Memorandum by the Department of Health
EUROPEAN COMMISSION GREEN PAPER—"IMPROVING
THE MENTAL HEALTH OF THE POPULATION: TOWARDS A STRATEGY ON MENTAL
HEALTH FOR THE EUROPEAN UNION"
I am writing further to my letter of 20 December
2005, when I discussed the concerns about the Green Paper that
your Committee had raised and said that I would let you see the
Government's response to the Commission as soon as it was ready.
I have enclosed a copy of the document that
we have just sent to the Commission. It represents the views of
the UK Government, including the devolved administrations. It,
together with this letter, also constitutes our formal written
evidence to your Committee's inquiry into the Green Paper.
I hope the response is reasonably self-explanatory.
To summarise, it generally concurs with the Green Paper's proposals
subject to two clear principles:
— that any EU strategy that emerges
must serve as a contribution to the Helsinki Declaration's implementation,
not as an alternative to it; and
— that it must accommodate and support
Member States' own local priorities (insofar as they are consistent
with Helsinki and the strategy).
The main extra points it makes are:
— the need for the strategy to address
inequalities in mental health—this maintains consistency
with the themes of last year's UK Presidency of the EU;
— the need for a strategy that integrates
health and social care with other policy sectors—for example
employment and education—that have a role in promoting mental
health and social inclusion; and
— the need for the strategy to be clear
about what specific action the EU will take and who will be accountable
for it.
We expect the Commission to consider the outcome
of its consultation over the coming months, and that we will have
a proposal for an EU mental health strategy by the end of the
year.
Let us know if you need more information. I
look forward to discussing the issues with the Committee soon.
THE RESPONSE OF THE UNITED KINGDOM GOVERNMENT
31 MAY 2006
CONTEXT
1. The UK Government and its devolved administrations
welcome the European Commission's Green Paper and the opportunity
to comment.
2. In the UK, health policy is a devolved
function for the Scottish Parliament, the National Assembly for
Wales and the Northern Ireland Assembly. Each of these home nations
has therefore developed its own strategic approach to mental health.
Wales, for example, developed a national strategy in 2001 followed
by a national service framework which was revised and republished
with an action plan in 2005.
3. This means that we have considered the
Green Paper from a position that has made mental health one of
the top three clinical priorities across the UK for improvement
and reform (along with cancer and coronary heart disease).
4. There are good reasons for giving that
level of priority to mental health. For example, in the UK:
— one in every four family doctor consultations
is about a mental health problem;
— one in six adults report a neurotic
disorder at any one time; and
— over a million of the people out
of work and claiming incapacity benefits in England list mental
or behavioural illnesses as their main disability.
5. This situation is far from unique—the
Green Paper sets out broadly similar figures for the EU as a whole.
6. Raising the priority of mental health
has led to some significant changes in mental health care in the
UK. In England alone, planned spending on mental health services
has risen by over 25 per cent since 1999, and there are 50 per
cent more psychiatrists and 20 per cent more psychiatric nurses
than in 1997.
7. There are now over 700 new, specialised
teams working for mental health outside hospitals in the community.
Since the 1990s, we have seen a four-fold increase in the use
of modern anti-psychotic medication. The suicide rate in England
has fallen to its lowest recorded level. About 75 per cent of
mental health patients rate the care they receive as either good,
very good or excellent.
8. So, as the Green Paper says (section
1, page 3), improvement is possible. But while real progress has
been made, we know that there is much more to do.
9. Social exclusion, discrimination and
stigma still add to the suffering of people with mental health
problems (and of those close to them). Less than a quarter of
adults with long-term mental health problems are in work. They
are nearly three times more likely to be in debt, and can struggle
for basic requirements of modern life like good housing or transport.
There are persistent inequalities in mental health and in services,
including those for black and minority ethnic communities. Over
4,000 people still take their own life each year.
10. We believe that services, quality of
life and social inclusion for people experiencing mental ill health
can all be improved further. We also believe that the promotion
of mental health and well-being now needs to embrace whole communities,
and move beyond specialised services for those immediately and
directly affected.
11. This is why, during the UK Presidency
of the EU, Minister of State Rosie Winterton welcomed the Commission's
Green Paper as a potentially valuable contribution to our shared
objectives for mental health. Our response sets out our views
on how the Green Paper could develop into an EU strategy that
supports improvements in mental health across Europe.
CONSULTATION
12. Before preparing its response the UK
Government invited views from a range of networks representing
a diverse selection of governmental and non-governmental agencies,
as well as users of mental health services and those who care
for them. The general public were able to comment through a web
site that also publicised the Commission's own consultation exercise.
The UK Government is grateful for the contributions it received
and considered them all before producing this response.
THE QUESTIONS
13. The Green Paper (pages 13-14) asks for
views on three specific questions that we will address directly.
A. How relevant is the mental health of the
population for the EU's strategic policy objectives?
14. The Green Paper (page 3) suggests that the
most pertinent of these strategic objectives are:
— putting Europe back on the path to
long-term prosperity; and
— sustaining Europe's commitment to
solidarity and social justice; and bringing tangible, practical
benefits to the quality of life for European citizens.
15. The UK believes that the mental health
and well-being of the population are directly relevant to all
three of those objectives.
16. The Green Paper itself explains the
relationship clearly, and the relationship in the UK is equally
clear from facts such as those we set out at the beginning of
this document. it has been estimated that the cost of mental ill-health
in the UK is the equivalent of 2 per cent of Gross Domestic Product.
Mental illness significantly increases the risk of unemployment,
poverty, poor physical health and substance misuse (and vice versa).
The injustices of stigma, discrimination and social exclusion
are still associated with mental illness and are still blighting
the lives of tens of millions of EU citizens and their families.
17. The close relevance of mental health
to the EU's wider strategic objectives has implications for the
scope of an EU mental health strategy. In particular, it demonstrates
the need—recognised by the Green Paper—for an integrated
strategy that involves agencies beyond the traditionally perceived
boundaries of health and social care. For example:
— a strategy should explicitly support
positive action on employment for people with experience of mental
ill health—both in terms of their employability and the
benefits to mental health of the right kind of work;
— encouraging social inclusion means
addressing participation and citizenship in every aspect of community
life—including arts, culture, recreation, sport and education;
and
— the human rights of those experiencing
mental illness may need special attention and protection.
B. Would the development of a comprehensive
EU strategy on mental health add value to the existing and envisaged
actions and does section 5 [of the Green Paper] propose adequate
priorities?
Added value
18. The Green Paper (page 7) suggests that
an EU strategy could add value in three ways:
— by creating a framework for exchange
and co-operation between Member States;
— by helping to increase the coherence
of action in different policy sectors; and
— by opening up a platform for involving
stakeholders, including patient and civil society organisations
into building solutions.
19. The UK agrees that each of these has
potential for added value. We have already expressed the view
that an effective mental health strategy needs to engage policy
sectors beyond health (including employment, education, inclusion,
regeneration and human rights), and the EU is obviously well placed
to facilitate that engagement at a European level. This leads
to another potential benefit of a strategy—to help raise
the profile of mental health and improve understanding of the
issues across the EU, its directorates and departments, and Member
States.
20. We address the ideas of exchange and
co-operation, and of a platform for stakeholders, later in this
response.
21. Underlying these questions, though,
we believe there are two fundamental tests of whether an EU strategy
would add value:
— would it complement, rather than
duplicate or confuse, existing European activity on mental health—in
particular, the World Health Organisation's Helsinki Declaration?
And
— would it be flexible enough to recognise
and accommodate Member States' varying starting positions, and
to support them in addressing their local priorities?
22. The UK is investing significant
resources in developing mental health policies and services that
match the ambitions of the WHO action plan for mental health in
Europe, agreed by Ministers at Helsinki in January 2005. The action
plan's priorities overlap with those that the Green Paper suggests
for an EU strategy, including their focus on:
— promotion of good mental health and
the prevention of mental ill-health;
— tackling stigma and discrimination;
and
— establishing good mental health information.
23. An EU strategy must make sure that this
overlap does not result in duplication of effort and confusion
over roles and responsibilities, but instead builds efficiency,
co-ordination and co-operation around a shared set of objectives.
24. We see no conflict here with the Green
Paper's expressed intentions. We welcome the Green Paper's description
of itself as a contribution to the implementation of the WHO action
plan (section 1, page 3). This is also how we believe an EU strategy
should be positioned—as a strategy for the practical support
that the EU can give to the Helsinki Declaration.
25. To add real value, an EU strategy should
offer support to all Member States as they work towards local
objectives that are consistent with the strategy (and the WHO
plan), even though the choice of priorities, the pace of progress
and the resources available for the work may vary between Member
States.
26. Again, we see no conflict with the ambitions
of the Green Paper. As it says (page 5), Member States are exclusively
competent for the organisation of health services, and Community
action should complement national policies on health. We also
share the Green Paper's recognition (page 7) that Member States'
diversity makes it impossible to draw simple conclusions or propose
uniform solutions.
Priorities
27. The Green Paper (page 8) proposes four
priorities for an EU strategy:
— to promote the mental health of all;
— to address mental ill health through
preventive action;
— to improve the quality of life of
people with mental ill health or disability through social inclusion
and the protection of their rights and dignity; and
— to develop a mental health information,
research and knowledge system for the EU.
28. These priorities are sufficiently broadly
defined to allow for local variations in emphasis. As we have
noted, the priorities are also among those of the Helsinki action
plan, to which the UK and other Member States are already committed.
We believe that confirming unity of purpose between the WHO and
the EU in this way is helpful, but that identifying additional—or
competing—priorities in an EU strategy would be counter-productive.
29. The UK has agreed to assist the WHO
European Office by developing programmes of European work linked
to the action plan. The focus for these programmes will be on:
— cross government action to tackle
inequalities and reduce social exclusion;
— addressing stigma and discrimination;
— the development and implementation
of new service models for community mental health; and
— mental health care research.
30. The emphasis on tackling inequalities
and social exclusion is one in particular that we would like an
EU strategy to support. The Green Paper acknowledges the issues,
and further action to address them would be entirely consistent
with the stated priorities of both the Green Paper and the WHO
action plan.
C. Are the initiatives proposed in sections
6 and 7 [of the Green Paper] appropriate to support the co-ordination
of mental health into health and non-health policies and stakeholder
action, and to better liaise research and policy on mental health
aspects?
31. The initiatives that the Green Paper
(pages 8-13) proposes are:
— promoting mental health and addressing
mental ill health through preventive action;
— promoting the social inclusion of
mentally ill or disabled people and protecting their fundamental
rights and dignity;
— improving information and knowledge
on mental health in the EU;
— creating a dialogue with Member States
on mental health;
— launching an EU Platform on mental
health; and
— developing an interface between policy
and research on mental health.
32. To a large extent these proposals arise
naturally from the Green Paper's priorities, which we have already
endorsed. We believe that it is whether, and how, the initiatives
are delivered as part of an EU strategy that will determine how
much value the strategy adds in practice.
33. Mental health promotion, for example,
should recognise the strong relationships between mental health,
physical health and general well-being. Effective promotion and
prevention should take place in a variety of settings, including
communities, schools, universities and workplaces, as well as
across the stages of life from childhood to old age. A strategy
must also take care not to widen inequalities by inadvertently
favouring or discriminating against any sector of society, regardless
of factors such as ethnic origin, age or socio-economic status.
34. Promoting social inclusion effectively
would provide another opportunity to break down the traditional
boundaries between governmental agencies in policy sectors such
as housing, employment, education, recreation and income.
35. The EU Platform on mental health could
avoid any risk of a strategy being seen as a bureaucratic or academic
exercise by keeping it firmly rooted in the needs and aspirations
of real people (and comprehensible to them). It could also have
an important part to play in disseminating ideas and information,
and in helping to understand the different cultures and sensitivities
of stakeholders and citizens across the EU.
36. Successfully widening the availability
of high quality information and knowledge, and developing the
interface between policy and mental health, would provide a solid
foundation for the other initiatives and are among the most important
benefits that an EU strategy could offer. Shared evidence and
expertise on issues like the mental health of migrants, for example,
is likely to become increasingly valuable.
37. There is a need for more research in these
areas, and we welcome the inclusion of mental health in the Commission's
proposals for Framework Programme 7. Larger scale studies across
the EU would be especially welcome as a means of developing a
more robust evidence base for these relatively underdeveloped
areas of knowledge, and larger routine datasets across Member
States would be valuable to regular research and the monitoring
of mental health.
CONCLUSION
38. The UK welcomes the Green Paper as the
foundation of an EU mental health strategy that:
— directly supports implementation
of the WHO Helsinki action plan and rationalises the relationship
between the WHO and the EU in the field of mental health; and
— supports Member States in taking
action on local priorities that are consistent with the strategy
and the action plan.
39. We believe the development of the strategy
presents an opportunity for the EU to adopt a more integrated
approach to improving mental health. A strategy will add real
value if it:
— sets out specific actions, identifies
who will be responsible for them and describes clear governance
arrangements for the strategy; and
— delivers better co-ordination across
relevant policy sectors including EU directorates-general and
departments in employment, social living and social funds, public
health, and education.
40. We look forward to continuing our involvement
in the strategy's development.
May 2006
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