NSUN member John Kapp proposes a way to roll out mindfulness approaches instead of medication based treatments


By John Kapp ([email protected])

Inspired by the cartoon: Nigel Farage’s Brexit image of a long queue of patients waiting at a door for A&E

The prime minister is right to focus attention on the crisis in mental health, (9.1.17) and giving commissioners a new target of ending treating sick children away from home by 2021.

However, this paper asks why 1 in 4 of us are suffering from a mental health problem at any one time? Half a century ago, before drugs were developed to treat it, mental sickness was rare (less than 1 in 1,000) and most sufferers made a full recovery after a year or two. There is now overwhelming scientific evidence that this epidemic is induced by the drugs given to treat it. (Whitaker 2010, 2015)

All that GPs can prescribe is antidepressants, which don’t even claim to cure depression, but do more harm than good with addictive side effects, so you tend to be on them for the rest of your life. Children as young as 5 are being put on them. A decade ago, the government tried to end the ‘Prozac nation’ by introducing the Improving Access to Psychological Therapies (IAPT) programme, but GPs can’t prescribe talking therapies because few contracts have been commissioned to provide them.

Antidepressant prescribing has since doubled, to over 60 million monthly prescriptions, so 5 million patients are on them, against NICE recommendations. Half the population (30 m) are now on NHS medication, making the NHS toxic, and creating a revolving door overwhelming primary care. Doctors were called to cure patients, not to harm them, so they burn out, take early retirement, and nobody wants to be a GP. Is this the elephant in the room behind the junior doctors concern for patients safety?

Mindfulness courses are highly effective against mental sickness which corporates like Google, and the House of Lords (Mindful Nation UK report 2015) are promoting. The Mindfulness Based Cognitive Therapy (MBCT) 8 week course has been trialled for depression, and recommended since 2004 by NICE in CG23. It teaches self care, (how to learn how to look after yourself better, so you need less public services). It has been shown to save £7 for every £1 invested in avoiding downstream costs.

MBCT courses could therefore cure the epidemic, but they are not being commissioned, despite government funding allocated under the Better Care Fund (BCF) legislation in 2013 of £3.8 bnpa for both 2015/16, and 2016/17. ‘Community Care Centres (CCCs)’ were supposed to be created in every GP cluster as mental health A&Es to treat the most vulnerable and expensive patients, personalised as Rachel (65, depressed and in sheltered housing), and Dave, (40, alcoholic and homeless).

My city of Brighton and Hove has about 10,000 of these, and got £20 mpa allocated for each year. However, not a single CCC has been founded, and no Rachel or Dave has yet been offered any treatment.

The Health and Social Care Act (HSCA) 2012 set up the governance structure, but it has 3 disconnects preventing its delivery, as shown by the dividing lines in the diagram below

£ in--> DOH, NHS England --> HWBs --> CCGs --> Procurement --> GP surgeries, A&E --> treatments out

The first disconnect is that the evidence base for antidepressants has collapsed, together with the associated notion that mental sickness is caused by chemical imbalances in the brain. (Whitaker 2010, Whitaker and Cosgrove 2015).

Neuroscience shows that the true cause is insecure attachment to the primary caregiver, leading to dysfunctionald neural pathways, which can be cured by mindfulness practice through neuroplasticity (Seigel 2010), (Mindful Nation UK 2015)

The second disconnect is that the HSCA intended to fill the ‘democratic deficit’ by devolving control of two thirds of the health budget (£70 bnpa) from the health secretary, Department of Health and NHS England to elected councillors on the Health and Wellbeing Boards (HWBs) who are hierarchically above the 220 Clinical Commissioning Groups (CCGs).

Five years on, those councillors have not yet accepted their statutory duty, so the democratic deficit is now a greater vacuum than before, and the previous powers-that-were can do nothing about it, which is frustrating for everyone.

The third disconnect is that CCGs were supposed to commission and procure the latest NICE recommended evidence based treatments, (such as MBCT courses) but they are just rolling over the same failed 5 year performance based block contracts which Labour tried to abolish in 2006.

The Conservatives have since urged changing to outcome based contracts, which incentivise providers to heal and cure patients, but the CCGs are disobedient, and get away with scandalous dereliction of duty because the HWBs fail to call them to account, and no one else can.

To illustrate this problem, my CCG (Brighton and Hove) has a health budget of £370 mpa, (£1 mper day, or £1,200 per person pa) but it is in a silo, accountable to nobody. I attend every meeting in the public gallery, and can report that they are just a talking shop, rolling over antiquated performance based block contracts, and messing up (such as that let last April to Coperforma for hospital transport).

The terms of reference of my HWB gives them the duty to call the CCG to account, but they deny this, and allow the CCG to go on mis-spending their budget, so the crisis intensifies, so we are the worst in the country. (However, this is an opportunity to lead the way out)

The solution is obvious, which Jeremy Hunt should call for. Councillors on HWBs should take their statutory responsibility for both the health and social care budgets, and subsidise social care from health. They should spend their combined budget (about £1,500 per head pa, which is ample) on the mass-provision of NICE recommended treatments, such as the MBCT course.

They should also force CCGs to change the procurement to outcome based contracts, addressing the co-determinants of health, (housing, employment, criminal justice) through social prescribing.

Jeremy Hunt still has the power to make these councillors do their duty.Then we would have a mental health service worthy of the name, in which doctors would want to work, fulfilling the original meaning of their name. (‘doctare’ is latin for ‘teach’) For further details see papers on section 9 of www.reginaldkapp.org.



References

Whitaker 2010 ‘Anatomy of an epidemic; magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America ‘ Random House NY.

Whitaker and Cosgrove 2015 ‘Psychiatry under the influence.’

Siegel 2010 ‘ the mindful therapist – a clinician’s guide to mindsight and neural integration’ WWNorton &Co

Mindful Nation UK report 20.10.15 All Party Parliamentary Group, House of Lords