Gregor Henderson: Mental health is just part of what it means to be human

Matthew

Hello. In my lifetime, society's approach to mental health has transformed. When I was young, mental illness was rarely discussed. Mentally ill people were seen as rare and dangerous and generally in need of being locked up for their own and society's protection. Today, a high proportion of the population openly talk about and seek help with mental health conditions. We've made great progress in parity of esteem with physical health. Yet the demand for services massively outstrips the supply. The money spent on treatment is so much greater than that spent on prevention. There's little consensus on what works in mental health care, and there is a danger that our approach seeks implicitly to medicalise more and more people.

Today as part of our Innovation in Action series and to mark Mental Health Awareness Week, I'll be talking to a thought leader on mental health treatment and prevention and a digital innovator, impatient at how slowly still we are taking up opportunities to use technology to help people with mental health challenges.

Matthew

I'm delighted to welcome Gregor Henderson, who is, amongst other things, strategic advisor to the online platform Togetherall and former director of mental health to Public Health England, Gregor how are you?

Gregor

Hi, Matthew. I'm very good today. Thanks very much.

Matthew

Now, I want to start with your sense of where we are now in relation to mental health. Looking back over your career, what's changed, what's got better and what most urgently needs to be addressed now?

Gregor

Well, there's been, I try not to use hyperbolic words, but when I look back over 30 odd years or so, I remember the days when we were building community services and decanting or moving and supporting people to leave long-stay hospitals to where we are now. It's been an absolutely amazing journey and so many good things have happened yet some of the challenges remain.

In your introduction, you talked about demand for services increasing. Can't meet all the demand that's there. Prevention has always been the poor kid on the block, never given enough resources. And we have been striving to articulate an integrated system for mental health care, mental health support, mental health awareness, because it all matters and interconnects, and it's really about understanding that mental health is just part of what it means to be human and trying to disentangle that, to piece it back together so that we can have responses to people wherever they are on a spectrum of mental health need. And I think the humanising of it is absolutely crucial.

Matthew

So, there's so much there, Gregor, and I just want to start with this issue of kind of medicalisation, which is, you know, when we think about people who've got physical health problems, people waiting for elective surgery, for example, we kind of our view is that they've got a problem and we should treat them. And the sooner we can treat them, the more people we can treat, the better. I have a problem with that approach when we think about people waiting for a mental health treatment in the sense that, the idea that success would be that we would treat more and more and more people, that more and more people in a sense would be medicalised. I feel uneasy about that. I feel that as a society, we should not see success as being having more and more people getting NHS treatment for mental health. What do you what's your view of that?

Gregor

I think, it's essential that we have a good mental health care system and we are whether or not we believe it, we are in the UK very blessed and a little bit more advanced than some other places. Now that's for one moment not to be complacent. The issue is that for me sometimes is that we're not seeing the whole thing. And what we are doing, sometimes inadvertently, is saying that when we think about mental health, we will invest in mental health treatment services, which is fine, but we need to invest in a whole set of other things.

So, the government has been for a while, not just in England but all across the UK, particularly in Scotland, looking at the wider determinants of mental health, trying to broaden out where we intervene, trying to get mental health responses in every part of social and public life, whether it's in education, employment, in housing, because it all matters. And you know, if you were to wave a magic wand and have one of the best interventions for dealing with mental health challenges in this country, it would be to eradicate poverty. Simple.

So, what we tend to have is a system that is invested in what we have always invested in, which is services, which is great. But now what people are demanding, and it comes from also within the psychiatric and medical professions all over, is this much more rounded, integrated response. If you like, bio psychosocial has always been there in the last 20 years, but we need to make that come alive. We need that to be a social reality that we're intervening on the emotional and the social, on the psychological. We are intervening on the structural factors that bring about poor mental health and exacerbate poor mental health problems. And it could be something as simple as investing in education or investing in more employment opportunities for people, mental health problems. Or it could be connecting people because the impact of loneliness is absolutely massive on how people think, feel and behave, and particularly how they think about themselves.

So, it doesn't frustrate me, it challenges and it's a great challenge is that how can we get the conversation about mental health broader, and also a conversation that is not adversarial because most of the doctors and psychiatrists I speak to are up for this bigger conversation.

Matthew

I'm glad, by the way, that you mentioned loneliness, critical, because that's a particular focus of Mental Health Awareness Week this year. But I want to come on to prevention in a second. But just in relation to treatment, you know, something that I hear quite a lot is that there is a huge variety of different ways of thinking about the best way of treating a variety of mental health disorders. What do you see has been the state of play there? Are we moving towards a greater consensus, a stronger evidence base?

Gregor

Yeah, we are. And I think one of the things that's helping us is this sense that there is no one profession or no one treatment methodology that has all the answers. When I was younger and potentially more radical, there was a lot of, I would align myself with some of the movements that would be much more patient or peer centric and sometimes were railing against the profession. So would mark the success of my early launch career in this on the number of psychiatrists that would leave a room when I was talking and then, you know, a few years later it struck me that, well, this is crazy.

So, any success since then has been the number of people that stay in the room and grapple with the variety of approaches, the variety of methods, the variety of things that need to be included. And that's where it gets so complex. And that is challenging. And that is also really absolutely fundamentally what we need to do, is to meet that challenge of the variety, because no one has the solution.

But the places that I see that begin to get this more right are the ones that have a relationship between all the different modalities, professions, but more importantly, have the relationship with those with lived experience and those going through the experience and are co-producing those solutions. And you see that in communities. You see that in places. And actually, you see it online.

Matthew

I recently interviewed a woman called Noga Reekie wonderful book called The Ceiling Outside the Science and Experience of the Disrupted Mind. And that book is all about her experience of sitting in on sessions in a Parisian hospital where patients are brought in who’ve got particular challenges. And what's interesting is that they speak to a whole range of doctors. There are neurologists, but there are also psychologists. They look at these people and their issues and they look at them in terms of the organic basis in relation to what's actually going on in their brains, the psychological basis in terms of particular kind of patterns and conditions, but also the kind of biographical basis for the illness. And when I interviewed Noga, I was struck by the fact that unfortunately it's quite rare, I suspect, for us to be able to provide that kind of holistic, multi-disciplinary way of thinking about what might be ailing people when you've got the kind of pressures that we have.

Gregor

Absolutely. And there's there was some work in Finland that created something that's now become known as ‘open dialogue’, where the centre of the attention is the person experiencing the challenges and the difficulties. And they're in open dialogue with their family, with their neighbours, with people in the community, with their care workers, whether it's a social worker, a nurse, a psychiatrist, a psychologist. And the open dialogue takes place amongst them all. But everybody's focus in that open dialogue is on what will be in the best interest of that person with them at the centre in control of it. Now, you're right, that happens not as frequently as we would like, and we have a system that, as you know, in the NHS and social care and public health, takes a while to begin to transform to the way we want it to be.

But when you asked earlier, have I seen changes? Yes. And I think we're still on that transformation. It's not revolutionary, it’s evolutionary, and I think with the move to ICSs, that can be more accelerated. I think one of the things we learnt from covid, particularly in relation to mental health, was the power of community, of people helping others and also the way in which digital services moved very quickly online, not just face-to-face services online, but blended services where there's some face to face and there's some stuff that you do on your own.

But now to this interactive organic space online, which is where an organisation like Togetherall comes in, this wonderful organic but human interaction taking place online. And one of the things, it doesn't frustrate me again, it challenges me, is how can we come back from covid and making the best of the community out there, it’s a resource, how can we combine that power of community, that power of supporting each other to an online environment and begin to scale that?

Matthew

So, Gregor, you're ahead of me because you know, you’re pre-empting in a sense, two or three questions I want to move to next. So, let's step back to that prevention issue, which is, in a sense what do we really know about prevention and what works in terms of prevention? Because, you know, clearly, in a sense, we could say, well, if society was better organised in a whole variety of ways, if we didn't have inequality, if we had less kind of rampant consumer capitalism, if we were not such a society so obsessed with status, if we didn't have the pressures of social media, but in a sense how much we might want to it's unlikely that the concerns of mental health are going to lead to the radical restructuring of society. So, in a sense, how do we how do we do prevention, given that what we know influences people's wellbeing is often things which are, you know, very deep aspects of modern society.

Gregor

I agree. And everything you've said that, you know, we mustn't be unrealistic about what can be achieved. As we've said, as we discussed, mental health care and treatment has moved significantly over the last 30, 50 years. The next stages are, as you say, to bring in the prevention and early intervention. And, you know, there is a lot known about prevention. There is a lot written, there's a lot of good science about prevention. And, you know, it can be really simplistically put as enabling people to get help before problems develop, improving their abilities to look after themselves, to look after their own mental health, learning from others, supporting others, and being able to do that in a non-stigmatising way. And there are so many different things that can be done.

But let's just take some examples from school life. Now, if in schools we have schools that are there to educate children, but in educating our children and young people, they are also providing the right tone and style to create an environment where someone can express themselves emotionally, where they can connect socially, where they can build their psychological skills. And this is the beginning of putting a mental health approach into school without medicalising it. Yes, some children, young people will have challenges, but the first place those challenges will be met is in that environment and it's skilling up people to be able to recognise, respond and deal with that flow of just normal human interactions. And if we start to look at mental health as something that every one of us can make a contribution to, then it becomes a lot simpler.

And what tires myself and many other commentators in the mental health world is that when we start having a national mental health conversation, it very quickly dissolves into how much more money are we going to spend on care and treatment? Now we need to spend more, but we need to have a conversation that is a lot more about what else can be done in prevention, in the workplace, at school, at home, in all the places we play and collect. And I think that the really welcome the Government's 12-week consultation on a new ten year strategy. But I have a fear that the consultation will concentrate again on how much more money we need to put into mental illness treatment services, which is fine, but I want a broader conversation and that's a conversation that people have been wanting to have for many years now.

Matthew

And that takes me to the point that you've been making already a couple of times, which is around the scope for integrated care systems.

Now, I too, share your welcoming of the fact that the government has said that this mental health strategy is going to be developed across. While I have to say, having worked in the central government myself, I suspect the engagement of departments beyond Department of Health is going to be pretty challenging, but hopefully we can do that at ICS level.

One of the points that I've been making to colleagues is that we really want mental health strategies in integrated care systems to be the responsibility of the integrated care partnership, not the integrated care board. And that sounds a bit technical. The reason for that is the integrated care partnership is truly a collaborative body. It is the multi-agency body, the local authority body. It'll be replicated at place level by place bodies. And it's really important. The ICS mental health strategies are not just about the health service and there's a real opportunity in ICSs it seems to me to have holistic mental health strategies which do look across social determinants, but also the range of public policy interventions, whether it's, you know, as you said, housing or education.

Take one really, really important and urgent issue here, which is debt. So, the cost of living crisis is going sadly, almost inevitably plunge hundreds of thousands more people into debt. And we know that being in debt is a major source of anxiety and other forms of of of mental disturbance. So, it's really important, isn't it, that in ICAC when we think about mental health, we think about it in those holistic system and place ways.

Gregor

I agree that the integrated care partnership is the one that needs to do that. I've been spending a lot of time over the last few months talking to the emerging ICSs, of course, as you and I know there has been a lot of integration taking place already. So in some ways this is the formalisation of things that people have been doing in local areas for a long time. And like any partnership, there are some places that have closer partnerships and relationships than others.

But I really do feel optimistic that we have an opportunity with ICSs to take that integrated approach. It will require a lot of integration with the local authority, not just with social care, but with public health, with all the other facets and levers that local government have at their disposal, which are crucial for acting on the determinants of mental health. And you mentioned debt and there are some amazing schemes out there where local authorities can almost tell digitally now where people are struggling, who's not paying their council tax, who's not paying their rent, and they can intervene early.

So, if we have this integrated system in local areas truly integrated, then I do think that will be to our benefit. And I'm hoping that like you, that the government strategy will make every attempt to create the conditions for that local integration and where possible, demonstrate that they can do great good cross-government departmental working as well. And, and during covid, I actually did think the March 21 COVID-19 government Mental Health and Wellbeing Recovery Plan was a good attempt at that. And I think that what can sometimes happen is that when resources are attached to that, the resources, vast majority of them go to the NHS and each of the departments is feeling well, we were kind of engaging in that, hoping to get more money, but we haven't got more money.

But I think we need to see a lot more of the already existing public investment as investment in the nation's mental health and with some tweaks, with some ways of adjusting it, ways of integrating it and rewarding integration, because very often across Whitehall that's not necessarily rewarded. Then we can begin to see the system move. But I agree with you, it's going to happen locally. I'm excited about some of the opportunities that I've seen. I'm excited about some of the places I'm hearing about and some of the things that I'm seeing with my own eyes. But I do think the notion of an integrated care partnership is key. They're quite big areas and I think to make the connexions and the pathways work, we've got to get down to place quite quickly.

Matthew

Let's turn to digital because you have this role with Togetherall I want to start with what is the state of the evidence base at the moment, Gregor, in terms of the efficacy of online digital services?

Gregor

It's a tricky it's a tricky minefield to navigate. But I think what we are seeing emerge is two stages of the ability to bring evidence in digital. The first is using the classic evidence science that we rely on, and that's fine. And that's there is lots of really good evidence for single issue digital programmes out there. And that's great. It becomes a little bit more complex when you are looking at digital in a much broader way than just an intervention that we would traditionally see in a mental illness treatment service. And by that I mean, when you start having early interventions and prevention and communities and peer support on online platforms, you're into a messy world of psycho, social, educational, community, and isolating the factors that may be at play here is very difficult.

One issue for me is that the way we assess digital health technologies. Is this as if they were clinical or medical devices? And I think when I look at the nice frameworks, when I look at some of the other ones I've seen, we need to expand the ability to assess digital innovations for more than just a clinical or medical standpoint, and we need to be able to do that from a community standpoint. What does it mean to be a member of an online community? How does it help the things that are important to you in your life? What is it that you get from that platform that you can't get anywhere else? How does it augment, supplement and complement some of the other services that you might be receiving?

So, I think that brings us to a point where we need to improve on the science. We need to improve on the investment in more complex digital technologies to see whether or not they do have the effect we want to have. But we also need to expand our vision and version of what digital mental health means. It's not just about care and treatment. It's about care treatment. It's about support. It's about prevention. Early intervention. It's about bringing some of what we know works into an online environment, not to replace traditional ways of responding, but to augment and add to.

Matthew

I think we tend to think potentially because we look at this through the lens of the NHS as mental health in the sense of you people getting access to mental health services because they get a diagnosis. And as we do with other health services, we think about how we can gatekeep and in a sense implicitly ration a service to a group of people because we can't meet the level of demand. But I think we need to think about mental health provision more like we think about, I don't know, parks and children's playgrounds, which is to say things which are openly available to people as resources in the community and where in a sense, you know, people don't go around saying, well, I'm going to show evidence that people walking in the park, walking their dog, playing football, enjoying the sunshine that that is good. It is just demonstrably something which is a resource for the for the community.

And I think we have to try to think about how we move to a kind of open access for services which feel relevant to people who are suffering from issues to do with their mental health. And I think that applies to digital on the one hand, and I'll come back to that in a second, but also some of the best practise I've seen on mental health. There’re no clinicians anywhere near, you know, it's drop-in centres where structure is provided, friendship is provided. There's a fantastic place just down the road from me here in Brixton, Brixton Clubhouse, which, you know, it's great and it's, I'm not criticising clinicians, but there aren't any clinicians there because what it does is just a great structure that people can walk in and they can get support, and then if they stay, they become a kind of member of the organisation and start contributing to it.

So, I think we've got to try to think about that model rather than simply this kind of model of how do we get more people through a door marked, you know, mental health treatment. Now I'm interested in what you think of that idea, but then also what can we do in relation to digital here? Because I remember quite early on in my time in the job here at the Confed, talking to a chair of an ICS expressing frustration about the fact that with so many people, young people waiting for mental health care in her ICS but yet the access to digital apps was rationed. As a young person, you had to go to your GP who had to refer you. And she was saying, well, this is crazy. If these things work and they certainly don't do any harm, why on earth are we just not making them freely available?

Gregor

I love the way that you describe mental health provision as a resource. I think that is a very, very good way to think about what can be provided for people by a whole range of those contributing with the person at the heart and the way in which we know communities work at the heart. If we can find ways of doing that online, I think we can begin to radically move on from the notion that to get proper treatment, you have to go through a door marked health service. For some people, it's going to be absolutely crucial to get that specialist care. And the majority of specialists, people in the NHS that I speak to want the people they're working with to have the social psychological community wraparound because they know that's going to aid and support their ongoing recovery. They're tired of that open door, back again, the supports that should have been in place in the community weren't there. And I love the idea of open access.

And, you know, with Togetherall I know for example, that they have been fitting in that space between getting no treatment and waiting for treatment and by having access, open access, as you said, I love that phrase to a digital resource, immediately the GP can say, look, I will refer you to the service, but that might not be available for a couple of weeks. In the meantime, get online and interact with this service. It's amazing. I mean 70 per cent of people say from Togetherall that it has helped them whilst they've been waiting for other resources, it's been 73 per cent said it was helpful while they're on a waiting list. And it means that you know the NHS and others can actively manage the wait, and in some cases, maybe as much as up to 30 per cent, the person may not need to go on to that more specialist care.

So, by having a psychosocial resource online, a community that provides self-help, care, the ability to speak to others with similar problems, doing courses online, participating in groups, journaling, doing assessments of where you are, you're actively doing something while you're waiting. And that may be the absolute key part of your recovery. And we've got some really good case study examples of where digital is part of an ecosystem of service and supports that can have a huge benefit to those that are struggling in distress and who also need ongoing care.

Matthew

You know, at the Confed we're increasingly focussed on how we work with health leaders to develop solutions. And, and I just give an invite to you which is that or proposal to you, which is I think there is a danger of a kind of Wild West out there in terms of digital mental health services. There are many now which are being marketed directly to the public. For example, I think there is a need to think about how we can bring together this sector, the sector of digital platforms, offering mental health services, and think about how some forms of self-regulation can make it easier for the public, for the NHS to navigate this system safely.

So, if that's of interest to you, let's, let's talk at some other time about how we might take that forward, because I worry a little bit that the enormous potential that you've described could be squandered if the sector isn't able to more effectively self-regulate and engage with the health service.

Gregor

I mean, I was looking at some background stats preparing for this and you know, 97 per cent of the UK population have access to the Internet, 84 per cent access to a smartphone projected to rise to 94 per cent by 2025. Investment in digital mental health is increasing. Mental Health Start-Ups globally, globally in 2021 alone raised 5.5 billion.

So, this is here. This isn't coming, this is here. This is big. And, you know, I worry that quite a lot of what is being created out there is not effective, is not going to be useful and may be more about making money for founders and start-ups and and whatever else. But, you know, I've been associated and looked at Togetherall for nearly 15 years. Togetherall, it was previously known as Big White Wall, that's been around for 15 years and the transformation of digital over that time has been quite phenomenal. And I think we will see the market begin to concentrate more on quality and the ability to handle risk and safety online, not just personal data safety online, but risk safety, security and the ability to respond to people in crisis online. And there's some very good ways of doing that. I think it does need some form of regulation. I think it does need some form of frameworks.

Australia, New Zealand seem to be ahead of the curve on that. Scotland is doing some really good things, looking at, as you say, open access, building solutions that will be once for the whole population of Scotland. Love that ambition. And I think what it does need is more of a dialogue with those out there in the digital world. And as I said, some have been around for a long time and if there is a way of finding a way of bringing together quite a disparate and competitive group of people, I'd say, to have sensible conversations with government and others about how we can innovate, continue to innovate, how we continue to support tech developing because navigating government is hard. And you know, when you do it on your own, it's even harder.

So, finding a collective way, for example, with the NHS Confed to have sensible conversations about the future of digital in mental health, maintaining the focus on innovation, not stifling that, and really beginning to have the ambitions that America has to make it forward leaning towards this. And, you know, it's not my area of expertise, but there I say it will also be good for UK PLC. I mean, I do see some amazing mental health digital innovations in the UK. I also see some stuff that shouldn't be online, but I also see some really good stuff and we have an opportunity here and I think we're missing in the government consultation, for example, we're missing that conversation getting digital providers. There's a lovely line saying, you know, we need to harness the power and potential of technology, but then it's left sitting. So maybe that's something we can do something about.

Matthew

Well, let's think about how we can take that forward, Greg. Look, we've nearly run out of time. And I want to ask you one last question. A really big issue for us at the Confed is health inequalities, and again that's a big opportunity for ICSs to help us move towards a health service which meets need, not just demand, for example. Just talk a little bit about the the interaction between health inequality and mental health provision and how we should understand the relationship between those two issues.

Gregor

You know, it's massive. It's absolutely massive. And I stated earlier that one of the best mental health policy innovations or interventions would be to eradicate poverty. I mean, it is absolutely huge. And I think one of the issues, we know that people who are more socioeconomically disadvantaged, people in different circumstances will be far more impacted by mental health problems than others. We've known that since time immemorial. And I think one of the things that I think ICSs give us the opportunity to do is to reach out and understand those communities needs more, bring some of the collective resources together more effectively. And you and I both know there's some amazing voluntary sector organisations and NGOs out there working locally, who had a pretty tough time during covid, and they are, you know, the thing that makes a difference to people's lives. And I would want to see integrated care partnerships caring more about the commissioning of local services that meet local needs, community activists and community navigators, community services and support.

So, I would want to see us tracking the way in which ICSs invest in those anchoring institutions in local communities, particularly for communities who are poorly served, LGBTQ plus, ethnic minority communities, etc. And I do think and I would say this, wouldn't I, but I do think digital has got an important part to play in that. When we look at some of the stats for Togetherall between 25 and 46 per cent of the people on the platform at any one time come from an ethnic minority. 24 per cent are unemployed, and they find Togetherall service useful for building and boosting their self-confidence to go back into the employment market. And 38 per cent of people on the platform Togetherall is their only form of support. S

o, for some people, the access that you and I have been talking about, open access, the access they're getting some mental health support is online because they're not getting it from anywhere else. And I think if you combine that with online digital solutions that can refer and access people to pathways locally, which we do when we're commissioned by local services, then you've got a really good way of using digital as a powerful way of connecting people to the things that are going on in their communities. So, community online meets communities in communities. It's a wonderful combination.

Matthew

Gregor thank you so much for joining us on Health on the Line.

Gregor

You're welcome. Thank you.

Intro/Outro

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