Mindfulness for mental health: snail’s pace provisioning in the NHS
Mental health: neglected at a cost
On 20th January the UK’s Deputy Prime Minister Nick Clegg gave a speech to launch the government’s “Mental Health Action Plan”, a speech that makes no secret of how the importance of mental health has been consistently marginalised in society, policy and National Health Service (NHS) provisioning till now.
According to the Mental Health Foundation, 1 in 4 people in the UK will suffer from a mental illness at some point in their lives. In England alone the wider economic cost of mental illness is estimated at over £105bn. But although mental ill health accounts for 22% of illness in the UK, it attracts only 11% of the total NHS budget, and NHS spend on it has been cut by 2% in the last 2 years.
Only as recently as 2011, the government “enshrined in law the equal importance of mental health alongside physical health” in its mental health strategy “No Health without Mental Health”, but the law has yet to materialise into results in the form of access to care. Waiting times are too long, and patients have little or no choice of providers of treatment.
“Since 2008, if you’ve needed a hip or knee replacement, you’ve been able to choose exactly which hospital you want to go to for treatment. You’ll also know that you should never have to wait longer than 18 weeks for your operation. But, if you’re a mental health patient, you don’t get these same rights and choices about where, when, or how you receive treatment. “ – Nick Clegg
Mindfulness-based therapies for mental health: recommended by NICE, favoured by doctors, but still largely unavailable the NHS
An example of the restricted choice and availability of mental health treatments is access to mindfulness-based therapies for depression and anxiety. “Mixed anxiety and depression is the most common mental disorder in Britain”. One of the most cost-effective treatments for those who suffer from repeated depression, is Mindfulness-Based Cognitive Therapy (MBCT), a group-based format of therapy delivered over 8 weeks in 2-hour sessions.
MBCT has been shown to reduce relapse rates of those who suffer from repeated depression, by half (read more on this here). The National Institute of Health and Clinical Excellent (NICE) has recommended it as treatment for depression in its Guideline 23 from 2004; the recommendation was updated in 2009 to make it a priority treatment available for such patients. However a decade later, the availability of MBCT on the NHS remains scarce.
In 2012 a survey explored to what extent and quality MBCT is being offered through NHS. The paper, authored by Rebecca Crane and Professor Willem Kuyken concludes:
“…MBCT is being inconsistently implemented across the UK, with a small proportion of respondents reporting thriving MBCT services (9%) alongside the remainder reporting that the implementation of MBCT has either not yet begun in their organisation, has little organisational support or is struggling to manage to develop with the available resources. It is clear that service provision on the ground falls well short of that envisaged in the UK national guidance for MBCT implementation (NICE 2009) and many other international evidence syntheses (e.g. Fjorback et al. 2011).”
The paper identifies many barriers to improving this situation, but at least doctors seem to agree on the importance of meditation as effective therapy for mental illness. In 2010 the Mental Health Foundation published a report reiterating the evidence for mindfulness-based therapies and calling for progress in its provisioning. In one of the surveys it commissioned of over 250 GPs (General Practitioners), interesting facts emerged about how doctors feel about mindfulness meditation:
72% of GPs think it would be helpful for their patients with mental health problems to learn Mindfulness meditation skills
68% of GPs think it would be very or quite helpful for their patients in general to learn Mindfulness meditation skills;
More than two-thirds (69%) of GPs say they rarely or never refer their patients with recurrent depression to MBCT. 5% refer to it very often. By comparison, 47% say they very often prescribe antidepressants to this patient group;
Three-quarters (75%) of GPs have prescribed antidepressants to patients with recurrent depression believing that an alternative approach might have been more appropriate. Two-thirds (67%) did so because there was a waiting list for the suitable alternative treatment, 57% because they didn’t have sufficient access to other suitable treatments, and 50% because it was the treatment option preferred by the patient. Nearly all (93%) the GPs surveyed agreed that it would be valuable to have more effective treatment options for patients with recurrent depression;
A fifth (20%) of GPs say they have access to MBCT courses for their patients (48% say they do not, and 32% don’t know if they have access or not);
66% of GPs say they would support a public information campaign to promote the potential health benefits of Mindfulness meditation; and
64% of GPs think it would be helpful for them to receive training in Mindfulness skills themselves.
So the picture becomes clearer: doctors feel that mindfulness meditation would benefit most patients with mental health problems, and although they would like to prescribe it instead of anti-depressants in many cases, they are restricted by barriers such as waiting lists, lack of access or at other times by patient preference.
Catch 22 of mindfulness provisioning: and one man’s fight to solve the problem
Looking into the topic I came across one man who has been fighting to increase the provision of mindfulness-based therapies in his area for 4 years; John Kapp is well known by the local council, Clinical Commissioning Group and Health and Wellness board in Brighton and Hove, for actively seeking a resolution to this problem. Last year he wrote a paper calling for the Bright & Hove Clinical Commissioning Group to pilot a new scheme that he proposes to facilitate greater access to mindfulness-based therapies through the NHS. I spoke with him to get a closer view on the issue.
Adiba: Mindfulness-based therapies are recommended by NICE and favoured by doctors – so why can’t patients with anxiety or depression be prescribed a course by their GP or A&E doctor?
Because GPs can only prescribe treatments (eg drugs) if contracts are in place (chemist shops) to provide them in exchange for a prescription. In Sussex, with 1.5 million people, of whom 160,000 are depressed, only about 20 MBCT facilitators are employed, to run 20 courses a year, for up to 20 patients per course, totalling 8,000 patient places pa, so
the waiting time is 20 years, and you can have an appointment in 2034. You may jump the queue if you are suicidal.
GPs cannot prescribe this course (except in emergency) because the waiting time is too long. This is because the Primary Care Trust (PCT) have not commissioned and contracted for enough provision of it yet. But if you call up the PCT and ask what is the waiting time for MBCT course, as I do, they reply “zero”. This is the politically correct answer, and demonstrates the ‘catch 22’ way that the PCT calculates waiting times from a supply based (provider-centred) viewpoint.
GPs know that the waiting time for the MBCT course is excessively long, so hardly ever prescribe it. The commissioning managers at the PCT therefore see hardly any demand for the course, so commission very little. This is a self-perpetuating system which denies patients their statutory rights to cost effective treatments.
Adiba: What can be done about it?
There are many MBCT facilitators running mindfulness and MBCT courses in the third sector for clients who pay around £160. Commissioners could contract with them to allow patients to pay for these courses with voucher prescriptions, which the facilitator cashes after the course, in the same way as pharmacists are reimbured for supplying drugs. I have been campaigning for this system for 4 years, and have founded a company to manage this, called Social Enterprise Complementary Therapy Company (SECTCo) see www.sectco.org.uk, and papers on section 9 of my website: www.reginaldkapp.org.
Adiba: How far have you got with your campaign?
The Clinical Commissioning Group (CCG) in Brighton and Hove are stuck in the medical model that drugs are the only treatment that works, despite the fact that they don’t even claim to cure anxiety or depression, but only alleviate the symptoms. They are overprescribed, but don’t work, and create side effects, so patients keep going back, overwhelming GPs and A&E.
The Health and Wellbeing Boards (HWBs) were set up under each local authority council last April, and Nick Clegg confirmed last Monday (20.1.14) that they are responsible for the mental health of their citizens.
I met with the deputy chairman of my Health and Wellbeing board on Friday 24th January, and I am pleased to say that finally after 4 years I met with a positive response. He agreed to get a paper presented to the next HWB meeting on 11.6.14.
Adiba: Thank you John
John Kapp’s voucher scheme is a practical proposal to alleviate the Catch 22 of mindfulness-based therapy provisioning in the NHS. I like his story of how he came to fight for this cause. He writes about it in his report:
“My physical health broke down 20 years ago, in 1992, when I was 55. I fell and suffered compression fractures of my lumbar vertebrae, and was diagnosed with osteoporosis, and ankolosing spondylitis (poker back).
In 2000, when I was 64, I lost my wife to cancer after 37 years of marriage. This was devastating to my mental health, as I was very dependent on her. I had psychotherapy with 3 therapists for 2 years. I had about 5 physical breakdowns with arthritis, each lasting up to 6 months, and had a hip replacement in 2004.
I am now 77, (the average life expectancy for men) and believe that I would now be demented or dead if I had not met the lady who I asked to be my second wife, whose answer was: ‘You are not in a fit state to marry anybody. Have you tried meditation?’
She introduced me to active 1 hour meditations (such as dynamic and kundalini) I led these 3 times per week, and also went on many residential meditation courses and groups. I took the MBCT course in Brighton in 2008, paying £185 for it. This taught me vipassana (watching my breath) which has transformed my mental and physical health improved my memory, and sharpened my mind. I now feel better than I did at 55.”
I wish him well in his campaign.
“We spend so much energy on physical health and hygiene—but we need to spend more on mental hygiene and the ‘hygiene’ of emotion.” The Dalai Lama
Find your local MBCT providers here: