Memorandum by King's Fund
1. The King's Fund is an independent charitable
foundation working for better health, especially in London. We
carry out research, policy analysis and development activities,
working on our own, in partnerships, and through funding.
BACKGROUND
2. On 18 October 2005 the European Commission
published a consultative Green Paper entitled "Improving
the mental health of the population: towards a strategy on mental
health for the European Union" (Commission document 13442/05
reference COM (2005) 484 final. Consultation on the Green Paper
closes on 31 May 2006).
3. Sub Committee G of the House of Lords
European Select Committee has decided to hold an Inquiry into
the policy issues relating to the Green Paper. Views were invited
on:
— whether an EU strategy on mental
health would be appropriate;
— if so, what elements it might contain;
and
— how it might complement and add value
to the strategies of Member States and the activities of the world
Health organisation and other international bodies.
IS AN
EU STRATEGY ON
MENTAL HEALTH
APPROPRIATE?
4. Yes, but it is vital that the strategy
does not duplicate work already being carried out by Member States
and that it has limited and clearly defined objectives.
5. We agree with the Green Paper view that
a strategy would provide a useful framework to gather together
the various disparate pieces of pan-European mental health work
currently being undertaken. Across Europe, the development of
national policies and the level of funding for mental health are
limited [1]. However it is important not to reinvent the wheel
or waste time ... on strategic blue sky thinking that does not
impact on practice. The WHO European Ministerial Conference on
Mental Health's Mental Health Action Plan for Europe, published
in January 2005, [2] presents a succinct but comprehensive plan
to develop and implement mental health policies and services in
12 key areas. (The Green Paper acknowledges this Action Plan as
a possible model at 7.1.) The commitment from Ministers was that
countries of the WHO European Region, which covers EU Member States,
would reflect these policies in their own mental health strategies
and plans, to determine what will be delivered in the next five
to 10 years. In focusing on raising awareness of the importance
of mental wellbeing, tackling stigma and discrimination, implementing
effective services, addressing workforce issues and involving
service users and carers in planning process, this Action Plan
already sets out a template for some of the priority issues that
the EU strategy might cover.
6. It is also worth bearing in mind the
potential for a number of Eastern European countries—and
Turkey—to join the European Union in the next few years.
These countries tend to have less well developed mental health
services with an emphasis on institutionalisation. It would be
helpful to have in place an EU strategy for mental health that
those countries could use as a template for developing their own
mental health systems as and when they become EU member States.
WHAT ELEMENTS
MIGHT AN
EU STRATEGY CONTAIN?
7. The Green Paper invites debate on the
priorities for an EU strategy. This does pose certain difficulties
as EU-wide priorities may or may not reflect the priorities within
individual Member States. For example, in the United Kingdom,
the Government's current priority for the next five years is on
developing community services for the wider population rather
than specialist services for the few. [3] However other Member
States may well feel their first priority is to develop better
services for those with the greatest need.
8. In February 2005 a two day event in London
organised jointly by the King's Fund, the London Development Centre
for Mental Health (now part of the Care Services Improvement Partnership,
CSIP) and Queen Mary College, University of London brought together
experts from seven European capital cities—London, Paris,
Rome, Belgrade, Prague, Berlin and Madrid—to share the experience
of mental health systems in order to identify common factors influencing
service provision and policy.
9. A number of common themes emerged from
this event that we suggest are pointers to the priorities that
might inform an EU mental health strategy:
— the move from institutional to community
care should continue, though it was essential that adequate resources
were allocated to the development of effective community services;
— mental health problems are on the
rise, especially within primary care services; a significant proportion
of this is due to people presenting with complex needs involving
drug and alcohol misuse;
— stigma remains a major burden on
service users and carers;
— refugees and migrant communities
provided a challenge across all countries;
— older and younger populations were
mentioned as particularly high risk groups vulnerable to mental
health problems;
— service user involvement was underdeveloped
in many cities; and
— the fragility of governments and
frequent changes in health ministers made implementation of reform
difficult.
Resources
10. The issue of resources is a crucial
one. It is worth noting that the WHO European Ministerial Conference
Action Plan [2] supported the implementation of the Plan "in
accordance with each country's needs and resources" . This
takes into account the reality of current and future funding of
mental health in different countries and the enormous variety
of service provision across different countries in areas such
as inpatient beds, community facilities and workforce levels.
Some EU Member States spend less than 5% of their health budget
on mental health; others (including the UK) spend over 10%. [4]
11. We suggest that the strategy should
acknowledge the resource pressures on health spending, but should
encourage all Member States to provide adequate resources to meet
assessed needs of their populations and to consider how they might
achieve both cost and health benefits by shifting resources from
institutionalised care to a range of community-based services
(a process already under way in EU Member States, though not in
many European countries currently outside the EU), and to increased
evidence-based mental health promotion activity.
The priorities
12. We believe an EU strategy should consider
the following as possible priorities:
(a) a multiagency approach: mental
health is not just an issue for health and social care services.
As the Green Paper rightly point out, mental ill health causes
significant losses and burdens to the economic, social, educational
as well as criminal justice systems. It would be important for
the EU strategy to target Ministers and organisations responsible
for these areas within all Member States—especially schools,
employment and housing authorities, and police and court services.
(b) mental health promotion and prevention:
the WHO Action Plan focuses strongly on the need for the better
promotion of good mental health and more preventative strategies,
such as developing programmes for parenting support and education
and the emotional wellbeing of children and young people. It is
becoming increasingly clear that the high prevalence of mental
health problems across Europe must partly be tackled through a
focus on prevention as well as the development of better treatment
and care services. Such an approach accords with the Green Paper's
remit to "improve the mental health of the population"
, and not just provide better services for those already suffering
from a mental disorder. It will be important, though, to ensure
that the evidence base for any promotion and prevention programmes
is clear and that limited resources are focused on high-risk groups.
(c) tackling stigma: Governments should
lead on tackling the stigma and discrimination faced by people
with mental health problems, common throughout Europe (and the
rest of the world). This stigma is a major barrier facing people
trying to recover from mental health problems, and can deter people
from seeking help when they first develop problems.
(d) children and older people: mental
health resources across Europe are primarily concentrated on adults
of working age with enduring mental health needs. While it is
important to ensure this population has access to a range of appropriate
treatment and care, the strategy should emphasise the need to
provide support both for children and older people, where the
prevalence of mental health problems is rising.
(e) refugees and immigrant populations:
evidence from the London event (see above) suggests that in many
European countries there are high levels of mental health problems
among refugee and immigrant populations. This is likely to remain
an issue over the coming years with the greater mobility of the
population within Europe, and increasing numbers of people entering
Europe from other parts of the world. The stigma of a mental disorder
may also be compounded for these groups by the stigma of being
from a minority ethnic community. The strategy should encourage
EU Member States to develop culturally appropriate services for
such populations.
(f) service user and carer engagement:
the strategy should emphasise the benefits of involving service
users and carers in planning and developing local mental health
services so that services reflect what they want rather than just
what professionals think they need.
(g) information and data exchange:
good policies and appropriate resource allocations rely on having
good data. The reporting and analysis of mental health data varies
considerably across EU Member States and leaves much to be desired.
[5] The strategy should point out the need for good data and encourage
Member Sates to develop information systems and share comparable
data across country boundaries.
HOW MIGHT
AN EU STRATEGY
ADD VALUE
TO THE
STRATEGIES OF
MEMBER STATES
AND THE
ACTIVITIES OF
THE WORLD
HEALTH ORGANISATION
AND OTHER
INTERNATIONAL BODIES?
The Green Paper suggests added value would come
with establishing a framework for exchange and cooperation between
Member States; by helping to increase the coherence of actions
in the health and non-health policy sectors; and by allowing involvement
of a broad range of relevant stakeholders into building solutions.
We believe an EU strategy for mental health
would have the potential to add value in these areas if it is
actively promoted by the European Commission and Ministers and
policy-makers within Member States. It will be good to have the
strategic thinking brought together within a European Commission
document—but implementing the strategy will require not
only political will but also the availability of resources.
For an EU strategy to be effective it will need
some resources to help Member States work individually and collectively
to gather and exchange good practice and to support service user
and carer organisations—which often have limited means—to
be involved in strategic thinking and planning at national and
local level. It will also require funds to develop further a programme
of comparable data collection across Member States.
REFERENCES
[1] WHO. European Observatory on Health Systems
and Policies: Policy Brief: Mental Health I: Key issues in
the development of policy and practice across Europe (2005).
[2] WHO. European Ministerial Conference on
Mental Health: Mental Health Action Plan for Europe: Facing
the Challenges, Building Solutions, January 2005.
[3] Department of Health. The National Service
Framework for Mental Health—Five Years On, December
2004.
[4] WHO. European Observatory on Health Systems
and Policies: Policy Brief: Mental Health III: Funding mental
health in Europe (2005).
[5] Marusic, Andrej. Mental health in the
enlarged European Union: need for relevant public mental health
action, British Journal of Psychiatry (2004), 184, 450-451.
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