Creating a Modern Mental Health System

Interview Transcript

Article | Creating a Modern Mental Health System
10th November 2020 Atheneum Team

Expert Profile


Non-Executive Director roles in the NHS in both Mental Health and Acute care Foundation Trusts




Nicky started her career training as a Nurse and went on to work in the Pharmaceutical Industry for 11 years in sales and marketing roles. After 11 years Nicky moved back into direct Healthcare taking a management role in leading independent mental health care provider, Cygnet. After 10 years she became the Chief Operating Officer of Cygnet and was responsible for the group’s focus on setting standards and delivering outcomes for patients and Commissioners. For the last 2 years, Nicky has taken Non-Executive Director roles in the NHS in both Mental Health and Acute care Foundation Trusts.

Section 1: Men’s Mental Health Consumption

1.1. What are the biggest factors contributing to men’s mental health issues?

Chronic pain is a term that has been around probably since 1980, 1985 and it’s categorized by a sense of an emotional outcome of a patient suffering from externally caused pain. But more importantly, the chronic pain definition from the International Association of Pain indicates that chronic pain is a pain symptom that’s felt over a period of time.

Normally, it is stress and a feeling of pressure. Men generally feel that they have a lot of responsibility. Whether they deliver on that responsibility, be that in the workplace or in the home, I think men respond to that pressure and stress very differently. It would be quite easy to get help and resolve those issues if you caught it early on.

However, if people allow it to escalate, that’s when it really becomes a much bigger problem. I think there are a lot of things around the way men are seen in the community, different cultures view their men very differently, and the pressures that are put upon them. There are a lot of factors, but I think some of the biggest ones are the in-built expectations and how men feel that they should feel, and how they feel that they should perform and what they should be able to do. This is a kind of competing. Testosterone has a lot to answer for, but it really does play quite a big part of it as well.

1.2. What are your observations on suicide rates?

I think it’s interesting, statistics say that theoretically 1 in 3 men have thought about taking their own life. In the UK population, it is thought that 1 in 4 people, not just men, have mental health issues. From that you would extrapolate that a high portion are men. Men and women present in very different ways with depression, there’s a lot more self-harming and so on with females, whereas men there is self-harming, without a doubt, but the way that they express the mental health issues are quite different. In our experience, there is without a doubt an increase, and we have seen it over the last five years in the mental health issues that men have presented with.

I think some of that is not necessarily that more men are having mental health issues, there is a small reduction in the stigma attached to men saying ‘that they feel down or that they have depression or that they’re not coping.’ I think that there is more recognition that that’s okay, and obviously there’s topics that have reached the public eye. Figures like the Royal family coming forward and talking about their mental health issues, and big name sports players, it helps establish the norm and that it is okay to talk about it. I think that a lot of the big employers have also taken steps to try and recognize depression and mental health issues within the workplace, and a recognition that men will suffer that. And what they can do about it by having a private counseling employee systems programs and so on, where people can go and get help. But without a doubt, there is an increase.

1.3. How do men access mental health care services?

There is only one way of accessing mental health services really, and that is through the GP. Most people can’t afford to go privately and get counseling and help. That is a route if people can afford it. I think the biggest route is through a GP. Presenting at a GP, not necessarily with mental health issues, but a GP being reasonably switched on and identifying that there are other things going on, and then referring for counseling or so on. Or as I say, I think actually employers are doing quite a lot.

So just for example, if you are employed by the NHS and you need help, you don’t have to go to your GP, you can access help through the employee assistance program. You can self-help to an extent and self-refer, and it’s anonymous. I think, especially for men, that quieter, more anonymous route is very helpful. Of course, it doesn’t help if you need further help because it has to be escalated, but it has to be through some kind of medical diagnosis. But often with men, it will be presenting at the GP with something else, and the GP will identify mental health issues. Which really means that GPs needed a lot of training because some are good, and some are absolutely rubbish.

1.4. How have mental health services changed their provision to facilitate men’s issues?

I don’t know that that much has changed apart from the awareness of men’s mental health and it being something that people recognize. So instead of it being, ‘it’s fine for someone to be depressed after someone close to them has died,’ it’s actually a recognition of the other factors. I think that there is more awareness, and I think a lot of that is thanks to sports people and high profile people coming forward and talking about their own mental health issues. Awareness has led to a more open-mindedness approach in health care as well. So with GPs, in mental health services, I’d like to say that people have been receptive to people whatever sex they are, but for you to actually have access to mental health services, you’re quite a long way down the line. To actually get help is the first step really.

There’s not always a recognition that you need help from an individual, but someone else has recognized that you need help and putting it to you in such a way that you might actually accept help. It might well present itself through alcohol, obesity, other addictions. A lot of men will present in that way with drinking too much and liver functions becoming abnormal and leading to an exploration of what’s actually going on. It’s often other things, and I think mental health services have always been there for men, women, anybody, but it’s accessing them. I think that that it is slightly easier.

In Northamptonshire, in the UK, there are a lot of crisis support groups that people can actually access and you don’t have to be referred to them, but there’s a real balance between people recognizing that they’ve got something up or they’re feeling down, and not labeling themselves as being depressed kind of thing, and being able to take a step to do something about it.

Section 2: Creating a Modern Mental Health System – The Workplace

2.1. What are the economic costs as a result of mental health?

Two things. The level of sickness and absence is huge through mental health. It’s thought to be billions every year. Furthermore, there is below par performance as a consequence. If you’re feeling fed up, let alone depressed, you would find it difficult to concentrate thus your ability to work at your peak performance is really curtailed. So the cost economically is absolutely huge. However, if you can catch it early on, then it’s reasonably quick to be able to do something, intervene, and help; and you will improve things very quickly.

The trouble is most people are diagnosed later down the line or they are prepared to admit it later when things have worsened. There is the impact on families and relationships too. It’s not just men that find it difficult to recognize, women have a perception about men as well. Women love to talk, and if you’re feeling fed up, two women can get together, and they’ll talk about what’s going on. Whereas with men they don’t, and they don’t talk to men and they don’t talk to women. It has to get further along the line before any help really comes along.

2.2. How can employers support their workers’ mental health?

There are the more formal routes, through the employee assistance programs, having counselors signposting to support services that employees can self-refer to. Some of the really good things that I’ve seen in ‘go-ahead companies’ where they are actually tackling it head on by not saying, “Well of course if you present with it, then we’d love to help you.” Instead they are actually exploring it and bring in external help to run groups. That can be for men, or it might be for mixed groups, but of employees too. There are training program, and we call it a mental health first aid program, where you can train managers to identify things starting to go wrong. You get a certificate at the end of the training. It can be in HR or general management. They’re taught to recognize some of the first steps of someone having mental health issues. It is not just depression, but it might include psychosis or paranoia, or a variety of other mental health issues.

Furthermore, employers can run groups and bring people in to encourage people to think about how they treat each other in the workplace and how to listen to people, and how to support people around them. The groups go beyond identifying men or women that have got mental health issues, but also create a culture in a workplace that is more observant and can identify people that perhaps need help or need some support. Following this they can be signposted to getting that support. Overall, it is about creating a culture of acceptance and removing that stigma, to create a culture where people don’t think less of a person because they are depressed.

As a manager, I’ve interviewed many senior people, and not many people would put on their CV that they have had a depressive illness or mental health issues, because they know that in the workplace, generally, you would be judged as a lesser person because you admitted to that. Trying within companies to create a culture where that isn’t the case is where I’ve seen some of the best successes, because it’s generally accepting. If somebody needs to take a few days off then they do, or if they need to be referred to get help, they can. Or even to have someone to talk to over a cup of coffee in the staff room without being judged. This is trying to create that culture of non-judgment. Some companies, through their private health, will provide other services, especially for addictions or actual diagnosed clinical depression or psychosis. But that’s a little bit further down the line.

2.3. What about private healthcare mental health provisions from employers?

Where private insurance is purchased by a company, they will often have an element of outpatient and counselor provision. So what I’ve called low level care, will cost a lot of money to get insurance that includes inpatient care. But a lot of employers will have private health insurance that will offer counseling services, referral to support services, and if there are addictions involved. Especially, in London, it got really big where cocaine users were being referred in by their employers and it had been paid for because it’s part of their insurance policy, this is less common now because insurance companies don’t like that. But a lot of individuals don’t have private health insurance, but a lot of the big companies will provide at least that level for their employees. However, there is a very limited uptake in it because people believe that if they access their private health insurance through that company, they will be labeled. Most people would consider having that label hanging over them would damage their future prospects. So, although it might be available, it’s probably the least utilized route of access because of the perceived repercussions.

2.4. Are the financial costs of mental healthcare provision justified?

In terms of bringing in experts to run groups and work on that cultural side of things, it’s not that expensive. It probably costs £1500-2000 a day to get somebody in. For an experienced person to facilitate groups and talks to have those kinds of generalized discussions with groups of employees. They need to be fairly small groups, they need to be carefully picked out and people have to volunteer to come along to them. You would have to run a few in order to be able to impact on cultural element of a company. But it’s not hugely expensive. I wouldn’t think so, compared to the potential positive upturn.

But if you provided the group sessions, you would have to make other services available. You would need to have an employee assistance program. You couldn’t start talking about mental health and bring stuff out into the open and then say, “Okay, well now just go and see your GP.” You would need to be able to provide some kind of additional supportive structure around those individuals. You really need to work on the management before you can provide those mental health services, because if the managers don’t buy into it and aren’t prepared to recognize mental health issues in the workplace, then you’re fighting a losing battle. There’s no point, because people will come forward and then there’ll be penalized for coming forward. You would have to kick change off starting in HR, and then have your senior management really committed to making change. Any counselors worth their salt wouldn’t come into a company just to do a couple of sessions. They would want to see that there was the ability to have cultural change, otherwise it would be a complete waste of time.

Section 3: A Modern Mental Health System – Community Care

3.1. What does mental health in the community level look like?

The key focus is for mental health provision to be in the community and only individuals who are very ill would get admitted. Different counties have very different community mental health structures. Within Northamptonshire for example, they have inpatient care, but also provide community care. We offer what we call ‘crisis cafes’, and there are ‘crisis houses.’ So let’s say tomorrow, you felt you needed help. You could walk into a crisis cafe, it is like an internet café with sofas and stuff around with coffee and tea. The cafes have trained counselors, they are not doctors and nurses but they will talk to you, and if need be, would signpost you to other services. If you were seriously poorly and potentially suicidal, then they would be able to arrange for you to go to a crisis house, or even potentially even go into an inpatient service.

Before those things were around the system relied on accident emergency. Either one of your loved ones felt things were in such a crisis that they took you to A&E or called an ambulance, and you went in and were admitted into the hospital structure. This might mean you got sent home and referred into the community, but it would be a much lengthier process. The beauty of these cafes and crisis houses is that they’re immediate and that you don’t have to be referred into them by a GP or any other medical professional. There is community access points, and you don’t have to be suicidal to go there. You could really just sit and start talking to somebody. It’s not necessarily about someone in critical condition, it’s about anybody really feeling that they can just reach out and get help.

3.2. What are the benefits of a community based mental healthcare plan?

A lot of more counties are now doing it. It has proven to dramatically reduce the incidence of suicide attempts and more importantly the impact on NHS hospital admissions. There has been a dramatic reduction in the number of admissions into hospitals, because people are being caught early and they’re recognizing issues within themselves. The trouble is that the population is a lot bigger than the 2 crisis cafes in Northamptonshire can cope with. So this provision need more rolling out and certainly needs more rolling out across the country. Of course in the community you have the GPs who are recognizing illness through either self-recognition of patients or through other diagnoses.

You also have the community mental health care teams. If you go into your GP, then you would be referred into a CMHT, a community mental health team. There, you might see a consultant psychiatrist, or you might see a nurse or a counselor, depending on what their issues are. You would get a treatment or see a psychologist, whatever your requirement was. The problem with that is, is there are quite long waiting lists to get into that, especially for young people who need to access things a little bit more quickly.

3.2.1 What is the impact of Telehealth on providing mental health services?

That’s one of the interesting things that’s happened in COVID with the pandemic is that people haven’t been able to access community services. The crisis cafes at first were shut, when we were in the peak of the pandemic. I think COVID has taught the NHS that there is a lot of help, and there is the IAPT (Improving Access to Psychological Therapies). It’s a telephone service that medical professionals can refer patients into. It’s like the employee assistance program, as it offers a number of telephonic counseling sessions. If during those telephonic counseling sessions you were found to have much greater need, you could be referred into that CMHT program, or if necessary inpatient care. But IAPT has been quite successful, and has been really ramped up during COVID. One of the things that we’re about to see starting to explode is the number of NHS employees needing to access IAPT and mental health care, so the aftereffect of COVID.

Telemedicine is without a doubt on the increase. Some people say it’s very hard to counsel someone over Zoom, but it works very well, especially for younger population. Not so much for the older population, but younger people that have grown up with Zoom, their phones and FaceTime then it’s second nature. But that’s one thing that COVID has done, I don’t know what the proportion is, but a large number of people know how to use Zoom and Microsoft Teams and FaceTime and stuff that never did before.

3.3. What can we learn from peer support women groups?

If you think about how women would access it, women are generally more able to talk, and society puts less pressure on women about talking about their emotions and their feelings. Until that changes, then it’s going to be difficult for men. I think the thing that’s really made the difference in reducing the stigma has been public figures coming out and talking about their mental health illnesses. Within mental health facilities, they’re running men-only groups. You might have alcoholics anonymous, narcotics anonymous, and a men’s group, because if you go to places you’ll often find there’s a women only room or a women only this or a women only that.

Now there’s a recognition that sometimes you need to have men-only groups. And I think that there’s a lot more increase in access to that kind of thing. I think that will be more successful. Really, it’s a cultural issue that needs to be overcome for it to be really reduced, because the stigma attached to men revealing their feelings and talking about how they feel and admitting a perceived weakness. Until that’s overcome, it’s going to remain a very difficult problem. All you can do is try and bring it out into the open and the more that can be done, the more it will help really.