction (4x), suicidal ideation (2x)

Martin Knapp, 2012 Tizard Lecture
Some of this may be caused by psychological
aspects of poverty, e.g. stigma:




 Chick Collins on the ‘Scottish Effect’
Current cuts will target and further stigmatise
particular groups, e.g. disabled people


By 2015 benefits - will be cut by more than £18
billion, local government in England will be cut by
£11.3 billion. 50% of local government spending is
on social care for disabled people.
58% of all cuts target disabled people and people
in poverty
36% of all cuts target disabled people
24% of all cuts target those who need social care -
1.9% of the population
Mental health spending itself may not decrease
much, but this is not necessarily a good thing


Rather than reducing inequalities itself, the
initiatives aimed at tackling health or social
problems are nearly always attempts to break the
links between socio-economic disadvantage and
the problems it produces. The unstated hope is
that people - particularly the poor - can carry on in
the same circumstances, but will somehow no
longer succumb to mental illness, teenage
pregnancy, educational failure or drugs.

Wilkinson & Pickett, The Spirit Level
1. Human Rights - Better fundamental
         legislation
         2. Clear Entitlements - Its ‘my budget’
         3. Avoid Crisis - Family support, lower
         thresholds
         4. Full Access - No ‘special’ funding for
         services
         5. Choice & Control - Freedom, capacity
         6. Fair Incomes - Enough for citizenship
         7. Fair Taxes - No ‘special taxes’, no
         charges
         8. Sustainability - Rethink health/social
         care split



Campaign for a fair society
3. Opening the doors of the asylum
Emerging themes in policy

1.Personalisation still has momentum

2.GPs may have more influence

3.LAs may have more influence

4.Social care will be slashed

5.PBR may make a difference
Let’s not be naive about policy change
jargon or new reality?
the need for entitlements
the search for accountability
opening up new forms of control
I used to work in the fashion design industry as a product developer until
I became ill. This was a hard time in my life. I was diagnosed with
paranoid schizophrenia...


...as I am now on the road to recovery my budget has reduced. I have
updated my plan myself and this has given me the opportunity to talk
about what I want for the future. The opportunity to be creative is very
important to me and is something that keeps me well. I now receive a
little support and a one off payment which I use to help me to buy
equipment to make jewellery. I hope that I will eventually be able to
teach other people how to make jewellery to give something back. My
goal is to start up my own jewellery business and be financially self-
supporting, and the recovery team is helping me with this.


Without the support that I have I would still be wondering where my life
is going, but now I have hopes for the future. I would definitely
recommend considering a personal budget. You can really make it work
for you in a way that I didn’t know was possible. I feel lucky that I have
been able to get back some of the life I have lost.


From Health Efficiency by Alakeson & Duffy
personalised support means...
creative support for folk with complex
                needs
Transportation                               13%   Crafts                           2%

Computers and accessories                    12%   Licenses/ certification           2%

Dental services                              11%   Entertainment                    2%

Medication management services               8%    Vision services                  2%

Psychotropic medications                     8%    Furniture                        1%

Mental health counselling                    8%    Non-mental health medical        1%

Housing                                      7%    Camera and supplies              1%

Massage, weight control, smoking cessation   5%    Education, training, materials   1%

Utilities                                    3%    Haircut, manicure etc.           1%

Travel                                       3%    Pet ownership                    1%

Equipment                                    3%    Supplies and storage             <1%

Clothing                                     2%    Other                            <1%

Food                                         2%    Total                            100%
the need to change investment patterns
integration through personalisation
rethinking outcomes




 LA Resources        ‘Social Care’       Well-being?

NHS Resources      Medical services   Clinical outcomes?

                                      Improved mental
Welfare funding     ‘what works’
                                           health
Rethinking commissioning

          • Total place - the
             Humpty-Dumpty
             challenge
          • Community sourcing -
             individuals, communities
             and local organisations
          • Innovate - you can’t
             move without changing
          • Measure - focus on what
             really matters
Localism anyone?
4. Don’t get mad, get even
WomenCentre:

1.Start with the whole woman - gendered
  and holistic

2.Offer a positive and comprehensive
  model of support - every woman is a one-
  stop-shop

3.Build a bond of trust - create the means
  for woman to do real work together
A positive model of service...




5 and 1/2 levels of support
Knitting together the bond of trust
The future social worker?
Time to Campaign?
Fund
 Life
Questions for you...

1.Do you believe change is possible?
2.Do you believe you can be part of
  it?
3.Will you work with us to make it
  happen?

If so...
You can get much more
information on all these
                                                                      You can also join
topics FREE at                                                        www.campaignforafairsociety.org

www.centreforwelfarereform.org
                                                                             #FairSociety
Subscribe and Follow




                                  These slides are © Simon Duffy
                                 2012 ■ Publisher is The Centre for
                                  Welfare Reform ■ Slides can be
                                  distributed subject to conditions
                                              set out at
                                  www.centreforwelfarereform.org

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Fund Life, Not Services

  • 1. Fund Life Not services: Reforming Mental Health Dr Simon Duffy ■ The Centre for Welfare Reform ■ Pavilion Conference, Leeds ■ 6th December 2012 ■
  • 2. The Centre for Welfare Reform • Welfare state is good - it is just designed wrong. • Move away from meritocratic thinking, instead value human diversity & equality • New thinking must promote justice, citizenship, family & community. • Innovate to build practical alternatives
  • 3. You can call anything a ‘reform’ but it doesn’t make it so. Government’s welfare reforms are not reforms but cuts.
  • 4. Key points 1.Mental health is ripe for reform 2.Our context is changing radically 3.Personalisation & PBR opens doors 4.But real change will be from people
  • 5. 1. Mental health system is crazy
  • 6. Fund life: a perspective • Funding for mental health services is currently invested in the wrong things • Improving mental health has more to do with citizenship and community than with services • Current systems of funding and commissioning have made no difference • Personalisation and greater community-focus could change that • Peer support will change that
  • 7. These findings [better long-term outcomes for schizophrenia in developing countries] still generate some professional contention and disbelief, as they challenge outdated assumptions that generally people do not recover from schizophrenia and that outcomes for western treatments and rehabilitation must be superior. However, these results have proven to be remarkably robust, on the basis of international replications and 15-25 year follow-up studies. Explanations for this phenomenon are still at the hypothesis level, but include: 1. greater inclusion or retained social integration in the community in developing countries, so that the person retains a role or status in the society 2. involvement in traditional healing rituals, reaffirming community inclusion and solidarity 3. availability of a valued work role that can be adapted to a lower level of functioning 4. availability of an extended kinship or communal network, so that family tension and burden are diffused, and there is often less negatively 'expressed emotion' in the family Dr Alan Rosen from Destigmatising day-to-day practices: What Can Developed Countries learn from Developing Countries? World Psychiatry 2006, 5: 21-24
  • 8.
  • 9.
  • 10. Of 44 women working with WomenCentre: Managing a serious health condition 64% Finding a safer place to live 27% Living with childhood abuse 51% Didn’t finish their education 76% Recent experience of domestic violence 85% Fractured family (for those with young families) 66% Children experienced abuse (for those with children) 55% Living with a severe level of mental illness 55% Living with some mental illness 91% History of drug or alcohol misuse 52% Victim of crime 41% Perpetrator of crimes 39% Worried by debt or lack of money 65%
  • 11. Lots of services, no support
  • 12. Our hypothesis Poor mental health is a function of real poverty Multiple reinforcing erosion of personal resilience
  • 13. Service label N Urgent problem N Real need N Victim of domestic 55 Debt 50 Better self-esteem 64 violence To overcome past Mentally Ill 39 Housing 48 54 trauma To manage Criminal 35 Benefits 46 51 current trauma To stop being Poor Mother 33 Health 37 50 bullied Misuses Alcohol 24 Rent 32 Guidance 50 Criminal Justice Uses Drugs 22 24 Relationship skills 45 Advocate Violent 19 Dentistry 8 Mothering skills 26 Chronic Health 16 Others 3 Others 1 Condition
  • 14. Our proper focus should be real wealth and the human spirit
  • 15. 2. It’s enough to make you mad
  • 16. Some big growth and some big cuts [Source: HM Treasury, 2010 October Spending Review]
  • 17. Biggest growth is in central spending
  • 18. Big cuts to benefits and social care
  • 19. End of Disability Living Allowance • Cuts in Housing Benefit & Council Tax benefit • Reductions in Access to Work • Reduced eligibility for ESA • Increasingly intrusive testing by ATOS • Introduction of Universal Credit • Benefits reindexed to increase poverty • End of Independent Living Fund • Increased eligibility for social care • Increasing bureaucracy in social care • Reducing budget levels in social care • Return people to institutions and care homes • Increasing social care charges • Increased taxes, e.g. VAT, Council tax • and many, many other measures
  • 20. What will be impact?
  • 21. Mental health will deteriorate as 1.Inequality will increase 2.Stigmatisation will increase 3.Real poverty will increase
  • 22. Income inequality correlated with mental illness
  • 23. Some of this may be caused by practical aspects of poverty, e.g. debt: 45% of people in debt have mental health problems compared to 14% of people who are not in debt Developing unmanageable debt is associated with an 8.4% risk of developing a mental health problem compared to 6.3% for people without financial problems (i.e. a third higher) Relative risks for people in debt: alcoholism (2x), drug addiction (4x), suicidal ideation (2x) Martin Knapp, 2012 Tizard Lecture
  • 24. Some of this may be caused by psychological aspects of poverty, e.g. stigma: Chick Collins on the ‘Scottish Effect’
  • 25. Current cuts will target and further stigmatise particular groups, e.g. disabled people By 2015 benefits - will be cut by more than £18 billion, local government in England will be cut by £11.3 billion. 50% of local government spending is on social care for disabled people. 58% of all cuts target disabled people and people in poverty 36% of all cuts target disabled people 24% of all cuts target those who need social care - 1.9% of the population
  • 26.
  • 27. Mental health spending itself may not decrease much, but this is not necessarily a good thing Rather than reducing inequalities itself, the initiatives aimed at tackling health or social problems are nearly always attempts to break the links between socio-economic disadvantage and the problems it produces. The unstated hope is that people - particularly the poor - can carry on in the same circumstances, but will somehow no longer succumb to mental illness, teenage pregnancy, educational failure or drugs. Wilkinson & Pickett, The Spirit Level
  • 28. 1. Human Rights - Better fundamental legislation 2. Clear Entitlements - Its ‘my budget’ 3. Avoid Crisis - Family support, lower thresholds 4. Full Access - No ‘special’ funding for services 5. Choice & Control - Freedom, capacity 6. Fair Incomes - Enough for citizenship 7. Fair Taxes - No ‘special taxes’, no charges 8. Sustainability - Rethink health/social care split Campaign for a fair society
  • 29. 3. Opening the doors of the asylum
  • 30. Emerging themes in policy 1.Personalisation still has momentum 2.GPs may have more influence 3.LAs may have more influence 4.Social care will be slashed 5.PBR may make a difference
  • 31. Let’s not be naive about policy change
  • 32.
  • 33. jargon or new reality?
  • 34. the need for entitlements
  • 35. the search for accountability
  • 36. opening up new forms of control
  • 37. I used to work in the fashion design industry as a product developer until I became ill. This was a hard time in my life. I was diagnosed with paranoid schizophrenia... ...as I am now on the road to recovery my budget has reduced. I have updated my plan myself and this has given me the opportunity to talk about what I want for the future. The opportunity to be creative is very important to me and is something that keeps me well. I now receive a little support and a one off payment which I use to help me to buy equipment to make jewellery. I hope that I will eventually be able to teach other people how to make jewellery to give something back. My goal is to start up my own jewellery business and be financially self- supporting, and the recovery team is helping me with this. Without the support that I have I would still be wondering where my life is going, but now I have hopes for the future. I would definitely recommend considering a personal budget. You can really make it work for you in a way that I didn’t know was possible. I feel lucky that I have been able to get back some of the life I have lost. From Health Efficiency by Alakeson & Duffy
  • 38.
  • 40. creative support for folk with complex needs
  • 41.
  • 42. Transportation 13% Crafts 2% Computers and accessories 12% Licenses/ certification 2% Dental services 11% Entertainment 2% Medication management services 8% Vision services 2% Psychotropic medications 8% Furniture 1% Mental health counselling 8% Non-mental health medical 1% Housing 7% Camera and supplies 1% Massage, weight control, smoking cessation 5% Education, training, materials 1% Utilities 3% Haircut, manicure etc. 1% Travel 3% Pet ownership 1% Equipment 3% Supplies and storage <1% Clothing 2% Other <1% Food 2% Total 100%
  • 43. the need to change investment patterns
  • 45. rethinking outcomes LA Resources ‘Social Care’ Well-being? NHS Resources Medical services Clinical outcomes? Improved mental Welfare funding ‘what works’ health
  • 46. Rethinking commissioning • Total place - the Humpty-Dumpty challenge • Community sourcing - individuals, communities and local organisations • Innovate - you can’t move without changing • Measure - focus on what really matters
  • 48. 4. Don’t get mad, get even
  • 49.
  • 50.
  • 51. WomenCentre: 1.Start with the whole woman - gendered and holistic 2.Offer a positive and comprehensive model of support - every woman is a one- stop-shop 3.Build a bond of trust - create the means for woman to do real work together
  • 52. A positive model of service... 5 and 1/2 levels of support
  • 53. Knitting together the bond of trust
  • 54.
  • 55.
  • 56. The future social worker?
  • 57.
  • 60. Questions for you... 1.Do you believe change is possible? 2.Do you believe you can be part of it? 3.Will you work with us to make it happen? If so...
  • 61. You can get much more information on all these You can also join topics FREE at www.campaignforafairsociety.org www.centreforwelfarereform.org #FairSociety Subscribe and Follow These slides are © Simon Duffy 2012 ■ Publisher is The Centre for Welfare Reform ■ Slides can be distributed subject to conditions set out at www.centreforwelfarereform.org