By Mary Sadid, NSUN Policy Officer
The World Health Organisation (WHO) has released a new report: Guidance on community mental health services: Promoting person-centred and rights-based approaches. This is accompanied by technical packages offering guidance on areas related to community mental health services. These publications aim to make the case for community approaches that protect the rights of those with mental health conditions and psychosocial disabilities in line with the Convention on the Rights of Persons with Disabilities (CRPD). The focus on social determinants is most welcome, making the mental health case for fundamental needs such as housing and access to employment. Whilst the report is rich in promising case studies, it also raises questions about the nature of community and the future of mental health care.
Situated in the WHO Comprehensive Mental Health Action Plan 2020-2030, the guidance is clear on the need to move away from the biomedical model towards a human rights approach grounded in the CRPD. But many questions remain – what do we mean by recovery, community, and what does moving away from a biomedical model actually look like?
The WHO’s work moves beyond the theoretical, providing real life examples of alternatives that resist the coercion and detention often rife in mental health settings. Targeting policy makers, case studies are accompanied by ‘cost and cost comparisons’ comparing the cost of in-patient hospital care with the community alternative. However, many of these alternatives are small scale, e.g. a crisis house hosting 3 individuals at a time, and we do not know if they are scalable.
What does this guidance mean for a UK context?
In the UK, mental health services are stretched, and demand is expected to grow by around 10 million in the next 3 to 5 years. Local mental health offers remain post code lotteries and initiatives to supposedly release pressure on the NHS can have a seriously detrimental impact on the people they claim to support. The guidance presents a patchwork of hopeful alternatives, but such models remain out of reach for most of us.
Political will is a major issue in reforming mental health care in the UK. We are far away from the WHO’s model legislation, the UN CRPD. Mental Health Act reform is tepid and won’t make a tangible difference for many. Inequities, including health inequality, are widening.
Many can’t access mental health services or they are moved on too quickly. Being on a mental health ward doesn’t necessarily mean receiving mental health care beyond the absolute basics. When this is our starting point, and health inequality is growing, we must consider how and if this new model of care will reach those who face multiple disadvantage.
Community – place, people, or practice
Many NSUN members do grassroots community work that may directly or indirectly benefit the mental health of those in their communities. Whilst their work may be used as a case study or model to support a shift away from the biomedical model and institutional care, it is not necessarily this work that will be funded in the turn to ‘community’.
The pandemic has seen increased visibility for community action. The other side of this coin is state failure. Where weak institutions have failed to protect, communities have stepped up, offering a partial buffer. We must be clear when we talk about community to avoid invoking the co-option of unpaid community labour by governments determined on shrinking the state offer.
The WHO’s guidance calls for respect of individual autonomy. If we broaden this view to collective autonomy, we can amplify the needs of groups and communities, including those with lived experience.