cruelty

Let’s stop being mean about people who are fat

This is an update on a blog I wrote earlier this year. I’m reprising it because of the fuss this week about Public Health England’s report into obesity and the Prime Minister’s apparent refusal to consider a possible tax on sugar.

Fat-shaming is a recent phenomenon. People who do it include doctors, nurses, NHS managers, politicians, journalists, comedians and ordinary folk like you and me. And it is weird, because according to statistics, over 60% of us in the UK fall into the category of people being vilified for our weak will, stupidity, greediness and for costing a lot of money in unnecessary healthcare.

I write as one who has done it as well as had it done to me.

I always liked the beach

I always liked the beach

Here’s me as a baby. Fully breastfed, I grew bigger than my tiny mother almost before I could walk. I take after my father. I am robust. I love my food.

Humans are built for survival. Some are wiry and can run fast for long distances. Others have staying power. In an emergency situation, chunky people like me can cope with cold and hunger because we can survive on our fat stores. We are the polar bears and the Arctic seals of the human race.

But our modern Western world has played havoc with these survival characteristics. As long as you have money, food is plentiful. The least nutritious, most fattening sorts of food are often the cheapest. And the combination of sugar, fat and salt in many processed foods such as cakes, biscuits, chocolate, ice-cream, crisps, milkshakes and even bread is, apparently, addictive.

This Ted Talkthis Ted Talk is enlightening. It helped me understand why losing weight is so hard. When you have gained weight, your body quickly adapts to being bigger, and adjusts your metabolism accordingly. Resetting the metabolic rate is extremely difficult. Once you have lost weight, you will probably have to eat fewer calories for the rest of your life to maintain your reduced size, even with regular, vigorous exercise. So you are fighting not only an addiction, but also your own nature.

And there is another factor. Many modern medications, particularly those used to treat various sorts of mental illness, have the unfortunate side effect of increasing one’s appetite. People taking them find they feel hungry all the time, and not surprisingly they eat more. I finished my antidepressants six months ago. Yet I have at least half a stone to shift, and despite extensive motivation and knowledge, it is proving a struggle. I know from chatting to others how distressing it is to gain four or five stone very quickly, with all the disability and stigma that goes with being overweight to add to the burden of the mental illness for which you have to keep taking the medication that leads to the weight gain.

I know people who have been to the doctor and been encouraged to lose weight. And then they buy a newspaper and are told that if they also buy a monster size bar of chocolate (which contains more calories than they need to eat in a whole day but no protein, vitamins or roughage) the newspaper will be free. If it were cigarettes or drugs, we would be horrified.

Given the cost to the NHS of obesity, with its links to heart disease, strokes, Type 2 diabetes, cancer, arthritis and other long-term disabling conditions, not to mention depression, anxiety and agoraphobia linked to body image and self worth, you would think that investing in prevention and effective treatments for obesity would be the place to start.

There is mention of this in the NHS Five Year Forward View. But until this week, there has been no systematic appraisal of the best ways to help people achieve and maintain a healthy weight, nor is there a coordinated, evidence-based commissioning approach to weight-loss and healthy weight maintenance services. Public Health England have produced a report about sugar, but we have learned this week that it has been witheld. Who knows what the real story is about who did this? I don’t really care. I just know that leaving obesity to individuals to tackle is unfair, ineffective and helps mo-one but the commercial giants who sell us all the stuff we don’t need.

Our current attitude to obesity is bizarre. Let’s tackle the food giants who push processed junk food at us from every direction possible. Let’s publish the economic appraisal to prove that helping people rather than criticising and lecturing them would in the end save a lot of money and even more unhappiness.And most of all, let’s stop blaming people for doing what comes naturally.

 

Ignore Russell Brand and vote for mental health

I start by declaring an interest. I really like The Right Honourable Norman Lamb. He knows his stuff on mental health. His values are sound, and he is an unassuming, witty and extremely kind man. He has also been dealing with distressing family issues and still managed to maintain focus on his job as Minister of State for Care and Support. Senior staff at NHS England such as Professor Sir Bruce Keogh vouch for him “holding our feet to the fire on mental health.”

Yet I became tetchy on reading the Liberal Democratic manifesto mental health promises yesterday. It feels a bit rich that a party that has been in power for a full parliamentary term, albeit as a junior partner in a coalition, should be making promises now after 5 years of not making these things happen.

My supporting evidence:

  • I:4 of us will be mentally ill in any one year, according to the Mental Health Foundation. Yet mental health services are still the poor relation within the NHS family, missing out on new money and bearing the brunt when public sector “efficiencies” are required, as they have been during the last parliament. Under the coalition, this imbalance has grown measurably worse. The funding promises made in yesterday’s Lib Dem manifesto will to some extent redress the balance – but only if they come to fruition.
  • I will need persuasion to believe that we will see this money, given the promises made in 2010 not in the last Lib Dem manifesto, but after the coalition government was formed. I was chairing the Mental Health Network of the NHS Confederation at the time, and was invited to speak at the launch of the coalition’s mental health strategy alongside Mr Lamb’s predecessor Paul Burstow. We felt excited and optimistic that parity of esteem between physical and mental health services was being promised at the start of the new parliament and ahead of any other health announcements. What happened?
  • Children’s mental health services, one of the top priority areas in the manifesto, are in a state of particular crisis. This is because of cuts to local authority funding of front-line services in schools and those provided by the third sector, reductions to NHS community services, substantial increases in referrals linked in part to the downturn but also modern pressures felt by young people. There has been near-chaos in the commissioning of these services arising from changes to the NHS and Social Care Act, which although a Conservative-led initiative which they now admit was a mistake, could have been halted or at least improved by the Lib Dems. One of the most troubling outcomes is that sick children now wait regularly in police cells while desperate clinicians and managers scour the country for a suitable hospital bed. Staff are overwhelmed, and parents are desperate. Given that 75% of mental illnesses start, as mine did, before the age of 18, and that early intervention is now known to make such a difference, this situation is not only cruel, it is also extremely short-sighted.
  • According to W Edwards Deming, if you don’t measure, you can’t manage. Mental health services have been crying out for a commissioning currency so they aren’t expected to respond to infinite levels of demand under open-ended block contracts. They need national benchmarks, targets and some form of payment by results, otherwise bids for increased funding will continue to be trumped by those for diseases such as cancer or heart disease, where there are a wealth of measurements. This was promised by the last Labour government in 2005 and by the coalition in 2010. It appears again in this manifesto; if the Lib Dems help to form the next coalition, will we be third time lucky?

Here are Royal College of Psychiatrists’ President Professor Sir Simon Wessely and Time to Change ambassador Alastair Campbell explaining why in their view, when it comes to mental illness and mental health care and support, government actions speak louder than words.

It’s not just the 1:4 of us who experience mental illness who should carefully consider these promises and those made by each of the other political parties. 4:4 of us will be voting on May 7th, or rather, we have the right to vote that others have died to get for us. This will apparently be the closest election in a lifetime. We have the greatest ever diversity of candidates. If we don’t each exercise our democratic right, we risk allowing those more certain than us about matters as important as mental health to decide who will run the country.

According to pundits, the outcome of the election is likely to be another coalition with at least two parties. This time, whoever forms the new government, I intend to make a fuss right from the beginning about funding and evidence-based support for mental health services. The more of us who do, the more they will realise that we mean business.

The recent dog-whistle headlines about the aircrash co-pilot show that we have a way to go in tackling the stigma of mental illness. So please ignore Russell Brand and vote; being disenfranchised would be really bad for our mental health.

 

 

Sometimes it’s good to feel angry

One effect of antidepressants is to knock the top and bottom from one’s emotional range. After dark weeks of despair, self-loathing and nothingness of my most recent depression, I welcomed this. It was a relief to feel calm, even blunted.

Now I’m on a reducing dose of medication, I notice a gradual return to a more responsive emotional state. I’m more joyful, sometimes a little more anxious. And I find myself getting angry again about things that matter to me.

Actually, I felt angry today.

While it’s great that NHS England and the government recognise the need to invest in children and young people’s mental health services (CAMHs), why has it taken so long to find this out? And why is investment an election manifesto promise, rather than simply the right thing to do for our young people?

I have two interests I should declare.

  1. I ran such services for 20 years, including 13 as a chief executive.

  2. I first saw a psychiatrist myself aged 15.

The current system isn’t working. But we need to understand how we reached this position, or we risk not improving things far enough, even at all.

CAMHs staff are, almost without exception, amazing people. They don’t look after one patient at a time. They deal with the complications of whole families. They have extraordinary skills, vocation, patience and perseverance plus bucket loads of compassion. But across the country, many are fed up with being blamed for failing children and young people. Because they aren’t failing them. We all are.

The current “commissioning” arrangements could not have been more badly designed unless they were intended to be poor value and counter-productive. It is unacceptable that the different “Tiers” of care are purchased by unrelated parts of the so-called “system”. And that when children fall between the gaps, it is the clinical staff and their employers who face the blame.

Local authorities are under even greater financial challenge than the NHS. Many have made massive cuts to the first line, lower tiers of these services, or made them even harder to access than the higher, NHS tiers. Yet their members sit, by statute, in judgement of the NHS through Health Overview and Scrutiny Committees. Watch me and colleagues participating in this arrangement at Kent County Council a year ago, during which time one councillor publicly suggested that commissioners had set up the trust and staff I then led to fail.

Commissioners of such services have in many cases not been given the chance to argue for increases in resources, or even to defend the services they commission from cuts. Some have even felt the need to assert that providers were exaggerating the now-proven, substantial national increase in referrals. The causes are multi-faceted.

In many unrelated parts of England, services are inundated and can’t cope. Crises occur daily and children wait in police cells to be assessed by hard – pressed clinicians who know there are no beds available anywhere in the country even if the child is in desperate need of admission.

3 useful facts:

  •  Anorexia isn’t a young person’s lifestyle choice. It is a serious mental illness that, without effective treatment, carries a 30% mortality rate.
  •  Psychosis is like cancer. The earlier it is diagnosed and treated, the better your prognosis and the least likely it is to recur. The same is true for most other serious mental illnesses.
  •  75% of mental illnesses start before the age of 18. Like my depression

My 8-point plan for NHS England

  1. Do not ask management consultants or experts in commissioning to design solutions. Ask the people who know. The ones who work in and run these services
  2. Stop setting organisations against each other by competitive tendering. This may be OK when you have time, but with this, you don’t.
  3. Commission one local statutory organisation in each area under the greatest pressure to be the system leader for all aspects of CAMHs except secure care, with commissioners working within the local system. Avoid competition challenges by declaring an emergency, setting targets for engagement with CCGs and GPs, and requiring the lower tiers to be expanded and provided outside the NHS, either directly by schools and/or the not-for-profit sector. Do this for long enough to allow things to settle and thrive, ie a minimum of five years.
  4. Don’t allow anything to cloud your judgement. It isn’t social care good, NHS care bad. Or vice versa. CAMHs teams should be multi-disciplinary and multi-agency. Parents and children don’t care who staff work for. What they care about is getting help that is responsive and effective.
  5. Carefully consider secure services for children and young people. Are they good value? Clinically effective? Compassionate? Safe? And are children in these services only because there are insufficient non-secure services? Only national commissioners can do this.
  6. Work as hard with the next government for increased funding for CAMHs as you would for heart disease or cancer care, were these services in an equally challenged state.
  7. Celebrate the amazing staff who do this work. Encourage ministers, the media, CCGs, trusts, schools and the third sector to do the same.
  8. Imagine what you would want for your children, were they suicidal, self-harming or hearing voices.

What could matter more?