General attitudes to mental health may have become more enlightened, but serious inadequacies remain in how we care for and treat mental health patients. After my in-depth investigation into mental healthcare provision in the UK, it is clear that damage can be done to individuals when the system fails them. Such failings are commonly blamed on three problems: lack of integration of mental health services with other healthcare provision; underfunding; and lack of skills and staffing capacity.
But one of the most pressing and overlooked issues to come out of my report is that failings in mental health care can involve violations of the most basic human rights of patients. Our report highlights the case of a woman who had a life-threatening reaction to the anti-psychotic drugs she had been given during a psychotic episode. Her physical symptoms were then ignored. The failure to fulfil her basic right to medical care led to her tragic and preventable death.
A mark of a decent society is how we treat our most vulnerable citizens. When people are in crisis it is fundamental that those trusted to care for them respect their human rights. This means treating everyone, especially those detained under the Mental Health Act who may lack capacity to make decisions about their own wellbeing, with respect and dignity, and not, as one case study in our report shows, leaving a mental health patient, held in seclusion, to menstruate into a plastic cup by failing to provide her with sanitary towels.
Many European ombudsman organisations consider poor treatment of mental health patients, such as lack of care, the loss of liberty and the absence of the right to appeal, primarily in terms of human rights violations. It is no coincidence that lots of European countries combine the function of national protector of human rights and the public service ombudsman function. In Northern Ireland the public service ombudsman examines the processes followed by public service providers and comments on the extent to which they have shown regard for human rights in individual cases. The aim there is to both humanise bureaucracy and improve public services. In the rest of the UK, applying a human rights approach to complaint handling is an emerging practice.
In one case in our report the wellbeing of a young person with bipolar disorder was severely compromised when care providers failed to carry out a risk assessment on another patient and the young person was assaulted. A failure to take precautions to keep someone safe when receiving mental healthcare is a breach of human rights. By highlighting this, we want care providers to prioritise the fundamental values of freedom, dignity and respect.
I visit many NHS hospitals throughout the year and I see much great work being done by staff in very difficult circumstances. And it is important to emphasise that the cases in my report are not systemic across mental healthcare. However, we should never have to ask any care providers to consider whether they are treating people in a decent and respectful way, or see cases coming to us where care appears to be Dickensian in its lack of compassion. Sadly, my findings highlight too many cases where this reflection is necessary.
David West was a young man whose case we investigated. He was discharged from a local community mental health service without a care plan in place because he missed one appointment. His GP was not informed and he was left without the drugs that he was reliant on, effectively in a no man’s land of care. He died of a drug overdose as a result. No one should ever feel that they have been abandoned or shut out by the NHS that was established to help them.
It is only by embracing a culture change that embeds human rights into the way we think about mental healthcare that we will give patients the service they deserve. For the parliamentary and health service ombudsman, that means more frequently expanding our focus beyond service failure to include issues such as compromised dignity and loss of liberty. By filtering our own investigations through a human rights lens, we will be able to emphasise their importance when we report back to those whom we investigate, and, ultimately, this will impact on the approach to care. We must learn from our European counterparts and work even more closely with the Equality and Human Rights Commission if we are to realise the essential improvements in mental health services that are needed.
Rob Behrens is the parliamentary and health service ombudsman
Individuals who have suffered mild depression or anxiety, or one-off mental health episodes, have been consistently refused life and other kinds of insurance, adding to their financial insecurity.
Dozens of customers told the Guardian they had been refused cover based on long-distant episodes of depression or if their medical report mentioned suicidal thoughts or self-harm. They said they were denied cover even when they had no physical health complaints.
Charities and campaigners said this was worrying and accused insurers of working from an outdated understanding of mental health. The concern is that insurers are dismissing customers with depression and anxiety to minimise risk and boost profits.
Labour and Liberal Democrat MPs have joined a growing number of voices calling for action. The shadow minister for mental health, Barbara Keeley, said:“It is unacceptable for insurers to discriminate flatly against people with mental health conditions or clobber them with higher premiums, particularly for mild conditions or historic episodes … Labour is calling for the government to investigate, as a matter of urgency.”
The Liberal Democrat MP Norman Lamb launched a Commons early day motion, a parliamentary device used to highlight an issue. Lamb said these practices amount to a serious discrimination and urged the government, the Equality and Human Rights Commission and the Financial Conduct Authority to look into it.
“These alleged practices are deeply shocking and, in my view, amount to an outrageous discrimination against people with mental ill health … the government must look into this as a matter of urgency and stamp out any loopholes in the law which are allowing these practices to continue,” he said.
Gaps in legislation mean customers have little protection against this form of prejudice, according to charities. Michael Henson-Webb, head of legal at the mental health charity Mind, said that the current definition of disability under the Equality Act does not cover everyone with a mental health problem, making it “difficult for individuals with mental health problems and their legal advisers to clearly determine their rights”.
The motion launched by Lamb has already been backed by the Labour MP Luciana Berger. She said: “The government has time and again told us how it is committed to equality for mental health. If they are serious they must act now to end this wholly unacceptable and discriminatory practice.”
She added: “It’s the government’s responsibility to ensure that insurance companies are obeying both the letter and the spirit of anti-discrimination laws.”
Prof Wendy Burn, the president of the Royal College of Psychiatrists, said: “It is deeply worrying to hear that insurance companies are making sweeping judgments about people without true understanding of their condition.”
The Guardian has also heard allegations from new complainants. Tony Blair’s former director of communications Alastair Campbell, an ambassador for Time to Change, said: “Whenever my partner Fiona and I have engaged with insurance, it is harder and more expensive for me than for her, because I have been open about having had mental illness, something she has not had.”
He added: “People are judged on past mental health problems differently to how they are judged on past physical health problems. It encourages people not to open up, which in turn means the stigma and taboo are reinforced. It is there in black and white in the NHS constitution – there should be parity between physical and mental health. But this scandal is just one more example of how far the reality is from the words in law.”
Dozens of others spoke out on Twitter. One person said: “[The same] happened to me. I was denied [insurance] as I struggled after a divorce and sought help from GP, so it was on my medical records.” Another said: “My husband can’t get life insurance because of his depression … we have six children. I’m just glad if anything happens to me my family is covered. Just disgraceful.”
Helen Undy, the head of external affairs at the Money and Mental Health Policy Institute, said: “One in four of us will experience a mental health problem each year, and by some estimates this rises to almost half of us across a lifetime. So if the insurance market isn’t working for all these people, then it really isn’t working at all.”
A treasury spokesperson said: “It is wrong for people to be refused insurance purely on the basis of a mental health condition. Insurance companies should follow both the best-practice guidelines from the Association of British Insurers, and equality law to ensure that full cover should be offered wherever possible.”
Insurance firms deny discrimination, with 7/7 victim among those turned down
Insurers have been accused of depriving access to life insurance and other kinds of cover to people with depression and anxiety, even for physical conditions unrelated to their mental health.
People who have suffered even mild mental health conditions or one-off episodes say they have been refused life insurance altogether, aggravating their financial insecurity.
Dozens of complainants have been in touch with the Guardian about the alleged discrimination. Charities and campaigners described the findings as “extremely worrying” and showed that insurers were operating based on an outdated understanding of mental illness.
In some cases, insurers appear to base their refusal on long-distant episodes of depression or anxiety, or when customers admit to having had suicidal thoughts or self-harming noted on their medical records. These customers are then allegedly deemed unsuitable to insure even for circumstances where death is not linked to a mental condition.
One refused applicant was a victim of the 7 July 2005 London bombings who experienced post-traumatic stress disorder. She described being turned down as “upsetting” and “worrying”, saying it showed ignorance about mental illness.
“I was never given a specific explanation as to why I had been rejected but I have not got any physical health issues,” said the woman, who did not wish to be identified.
“I can see it from the perspective of the insurance company; they are not going to want to provide cover for mental health related issues to someone who has had mental health problems. But I was surprised to be rejected for any coverage at all, particularly given my otherwise good health,” she added.
Others say they were penalised after attending one or two grief counselling sessions following a family death, leading to rocketing premiums.
Charities warned that gaps in the law mean customers have little protection against this form of prejudice.
“The difficulty is that the only protection available is to people who are disabled under the Equality Act and even then there are certain exemptions for insurance business,” said Michael Henson-Webb, head of legal at mental health charity Mind.
“The current definition of disability under that Act doesn’t cover everyone with a mental health problem and makes it difficult for individuals with mental health problems and their legal advisers to clearly determine their rights.”.
Laura Peters, advice manager at Rethink Mental Illness, said: “What is judged as ‘high risk’ seems to be based on an increasingly outdated understanding of mental illness. This viewpoint is resulting in people … being disproportionately penalised for their condition with eye-watering premiums or flat out rejection. Life and health insurance can be a vital safety net.”
“It feels to me wholly inappropriate and discriminatory. This is something that the government needs to investigate as a matter of urgency. We need to get a fundamental review of these policies,” he said.
The Guardian heard from dozens of people about the matter. Many of them were rejected for life insurance but others had problems getting health or travel insurance. They said the reason for their refusal had not been made clear but many said the only probable cause was their mental health record.
Many believed they were turned down because of having suicidal thoughts or self-harming noted in their medical records, but others said they were told to apply again at a later date due to having had a recent diagnosis.
The suspicion is that insurers are cherry-picking customers to minimise risk and boost the bottom line.
Henson-Webb said: “Some insurers are operating with a total lack of transparency. That so many people seem none the wiser as to why they have been declined insurance means they aren’t being given information about how decisions have been made.
“It looks as though some insurers are making crude assessments such as the ‘three strikes’ rule, which could amount to discrimination.”
One insurance broker, who asked to be anonymous, said: “Some insurers target different markets and like ‘clean lives’. It sounds awful but they are hard-nosed businesses.”
He added: “My wife looked to apply for new cover recently and she had gone to her GP about work-related stress and the insurer automatically increase the premium. How many people go through work related stress? I thought that was ludicrous.”
Another respondent, 27-year-old Cara Lisette from Hampshire, said that she had been denied cover but at the same time her partner who had an eye condition had been accepted with exceptions put in place. “This seems unfair, that he can get cover that excludes his condition but I cannot get the same,” she said.
A lot of those who responded said that discrimination had made them wary of getting further treatment.
Insurers say applications for life insurance go through careful assessment and are evidence based. They say that when dealing with customer’s with mental health problems they ask questions such as how long it has lasted and how it has been treated. They also ask about any time off work or suicide attempts. Insurers acknowledge that in a small number of cases, mental health backgrounds may result in a premium loading or exclusion, or in the most severe cases, a refusal to offer cover.
A spokesman for Royal London said: “Most mental health conditions are mild or self-limiting, and as a result we are able to offer standard rates to more than 90% of customers who inform us of their condition.”
An Aviva spokesperson said: “We take our responsibility to comply with the Equality Act 2010 very seriously. The Act includes special rules that permit insurers to assess customers individually and to offer acceptance terms at the standard rate, at an increased premium or to refuse to offer cover based upon each individual applicant’s risk.
“We do not refuse to offer cover or offer cover on different terms to people with a disability, unless there is statistical evidence the condition presents a higher risk than for someone who does not have a history of the condition.”