19 November 2020
Suicide and the State
Rights and responsibilities.
By Lynda Goetz
Suicide and the State – a huge subject and one which clearly cannot be covered in a 2,000 word article for the Shaw Sheet. The historical attitude of state (and Church) to suicide as well as the moral question of whether an individual has the right to take their own life are not touched upon here. The issue rather is the contemporary response to mental health and suicide and the role of the state in dealing with it.
Last week, many of the national newspapers carried news items around the increase in numbers so far this year of suicides and of those with suicidal thoughts. In an opinion piece in The Daily Telegraph on 2nd November, entitled ‘If we surrender our human rights cheaply, the cost will be immense’, Sir Graham Brady, chairman of the 1922 Committee of back bench MPs, pointed out a couple of interesting statistics and then came up with a novel calculation based on these. The statistics were that the average age of those who had died of Covid-19 was 82 and that of the nearly 6,000 suicides in the UK in 2019, the average age was 37. The calculation was that if suicides in 2020 were up by 50% (the London ambulance brigade has said the number of call outs to suicide attempts is up by 68%) then, in terms of the number of years of life lost, this would be the equivalent of 120,000 Covid deaths. This illustration was part of his attempts to urge the government to provide a full impact assessment of lockdown – not just to look at it on the basis of how many potential coronavirus deaths they hoped to avoid.
As we now all know, of course, the arguments of those against lockdown failed to convince. This hasn’t stopped the rebels, who have formed a breakaway group of around 70 MPs to fight a third lockdown in December. They call themselves the Covid Recovery Group and have set out three ‘Guiding Principles’: the first of which is a demand for a full cost benefit analysis on a regional basis looking at the economic and health costs of a lockdown; the second is for ministers to end the ‘monopoly’ on government scientific advice; and the third to improve current measures for tackling the virus, such as ‘Track and trace’.
Although they have been used around the world, there is little evidence that lockdowns are proving very useful against the spread of the virus and that they merely serve to ‘kick the can down the road’. However, there is mounting evidence that lockdowns are inflicting damage in so many other ways; economic damage and damage to health, both physical and mental. A vast number of people seem to view ‘the economy’ as something apart from them. They talk about ‘putting lives before the economy’ as if the two were entirely separate. The economy is all of us; all of our work, all of our businesses, all of our employment, all of our tax and social security contributions. Without all this, there is no economy (and no money to pay for the NHS or indeed anything else). Our contributions to the economy not only keep the state functioning and ‘put food on the table’, they also give us direction, purpose and responsibility. All those whose businesses are failing because of the effects of lockdown, all those who have been made redundant and those whose chances of employment have been reduced because of the hugely damaging effects on the economy, are likely to be experiencing mental health issues. People’s health and the economy are inextricably linked.
Mental health has always been far less well provided for than physical health – the latter, generally at least, rather easier to diagnose and to deal with. Mental health is far less well understood and usually far harder to ‘fix’. Increasingly we expect the state to be responsible. In this country the government does appear to have accepted this. The 2012 Health and Social Care Act created a new legal responsibility to deliver ‘parity of esteem’ between mental and physical health. The aim of the government at the time was to achieve this by 2020. We are now in 2020 and it is hard, if you have any dealings with mental health issues, to see any parity. The problem is being addressed, but it would seem there is a long way to go and the focus this year on coronavirus to the detriment of almost all other services in the NHS is going to make this issue far worse before it has any hope of getting better.
In 2015 the Kings Fund verdict concluded ‘Sufficient funding will need to be available to help local areas develop new approaches to mental health, ensuring that services are better connected with physical health care and other public services. Workforce shortages in some mental health professions must be addressed. There will also need to be investment in training and education aimed at giving GPs, nurses and other staff in all parts of the NHS the skills to help people with mental health problems to enjoy the same care and outcomes as anyone else’. In January 2019 the NHS Long Term Plan was published. This, inter alia, provided for Primary Care Networks (PCNs) the purpose of which was to set up integrated care systems throughout the country at a neighbourhood level. A blog by Dr. Jihad Malasi on the Kings Fund website in July of this year suggests there is still a long way to go in terms of providing a holistic approach to physical and mental health.
This lack of an integrated or holistic approach was brought home to me by the recent experience of a serious suicide attempt by someone in our family. His rescue and resultant treatment revealed a shocking disconnect between the various NHS services. Individually the various departments and medical personnel involved in his care were brilliant, but there was little or no liaison between them. Each department appeared to function in its own little bubble with minimal coordination between departments.
The situation once he was out of hospital was even more distressing. Why on earth spend thousands sending out ambulances, paramedics and doctors and then discharge them to ‘take their chances’ in the ‘community’? What in fact does ‘community’ mean in this context? There appeared to be no community physiotherapy available. Physical issues contributing to the mental anguish seemed to be ignored and the follow-up psychiatric crisis teams (different people on the two occasions which constituted their input) appeared only to want to offer anti-depressant medication, in spite of the fact that this had been refused in hospital on the grounds that the patient had no wish ‘to be numbed’. Although drugs have their place, they are well known in many cases to cause long-term problems, particularly with regard to coming off them. The side-effects can be at least as bad as the original depression.* In spite of this, according to government statistics 17% of the adult population (i.e. 7.3 million people) were prescribed anti-depressants in 2016 to 2017. Of these, nearly a million had been receiving prescriptions continuously from 2015 to 2018.
Talking therapies, of which there are various kinds, are basically designed to realign people’s way of thinking to overcome negative or unhelpful thought processes or behaviours. A study in 2015, reported on the NHS website and in a national newspaper, appeared to show that talking therapies were as useful as medication, and that both should be offered. In practice, particularly in our current crisis, this option does not appear to be available. When I pointed out to the crisis team that we were looking for talking therapy rather than drugs, the response was, “Well, you’ll be waiting not days or even weeks, but months.” It transpired that even that assessment was optimistic and in reality it could be a year before any help of this sort would be available. This for a man who had, two weeks earlier, failed to end his life by jumping from a tree with a rope around his neck? He responded by making another attempt at taking his life two weeks later.
It is almost impossible to describe the feelings of helplessness experienced by families facing such situations; the lack of any real help offered and the failure of a system where there appear to be no joined up services adds to the desperation of an already traumatic situation. But perhaps we are expecting too much? As a country we have invested so much faith in the NHS, so many resources, both human and fiscal, that we look to it for services it cannot provide. Even if we were to reform this giant behemoth and slim down the vast and frequently incompetent bureaucratic elements, there is no real end to the demands which are and will increasingly be made on it.
The NHS Mental Health Dashboard brings together key data to measure performance in delivering the NHS Long Term Plan for Mental Health. According to this, Investment in the Mental Health Five Year Forward View and Long Term Plan will deliver timely, high quality mental health support, including (inter alia) by 2023/24:
Expanding access to talking therapies so that an additional 380,000 people per year get support for common disorders.
But if there are 7.3 million people who are prescribed anti-depressants, this is a drop in the ocean! As stated in a Health Foundation blog, the problem is one of priorities. Should priority be given to this over other much-needed interventions such as radiology or weight management programmes? Should we, the public, be educated to understand and accept that the NHS has to have priorities and that difficult decisions have to be made every day? Does the whole model need to be re-examined so that at the very least we take more responsibility for ourselves, our health and that of family and friends and that we are aware of the cost of procedures and processes? Should we perhaps move to a system with more local financial control? One in which, for example, no NHS managers (or indeed local councils) should be forced to spend several millions before the financial year end to ensure they get the same funding the following year? (No private organisation would ever run its finances in such a way! It is pointless and shockingly profligate). Should there be an element of compulsory insurance, as in so many other countries, or perhaps an extra element of specific contribution? If so many people really do ‘revere’ the NHS then this should be a relatively easy levy to impose.
There is no doubt that the effects of Covid lockdowns on people’s mental health have already resulted in more need than ever for these services (and this should definitely be part of the cost benefit analysis which the back benchers are urging on the government), but perhaps we also need some sort of rethink not only on how the NHS is funded, but on how we treat the NHS. Morale amongst medical staff is low. The doctors and nurses whom everyone clapped for on doorsteps earlier in the year in a rather bizarre display of support are still not properly remunerated for the hours they work or properly appreciated for the important jobs they do. Many nurses are leaving or doing agency work. Junior doctors are going to work in Australia or New Zealand where they are better treated and better respected (see my article Locum Doctors, October 2019).
Perhaps in addition to increasing the funding to the NHS via insurance schemes, we need to become more self-reliant, more resilient and to look to other sources of assistance for our ailments, both mental and physical (as Vic Leader suggested in his Shaw Sheet article a couple of weeks ago). The state can only do so much and after the billions spent on shoring up the economy, schools and the NHS, perhaps it is time we, the public, stopped looking to a totalitarian government to provide for our every need and started taking more responsibility for ourselves. That probably goes for Covid-19 as well. Perhaps we have the government we deserve.