The summaries below set up the main points from each day of the DeSTRESS project conference, Poverty, Pathology and Pills held on 15/16 January in London. You can also view or download abstracts and slides for each presentation.
A brief report followed by abstracts and slides from the first day of the conference.
Stagnating life expectancy rates show the nation’s temperature rising. Jessica Allen (UCL Institute of Health Equity) pointed out that poorer groups have seen past improvements reversed, with psycho-social factors a key driver. Many people feel they have little control over their lives, increasing stress levels. The growing incidence of adverse childhood experiences is storing up mental health problems for the future.
Vanessa Pinfold (McPin Foundation) reflected on people’s experiences of mental health in low income communities. The quality of the services they receive is overlooked, and the impact of poverty on the social, economic and environmental context of people’s lives is ignored. Working together, communities can build a sense of identity through their people, places and activities, and improve mental health. It’s possible, but only as long as they have the capacity and voice to do so.
DeSTRESS works with communities in areas with some of the fastest rises in anti-depressant prescribing in the country. It focuses on the impact of poverty on the lives of people and their mental health, their interactions with GPs and primary care services. It explores how the impact of poverty can be mitigated and the quality of the GP/patient relationship improved.
The project’s message is that understanding the issues and identifying potential action requires meaningful community engagement. It means co-creating an identity in partnership with residents, promoting self-organisation for mutual support, developing a ‘voice’ that can be heard and listened to, and learning from and responding to patient experience in shaping services. It means getting GPs to rethink how to respond to such experiences in partnership with patients, and not just reach for the prescribing pad.
Austerity has complicated the response as a result of welfare reform and reductions in public services. Lynne Friedli (Centre for Welfare Reform) showed how people in low income communities are stigmatised. Often, they are blamed for their poverty and/or mental health condition. Work has been put on a pedestal by society. People who are not working – whether because of ill-health, disability or family issues – are judged to have an attitude problem. People face work capability assessments, which take scant account of advice from health professionals, or risk losing benefits, making a bad situation worse. This leads to a state of ‘enforced employability’.
Lone parents experience social isolation and loneliness, noted Laurie-Anne Campbell (Glasgow Caledonian University). It is exacerbated by poverty, with adverse effects on health and wellbeing. A Scottish survey showed that 84% of lone parents ‘feel down’ at least part of the time.
The strong link between poverty and the incidence of self-harm among children of poorer families was emphasised by Pearl Mok (Univ. Manchester). She showed a three-and-a-half times difference between the rates in the highest and lowest social groups. Upward social mobility seems to diminish the risk.
Joanna Moncrieff (UCL) argued there are doubts about current practice in mental health diagnosis and treatment, not least because of the anti-depressant prescribing boom and lack of curiosity among medical practitioners of patients’ circumstances. There is no evidence that depression is a disease, which means that “with the disease model, the doctor surrenders his common sense” (Adolf Meyer). Diagnosis and treatment should take more account of social as well as biological factors.
Social prescribing – non-medical solutions to improve health and wellbeing – is a possible way forward, not least as a process of engaging with the wider aspects of people’s lives, suggested Bethan Griffith (Univ. Newcastle). There are many delivery models, which makes it hard to judge effectiveness. Patients were keen, but health professionals more hesitant to being involved without clearer terms of engagement.
Local groups self-organise help through peer support as in Thanet, Kent, reported Kay Byatt and the SpeakUp team. But, she stressed ownership is crucial. Support is provided directly by group ‘members’, not for ‘service users’. ‘Using your hurt to promote a passion for caring’ strengthens the community and helps relieve pressures on GPs.
Jenny Popay (Univ. Lancaster) asked whether social prescribing and peer support is enough to release community potential? Individual initiatives can only prompt an ‘inward gaze’ into local, behavioural factors, which risks widening inequalities because of the imbalance of resources between areas. The ‘outward gaze’ of community empowerment is neglected. ‘Collective control over decisions’ is the way to rebalance the power relationship and realise the ‘Health for All’ ambition of the WHO Alma-Ata declaration (1978).
A brief report followed by abstracts and slides from the second day of the conference.
What price ‘parity of esteem’ between mental and physical health after years of neglect? Asked Paul Farmer (MIND). He said achieving such ‘parity’ means
Communities living ‘below the breadline’ have a spirit that’s hard to break, despite the hardship said Karen Coombes (DeSTRESS project). She said her Plymouth housing estate is cut off from mainstream services, shops and transport, its local environment blighted by a giant incinerator, and her fellow residents harassed by benefit system driven work assessments which ignore – and exacerbate – mental health problems, and bar the path to a decent income.
Debt fosters depression, observed Adele Ring (Univ. Liverpool). Like a disease, unmanageable debt consumes people’s lives and amplifies the impact of poverty through psychological distress and relationship breakdown. Experience in Liverpool shows how a coordinated effort can break this vicious circle through work, financial advice and community support.
Violence too, is a symptom of poverty and deprivation. Tony Bone (formerly Police Scotland) related how parts of Kilmarnock have three-times as many A&E admissions for assault as other areas, much lower rates of male life expectancy, and a host of social difficulties. But, “people who have a stake in their community tend to protect it”. Community programmes have promoted listening events, set up job clubs and small businesses and encouraged services to reduce social isolation.
Too often it’s the ‘system that’s sick, not the people’ – a system bedevilled by inequalities, a breakdown of social cohesion and trust, and a lack of data. Is this a moment for people in low income communities to take responsibility for their own affairs insisting that “nothing about us, without us, is for us”? asked Heather Henry (Brightness Management)
The willingness to share policy responsibility across the UK was questioned by Gregor Henderson (PHE), even though local action on mental health offers the greatest scope for improvement. Scotland is more imaginative than ‘top-down’ England – though the transfer of public health responsibilities to local authorities in England is a possible pointer to a different future.
The costs and incidence of mental health in the UK does not compare well with other European countries said Kate Cornford (OECD). These costs are likely to be a significant underestimate, and inequalities are a particular challenge.
Helen Gilbert (King’s Fund) said that people’s lives will only be changed by
Many GPs have been forced onto the defensive by austerity, resulting in a more medicalised approach to mental health when a multi-faceted approach is needed, observed Chris Dowrick (Univ. Liverpool). Manchester has sought to improve access to – and quality of – primary care services by working with local communities, identifying local champions and establishing consultative focus groups.
These pressures risk stress and burnout for GPs as services cannot keep pace with growing demand reported Karen Mattick (Univ. Exeter). They need support to face such pressures, and encouragement to share the burden with other primary care staff. Medical education is one way of alerting future GPs to the realities of practice.
Diagnosis is often the easy bit for GPs, understanding what matters to patients is much harder, declared Helen Stokes-Lampard (RCGP). While the ‘inverse care’ law applies more than ever, greater personalisation of care will help, ensuring the right connections are made with patient’s lives and circumstances.
A broader approach – beyond prescribing pills – is one that joins the condition of people’s lives to their mental health, concluded the DeSTRESS team. It’s closer to a human rights model. A GP mindset that ‘thinks we know what our patients know’ misses the reality. ‘Ollie’s story’ told by his mother, Debbie Roche, related the experience of a young man suffering from anorexia and its devasting impact on his family, as well as the challenges and obstacles faced in securing necessary mental health support.
Things can be different urged Daisy Parker (Univ. Exeter). Patients shouldn’t feel they are (a) being judged (b) wasting time or (c) being told ‘that’s life’, GPs can start to ‘look and listen’ to what patients are telling them, understand patients have lives as well as possible conditions, and show they are human too.
There is scope for a new approach that improves the quality of the GP/patient consultation emphasised Matteo Pizzo (Camden and Islington NHS). It needs to: enable primary and secondary mental health teams to work together; recognise that mental health is more than just an individual ‘problem’; allow space for the disclosure of emotional problems; recognise the conversational cues and clues; and establish what will support people best in their lives. He stressed that GPs don’t have to be superhuman – they don’t have to ‘fix’ every person but can work together with their patients to agree an appropriate way forward.