Delivering benefits to the mental health of children, families and societies during times of austerity: are we failing to grasp the nettle?
UK expert in child psychiatry Dr Richard Williams explains why funding mental health services for children and families should be seen as an investment during harsh economic times.
The World Health Organisation identifies child and adolescent mental health as an essential component of health. But, it is evident that mental health services for children and adolescents are perennially underfunded if we compare the gains to the health and wellbeing of persons and nations that could be delivered with the scope and capabilities of services that are supported presently by public resources.
The term ‘equity gap’ describes the differences between the potential capabilities of services to deliver effective interventions that are well orientated to people’s assessed needs and the actual capacities of local services to deliver those health gains. Put another way, equity gaps refer to benefits to the health of people and societies that are still waiting to be delivered. They aren’t news. As a colleague has put the abiding situation, ‘ … despite child and adolescent mental healthcare improving, it feels as if it has been in a permanent state of austerity!’ In 2003, the WHO characterized the major barriers to achieving universal child and adolescent mental health services as including: lack of financial and human resources; poor facilities; stigma; limitations to effective communications and accessibility; and poor knowledge of mental disorders.
Ironically, the impacts of research and service developments are shifting the goalposts by progressively increasing the potential capabilities of services to intervene effectively to improve people’s mental health. So, despite slowly increasing investment in services, the gap is still growing between availability of services and what they could do for us.
The term ‘health inequalities’, on the other hand, describes the differential needs for healthcare, including mental healthcare, of people from different parts of societies. It also refers to the differential availability of services that may result in people with the most prevalent needs having poorer access to the up-to-date services from which they could benefit. Health inequalities are also not new!
In the last several decades, much of the world has faced an uneasy conjunction of awareness and capability. On one side, professional capability is increasing progressively. However, on the other hand, growing global awareness of people’s mental health needs, sustains a simmering sense of urgency for advocates, services users and mental health practitioners about persisting mental health equity gaps and inequalities. Research in a number of societies, has shown that families that have the lowest incomes are most likely to be at risk of mental ill health. Not only that, but, generally, effective services are less accessible to people who have the greatest needs arising from lack of societal affluence.
Now, on top of these two limitations in our ability to meet people’s mental health needs are potential threats to mental health services from reductions in disposable incomes as a result of the global economic problems. Austerity measures that are being taken in many countries could, if not handled with the greatest of care, threaten families’ mental health raising, thereby, needs for services. During economic stress, there is evidence that the abilities of adults who are most affected to offer their children the kinds of parenting from which they benefit are under pressure. Research also shows that their children’s worries erode their parents’ quality of parenting. This creates the potential for resonant increases of risk to children’s mental health in the present economic problems.
At the same time, health service budgets in many countries are under increasing pressure and budgetary restrictions can result in threats to clinical programs, training, and research. Other barriers to investing in child and adolescent mental healthcare include: the difference in the timeframes required for evidence-based mental health interventions to be effective and the tendency of the responsible authorities to adopt short-term financial foci; and limitations in general awareness of the savings that modeling suggests can accrue to the public purse. This tension poses a challenge for determining how best to cope with the impacts of financial stringencies on delivering mental health services. Do we make reductions in services where we think them least damaging or is it credible for us to argue for a more radical approach?
The second option arises because financial modeling of healthcare by, for example, Martin Knapp and his colleagues* has shown that savings in public expenditure could be made over time if we, first, protect and, second, increase investment in certain evidence-based interventions. He and his colleagues report, for example, that effective early intervention with young people who have psychoses could save costs falling on health budgets after the first year of investment and that the total gross savings in years 2 to 5 of these programs could exceed the costs by a ratio of 8:1.
But this evidence raises a further challenge. How should slender financial resources be apportioned to promoting and protecting children’s emotional wellbeing, mental health and resilience, on one hand, and to developing better services for people who are already ill, on the other?
There remain uncertainties about the priority of investing in public mental health. That approach describes measures taken by societies to promote and protect the mental health of families, groups of people and communities by interventions that are not therapeutically offered to single persons, but to preventatively to communities, families and groups. There are two sorts. Universal services may, for example, be delivered through schools and other groups, for unselected populations of people: they are intended to reduce general risks to people’s mental health. Targeted interventions are focused on groups of people who are recognised as being at greater risk, such as, for example, young people who are not in education, employment or training. But, uncertainties about the effectiveness and value for money of health promotion services at a time when there remain equity gaps and mental health inequalities for people who already have diagnosed mental disorders raises the question about how limited public finance should be allocated within mental healthcare.
In this context, there is now increasing evidence that certain public mental health interventions, if applied systematically, are effective. Health economic claims by Knapp and colleagues from financial modeling* have shown that some of these interventions are good value for money in that they save investment in clinical health, social and criminal justice services if they are sustained over 2 to 8 years. Certain programs that aim to support parenting can prevent persistent conduct disorder and gross savings from year 6 of applying these programs can exceed the average costs of the intervention by a ratio of 7:1. School-based social and emotional learning programmes can also prevent conduct problems in childhood with the modeling showing that gross savings could exceed program costs in years 2 to 5 of 48:1. These programs also appear to promote the psychosocial resilience of children and young people to austerity, adversity and challenging life-events by offering them social support at the right times and in the most appropriate ways.
The conclusion is that nations should invest in mental healthcare by advancing a mix of public mental healthcare and programs that provide effective early interventions for children and young people who develop mental disorders. Critically, these investments should be protected during economic downturns. The reasons are not only humanitarian. Paradoxically, investing in child and adolescent mental healthcare during economic downturns is an austerity measure.
- Knapp M, McDaid D, Parsonage M (eds). Mental health promotion and mental illness prevention: the economic case. London: Department of Health, 2011.
Richard Williams OBE is the Professor of Mental Health Strategy in the Welsh Institute for Health and Social Care in the University of Glamorgan Wales. He is President of the Royal College of Psychiatrists, Wales and is currently in Australia speaking at the Royal Australian and New Zealand College of Psychiatrists’ child and adolescent conference in Manly.