impact of austerity

Austerity impact special
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MENTAL
HEALTH
NURSING
DECEMBER 2013/JANUARY 2014 • VOL 33 • NUMBER 6
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02
in HEALTH
Editorial
Contents
Dave Munday
Professional officer,
Unite the Union
(in the health sector)
Hard times
There is a lot in life that fascinates me. As a public health
nurse, I’ve always been interested in the wider determinants of
health, and so with the global financial crash in 2008 the issue
of austerity has bubbled to the front of this thinking. As part of
this there is a real sense of how our government is killing us.
I have often thought how politicians, international institutions
and companies push their own preferred theories on how it has
impacted on millions of people across the globe.
We have the ‘advantage’ of ‘natural experiments’ to show us
the different outcomes of national and international economic
policies. The countries that have rejected austerity have seen
quicker and stronger recoveries. Iceland went much more bust
than most and yet actually saw an improvement in its public health
statistics compared with Greece, where the rush to austerity has
caused so much damage to its citizens. An increase of 52% in
the new cases of HIV infection (between January and May 2011),
while in 2009 15% more Greeks reported their health as ‘bad’ or
‘very bad’ compared with 2007, and suicide rates rose 20% more
in 2009 than 2007.
For our members working in mental health, it’s not just words
on a page. Every day you deal with our fellow brothers and sisters
who have to cope with the effects that austerity has on their lives.
Whether it’s cuts to their benefits, cuts to their services, the loss
of their homes or families broken apart. But worse, for those who
have had their safety nets ripped away, we as a society will suffer
long-lasting damage, but those individuals will wear those scars for
a lifetime. What depresses most though is that our government has
argued that this is the bitter medicine that we need to take to keep
the patient living. However, this is just not true and the medicine
they are forcing upon us is harming the 99%. We also know that as
the government has tried to redirect blame away from financiers
and their complicated financial instruments to public sector
workers, your working conditions have been attacked.
However, I have no doubt that we will continue the fight to make
our world a fairer and more just place. I have long wanted this
journal to focus on the issue of austerity and mental health as part
of this struggle, and am pleased to introduce this special edition.
Speaking in 1968, Robert F. Kennedy said: ‘Too much and too
long, we seem to have surrendered community excellence and
community values in the mere accumulation of material things…
Yet the gross national product does not allow for the health of our
children, the quality of their education, or the joy of their play...
It measures neither our wit nor our courage; neither our wisdom
nor our learning; neither our compassion or our devotion to our
country; it measures everything in short, except that which makes
life worthwhile.’ MHN
News
04
MHNA Update
06
Austerity is bad for mental health: implications
for mental health nurses
07
Self-reported and biological measured stress
among young Greek adults living in a stressful
social environment in comparison with Swedish
young adults
10
What studies into systems tell us about mental
health work and services at a time of austerity
13
Austerity and financial restrictions in mental
health nursing – can it be a good thing?
16
Assessing the impact of the financial crisis
in mental health in Greece
19
The impact of cuts on mental health services:
Good mental health in Leicester?
22
Challenging austerity policies: democratic alliances
between survivor groups and trade unions
26
The age of austerity: the impact of welfare
reform on people in the North East of England
30
The recent global socioeconomic crisis and
its effects on mental health in Portugal
33
Employment: Hunt to freeze pay again
36
Reflections
37
• Join Unite/MHNA – inside back cover/
back cover
Cover image: Iida Yli-Kauhaluoma
EDITOR Phil Harris – [email protected]
EDITORIAL BOARD
• Mike Ramsay, chair of editorial board; lecturer in nursing (mental health), University of Dundee
• Mandy Bancroft, director of widening participation and recruitment, University of the West
of England
• Terez Burrows, team leader, Wathwood Medium Secure Unit, Nottinghamshire
• Steve Hemingway, senior lecturer in mental health, University of Huddersfield
• Dan Hussey, University of Huddersfield
• Alun Jones, adult psychotherapist, North Wales NHS Trust
• Steve Jones, senior lecturer, Edgehill University, Faculty of Health, University Hospital Aintree, Liverpool
• Dave Munday, professional officer, Health Sector, Unite the Union
• Andrew Roe, service user representative
• David Rushforth
• Barbara Woodworth, clinical sSpecialist in liaison psychiatry, Cheshire & Wirral Partnership NHS
Foundation Trust.
PUBLISHER Ten Alps Creative on behalf of the Mental Health Nurses Association © MHNA 2013
ONE New Oxford Street, High Holborn, London WC1A 1NU
ADVERTISING OFFICES Claire Barber, Ten Alps Creative, ONE New Oxford Street, High Holborn,
London WC1A 1NU • [email protected] • 020 7878 2319
SUBSCRIPTIONS MHN is free to members of the Mental Health Nurses Association.
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• [email protected]
ISSN 2043-7501
(Starting from Volume 30, Number 2, ISSN 20437051 replaces the print journal ISSN 1353-0283
when there is no print issue)
03
News review
Report highlights the damage caused
by pan-European austerity measures
A major report from the
International Federation of Red
Cross and Red Crescent Societies
has highlighted the human cost
of governmental financial policies
across Europe.
Think differently: humanitarian
impacts of the economic crisis in
Europe argues that the population
of the continent is sinking into
poverty, mass unemployment,
social exclusion, greater
inequality and collective despair
as a result of austerity policies
adopted by governments in
response to the economic crisis.
The report says: ‘While other
continents successfully reduce
poverty, Europe adds to it.
‘The long-term consequences
of this crisis have yet to surface.
The problems caused will be felt
for decades even if the economy
turns for the better in the near
future… We wonder if we as a
continent really understand what
has hit us.’
The report was produced
following a study of 52 Red Cross
and Red Crescent Societies in its
Europe zone in early 2013.
It states: ‘As the economic
crisis has planted its roots,
millions of Europeans live with
insecurity, uncertain about what
the future holds. This is one of
the worst psychological states of
mind for human beings.
‘We see quiet desperation
spreading among Europeans,
resulting in depression,
resignation and loss of hope.
‘Compared to 2009, millions
more find themselves queuing for
food, unable to buy medicine nor
access healthcare.’
The report can be
found at: www.ifrc.org/
PageFiles/134339/1260300Economic%20crisis%20Report_
EN_LR.pdf.
Mural to protest
against the cuts
Unite has unveiled a large-scale
mural on a building in north
London as a symbol of protest
against the government’s attack
on the NHS.
The mural of black and white
images, launched to coincide with
black history month, shows the
faces of more than 400 people
opposed to the government’s
NHS cuts, with a big portrait of
Mary Seacole, the Jamaican-born
nurse whose pioneering work
during the Crimean War was
overlooked by the UK for 100
years, at its heart.
Survey shows government’s cost of living crisis is worsening
The government’s cost of living
crisis is strangling households,
according to an independent
survey showing a drop of
disposable income of £129 a
month since May this year.
The survey, which involved
3,940 Unite members working
across the economy, underlines
how the much heralded
‘recovery’ is passing by ordinary
working people, with two-thirds
(66%) reporting a drop in their
disposable income over the last
six months.
Health workers have
experienced the biggest fall in
spending power, with a massive
£233 drop as pay cuts and rising
costs eat into family budgets.
Women are hit the hardest by
the cost of living crisis, suffering
a drop of £190 month, nearly
double the average for men of
£95.
04
Rising food, energy and
housing costs are hitting people’s
pockets. Over half (53%) of all
respondents reported the biggest
increase in the price of essentials
being food, while a quarter said
energy costs.
The survey also found that
62% have experienced hikes in
their rent, while one in four home
owners said they were struggling
with mortgage payments; neither
group has been helped in any way
by the government’s controversial
‘Help to Buy’ scheme.
Unite general secretary Len
McCluskey said: ‘An economic
recovery may be being enjoyed
within the super-wealthy circles in
which the prime minister moves,
but it is passing ordinary people
by. Back in the real world there is
a cost of living crisis strangling
the finances of households across
the nation.
‘While the rich get richer and
ordinary people face soaring
costs, dropping income and with
winter ahead, our most vulnerable
will face the hideous dilemma of
whether to heat or eat.
‘This country, remember, is the
seventh richest on the planet – so
why is it the only banks that are
giving in this country are food
banks?
‘Now David Cameron has
pledged that austerity is here to
stay. He is laying siege to the
living standards of the people who
will be keeping the NHS going this
winter and, if you are woman, you
face double the squeeze.
‘His government is irresponsibly
oblivious to the struggles of
ordinary people, governing for the
few and not the many.
‘This country is being walked
into widespread impoverishment.
Relief could be easily provided
– like a cap on energy prices
and a boost to the minimum
wage – but we cannot expect this
government to provide it.
‘They are 100% to blame for
cost of living crisis sweeping
households across Britain and we
will not let them forget this.’
The survey was undertaken
by independent social media
specialists Mass1. The
organisation has been following
Unite members since 2011 to
track the impact of austerity
measures on their wages and
lifestyles.
The survey identified early the
shift away from the established
supermarkets, as workers sought
cheaper food and revealed the
growing use of payday loans to
bridge the point in the month
when the salary ran out, yet the
next payment was at least a week
away.
News review
CQC and Mind work together for mental health
The Care Quality Commission
(CQC) and mental health charity
Mind have joined forces to help
provide the regulator with better
information about mental health
services.
CQC will be training the Mind
helpline team so they can talk
to people about how to share
their concerns.Information
from members of the public
about the care they receive is
valuable intelligence to CQC. This
information is used to inform
where, when and what to inspect.
Sophie Corlett, director of
external relations at Mind, said:
‘We’re here to make sure anyone
with a mental health problem has
somewhere to turn to for advice
and support.
‘The Mind helpline answers
40,000 calls a year. We are
looking forward to working with
CQC to raise their profile with
people and help them share
information about their care.”
Professor Sir Mike Richards,
the CQC’s chief inspector of
hospitals, will publish proposals
on changes to the way it inspects
other types of mental health
services, including how it will
integrate its regulatory work with
its monitoring of people’s rights
under the Mental Health Act.
Sir Mike is planning to appoint
a deputy chief inspector with
mental health expertise to assist
him in this. He said: ‘This is a
very important appointment
and signals our determination
to strengthen our regulation of
mental health services.
‘Our monitoring of the Mental
Health Act will be integrated
into our inspections wherever
possible, although we will
continue to run a programme of
visits to people who are subject
to the Mental Health Act to speak
with them in private as we are
required to do under the Act.’
Care and Support Minister
Norman Lamb said: ‘I am
determined that mental health is
treated with as much importance
as physical health by the NHS and
the health regulators.
‘The appointment of a new
deputy chief inspector with
expertise in mental health at the
CQC is central to this because it
will ensure that the same rigorous
inspection standards are applied
to mental health as other NHS
services.
‘A named individual will be
responsible for leading specialist
inspection teams which can
highlight good care and root out
poor services.’
Letter: mileage allowance and the impact on community staff
Dear editor,
I read with interest the mileage
allowance article in the October/
November edition (Brown B
and Lazou J. (2013) Mileage
Allowances: the new scheme.
Mental Health Nursing 33(5):
19-20).
As a community nurse of
28 years I don’t think mileage
allowance ever covers expenses,
and for the majority of regular
users will continue to find this in
the future.
The article authors have
put a positive spin on the new
arrangements but I believe the
trade union negotiators should
hang their head in embarrassment
for what they ‘achieved’.
Of course there are positives
such as regular independent
reviews of motoring costs, though
I doubt this will cover regional
variations. Here in Northern
Ireland fuel and insurance costs
are consistently higher than in
mainland Britain.
The first principle noted was
fairness, ‘should reflect cost of
motoring’, 3,500 miles annually
(17 miles per working day).
When I have met this limit
will the service station reduce
the cost of fuel in ‘fairness’ to
reflect the expense? The distance
of 17 miles is a small amount
for anyone working in a rural
setting. Apparently to continue
to pay above would ‘run the risk
of putting staff into profit’ (NHS
Employers website).
If an employee ‘reasonably
declines offer of lease car’ they
can be put onto the ‘reserve rate,
24p’. Exceeding 3,500 allows for
‘discussion on lease/pool/hire
car use’.
I had a lease car for some
years but it is not always
financially suitable for individuals
and the increased personal
taxation is a significant negative.
In the current financial climate
can we expect employers to
purchase or hire cars for staff
to use? No. Those who exceed
the allowance will sponsor their
employer.
As a former Northern Ireland
representative on the NPC
for MHN and a workplace
representative I wrote to Unite
negotiators in 2011 when the
consultation was taking place.
Unfortunately in discussion with
other trade union representatives
it seems senior negotiators
completed this in a quiet,
distanced manner.
NHS negotiators must have left
with wide grins on their faces and
high fives all round.
As a result, community
workers, including the lowest paid,
will continue to meet the cost
of community working. All trade
union representatives are being
challenged over the decision
made at national level.
Response from Barrie Brown,
Unite national officer for health
The fuel and other motoring costs
are AA rates based on UK data
and there will always be regional
differences.
The 3,500 trigger point, which
was inherited from the GWC
standard mileage rate, remains
an issue that the unions want to
review.
The new agreement provides
for staff to use lease cars on a
pool car basis, which avoids any
personal taxation liability.
It is also worth mentioning that
the reserve rate is 33p, not 24p.
None of the negotiations
were completed in a quiet and
distanced manner – the reality
is that the mileage review’s
recommendations were presented
to the NHS staff council in
July 2010 and in the ensuing
consultation Unite members
accepted the new proposed
agreement for implementation on
1 July 2013.
The Unite representative on the
mileage review was a health visitor
with over 30 years’ experience in
the NHS who is very familiar with
the mileage issues for staff who
use their own cars for NHS work.
We have a number of NHS
employers who say they cannot
afford the new national mileage
rates and are seeking to have
local ones with reduced payments.
Also, there are trusts in England
that are refusing to implement
the new agreement since it is too
costly.
05
MHNA Update
Unite/MHNA update
Dave Munday
Professional officer
Unite the Union
(in the health sector)
[email protected]
And so another year draws to a
close. 2013 has brought much to
consider and reflect on. Reflection
should be a fundamental part of our
nurse training, and one which we
hold on to as we develop and grow
throughout our careers. I probably
get a bit more time to reflect than
many – not because the job is quiet,
but I’m often expected to provide
my reflections in journals, TV and
radio, and also in discussions with
members, managers and ministers.
I also spend a fair bit of time on
trains and planes, and when you
can’t have the laptop on, reflection
fills that space.
By the time you read this, the
government’s response to the
Francis report will have been
released. The report of the Mid
Staffordshire NHS Foundation Trust
Public Inquiry was published on 6
February 2013. In the 286 days
since, much has been reflected
upon and written. This has included
work such as Keogh’s hospital
review, first of 14 trusts and then in
his work to look at the ‘A&E crisis’.
One of the leaked responses
suggests that the government
response will be that doctors,
nurses and managers are set to
face five years in jail if they neglect
patients. On the face of it, would
anyone really argue that where any
individual suffers because the acts
of or omissions of another that
they don’t have tough sanctions
as a response? However, this
continues the theme of Jeremy
Hunt’s PR exercise, which is
that Mid-Staffs was the result of
uncaring, uncompassionate nurses
06
who work for an uncaring and
uncompassionate NHS. Moving the
focus away from it being about trust
boards racing to achieve the targets
that it was set, not on patient care
but on achieving foundation trust
status. We also see the position
that staff are caught in with the
allegations coming out from a report
into Colchester general hospital.
Again the rumours abound that staff
had tried to raise their concerns but
they were quickly shot down by the
people they told.
We have been developing two
resources that will help. The first is
a book on record keeping, which
provides members with a good
knowledge of record keeping and
how people can stay on the right
side of the Nursing & Midwifery
Council when completing their
records. It also goes in to detail
about electronic records, which is
an often requested resource. We’re
also producing a book on duty
of care, which should fill another
important gap for our members.
Both of these books will be out
before the end of the year and we’ll
be advertising them to all our Unite
in Health members.
Speaking of the NMC, one of the
pieces of work that it is pushing is
nurse (and midwife) revalidation.
After looking at a number of options
during 2013, the council has now
decided on its preferred approach.
This will be fleshed out over the
next few months with more detail
coming out for discussion in 2014.
I’ve attended meetings and taken
the opportunity to ensure that our
members’ concerns are raised.
I hope you’ve seen the information
and campaigning that the wider
union has being doing on the
coalition’s policies of austerity. As
I have highlighted in my editorial
for this austerity special edition, it’s
an issue that I’m really passionate
about. My ‘interest’ was first
influenced when I was contacted
by a researcher for Channel 4
early on in the coalition, asking for
information from MHNA members
about any effects on increased
levels of poor mental health or
suicide. They highlighted some of
the early evidence coming out of
Greece that showed rates there
getting worse. They also highlighted
some of the evidence from previous
economic shocks that they were
aware of. A few months back, we
discussed at the journal’s editorial
board the idea of an austerity
focused edition and we are pleased
to make this a reality. It is an attempt
not to tell people what to think, but
to trigger thoughts from those who
read it, to consider the issues more
deeply. After all, we live in a time
where the impacts of the coalition’s
policies of austerity are having both
direct and indirect impacts on our
society, and also importantly on
you during your daily lives. Although
argued as a bitter medicine that will
make the patient better, I believe
it’s a slow poison that inflicts much
misery and suffering on the most
disadvantaged.
The other issue that we’ve seen
increase in 2013, is the continued
fragmentation and privatisation of
our NHS. The majority of contracts
that have gone to tender this
year have been won by private
companies. Some, by one of the
four outsourcing contractors,
which the Guardian highlighted in
November as paying little to no
corporation tax. So although the
government paid out £4 billion to
Serco, Capita, Atos and G4S, the
National Audit Office estimated that
of the approximately £1.05 billion
profit, the four paid between £75
million and £81 million, with Atos
and G4S thought to have paid no
corporation tax at all. So where
austerity Britain damages our
citizens, multi-nationals appear to
get off scot free.
Under Secretary of State Jeremy
Hunt, in his first year in that post,
£5.6 billion on contracts have been
put out to tender. If you look back
to before his tenure in the job to
January 2012, just under two years,
£10.7 billion has gone out to tender.
How many of these have been won
by NHS organisations? The answer
is £300 million – just 3%.
So what will 2014 have in store
for us? My predictions are more
talking down of the NHS by the
government; more talking down
of its staff; further attacks on NHS
workers’ terms and conditions;
more blame levied at doctors,
nurses and middle managers; more
blame levied on ‘skivers’.
However, I also know that we’ll
continue to see individuals and
groups resisting these changes.
We’ll see the compassion of people
come to the fore. The willingness to
not only fight for what you need in
your own lives, but the willingness to
fight against the injustice that affects
others. We’ll see the fight continue
to defend an NHS that the majority
of the country still rates highly and
wants to see sustained. What gives
me the greatest hope for 2014
is something an excellent nurse
colleague said to me during my
training. For evil to proposer, good
people stay silent. I hope you’ll join
with me and never stay silent.
Finally, I want to offer my personal
thanks to members of the MHNA
Organising Professional Committee
(OPC) chaired with great energy by
George Coxon, and the members of
the journal’s editorial board, similarly
chaired with great wisdom by Mike
Ramsay. MHN
Austerity special
Austerity is bad for mental
health: implications for
mental health nurses
Steve Hemingway and colleagues discuss the impact of austerity and argue that
it is time for mental health nurses to help counteract its catastrophic impact
Steve Hemingway
Senior lecturer in mental health,
University of Huddersfield
Correspondence:
[email protected]
George Coxon
Chair, Mental Health Nurses Association
Dave Munday
Professional officer, Mental Health
Nurses Association
Mike Ramsay
Lecturer in nursing, University of
Dundee
Abstract
This paper examines the impact of
austerity measures on mental health service
provision across the UK and Europe and
argues that mental health nurses should be
challenging the draconian that changes that
have been imposed.
Key words
Austerity, mental health nursing, service,
impact, cuts, Big Society
Reference
Hemingway S, Coxon G, Munday D,
Ramsay M. (2013) Austerity is bad for
mental health: implications for mental
health nurses. Mental Health Nursing
33(6): 7-9.
Introduction
The term ‘austerity’ has been a buzzword ever
since the recession began in 2008. European
governments, either through choice or under
pressure from financial institutions, have
implemented extreme austerity policies (McKee
et al, 2012). This in turn has resulted in changes
to service provision for all aspects of health care
and mental health care is no exception.
This paper reviews the evidence of austerity
cuts in the last few years with a focus of the
effects on care provision and related health
outcomes. The consequences for the mental
health nurse is then discussed. Finally we ask is
there something we should do to help halt the
decline of the services people with mental health
conditions should expect as a human right?
other health workers, a large increase in drugs
prescribed and clinical supplies. This resulted in
reduced waiting times, overall volume of health
‘inputs’ up 86%, and satisfaction with NHS up
from 36% to 71% (Lupton, 2013).
Given the current state of the economy it
could be argued that to continue spending
at the rate that the Labour administration
implemented and thus accrued debt could be
at the very least poor timing (Knapp, 2012).
Whether the austerity measures actioned by the
current government can be justified may have
to be left to historians to debate, but there is
evidence that people overall are suffering and
it is certainly not good for the population of the
vulnerable, including people with mental health
difficulties.
Why austerity?
Speaking in the lead-up to the last UK
general election, David Cameron described
the circumstances that led to the economic
recession as ‘the rainy day we didn’t save for
had arrived’.
With recent findings showing that European
individual states’ debt is near or equal to their
respective gross domestic product status,
Cameron’s statement seems to stand up. It may
take until 2030 to get the overall debt we owe to
manageable proportions. Some have also stated
that we are the generation who ‘sold the family
jewels and also left our grandchildren with a debt
legacy’ (Newbold and Hyrksas, 2010).
Public spending had an overall public spending
increase of 60% in the so-called ‘golden years’
of Labour (1997-2010 spending on health
increased from 14-18% of this total).
Expenditure was on an NHS capital building
programme, extra doctors and nurses,a sizable
impact on pay and terms including the hospital
doctors’ contract, GMS terms for GPs and
the implemtation of Agenda for Change for all
The Big Society agenda
This concept has been championed as one way
of enabling people to care for each other (Bach,
2012) . Big Society is inextricably linked to the
austerity cuts (deficit reduction) but also to a rise
in the third sector and volunteering promoted as
a more person-centred and cost-effective way
of delivering public services in tough economic
times (Bach, 2012) .
Competition, market forces, efficiencies
and economies being brought into healthcare
through a new enterprise culture jars with the
traditional model of the NHS, but many would
argue the Big Society is about managing an
ageing population and the finite resource trying
to provide for infinite demand and need.
The circa £110bn NHS budget cannot
continue to provide for people as it once did and
we need to develop new ways to providing for
people. The Big Society, it is claimed, is more
about sharing self-care, self-management and
taking control of our lives, and developing a
renewed sense of community. However, the fact
remains that people with mental health problems
07
Austerity special
do less well than the greater population (Naylor
and Bell, 2010). Figures show the Department of
Health spends only up to 14% of the overall NHS
budget on mental health care yet the overall
health burden is substantially higher.
The June 2013 edition of Mental Health
Nursing outlined that the third sector has a
role to play in improving mental health service
provision (Firth-Lewis et al, 2013), and increasing
service user involvement (Clifton et al, 2013).
However, the agenda behind the Big Society has
obvious implications for public health service
workers including mental health nurses.
Interestingly the Cameron government
has excluded trade unions in the Big Society
shake up. Trade unions may have been seen
as part of this new way to promote change as
voluntary organisations representing a form of
collective industrial citizenship and community
engagement. Instead trade unions are
attempting to redefine the Big Society in terms
of defending and campaigning for the rights of
communities impacted by austerity measures
(Bach, 2012).
The reprovision of services from the old
model of the traditional health and social sectors
to private and voluntary providers can also be
seen as a way of challenging the longstanding
system of employment relations, and Unite has
for some time been at the centre of opposing
what this can mean for the rights and financial
entitlement of its health service members.
One of the workers’ conditions that has
been taken for granted by public service staff
including mental health nurses is the regulations
determining pay nationally (Bach, 2012).
Hospitals have not been given foundation trust
status for nothing, thus they can opt out of
national pay and conditions (Unite, 2012).
Austerity and mental health
The relationship between economic recession
and mental health conditions is well recognised
by practitioners (McDaid and Knapp, 2010).
Unemployment, loss of income, problems
with housing and social inequality all are a
consequence and this lowers mental wellbeing
and resilience. Decreased wellbeing will put
greater burden on people and will in many
cases increase mental health problems, alcohol
abuse, suicide rates and social isolation, and
deteriorating physical health (Knapp, 2010).
Knapp (2010) gives an example from the UK
where 45% of people in debt have associated
mental health problems in comparison to 14%
with no debt at all. Thus there are personal and
08
socioeconomic outcomes, which are profound
(McDaid and Knapp, 2010).
Across Europe the impact of the recession
and austerity measures have been catastrophic.
One of the most reported outcomes has been
an increase in the suicide rate. Greece, which
has had to bear the reality of the economic
downturn enforced by the EU of public spending
cuts, has had significant austerity related impact
of the lives of its population, with appalling
consequences generally (Economou et al, 2013)
and specifically affecting mental health provision
(Pikouli et al, 2013).
Suicidal behaviour
Between 2009-2011 there was a substantial
increase in the rates of people stating they
had suicidal ideation and in actual attempts
(Economou et al, 2013).
The most vulnerable groups were men,
people with responsibilities through marriage,
financial strain, lack of interpersonal support
and a history of suicide attempts (Economou
et al, 2013). Suicide prevalence related to the
economic conditions gender and age.
Barr et al (2012) also found a significant
increase in both men and women who killed
themselves, however they also calculated that
an increase of unemployment in men led a 1.4%
increase in suicides.
The rise in suicidality is also seen across
Europe and is more prevalent where there is less
social care provision for unemployment in the
central and eastern areas (Stuckler et al, 2009),
but is less in countries with high public spending
(Lundkin and Hemmingsson, 2009).
In times of recession people tend to spend
more on cheaper or convenience foods, their
lifestyle can deteriorate and this leads to
increased mortality and morbidity for the general
population (Stuckler et al, 2009).
This can lead to poor disease management
for people who are concerned about increasing
financial stress rather than focusing on their
health needs (Hewison, 2010). When the
provision of services for physical health needs
of the seriously mentally ill is lacking anyway,
austerity measures will potentially compromise
efforts to improve it (Hemingway et al, 2013).
In contrast, some argue that in times of
recession people may lead more healthy
lifestyles because of less extravagant diets and
excesses. Thus there are healthier activities
such as walking instead of driving (Stuckler and
Banu, 2013). We will leave it up to the reader
to speculate if cutting services leads to better
health outcomes for mental health service users.
A different plan
There has been growing criticism of the way
the coalition government in the UK and other
administrations across Europe have handled or
reacted to the debt crisis.
The previous government UK did not
particularly overspend in the public arena and
spending was certainly modest compared
to other European countries (Lupton, 2013).
Cameron’s government, which has implemented
cuts of 4% year on year because of the
supposed extravagance on spending on the
public sector, including health, has made
accusations that we have spent beyond our
means (Newbold and Hyrkas, 2010). Yet the
‘rainy day we did not save for’ was certainly not
brought about by Labour’s efforts attempt to
improve public services (Lupton, 2013).
There is a growing mass of opinion that
investment in countries’ economies could
stimulate growth and therefore pay back debt,
facilitating other ways to spend money to create
growth and prosperity, which increases taxes
rather than retrenchment which cuts costs
(Stuckler et al, 2009).
In turn, financial prosperity and related
emotional security could have a health-promoting
effect, where keeping people in or creating new
employment would negate the dire morbidity
and mortality outcomes that have and can arisen
from austerity (Stuckler and Banu, 2013).
What are the consequences for mental
health nurses?
There has been a surprising dearth of
commentary or research relating to the impact
of the austerity period on the outcomes of
mental health nursing interventions and the
effect for service users.
This may be due to mental health nurses
themselves having to cope with the increased
pressures of doing more with less resources.
The effect of dealing with an increased
presentation of self-harm and suicidality for crisis
liaison services brings with it increased pressure
and responsibility for the mental health nurse
in proactively dealing with such circumstances
(Santos, 2013).
Colley (2012) demonstrates how public
service workers have been compromised
ethically with them having to deal with the
ethical concerns of poorer working conditions
decreasing the effect of their interventions.
Colley’s paper shows how youth work, for
Austerity special
example, has changed from client-centred ethics
to economic-driven targets.
The challenge the mental health nurse may
face is keeping a recovery focused mode of
working when faced with the austerity changes
(Santos and Amaral, 2011). On debating the
philosophical implications for nursing of austerity
Allmark (2012) commented that if virtue was
lost, this in essence does appear to mirror
Colley’s findings.
The recent Francis report and lengthy
investigation into the details of deaths at Mid
Staffordshire has called for even greater
emphasis on clinicians speaking out when they
feel their professional capabilities and patient
safety is compromised.
The NMC (2009) professional code of conduct
continues to make it important for mental health
nurses to adhere to a duty of candor and raise
References
Allmark P. (2013) Virtue and austerity. Nursing Philosophy
14: 45-52.
Bach S. (2012) Shrinking the state or the Big Society?
Public service employment relations in an age of austerity.
Industrial Relations Journal 43(5): 399-415.
Barr B, Taylor-Robinson D, Scott-Samuel A, McKee M, Stuckler
D. (2012) Suicides associated with 2008-2010 econonomic
recession in England: time trend analysis. British Medical
Journal doi: 10.1136/bmj.e5142.
Clifton A, Noble J, Remnant J, Reynolds J. (2013) Coproduction, collaboration and consultation: the shared
experiences of a third sector organisation and researchers
in the North East of England. Mental Health Nursing 33(3):
XX.
Colley H. (2012) Not learning in the workplace: austerity and
the shattering of illusion in public service work. Journal of
Workplace Learning 24(5): 317-37.
Economou M, Madianos M, Peppou L A, Theleritis C, Patelakis
A, Stefanis C. (2013) Suicidal ideation and reported suicide
concerns about care and risk when and where
they arise. Should mental health nurses therefore
challenge cuts in service provision that could
compromise the care of service users?
In a mental health commentary McDaid and
Knapp (2010) pointed out that the economic
situation may be the time for radical innovation
within mental health services. As well as pointing
out that it should be a time to cut back on
management and administration, there should
be a rebalance toward community provision of
mental health care with a service user seeing a
specialist (which could include a mental health
nurse) early in the referral process, and then
services may then be appropriately designed for
the service user (Knapp and McDaid, 2010).
Knapp (2012) commented that selected
interventions do have an economic pay-off. Thus
investment in improving mental wellbeing in
15(3): 54-5.
Lundkin A and Hemmingsson T. (2009) Unemployment and
suicide. The Lancet 374(9686): 270-1.
Lupton R. (2013) Social Policy in a Cold Climate. LSE: London.
Available at: http://sticerd.lse.ac.uk/dps/case/spcc/
SPCC_lupton.pdf. Accessed 1 November 2013.
McKee M, Karanikolos M, Belcher P, Stuckler D. (2012)
Austerity: a failed experiment on the people of Europe.
Clinical Medicine 12(4): 346-50.
Naylor C and Bell A. (2010) Mental health and the productivity
challenge improving quality and value for money. Kings
Fund’s Centre for Mental Health: London.
NMC. (2009) The code: Standards of conduct, performance
and ethics for nurses and midwives. NMC: London.
McDaid D and Knapp. M (2010) Black-skies planning?
Prioritising mental health services in times of austerity.
British Journal of Psychiatry 196: 423-9.
Newbold D and Hyrkas K. (2010) Managing in economic
austerity. Journal of Nursing Management 18: 495-500.
Pikouli K, Konstakapoulus G, Ioannidi N, Sakellari E,
attempts in Greece during the economic crisis. World
Ploumpidid D. (2013) The impact of financial crisis on the
Psychiatry 12: 53-9.
services of a community mental health center in Athens,
Firth-Lewis B, Carr J, Russell-Smith S, Haghighi S, Denton L,
Lennox C. (2012) Dual diagnosis: Wakefield District partners
Greece: 2008-2011. Poster presentation Horatio Congress,
Istanbul, Turkey, 31 October.
in provision of effective treatment for adults with substance
Santos CS. (2013) Prevention of depression and suicidal
misuse and mental health conditions. Mental Health Nursing
behaviours inside a socioeconomic crisis. MH nurses:
33(3): 20-1.
new answers or old problems? Horatio Congress, Istanbul,
Hannigan B and Allen D. (2013). Giving a fig about roles, policy
and context in mental health care. Journal of Psychiatric and
Mental Health Nursing 18: 1-8.
Hewison A. (2010) Feeling the cold: implications for nurse
managers arising from the financial pressures in health care
in England. Journal of Nursing Management 18: 520-5.
Hemingway S, Trotter F, Stephenson J, Holdich P. (2013)
Diabetes: increasing the knowledge base of mental health
nurses. British Journal of Nursing 22(17): 991-6.
Hurley J and Ramsay M. (2008). Mental health nursing:
sleepwalking towards oblivion? Mental Health Practice
1(10): 14-7.
Karanikolos M, Miadovsky P, Cylus J, Basu S, Stuckler D,
Turkey, 1 November.
Santos CS and Amaral AFS. (2011) Effectiveness of
psychiatric mental health nurses: can we save the core
of the profession in an economically constrained world?
Archives of Psychiatric Nursing 25(5): 329-38.
Stuckler D, Basu S, Coutts A, McKee M. (2009) The public
health effect of economic crises and alternative policy
responses in Europe: an empirical analysis. The Lancet
374(9686): 315-23.
Stuckler D and Banu S. (2013) The Body Economic. Penguin:
London.
Unite. (2012) Austerity measures ‘may increase suicide
rates’, says Unite. Available at: http://archive.unitetheunion.
Mackenbach JP. (2013). Financiial crisis austerity and health
org/sectors/health_sector/latest_news-1/latest_news/
in Europe. The Lancet 381(9874): 1323-31.
austerity_measures__may_increa.aspx. Accessed 13
Knapp M. (2012) Mental health in an age of austerity. EBMH
the workplace, suicide awareness training and
the use of cognitive behavioural therapy can
increase productivity and increase the rate of
suicide detection (Knapp, 2012). This echoes
research by Barr et al (2012), who assert
that if interventions are targeted in specific
geographical areas hit by unemployment
then this may reduce the chance of suicide,
particularly among men.
Hannigan and Allen (2011) suggest the mental
health nursing role may become blurred as they
adapt to meet service user need with a changing
lack of provision. Simpson (2013) highlighted
the possibility of traditional mental health nursing
roles being replaced by people with a mental
health condition acting as peer support workers
to service users discharged from hospital.
Pikouli (2013) showed how austerity cuts
can devastate the working conditions of mental
health nurses and compromise the care they
deliver. Santos and Amaral (2011) suggests
it is now a time for mental health nurses to
understand their core role and, in essence,
justify themselves as a profession. Otherwise
the possibility of a generic mental health worker
may become a real possibility (Mental Health
Foundation, 2013), with the potential of the loss
of mental health nursing as we know it (Hurley
and Ramsay, 2008).
The reality is that we are in a working
landscape that has changed rapidly and will
continue to do so (Naylor and Bell, 2010). There
are also related profound issues mental health
nurses as a profession need to consider in
addressing the future of their role.
September 2013.
Conclusion
Alongside the overwhelming evidence that
austerity is bad for the mental health for people
we seek to help toward recovery, is it time to be
more active politically.
Things do not change unless a case is made.
Mental health nurses should be challenging the
changes that are imposed on service users. The
next election of 2015 will be a watershed in the
future of the NHS and mental health.
If we still want a universal provision of health
that proactively supports vulnerable populations
such as people diagnosed with mental health
problems, then we will need mental health
nurses at the forefront of this care.
Alternatively the privatisation of health
provision may ensue, where we may be
employed but the conditions we work in and
interventions we can use are far less than we
would want. MHN
09
Austerity special
Self-reported and biological
measured stress among
young Greek adults living in a
stressful social environment
in comparison with Swedish
young adults
Åshild Faresjö presents the findings of an investigation into stress and economic hardship
Åshild Faresjö
Division of Community Medicine,
Faculty of Health Sciences, Linköping
University, Linköping, Sweden
Correspondence:
[email protected]
Abstract
A cross-sectional study among young adults
from Athens in Greece and the city of
Linköping in south-eastern Sweden was
performed. The study comprised answering
a questionnaire and testing hair samples
for cortisol levels. Perhaps surprisingly,
Greek cortisol levels were significantly lower
than comparable Swedish young adults,.
However, the Greek sample reported
significantly more experiences of serious life
events, higher perceived stress, and higher
scores for depression and anxiety, and lower
scores for hope for the future. Living every
day in a social environment affected by the
economic and social crisis is stressful for the
whole population.
Key words
Stress, recession, economic crisis, young
adults
Reference
Faresjö Å. (2013) Self-reported and
biological measured stress among young
Greek adults living in a stressful social
environment in comparison with Swedish
young adults. Mental Health Nursing
33(6): 10-2.
10
Introduction
The worldwide financial crisis during recent
years has raised concerns of negative public
health effects (Karanikolos et al, 2013).
This is notably evident in southern Europe.
In Greece, where the financial austerity has
been especially pronounced, the prevalence of
mental health problems including depression
and suicide has increased, and outbreaks of
infectious diseases have risen.
The financial crisis in Europe and changes
in the economy, particularly its effect on
unemployment, will adversely affect population
health (Stuckler et al, 2009).
Stress-related disorders constitute an
increasing public health problem globally, and
the WHO has declared that along with mental
health problems, stress-related disorders are
major causes of early death in Europe (World
Health Organization, 2011).
Recession in the national economy leading
to high unemployment rates has been shown
to correlate with decreased quality of life,
physical and mental illness such as anxiety,
depression, and climbing suicide rates,
and increased levels of the stress hormone
cortisol.
This has been suggested to be the result
of increased negative mental conditions such
as insecurity for the future, rising demands
of adaption, and loss of protective social
networks (Falagas et al, 2009).
It is important to note, however, that
individuals react differently and can be more
or less vulnerable to stressors.
Economic crises are a type of community
stressor that could affect a country and its
whole population in many different ways, such
as destabilisation in the labor market, increased
unemployment rates, and reductions in the
public sector (Stuckler et al, 2009).
After some years of economic growth,
Greece was hit by the financial crisis starting
with an economic recession from 2008.
The health impacts in recent years of the
economic crisis in Greece has been connected
to diminishing perceived health and quality
of life, increased prevalence rates of mental
health problems including an increased risk for
depression by 2.6 times in 2011 compared to
2008, and a rise in the suicide rate of almost
20 % in the Greek population as the crisis has
developed (Madianos et al, 2011).
The steroid hormone cortisol plays a crucial
role in the stress response, and is increased
in situations perceived as stressful to the
organism.
Measuring the concentration of cortisol
in blood, saliva, and urine are established
methods for momentary assessments of
the activity in the hypothalamic-pituitaryadrenocortical axis (HPA), for example salivary
cortisol values only relates to the previous 20
minutes.
Some of the functions of cortisol in the
body are to recruit energy from adipose and
Austerity special
muscular tissues and to suppress the immune
system.
If the cortisol levels become too high or
too low for a longer period, a state of hyperor hypocortisolism is present, and both are
associated with stress-related disease.
Hypercortisolism is associated with
a number of various diseases, e.g.
cardiovascular diseases, type 2 diabetes,
depression, and slow wound-healing
(Whitworth et al, 2005).
It has only been possible to measure
physiological stress by analysing cortisol in
blood, saliva, or urine samples.
The shortcoming of these methods is that
they cannot detect stress longitudinally since
they only indicate stress over a short time
interval.
Further, individual cortisol levels can also
fluctuate depending on a wide array of factors
and be influenced by the situation as well as
the time of day due to the circadian rhythm,
food intake, and also exercise habits.
The new method of measuring cortisol
in hair has been developed with the ability
to retrospectively measure the mean
cortisol levels over time, which diminishes
these shortcomings, and makes it possible
to measure long-term cortisol exposure
(Kirschbaum et al, 2009).
Cortisol in hair merely specifies cortisol
levels as the cumulative activity of the HPA
axis, although it is not known whether this
is due to one stressful event per se, or
numerous acute stress experiences since it is
a mean value over a time period.
Research indicates that hair can be used as
a retrospective calendar for months, and the
evidence is growing for using cortisol in hair
as a new biomarker of systemic stress both
from animal and human studies.
Methods
A cross-sectional study among young
adults from Athens in Greece and the city
of Linköping in south-eastern Sweden was
performed.
The participants were all university
students recruited from Athens University and
Linköping University, studying in their second
or third year in the medical or psychology
programmes.
The data collection comprised answering
a questionnaire and taking hair samples. The
total number of participants in the study was
n=114 Swedish and n=125 Greek students,
and the participation rate was 66% in Sweden
and 63% in Greece.
Important to note was the exclusion of
students with hair shorter than 3 cm, since
this was an exclusion criteria.
All participants gave their written informed
consent to participate in the study before the
collection of hair samples was done.
The Research Ethics Committee at the
Faculty of Health Sciences, Linköping
University, Sweden and The Research Ethics
Committee at Athens University, Greece
approved the study in 2012.
Questionnaire and cortisol measurements
A questionnaire including validated and
previously tested questions was used
measuring sociodemographic variables
including: age, sex, and self-reports of
longstanding chronic illness (coronary heart
disease, diabetes, cancers, or rheumatic
disorders), and potential intervening factors
like smoking.
Possible confounders within the previous
three months included: permed or coloured
hair (it was not specified in the questionnaire
if the hair was permed or coloured), regular
medication in general and regular medication
of glucocorticoids like steroid creams, nose
sprays, or inhalation aerosols (no specification
was made in the questionnaire which specific
type of these glucocorticoids the respondent
used).
Further, experiences of serious life
events during the last three months such as
divorce, unemployment, surgery, economical
problems, serious illness, or a death in family
were recorded.
Self-reported health was measured by
three categories: not so good, average,
and good. The variable ‘hope for the future’
was measured in five categories: completely
hopeless, hopeless, neither hopeless or
hopeful, partially hopeful, or very hopeful.
Included in the questionnaire were also The
Hospital Anxiety and Depression Scale (HAD)
and the Perceived Self-rated Stress Scale
(PSS 10-item version). Swedish and Greek
Greece was
hit hard by the
financial crisis
that started
in 2008
translations were used for both PSS and HAD.
Cortisol was measured based on the
established competitive radioimmunoassay
method and approximately a 3mm-thick piece
of hair was cut off close to the scalp from the
posterior vertex area of the head.
No hair was shorter than 3cm in length, and
all participants donated sufficient hair volume
for the analysis.
Results
The mean cortisol levels of the total study
sample (N=236) were: 25.4 pmol/g (SD
22.4).
The Greek mean cortisol levels were 19.8
pmol/g (SD 21.3), and the Swedish 31.6
pmol/g (SD 22.0). Greek cortisol levels
were significantly lower (p<0.0001) than
comparable Swedish young adults, also after
adjustments for differences in sex and age
distribution between the sites.
The Greek sample reported significantly
more experiences of serious life events
(p=0.002), higher perceived stress (PSS)
(p<0.0001), higher scores for HAD depression
(p<0.0001) and HAD anxiety (p<0.0001),
and lower scores for hope for the future
(p<0.0001).
No differences between the sites were
found concerning self-reported health.
There were no sex (p=0.57) or age
(p=0.14) differences in mean cortisol levels.
Some of the indicators were significantly
associated to cortisol levels like; ‘longstanding
illness’ (p=0.04), ‘self-reported health’
(p=0.02), and HAD depression (p=0.02). The
variable ‘hope for the future’ almost reached
the chosen significance level of p<0.05.
The potential confounders, daily smoker
(p=0.34), coloured or permed hair (p=0.58),
regular medication (p=0.10), and medication
with synthetic glucocorticoids (p=0.16), were
not statistically significantly associated to
cortisol levels.
Discussion
The main findings in this study was that young
Greek adults had significantly lower cortisol
levels than comparable Swedish young adults,
despite that the Greeks reported higher
perceived stress, reported more experience
of serious life events, had lower hope for the
future, and had widespread symptoms of
depression and anxiety (Faresjo et al, 2013).
All health indicators measured in this study
point in the same direction: the Greek young
11
Austerity special
adults reported lower health status than the
Swedish.
One could therefore expect that their
cortisol levels should be higher since a broad
area of research has shown that recent
or ongoing stress generally seems to be
associated with increased hair cortisol levels
(Staufenbiel et al, 2012).
However, the young Greeks had on the
contrary significantly lower cortisol levels than
the Swedes.
A hypothesis to explain this phenomenon
could be that the cortisol levels of the Greek
young adults might have been suppressed
after living in an environment with economic
and social pressure.
Although our results reveal lower cortisol
levels in the Greek subjects, we cannot label
these as hypocortisolism, which is diagnosed
in clinical settings.
However, this finding is comparable with
other studies where individuals under longterm stress exposure and trauma show a
down-regulation of their HPA axis (Hinkelmann
et al, 2013).
The basic mechanism of the HPA axis is that
References
Falagas ME, Vouloumanou EK, Mavros MN,
stress first leads to hyperactive functioning,
but if the stress exposure is longstanding and
individuals are no longer able to cope with this
exposure, a state of exhaustion is reached and
the system turns to hypoactive functioning.
This tendency of hypocortisolism has been
reported for patients with a variety of stressrelated disorders such as chronic fatigue
syndrome, fibromyalgia, lower-back pain,
post-traumatic stress disorder, and burnout
(Preussner et al, 1999).
The results of this study should be
considered in light of some limitations.
Only young adults, i.e. university students,
were included, which might indicate that
these groups should be less affected by the
economic crisis than the general population.
Although these groups are not in the labour
force, they do not live their lives isolated from
the rest of the community.
Therefore, they are at least indirectly
affected in their daily life by the economic
and social crises as the rest of the Greek
population.
The down-regulation of the HPA axis is
a mechanism that biologically copes with
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Faresjo A, Theodorsson E, Chatziarsenis M, Sapouna
V, Claesson H-P, Koppner J, Faresjo T. (2013) Higher
Kirschbaum C, Tietze A, Skoluda N, Detternborn L.
Staufenbiel S, Penninx B, Spijker A, Elzinga B, van
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Hinkelmann K, Muhtz C, Dettenborn L, Agorastos A,
Madianos M, Economou M, Alexiou T, Stefanis C. (2011)
Wingenfield K, Spitzer C, Gaof W, Kirschbaum C,
Depression and economic hardship across Greece
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12
the long-term exposure to a stressful social
environment.
A reduced HPA axis reactivity in chronically
stressed individuals is maladaptive since it is
also linked to the immune system response.
The financial crisis in southern Europe has
posed major threats to public health, where
not only suicides, but also new outbreaks
of infectious diseases are becoming more
common (Karanikolos et al, 2013).
To be repeatedly exposed to intense
stimuli of a high allostatic load could lead to
a lowering of the cortisol levels, and possibly
also a reduced immune defense with harmful
health effects in humans.
Living every day in a social environment
affected by the economic and social crisis
with high unemployment rates, reduced
salaries, and reduction of the social security
nets that Greece has for some years
experienced, is stressful for the whole
population (Madianos et al, 2011).
Although the coping strategies to handle
this type of stressful situation could vary in
the population, there also might be social or
cultural differences in this respect. MHN
analysis. The Lancet 374: 315-23.
Whitworth JA, Williamsson PM, Mangos G, Kelly JJ.
(2005) Cardiovascular consequences of cortisol
excess. Vasc Health Risk Manag 1: 291-9.
World Health Organization. (2011) Mental health in
Europe. World Health Organization: Copenhagen.
Austerity special
What studies into systems
tell us about mental health
work and services at a time
of austerity
Ben Hannigan presents a summary of research carried out into the understanding of
systems of mental health care and the effects of economic restrictions on services
Ben Hannigan
Reader in mental health nursing,
School of Healthcare Sciences,
College of Biomedical and Life Sciences,
Cardiff University
Correspondence:
[email protected]
Abstract
This paper presents a summary of findings
from studies into systems of mental health
care in a time of economic hardship and
expenditure reduction.
Key words
Austerity, mental health, systems
Reference
Hannigan B. (2013) What studies into
systems tell us about mental health work
and services at a time of austerity. Mental
Health Nursing 33(6): 13-5.
Introduction
This paper draws on findings from two
studies completed as part of a larger
programme of research concerned with
improving understanding of systems of
mental health care.
The paper’s aim is to offer insights for
mental health nurses and others concerned
with services and work during a time
of economic collapse and expenditure
reduction.
Economic crises, austerity and mental
health
Austerity measures are designed to reduce
government debt, and here in the UK (as
elsewhere in the world) have become a
significant part of politics and economics
following the global crash which first began
to unfold in 2007 (Clarke and Newman,
2012).
Economic collapse of this magnitude hurts,
as do subsequent cuts in public services
funding. They also hurt in uneven ways,
challenging simple appeals to ‘everyone
being in it together’.
Illustrating this Knapp (2012) points to the
two-way relationship between mental health
and financial hardship. Reductions in income,
loss of employment and personal debt
challenge individual wellbeing and resilience,
and are associated with diminished wellbeing.
People who live with mental health
difficulties are also more likely than those
who do not to be out of work, in poverty and
socially isolated.
As efforts to reduce government
expenditure across the UK bite nurses and
others are finding that mental health services
are not being spared.
Evidence published in August 2012
revealed a 1% real terms reduction in adult
mental health services investment in England
in 2011-12 compared to the year before
(Mental Health Strategies, 2012).
The Guardian newspaper reported at the
time that this represented the first absolute
reduction in mental health expenditure for a
decade (Ramesh, 2012).
This trend looks to have continued.
Drawing on currently unpublished figures,
recent reports are of a further 1% reduction
across England for the year 2012-13
(Brindle, 2013).
In this same newspaper article, England’s
then-national clinical director for mental
health, Dr Hugh Griffiths, is reported to
have told the House of Commons Health
Committee of being ‘disturbed’ at stories of
reductions in mental health services in some
localities.
Today’s retractions in funding for services
contrast sharply with the situation found in
the first ten or so years of this century.
Economic
collapse of this
magnitude
hurts, as do
funding cuts
13
Austerity special
Having for decades been a neglected
Cinderella service, largely during the period
of New Labour administration from the end
of the 1990s the mental health field began
to attract new government attention and
support (Lester and Glasby, 2010).
Policymakers across all parts of the UK
started to take seriously the need to invest,
and to develop standards and services.
Of the four countries of the UK England
saw perhaps the most obvious changes.
Community mental health care shifted
dramatically in response to the publication
of a ten year National Service Framework
for Mental Health (Department of Health,
1999) and associated guidance documents
specifying (among other things) the
establishment of new types of service
(Department of Health, 2001).
Alongside comprehensive, locality-based,
community mental health teams (CMHTs)
appeared new teams offering crisis resolution
and home treatment as an alternative to
hospital admission, assertive outreach and
early intervention.
Later developments saw the establishment
of services dedicated to improving access
to psychological therapies (CSIP Choice and
Access Team, 2007).
Rather less differentiation of services
appears to have happened in Wales, largely
informed by a (now superseded) strategy
launched in the early part of the century
which reaffirmed commitments to the single
CMHT model (National Assembly for Wales,
2001).
But here, too, community mental health
services have changed over time as crisis
resolution and home treatment (CRHT) teams
and other innovations have spread.
What can we learn from research?
Over a period closely corresponding with
these years of service expansion, and now
apparent retraction, I have had opportunities
to research and write about the changing
mental health landscape.
My interests have particularly been in
studying systems of community care: the
policy context, the emergence and impact
of new services, the work that nurses and
others do and the experiences of users.
Underpinning this has been the observation
that the mental health arena is a remarkably
complex one.
This reveals itself in a number of ways.
14
One is that it is a field which has always
been subject to influence by individuals,
groups and organisations with sometimes
very different ideas and values about care,
treatment and services.
In this context it is not surprising that
when mental health policymakers and others
contemplate what needs to be done they
invariably find that the problems they face
and the solutions they propose are not
readymade, but have instead to be actively
identified, worked at and defended (Hannigan
and Coffey, 2011).
Changes to mental health law for England
and Wales, for example, were premised on
the idea that community care had ‘failed’.
This was a notion strongly contested by
some in the field.
In the UK
England
perhaps saw
the most
obvious changes
Work and roles in community mental
health care
Much of the research data I have generated
over the years has come from qualitative
interviews conducted with workers located at
different levels within mental health systems
(senior managers, team leaders, frontline
practitioners), and from interviews conducted
with users and carers.
I have also had opportunities to use
written records (including local policies and
practitioners’ notes) as sources of data, and
to directly observe workers in their day-today jobs. In a study of the organisation and
delivery of interagency and interprofessional
community mental health in two contrasting
sites in Wales I was struck by the differences
in local context, and the shaping effects
these had on the work and roles of nurses
and others. In a paper reporting findings from
this study we wrote how:
‘Forces shaping roles in contrasting (but
locally recognisable) ways were differing
workplace histories of interagency and
interprofessional relations, which served
as precursors to differing degrees
of current commitment to new, more
‘‘modern’’, ways of working.
‘Other patterning factors included
practical contextual features such as
the size of NHS and local authority
organisations, and the availability (or
not) of new members of staff to fill gaps
in the workforce’ (Hannigan and Allen,
2011: 3).
In one of the two sites participating in
this project a strong local history existed of
what staff described as ‘joint working’ across
health and social care boundaries.
When people left their jobs it also proved
hard to replace them, with the relatively small
size of statutory care provider organisations
limiting efforts to move staff from one part of
the system to fill gaps in others.
Here, compared to the second site,
CMHT workers also came from a narrower
range of professional backgrounds. In my
analysis of these data I found these distinct
organisational features helped pattern the
work which was done and by whom.
In the ‘joint working’ site where a lessrich mix of professionals was found,
nurses and others fulfilled roles which were
relatively generalist. Blurring of occupational
boundaries (between nurses and social
workers, for example) was locally seen as
desirable and part of a long-established
team culture. It also reflected very practical
resource contingencies.
In our paper reporting these findings we
set these observations in a larger context,
and drew some lessons for services at a time
of austerity (Hannigan and Allen, 2011).
We speculated that the relatively generalist
mental health worker (who may be a nurse,
a social worker or some other type of
practitioner by initial preparation) may find
him or herself in particular demand during
times of service retrenchment and retraction.
We suggested that the practitioner able to
competently coordinate care, to perhaps act
as an approved mental health professional
(Coffey and Hannigan, 2013) and/or to
administer and even prescribe medication
may prove particularly attractive to hardpressed managers needing to ensure that
(even with limited staff) a whole range of
necessary tasks can be done.
Crisis services and their system impact
In this second study I was interested to
examine the establishment, work and wider
impact of a single CRHT team set in its local
Austerity special
system context, and to explore the work of
staff and the experiences of users.
In a research paper from this project I
reported the satisfaction of service users
with crisis care as an alternative to inpatient
admission, and the positive views of staff
throughout the locality of the quality of the
care provided (Hannigan, 2013).
What I also reported was evidence of
significant system-wide reverberations flowing
from the setting up of a new standalone
team, and of the decision to do so having
been a contested one.
Without additional resources staff were
required to move across the local system as
a hospital ward closed to fund the new CRHT
team. Some CMHT workers described having
to do additional work, and others talked of
some of the most needy patients receiving
care from some of the least experienced
staff.
What this study reinforced is the
significance of the interconnections which
bind together the parts found within mental
health systems, and how change in this
context can lead to improvements but also to
unintended and unwanted consequences.
The most needy
patients were
receiving care
from the least
experienced
staff
References
Brindle D. (2013) Spending on mental health care falls
for second year running. The Guardian. 15 March
2013. Available at: www.theguardian.com/healthcarenetwork/2013/mar/15/spending-mental-health-falls
(Accessed 10 October 2013).
It also drew attention to the relative lack of
knowledge that currently exists surrounding
the activities and contribution of new types of
mental health team, or of their wider system
effects.
Since completing this study anecdotal
evidence has started to emerge of the
disappearance of some of the newer, more
functionally oriented, services set up in the
first decade of the century.
Since their widespread introduction in the
UK the evidence that intensive (and relatively
expensive) assertive outreach teams (AOTs)
provide a wholly superior service to that
provided by locality CMHTS has been called
into question (Burns, 2010).
The combination of austerity and
an equivocal evidence base may lead
to dedicated AOTs facing threats to
their existence, and perhaps some
of the anecdotes heard over service
reconfigurations and cuts are examples of
this happening in practice.
Findings from the CRHT study referred
to above suggest that any organisational
change within an interrelated system, which
might include services closing as well as
opening, can be expected to trigger powerful
disruptive waves with the capacity to
destabilise.
Conclusion
As austerity measures filter downwards
towards localities the organisational shape of
mental health services, along with the work
(and the workloads) of nurses and others, are
Department of Health. (1999) A national service
framework for mental health. Department of Health:
London.
Department of Health. (2001) The mental health policy
implementation guide. Department of Health: London.
Hannigan B. (2013) Connections and consequences in
likely to change.
Complex adjustments and
accommodations will occur within local
interrelated systems, and workers’ roles may
expand as gaps emerge which demand to be
filled.
It is hard to imagine all this happening
without service user experiences also being
affected. System convulsions of this type
may happen (or, be happening already) in
spite of the suggestion that action to protect
mental health and wellbeing and to intervene
early saves money, and that demand for
mental health care is always likely to rise
during periods of economic crisis (McDaid
and Knapp, 2010).
In what otherwise looks to be a dispiriting
and challenging immediate future, it might
just be worth holding in mind McDaid and
Knapp’s (2010, p424) idea that ‘times of
austerity also present an opportunity to be
more daring and innovative within the mental
health system’.
For example, barriers have long existed
between health and social care agencies,
sometimes to the detriment of users and
their families.
The current need to save money may
conceivably trigger new thinking about old
problems such as this.
This is certainly not to welcome austerity
and the pain it causes, but it does serve to
alert practitioners, managers and others
of the heightened importance of working
together collaboratively and of making joinedup decisions when times are hard. MHN
Lester H. and Glasby J. (2010) Mental health policy
and practice (2nd edition). Palgrave Macmillan:
Basingstoke.
McDaid D and Knapp M. (2010) Black-skies planning?
Prioritising mental health services in times of austerity.
British Journal of Psychiatry 196(6): 423-4.
Mental Health Strategies. (2012) 2011/12 National
Burns T. (2010) The rise and fall of assertive community
complex systems: insights from a case study of the
treatment? International Review of Psychiatry 22(2):
emergence and local impact of crisis resolution and
Survey of Investment in Adult Mental Health Services:
130-7.
home treatment services. Social Science & Medicine
Report prepared for the Department of Health. Mental
Clarke J and Newman J. (2012) The alchemy of
austerity. Critical Social Policy 32(3): 299-319.
93: 212-9.
Hannigan B and Allen D. (2011) Giving a fig about roles:
Health Strategies: Manchester.
National Assembly for Wales. (2001) Adult mental
policy, context and work in community mental health
health services for Wales: equity, empowerment,
as approved mental health professionals in England
care. Journal of Psychiatric and Mental Health Nursing
effectiveness, efficiency. National Assembly for Wales:
and Wales: a discussion paper. International Journal of
18(1): 1-8.
Coffey M and Hannigan B. (2013) New roles for nurses
Nursing Studies 50(10): 1423-30.
CSIP Choice and Access Team. (2007) Commissioning
a brighter future: improving access to psychological
therapies: positive practice guide. Department of
Health: London.
Hannigan B and Coffey M. (2011) Where the wicked
Cardiff.
Ramesh R. (2012) Mental health spending falls for first
problems are: the case of mental health. Health Policy
time in 10 years. The Guardian. 7 August 2012.
101(3): 220-7.
Available at: www.theguardian.com/society/2012/
Knapp M. (2012) Mental health in an age of austerity.
Evidence-Based Mental Health 15(3): 54-5.
aug/07/mental-health-spending-falls (Accessed 10
October 2013).
15
Austerity special
Austerity and financial
restrictions in mental
health nursing – can it
be a good thing?
Victoria Wilford explains how financial restrictions led to a change in service provision with
the aim of improving efficiency for staff and delivering better care for service users
Victoria Wilford
Lecturer/practitioner in mental health
nursing, University of Huddersfield,
and community psychiatric nurse,
South West Yorkshire Partnership
Foundation Trust
Correspondence:
[email protected]
Abstract
This paper explains how financial
restrictions in a Yorkshire trust led to a
change in service provision with the aim of
improving efficiency for staff and delivering
better care for service users.
Key words
Austerity, financial restrictions, mental
health nursing, service redesign
Reference
Wilford V. (2013) Austerity and financial
restrictions in mental health nursing –
can it be a good thing? Mental Health
Nursing 33(6): 16-8.
16
Introduction
The current climate of economic difficulties
has led to implications for the healthcare
system in terms of change, reorganisation
and innovation in healthcare (Newbold and
Hyrkas, 2010; Turley, 2009).
This is despite government claims that
there will be no cuts to the NHS budget and
health care provision will remain free to all
regardless of ability to pay (Department of
Health, 2011).
2012/13 saw a landmark change in the
way mental health services for adults of
working age were organised with the local
area.
The approach of using care pathways,
mental health clusters and care packages has
been recognised as the future for the delivery
of mental health care and has been used by
the Department of Health as a model for the
development of a currency for mental health
– Payment by Results (South West Yorkshire
Partnership Foundation Trust, 2013a).
The aim of this is to provide a transparent
method of paying for services provided by
mental health trusts rather than reliance on
historical budgets.
This has led to the development of core
care packages based on a summary of
assessment which indicates the care cluster
of a service user based on their assessed
needs.
This method of assessment and provision
of care has been developed within the trust
since 2006 and has been recognised and
adopted by the Department of Health to
form the basis for mental health currency
for mental health services nationally (South
West Yorkshire Partnership Foundation Trust,
2013a).
Mental health clusters have been mandated
since April 2012, meaning that all service
users need to be assessed and allocated to a
cluster by their mental health service provider.
This has to be reviewed and updated
according to the protocols provided in the
mental health clustering booklet.
These clusters form the basis for
the contractual agreements between
commissioners and mental health service
providers (South West Yorkshire Partnership
Foundation Trust, 2013b).
In simplified terms this means that mental
health service providers are paid according to
packages of care provided rather than a block
allocation of funding – effectively the money
follows the service users journey through the
service, giving more options to provide for
service user choice and complexity of care
provision.
In addition, clinicians will have direct effects
on the levels of funding received by the trust
through delivery of high-quality care and
achieving better outcomes for service users.
The current
climate has
implications in
terms of change
and innovation
Austerity special
This was a directing factor for change
within service provision to provide care with
team specific care pathways.
These would provide specialist services
for the assessed care packages as identified
by the mental health cluster and would have
benefits for services users, clinicians, the
organization and commissioners.
Influencing factors
Payment by results is not the only influencing
factor on development of services. Other
guiding factors are Commissioning for Quality
and Innovation (CQUIN) targets and quality
indicators and outcome measures.
Measuring quality and outcomes is an
important aspect of payment by results for
service users, clinicians and commissioners
(Department of Health, 2013).
These quality indicators and outcome
measures include proportions of service
users on the Care Programme Approach
(CPA) and the numbers having had a CPA
review in the last 12 months.
In terms of the effect on this on local
services at frontline level, the essential
elements were to change current generic
multidisciplinary community mental health
services for working age adults to specific
pathways, specialising in assessed cluster
based psychotic and non-psychotic disorders
named care management and community
therapy respectively.
This was a massive change from existing
practice of working in three geographical
sector-based services with mixed psychotic
and non-psychotic caseloads.
Two larger teams
The proposal was for two larger
community mental health teams, which
would not be sector based – these would
remain multidisciplinary including mental
health nurses, occupational therapists,
social workers, approved mental health
practitioners, community care officers and
medical staff.
As a means of achieving this, an options
appraisal form was completed by all nonmedical staff (medical staff remaining sector
based) to state pathway preference with
supporting evidence for this choice.
Staff were informed by mid-October 2012
which team they were allocated to. The date
for the pathways to begin was scheduled for
February 2013.
Initial problems
led to closer
working
relationships
between staff
One direct result of the change was the
huge numbers of cases that would need to
be transferred between practitioners so that
services users could be aligned with their
allocated pathway.
This process needed to be gradually
managed to ensure that all service users were
given the opportunity to become accustomed
to new worker provision, which some would
find unsettling in terms of their mental health.
The agenda agreed meant that the first
planned transfers of care coordinator role for
service users from the community therapies
pathway to care management were from the
identified ‘assessors’ within the community
therapies pathway.
These roles had been identified because of
the high volume of new referrals coming into
the community therapies pathway requiring
a high number of assessment slots to be
available to meet the target of 14 days
from point of referral to initial face-to-face
assessment.
Prioritising these cases for transfer to care
management pathway allowed the identified
assessors to increase capacity to undertake
higher numbers of assessment slots than
other team members.
There were initial teething problems, for
example the target for assessment was above
14 days during the initial period.
However, this was flagged up by staff to
the pathway manager and clinical lead as an
issue, which led to closer working relations
between frontline staff and management in
terms of reviewing systems and looking what
was working elsewhere – the advantage of
being the last area to redevelop services.
The focus was made on the referrals
coming through to the team after being
triaged by the local single point of access
(SPA) service.
Initially most referrals were accepted for
assessment even if the referral information
was poor – this was the easier option as it
meant service users could be seen and then
signposted to the most appropriate service
and/or discharged from secondary services.
However, this was resource intensive and
the volume of referrals meant that this was
not sustainable, leading to targets for initial
assessments not being met.
This was not an issue in other parts of
the trust, which had developed a re-triaging
process that meant referrals were more
stringently reviewed before allocating to an
assessment slot.
This involved members of the community
mental health team’s ‘triaging team’,
consisting of assessors, duty worker and
consultants, reviewing referrals and making
multidisciplinary decisions about how to
progress them.
This process involved several options,
including returning referrals with inadequate
information to GPs (discharged and asked
to re-refer), signposting referrals to other
services before being seen, and returning
to SPA with referrals that were poor or
inappropriate.
This had reduced the number of referrals
requiring assessment in other areas and
meant they could maintain the 14-day CQUIN
target for new referrals to be seen.
Increasing efficiency
The implementation of a similar process
within our team was aimed at reducing the
number of inappropriate assessments to
therefore ensure that assessment slots were
available for those who needed them within
the target of 14 days from point of referral to
face-to-face initial assessment.
The triaging process also included
reviewing any non-attenders at allocated
assessments to ensure that the trusts’ nonattendance policy was adhered to (South
West Yorkshire Partnership Foundation Trust,
2011).
In the longer term there are plans to review
the criteria for referral to the Community
Therapies community mental health team as
the current feeling is that it is the ‘catch all’
for referrals that do not fit anywhere else.
There will still be a role for the community
mental health team in assessing perceived
risks of service users that may otherwise fit
the criteria for other services.
However, this must not become the ‘fall
back’ situation for these service users who
may be more suitable for services other than
the community mental health team.
In addition other services need also to
accept referrals that have come through to
17
Austerity special
The community
mental health
team has
become more
focused on what
is provided
the Community Therapies community mental
health team, are triaged by the team and
considered to require an alternative.
Given the need to meet CQUIN targets
from referral to point of initial contact,
other services can be reluctant to accept
referrals that have not been assessed by the
community mental health team but have been
triaged as more suitable for another service.
This will reduce the demand for
assessment slots within the community
mental health team and avoid service users
being re-assessed.
An alternative option would be to have
a team of assessors to purely assess all
new referrals coming into SPA and then to
signpost on to the appropriate service.
This would allow the community mental
health team to work as care coordinators and
to provide the specialist care packages as
identified by the mental health care cluster.
With regards to specific roles within the
ranks of the community mental health team,
nursing remains a distinct discipline due to
skills within medicine management, including
administration and monitoring.
At present there is no indication that a
generic community mental health worker role
would be required (Hannigan, 1999).
Effects on care provided
In terms of the effects on the care
provided by community mental health team
practitioners within the specialist pathways,
One-to-one work
In terms of one-to-one work with service
users, the development and use of care
packages based on assessed need has given
greater scope for more focused, specific and
time-limited work, along with development of
recovery focused strategies by community
mental health team practitioners.
This is in line with development of a service
that users can ‘dip’ in and out of, that can be
accessed when required and not necessarily
a ‘service for life’, as the community mental
health team has tended to be seen by some
in the past.
That is not to say that some service users
will not need a longer-term service, and there
are care packages within the mental health
clustering process that allow and support this
assessed need.
The effect of payment by results on this
is the financial implications that come with
service users being assigned to an incorrect
cluster, meaning that the numbers do not add
up – for example in the situation where the
References
health. Health and Social Care in the Community 7(1):
Department of Health. (2011) Working Together for a
25-31.
Stronger NHS. Department of Health: London. Available
Layton S and Lambe A. (2011) Learning before, during
at: www.gov.uk/government/uploads/system/uploads/
and after: Applying Knowledge Management to the NHS
attachment_data/file/216104/dh_125855.pdf
in times of austerity and change. Business Information
(Accessed 8 November 2013).
Review 28(4): 236-41.
Department of Health. (2013) Mental Health Payment by
Results Guidance for 2013-14. Department of Health:
London. Available at: www.gov.uk/Mental_Health_PbR_
Newbold D and Hyrkas K. (2010) Managing in economic
austerity. Journal of Nursing Managment 18: 495-500.
South West Yorkshire Partnership Foundation Trust.
Guidance_for_2013-14.pdf (Accessed 8 November
(2013a) Clinical Pathways and Mental Health Currency
2013).
> Background. South West Yorkshire Partnership
Hannigan B. (1999) Joint working in community mental
18
the development of these teams has allowed
a greater focus on what care is provided
within the pathway.
New alternatives to providing care are
being developed, for example the use of
groups based on skill development and
self-management of mental health as an
alternative to one-to-one care coordination.
These groups can help service users to
develop skills that can be used to aid their
own management of mental health and also
as a platform to build confidence to go on to
alternative sources of support for their mental
health within the community.
They can also prepare service users for
more intensive work within other parts of the
pathway such as secondary psychological
therapy services.
Foundation Trust: Wakefield. Available at: http://nww.
cluster indicates a less intense care package
than is required.
Training has been made available
throughout the trust to enable workers to
cluster correctly at initial and indicated review
periods and therefore avoid this scenario.
At present there is no direct financial
implication for quality indicators. However, the
Department of Health (2013) suggests that
this is possible in the future.
Conclusion
In summary, the evolution in local services to
support the development of specialist care
pathways, which in turn supports the progress
towards a means of applying payment by
results to local mental health services,
remains a work in progress at frontline level.
Community mental health team
practitioners are striving to provide a
specialised service within their designated
pathway that meets the identified needs of
their service users.
This includes assessment using the mental
health clustering tool, which in turn supports
the payment by results agenda.
This has meant that the community mental
health team has become more focused
on what is provided and when, and is able
to ensure that this service is appropriate
to service user needs, to provide service
users with the right service at the right time,
including being referred onto alternative
services or discharged if this is appropriate.
The service is becoming more flexible in
this way and such developments mean that
service users have a more responsive service
that is available for them if and when they
require it.
The aim is to provide maximum value from
the service during a time of austerity when
maximum value for money is required (Layton
and Lambe, 2011). MHN
swyt.nhs.uk/inpac/Pages/Background.aspx (Accessed
8 November 2013).
South West Yorkshire Partnership Foundation Trust.
(2013b) Clinical Pathways with Mental Health Currency
(PbR). Internal Staff Bulletin June 2013.
South West Yorkshire Partnership Foundation Trust.
(2011) Did not attend and no access visits. South West
Yorkshire Partnership Foundation Trust: Wakefield.
Available at: www.southwestyorkshire.nhs.uk/
documents/872.pdf (Accessed 8 November 2013).
Turley M. (2009) The age of austerity. Public Finance 17
April: 22-23.
Austerity special
Assessing the impact of
the financial crisis in
mental health in Greece
Evanthia Sakellari and Katerina Pikouli discuss the impact of the economic crisis in Greece
and its related effects on mental health service users and services to support them
Evanthia Sakellari
Lecturer, Department of Public Health
and Community Health, Technological
Educational Institute of Athens, Greece
Correspondence:
[email protected]
Katerina Pikouli
Health visitor, Community Mental
Health Centre, “Eginition” University
Psychiatric Hospital, Athens, Greece
Abstract
Evanthia Sakellari and Katerina Pikouli
discuss the impact of the economic crisis
Greece has experienced and its related
effects on mental health service users and
services to support them.
Key words
Austerity, recession, mental health,
impact, Greece
Reference
Sakellari E and Pikouli K. (2013)
Assessing the impact of the financial
crisis in mental health in Greece.
Mental Health Nursing 33(6): 19-21.
Introduction
Mental health depends on a variety of
socioeconomic and environmental factors
(Herrman et al, 2005).
Research has shown that financial difficulties
and housing problems lead to mental health
problems (Lee et al, 2010; Taylor et al, 2007).
Furthermore, high frequencies of common
mental disorders and suicide are associated
with poverty, poor education, material
disadvantage, social fragmentation and
deprivation, and unemployment (DeVogli and
Gimeno, 2009; Fryers et al, 2005).
The onset of the global financial crisis in
2008 resulted in a dramatic initial economic
shock across Europe.
Real gross domestic product (GDP) per
capita declined by 4.5% across the WHO
European region in 2009, since unemployment
has increased sharply (WHO Regional
Committee for Europe, 2013).
Economic trends and society
An absence of economic growth means loss
of income and employment, and reductions
in social assistance for people, which has
consequences that are likely to last for many
months, during which time protection of
health and access to health and social care
services for the most vulnerable members
of society are particularly important
(Karanikolos et al, 2013).
Unemployment, a drop in income,
unmanageable debt, housing problems and
social deprivation can lead to lower wellbeing
and resilience, more mental health needs and
alcohol misuse, higher suicide rates, greater
social isolation and worsened physical health
(Knapp, 2012).
It has been found that people
who experience unemployment and
impoverishment have a significantly greater
risk of mental health problems, such as
depression, alcohol use disorders and suicide,
than those not affected (McKee-Ryan et al,
2005).
The link between deteriorating economic
conditions and increases in poverty rates,
inequalities and social conditions were seen
by the World Health Organization (2011) to
be at the core of mental health risks.
It is clear that mental health at a population
level is highly sensitive to economic downturn,
increasing the likelihood of individuals falling ill
and slowing recovery from illness.
In the European Union, the number of
suicides among people under 65 years has
increased since 2007, reversing a downward
trend (WHO Regional Committee for Europe,
2013).
A workshop entitled ‘Mental Health in Times
of Economic Crisis’ organised by the European
Parliament’s Committee on Environment,
Public Health and Food Safety concluded
that Europe is facing a mental health crisis,
and recognised that every 1% increase in
unemployment correlates to a 0.8% rise in
suicides (European Union, 2012).
Assessing austerity plans
During recessions, social inequalities in health
can widen (Kondo et al, 2008). A report
about assessing the impact of European
governments’ austerity plans on the rights of
people with disabilities (Hauben et al, 2012)
concluded that the crisis and related austerity
measures are clearly linked to these growing
inequalities between persons with different
income levels and capacities but also between
different vulnerable groups.
19
Austerity special
Impact of financial crisis in health
in Greece
Austerity policy has proved – in Greece,
Italy, Portugal and Spain – to be primarily an
attack on wages, social services and public
ownership (Busch et al, 2013).
Greece seems to be the most severely
afflicted European country. In terms of public
health and infectious diseases, HIV infections
have risen markedly with the epidemic
concentrated among a growing number of
intravenous drug users (Kentikelenis et al,
2011) and there are even worrying signs of
increases in malaria cases (Danis et al, 2011).
The health budget in Greece for 2011
decreased by€1.4 billion Euros, with 568
million Euros saved through salary and
benefit-related cuts and 840 million Euros
saved through cuts in hospital operating costs
(Kaitelidou and Kouli, 2012).
Since 2011 a horizontal cut of 50% of
the costs ceilings for rehabilitation aid and
equipment has been imposed along with an
additional 30-50% cuts on medical supplies
and specialised health services (Hauben et
al. 2012).
There are also delays to disability benefits
exceeding two to six months in cash and inkind respectively (Strati, 2011).
Meanwhile, the Greek Ministry of Health
reported a significant increase in the
demand for public health services by 20-30%
compared to 2009 (Hauben et al, 2012)
and a decrease in those to private hospitals,
because patients could no longer afford
private health insurance (Karamanoli, 2011).
In addition, increasing numbers of Greeks
are now depending on street clinics once
used to treat undocumented migrants (McKee
et al, 2012).
The Greek organisation ‘Doctors of the
World’ estimates that the percentage of
Greeks seeking medical care in street clinics
20
has increased from 3-4% before the crisis, to
about 30% (Kentikelenis et al, 2011).
Furthermore, the number of those who eat
in catering centres provided by the church
has been multiplied, mainly because of the
number of Greeks who resort to this solution
(Efthimiou et al, 2013).
Mental health impacts
The incidence of mental disorders has
increased in Greece and self-reported general
health and access to healthcare services have
worsened (Kentikelenis et al, 2011).
A rise of 40% in suicides has been reported
between January and May 2011 compared
to the same period in 2010 (Economou et al,
2011).
A study that analysed the content of phone
calls in the Help Telephone Line for Depression
from May 2008 to June 2011, concluded
that by the first semester of 2010 there
was an increase in the number of calls by
individuals who reported directly or indirectly
that they were affected by the economic crisis
(Economou et al, 2012).
Another study in Athens, by Giotakos et al
(2011), showed that a lower mean income
was correlated to a higher percentage
of individuals who received care in the
emergency of the four psychiatric hospitals
in total in Athens, as well as a positive
correlation was found between outpatient
visits and emergency of one of the psychiatric
hospitals and unemployment.
A similar survey conducted at a mental
health centre in the area of Attiki showed a
progressive increase in new demands and
growing needs of the local population for
mental health services (in 2008-2011); new
demands for related issues, widespread
personal insecurity, anxiety, confusion and
mental morbidity regarding the new uncertain
situation (Giotsidi et al, 2013).
The results of the a study by Madianos et
al (2011), examining the possible correlation
between economic crisis and the prevalence
of major depressive episode, showed that
individuals who faced serious financial
adversities had a greater risk to develop a
major depressive episode.
Moreover, a large increase was reported
in the prevalence percentage of major
depression episode in the year 2009 in
comparison to 2008 (Madianos et al, 2011).
Discussion
Austerity measures can exacerbate the shortterm public health effect of economic crises,
such as through cost-cutting or increased
cost-sharing in health care, which reduce
access and shift the financial burden to
households (Karanikolos et al, 2013).
Policy choices can influence the impact
of any economic recession on mental health
outcomes, while unwise austerity measures
in public services for children, families and
Images_of_Money
It also concluded that cuts in social security
benefits are having a direct impact on healthrelated rights. Increased user charges and
other co-payments for medication and other
health services have a direct impact on the
application of the right to affordable health.
The report also recognised that related
austerity measures in social security benefits
have a strong indirect impact on access
to health services in terms of affordability,
particularly where formal or informal payments
are required to access health services.
Austerity special
young people may result in long-lasting and
costly mental (and physical) health damages,
and create an obstacle to economic recovery
(Wahlbeck and McDaid, 2012).
Kentikelenis and Papanicolas (2012)
support that there is a need to safeguard
programmes for vulnerable groups, such
as those with mental illness, and all these
measures require political decisiveness and
coordination across ministries with a shared
focus on equity and quality.
At the workshop on Mental Health in
Times of Economic Crisis by the European
Parliament’s Committee on Environment,
Public Health and Food Safety, Dr Bertollini
stated that mental health problems caused
by the financial crisis can be addressed in
various ways, including the development of
employment programmes, family support
services, debt relief support services, alcohol
reduction measures, and the improvement
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its impact on mental health. Encephalos 48(2): 54-61.
of mental health services. He concluded
that a strong social net and a higher public
expenditure on social protection may protect
citizens from mental diseases (European
Union, 2012).
However, the rescue package prescribed
by the ‘troika’ of lenders from the European
Commission, European Central Bank and
International Monetary Fund came with
conditions of stringent austerity, including cuts
to social welfare, education, and health during
the next years, leaving Greece with very few
options to counteract the escalating social
crisis (Karanikolos et al, 2013).
The situation raises a number of concerns,
namely that public access to the health
system could continue to worsen, the
burden on family budgets could increase,
the provision of health services could
deteriorate and private capital in the health
sector could expand without adequate
Giotakos O, Karabelas D, Kafkas A. (2011) Financial crisis
and mental health in Greece. Psychiatriki 22: 109-19.
Hauben H, Coucheir M, Spooren J, McAnaney D,
monitoring (Kaitelidou and Kouli, 2012).
Thus, it is important to tackle the current
financial crisis through the organisation of
those services that respond to the increased
demands of society, both in psychological
support and intervention as well as social
protection (Bouras and Lykouras, 2011).
Conclusion
Over the past few years there have been many
reports within the scientific world and many
headlines in the media regarding the financial
impact on everyday life.
However, so far, the discussion in Greece
is limited to financial issues and meeting the
goals the troika has set.
It is clear that the health and wellbeing of
people is not considered when decisions on
measures are taken and there has been a
failure to address the health and social needs
of people in Greece. MHN
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Delfosse C. (2012) Assessing the impact of European
(2011) Depression and economic hardship across
Crisis, Austerity Policy and the European Social Model,
governments’ austerity plans on the rights of people
Greece in 2008 and 2009: two cross-sectional
How Crisis Policies in Southern Europe Threaten the
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McKee M, Karanikolos M, Belcher P, Stuckler D. (2012)
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Economou M, Madianos M, Theleritis C, Peppou LE,
Stefanis CN. (2011) Increased suicidality amid
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Karamanoli E. (2011) Debt crisis strains Greece’s ailing
health system. The Lancet 378: 303-4.
Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S,
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McKee M, Stuckler D. (2011) Health effects of financial
crisis: omens of a Greek tragedy. The Lancet 378:
1457-8.
Kentikelenis A and Papanicolas I. (2012) Economic crisis,
austerity and the Greek public health system. The
European Journal of Public Health 22(1): 4-5.
Knapp M. (2012) Mental health in an age of austerity.
Evidence Based Mental Health 15: 54-5.
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costs of unsustainable housing commitments.
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Wahlbeck K and McDaid D. (2012) Actions to alleviate
the mental health impact of the economic crisis. World
Psychiatry 11(3): 139-45.
World Health Organization. (2011) Impact of economic
crises on mental health. WHO Regional Office for
Europe: Geneva. Available at: hwww.euro.who.
int/__data/assets/pdf_file/0008/ 134999/e94837.pdf
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Fryers T, Melzer D, Jenkins R, Brugha T. (2005)
The distribution of the common mental disorders:
social inequalities in Europe. Clinical Practice and
Epidemiology in Mental Health 5(1): 14.
Lee S, Guo WJ, Tsang A, Mak AD, Wu J, Ng KL, Kwok
K. (2010) Evidence for the 2008 economic crisis
level meeting on Health systems in times of global
OsloHealthSystemCrisis-2.pdf (Accessed 7 November
2013).
21
Austerity special
The impact of cuts on
mental health services:
Good mental health
in Leicester?
Jim Dooher and Liz Rye present the findings of a study exploring the views of service
users and carers on service provision in the context of funding restrictions in Leicester
Jim Dooher
Principal lecturer/senior research fellow,
De Montfort University, Leicester
Correspondence: [email protected]
Liz Rye
Deputy chair, Service User and Carer
Research Audit Network
Abstract
This paper presents the findings of a study
exploring the views of service users and
carers on service provision in the context of
funding restrictions in Leicester.
Key words
Austerity, cura, service redesign,
mental health
Reference
Dooher J and Rye L. (2013) The impact
of cuts on mental health services: Good
mental health in Leicester? Mental
Health Nursing 33(6): 22-5.
22
Introduction
Publicly funded services for people with
mental health conditions continue to endure
considerable pressure, and while there is
no evidence to suggest that mental health
services are being disproportionately cut, the
negative effects (whether real or perceived)
upon those who use these services and their
carers are profound.
In 2010 the new coalition government
announced the results of its spending review.
The review detailed budgets that were to be
cut over the following five years and outlined
measures relating directly to the voluntary
sector. These included the announcement
of a new £100 million transitional fund, and
additional resources to implement the ‘Big
Society’ agenda.
In mental health however, despite transitional
funding, our experience is that services are
being lost. Service users and their carers are
very worried about future support, and the
voluntary sector has been pitched into unstable
short-term funding at best, and lowest price
based competitive grants at worst.
The UK voluntary and community sector
will lose around £911 million a year in
public funding by 2015-16 (National Council
for Voluntary Organisations, 2011), and
without doubt Leicester City and County are
contributing to this saving. Voluntary sector
services are also struggling to access other
sources of funding with a significant decrease
in charitable giving due to the recession and
increasing competition for charitable grants
such as the lottery.
The evidence contained in this article is
based upon several pieces of work conducted
by the Service User and Carer Research
Audit Network (SUCRAN), a service user and
carer led research group, which conducted a
qualitative study of mental health service users
and their carers in Leicester City (SUCRAN,
2013).
Background and approach
The views of 60 people were obtained to
ascertain the features of services that protect
their mental health, prevent admission to
hospital and ensure positive health outcomes
when secondary care is needed. In addition,
the views of 407 mental health service users
(City and County) were captured through oneto-one interviews (SUCRAN, 2012).
The reports that were generated from these
first-hand accounts identified more than just
a wishlist of the kinds of services wanted
now and in the future. They illustrate a rich
understanding of the impact of changes to
mental health service provision, identifying not
only specific concerns over perceived gaps
in current service provision, but also what is
working well.
However, the legitimate demands of current
service users have emerged from a plethora
of legislation and social policy, which has been
introduced under the fanfare of progressive
and empowering social care, dynamic and
positive. Considering a few of these drivers
enables us to consider just how much progress
has been made.
In the late 1980s there was a flurry of
Austerity special
white papers and governmental direction that
promoted decarceration from the Victorian
asylums and the development of ‘community
care’. (Griffiths, 1988, Department of Health,
1989a; 1989b).
These documents were the forerunners to
the Community Care Act of 1990, a major
piece of legislation that sets out the basis
for community care as we know it today.
These were driven by the principles that state
provision was bureaucratic and inefficient; that
the State should be an ‘enabler’ rather than a
provider of care; a separation of the purchaser
provider roles; and devolution of budgets and
budgetary control.
Of the Act’s six key recommendations,
the use and promotion of the independent
sector was to be achieved through greater
collaboration with the voluntary and private
sector to make ‘maximum use’ of this welfare
model.
The development of the voluntary and
independent sector saw a shift of both
resources and service user dependence
towards non-statutory provision with funding
structures and responsibilities defining more
responsive localised services.
Successive governments have sought to
make these services more efficient through
competitive tendering for an ever-decreasing
pot of resource.
This competitive process has served to
fracture previously healthy collaborative
relationships within the voluntary sector,
generated unhealthy tension and created
pervasive anxiety, not only for those working
within organisations that provide services,
but also – and more importantly – for the
recipients of those services.
Views of users and carers
The impact of these cuts has not only resulted
in the voluntary sector’s inability to plan
strategically for the medium term but also in
anxiety and anger for the people who wish to
use their services:
‘Lack of government funding for the
voluntary sector really gets my blood
boiling; poor strategy and reduced
services. It all adds up to a very shortsighted and blinkered approach which, in
the long run, has huge costs.’
Service user
Service users have identified a perception
that the local partnership trust seems to have
had difficulties with implementing change,
financial problems, shortages of nursing staff
and an over-reliance on agency staff who
generally do not know the service users they
are caring for.
There is a real concern about the premature
discharge of individuals from hospital.
Proposed reasons for this included lack of
funding, but more specifically a shortage of
hospital beds.
A largely unseen effect of service reprovision
is the effect upon the role and responsibility
of the carer. In the absence of a consistent
statutory safety net, informal carers become
the primary backstop when things go wrong:
‘Carers unable to work when services
diminish as carers will have no choice and
will have to become more involved, when
mental health issues become unstable
due to lack of support!’
Carer
As this comment suggests, carers often
have no choice, and often provide both
emergency, out-of-hours assistance, and dayto-day support, which invariably impacts upon
their own economic productivity, and potential
stress.
The financial costs of caring can be
significant. Research by Carers UK (2004)
found that 72% of carers are worse off
financially as a result of becoming carers,
are over twice as likely to have mental health
problems if they provided substantial care
and twice as likely to be ‘permanently sick or
disabled’ compared to those not caring.
Concerns were expressed about future
provision of advocacy services and the
communication with essential voluntary
services and the replacement of local
involvement networks (LINks) with HealthWatch
was said to be both ‘expensive and
unnecessary’ rather than extending the role of
LINks, which was originally proposed by New
Labour.
‘When I am unwell, I don’t have enough
support.’
Service user
‘Services have been cut back, and are
affecting my routine and activities.’
Service user
Participants suggested that there is not
enough provision for advice on welfare benefits
and housing related support, and that the
‘one-stop’ gateway ‘single-access referral’,
in which there is no specialist mental health
services available through its process, is not
working well. Errors and misunderstanding
were reported that were perceived as costly,
unnecessary and wasting everyone’s time.
In primary care there is concern with general
practitioners who are said to be generally
difficult to access and both unavailable and
unhelpful when needed. It appears that it is the
family, voluntary sector or non-mental health
services that people turn to in these situations:
‘I had to find the help that I needed from
my advocate and couldn’t find it through
my consultant psychiatrist or GP. The
services that I could take part in and the
help that I needed that would benefit me.
Lack of understanding through GP and
consultant psychiatrist.’
Service user
‘When the doctor’s surgery is closed and
you just want someone to talk to apart
from focus line, there is no support.’
Service user
This highlights a perceived lack of support
from primary care and social services, and
particularly out of hours and at weekends,
where again, carers and family members
provide the safety net.
Service users and cares perceive
unresponsive and inconsistent primary care
services to be contributory to the need for
crisis interventions, hampering considered,
well-formulated strategies for care that
anticipate care needs.
The Leicester City Joint Commissioning
Strategy for Mental Health 2011-2013
identified that people who experience mental
health problems still encounter significant
difficulties in their daily lives, experience
gaps in services and variation in the support
available to them.
The document recognises that ‘for too long
many people have had to wait too long for
treatment, many find that they are not treated
as individuals or with dignity and respect,
and services are not as well aligned as they
might be to meet the diverse needs of local
communities’.
It is not surprising therefore to find that
these astute observations are underpinned by
the experiences and consequent viewpoints of
people who use services on a regular basis.
Study participants reported that the
23
Austerity special
importance of a stable home environment
with a mix of personal and shared space was
a cornerstone of recovery and good mental
health.
Supported housing is seen as a positive
long-term solution for both service users and
the people who care for them, providing a safe
place to nurture the survival skills necessary
to become a more independent and productive
member of the community and thus reducing
the likelihood of intervention by statutory
services.
When service reconfigurations threaten
the possibility of someone’s ‘home’ ceasing
to exist, this creates anxiety, insecurity and
undermines good mental health:
‘Living in shared housing benefits us, and
there are less admissions to hospitals.
Living in a smaller shared house gives
support workers time to see each one of
us.’
Service user
The notion that meaningful and worthwhile
daytime activity is a costly and complex
process was overturned by participant views
that highlight seemingly simple things that
are working well and protect good mental
health, such as talking, playing cards, bingo
and games, music and poetry, art, yoga,
concentration games, trips out, leisure cards,
newspapers and using computers and walking
groups.
Drop-in facilities work well and provide the
basis for social interaction (SUCRAN 2011b;
2012), and for some, the only opportunity to
meet with other people.
The isolation of living alone was highlighted
by a number of participants and the benefits
of just getting out of the house, meeting
and mixing other people was highlighted
consistently.
Participants seek peer support and
someone to talk in the absence of formal
help. Implicit in these comments is a theme of
loneliness and the importance of being able
to socialise in an environment that is safe and
comfortable.
The importance of social contact facilitated
by the voluntary sector in Leicester cannot be
underestimated, and it is clear that something
as simple as human contact seems to be
averting intervention from statutory services
including hospital admissions, preventing
isolation and promoting friendships that form
the glue of a cohesive community (SUCRAN
24
2011b; 2012).
The studies uncovered palpable anxiety
surrounding the future of services that are
currently in place, and both service users and
carers feel powerless to save those which
have been earmarked or under threat of
closure:
‘All the varying activity groups (arts,
crafts, etc). The drop-ins (especially when
people are feeling low – they can come
in and have a chat), a place for people to
go to (local and easy to get to), friendly
where people feel comfortable, peer
support available.’
Service user
Loneliness for people with mental health
conditions and older people is a public health
issue in its own right that is being directly
tackled by the voluntary provision.
Research suggests that nationally five
million people say the television is their main
company, while 12% of older people feel
trapped in their own home (Masi et al, 2011).
The importance of social contact facilitated
by the voluntary sector in Leicester cannot be
underestimated.
Comparison with strategic aspirations
When considering the views that service users
and carers have expressed, and comparing
them with aspirations of the mental health
strategy for England No Health Without Mental
Health (Department of Health, 2011), provider
organisations have been charged with the
responsibilities of ensuring good mental and
physical health, recovery, respect, dignity and
compassion, positive experiences of care,
avoidance of harm, stigma and discrimination,
which chime harmoniously with the wants and
needs expressed by service users and carers.
What is wanted and what should be
provided are wholly compatible. However,
when we overlay the variables of change,
financial prudence and increasing user
expectations, we find ourselves in a position
where both statutory and voluntary services
are precariously scrapping for diminishing
resources, and the people who receive
services are understandably anxious about the
inevitable reductions in the provision they rely
upon.
Service users have over time been guided
by government policy to depend upon the
voluntary sector for significant elements of
care, but this is increasingly under threat and
the anticipated loss of the support required to
survive in the community is causing genuine
worry, if not mental ill health.
This loss incorporates housing, welfare
benefits, help for families and carers, and even
the most basic social opportunities for this
vulnerable group.
The importance of a stable home
environment with a mix of personal and shared
space is a positive contributor to recovery and
good mental health. Conversely, when service
re-disorganisation threatens to take away
someone’s ‘home’ this undoubtedly has a very
negative effect, creating anxiety and insecurity,
and undermining good mental health.
The voluntary sector has been thrust into
a world of competitive tendering where price
not quality is the key to success, and this has
resulted in it ‘eating itself’.
Infighting, disinformation, loss of trust and
respect are all outcomes undermined further
by unstable local authority and health provision,
which is staffed by demotivated workers who
are exhausted by their internal struggles and
reluctant to innovate or be creative beyond
their minimalistic checklist-driven routine.
As the erosion of the voluntary sector
progresses, we will no doubt see an increased
demand for statutory services in both primary
and secondary care, which obviates any
potential savings that may have been made.
Demand for care and support will remain,
but without the basic pillars of community
support we will no doubt see an increase in
disenfranchised, vulnerable, lonely, ex-service
users with nowhere to go and no opportunities
for their voices to be heard.
Safe and supported housing is a critical
element of good mental health and a wholly
positive long-term solution for both service
users and the people who care for them.
Supported housing provides a safe place to
nurture the survival skills necessary to become
a more independent and productive member
of the community and reduces the likelihood of
intervention by statutory services.
When things do go wrong the opportunity
for alternatives to hospital admission should be
available in the community and might include a
range of crisis, recovery, respite and ‘halfway’
accommodation.
Better awareness and education of NHS
staff such as those in general hospitals and
importantly GPs is needed to coordinate the
earliest possible intervention.
This, coupled with improved communication
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between professional disciplines and the
third sector, would improve the experience of
service users and carers. Better information
sharing will go some way to ensure continuity
and that appropriate care packages are in
place before discharge and that discharge is
a considered process driven by patient need
rather than bed occupancy issues.
When we consider daytime activity and
education, we see that simple low-cost options
work well, and emerging from this review is
the belief that people need social interaction
followed by care and support, followed by
learning and education, assuming they have
a place to live from which to extend this
activity – and the importance of social contact
facilitated by the voluntary sector in Leicester
cannot be underestimated.
Summary
The loss of services and the impact of service
redesign has resulted in the voluntary sector’s
inability to plan strategically and in problems
for the people who wish to use those services.
Drop-in centres give people a purpose and
meaningful activity, but in the absence of
services informal carers become the primary
backstop when things go wrong.
Listening to service users and carers is
very important to ensure provision of services.
Raising awareness of mental health issues
to challenge stigma is also important, and
providers need to develop sensitivity and
competence to effectively communicate and
meet the diversity of the people of Leicester.
References
Carers UK. (2004) In Poor Health: the impact of caring on
health. Carers UK: London.
Department of Health. (1989a) Caring for People:
Worry was a consistent theme identified by
service users, which emerged parti dcularly
when considering finance and benefits.
For people who use services it is important
for their expertise about their own condition
to be recognised if we are to have true
partnership in care, and multidisciplinary teams
should positively embrace service user and
carer views in formulating plans.
The Joint Commissioning Strategy for
Mental Health 2011-2013 strongly suggested
that local access to mental health support
is important with convenient opening hours,
parking, meets specific cultural and religious
requirements, and provides good disability
access and public transport links.
The study asked what types of services
would meet service user and carer needs.
Overwhelmingly, group support, drop-in
services, community based individual and peer
support services, together with education,
topped their survey.
Furthermore respondents felt it was
important to be able to choose the services or
packages of support that would help maintain
their mental wellbeing if they were given
the money to do so. The SUCRAN studies
underscore these findings and demonstrate
consistency in the wishes of people who use
services and their carers.
The Mental Health Alliance Convention
Report 2011 highlighted a demand for
increased choice and involvement to overcome
a perceived lack of understanding and support
for carers, and in particular, poor recognition
Leicester City NHS. (2011) Joint Commissioning Strategy
Mental Health 2011-2013. Leicester City NHS:
Leicester.
Masi CM, Hsi-Yuan C, Hawkley LC, Cacioppo JT. (2011)
of carers’ own mental health needs and
respect for their views regarding those they
care for.
Both service users and carers preferred
voluntary sector styled services and wanted to
see more investment in this area. They found
these to be more flexible, responsive and
empathic, and the majority of service users
were unhappy with hospital-based services.
Involving service users in service design,
delivery and care will increase self-efficacy
and the internal locus of control required
to promote recovery, improve self-esteem,
raise awareness of oppressive practice and
improve the person’s belief. Furthermore, it will
increase the ability to have power, influence or
control over physical, psychological, spiritual
and social aspects of health.
Little appears to have improved in the last
10 years and the observations of Dooher
and Byrt (2002) and Dooher and Byrt (2003)
are still apposite in that there is a need for
professional willingness to empower service
users and carers in individual care, service
delivery, health policies and wider society.
There needs to be better communication
and relationships, a shift in professional
cultures and attitudes underpinned by real
consultation based upon full information.
The consistency and strength of service
user and carer views highlights the need
for strategic planners to listen and make
commissioning or decommissioning decisions
that limit the negative impact for the people
they serve. MHN
centre/services-for-business-sucran.aspx (Accessed 1
November 2013).
SUCRAN. (2011b) Improved Access to Psychological
Therapy: Report. SUCRAN. Leicester. Available at:
Community Care in the next Decade and Beyond.
A Meta-Analysis of Interventions to Reduce Loneliness.
https://preview.dmu.ac.uk/research/research-faculties-
HMSO: London.
Pers Soc Psychol Rev 15(3): 219-66.
and-institutes/health-and-life-sciences/nursing-and-
Department of Health. (1989b) Working for Patients.
HMSO: London.
Department of Health. (2011) No Health Without Mental
Health: a cross-government mental health outcomes
National Council for Voluntary Organisations. (2011).
Counting the Cuts: The Impact of Spending cuts on the
UK Voluntary and Community Sector. NCVO: London.
SUCRAN. (2009) Service User Experience of Mental
midwifery-research-centre/services-for-business-sucran.
aspx (Accessed 1 November 2013).
SUCRAN. (2012) Evaluation of Service user Experiences
within Mental Health Services in Leicestershire County,
strategy for people of all ages. Department of Health:
Health Provision in Leicester and Leicestershire and
Rutland and Leicester City. May 2012. SUCRAN.
London.
Rutland: A Research Project Designed, Delivered and
Leicester. Available at: https://preview.dmu.ac.uk/
Evaluated by Service Users and Carers. January 2009.
research/research-faculties-and-institutes/health-and-
Participation: Power, influence and control in
SUCRAN. Leicester. Available at: https://preview.
life-sciences/nursing-and-midwifery-research-centre/
contemporary healthcare. Quay Books: Wiltshire.
dmu.ac.uk/research/research-faculties-and-institutes/
services-for-business-sucran.aspx (Accessed 1
Dooher J and Byrt R. (2002) Empowerment and
Dooher J and Byrt R. (2003) Empowerment and Health
Service User. Quay Books: Wiltshire.
Dooher J and Byrt R. (2003) The Concept of
Empowerment. In: Cutcliff J and McCenna H. Conceptual
Issues in Health. Palgrave Macmillan: Hampshire.
Griffiths R. (1988) Community care: agenda for action.
Department of Health and Social Security: London.
health-and-life-sciences/nursing-and-midwifery-researchcentre/services-for-business-sucran.aspx (Accessed 1
November 2013).
SUCRAN. (2011) Mental Health Charter Audit. August
November 2013).
SUCRAN. (2013) Mental Health Pre Summit Responses
and Report for Jon Ashworth MP. SUCRAN. Leicester.
Available at: https://preview.dmu.ac.uk/research/
2011. SUCRAN. Leicester. Available at: https://preview.
research-faculties-and-institutes/health-and-life-sciences/
dmu.ac.uk/research/research-faculties-and-institutes/
nursing-and-midwifery-research-centre/services-for-
health-and-life-sciences/nursing-and-midwifery-research-
business-sucran.aspx (Accessed 1 November 2013).
25
Austerity special
Challenging austerity policies:
democratic alliances between
survivor groups and trade
unions
Mick McKeown and colleagues examine the reality and motives behind the austerity
policies of government, and consider some activism-inspired remedies and challenges
Mick McKeown
Principal lecturer, School of Health,
University of Central Lancashire
Correspondence:
[email protected]
Fiona Jones
Researcher, EmPowerMe,
Community Futures
Helen Spandler
Reader in mental health,
School of Social Work,
University of Central Lancashire
Abstract
This paper offers a critique of austerity
policies in a context of mental health
and contemplates some activist-inspired
remedies.
Key words
Austerity, policy, mental health, activism,
trade unions
Reference
McKeown M, Jones F, Spandler H. (2013)
Challenging austerity policies: democratic
alliances between survivor groups and
trade unions. Mental Health Nursing
33(6): 26-9.
Introduction
This paper offers a critique of austerity
policies in a context of mental health
and contemplates some activist-inspired
remedies.
These policies of austerity powerfully
stalk the globe, preying on the poor, weak
and vulnerable, redistributing their meagre
assets wholesale to the pockets of the
rich and super-rich while simultaneously
stigmatising and blaming the victimised for
their predicament.
In times like these, mental distress
escalates, social solidarity is purposively
and divisively undermined and psychiatric
services mop up their share of the
dispossessed and can be seen to function as
a safety valve on protest and dissent.
Wherever such power is exercised,
however, there is also resistance. Here we
present an argument for the value of alliances
between organised mental health care
workers in trade unions and self-organised
survivor groups.
Despite significant barriers to success, we
remain optimistic that efforts in this direction
offer the ideal means of resisting austerity
policies and could also herald a democratic
transformation of the social relations of care.
Austerity: policy ‘madness’
Let us be clear, there is no uncomplicated,
economically rational justification for the UK
coalition government’s politics of austerity.
The irrationality of these policies in
economic terms suggests the architects of
26
austerity are simply confused, completely
cynical or perhaps delusional.
There is also a need to be semantically
clear, this is not ‘austerity’ – it is robbery,
plain and simple: a massive redistribution of
wealth from the less endowed classes to the
most affluent (Kushner and Kushner, 2013).
The latest UK Office for National Statistics
data show the wealthiest 10% of the
population holds 44% of all wealth, and the
poorest 50% of households only have 10%.
Such inequalities are most strongly
associated with the existence of key social
problems, poor educational attainment, and
– crucially – deleterious effects on public
health (Wilkinson and Pickett 2009).
In the countries where austerity policies
have hit hardest (such as Greece) suicides
rates have risen sharply (Kentikelenis et al,
2011).
It is a glaring paradox that some of the
wealthiest multinational companies, the
banks, did their best to wreck the global
economy and have been to a large extent
rescued by state bailouts and quantitative
easing.
The politics of austerity insist that the
foolhardy errors of speculatory finance
We need to be
clear: this is not
‘austerity’ – it is
robbery, plain
and simple
Austerity special
(in effect, gambling) are to be paid for by
savage cuts in welfare and public sector
spending.
Before the so-called banking crisis
the UK economy was fairly buoyant and
mental health and other public services had
experienced a significant period of growth.
Levels of public spending or high levels of
borrowing to pay for it were not responsible
for the economic collapse nor are they
essentially problematic in economic terms.
The national debt as a percentage of
GDP has been consistently higher than it is
now in 200 of the last 250 years and our
current levels of public debt are relatively low
compared with other developed countries.
Scaremongering about the ‘deficit’ and
attempts to ‘cure’ it rapidly using the singular
weapon of spending cuts is mistaken
economics and can only really be explained in
terms of ideology (Krugman, 2012).
The ideology in question is
neoliberalism, an economic philosophy
that views unregulated market forces as
unarguably virtuous and public spending
or state intervention as the enemy of
entrepreneurialism and growth.
Since the late 1970s all UK political parties
have embraced this philosophy to a greater
or lesser extent, reaching an apotheosis with
the current coalition.
The irony is that the global financial
crisis and its obvious causes ought to
have sounded the intellectual death knell
of neoliberalism, yet its hegemony remains
strong; surviving to roam zombie-like,
continuing to visit its destructive force in
the privatisation and marketisation of public
services (Quiggin, 2010).
That this state of affairs can persist speaks
of the relative weakness of the organised left
and an unholy trinity of multinational firms,
right-wing governments and mass media,
who propagate the myth that public spending
is the cause rather than the fall-guy of the
banking crisis (Crouch, 2011).
Progressive economists and even some
within the International Monetary Fund (IMF)
now question the haste with which the
government has pursued deficit reduction.
Others on the left go further, and argue
that measures such as progressively
taxing the wealthy; getting to grips with
tax evasion and the flight of capital to tax
havens; introducing new taxes on financial
transactions (the so-called ‘Robin Hood Tax)’;
or cancelling expenditure on Trident would
all be more effective ways of reducing debt
and, crucially, would leave our public services
intact.
Mental health as a collective public
health concern
Mental health is an important public health
issue for a number of reasons (Herrman et
al, 2005).
Aside from the individual and collective
costs of unchecked emotional and psychic
distress, the goal of mental wellbeing
has wide appeal and is arguably of great
importance for community cohesion and
economic productivity.
Mental ill-health is a major source of
economic burden (Wittchen and Jacobi
2005, McDaid and Park 2010); economic
disadvantage either precipitates or is
associated with widespread mental
distress (Saraceno et al, 2005); and urban
environments are particularly pathogenic
(Martins et al, 2012).
Addressing the social disadvantage relating
to compromised mental health has been a
key focus of European and UK health policy
for some time (Knapp et al, 2007, JanéLlopis and Anderson, 2005; Sayce, 2001;
McKeown and Jones, in press) and in these
times of austerity remains a crucial concern
(McDaid and Knapp, 2010).
Widespread stigma and discrimination
exacerbate negative experience of mental
ill-health and contribute to inequalities of
access to health care services across the
board (Wahlbeck and Huber, 2009; McDaid,
2008); this can be plausibly framed as a
human rights issue (Burns, 2009).
The framing of social policy objectives
in terms of public health was central to the
foundational mission of the NHS and wider
welfare state and has, despite obvious
overtones of paternalism and control,
typically been associated with progressive
demands for societal and service-level
change.
Not least, this has involved analyses that
point to social causes of ill health and argue
for broad-based interventions that tackle
inequalities, particularly in terms of access to
economic resources for poor communities,
as upstream measures for the promotion of
better health.
Welfare benefits, social housing, free
education and the health service are all
The proposals
to deliver deficit
reduction are
an unnecessary
public health
hazard
important bulwarks against the forces of
misery in society, recognised by Beveridge
as the five giants: want (poverty), idleness
(unemployment), disease (ill-health),
ignorance (lack of education) and squalor
(poor housing).
Here we argue that the current
government’s proposals to deliver deficit
reduction via massive public spending cuts
constitutes an unnecessary and serious
public health hazard by undermining, perhaps
fatally, the state’s defences against social ills.
Beyond the state, mental health activism
has been organised to demonstrate the
effectiveness of alternative systems of
mutual aid, social capital and enterprises.
Such participation, cooperation and
peer support can promote and consolidate
wellbeing, challenge stigma and interact
productively with other forms of community
activism to deliver more pro-social, inclusive
communities and cities (Sennett, 2012; Amin,
2006; Fetchenhauer et al, 2006).
However, these initiatives need to be
supported and nurtured by public funding,
and sit alongside state provided welfare
provision (not replace it).
Significant commentators such as the
World Health Organization and UK mental
health charities have consistently warned
that recession is bad news for public mental
health, heralding significant increases in
mental ill-health and suicide, especially
among the poorest in society.
These worries are backed up with evidence
from previous periods of economic downturn,
which resulted in just such rises in the
incidence of mental distress and increasing
demands placed upon services.
If health care is rightly seen as a public
good, then neoliberalism will inevitably fail to
deliver equity and fairness.
The reorganisation of the NHS, predicated
on the rhetoric of reducing public borrowing,
has no guarantee of actually saving money,
with transaction costs attendant on servicing
the market, rather than direct care, likely to
27
Austerity special
Service users
may find it
difficult to find
solidarity with
workers they
blame for
service failings
increase significantly.
The suspicion remains that this
‘restructuring’ of the NHS and wider welfare
is less about balancing the budget and more
about wholesale retreat from state provision.
In mental health, this could mean what is
left of state provision will merely be about
control and coercion, not support and care
(we have already seen rates of involuntary
detention and the use of community
treatment orders increase).
Turning the tables on the austerity
advocates
These forces antithetical to mental health
can be resisted if communities, service users
and trade unions similarly unite to defend the
institutions of welfare.
Campaigning and activism contributed to
the establishment of state welfare in the first
place, with various socialist groupings and
trade unions in the vanguard.
It is encouraging that recently, trade
unions such as Unite and Unison have been
developing organising strategies that are
more thoroughly engaged with community
politics and activism.
These more reciprocal and relational
forms of trade union organising offer greater
potential to transcend differences and
conflicts between worker and service user
interests.
The rise of welfare has been matched
by the evolution of an emancipatory social
movement of patients. Service user and
carer focused movements agitate and
organise for transformations in both wider
society and specifically within the context
of health care provision; most notably in a
challenge to the privilege and exercise of
medical expertise and power.
The latter critique is supportive of public
health principles that reject the narrow illness
focus of biomedicine.
Service user activists, staff and people in
local communities have, on occasion, come
28
together in radical alliance for example, in
the formation of the Mental Patients Union in
the 1970s (Spandler, 2006).
As much as these alliances have been
about the defence of particular units
against closure or privatisation, they almost
always involve challenges to practitioner
power, control over decision-making or the
organisation of services.
Peter Sedgwick (1982) previously
remarked upon shortcomings among
trade unions, workers, and the wider left in
identifying common interests with mental
health service users and how social change
might be enacted on this basis.
Indeed, the labour movement has not
always covered itself in glory on mental
health territory, and their various interests
have often conflicted (Warner, 2013).
As cuts in services bite it is possible that
service users might find it difficult to realise
solidarity with groups of workers they blame
for service failings.
However, we would argue that, ultimately,
service users and workers do have common
interests and these alliances should
form the basis, not only of resistance to
welfare cuts, but also to a progressive and
democratic transformation of the mental
health system itself.
The extent to which trade unions are
fully prepared to take up these challenges
is open to question, especially with regard
to their internal organising, hence the calls
for renewal of organisational structures and
processes.
It has been persuasively argued that
historical forms of mutual support have been
curtailed as members become dependent
and over-reliant on a servicing model of
organisation.
One possible solution, to enhance the
role of lay activists, risks burnout for the
committed. Other approaches promote
thinking about mutual support over a range
of issues; not all immediately recognisable as
union objectives but placing the emphasis on
connections between community concerns
and trade union activity.
Traditional unions, faced with
technological change, fragmentation of
workplaces and globalising economies, have
been urged to form more broadly based
political alliances.
Progressive commentators on trade union
organising describe a notion of insurgent
social capital to help explain the mobilisation
of personal resources, solidarity and interconnections that can result.
Such ideas have led to the development of
inward facing models of organising focused
on strengthening relationships between
members and outward facing approaches
such as ‘reciprocal community unionism’.
In the latter model, trade unions mobilise
resources in support of community
campaigns and the community comes
together to participate in union campaigns.
Examples of alliances of this sort include
campaigns by Citizens Groups for a Living
Wage, mobilising a very broadly based
coalition of trade union and community
groups.
Arguably, these initiatives cascade
activists’ dynamism into other fields, for
instance increasing participation in local
democracy, or other campaigning, such
as the protection of employment rights
for those at the margins of the waged
economy, including immigrant and disabled
workers.
Proponents of trade union renewal
such as Richard Hyman (2007) argue that
trade unions can reclaim themselves as
campaigning organisations concerned with a
politics of contention.
But this is inextricably linked to the
very identity of unions which is mediated
by the ways in which they communicate
internally and externally, at once becoming
more visible to their membership and the
community at large.
In this sense unions are concerned with
discourse and actions that are more likely
to define the union in progressive terms,
promote affinities and relationships, and
challenge any prevailing negative public
image.
In the achievement of this positive,
community oriented identity, the unions
can find outlets for cooperative activism
around common causes, put aside divisive
internecine tensions and attempt to build new
democratic relationships between activists
and leadership, and service users and
workers.
Benefits will be maximised if all parties
make progress towards establishing alliances
in advance of any dispute or campaign,
so that solidarity can be relied upon with
confidence rather than built from scratch
every time it is needed.
Austerity special
Towards a new democracy
In conclusion we contend that the
government’s policies are a major threat to
the survival of the welfare state as we know it
and pose a massive and concerted attack on
collective health and wellbeing – not least in
the field of mental health.
The NHS was arguably forged by
social movement activity, is defended by
movements against market reforms, and is
challenged at the very point of care provision
by an emergent, radical user movement.
This melting pot of often seemingly
conflicting interests should not be used as an
excuse to cut services and support.
Rather it affords opportunities for workers,
community, and user activists to come
together in productive alliances to resist the
obvious challenges of the cuts and neoliberal
dismantling of universal welfare (McKeown et
al, in press).
More importantly, perhaps, such alliances
open up the possibilities for dialogue and
critical thinking about a new politics of
mental health, more equitable power relations
and alternative service configurations that
more adequately give expression to the
transformational goals of the service user/
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29
Austerity special
The age of austerity:
the impact of welfare
reform on people in the
North East of England
Andrew Clifton and colleagues report the headline findings of a study to explore
what impact the coalition’s welfare reforms are having on people in the North East
Andrew Clifton
Senior lecturer in mental health nursing,
University of Huddersfield
Correspondence: [email protected]
Joanna Reynolds
Senior lecturer, Northumbria University
Jennifer Remnant
PhD candidate, Newcastle University
Jane Noble
Senior mental health development
worker, North Tyneside Mental Health
Forum
Abstract
This paper outlines the main findings
of a collaboration between university
researchers and mental health service users
to determine the impact of welfare reforms
on people in the North East of England.
For many people who participated, the
reforms have had a significant impact on
their financial, psychological and emotional
wellbeing.
Key words
Austerity, mental health, Welfare Reform
Act, benefits, welfare reform
Reference
Clifton A, Reynolds J, Remnant J, Noble
J. (2013) The age of austerity: the impact
of welfare reform on people in the North
East of England. Mental Health Nursing
33(6): 30-2.
30
Introduction
According to Mark Carney, the Governor of the
Bank of England, the UK economic outlook is
getting brighter: ‘For the first time in a long
time you don’t have to be an optimist to see
the glass is half full. The recovery has finally
taken hold’ (Carney, 2013).
Unemployment is falling; as have interest
rates and GDP growth has been upgraded
from 2.5% to 2.8% for the year 2014.
Yet despite these ‘green shoots of
recovery’, as a result of the impact of
government austerity measures and social
policy decisions, the outlook for millions of
citizens remains bleak.
The Welfare Reform Act received Royal
Assent on 8 March 2012 and legislates for the
biggest change to the UK welfare system for
over 60 years.
The coalition government is looking to
reassess all those on Incapacity Benefit
(IB) with a new test, the Work Capability
Assessment (WCA), which measures a
person’s entitlement to Employment and
Support Allowance (ESA).
Eighteen months on there is much
anecdotal evidence suggesting the reforms
are having a negative impact on the economic
status and wellbeing of mental health service
users. In particular the WCA is causing fear
among many mental health service users due
to the nature of the testing procedure carried
out by the healthcare firm Atos, which has the
responsibility of identifying the people on IB
who are deemed ‘fit for work’ (Domokos and
Butler, 2012).
As recently as 22 May 2013 two people
with mental health problems won a legal
challenge in the High Court claiming the WCA
test would discriminate against them, with
the judge stating the test puts people with a
mental illness at a ‘substantial disadvantage’
(BBC, 2013).
Against this background, a collaboration
between researchers from Northumbria
University and mental health service users was
established to explore what impact, if any, the
welfare reforms are having on people in the
North East of England.
A discussion on the nature of the
collaboration is reported elsewhere (Clifton
et al, 2013) and this article will provide a
summary of the main research findings.
Ethical approval was granted by the Faculty
of Health and Life Sciences Research Ethics
Review Panel, University of Northumbria, the
employer of the researchers, and a mixed
methods design was used incorporating two
key methods: use of a questionnaire plus focus
groups to collect data for further analysis.
Findings
A total of 15 participants completed the
questionnaire and attended a focus group one
week later. A summary of research findings is
presented below.
The current system is inaccessible and
non-inclusive for us
The participants discussed the different ways
in which the system prevented or challenged
their engagement with it.
Austerity special
The different component parts of the
system (the ESA application form, WCA and
tribunals) function separately from each
other, and not as a joined-up system. This
means that people who are making an ESA
application have to abide by each part of the
system’s own set of requirements.
Some of these requirements seem to be in
direct conflict with each other; for example,
some service users talked about being turned
down for ESA, because they were deemed fit
to work, but when they went to the Job Centre
to look for work, they were refused the right
to sign on because the Job Centre deemed
them unfit to look for work.
The participants (many of whom are
educated to undergraduate and postgraduate
degree level) stated that the communication
within the system also prevents engagement;
the letters they receive and the forms to
complete are not written in plain English and
do not provide clear information:
‘The government letter – why they can’t
give you letters in English… instead of
big words… The way they put their form
– their government words – and, like,
long words… instead of just putting them
in plain English.’
Participants
spoke about
increased
anxiety, dread
and distress
Participants explained that an independent
insurance company has been commissioned
to conduct the ESA assessments with
applicants, and that the staff completing the
assessments with applicants are on financial
incentives, where the more people they
deem fit to work, the more commission they
receive.
Participants described feeling judged and
seen as a ‘scrounger’ by the staff conducting
the WCA interview. They stated that the WCA
questions, and the person asking these
questions in the interview, were unempathic
and did not treat them as an individual with
their own specific set of needs and abilities.
Instead, participants talked about being
‘shoehorned’ into categories that are an
incorrect ‘fit’.
Because of the target-driven nature of
the WCA part of the system, participants
experienced a strong sense of being rushed
through the system and reflected that
individuals are not looked at in their own
context or as their own individual case:
‘It can’t be right that the people who are
assessing you are going to make financial
gain out of you…’
Not only is the system described as
inaccessible, but participants talked about the
fact that once people are within the system,
they are ‘trapped’ and not supported to exit
the system.
Participants discussed the current
government policies and the role these are
playing in this lack of support for service
users to exit the system, as the following
conversation from the focus group illustrates:
‘With support and adequate provision
there are people who can contribute
to society. I personally value everyone
in their social role. Unfortunately
government policies don’t seem to do
this.’
‘Which is actually quite ironic since
Mr Cameron brought through the Big
Society, isn’t it really?’
31
Austerity special
‘Yeah, we’re all in the same boat
apparently.’
‘And George Osborne said we’re all in it
together.’
‘And I would like to know as well the
impact on the North East that closing
Remploy has. Because I think that it’s a
disgrace. It really is.’
The system makes us more ill
Participants talked about the cyclical nature of
the system, describing it as a ‘revolving door’
or ‘vicious cycle’ of forms, appeals, tribunals
and reassessments.
They talked about the increased anxiety,
dread and distress that they experience within
this constant cycle. Unsurprisingly, this has
a significantly negative impact on their health
and wellbeing.
They describe a system that is designed
to gather evidence of incapacity and this is
in direct opposition to their own treatment,
and personal, goals of improvement and
development, with a more solution-focused
approach to their mental health and wellbeing.
The cyclical nature of the system means
that the applicant undergoes constant
questioning, both within the system and selfdirected questioning, e.g. ‘am I better?’
The ESA forms are annual but the tribunal
to appeal the decision of ESA can take six
months, so it feels like every six months
there is a reminder for people: ‘How far have
I come?’, ‘Am I better yet?’ – and this has a
detrimental effect on their sense of being able
to progress:
References
BBC. (2013) Two win sickness benefit test legal
challenge. Available at: www.bbc.co.uk/news/uk22620894 (Accessed 22 May 2013).
Carney M. (2013) Bank of England Inflation Report,
12 November 2013. Bank of England: London.
Clifton A, Noble J, Remnant J, Reynolds J. (2013)
‘Co-production, collaboration and consultation: the
shared experiences of a third sector organisation
and researchers in the North East of England.
Mental Health Nursing 33(3): 23-6.
Domokos J and Butler P. (2012) Mental health
of benefit claimants is put at risk by welfare
reform. The Guardian 12 June 2012. Available
‘Well, I got my ESA 50 through last
September. Six months after my tribunal.
And I spent 24 hours crying. Because I
thought, “Oh, well how was I meant...?
Was I meant to be better by now?” I
hadn’t come as far as I wanted to be.
It makes you ill. It makes you worse. It
makes you ask questions about yourself
that... That you wouldn’t ask. It’s not right.
It makes you doubt yourself. It makes
you think: “Am I lying? No. What’s wrong?
Am I ever going to get better? Am I going
to have to go through vicious circle
again? Is this the beginning of another six
months of assessments and tribunals and
meetings and forming statements and...?”
You despair.’
The financial implications for participants in
the system, as they describe in the following
section, also have significant negative impacts
on their health and wellbeing.
The system makes us poorer financially
Many participants discussed the negative
impact of the system on their finances and
their ability to live day to day.
Within the system, participants are required
to call premium rate telephone numbers and
pay for medical reports/assessments. When
benefits are suddenly removed or severely cut
(if they are deemed fit to work following their
ESA application), appeals and tribunals are
required before benefits can be reinstated,
and during this period (often of six months),
people will accrue significant debts in order to
live day to day:
‘[When I was initially declined on
my second assessment my money
stopped]… I had to get everything
reinstated. But then I was back at the
assessment rate until my tribunal, which
was six months away. So I’m then on the
lower rate – even though I was previously
being awarded the higher rate… And
it was only once... my decision was
overturned at tribunal. I got the arrears
paid back – which is a hefty sum… And
you suddenly realise this... That money – I
didn’t see any of it, because I had to pay
back the debts that I’d accrued over that
time.’
at: www.guardian.co.uk/society/2012/jun/20/
mental-health-benefit-claimants-risk (Accessed 22
December 2012).
32
‘While people are in that situation, they
can lose their house, they can lose their
marriage. They can lose everything.
[They] get everything paid up, but by the
time they get it paid up – as I say, without
interest – it’s too late… because they’re
on the street. It’s a long period of time
to be without any money… or on less
money than you’re used to getting.’
‘You know, there are people who can’t
afford to eat.’
Participants discussed the multiple
impacts of the different funding cuts within
the recent welfare reform, including the
so-called ‘bedroom tax’, NHS cuts (meaning
participants are waiting up to 18 months
for a psychiatry appointment) and the cuts
to, or total removal of, funding for third
sector organisations, who are typically the
organisations who provide the vital support
and provision for people’s mental health and
wellbeing.
Participants suggested that these
compounding factors are likely to result in
increased psychiatric hospital admissions, and
an increase in crime rates:
‘No, I was just thinking that a lot of the
cuts already on – around the benefits and
everything else – I think it’s going to see a
bigger rise on the population of prisons…
and some hospitals.’
Conclusion
In this article we have presented a summary
of findings resulting from a collaborative
consultation examining the impact of welfare
reforms on people in the North East of
England.
These are the experiences of real people
who on a daily basis have to endure the
significant impact the reforms are having on
many individuals throughout the UK.
Time will tell the nature and extent of the
current welfare reforms on mental health
service users.
However, without a shadow of a doubt, for
many of the people who participated in this
study these reforms have had a significant
impact on their financial, psychological and
emotional wellbeing.
The coalition government’s current mantra
is that reforming the benefit system aims to
make it fairer, more affordable and better able
to tackle poverty.
However, this perspective does not
reflect the experiences of the people who
participated in this consultation. MHN
Austerity special
The recent global
socioeconomic crisis
and its effects on mental
health in Portugal
José Carlos Santos and John Cutcliffe discuss how the economic downturn seen
across the globe has impacted on the mental health of the Portugese population
José Carlos Santos
Adjunct Professor. Coimbra Nursing
School, Coimbra, Portugal
Correspondence:
[email protected]
John Cutcliffe
Adjunct Professor of Nursing,
University of Ottawa, Canada and
Adjunct Professor of Nursing, Coimbra
Nursing School, Coimbra, Portugal
Abstract
José Carlos Santos and John Cutliffe discuss
how the recent global economic downturn
has impacted on the mental health of the
population of Portugal.
Key words
Austerity, mental health, suicide,
Portugal
Reference
Santos JC and Cutliffe J. (2013) The
recent global socioeconomic crisis and
its effects on mental health in Portugal.
Mental Health Nursing 33(6): 33-5.
Introduction
The recent global financial crisis has had
a huge influence on population health
in many countries as a result of many
factors, namely the transformation of
health systems through more payment from
users; health budget cutbacks and a rise in
unemployment, but also through reduction
in welfare programmes, (in some cases)
severe austerity measures, transformation
in labour markets, and the decline in
official development assistance, which has
increased inequality in health (Ruckert and
Labonté, 2012).
According to Stuckler and Basu (2013:
140): ‘The side-effects of the austerity
treatment have been severe and often
deadly. The benefits of the treatment have
failed to materialise. Instead of austerity,
we should enact evidence-based policies
to protect health during hard times. Social
protection saves lives.’
Mental health and socioeconomics
The World Health Organization (2011)
argues that mental health problems are
related to a range of socioeconomic factors
such as deprivation, poverty, inequality and
Mental health
problems have
increasingly
significant
economic effects
other social and economic determinants of
health.
Further, it asserts that unemployment and
poverty can contribute to depression and
increase suicide risk (WHO, 2011).
Evidence indicates that if you have
financial difficulties, you are two to four
times more likely to have major depression
up to 18 months later (Skapinakis et al,
2006), and suicidal thoughts are three
times more common among those who have
difficulties paying back their debts (Hintikka
et al, 1999).
While there is widespread acceptance
within the associated theoretical and
empirical literature that economic crises
may have pronounced effects on mental
health, the inverse is also acknowledged
whereby mental health problems have
increasingly significant economic effects.
The economic consequences of mental
health problems – mainly in the form of lost
productivity – are estimated to average
3-4% of gross national product in European
Union countries (Gabriel and Liimatainen,
2000).
Furthermore, it should be noted that
after the 2008 economic crisis, rates of
suicide increased in the European Union and
American countries, particularly in men and
in countries with higher levels of job loss
(Chang et al, 2013).
The effects of the economic crisis on
mental health: the Portuguese example
Portugal has high rates of psychiatric
33
Austerity special
PedroSimoes7
morbidity. it is reported that around 16.5%
of the Portuguese population suffered from
anxiety disorders, in the last 12 months of
life, 7.9% from mood disorders, 3.5% from
impulse control disorders, and 1.6% from
substance use disorders, in a total of 22.9%
of people with mental disorders (Almeida et
al, 2013).
Besides this prevalence of mental health
problems, there is also a three-year delay
in the onset of treatment for dysthymia, a
four-year delay for depression and a six-year
delay for bipolar disorder (idem).
The fieldwork conducted in 2010
indicated a high prevalence of mental health
problems and a significant delay in health
responses, which is particularly evident in
so-called depressive disorders.
Similarly, suicide rates in Portugal appear
to have stabilized around 10 per 100,000
people, and they are four times more
common in men than in women (Sociedade
Portuguesa de Suicidologia, 2013).
At an economic level, the unemployment
rate has dramatically increased over the
last few years from 8% in 2000 to 15.6%
in the last three months of 2013 (Instituto
Nacional de Estatística, 2013).
According to the 2013 European Union
Eurostat report, with data from 2011,
28.6% of Portuguese children were at risk
of poverty and social exclusion, against an
average of 27% in the European Union.
34
As for the elderly, 24.5% of people
aged 65 years or more were also at risk,
a number that is clearly higher than the
European Union average (20.5%).
As a result, more and more families are
unable to pay their mortgages, have to give
their houses back to the banks and, in some
cases, have to return to their parents’ home
(Observatório Português dos Sistemas de
Saúde, 2013).
By the end of September 2013, there
were 658,900 families falling behind on
home loan payments (Diário de Notícias,
2013).
In the European Union zone, Portugal is
the most unequal country according to the
Gini index, which measures the distribution
of income. Scoring 34.2 in the Gini
coefficient (the higher, the more unequal),
Portugal is moving further away from the
European Union zone average of 30.5
and the European Union average of 30.7
(Dinheiro Vivo, 2013).
As a result of the adopted austerity
measures, the economy has been
deteriorating, which has had once again an
impact on people.
This is particularly evident in the
unemployment rate, which has reached
unthinkable proportions among young
people and has led to a new reality of
families with all active members unemployed
or families whose oldest family member,
There has been
an increase in
risk factors for
mental health
problems
sometimes already retired, is the only
source of income (Observatório Português
dos Sistemas de Saúde, 2013).
For all of these reasons, there has been
an increase in risk factors for mental health
problems over the last few years, namely
unemployment, family indebtedness, and
social inequalities.
Only 44% of unemployed people in
Portugal receive unemployment benefits,
weakening an essential protective factor in
the area of social security.
Despite the limitations of the data
regarding the impact of the economic
crisis on mental health problems, there are
indications, particularly preliminary data
from a northern region, which point to an
increase of 30% in the cases of depression
between 2011 and 2012 (Barbosa, 2013).
In this period, suicide attempts have
also increased by 47% in females and
35% in males, according to the same
data (Barbosa, 2013). However, this data
should be carefully analysed given the
heterogeneity in recording suicide attempts.
The increase in levels of anxiety and
depression in Portugal has been identified
by different sources, such as surveys on the
perceptions of professionals (Observatório
Português dos Sistemas de Saúde, 2012)
and clinical records by family doctors
(Observatório Português dos Sistemas de
Saúde, 2013).
A further indicator or proxy measure
is that of the use of medication. The use
of antidepressants and mood stabilisers
increased by 7.6%, while the use of
anxiolytics and hypnotics in outpatients
slightly increased by 1.5% between 2011
and 2012 (Observatório Português dos
Sistemas de Saúde, 2013).
In the population over 65 years,
the prescription of anxiolytics almost
doubled between 2011 and 2012, while
antidepressants and mood stabilisers almost
doubled within the same timeframe (IMS
Health, 2013).
The Health in All Policies Statement
Austerity special
Health systems
have not
adequately
responded to
the burden of
mental disorder
(Council of the European Union, 2007),
signed by the Ministers of Health of the
European Union, acknowledged that the
health status of a population is largely
influenced by factors that are external to the
health sector, and that failures in protecting
and promoting the health of the population
have severe economic consequences.
Mental health, however, seems to be
missing from this statement.
In fact there is a need to increase the
mental health budget to reduce the current
clinical and economic burden attributed
to mental health problems (World Health
Organization, 2006), but also to work on the
social determinants of health, across the life
course, and in wider social and economic
spheres, to achieve greater equity and
protect future generations (Marmot, 2012).
In Portugal, the social and family network
may have mitigated the impact of economic
instability on mental health to some extent
(Infarmed, 2013); however, a more thorough
and accurate assessment is needed to
understand the actual impact of the crisis on
mental health.
Meanwhile, the implementation of the
National Plan for Suicide Prevention 20132017 (Direção Geral de Saúde, 2013) may
be essential to prevent and control the
expected increase in suicide rates.
Between 76% and 85% of people
with severe mental disorders receive no
treatment for their mental health problem
in low and middle-income countries and
between 35-50% in high income countries
(World Health Organization, 2011).
User and family associations are
present in 64% and 62% of the countries,
respectively. User associations are more
prevalent in higher income countries – in
83% of high income countries versus
49% of low income countries – as are
family associations, which are present in
80% of high income countries and 39%
of low income countries (World Health
Organization, 2011).
Only 36% of people living in low-income
countries are covered by dedicated
mental health legislation compared to 92%
in high-income countries (World Health
Organization, 2011).
Health systems have not yet adequately
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CIECO118206.html?page=0 (Accessed 1 November
Almeida J, Xavier M, Cardoso G, Pereira M, Gusmao R,
2013).
Correa B, Gago J, Talina M, Silva J. (2013) Estudo
Direção Geral de Saúde. (2013) Plano Nacional de
responded to the burden of mental
disorders; as a consequence, the gap
between the need for care and treatment
and its provision is large all over the world
(World Health Organization, 2013).
Opportunities
While these data seem to paint a rather
bleak picture, it is the view of the authors
that this time can be actually be an
opportunity for mental health nurses, as
periods of economic downturn can be
times of innovation for service delivery and
dynamic changes in roles and skill mix.
Mental health nurses may not realise this,
but they are in a primary or pole position to
give voice to the quality principle and lead
the development of new models of care.
Mental health nurses could develop
innovative new models of care delivery, and
nurses are ideally placed to coordinate the
delivery of care closer to patients’ homes
and along care pathways (Royal College of
Nursing, 2009).
Community care, skill-mix,
psychotherapies, e-health-therapy and
further research need to be reconsidered to
improve the mental health of the population,
and perhaps we, as mental health nurses,
are in a unique position to contribute to and
achieve that. MHN
economic downturn: a roundtable discussion,
October 2009. Royal College of Nursing: London.
Ruckert A and Labonté R. (2012): The global financial
Epidemiológico Nacional de Saúde Mental, 1º relatório.
Prevenção do Suicídio, Programa Nacional Para a
crisis and health equity: toward a conceptual
World Mental Health Surveys Initiative: Lisboa.
Saúde Mental, Direção Geral de Saúde.
framework. Critical Public Health DOI:10.1080/0958
Barbosa A. (2013) O que faz e/ou pode fazer o SNS
antes & depois do hospital. In: Debate preparatório
do 1.º Congresso da FSNS, Porto 21 de Março
2013 – A saúde dos portugueses: antes & depois do
hospital. Porto: FSNS, 2013.
Gabriel P and Liimatainen M. (2000) Mental health in
the workplace. International Labour Office: Geneva.
Hintikka J, Saarinen PI, Viinamäki H. (1999) Suicide
mortality in Finland during an economic cycle, 19851995. Scandinavian Journal of Public Health 27: 85-8.
Chang S, Stuckler D, Yip P, Gunnel D. (2013) Impact of
IMS Health. (2013) Pharmaceutical drug data. [Em
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study in 54 countries. British Medical Journal 347:
imshealth.com/portal/site/ims (Accessed 1
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“Health in all Policies”. [Em linha]. Rome: Council of
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www.salute.gov.it/imgs/C_17_primopianoNuovo_18_
documenti_item Documenti_4_fileDocumento.pdf.
Diário de Notícias. (2013) 660 mil famílias não
conseguiram pagar empréstimos. Available at:
www.dn.pt/inicio/economia/interior.aspx?content_
id=3529036 (Accessed 1 November 2013).
Dinheiro Vivo. (2013) Portugal é o país mais
desigual da zona European Union 16 March 2013.
Available at: www.dinheirovivo.pt/Economia/Artigo/
Instituto Nacional de Estatística. (2013) Instituto
Nacional de Estatística. Available at: www.ine.pt
(Accessed 1 November 2013).
Infarmed. (2013) A Utilização de Psicofármacos no
Contexto de Crise Económica. Infarmed: Lisboa.
Marmot M. (2012) WHO European Union ropean review
of social determinants of health and the health divide.
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Observatório Português dos Sistemas de Saúde.
(2013) Relatório de Primavera 2013. Duas faces
1596.2012.685053
Sociedade Portuguesa de Suicidologia, SPS (2013)
Estatísticas.
Skapinakis P, Weich S, Lewis G, Singleton N, Araya
R. (2006) Socio-economic position and common
mental disorders. Longitudinal study in the general
population in the UK. British Journal of Psychiatry
189: 109-17.
Stuckler D and Basu S. (2013) The Body Economic:
Why austerity kills. Allen Lane: London.
World Health Organization. (2006) Economic aspects
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and Research Department of Mental Health and
Substance Abuse. World Health Organization: Geneva.
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Geneva.
35
Employment
Hunt to freeze pay again
James Lazou reports on the government’s plan to avoid NHS pay rises
and Unite’s efforts to ensure a fair and living wage for staff at all levels
JAMES LAZOU
UNITE
RESEARCHER
Abstract
This article gives an update on
the Pay Review Process and
government plans to withhold pay
increases in the NHS.
Key words
Pay Review Body, salary, freeze
Reference
Lazou J. (2012) Hunt to freeze pay
again. Mental Health Nursing
33(6): 36.
Introduction
This year’s NHS pay round
has been sent into turmoil by
the Department of Health’s
announcement that it will freeze
pay again this year.
Despite Treasury promises
in 2012 of a miserly belowinflation 1% increase for
NHS staff over the next two
years, Jeremy Hunt has now
announced that he wants to
withhold the pay increase
altogether until staff accept
further draconian cuts to their
terms and conditions.
Hunt says that the Department
of Health does not have the
money to spend on staff – yet
his department has just wasted
£3 billion on a reorganisation
that no one wanted, including
spending £1.4 billion of NHS
funding on 32,000 redundancy
pay-offs and letting the Treasury
claw back £2.9billion of
Department of Health funding
over the last two years.
The new system has added
an astronomical level of cost,
36
which each day is funded by
the taxpayer to manage the
administration of a growing
healthcare market, without a
penny going back to improve
patient care.
Unite has consistently
maintained that there is enough
money available to give NHS
staff a decent pay rise – and
that the pay cuts are an
ideological attack on the public
sector by a government that is
trying to sell it off.
Bizarrely, Jeremy Hunt has
claimed that pay cuts will
improve patient care.
Given that NHS staff have
now suffered a 15% pay cut in
real terms since his government
took office, and have only
experienced above-inflation pay
increases in eight months since
2006, this novel theory does not
seem to have got results yet.
Only NHS staff can improve
patient care and Unite’s
evidence is showing that staff
morale is rock bottom.
Unite’s member survey
this year showed that 68% of
respondents reported that their
morale/motivation was worse or
a lot worse since last year.
The four main reasons given
were: increased workplace
stress (76%); restructuring and
reorganisation (64%); falling
value of take-home pay (61%);
and attacks on terms and
conditions (56%).
If the government wants to
improve the NHS staff must be
treated fairly; but there must be
enough of them to deliver a safe
and effective service.
Inequalities, discrimination,
unfairness
Unite is increasingly concerned
about the growing inequalities
within the NHS pay system.
Senior managers have seen
a whopping 13% increase in
their income since 2009, while
nearly 20,000 staff on bands
1 and 2 are not even getting a
living wage of £7.45 an hour.
At the same time, amendments
to Agenda for Change signed
off earlier this year (that Unite
opposed) will now bring in
performance-related pay for
staff to gain their increments.
Such systems are widely
discredited as leading to
discrimination and unfairness
– two of the crucial issues
that Agenda for Change was
originally designed to avoid.
Challenging this growing
inequality was at the heart of
Unite’s own submission to the
Pay Review Body (PRB).
Not only is Unite calling for
Jeremy Hunt to withdraw his
pay freeze proposal, but also to
replace this with a substantial
above-inflation pay uplift so that
staff can catch up with inflation
and the lowest paid don’t have
to rely on food banks and inwork benefits.
The 1% originally on offer
would only mean £10 a month
to some of the worst paid in the
NHS, while for those at the top
it can be closer to £100. Unite
believes that this is not fair.
The price of a loaf of bread
costs the same for everyone,
so Unite has called for a
bottomloaded flat monetary
increase so that those lower
down the spine can catch up.
Percentage pay rises over the
last decade have meant that the
Agenda for Change pay spine
has stretched 9% since it was
created, while the pay of some
doctors, dentists and senior
managers has increased faster
still.
Unite believes that this needs
to be revisited so that pay rates
are brought into a properly
evaluated pay system and pay
rises are fairly distributed.
As a bare minimum, Unite is
expecting the introduction of the
‘living wage’ across the NHS, as
is already in place in Scotland.
Its introduction would add only
£5million to the wages bill and
would benefit about 20,000 lowpaid NHS employees.
Have your say
Jeremy Hunt has hobbled the
PRB process before it has even
begun, while claiming that NHS
staff morale is high and that
staff don’t need a cost of living
pay rise.
Do you agree? If not, then
write to the Secretary of State
and tell him just how you feel
about these claims. Visit the
website: www.unitetheunion.org/
lettertohunt. MHN
The price
of a loaf
of bread
costs the
same for
everyone
Reflections
Books and resources
The Body Economic:
Why austerity kills
David Stuckler and Sanjay
Basu
Allen Lane (2013)
ISBN: 978-1-8461-4783-8
240 pages
£20
‘Thank you for participating in this
clinical trial. You might not recall
signing up for it, but you were
enrolled in December 2007, at
the start of the Great Recession.
This experiment was not governed
by the rules of informed consent
or medical safety. Your treatment
was not administered by doctors
or nurses. It was directed by
politicians, economists, and
ministers of finance.’
And so in the first paragraph of
the preface you are set up with
what to expect from the rest of
this book.
When thinking about a ‘good
read’ you could be forgiven
for giving any book based on
economics a wide berth, but the
authors Stuckler and Basu here
give you a great book on the
subject.
It doesn’t just look at the
current predicament facing many
countries, but also reflects on
previous economic shocks like
the ‘Great Depression’ in the US
in 1929, the ‘Post-Communist
Mortality Crisis’ in 1990, the ‘East
Asian Financial Crisis’ in 1997 and
Iceland’s and Greece’s response to
the ‘Great Recession’ in 2008.
It digs down in to these ‘natural
experiments’ so that we can at
least understand lessons from
our history, and does this in a
way that engages a reader who
has little grasp of the theories of
economics.
The book proposes that we
focus on ‘the body economic’.
It argues that when people are
asked about what they value
most, the response is rarely about
material possessions but instead
consistently about their health and
that of their families.
It returns to this point often
across all the examples – showing
where some societies have failed
and others have succeeded.
It also keeps us grounded that
this just isn’t about the figures, but
about the millions of lives that have
been affected.
I would certainly recommend
this book to anyone who is
interested in the health effects of
recession and austerity.
Dave Munday
The Art and Science of
Mental Health Nursing:
Principles and practice
(3rd Edition)
Ian Norman and Iain Ryrie
(Editors)
Open University Press/
McGraw Hill Education
(2013)
ISBN: 978-0-3352-4561-1
689 pages
£32.99
This text has been a mainstay
recommendation for students and
practitioners since its first edition
in 2004.
The second edition developed
and updated from the first and here
I believe the editors have went a
step further by not only providing
a refreshed text (many with new
authorship) but the content has
been augmented and contemporary
themes in mental health nursing
have been given prominence.
As one example, it is gratifying
to see a chapter on dementia
retained, but also further supported
with a new one on functional
presentations in the older person.
The text has the same six titled
sections as previously, but in an
improved layout.
I found the interventions section,
with its chapters on physical health
promotion and engaging with
families and carers, particularly
helpful.
There is impressive prominence
given to specific talk-based
techniques: counselling, group
working, solution-focused
approaches and motivational
interviewing.
The mental health law chapter
helpfully refers to Acts that have
cross-UK relevance and flags that
there are differing instruments in
the four UK countries, but less
usefully – for those outwith – dwells
extensively upon the English and
Welsh provisions.
Like all of the chapters, it is very
well researched, presented and
written.
Overall, this edition improves an
already impressive resource: no
mean feat in itself.
It is difficult to do justice to a
text of this size in a short review,
but I thoroughly recommend this
book to all mental health nursing
students, including those studying
to Master’s level, plus qualified
practitioners could do worse than
refresh their knowledge or enhance
their understandings by dipping into
chapters when they need to.
Mike Ramsay
Overcoming Anxiety:
A self-help guide using
cognitive behavioural
techniques
Helen Kennerley
Robinson Publishing (2013)
ISBN: 978-1-8490-1071-9
288 pages
£10.99
Helen Kennerley has authored
many books in the ‘Overcoming...’
psychology titles series.
‘Overcoming Anxiety’ is a stepby-step self-help course based
on cognitive behavioural therapy
techniques.
She offers practical strategies to
help those suffering from anxiety,
providing an in-depth description
of exercises one can undertake
to manage the physical and
psychological symptoms of anxiety,
including – but not limited to –
controlled breathing, distraction
and graded practice.
Templates are given to assist in
written activities that can aid the
reader in battling their anxieties,
When brought together, these
activities create a guide that is
ultimately successful in training
the reader to overcome anxiety. In
short, it achieves what it sets out
to do.
Although the book fulfils its
37
Reflections
Contributors
Dave Munday
Professional officer, Unite/MHNA and member of editorial
board, Mental Health Nursing
Mike Ramsay
Lecturer in Nursing (Mental Health), School of Nursing and
Midwifery, University of Dundee, and chair of editorial board,
Mental Health Nursing
offering practical techniques that
can be used to educate and inform
patients.
Therefore, I would recommend
this book to nursing students who
have an interest in psychological
therapies, as this book certainly has
a role to play in helping patients to
rediscover their enjoyment of life.
Kevin Barr
Kevin Barr
Mental health nursing student, University of Dundee
Robert Muirhead
Lecturer in Child Nursing, School of Nursing and Midwifery,
University of Dundee
purpose, there are minor flaws in
the examples given that may not
cater for a wider readership.
This is evident in the ‘When it
becomes a problem’ chapter, which
gives examples of common thinking
biases, such as exaggerating,
scanning and ignoring the positive.
While Kennerley succeeds in
clearly portraying these biases –
that readers will be able to identify
their own thinking biases – the
examples given are highly focused
Books, CDs,
DVDs or
websites relevant
to mental health
nurses
38
on anxiety reactions in workplace
situations, and do not necessarily
relate to those who do not work.
This may make it difficult for the
reader to identify with the examples
given, suggesting that a broader
range of examples would help in
achieving the aims of the book.
The text may not apply to a
particularly wide audience, but
does succeed in providing people
suffering from anxiety a clear and
concise guide to help them manage
their anxiety in healthy ways.
Kennerley achieves this by
acknowledging most of the
difficulties faced by anxiety
sufferers, using her expertise in
CBT to instil hope in her readership
that anxiety can be overcome if
they implement such techniques.
In terms of target audience, this
book may alienate nursing students
who have never experienced
severe or chronic anxiety, but
what Kennerley does do is inform
readers of the effects anxiety
can have on our people’s lives,
The Art and Science of
Motivation: A therapist’s
guide to working with
children
Jrnny Ziviani, Anne A. Poulsen
and Monica Cuskelly
Jessica Kingsley (2013)
ISBN: 978-1-8490-5125-5
296 pages
£19.99
Understanding and recognising the
complex motivations of children is
a necessary skill of the practitioner
working with this group of clients.
This book will identify, demystify
and reassure practitioners of
all levels about their current or
intended practice.
The editor has gathered a strong
group of mainly experienced
occupational therapist academics
and some practitioners to produce
this book.
The editor has identified the selfdetermination theory (STD) and the
ecological model of the synthesis
of child occupational performance
and environment – in time (SCOPE–
IT) as the spine, which this book is
built around.
The text is presented and
written in a clear way, with a good
balance of the research with clinical
examples.
The clinical examples are from a
range of issues that broadens the
appeal of this book.
The first two chapters do focus
on the discussion and use of SDT
and SCOPE-IT, leaving the reader in
no uncertain terms how this book is
going to progress, the spine.
The bones and the meat of the
text are fluently written and expand
on the subject, informing the reader
of the complexity of motivation in
children.
Although identified a broader
discussion about children’s
communication, would have
contributed to this book, as it is
fundamental to gaining insight form
the child about their motivation.
This is a book that has a
definite appeal to all those working
with children, as it provides a
comprehensive explanation and
understanding of the literature
surrounding children’s motivation.
If you are not familiar with SDT
or SCOPE-IT, this too is also very
well discussed. This book will
provide insight into the motivation
of children for all professionals who
work in child health.
Robert Muirhead
If you have been involved in the creation of a resource relevant to mental health
nurses, then why not send it to your journal for review? We are interested in
all materials that support the education, continuing professional development
requirements or practice of mental health nursing – from academic reference books
to CDs, DVDs and innovative websites. Don’t hide your achievements – communicate
and share them with your colleagues. To discuss a resource review, contact the journal
editor via email to: [email protected]
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