Britain's next great health crisis is already here

Even if you don’t personally live with the same problems that many of us do, then a moment’s reflection will reveal how the current crisis of physical health will inevitably bear on mental health too. With millions infected by Covid-19 and hundreds of thousands dead around the world, no area of life has gone unaffected: businesses closed, jobs lost, friends separated, relatives grieving. And these are merely the more obvious effects. Beyond the lost lives and livelihoods there is a ubiquitous worry about getting sick, plus a pervasive sense of uncertainty, insecurity and gnawing anxiety that has seeped through the locked-down economy. In the UK, around nine million people are expected to be furloughed, many of them facing an agonisingly precarious future. Sinking incomes have already translated into around a million new claims for universal credit, a new benefit that was synonymous with delays and hardship before the sudden crisis hit it.

Meanwhile, those who are still in demand from employers have different problems, whether it’s NHS and care staff with inadequate personal protective equipment (PPE) or manual and service workers who can’t afford not to work, can’t do so from home, and must now set off with no greater protection against the virus than gratingly cheerful government advice about “staying alert” and, if possible, somehow getting there without catching the bus. No wonder that even those without any history of mental illness are starting to feel the strain.

Beyond control

“Because there’s no vaccine or known way of getting to the other side, the level of uncertainty is through the roof,” explains therapist Simon Coombs. “At the moment, we have no control. So for someone who’s never really struggled… they’ve really been dropped in at the deep end.”

Jon, an office worker from Sheffield in his late 30s, had previously supported friends and an ex-partner through various issues with their mental health. But, until the coronavirus pandemic, he had never struggled himself. “I feel quite naive now,” he says, “because I thought that looking after people who weren’t well meant I understood what it was like to feel so anxious and depressed.” He laughs. “I really didn’t.”

Finances weigh heavily on his mind. Laid off from his job because of Covid-19, Jon has relied on bits and pieces of freelance work to get by. But these are few and far between, and when he and his flatmate requested a rent reduction from their landlord, they were rejected. “I’m already living off my savings,” he says. “And trust me, there isn’t much of them.”

A persistently low mood came first, then problems with sleep. Normally a fairly regular sleeper, Jon has recently been averaging two to three hours a night, worrying about money and work and feeling so anxious “it makes me physically nauseous.” “Then the next day I feel like a zombie—I can’t do anything except lie in bed or sit on the sofa looking at my phone,” he says. “I would say, 100 per cent, that this is the lowest point of my life by far.”

“I live in a flat with no garden and I’m not really near any substantial green space, so I’m spending a lot of time on my own indoors,” he continues. He has a flatmate (who he gets on with), but her job has moved entirely to home working, so she’s busy during the day: “I don’t like to bother her,” Jon explains. Now, for the first time in his life, Jon is seriously considering seeing a therapist.

A British Association for Counselling and Psychotherapy survey underlines that Jon is not alone. Ninety-eight per cent of counsellors said that coronavirus has come up in therapy with both new and regular clients. A minority reported a significant increase in clients since lockdown began, which is pretty striking given the impossibility of in-person appointments, and the need for new patients to navigate the whole process online. The picture is just as grim in surveys of patients rather than practitioners. Rethink Mental Illness found that 80 per cent of those living with severe conditions had felt their mental health worsen due to coronavirus; 28 per cent said their health was “much worse.”

Loss, debt, ongoing economic uncertainty and anxiety about personal health will all create a need for counselling after lockdown ends, as over 20 organisations representing 65,000 professionals—including the British Psychoanalytic Council, Cruse Bereavement Care and the Association of Child Psychotherapists—wrote in an open letter to Health Secretary Matt Hancock in May. But “supporting the nation through the coronavirus crisis” with the help of counselling and therapy, as the professionals urged, is not looking like a straightforward task. For one, many practitioners are self-employed themselves, and likely to be struggling to keep their own businesses afloat. And for clients, access is always limited. Though therapists charge a range of fees, the average is somewhere between £50 to £120 per hour, with low-cost options limited; even these can cost up to £20, and £10 sessions with trainee psychotherapists are few and far between. Shut out from receiving private therapy, those living in poverty are often left to endure long NHS waits alone. One 2018 survey found some patients had waited up to 13 years for support, with waits of many months common. And as demand grows, the waiting lists will now soar in parallel.

“I can barely afford rent,” Jon says. “How am I supposed to pay for therapy?”

Talk Talk

Long a taboo, mental health has suddenly been something of a buzzphrase over the last few years, with stigma-busting campaigns such as Time to Talk making headway in confronting stereotypes. Indeed, “talking” is at the heart of many campaigns: Get Britain Talking, for example, urged ITV viewers to open up.

Wider media interest is rising too—a 2018 Mind survey found coverage had rocketed by 22 per cent in a mere 12 months. There have been more news reports, more interviews where celebrities “open up” and more storylines on TV soaps. Prince William and the Duchess of Cambridge Kate Middleton have made mental health central to their platform, promoting “kindness and self-care” through their Heads Together campaign, and both William and his brother Harry have spoken publicly about their struggles after the death of their mother in a way that would have been unthinkable for the stiff-upper lip royals of past generations.

It’s hard to criticise such campaigns—it’s better to talk than stay silent. But by focusing on milder conditions and general “wellbeing,” the new interest still tends to look away from the experience of many with more severe or chronic conditions—personality disorders, schizophrenia and others. “Kindness and self-care,” whether promoted by the younger royals or not, is unlikely to much change the life of someone experiencing psychosis.

But are words replacing action? All the new positive talk has come in parallel with a long squeeze on NHS finances and outright cuts to many welfare services. You might be eager to talk about your mental health, but even if you can persuade a GP this is a good idea, it’ll often be months until you see a psychiatrist or NHS psychotherapist. Former prime minister Theresa May’s efforts to reduce the “stigma” around talking about mental health made an important point, but was it just a coincidence that she pushed that theme quite so hard after long years of austerity? “It is always wrong for people to assume that the only answer to these issues is about funding,” May said. Perhaps, but funding matters, too. All the talk about talking took responsibility away from the state and pushed it back onto individuals.

Though a lot of noise has been made about mental health spending in the last few years, much of it has been hot air. Having been savagely squeezed, the trumpeted largesse to mental health trusts has often done nothing more than make up for previous cuts, often inadequately. Shortages are rife, with a 30 per cent slump in the number of beds for mental health patients. In the past 10 years, the UK has lost 6,000 mental health nurses—nearly 11 per cent of the workforce. In 2019, the UN special rapporteur on health released a report that concluded that austerity measures in the UK had significantly contributed to poor mental health.

There have also been ongoing issues with “off-rolling” patients once they leave hospital. Secondary services—community mental health or crisis and recovery teams—have long supported people after discharge. But according to a report from Manchester Mind published in October 2019, cuts to services now routinely place this responsibility at the door of GPs who are ill-equipped to deal with serious mental illness. When people have no one to turn to who knows how to support them, it predictably leads to more intense distress—and in some cases death, whether from suicide, neglect of physical health or from accidents such as drug overdoses or alcohol abuse. All this forms the backdrop to the emerging mental strain from the pandemic, and threatens to combine with it to produce the perfect storm.

A little less conversation

No part of the NHS was prepared for coronavirus. In 2016, when an operation named Exercise Cygnus simulated an influenza pandemic in the UK, the findings were stark. There were serious gaps in resources, including a lack of ventilators, PPE and critical care beds—all problems the NHS has faced since the pandemic hit. But away from the respiratory care “frontline,” less thought was given to the preparedness of mental health services, and they were never likely to fare well. And indeed, in late April, a survey commissioned by the Royal College of Psychiatrists found that 23 per cent of psychiatrists had no access to PPE at all, and that only half of those who had wanted tests had been able to get one.

The suffering isn’t restricted to hospitals. Access to services in the community has also decreased; some staff have had to take on outside caring responsibilities or have been ill themselves, leading to shortages. And with face-to-face appointments out of the question, much now relies on patchy provision of digital or phone consultations.

“Stay at home” messages have certainly played an important role in tackling the spread of the virus, but they have also contributed to many eschewing medical services they really need. One woman I spoke to told me that she’d avoided A&E after needing a self-harm wound sutured. “In normal circumstances I definitely would have considered it serious enough to go to A&E,” she said. “But, as I’m sure lots of other people who have presented at A&E with a mental health crisis can attest, you don’t always get a great reception there when you’ve self-harmed, and I just couldn’t face it at this point. I didn’t want to feel like I was wasting their time, or like I shouldn’t be there, or like I was putting other people at risk by going to hospital.” She had her own concerns about catching the virus too, worrying she’d have a higher chance of contracting it if she went. She dealt with her cuts herself.

Sean Duggan, Chief Executive of the NHS Confederation’s Mental Health Network, confirms that referrals, which typically come through GPs, have dropped off recently. “We went through a stage where there was a bit of capacity in the system, not so many people referring [to GPs],” he says. He suggests “it was a combination of people frightened to refer and deciding to stay at home to protect themselves and the NHS—they were self-caring instead.” But now, Duggan believes, mental health services need to prepare for things to change fast, with “a huge demand on all of our services.” “I worry that we’ll predict a surge in demand for mental health services [and prepare for it], but that the demand will be even more than that,” he says. “The problem is that we don’t know, and I’m worried about that.”

Many who have suffered with mental health problems in the past will now be retraumatised or triggered by isolation or worry; problems left untreated in lockdown will foment and worsen; and—meanwhile—insecurity, hardship, isolation and grief will push previously “stable” people into distress. Although it’s impossible to know how many more people are going to be affected, many conversations I’ve had suggest that there may already be a rise in the number of people seeking help who had previously had no contact with mental health services before now.

If patients were sometimes waiting years to access therapies and services before, how long will they have to wait now—and how will the services cope? An optimist might point to the hero-worship of healthcare workers, and the way that a resistant Boris Johnson eventually conceded to exempt the health and care staff from the “NHS surcharge” imposed on overseas workers applying for leave to remain. This might be taken as evidence that political self-interest, if nothing else, will finally move the government to show some generosity towards public services.

But the virus, the lockdown and the furlough scheme will plunge the government deep into the red, which will make it harder to hold out much hope that decent funding will be provided on a sustainable basis. And it’s not just money that prevents governments from supporting mental health programmes, but also a lack of understanding. Johnson has shown a questionable grasp of mental health issues: in a much-criticised Telegraph column last year, the prime minister asserted the one reliable “cure is work,” suggesting anyone struggling should be inspired by Winston Churchill’s “almost superhuman production of books, speeches and articles,” which “pitchforked off his depression.” This is offensive bluster, of course, but in the Covid-19 economy the reality is that many people will have no work. And with no certainty around who will be able to access services, or the kind of care we’ll receive when we do, many are wondering what—if anything—they can do to improve their situation.

When someone is struggling to cope, they need more than the tips for general wellbeing beloved of some campaigns. In and of themselves, they are no bad thing: it goes without saying that taking care of your health and doing things that make you calm and happy are good. If taking a bath makes you relax after a difficult day, bathe away; drink your herbal tea, talk to your friends, learn to knit, buy that mindful colouring book. But the new battalion of mental health talking heads—celebrities, politicians and princes—are likely to be shielded from hardship and inequality; it is time we heard much more from those who truly are at the sharp end.

As those of us with severe or chronic conditions can tell you, the mainstream idea of “self-care” is not going to make a difference; the same goes if you’re homeless or don’t have a job, if you experience daily racism or find yourself forced to choose between heating and eating. “Be kind to yourself” might be a nice sentiment, but it’s almost meaningless: a toothless slogan that says absolutely nothing about people’s real lives and experiences. Yes, it’s good to talk. But as we begin to discuss the sheer scale of the unanswered need, we must be fully prepared for an awkward conversation.