Cultural change is as important as funding in transforming mental health

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There is a growing disquiet around mental health. Across the board people are calling for change, but what exactly is it that needs to be done and how can we bring about the ‘parity of esteem’ that we all seek?

As the London Health Commission considers how best to provide for the health and wellbeing of Londoners, the London Mental Health Trust Chief Executives Group asked The King’s Fund to engage with stakeholders to help develop a vision for London’s mental health over the next 5–10 years. Our report, Transforming mental health: a plan of action for London, is the culmination of that process.

Our engagement events attracted a wide range of attendees, including:

  • NHS mental health and primary care providers
  • social care providers
  • specialist housing providers
  • local authority and clinical commissioning group (CCG) commissioners
  • representatives from NHS England, Public Health England and the Metropolitan Police Service
  • independent and voluntary sector providers and innovators
  • academics
  • clinicians
  • service users and carers.

These events were booked up immediately, showing that there is a real passion to improve the mental health of those living in London. The experiences that were shared at those events also demonstrated an abundance of expertise in the capital. By the end of the workshops participants had developed a strong consensus on what was working, where the problems were and, importantly, what needed to change. 

So, are Londoners unique? It appears not. Many of our findings are reflected in the most recent national vision, Starting today. And a more thorough search of the literature highlights the same issues arising again and again in reports going back over a decade. For the organisations writing these documents alarm bells should be ringing!

Mental health can rarely be considered in isolation; its impact infiltrates every part of our lives and all sections of society. As mental health cannot be separated from physical health, so improving health outcomes overall requires the involvement of multiple stakeholder groups. However, while attendees at our sessions could agree on a vision for the future, they held disparate and often conflicting views on how to achieve this. This was matched on the ground by widespread reports of disharmony between providers and commissioners; a lack of engagement with services users, carers and clinicians; and numerous strategies with duplication of effort and little in the way of shared agendas. Therein lies the problem.

These cultural issues create a significant barrier to implementing change. While we are not blind to the financial pressures that face mental health provision (our previous work on mental health transformation highlighted the importance of financial support for transformation), funding alone is unlikely to deliver the systemic changes being demanded without a shared plan of action. 

But there is light at the end of the tunnel. Our work on collective leadership demonstrates that collaboration is at the heart of culture change. Observing commissioners, providers, service users, academics, carers and clinicians working together to create the first parts of the action plan proves that it can be done. Groups such as Lambeth Living Well Collaborative are already putting this into practice at a local level. Our report highlights nine key steps to facilitating collective solutions and ensuring progress at an organisational and systemic level. 

As we move towards a general election, the voice of the mental health community has not gone unheard, but shouting about the siloed status of mental health is not the same as breaking down the walls of that silo. As anyone who lives with mental health problems will tell you, navigating life is a continual process of reaching out and building relationships in order to overcome barriers – isn’t it about time everyone else stepped up to do the same?


Ricky Banarsee

Director WeLReN,
Imperial College
Comment date
12 November 2015
The report is a timely reminder of the issues which are at the heart of mental health services delivery. It reflects the underlying dynamics of financial imperatives, quality and outcomes. With ever decreasing resources (in real term) and increasing health inequality, the scenario highlighted by Helen will surely get progressively worse.
Although it has a focus on community care, the report is a bit thin on the role of primary care and its impact of mental health delivery. Faced with mounting cost pressures, mental health services are turning to a skill-mix approach for quick-fixed solutions. In many areas, social workers are taking the role of psychiatrists to monitor and review of mental health cases. The bottom line of this approach will inevitably lead to increased pressures on primary care services. GPs are squeezed in the middle. They complain that in areas they feel less confident are also areas where they feel less supported. The CQC recently found that patients satisfaction with GPs re mental health issues were at 60%.
A future mental health services could be primary care led, with specialist interventions and expertise easily accessible in primary care settings. This will involve professionals on both sides of primary and secondary care working together in a more collaborative way, alongside patients and family and carers. However the very language of “both sides” may be unhelpful. What could be welcomed is to see is a merging of primary and secondary care services so that the distinction (and many of the problems that arise from people being moved from one ‘box’ to the other) becomes much less evident.
I would agree with her views on service reconfiguration. Although whole system integration is a preferred model, there were many reservations from both health and local government about the likelihood of it being achieved. Despite their support for whole system integration, health and local government respondents revealed contrasting opinions on the ideal structure of integrated arrangements.
Is there a better strategy? Part of the problem may lie with the information local commissioners work with. Their over- reliance on JSNA to provide health intelligence for policy and strategy is a weak approach. These are not often untested, inaccurate and unreliable. There is a lack of rigour and standards in the way information is collated. More often JSNA lack depth and a real description of needs - there is no qualitative data to support the desk-top based JSNA giving a on the needs of the community. We should be aiming at developing a standardised methodology.

Trivedi Effect

Comment date
24 December 2014
It's really very useful report. Keep it up!

Wendy Micklewright

Is my job important ?,
I represent myself
Comment date
14 October 2014
The arrogance of Kings and the CEO's of so called "mental Health" institutions is staggering... The money spent on this research is wasted money. It could have been spent on housing and people's basic human rights. The money wasted on psychiatric drugs that make people physically ill is staggering .Illness is big business so is Research like this I would draw people's attention to Pat Bracken , Ben Goldacre and Micheala Amering's work. Hope you will find this information interesting. I do not need overpaid academics telling me what I already know. I find "authority " scary some socialists and Buddhists do not believe in leadership ... Jimmy Saville ,
Rotherham , Rochdale , do we learn nothing as a society ?

Some voice hearers do not like talking in the voices, mouthing words without speaking

I have heard voices in languages I do not understand, others have too

250 million across the world hear voices in all countries of the world often due to trauma

People who are the survivors of torture ( 80% according to some figures , perhaps Amnesty International ) are voice hearers / hallucinate

In the UK people with so called learning disabilities and physical disabilities

sometimes grew up on mental health wards. Often people with so called learning difficulties

do not communicate in the same way but could easily be voice hearers.

Autism was sometimes misdiagnosed as Schizophrenia

People with Dementia may also hallucinate

The Schizophrenia commission report states page 56 people traditionally known as voice hearers are no more violent than anyone else.

I am a voice hearer with no diagnosis.

I take no drugs legal or illegal.

Some think the doctor's diagnosis are often WRONG

Some think the psychiatric drugs cause huge problems as does the Mental Health system

I would recommend Pat Bracken's Copenhagen talk and the Schizophrenia report ( which I have signposted below )

What would you like for yourself, what are your dreams and aspirations ?


with support you can come off the drugs but I know from family and friends how scary the psychiatric system can be, be kind to yourself you are a good person.

Here is some information which I hope you will find useful
This is another disturbing terrible case to do with the mental
health system in the UK

It is not an illness to hear voices or hallucinate
1 in 20 hear voices or hallucinate

For more information contact
HVN, Limbrick Centre, Limbrick Road, Sheffield,S6 2PE
Tel: 0114 271 8210
Email : Website :

Hearing voices network also publish 4 magazines a year with very interesting articles !

The HVN website features some of the HVN groups across the UK

The local group I am involved with (in Richmond Surrey )
is as follows :-

11:30 am at the Richmond Royal on Thursdays please contact

0203 513 3200 for more information
FREE to attend for as long as you like
FREE cup of tea and biscuits!

ALL WELCOME we are just a friendship group

Other useful web links:-

Postpsychiatry -Reaching beyond the technological paradigm in mental health by Dr Pat Bracken on YOUtube

Ben Goldacre books ( Bad Pharma and Bad science) and the Schizophrenia commission report

make very interesting reading.The Schizophrenia report is available through the link above for your
information. I also have the following quotes from various people :-

There is also a good piece in the British Journal of Psychiatry

Dr Pat Bracken sent me a copy of the article :-

"Psychiatry beyond the current paradigm"

For medical staff it can be accessed via the following link:-

For non medical colleagues, you can get a copy of the article from me (via email).

It is a brilliant article which mentions the HVN and
challenges CBT, the NICE recommendations and of course
ECT treatment, if I have read the article correctly.

The article was written by approximately 29 people,
some of whom are (I think) members of the critical Psychiatry network.

Their website :-

To quote from the article:-

There is also evidence that many patients who are not active
in the service user movement find psychiatric interventions
problematic and sometimes harmful. In their study of users’ views
of services, Rogers etal found that many service users did not
really value the technical expertise of the professionals. Instead,
they were more concerned with the human aspects of their
encounters such as being listened to, taken seriously, and treated
with dignity, kindness and respect.

To quote from Prof. Micheala Amering:-

While the complex,as well as polarized, discussions about recovery are
both fruitful and necessary, I would like to suggest that in order to
meet the challenges outlined by these debates we might profit from a
simple formulation for our efforts. To guarantee
the human rights of people who come in contact with psychiatry could be
the main focus for all of us in the international mental health
community , be it as peers , clinicians, family and friends, advocates,
therapists or in our research work as scientists.
Such a focus might have far reaching implications.

To paraphrase from the HVN magazine autumn edition 2012, Twinkle O'Sullivan.

Twinkle describes lying to the people "in control" about ECT and voices
because the "ECT treatment" was so bad.

This is a powerful campaign as well :-,1M1T4,7XHDXM,5LCO7,1

I have problems with some approaches that are suggested

I do not talk out loud to my voices ( I did scream for hours once and it was scary )

I speak to them without speaking out loud,
so I talk but do not make any noise out loud

You can ask your voices a simple question :-

"are you a person , you do not have say"

The answer is often that they are people

Some in the Hearing voices group I attend are so kind

and they say you DO NOT have to work out who your voices represent

If it is non controlling positive telepathy then making other vulnerable

people, as we all are, pretend to be people they are not in the voices

could cause them huge problems

Gregor Henderson

National Lead for Mental Health,
Comment date
26 September 2014
very helpful report. It helps to back the calls we are making for a much greater focus on population mental health - promotion and prevention. Work that takes place outside of mental illness treatment services, but is crucial in enabling services to do what they need to do best. The transformation begins as you say through collaborative and collective efforts. We are keen to work with others across the system to help make this happen.

Terry Roberts

Member of the public,
Comment date
25 September 2014
I wonder sometimes at the amount of time spent at meetings/workshops and what use comes of the findings. Indeed whether the findings are no more than those that were already known. They certainly give managers breathing space and people can be easily convinced that ''something is happening' but in reality they are only 'tinkering at the edges' and often a delaying tactic
If there was a strong and sincere desire for change, it would happen but with little pressure to actually it, nothing will so its a case of 'lets have another meeting'.
Sorry to be so negative but history has shown that such action is simply ' a touching of the tiller' and no real change in the path of the boat ever takes place. Cant anybody grab this by the scruff of the neck and ensure real change over a specified and known time period?
I don't mean to make this sound simple but there are senior managers out there selected because of their management skills and paid well for it, so why don't they do their job and get real results?


Comment date
25 September 2014
mentioned is that the mentally ill are mostly cigarette smokers. Well air pollution, PM 2.5 and below are even more dangerous , yet no mention is made of this likely contributing factor .


Comment date
25 September 2014
Very interesting report, but there seems little inclusion of IMHA provision, both in terms of stakeholders and vision

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