The US Versus UK: Comparing Mental Health Care and Stigma

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When I was a child growing up in the UK, much of my knowledge of the US came from reading comic strips like Peanuts, which were published in the Sunday newspapers. I remember reading the series in which Lucy, the female nemesis of the insecure Charlie Brown, set up a makeshift shack offering psychiatric counseling for five cents a session (no insurance accepted, presumably). Having no clue what a psychiatrist was, I asked a friend’s elder brother, who often knew about adult things, for an explanation.

“I think that’s the person they send you to see if you’ve gone completely nuts,” he said.

Although the UK’s awareness of mental health care has improved radically since back then, there is still an associated stigma that would surprise most Americans. For instance, a visit to a psychologist in the US is perceived as somewhat routine, but that’s not so in Britain, where seeking therapy is a big step – it’s an admission of an illness that is considered shameful, so therapy sessions would probably be kept secret.

Much of this has its roots in Britain’s reserved culture – the idea that someone who is, for example, depressed should “just get on with it,” “sort it out,” and not under any circumstances “make a fuss.” Those seeking treatment would not tell their colleagues at work, fearing it would hamper their careers. What’s more, to claim that the work itself was contributing to depression or anxiety would be viewed as an admission that you simply weren’t up to the job.

Fighting Stigma in the UK

Thankfully, British perceptions of mental illness have been changing over the last few years, due to government policy initiatives, charity-run organizations like Time for Change (an organization that is not a charity itself, but run by a charity), and – surprisingly – the intervention of Britain’s popular Royal family, who are traditionally known for their “stiff upper-lip” (that is, their reticence to express their feelings). A turning point came recently, in April 2017, when Prince Harry, who is fifth in line to the throne, told the Daily Telegraph newspaper that he had sought therapy to deal with the death of his mother Princess Diana, who was killed in a car accident in 1997.

“I can safely say that losing my mum at the age of 12, and therefore shutting down all of my emotions for the last 20 years, has had a quite serious effect on not only my personal life but my work as well,” Prince Harry told the Telegraph. “My way of dealing with it was sticking my head in the sand, refusing to ever think about my mum, because why would that help [I thought] it’s only going to make you sad, it’s not going to bring her back.

“So from an emotional side, I was like ‘right, don’t ever let your emotions be part of anything…and then [I] started to have a few conversations and actually all of a sudden, all of this grief that I have never processed started to come to the forefront and I was like, there is actually a lot of stuff here that I need to deal with,” said Harry, who finally took mental health counseling on the advice of his brother, Prince William. “I know there is huge merit in talking about your issues and the only thing about keeping it quiet is that it’s only ever going to make it worse,” he said.

Comparing the British and US Mental Health Care Systems

Stigma isn’t the only difference in mental health care between the US and the UK. Americans may be surprised to discover that mental healthcare in the UK is free for everyone, regardless of their income, as part of the country’s much-loved National Health Service (NHS). The government formed the NHS in 1948 to bring quality free health care to all, and it encompasses mental health alongside access to general practitioners (GPs), surgery, hospital stays, and all other forms of medical care.

The NHS is funded mainly by government direct taxation, and partially by the National Insurance system (a kind of Social Security contribution), and treatment is free at point of service to everyone. (There is a standard charge of about $11 for all prescriptions, although there are exemptions for those over 60, those under 16, pregnant women, those on income support, and others).

Britons frequently grumble about the NHS, and it often suffers from waiting lists and government funding cuts. But it’s very well-regarded by the public, and considered superior to the US system, where access to care depends on the sick person’s ability to pay, and patients are at the mercy of their medical insurance companies. A 2017 poll in the Daily Telegraph found that 66 percent of those polled were willing to pay more tax, if the increased revenue went to the NHS.
Mental health is available for free on the NHS in all three bands – children, adult, and the aged. Both psychiatrists and psychologists are part of the system. As in the US, psychiatrists hold a medical degree that allows them to prescribe medication, while psychologists use talk therapy techniques.

A difference from the US system is that to obtain mental health care under the NHS system, patients must be referred to a psychiatric specialist by their GP – patients can’t refer themselves. This is because mental health care is regarded as part of a patient’s overall health care, and should be approached in the light of his or her full medical history. There are no reported problems of patients denied care because of this procedure. Those experiencing mental problems arising from drug abuse or alcohol abuse do not need a referral from a GP to obtain treatment.

Patients are referred to a local mental health team by their GP, where the best method of treatment for their condition is assessed. Treatment can be administered by a psychiatrist, a psychologist, or a mixture of the two; deep-seated mental problems usually involve a period of care with a psychologist. There is flexibility in choice of practitioner, and patients have the right to choose their first mental health practitioner. If a patient is unhappy with the practitioner’s diagnosis, he or she can receive a second opinion, although a second opinion is not legally mandated.

There are waiting lists for some mental health care treatments, especially if a bed in an institution is needed. (But most services, as in the US, are outpatient or home visit.) Consultant-led medical services have an 18-week maximum wait that’s mandated by law. This is something that Americans, used to quick treatment, are surprised by. There is also overcrowding in mental health institutions.

Both problems result from government cuts in funding to the NHS, rather than being a deficiency of the system itself – there is no dedicated NHS tax, and its funding comes from overall government taxation. So it is vulnerable to government budget cuts, which negatively affect services. Overcrowding and waiting times could be improved with extra funding to pay for, say, more beds in mental health institutions, which have been reduced in the last decade due to government funding cuts.

Private US-style mental health care is available in the UK, and patients can choose to go outside the NHS system and pay their way if they prefer. Although patients are free to choose their private practitioner, psychologists in the private sector usually still ask for a referral from the patient’s GP so the patient’s overall health can be referenced. The cost of a private psychologist in the UK is between $65 and $130 an hour – not expensive by US standards, but considered expensive by the British.

Private medical insurance is available in the UK, from companies like Bupa UK, but this is very rare, and usually only offered as part of a kind of bonus package from an employer. Those with private insurance do not have to give up their right to use NHS services — use of the NHS is a legal right for all British citizens.
As in the US, government policy on mental health care is in flux, due to the minority government that resulted from the 2017 general election. But both the right-wing Conservative party, and the left-wing Labour Party promised a raft of improvements to the country’s mental health care system in their political manifestos. Activists say they are pleased that mental health is finally getting the attention it deserves, after years of being treated as the stepchild of the NHS. But what occurs in practice will probably be decided by the long-running debate over NHS funding as a whole – Labour support more funding for it, but the Conservatives want to give it less.

Although free mental health care is well established in Britain, how it should be funded is a debate not too dissimilar to the one happening right here in America. Increasing access to care is something that both countries should be obliged to improve.

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Richard James Havis

Contributor