Labour

Rethinking mental health in the twenty-first century - Speech by Andy Burnham

Andy Burnham MP, Labour's Shadow Health Secretary, in a speech to the Centre for Social Justice, said:

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This is my first major policy speech since returning to the Health brief and I was clear from the moment I came back that I wanted it to be about mental health.

That’s because, since my time as Secretary of State was so rudely interrupted, I’ve had a sense of unfinished business and felt the need to say what I’m going to say today.

I can trace it directly back to a moment in the middle of 2009.

It was shortly after I arrived in the Department of Health. I was sitting in the office and was looking through the Bradley Report on Mental Health in the Criminal Justice System, commissioned by Alan Johnson.

To be honest, I wasn’t fully engaged on it. The truth is Ministers often don’t feel the same sense of ownership to things commissioned by your predecessor.

But then a statistic leapt off the page: 70% of prisoners have two or more mental health conditions, but many are undiagnosed or untreated.

I read it, and re-read it. It couldn’t be right, could it? A typo, surely? So I asked officials to check it out.

I was truly taken aback to find it was accurate.

That was the precise moment when I began to think differently about mental health policy.

But, before I got chance to do anything about it, I got swept up in the business of the department, a swine flu pandemic was declared and, anyway, I had already resolved to make social care my personal priority.

But I have often thought about it since and come back to it now at the first opportunity as I want to take this moment in Opposition to send the clearest message I can about our thinking going forward.

My purpose in this speech is to establish the clear principle upon which I will base the renewal of Labour’s health policy: a whole-person approach to good health. In this century of the ageing society, when people live longer, more isolated lives, we need to think of the reform of the NHS, social care and mental health not as three separate, distinct challenges but together as an integrated, preventative, people-centred system.

But I wanted to make this speech for another reason: to make a reflection about the place of mental health policy in Whitehall.

While I had became convinced of the absolute centrality of mental health to the big social challenges of the 21st century, I can recall finding no real reflection of the same in the submissions that crossed my desk nor the meetings that filled my ministerial diary.

Of course, it’s up to Ministers to set the agenda. And the Labour Government did make important progress on mental health, with the National Service Framework early on and then the Improving Access to Psychological Therapies programme towards the end.

But, important as these changes were, Government hasn’t caught up with the changed reality of the 21st century.

People are living longer, less stable, more stressful and isolated lives.

But public services are still, by and large, working on a post-war model when people’s lives were shorter and the dangers we faced were physical.

And the danger is that our national tendency not to talk openly about mental health means we will be slow to make the changes we need to see.

This stiff upper-lip culture is ingrained across our society, Government and Parliament.

Even in the main Department of State that is best placed to do something about it, the urgent demands of hungry acute trusts predominate – even though it widely estimated that around one in four people in hospital have a mental health problem.

So my case today is that the challenges of 21st century living demand a re-think in our approach to mental health.

Specifically, I will focus on three points.

First, if people are to get the support they need from the NHS to live full and economically active lives, and if it is to be sustainable in the 21st century, then mental health must move from the edges to the centre of the NHS.

Second, we can no longer look at people’s physical health, social care and mental health as three separate systems but as part of one vision for a modern health care system.

Third, change in our public services will only be successful if matched by a wider change in attitudes towards mental health. A country which has so often led the world in challenging discrimination needs to recognise that we’ve got much to learn from other countries when it comes to the stigma of mental ill health.


It’s in all our interests that we make this change. It becomes ever more likely that each of us, or those close to us, will experience poor mental health as we all grapple with the challenges and pace of modern life.

So let me start with the NHS.

I love the NHS as much as any politician. But it is still based on 20th century presumptions about healthcare.

Let me explain what I mean by this, with reference to my constituency.

When the NHS was set up, Leigh was a place with physical danger at every turn.

Housing was poor. Air quality dreadful. Work in the mines and the mills was physically arduous and dangerous.

Levels of disease, industrial illness and accidents at work.

But, on the plus side, jobs were stable and extended families lived close to each other.

And, because of the ever-present physical dangers, people learned to lock arms and face them together.

Safety underground depended on everyone looking out for each other, and this culture of solidarity carried over into the streets above.

So Leigh, like many other towns across England, was physically dangerous but emotionally secure.

And it was to face the challenges of this world that the National Health Service was brought into being.

But life has changed. Towns like Leigh are physically much safer places to live and work but people are living more stressful and insecure lives than their parents and grandparents.

Health problems are much more likely to arise from lifestyle choices or even addiction.

Has the NHS has yet fully woken up to these huge social changes?

I wish I could say it has, but I don’t think I can.

One in four of us will experience a mental health problem in our lifetime, an increase linked to how we live our lives in the 21st century.


Mental ill health will soon be the biggest burden on society both economically and sociologically, costing around £105 billion per annum.

By 2030, the World Health Organization predicts more people will be affected by depression than any other health problem.

But we spend a fraction of our overall health budget on mental health. Mental health research only receives just 6.5% of total funding in the UK compared with 25% for cancer, 15% for neurological diseases and 9% for cardiovascular conditions.

But it’s not just about funding. It’s also about how our health system functions.

Our health system still reaches for medical interventions first, rather than social or psychological that might be more successful at breaking the cycle and helping the individual take control.

In 2009, the NHS issued 39.1 million prescriptions for anti-depressants, with a big increase around the time when the financial crisis hit. On the decade, this represented a 95% increase, with 20.2 million issued in 1999.

There is another problem with the way the system functions.

When people arrive at hospital, our system is still geared up to respond to the specific problem before it - the fractured cheekbone, the broken hip or the cancer – without seeing the whole person behind it, or indeed the other health problems that an individual may have.

It tends to treat rather than prevent, responding after the event without looking at the living conditions or the psychological problems that may lie behind it.

And perhaps it does that because of the culture of separateness between our physical and mental health systems in England.

This is not helped by the fact that we have different organizations for both, with separate mental health trusts.

But this separateness has deep roots in our society.

Most mental hospitals are located on entirely separate sites to mainstream – despite the clinical need to connect the physical with the mental.

Some are still based on sites that have long been associated with a mental health institution, with their place names looming large in the folk memory and language of local people which in turn builds the fear of mental ill health and what takes places behind closed doors.

Mental health has been 'retro-fitted' into the system but often loses out - the 18 week targets never applied to mental health, nor was a tariff developed. These operational differences compound the inequality between the two systems.

And yet the fact that so many physical health problems are linked to underlying mental health problems arising from modern living means this is no longer sustainable.

But this takes me to my second point about placing mental health at the heart of wider public service reform.

Today, we have in effect three separate systems – the mainstream NHS overwhelmingly focused on physical health, with two poor relations: a malnourished social care system and a mental health system in the margins.

But, in the century of the ageing society, the NHS will not function itself if its two poor cousins aren’t given a higher priority.

Failures or gaps in social care lead to so many older people entering hospital. And it is undiagnosed or untreated mental health problems that can lead to the addiction that causes violence or creates a range of health problems.

So what does this all mean for health policy?

First, if we want a truly preventative health service then there will have to a more balanced approach to the health budget, with a greater percentage of available resources being devoted to mental health.

Second, we need to end the culture of separateness in the physical and mental health systems. It’s time for politicians to grasp the nettle of the reshaping of hospital services for the 21st century and as part of that we need to argue for the co-location of acute and mental health services on the same site. This separateness can lead to inequalities in health. For people in the mental health system, physical health needs can get completely missed. As a result people with severe mental health problems die on average 25 years earlier than other people.

Third, we need to change attitudes in clinical practice and encourage all clinical staff to see promoting good mental health as part of what they do. Awareness of mental health issues should be part of the training for all doctors, nurses and others who work in the NHS. We need to get to the point where when people go to their GP, it would be as normal for them to expect questions about mental as well as physical health and for social or psychological support to be offered as routinely as medication, perhaps more so. That means nurturing embryonic IAPT services and preventing them falling victim to the salami-slicing cuts across the NHS, as identified by the Health Select Committee. I recently shadowed a GP in Coventry and was surprised by the number of time he referred to IAPT. As he said, a huge step forward and an avenue that simply wasn’t available only a few years ago. It came about because of Lord Richard Layard’s work, who made both the social justice case, but als o the economic case. It makes no sense to disinvest right now in a service that saves us money in the longer term, by reducing demand for GP consultations and hospital admissions, but unfortunately, there are signs already that these vital services are in danger. We need strong advocates for IAPT amidst the current chaos in the NHS.

Fourth, it points to a proper strategy for lifting rates of physical activity in England to the best in Europe, championed by the NHS. This strikes me as the essential first stage in any good mental health policy, but promoting physical activity remains an orphan policy in Whitehall. It needs to be core business for the DH as the key to breaking cycles of poor health choices, stress and isolation

Fifth, we need to reform social care, mental health and the wider NHS together – to recognise that people are people and can’t be separated out according to the administrative quirks of three historically separate systems. Longer lives in a more uncertain world mean we’ll all need a personalized mix of the social, mental and physical if we are to stay supported at home and out of institutions.

The King’s Fund have highlighted what they call the ‘long term conditions dividend’ – the significant wellbeing and financial gains from responding more effectively to the mental health and psychological needs of people with long term conditions. Addressing these needs should be part of personalised care planning for everyone with a long term condition.

My great worry is that the drive in the Health and Social Care Bill towards a more market-based system in healthcare will take us in the opposite direction, towards greater atomisation and fragmentation of services rather than true integration. As the joint editorial from the HSJ, BMJ and Nursing Times says today, the Bill contains no meaningful incentives for integration of services. By contrast, Monitor can issue fines to drive competition into the heart of the system.

This will reinforce separateness and fragmentation in our health and social care system and is one of the fundamental reasons why we will continue to maintain our outright opposition to the Health and Social Care Bill.

But there is much longer term battle for us all that calls for cross-party consensus.

Real change to health services to meet the demands of the 21st century will only come when we change attitudes to mental health in wider society.

As a country, we have set an international lead on equality legislation and intolerance of nearly all forms of discrimination.

And yet, conversely, archaic attitudes and outdated thinking still define our approach to mental health.

As Lord Stevenson has argued: “This is the last significant form of discrimination in our society” – but, unlike others, we all have a vested interest in this fight as this is discrimination with the potential to directly affect us all.

It is hard as it gets. Not only do people have to face the direct effects of depression, their problems can be compounded by the reactions of others.

People don’t feel able to admit to having a problem. It could change employment your prospects or lose you friends.

With most illnesses, you get a sympathetic shoulder to cry on. With mental illness, people may still get the cold shoulder.

And even if people do admit a problem, family and friends may not know how to advise them.

That is why the public debate that has been so powerfully led by Alastair, Stephen Fry, Frank Bruno and others is so tremendously important.

It is essential that the excellent Time to Change campaign, led by Mind and Rethink and funded by the Department of Health, ultimately prevails.

Just as football helped change attitudes to racism in the 80s and 90s, so sport can lead the way in changing social attitudes towards mental health.

As a cricket-lover, I have followed Marcus Trescothick’s fight against depression.

It is a compelling story and he deserves huge credit for the courage he has shown.

Cricket didn’t initially respond well but has since begun its own journey of understanding and that is something that all institutions and employers need to do.

I’m also interested in the Mental Health First Aid movement, which – just like traditional first aid – gives people the confidence to deal with mental health issues that they come across, in friends, family members or co-workers.

However, sport cannot take on the burden alone. The media, in its current period of self-reflection, needs to change the way depression or breakdowns are often portrayed.

Employers also have massive role to play in this area. One in six employees experience work-related depression and anxiety. Research from Mind found that stress has forced one in five workers to call in sick, yet the vast majority of these say they have had to lie to their boss about the real reason for not turning up.

By working to remove the stigma surrounding mental health problems, we will begin to create a climate where people feel able to talk openly about their own mental health in the same way as physical health.

This is particularly important for children and young people who are often too afraid to talk about what they are going through.

As “Completing the Revolution” highlighted we need to be doing more to address mental health problems at an early age. Half of all long-term mental health conditions start by the age of 14.

Tackling mental health problems early will help improve physical health, education and employment prospects. The savings to the individual and society are vast.

So this isn’t just a job for the Department of Health.

It’s a job for the Treasury, the Home Office, DWP, Education, DCLG – indeed the whole of Government throwing its weight behind it.

Perhaps there needs to be a senior Minister for Mental Health, even possibly at Cabinet level, to lead this coordinated drive.

Some progress is being made.

David Cameron and Nick Clegg are right to focus on well-being in the consideration of new Government policy.

But in this policy area the language is important.

I don’t think we should frame discussion about mental health in terms of happiness – itself an excluding term with the potential to reinforce.

There is a real risk for the Government to talk of a Happiness Index when millions of people don’t have the basics. It risks sounding out of touch and that risks damaging an otherwise laudable policy intent.

It seems to me that some of the terminology behind this drive, which developed here in the last decade, needs to be changed to reflect the new economic reality that many people face.

There’s a graph in Alastair Campbell’s new e-book, The Happy Depressive, which shows the only point at which happiness and income correlate is when people move from a low income to a middle income.

For many people, particularly in the current climate, it follows that happiness might simply not be achievable in the short term, but talking about it in this way risks reinforcing the sense of divide between those who consider themselves happy and those who do not, compounding a sense of failure.

It implies that you’ve got to be happy and if you are not happy, you are failing. That is not the case.

A focus on happiness might also lead to the wrong policy choices.

Let me illustrate that with a specific point.

Jane Ferrie has talked much about the links between job insecurity and mental illness. In the 1980s suicide rates for young unemployed men rocketed. A recent study in the Lancet found that every 1% increase in unemployment was associated with a 0.79% rise in suicides. Yet successive Government’s haven’t done anywhere near enough to build the resilience of people out of work.

If we don’t do more now, and the focus is on raising levels of happiness rather than resilience, then we risk repeating the mistakes of the past.

So instead our policy aim should be to help all people cope and surely it’s therefore better to frame this debate in terms of building personal resilience and control.

But challenging attitudes must start at the very top.

At present, the message sent out by our laws risks legitimising rather than eradicating this discrimination.

Under existing legislation, people who have suffered a breakdown can lose the freedom to run a company or to make a wider contribution to society by serving in Parliament, as a school governor or on a jury.

The clear message is that recovery from breakdown is not possible. That is wrong and has to be challenged.

When the Norwegian Prime Minister Kjell Magne Bondevik had to take time off for depression, he admitted that was the reason. By doing so he changed the culture in Norway – and he also got re-elected and went on to become Norway’s longest serving non Labour Party Prime Minister since World War II.

Rather than question Bondevik’s suitability for office, Norwegians admired his honesty and bravery.

Politicians in the UK need to show the same kind of leadership. We should work together to give a lasting legacy to the Time to Change campaign by repealing these archaic and discriminatory laws.

Lord Stevenson has put forward a Private Members’ Bill to end these discriminations and I can say today that it will have Labour’s support, even if it needs to be re-introduced.

These are two predominant reasons why we should repeal these laws.

Firstly, it would enhance our wider understanding of mental health and Parliament, schools, companies and courts would be richer from the involvement of people with experience of mental ill health.

Secondly, it will send an important message.

A message to employers, to politicians, to society - no longer will we tolerate an outdated prejudice that prevents capable people from taking part in public life.

In conclusion, mental health is an equality issue and social progress in the 21st century depends upon us waking up to that. Children from the poorest 20% of households are at a three-fold greater risk of mental health problems than children from the richest 20% of households.

And, as the Bradley Report brought home to me, many of them will sadly end up in the criminal justice system if we don’t change things.

Labour will only fulfill its historic mission of creating a fairer more equal society in this century if we not only lead the way on changing attitudes on mental health, but also changing services towards a whole-person approach to healthcare – so that the problems we might all face at some point in our lives don’t stop us from reaching our potential.