Mental health promotion in the current economic climate
Michael Parsonage, ex-Treasury Economist and Senior Policy Adviser, Sainsbury Centre for Mental Health
Public spending is going to be severely constrained for some years to come. At the same time, the prevalence of mental health problems is likely to increase because of higher unemployment and other consequences of the recession. Public sector budgets for mental health will therefore be squeezed from both ends.
This is not perhaps the most helpful backdrop against which to argue the case for increased spending on public mental health, that is, the prevention of mental ill-health and the promotion of positive mental health and wellbeing in the population as a whole. Such expenditure is a form of investment and thus requires spending now in return for benefits in future years. Past experience suggests that investment-like activities, which also include training and research, are often the first to be cut when budgets are tight.
In the case of public mental health, a further complication is that the evidence base, particularly on the cost-effectiveness of interventions, is much less complete than one would like. For example, while there is plenty of evidence to show that physical exercise is good for people's mental health and wellbeing, much less is known about the value for money of specific measures aimed at promoting physical activity.
Notwithstanding these problems, the case for promotion and prevention remains strong, in some areas at least. Essentially this is because the costs of poor mental health are so high, for individuals and for society as a whole. Longitudinal studies show, for example, that serious behavioural problems in childhood can lead to a wide range of adverse outcomes throughout the life course, including continuing mental health difficulties, poor educational performance, unemployment, low earnings, substance misuse and criminal activity.
Prevention and early intervention make sense, not only because of the scale and duration of these damaging consequences but also because early behavioural problems become progressively less treatable, the longer they are established. Also, many of the short-term costs of childhood mental health problems fall on local authorities, suggesting that effective prevention and early intervention may offer substantial scope for ‘quick wins'. One study of a sample of children with very complex mental health needs found that on average service costs were over £50,000 a year per child, with 90 per cent of these costs falling on education and social service budgets.
A database of information on the costs, benefits and budgetary implications of evidence-based interventions in the areas of prevention and promotion is currently being prepared for publication by the Department of Health, in the form of a cost calculator for use by commissioners.
To summarise, some key messages for commissioners and managers of services in the current economic climate include the following:
Prioritise and follow the evidence: the public mental health agenda is potentially very broad, and it is unrealistic to pursue improvements on every front. Prioritisation should be based on the available evidence, which suggests strongly that many of the ‘best buys' are to be found in programmes aimed at children and young people. Some workplace-based interventions, and low-cost environmental improvements such as noise reduction, are also particularly effective.
Avoid short-term cuts: temporary reductions in funding are likely to reduce the effectiveness of established programmes. One review of evidence on interventions in the early years found that among the key characteristics of effective programmes are that they are long term in nature and sustained by committed funding.
Implementation matters: it is a false economy to cut corners on the implementation of evidence-based programmes, for example, by employing staff with inadequate training. One review of mental health promotion programmes found that the outcomes for well implemented programmes are typically two to three times better than for poorly implemented ones .
Mainstreaming: many things affect mental health, and better mental health has many potential benefits. A concern for mental health and wellbeing should therefore be everybody's business. A key role for local government should be to foster this wider perspective and encourage the mainstreaming of wellbeing in as wide a range of settings and organisations as possible.
Clark, A., et al. (2005) Children with complex mental health problems: needs, costs and predictors over one year. 'Child and Adolescent Mental Health', 1(4), pp 170-178.
30 November 2010