Lord Gus O’Donnell On Why We Must Stop ‘Spending On Failure’ With Mental Health
This post first appeared on the Huffington Post
For six years Lord Gus O‘Donnell was the most powerful person in British politics most people had never heard of. As cabinet secretary, he headed up the civil service, presided over the 2010 coalition negotiations and was nicknamed GOD for his power more than his initials. In 2011, he retired and was made a crossbench peer. The former lecturer found his way back to his old passion of economics and began chairing the think tank Frontier Economics. But when he meets The Huffington Post UK at its swish offices in central London, it is to talk about mental health and his call for “radical” change on how we address it.
Last year, he chaired a commission on wellbeing and policy which said the government needed to act to treat it as professionally as physical health, support parents and give schools the tools to help ensure their pupils’ wellbeing. His background as an academic economist, helping run the national finances and reviewing huge amounts of data on how the country is doing, has led him to this conclusion: We are “spending on failure”.
“We do need to change the bias enormously away from spending on failure, as I would put it, to spending on prevention… by the time somebody’s got a severe depression, that’s failure.”
O’Donnell recites the statistics by bullet point, as if pitching an idea to the government he is no longer part of: one in six adults in the USA and Europe suffers from depression or “a crippling anxiety disorder”. Mental health accounts for almost half of all days off sick and half of people on disability benefits. A World Health Organisation study found mental health and child disorders account for 38% of the global cost of illness.
“Immediately, that says to me, former head of the Treasury, boy, we’re missing a trick here. If, by tackling mental health issues you can reduce sickness, first of all you’re starting to put our productivity up [and] people are at work,” he said.
O’Donnell believes there is “a massive issue of presenteeism” in Britain’s workplaces where people are “too nervous” to tell others that they have a mental health problem and end up not being productive. This and the cost of people on benefits with mental health issues makes earlier intervention “a no brainer,” he says.
“If we could crack this and we get people off disability benefits, get them back to work, so instead of being a cost to the exchequer, they’re actually at work, paying income tax. And you’re struggling for deficit reduction measures… This is where we should be concentrating.”
“Are you into QALYs?” he asks suddenly. I momentarily weigh the pros and cons of lying to the former cabinet secretary in a bid to appear intelligent. “No,” I answer. QALYs, I now know, are Quality Adjusted Life Years, the number of extra years of “full quality” life a drug or treatment buys. O’Donnell cites the fact that, for drugs that treat physical diseases, a QALY costs an average of around £30,000. “If you translate that into the mental health world, the kinds of cost of a QALY are somewhere in the region £6,700 to £21,000, so they’re really much less. If you were allocating your health budget to maximise quality of life, you would be putting a lot more into therapies we now have.”
O’Donnell’s argument is sound but here is his dilemma: He no longer controls anyone’s budgets. He can advocate, but the decision makers will not necessarily listen. Experts on the Huffington Post’s roundtable on mental health also advocated spending more on prevention of problems to save money on trying to cure them later on. But, the roundtable heard, “the decision-makers start to pull the drawbridge up and want to keep their money for themselves” when their budget is being cut, the exact time they need to be saving money the most. How do you motivate people controlling different government fiefdoms to work together?
O’Donnell calls motivating people to do this “a real struggle”. “If I had a pound for every time some had come to me and said ‘just let me spend a pound now and you’ll get £10 in X years…’ Yeah, yeah, yeah yeah..”
He warns we’re about to get into something “very technical,” which, so shortly after talking QALYs, sounds ominous. “DEL-AME switches?” he asks optimistically. I reflect on how grateful I am to have never been a civil servant, before saying I’m ready for the explanation.
Departmental Expenditure Limit is a ministry’s budget set by the government. Annually Managed Expenditure, on the other hand, is a separate budget that usually covers demand-led expenses that are harder to predict, such as welfare or tax credits. The “switch” is effectively an investment model: spend more DEL now, such as on a work programme, to save more on AME later in the form of reduced payouts, such as unemployment benefit. The separation of the two exposes a problem for O’Donnell.
“I think the way you’re gonna solve this is by bringing the budgets together, that’s the bottom line,” he says. “So the people that do the spending actually get the benefit from the reduction in payments out. There are ways you can do that.” He isn’t just talking about Whitehall departments. Local authorities could consider bringing budgets together “if they can manage that flexibility,” he says.
“But I think the key is, make sure the spending and the benefits all accrue within one budget area… If you do the spend and somebody else gets the benefit, particularly if you’re in a very political world. If department A, their secretary of state has to spent a lot of money and the secretary of state for department B gets all the credit… That’s a hard sell.”
O’Donnell’s old job is the type euphemistically described as “stressful”. But he says he himself has never had a mental health issue. Has he ever known anyone who has? “Yes, certainly, absolutely.” People who go through it and then go public about it are “heroes,” he adds, saying only those with the personal experience of it appreciate how bad it is.
“People like me, who haven’t had a mental health issue, almost certainly underrate how bad it is… We just don’t know… I’ve seen people who have been through that, it’s very scary and very worrying how quickly it comes on and how it happens to the most unexpected people.”
He quotes his predecessor as cabinet secretary Andrew Turnbull, who said: “There are some people who are set on this earth to be amplifiers and there are some who are there to be shock absorbers.”
O’Donnell sees himself as the latter. “I had a kind of classic rule, when people used to say ‘there’s a crisis’, my question was always: ‘How many people are dead?’ And mostly the answer to that was zero.” His instinct was always to say: “let’s look at this carefully, let’s not have a knee jerk reaction.” He describes one such case in June 2010, shortly after the killings by Derrick Bird and Raoul Moat, which prompted calls for tighter gun laws. O’Donnell urged caution, stressing the country already had very tight laws on the issue. “There were a lot of people calling for a knee jerk reaction and, actually, the prime minister was brilliant, he just sat down, thought about it, looked at the evidence, and said, ‘right ok, I agree’.”
Since retiring from government, O’Donnell says he’s improved his own wellbeing by “think about those things you really enjoy doing and spend time doing them”. That’s a mixture of “doing charitable work, helping others, paying back… Economics, because I’ve always loved economics, I’m in clover here, I’m surrounded by 160 economists, for me, that’s fantastic. Not working all the hours there are, so time with family and sport, I’m very keen on sport.”
He smiles thinking of the contrast with his time as cabinet secretary. “It’s a very full on job. You don’t leave it behind as you go home… I can go out now and I can not take a mobile phone, because I’m not in that position where there’s a crisis and then I must be contactable and must be reached. That to me is fantastic. For some people, this is a nightmare, they’re no longer needed. They’re no longer crucial and essential, for me it’s just great, I’m very very happy with that.”
This week, Depression Alliance surveyed 50 MPs if they, a family member or a friend had been diagnosed with depression – 32 said yes. In his time as a shock absorber at the highest levels of government, O’Donnell says he did know politicians with mental health problems but says they were “reflecting the stigma” and keeping it hidden.
“I don’t remember there were many who had ever come out. I was aware of some where, there certainly were issues, mental health issues. It’s something I’ve got buried away in my brain in the ‘confidential’ part. I wouldn’t ever reveal who they were… basically they thought, this would harm their re-election chances,” he says.
“Society judges people who’ve got mental health problems as deficient or incapable of doing certain things. When you’re considering, do I come out or not? If you think, by coming out, you’ll be the subject of huge prejudice, you don’t.”
For all his calm and academic arguments, O’Donnell is angry about this issue. He says he finds the fact one in four children and one in three adults with mental health issues get no treatment “offensive”. Unsurprisingly, when asked what the first thing the next government should do, he says it should introduce a target that everyone diagnosed with a mental health issue is treated “properly,” saying the fact people can receive no or the wrong treatment “a scandal”.
He asks if he can have a second action the government should take immediately: create a systematic way of measuring the wellbeing of children. His commission advocated early intervention to help children develop “capacity for empathy and resilience” and help them become happier, healthier adults. So, he says, we should ensure we can tell how a classroom’s wellbeing has gone up or over a school year.
“I’m a passionate believer in: you collect the data, you present the data, that’s really powerful,” he adds. “We have fantastic SATS data and all the rest of it but we’re missing something really important.”
Those are the first things to do. I ask where he hopes we’ll have got to on mental health by the time of the next general election. He hopes we will stop separating physical and mental health and “naturally assume the two go together”. If we can “normalise” mental health so that people talk about experiencing depression as they would breaking a leg, the stigma will be gone, he says.
“It’s the nature of the disease, if you’ve got a broken leg, nobody blames you…that’s not the case with mental health. I think a lot of people feel, ‘well this somehow reflects on me, I’ve done something wrong’… It’s not the kind of thing that makes you want to reach out and say things.”
He recognises the level of stigma on mental health but says “leaders in society” have a duty to speak out and correct false perception. “Migration, people’s perceptions of reality are miles away from the truth. Teenage pregnancy rates, people think they’re massively more than they are. There are lots of areas where people’s perceptions are just wrong. I think leaders have a duty to try in every sphere, health leaders, politicians, people in senior positions of all walks, to try and talk about things and correct these perceptions.”
When discussing stigma, the academic economist doesn’t refer to QALYs or DEL-AME but a Coleridge poem. He begins to recite from memory. ‘A grief without a pang, void, dark and drear’. He consults the book about “the power of evidence-based psychological therapies” he has with him for the rest:
A stifled, drowsy, unimpassioned grief,
Which finds no natural outlet, no relief,
In word, or sigh, or tear
He summarises Coleridge’s point as if quoting a fellow behavioural scientist. “Basically, what he’s saying is, this isn’t the kind of thing you can talk about… people who’ve got depression retract into themselves and don’t go seeking help quite often.”
He makes an analogy that suggests overcoming stigma will be something we see over generations, rather than in the lifespan of the next government. “It’s very much like the gay rights movement… during my lifetime, I’ve seen that change dramatically. I’ve gone through the voting lobbies in the House of Lords to support gay marriage,” he says. “As a society, we got rid of the stigma, I hope, around colour, religion, sexuality. We need to get rid of the stigma around disease… I don’t think people realise quite how prevalent [mental health problems are], because everyone wants to keep quiet about it… It’s crazy we’re not doing more but it does reflect, there’s still a stigma.”