GP recruitment crisis intensifies as vacancies soar to 12.2%

Vacancies for GPs are at their highest ever level, research suggests.

A survey of 860 GPs for Pulse, a news magazine for general practitioners, found 12.2% of positions were currently vacant – up from 11.7% at the same time last year and from 2.1% in 2011, when Pulse started collecting the data.

The findings show 158 GPs (18%) have been unsuccessful in filling a vacancy in the past 12 months. In that period, the average time taken to recruit a GP partner has risen from 6.6 months to 7.4.

Pulse said some practices were having to hire non-GPs to fill the gaps, while others had closed after failing to recruit a GP partner.

A report from the Commons public accounts committee in April found there had been “no progress” in the previous year on increasing the number of GPs, despite a government target to recruit 5,000 more by 2020. The report said the number had actually fallen, from 34,592 full-time equivalent doctors in September 2015 to 34,495 in September 2016.

MPs said more trainees needed to be recruited and that existing GPs should be encouraged to stay on.

Prof Helen Stokes-Lampard, chair of the Royal College of General Practitioners, said of Pulse’s findings: “We know that practices across the country are finding it really difficult to recruit GPs to fill vacant posts, and the degree to which this problem has increased over the last six years is staggering.

“In the most severe cases, not being able to recruit has forced practices to close, and this can be a devastating experience for the patients and staff affected, and the wider NHS.”

Stokes-Lampard added: “At present, UK general practice does not have sufficient resources to deliver the care and services necessary to meet our patients’ changing needs, meaning that GPs and our teams are working under intense pressures, which are simply unsustainable.

“Workload in general practice is escalating – it has increased 16% over the last seven years, according to the latest research – yet investment in our service has steadily declined over the last decade and the number of GPs has not risen in step with patient demand … This must be addressed as a matter of urgency.”

GP recruitment crisis intensifies as vacancies soar to 12.2%

How schools are dealing with the crisis in children’s mental health

It could easily be a child’s bedroom. In the centre is a large mat, while a selection of dolls and soft toys line the walls. It is hard to believe that this nurture point in Plaistow, east London, aimed at helping children deal with their emotional problems, was once a school staff room.

Youngsters aged five to 11 can drop in three days a week and speak to a trained counsellor from the charity Place2Be. But as well as worries over friendships, bullying or problems at home, headteacher Paul Harris reveals that a growing number of children are suffering from anxiety as a result of Brexit and the election of Donald Trump.

Fortunately, pupils at Curwen primary and its sister school, Kensington primary in Manor Park, can speak to a counsellor before their problems become overwhelming.

The lunchtime drop-in – known as Place2Talk – is part of a package of support services offered by the charity, which includes one-to-one counselling and play therapy for children suffering from more serious mental health issues.

Working with 282 primaries and 50 secondaries, the charity provides early intervention support in schools to children who are troubled and unhappy.

The charity is not the only one working with schools. The Art Room charity supports five- to 16-year-olds who are experiencing emotional and behavioural difficulties.

There are eight Art Rooms in schools in Oxfordshire, London and Edinburgh, supporting 500 children a week by offering art as therapy to increase their self-esteem, self-confidence and independence.

It is this kind of partnership that Theresa May, the prime minister, said in January that she wanted to see more of. She said then that one of her priorities was children’s mental health, which has long been recognised as in crisis.

Statistics show that one in 10 children – or an average three children in every classroom – has a diagnosable mental health problem, and that 75% of mental illness in adults has its roots in childhood.

The prime minister said, before the election was announced, that she wanted every secondary school to be offered mental health first aid training, as well as new ways introduced to strengthen links between schools and NHS staff alongside more online support services for children and young people. May’s recognition of the crisis in children and adolescent mental health has been welcomed. But headteachers say that cuts of £3bn to school budgets threaten existing in-school care and want mental health funding ringfenced.

Harris, who is also executive head of three other primaries in the London borough of Newham, says the proposed school funding cuts mean losing the service of 17 teaching staff: “I believe support needs to start young in primary schools to build resilience before children go on to secondary.

“Cash needs to be earmarked for this from health budgets, otherwise we will lose this vital service.”

Celine Bickerdike: ‘Teachers had to believe you had a problem before you could access the school’s services’

Celine Bickerdike is a young champion for the mental health charity Time to Change

Celine Bickerdike, 19, is an apprentice in Leeds and has secured a university place to study history. She has had anxiety and depression since aged 12. But it was five years before she sought professional help.

“My first experience of being judged because of having a mental health problem was when some girls took my antidepressants from my bag and started reading out the side-effects in front of everyone. They humiliated me. How can people be so cruel?

“There was some school mental health support, but teachers had to believe you had a problem before you could access it. Most of my teachers thought I was OK – one even said that I was stressed because I wasn’t working hard enough. I broke down during my mocks, which was when my history teachers, who I was really close to, told me to go and see a doctor.

“I put an enormous amount of pressure on myself to get the grades I needed for university. I was anxious about the future – and failure.

“I didn’t get into the university I wanted and this really took its toll. I felt completely lost. All my friends were at university. I had gone from having a promising future to being on job seeker’s allowance.

“I think initially, my parents didn’t take my mental health problems seriously; they thought it was just ‘hormones’. I’d always been a bit of a worrier so they assumed that my problems were small because of that.

“Nowadays I find it easier to talk to people about my mental health because I’m more confident and don’t doubt my condition as much. People’s conditions should be believed as soon as they develop so that it’s easier to prevent them worsening like mine did.”

How schools are dealing with the crisis in children’s mental health

"Shattering stigma starts with simple conversations": tackling the child mental health crisis

Public concern around child and adolescent mental health is at an all-time high. The prime minister, Theresa May announced in January her intention to better identify and help the growing number of young people in schools who are at risk of developing mental health issues. Prince Harry and the Duke and Duchess of Cambridge, meanwhile, are using their profiles to convince the public that “shattering stigma on mental health starts with simple conversations”.

And yet, despite growing awareness of the issue, child and adolescent mental health services (Camhs) are under an increasing amount of pressure. Healthcare professionals bemoan a lack of resources and staff while the health secretary, Jeremy Hunt, has described Camhs as the “biggest single area of weakness of NHS provision”.

What are some of the issues facing children and young people today? What problems are services confronted with? What examples of best practice are there and how can the health, education and social care sectors provide better mental healthcare for children and young people? These were some of the questions addressed by experts in mental health at a roundtable discussion, chaired by the Guardian’s health policy editor Denis Campbell and supported by online counselling service XenZone.

“For children, there are so many messages about what to be, what to look like, how you should present yourself to the world. It’s 24/7 and social media judges most things,” said Anne Longfield OBE, children’s commissioner for England. “There’s anxiety around exams, schools and increasingly linear expectations. That all builds up.”

Sarah Hulyer, an activist from YoungMinds, the young people’s mental health charity, agreed that exams and stress are part of the problem. She also talked about the considerable effect of social media on young people’s mental health. “I think social media is negative in several ways in that your public life never ends. You’re always being watched,” she said.

Hulyer pointed out that social media can glamorise mental health problems and emphasised how important it is to start a conversation about mental health at a young age. “A lot of young people learn about mental health in the media, but often the only things talked about are anxiety and depression,” she said. “Young people don’t know [the range of] problems there are until they’ve had them explained to them.”

Attendees also discussed the problems facing services. Norman Lamb, Liberal Democrat MP and former mental health minister, said: “We’re faced with a dysfunctional system with awful access, which leads to people taking their own lives. We’re not going to solve the whole problem if we focus on the system giving treatment. It has to be about prevention and a fundamental shift of emphasis.”

Most agreed that there were significant problems facing the Camhs workforce. “We do not have an available workforce with sufficient morale to deal with the problem,” said Dr Bernadka Dubicka, consultant child and adolescent psychiatrist and chair-elect of the child and adolescent faculty, Royal College of Psychiatrists. She believes there are vast numbers of children and adolescents who could have been helped before they were referred to Camhs.

Sean Duggan, chief executive of the Mental Health Network at the NHS Confederation, claimed that the importance of child and adolescent mental health has not been properly recognised in the sustainability and transformation plans (STPs) that have been drafted to improve health and care in England. “STPs are here to stay and are a vehicle for setting priorities,” he said, adding that child and adolescent mental health is an urgent priority that needs to be addressed.

Although many around the table underlined the role that schools can play in reducing mental health problems among pupils, Malcolm Trobe CBE, general secretary for the Association of School and College Leaders, pointed out that there is a gap between what schools can deal with and their access to external support.

“Teachers have workload pressures – they just don’t have the time [to offer additional support],” he said. But he also asked where children with mental health problems were going to get that extra support: “We’ve got to move from talking about it to actually doing something. Health and education departments have got to work together so we have a strategic view of this.”

While the majority of those in attendance bemoaned the state of child and adolescent mental health services in the UK, Dr Matt Muijen, adviser in international mental health, painted a different picture. “There’s an unusual publicity about poor mental health in England. That creates demand,” he said.

“When you look at the supply side, you have remarkably good standards. There is no separate budget for child mental health but you’re the second highest funder of mental health services after the Netherlands. As a proportion of the health budget, you are by far the highest.” He went on to criticise local authorities for their inability to commission services, adding: “I always feel like health services in England are constantly changing, with a total lack of stability with no one quite knowing what they’re expected to do.”

Given the huge demand on services, attendees agreed that action was needed and floated possible solutions and examples of best practice. Elaine Bousfield, founder and chair of XenZone, suggested a digital approach could help, as long as it is tied into the wider health and social care system.

Bousfield spoke about XenZone’s online counselling and emotional wellbeing platform for children and young people. It’s used by them to talk to someone – generally for one to three sessions. “The beauty is they’re not then ruminating and adding to their anxiety,” she said. “Quite often young people don’t know what’s going on. They just feel terrible and they might not know why. They need a space where they can talk about that.”

Hulyer said a large part of the solution lies in the digital world, as that is how young people communicate. She said young people have a despondent view of Camhs and don’t believe that services will ever be there for them. She stressed the importance of learning about mental health at school and how it should be part of the curriculum. “You learn about physical health, so you should learn about resilience; how to deal with stress.” Hulyer also said that parents need support and talked about a helpline set up by YoungMinds that they can call for information and advice.

Dr Emma Blake, paediatric mental health consultant and chair of the Child Mental Health Committee at the Royal College of Paediatrics and Child Health, also highlighted MindEd, an online service for adults designed to provide help with, and information on, child and adolescent mental health.

Lamb and Duggan, meanwhile, cited some areas of the country where services are working well to tackle child and adolescent mental health. In Oxfordshire, mental health professionals go into schools every week and work with teachers to increase their understanding. Lamb said they had seen a drop in referrals to Camhs because they are intervening much earlier.

In Northamptonshire, a referral management centre was developed in 2015, which includes a consultation line open to young people and families, a texting service offered by school nurses, online chat for young people to talk to a mental health professional, self-referral, a children’s crisis home treatment team and two adolescent in-patient wards. Duggan also highlighted a new programme at Sussex Partnership NHS foundation trust – the Discovery College.

The concept is based on the existing recovery college, which involves free courses developed and delivered by health professionals. The discovery college applies the same principles for children and young people. It involves free courses for 13- to 20-year-olds, providing knowledge and skills to maintain and manage mental health.

Despite these positive schemes, there is still frustration over the lack of action relative to the tone of the conversation around child mental health.

During his time in government, Lamb produced a blueprint for mental health services, Future in Mind, which brought together a number of key proposals. Two years on, the government is now producing a green paper on the same subject. “This is an excuse to carry on talking rather than doing,” he said. “I’ve said to the health secretary to create incentives around the country to make urgent progress. The green paper can provide some value, but we need to do what we said we were going to do.”

At the table

Denis Campbell (Chair)
Health policy editor, the Guardian

Anne Longfield OBE
Children’s commissioner for England

Noman Lamb MP
Liberal Democrat health spokesman

Prof Miranda Wolpert MBE
Director, Evidence Based Practice Unit, UCL and Anna Freud Centre

Dr Emma Blake
Chair, Child Mental Health Committee, Royal College of Paediatrics and Child Health

Dr Bernadka Dubicka
Chair-elect, Child and Adolescent Faculty, Royal College of Psychiatrists

Sean Duggan
Chief executive, Mental Health Network, NHS Confederation

Elaine Bousfield
Founder and chair, XenZone

Sarah Hulyer
Activist, YoungMinds

Tony Hunter
Chief executive, Social Care Institute for Excellence

Dr Matt Muijen
Adviser in international mental health

Charlotte Ramsden
Chair, Health, Care and Additional Needs Policy Committee, ADCS

Prof Helen Stokes-Lampard
Chair, Royal College of General Practitioners

Malcolm Trobe CBE
General secretary (interim), Association of School and College Leaders

"Shattering stigma starts with simple conversations": tackling the child mental health crisis

Signs of hope in the prison mental health crisis

Mental health problems in the prison population have long been a matter of concern. Suicide rates in prisons in England and Wales are at an all-time high; a record 119 people killed themselves in 2016 – an increase of 29 on the previous year, according to figures from the Ministry of Justice. The rise in prison suicides has been accompanied by a 23% increase in incidents of self-harm, to a total of 37,784.

“It’s a huge issue because lots of people in prison have mental health problems,” says Dr Steffan Davies, consultant forensic psychiatrist and co-chair of the Community Diversion and Prison Psychiatry Network at the Royal College of Psychiatrists. A study by the Prison Reform Trust found that 72% of male and 70% of female prisoners experience two or more diagnosable mental health disorders. Research by the National Institute for Health and Care Excellence found that 7% of male and 14% of female prisoners have a psychotic disorder – 14 and 23 times the level in the general population respectively.

The situation looks set to get worse. In recent years, staff numbers have dropped significantly, budgets and staff training have been cut, the prison population has more than doubled, and the introduction and rising use of new psychoactive substances has contributed to increasing violence.

Jacob Tas, chief executive of the social justice charity Nacro, says: “The overcrowded prison environment is likely to worsen existing mental health problems that are often the key drivers for offenders to commit further crimes or become violent while in prison.”

Davies adds: “It does feel like things are getting worse and I’m hearing it’s hard to recruit people to prison mental health services. People are leaving, and quite a few find it an extremely stressful environment to work in.”

While the general outlook is bleak, projects such as the self-management training programme at HMP & YOI Parc, Bridgend, south Wales, hold out some hope. Developed as a partnership between the Mental Health Foundation and G4S, and funded by Big Lottery Fund Cymru, the aim was to improve prisoners’ mental health through self-management and peer support.

The programme was delivered between September 2013 and December 2016, and involved two to three hours’ training one day a week for four weeks. Up to 10 participants could attend. Training included positive thinking, goal setting and problem-solving.

Fifty prisoners filled in the Warwick-Edinburgh mental wellbeing scale at the start of the course and a month after its completion: the mean score showed a significant increase in the prisoners’ wellbeing.

Lauren Chakkalackal, senior research officer at the Mental Health Foundation, says: “A number of positive stories came from the project. It was an opportunity for people to feel listened to and express how they were feeling.

“A group of prisoners produced resources to better support the mental health needs of new prisoners. The prisoners themselves took ownership of that group.”

Plans are afoot to develop similar models in other prisons and the project is being redesigned to support older prisoners and young offenders.

Signs of hope in the prison mental health crisis

Amsterdam"s solution to the obesity crisis: no fruit juice and enough sleep

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The city is successfully fighting fat by promoting tap water in its schools, along with healthy cooking classes and a ban on fast food sponsorship

The city of Amsterdam is leading the world in ending the obesity epidemic, thanks to a radical and wide-reaching programme which is getting results even among the poorest communities that are hardest to reach.

Better known for tulips and bicycles, Amsterdam has the highest rate of obesity in the Netherlands, with a fifth of its children overweight and at risk of future health problems.

Related: For children’s health, the government has to treat sugar like cigarettes | Gary Taubes

Continue reading…

Amsterdam"s solution to the obesity crisis: no fruit juice and enough sleep

My teenage cousin is having a crisis, but her mother won’t get her the help she needs

My cousin is 16, and apparently going through a crisis. She hates college, skips classes and has spoken to my grandmother often of hating her life and not enjoying anything any more. My grandmother is in bits about this and has tried to talk to my cousin’s mother, her daughter, about getting her some help. However, my aunt’s response has been, “She’s not going to turn out mental like the rest of you people.” (Other members of the family, including me and my grandmother, have had mental health problems.)

My cousin enjoys watching videos and playing video games, but her parents have banned them and see them as an example of her laziness. She is not sleeping either, so her constant exhaustion is taken as yet more evidence of laziness.

What terrifies me is that this is what my mother did to me, and I can only see it getting worse. When I began self-harming in my teens, my mum also banned me from my one hobby, screamed at me when I had a panic attack and slapped me when she found out I had self-harmed.

I had problems with substance abuse and dropped out of school. I moved away from home as soon as I could.

I am now in my mid-20s, and not close to anyone in my family apart from my grandmother. I have now moved somewhere else and, although I don’t see my parents, I am in contact with them. I haven’t seen my cousin for a few years and have no contact details for her. Anyway, I am not sure how, “Hi, I know we haven’t spoken in years but you remind me of me” would go down. I am trying to help my grandmother find a way to talk to my aunt in a manner that won’t enrage her, but my grandmother is a very non-confrontational person and, as much as she is trying to help my cousin, having to confront my aunt has only resulted in my grandmother being screamed at and threatened with losing contact with her grandchild.

I don’t know how to help my grandmother or my cousin, but I feel as if I have to do something, or history may repeat itself.

That you have come so far from a very toxic and unsupportive environment is incredible and a real credit to your strength of character.

It is great that you are so caring about your cousin and grandmother, but I think there is a lot of over-identifying going on. Your cousin doesn’t sound as if she is in a great place, but the facts pertaining to her were thin. The rest of your letter was about your experiences within the family and your fears of what might happen. I am not trying to minimise how you feel, or what is happening in the slightest – but the key is to separate the different strands so you can work on the right bits at the right time.

I consulted Stuart Hannah, a child and adolescent psychotherapist (childpsychotherapy.org.uk), who said: “The news about your cousin is filtered through your grandmother, via her daughter [your aunt].”

News filtered through people who have their own agenda or narratives can get distorted and then there is less likelihood of anyone getting the help and support that is right for them.

I disagree that it is not worth contacting your cousin: I think you should get in touch. Sure, if you go in there with “you remind me of me” that may not be conducive to further communication. But if you make a different sort of contact, more of a general “hi”, and see what happens, that may be really helpful to her in time (don’t expect miracles straight away). After all, you are not that much older than her, a mere decade, and you share a grandmother. There should be lots of other things to talk about so she feels she has someone to talk to if she feels like it – so it’s about her agenda, not anyone else’s.

It sounds as if you have a lot of issues you haven’t dealt with yourself and I wonder if you have some support (apart from your grandmother). If you do, you could come at this situation with less of your own baggage and would be better able to support your grandmother.

I don’t know what the conversations with your grandmother are like, but Hannah counsels: “How can you offer [your grandmother] something different? Something that isn’t judgmental or blaming [that she seems to get from her daughter]. You can listen from a neutral place. Don’t go down the slagging-off route [if you do], and suspend judgment of family members. If you can hear your grandmother’s experience, that may in turn help her listen to her daughter.”

Being empathic is great – however, if we over-identify with a situation (and both you and your grandmother might be), then the danger is, when we hear about something similar we can start to overlay our own experiences on to this new situation. This stops us seeing what is really going, and it imbues everything with extra emotion.

I think, given everything you have said, there is an element of trying to save your younger self, and that’s laudable, but there is a limit to how much you can do. You may also find this website helpful:

Youngminds.org.uk

Your problems solved

Contact Annalisa Barbieri, The Guardian, Kings Place, 90 York Way, London N1 9GU, or email annalisa.barbieri@mac.com. Annalisa regrets she cannot enter into personal correspondence.

Follow Annalisa on Twitter @AnnalisaB

My teenage cousin is having a crisis, but her mother won’t get her the help she needs

Crisis looms for social policy agenda as Brexit preoccupies Whitehall

Ever since Theresa May set out her vision to govern for everyone and not just the privileged few last July, those in the charity sector who work to reduce poverty and inequality have waited patiently. Campbell Robb, the chief executive of the Joseph Rowntree Foundation, was one of many charity leaders who hoped for progress. He wanted to see a revamp of the government’s much-criticised “troubled families” programme, a £1bn scheme set up by David Cameron in 2011 and billed as the Tories’ flagship social policy initiative.

But when the Department for Communities and Local Government issued its first annual report on the programme , the charity sector was hugely disappointed. Robb described the document that emerged as “thin” and a “testament to the vacuum” that exists where we need to see “big political and social change”. It was barely noted in the media, which focused instead on a range of austerity-driven changes to the tax and benefit system, announced originally by George Osborne, which came into effect at the beginning of the new tax year. The changes hit the poorest hardest, while helping millions of the better off. The view increasingly held by thinktanks, and across the public sector, is that May’s government – even if well intentioned in wanting to reduce inequality and enhance opportunity for all – is too distracted and too constrained by the state of the public finances to do so.

“There is a danger that Brexit could suck the oxygen out of attempts to implement a sweeping programme of social and economic reform that is badly needed at home,” Robb said.

Even within parts of the Tory party, MPs and others worry that Brexit is now the only show in Whitehall, one so all-consuming, so draining of civil service and ministerial energies that everything else – the May agenda included – is on the back burner.

“David Cameron came into office with a new social vision of Conservatism and promptly sacrificed it on the altar of austerity,” says Phillip Blond, director of the ResPublica thinktank. “It is vital Theresa May does not let her one-nation Conservatism experience a similar sacrifice at the behest of Brexit. The trouble with Brexit is that those who voted against the EU as a proxy for globalisation and its general destruction of working-class security, risk finding May’s ‘global Britain’ to be far, far worse for them.”

Ryan Shorthouse, director of the liberal conservative thinktank Bright Blue, says he always suspected Brexit would syphon the energy out of Whitehall and voted against it partly for that reason: “A persuasive argument for voting Remain, I thought, was the lengthy and disproportionate focus that would be required of politicians and policy-makers to undertake the process of Brexit, which is indeed what we are now experiencing. There are other important and pressing issues that urgently require deeper thinking and discussion: the affordability and quality of social care, the upskilling of those on the lowest incomes, the financial sustainability of the NHS, and decarbonising our economy.” The green agenda, once central to May’s predecessor, hardly registers these days.

When the financial crisis broke in 2008, Nick Pearce, now professor of public policy at the University of Bath, was in charge of the No 10 policy unit under Gordon Brown. “It was the biggest economic shock the UK had faced since the second world war,” he says. But it did not preoccupy every government department as Brexit does. “It was largely dealt with by the prime minister, his advisers, the chancellor and Treasury officials, and the Bank of England. It was not like Brexit. Most of Whitehall now has Brexit at the top of the in-tray.”

It has already been decided that the next Queen’s Speech will be dominated by Brexit-related bills. Ministers have been told to limit their bids for domestic legislation so the way is clear for parliament to focus on the “great repeal bill”, which will incorporate the mass of EU law into UK law, and on other Brexit-related bills including one on immigration. A recent report by the National Audit Office says the civil service has already created more than 1,000 extra roles in the two new Brexit departments – for International Trade and for Exiting the EU.

‘Lego bricks and boiled eggs’: the three Brexiteers explain everything

And that is just the start, as the search for trade experts – outsourced over the last four decades to Brussels – intensifies. Many civil servants have shifted from domestic roles to Brexit posts in a huge, destabilising, but necessary, reconfiguration of Whitehall. Jeremy Heywood, the cabinet secretary, has described the task of managing his Brexit troops in Whitehall as “the biggest, most complex challenge facing the civil service in our peacetime history”. The NAO says new skills have to be learnt and found – a process which inevitably means less use of expertise gathered over decades by senior mandarins.

The poorest third of households are faring even worse than they did after the 2008 crash

The Resolution Foundation

Its report says: “Departments which have had large amounts of EU-derived funding and legislation, for example, will need legal, economic and sector experts to deal with the implications of leaving the European Union, and will have to do so using their remaining staff while also seeking to achieve pre-existing priorities.” Lord Kerslake, a former head of the civil service, says it is entirely right that the focus is on delivering a successful Brexit, but he fears problems will develop down the line in unrelated but vitally important areas as eyes are taken off the ball. “Nobody has quite got the measure of this because of the dominance of Brexit,” Kerslake says.

“Of course there is a need to equip government for Brexit but there is also a need to carry on with the rest of the business of government. There is a risk for the government in this: that things that would have surfaced through being debated and being challenged in normal times will now not surface early, and not until they become crises.”

The Angel of the North statue. The fate of English devolution – formerly a priority – is in question. Photograph: Christopher Thomond for the Guardian

Emma Norris, programme director at the Institute for Government, says the repercussions are already being felt on issues of critical importance. “After trailing a big decision on airports, a parliamentary vote on Heathrow was pushed to late 2017. Key social reform policies in education have been delayed too, like the national funding formula, which was originally due to be implemented this year, but will be delivered at least 12 months late.

“The fate of English devolution – formerly a major priority – is also in question. Adult social care and hospitals are being pushed to breaking point and, in the case of prisons, beyond it. Ambitions to reduce demand, make better use of technology and find new ways of working have yet to be realised. Without action, within the next two years the government could face a disastrous combination of failing public services and breached spending controls against the backdrop of Brexit.”

She adds: “Even the prime minister’s personal priorities are moving slowly. David Cameron’s life chances strategy was scrapped in favour of a new focus on social mobility. But many of the details of this are yet to come and, as the Social Mobility Commission recently reported, inequality is rising.”

The Resolution Foundation maintains that the need to address stagnating living standards and rising inequality is “the non-Brexit challenge of this parliament”. It points out that typical incomes are set to grow by 3% over this parliament – barely any faster than during the Blair/Brown Labour governments, which coincided with the financial crisis and its aftermath. The thinktank says May’s priority, the “just managing families”, are doing worst of all, with the poorest third of households faring even worse than they did after the 2008 crash. This, it predicts, means we are heading for the “biggest rise in inequality since Margaret Thatcher was in Downing Street”.

Pearce points out that Brexit will also skew spending priorities, creating new pressures on finite resources for a government struggling to keep public finances on a tight rein. “Economic priorities – such as R&D, skills and infrastructure spending – will get higher priority in public spending. Brexit will also create powerful new lobbies, such as farmers, universities and key business sectors, who will be arguing for funding to replace lost European Union resources. These lobbies will find themselves competing with the public services that have lost most from austerity, such as social care. And they will also be up against a neo-Thatcherite wing of the Conservative party that wants to use Brexit to cut corporate taxes and public spending even further.”

Torsten Bell, the Resolution Foundation director, says May cannot afford to overlook problems at home as she conducts her Brexit battles with the EU. “The living standards outlook is bleak and risks giving us the inequality rises of the 1980s, without the feelgood factor of rising incomes. But it can and should change. After all, Theresa May knows her record will be judged as much on the Britain she builds as the Brexit she delivers.”

Crisis looms for social policy agenda as Brexit preoccupies Whitehall

Four select committees launch joint inquiry into UK air pollution crisis

MPs from four influential committees are coming together to launch a joint inquiry into the scale and impact of the UK’s air pollution crisis.

In an unusual development, the environmental audit committee, environment, food and rural affairs committee, health committee and transport committee will hold four sessions to consider mounting scientific evidence on the health and environmental effects of toxic air.

Dr Sarah Wollaston, the health committee chair, said poor air quality was “affecting the health of millions of people across the UK”.

“Our joint inquiry will include an examination of the scale of the harm caused and the action necessary to tackle it,” she added.

Last month, the Guardian revealed the risk to children’s health posed by air pollution, identifying 802 educational institutions in London where pupils as young as three are exposed to illegal levels of air pollution.

The government says toxic air causes up to 50,000 early deaths – 9,000 of them in the capital – and costs the country £27.5bn each year.

The government’s own statistics show 38 out of 43 UK “air quality zones” breach legal limits for air pollution and last year the high court ruled ministers must cut the illegal levels of NO2 in dozens of towns and cities because their current policies to improve air quality were so poor they were unlawful.

The government has to announce its new plans before 24 April and the inquiry will examine whether these proposals go far enough to cut pollution “not only to meet legal limits but also to deliver maximum health and environmental benefits”.

Mary Creagh, chair of the environmental audit committee, said: “The UK courts have twice found that the government has failed to deal with our air pollution problem properly. Now ministers will face unprecedented scrutiny in parliament to ensure they finally step up to the mark to ensure adults, and children in particular, do not have their health damaged by filthy air.”

Much of the most dangerous pollution comes from diesel vehicles and there is growing pressure on the government to introduce a diesel scrappage scheme to encourage people to swap polluting diesel vehicles for cleaner alternatives.

Louise Ellman, chair of the transport committee, said the UK economy depends on an “efficient and flexible transport system” but added: “Emissions from vehicles are a significant problem and the standards that governments have relied on have not delivered the expected reductions. We will be asking what more can be done to increase the use of cleaner vehicles as well as to encourage the use of sustainable modes of transport.”

Neil Parish, chair of the environment, food and rural affairs committee, said the joint inquiry was unprecedented.

“The solutions to cleaning up our air are not the responsibility of just one minister. That’s why we have taken the unprecedented task of convening four select committees so we can scrutinise the government’s efforts from every angle and look for holistic solutions that are good for health, transport and the environment.”

Four select committees launch joint inquiry into UK air pollution crisis

NHS services face "impossible" budget crisis, health trusts warn

Frontline NHS services face “mission impossible” in meeting next year’s targets, health trusts have said.

Longer waiting lists for operations and delays at accident and emergency departments in England loom under the present financial constraints, said NHS Providers, a trade association that represents acute, ambulance, community and mental health services.

Chief executive Chris Hopson said the government needed to “sit up and listen”, the BBC reported. “NHS trusts will strain every sinew to deliver the commitments made for the health service. But we now have a body of evidence showing that, with resources available, the NHS can no longer deliver what the NHS constitution requires of it.

“We fear that patient safety is increasingly at risk.”

NHS Providers predicted its members would receive £89.1bn in funding in 2017-18, an annual rise of 2.6% but less than the 5.2% demand is expected to grow by.

It warned the number of people waiting more than four hours in A&E would increase by 40% next year to 1.8 million, and the number waiting more than 18 weeks for routine operations would rise 150% to about 100,000.

The NHS is already under strain in the wake of the Brexit vote. The number of EU nationals registering as nurses in England has dropped by 92% since the referendum in June, and a record number are quitting the NHS.

Only 96 nurses joined the NHS from other European nations in December 2016 – a drop from 1,304 in July, the month after the referendum.

The service is also facing a long-term failure to hire enough people. Applications for nursing courses plummeted by almost a quarter in a year after the government axed bursaries for trainees in 2016. Numbers fell by 9,990 to 33,810 in 12 months, according to figures released in February by the university admissions service Ucas. Meanwhile, one in three nurses is due to retire in the next 10 years and there are 24,000 nurse jobs unfilled, Royal College of Nursing figures show.

NHS services face "impossible" budget crisis, health trusts warn

After my suicide crisis I set up a centre to give others a safety net | Joy Hibbins

It took just minutes for a deeply traumatic experience in March 2012 to fracture my life. I experienced such terror during those moments that I couldn’t sit with my back to a door for weeks. I was convinced that someone would come in and harm me. The event replayed constantly in my mind. I couldn’t escape. I was in the grip of severe post-traumatic stress disorder and within days I was at the point of suicide.

I called my out of hours GP and was referred to a mental health crisis and home treatment team, but I found it hard to connect with the number of different people involved in my care. Their methods were very practical. They would tell me to distract myself when I felt suicidal. But what I wanted was emotional support from a team who knew and understood me as an individual. The clinical distance of psychiatric staff left me feeling detached and alone

On a summer’s day in that year I started to picture in my mind what would have helped me: a suicide crisis centre. It would be a place I could visit every day. If I was at imminent risk of suicide, I could be supported there over a number of hours. The staff would be highly trained, skilled professionals – but they would also be kind, caring and empathic.

In the months that followed I worked tenaciously to make that picture a reality: focusing on setting up the crisis centre gave me a reason to live. There are now 25 of us working there, and we will soon be marking four years of providing services. A high proportion of our clients are men, and this is significant; nationally, three times (pdf) as many men die by suicide as women.

We never set out to achieve zero suicides. That would have been a massive pressure on all of us. We simply set out to do everything that we could for each individual to help them survive. We have never had a suicide of a client under our care.

One of our clients says he carries us in his pocket. He feels that we are always with him

We don’t just provide a static centre for people to visit when they are in crisis. If they are very distressed, they may not be able to get to us, so sometimes we need to go out to them. The combination of an accessible crisis centre, home visits and our emergency phone lines places a safety net around our clients.

The quality of the relationship is so important when you’re supporting someone at risk. We work hard to build a strong connection with our clients. It’s the reason they call our emergency line at 3am, when they might not have called another service. They get through to someone they know and that makes a difference. Clients often say they wouldn’t have called an anonymous service at that point.

If you build a strong connection with clients, it can “hold” them even when you are not with them. One of our clients says he carries us in his pocket. He feels that we are always with him.

I sometimes get asked how I cope with the emotional intensity of the work. Firstly, we get excellent support and supervision from senior staff who are available at very short notice. Secondly, I see such wonderful personal qualities in our clients and that’s a source of optimism. They will go out into the world and affect other people in a positive way. That gives me huge hope for the future.

When I started to talk about my plans back in 2012, people were sceptical. It seemed such an ambitious project for a person who had recently been in crisis. But I knew it had to be set up.

MPs on the Commons health select committee recently asked us to provide evidence about our suicide crisis centre for an inquiry into suicide prevention. Their final report has just been published.

We are contacted by people from all over the country who would like a similar centre in their area. I hope that will be possible. I know how much they are needed.

• Joy Hibbins is founder and director of Suicide Crisis, which runs a suicide crisis centre in Cheltenham, Gloucestershire.

In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here.

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The day I made a difference is the Guardian Voluntary Sector Network’s series that showcases the work of people involved with charities. If you have a story to share about a landmark moment in your life, email voluntarysectornetwork@theguardian.com.

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After my suicide crisis I set up a centre to give others a safety net | Joy Hibbins

The solution to the NHS funding crisis? Its property | Dag Detter

The NHS was offered little relief in Wednesday’s budget. The proposed spending increase of £250m in social care the first year and then £130m the following two years will hardly cover inflation, let alone other cost pressures that the shortfall places on the health service. With such austerity the NHS faces years of underfunding, according to a King’s Fund report.

Yet the most promising avenue towards financial salvation is not even contemplated. The NHS is one of the country’s largest property owners; but also one of the least efficient property managers. Decades of debate have raged between those who want to keep it that way, and those who want to privatise or outsource property management to the private sector. The glaring third alternative has been left by the wayside – professional management of NHS property while maintaining public ownership but isolated from short-term political meddling.

The British Medical Association asks for a short-term £10bn funding increase, which would bring the NHS up to about 10.3% of GDP, still below spending in many other European countries such as Germany or Sweden. The government simply stalls, requesting NHS efficiency savings of £22bn by 2020. It refuses to clear the path towards professional NHS property management beyond the marginal initiative of the NHS Property Services, which manages only a fraction of the total portfolio.

The NHS in general, or each individual trust, has no detailed list of assets or even a basic understanding of the portfolio value and yield. Without a professional understanding of the extent of its real-estate portfolio, or recognising the market value, it lacks incentives to maximise value. Many of the buildings owned by the NHS are not even managed to maximise healthcare quality. For example, because of political pressures, opening new hospitals and health facilities is much easier than closing old, underused and inefficient NHS buildings, despite the fact that transferring services to more modern facilities will usually deliver better health outcomes.

International examples point to the benefit of specialisation by separating the property operations from the service providers, while retaining public ownership. In Sweden, local healthcare providers are serviced by a separate property company, both owned by the local government. A similar example in the UK can be demonstrated by London & Continental Railways, which has successfully helped to develop the commercial assets around King’s Cross, Waterloo and Stratford stations in London, and around the former Manchester Mayfield station.

A separate professional holding company at a national or local level would improve visibility of asset and portfolio data (floor areas, running costs, metrics such as building costs per medical procedure/patient) and would help make the case for closures, proving that a closure can be about good estate management and health outcomes, rather than being incorrectly attributed to “NHS cuts”, as usually seems to be the case. Over the coming years, many new ways of delivering digital healthcare can be realised, which makes it even more important to adapt facilities quickly and efficiently.

If the entire NHS portfolio were transparent and professionally managed, the value it would create would help to fund healthcare. One can draw a parallel to retail chains such as Tesco that earn more on their property management than on sales in their shops. Most NHS properties are in residential areas and so can easily be redeveloped in ways that yield more housing as well as better health provision.

If such a holding company for the property could generate a return of a modest 3% yield, it would mean almost £2bn in additional funding for the NHS. This may seem marginal for a budget of £116bn last year, but could prove decisive and, together with the operational efficiency gains, it could end up being a much larger sum since healthcare specialisation and new healthcare technology require functional, yet flexible facilities. With the two management organisations at arm’s length, it would help to raise quality, as well as release land for much-needed housing and offices, while earning a higher return on some of its property.

In recent years, investing in NHS facilities in cooperation with the private sector through private finance initiatives has gained a poor reputation, perhaps rightly so. This makes it even more important for an independent and professional property holding company to develop its own competence. That may also be a prerequisite for any future cooperation with private sector partners. Frustratingly, the political impasse creates a need for simplistic solutions – spend more or prioritise public fiscal balances. This solution may not suit those looking for a quick fix. But it may turn out to be the only realistic long-term funding plan for the NHS.

The solution to the NHS funding crisis? Its property | Dag Detter

NHS finances facing "nasty hangover" after bid to avert winter crisis

The NHS’s already precarious finances are facing a “nasty hangover” after hospitals cancelled tens of thousands of operations recently in a bid to avert a full-blown winter crisis, experts have said.

Handing large numbers of operations over to private providers and hiring extra staff to cope with extra demand during December and January has also dealt a big blow to NHS trusts’ efforts to balance their books, the King’s Fund said.

The backlog of patients needing non-urgent surgery as a result of the widespread postponement of procedures this winter will also force patients to wait even longer for their operation, Richard Murray, its director of policy, said.

“Increasing spending on agency staff, outsourcing work to the private sector and suspending planned treatment may have helped to relieve pressure in the short term but are likely to result in a nasty hangover as hospital finances take a hit and waiting times increase further,” said Murray.

The service’s finances are deteriorating so sharply there is a real risk the Department of Health could bust its budget for 2016-17, according to the thinktank’s new analysis of NHS performance.

Its latest quarterly monitoring report on how the NHS in England is faring predicts that it is facing several more years of finding it impossible to live within its budget, despite government orders to do so. Hospital trusts ran up a deficit of £2.45bn last year and are on course to overspend by over £1bn again this year.

For example, 53% of hospital trusts and 63% of NHS clinical commissioning groups (CCGs) that the King’s Fund surveyed are fairly or very pessimistic about ending 2017-18 in financial balance. And looking further ahead, 74% of trusts and 86% of CCGs doubt they will achieve the huge savings expected of them by 2020 under NHS England chief executive Simon Stevens’s Five Year Forward View (pdf).

The NHS is now overspending by so much that many hospital trusts plan to cut staff in order to try to put their finances back in order. “Financial pressures mean some trusts are reducing their workforce, with 29% of finance directors reporting that their organisations have plans to reduce permanent clinical headcount,” the King’s Fund’s analysis said.

However, it said doing so risked endangering patients’ quality of care, especially with demand for medical treatment rising so sharply because of the ageing and growing population. Almost two-thirds (63%) of hospital trusts and 56% of CCGs think patient care has worsened in their area over the last year, the study found.

“It will be very challenging to reduce the clinical workforce at a time when many NHS hospitals are routinely running at high bed-occupancy levels and demand continues to rise,” the report said.

The research also appears to refute Theresa May’s view that patients’ difficulty in accessing GP services is a key cause of A&E units becoming so busy. In January she was criticised by GPs when she made clear that surgeries should open for longer to help relieve the strain on hospitals.

Asked to identify the key reasons for hospital overload, 80% of trust personnel surveyed cited the severity of patients’ illnesses, 70% mentioned the inability to discharge patients who were fit to leave, 61% said rising demand, and just 20% highlighted access to general practice.

Dr Helen Stokes-Lampard, the chair of the Royal College of GPs, said: “We’re pleased this report shows, without any doubt, that the recent winter pressures that have been facing our colleagues in emergency departments have not been because GPs – or any other clinicians in the NHS – aren’t working hard enough, but that the resources and workforce to cope with escalating patient demand simply aren’t there.”

Overall, said Murray, the fund’s findings “are further evidence of a service buckling under the strain of trying to meet rising demand while maintaining current standards and should give the chancellor pause for thought ahead of next week’s budget”. While Philip Hammond is expected to use his first budget on 8 March to boost funding for social care, he is unlikely to increase spending on the NHS.

The Department of Health declined to comment. NHS England said: “NHS frontline services have come under real pressure this winter but it is a tribute to the professionalism and dedication of GPs, nurses and other staff in A&E who continued to see, treat, admit or discharge the vast majority of patients within four hours.”

NHS finances facing "nasty hangover" after bid to avert winter crisis

Labour’s failure on the NHS is prolonging this health crisis | Polly Toynbee

Remember Mavis Skeet? In 2000 the 74-year-old led the news for weeks when her operation for cancer of the oesophagus was cancelled four times, until it became inoperable and she died. Liam Fox, then shadow health secretary, exclaimed: “This is not an isolated case. The NHS is not coping!”

When does a rumbling NHS crisis erupt into a volcanic political eruption? Labour’s miserable failure to “weaponise” the NHS into a winner in Copeland makes it worth looking back.

Mrs Skeet was the tipping point for Labour. The worst flu epidemic in a decade blew away Tony Blair’s pre-election “waiting lists cut” pledge. Instead Labour stuck to a draconian Tory budget, but this one case sent Blair into the TV studios promising to match average EU spending – and Labour did. The best NHS decade followed: 7% annual budget increases saw waiting times plummet, as heart and cancer results improved.

Margaret Thatcher’s eruption came in 1987 with the NHS squeezed dry. Babies died waiting for operations at the Birmingham Children’s Heart hospital. Through gritted teeth, the NHS “safe in our hands”, she bunged it £100m and punished it with the internal market.

In this latest seismological era, political vulcanologists can’t predict exactly when the top will blow. With its lowest ever funding rises, its hardest years are still to come, despite soaring numbers of the old, hospital admissions up by 31%, and 22% more A&E patients since 2010. Staff shortages follow cuts in nurse training and worsening GP and specialist recruitment. Even if extra is found for social care, the National Audit Office suggests it won’t stem the flow of patients into hospitals.

Are things bad enough yet? The British Medical Association reports that 15,000 hospital beds have been cut in the past six years. The Royal College of Surgeons protests at cancer operations being cancelled. Ambulances frequently stack up outside hospitals. Look at all that molten lava bubbling away.

Mavis Skeet’s death in 2000 became a tipping point for the NHS under Labour. Her operation for cancer of the oesophagus was cancelled four times. Photograph: PA

Ahead of next week’s budget, Theresa May pretends the NHS has an extra £10bn – at loggerheads with Simon Stevens, the head of NHS England, who publicly disputes it. What forces a U-turn? Before it was deaths, but already two patients have died on Worcester Royal hospital trolleys, one after a 35-hour wait. Coroners have protested to the health secretary, Jeremy Hunt, after two recent deaths due to lack of intensive care beds: the case of Teresa Dennett, who died from a stroke, and Mary Muldowney, who died after a brain haemorrhage.

The war zone of A&E has featured nightly on BBC news, with a graphic documentary series on the controlled mayhem in barely coping hospitals. When is enough enough? Not quite yet, it seems. The government has been lucky, with no flu epidemic in any recent winters or any Arctic freeze-over. With beds at full capacity, it would only take a mild outbreak to tip over the NHS.

The pressure-cooker is finance: monumental debts swell by millions a month as hospitals receive absurdly frantic threats if they don’t cut back. In December they were told to free beds by cancelling operations, causing longer waiting times and lost revenue from missed operations. Look at King’s College hospital, in south London: its chair, Bob Kerslake, calls official finances “kidology”. Ordered to make a surplus this year, King’s can’t avoid a £2m loss – yet the punishment is a cut in funds, sending its deficit to £30m, and an instruction to make a £26m surplus next year: this is mirage accounting, mirrored everywhere.

So far these debts are Hunt’s and chancellor Philip Hammond’s problem: what do patients care? But if the Treasury really means to recoup the money, plus the £22bn in savings it demands of the NHS by 2020, then Vesuvius will blow. Wards and units will close, staff will be laid off, the chaos will be unprecedented. It can’t happen.

When the government is forced, kicking and screaming, to pay up, who will it blame? It will call the NHS “unsustainable” and “a bottomless pit”. (Hammond already has.) Yet more “reforms” and re-disorganisations will be hurled at it: payment for services, top-up insurance and tax rebates for private payers will resurface. The government will ignore the UK’s fall in the EU spending scale since 2010, and is now sixth out of the G7 countries, with fewer beds, doctors and nurses per capita.

Who has the political heft and credibility to defend it? Fear of Labour’s NHS moral hegemony kept Thatcher, John Major and David Cameron in check. No longer. Labour thought the NHS was its big bazooka in Copeland, where a maternity unit is under threat. But the naked desperation of Labour’s “Babies will die!” leaflets shot the very last bolt in Jeremy Corbyn’s arsenal. Each time he raises the NHS at prime minister’s questions his feeble attempt at “weaponising” sounds pathetically opportunist: May bats him away with balderdash statistics he is too incompetent to refute.

This has never happened before: polls find May more trusted than Corbyn to run the NHS by 45% to 35%. Far worse, Labour’s failure to counter the right’s message has left more people blaming the NHS crisis on migrants and patients’ bad lifestyles than Tory underfunding or rising numbers of older people. As ever the Mail and the rest carry endless NHS tourism or obese wastrel stories – but Labour has always had to fight twice as hard to get a hearing for the facts on the NHS.

Whoever follows Corbyn will now find it ferociously hard to regain that lost NHS ground. By 1997, hammering away in opposition, Labour had made the threadbare NHS the top issue and owned it. Hard-won economic credibility earned it the trust to run the NHS better. Now Ben Page of Ipsos Mori finds the NHS the second issue after Brexit, but Labour doesn’t own it, or anything else: Corbyn falls behind on everything, with every demographic, so even Labour voters prefer May.

Because the NHS crisis has so far exploded in debt rather than closures, most people’s experience is not yet bad enough to reach tipping point. Page says satisfaction is down on 2010, but not rock bottom, with always a long lag in perception. A third would pay more tax for the NHS, but the rest want savings by denying obese people and migrants.

Austerity has entered the nation’s blood stream: Page finds most people still think it necessary – despite the reckless tax cuts ahead. Banging on about “austerity” without specifics gets Labour nowhere. May’s own polling and her Copeland result tell her this – but hubris is her greatest peril. There may be no opposition, but if she and her chancellor really try to squeeze the gargantuan debt out of the NHS, all hell will break loose anyway.

Labour’s failure on the NHS is prolonging this health crisis | Polly Toynbee

It’s painful watching the male crisis onscreen – more painful in real life | Deborah Orr

Had Moonlight not come along, hard on its heels, Manchester By the Sea might have seemed like the most emotionally revealing film about a man to have been released in years. But since Moonlight is probably one of the most emotionally revealing films about a man ever to have been made, it wins.

It isn’t fair to set the two in competition. They’re doing similarly important things in their different ways – exploring negative aspects of masculinity. In Manchester By the Sea a single, unlucky catastrophe turns a warm, fun-loving young man into an angry, aggressive, emotionally shut-down loner. In Moonlight, a whole childhood conspires to drive a man to become a numb synecdoche of all that has blighted his own upbringing.

It’s undoubtedly because I’ve recently been diagnosed with a trauma-induced anxiety disorder myself. But I immediately saw the symptoms of chronic or complex post-traumatic stress disorder in both leading characters.

In Manchester By the Sea, Lee Chandler, played wonderfully by Casey Affleck, displays symptoms of chronic PTSD, in which a single trauma comes to dominate the brain’s neural pathways in an extremely unhealthy way. You can also see these symptoms simply as emotional reactions that any person in Lee’s situation might develop. But the point is this: we are so used to these destructive and damaging responses to life’s vicissitudes that they seem natural rather than horribly dysfunctional.

In Moonlight, Chiron, played by three actors as a child, a teenager and an adult, already has complex PTSD, to my eyes, as a little kid. Complex PTSD is brought on when a person is subjected to a series of traumas, most often by a caregiver they ought to be able to trust unconditionally, but from whom there is little chance of escape. Abused or neglected children are very susceptible to C-PTSD. By the time Chiron is an adult, from my reading of the film, C-PTSD is rampant.

There’s a lot of controversy at the moment about whether armchair diagnosis of mental health problems should be indulged. I think it’s totally valid when the character being examined is fictional. I’d say it’s more than valid. It’s necessary if humans are going to get to a point where we can understand ourselves and the messes that we make.

In Manchester By the Sea, Lee is a man who really, really needs therapy, though this isn’t mentioned as an option in the film. The culture he’s in is far too blue-collar for that. Lee fights his miserable losing battle with his trauma, guilt and shame alone. As with Chiron in Moonlight, his symptoms are classic too. It’s so plain in the film that what a psychiatrist would call symptoms are also self-protecting emotional responses, recognisable to anyone who cared to view them in that way.

Having mentioned the controversy around amateur diagnosis, I’m now going to tread carefully. After the screening of Moonlight I attended, there was a Q&A session with Tarell Alvin McCraney. He wrote the play on which Moonlight is based, In Moonlight Black Boys Look Blue.

McCraney makes no secret of the fact that the early part of the story, of a boy growing up in Miami with a crack-addicted mother, a flawed father-figure who loses his life very young, and the experience of being bullied as a “faggot” by his peers, is based on his own life. McCraney’s life clearly has not followed the trajectory of Chiron’s because, you’ll be glad to know, the film doesn’t end with our hero sitting down to write an amazing play that becomes a film. You’ve seen that movie already, more than once.

Boys are told not to cry, told to fight back, told to toughen up, in a way that girls less frequently are

McCraney – intelligent, gloriously articulate, handsome, elegant, funny, charming, polished, self-deprecating – is also frank. On the platform he acknowledged that he knows how people see him, which is pretty much the way I saw him, as listed above. It wasn’t just me. The room was full of love for him. However, he says, this is not at all how he sees himself. Instead, he is “terrified”, has “intimacy issues”, sometimes can’t bear crowds and has to be alone, and sometimes finds himself drifting away from feeling present in the world. He has survived his upbringing and thrived fantastically well. But the psychological scars are there and he is aware of them.

McCraney says that he doesn’t find writing about his past cathartic. Instead, it depletes him. It costs him a lot. I think that while some men, men like Lee, fight with their fists, McCraney fights with his creativity. It’s a much healthier way to do battle with trauma. But that’s still what it is – a battle with trauma.

I find myself thinking that while both Lee and Chiron are extreme examples, a lot of the cliches about the transformation of boyhood into manhood centre on the suppression of trauma. Boys are told not to cry, told to fight back, told to toughen up, in a way that girls less frequently are. (Although girls do toughen up. I did.) Sure, this can result in creativity like McCraney’s. But our experience of the world and its history suggests that very often it results in bombast and aggression, anger and violence.

We are used to hearing about theories of gender as a performance. I wonder if that’s too glib. Maybe gender is more of a neurological response, with hyper-masculinity a pathological response to trauma, and hyper-femininity a defence against an aggressive masculine pathology. Or maybe I’m barking up the wrong tree. Who knows?

The crucial thing is that these films are urging people to look hard at these profound issues around human behaviour, and really think about what makes people who they are. I’m thankful for both of them, and for the pain and struggle sometimes involved in “being a man” that they so sensitively portray. Especially Moonlight. I don’t think there’s ever been another film quite like it.

It’s painful watching the male crisis onscreen – more painful in real life | Deborah Orr

‘I was literally tearing myself up’: can the performing arts solve its mental health crisis?

Operatic soprano Greta Bradman was19 years old when she started to self-harm. Intense bullying through high school had coincided with her parents’ divorce. She felt isolated and started skipping school. A year earlier her grandfather, cricket star and national hero Sir Donald Bradman, had died.

Donald Bradman and his grand daughter were close – their relationship has been chronicled in a double episode of Australian Story – and he had instilled in her a love of classical music. Greta saw singing as “a kind of solace” for her pain, and she was accepted into the Elder Conservatorium of Music in Adelaide. But that overwhelming sense of self-loathing stayed with her, and she began trying to destroy the one thing that brought her joy: her voice.

“I wanted to take away the possibility of singing as a career,” she says. She describes it as needing to punish herself – for missing school, for being “completely worthless”, for having the audacity to wrap her identity up in art.

“It was a combination of wanting to hurt my voice and to get that sense of relief that can come from self-harm. But it’s a completely maladaptive coping strategy, which took me further and further down the cycle of self-loathing … It was bound up in me as an artist – not really knowing how to go about it, and not feeling like I could necessarily succeed, but at the same time being terrified of the prospect of success.”

‘I wanted to take away the possibility of singing as a career’: operatic soprano, radio host and psychologist Greta Bradman. Photograph: Pia Johnson

Eventually, Greta climbed out of the cycle. She stopped self-harming when she was 23 and became pregnant with her first child. Today, her voice well and truly intact, she is one of Australia’s leading sopranos, with a radio show on ABC Classic FM, an upcoming principal role as Mimì in La Bohème at the Sydney Opera House, and a plaque on the Adelaide Festival Centre’s walk of fame.

She also practices pro bono as a provisional psychologist, with a masters in clinical psychology. Bradman has combined both passions to consult on a major new industry-first initiative from Arts Centre Melbourne – the Arts Wellbeing Collective – to help others in the creative arts who have struggled in similar ways.

The collective, which launched on Thursday, is unprecedented – if not around the world, then certainly in Australia. It comprises close to 90 Victorian arts and culture organisations, including Melbourne festival, Melbourne Theatre Company, Victorian Opera and Regional Arts Victoria, who have come together with a common aim: to improve mental health and wellbeing for Victorian performing arts workers – those on stage and in front of the camera, as well as those working behind the scenes.

Developed in consultation with prominent psychologist Dr Michael Carr-Gregg, and drawing from the practice of positive psychology, the program, in its pilot phase, will feature a series of workshops and a dedicated website filled with resources tailored to the mental health needs of the performing arts sector – a sector which recent research has shown is in crisis.

Performing arts work: a lethal cocktail

In 2016, a major report was released by Victoria University and Entertainment Assist following an extensive study of entertainment industry workers.

The report – which focused on performing artists and composers, performing arts support workers and broadcasting and media equipment operators – was alarming. Levels of moderate to severe anxiety in the performing arts industry were 10 times higher than the general population; levels of depression in industry workers were up to five times higher; and workers were four to five times more likely to plan to commit suicide, and twice as likely to attempt it.

As Bradman explains, the performing arts industry comprises a unique cocktail of working conditions that, without the right levels of support, can prove deadly.

“As a performer, you’re working when everyone else is working, and then you’re working when everyone else is having fun,” she says. “The work hours are unique, and on top of that you’ve got the lack of work security, and the financial pressures.”

An Australia Council report released in 2010 found more than half the country’s artists were making less than $ 10,000 a year from their creative pursuits, regardless of the hours they put in. Many of those hours come in shifts, Bradman says, which come with their own set of risks – from obesity and cardiovascular disease through to sleep problems and other mental health issues.

There are social factors too, including an imperative to socialise and network at events that revolve around alcohol and drug consumption. “Looking at future work possibilities and career progression can be somewhat tied to that too,” Bradman says.

And all that’s to say nothing of work instability, and what it can do to one’s mental health. “For performing artists, and also for people backstage, you might go through a phase of getting a lot of work, and then all of the sudden the work drops off. That can have a big impact on your sense of identity.”

You have these immense highs of being part of a [big show] … and then suddenly it’s all gone

Greta Bradman, operatic soprano

The extreme highs and lows of the work itself compound the issues. “I’ve experienced this myself,” Bradman says. “You have these immense highs of being part of a family, a community, that comes together for this incredible project – particularly if it’s a long project, like a musical, an opera, a long run of a dance. You’re so close to the people, and you’re all so bound up in it – and chemically, from a neuropsychological and psychological perspective, there is so much going on in those relationships … but it’s all bound up within that world of the show, and suddenly the show ends and it’s gone.

“There’s a huge sense of grief and loss that can come from that – and a sense of needing to renegotiate your identity.”

While Bradman fundamentally disagrees with the myth of the “struggling artist”, which romanticises mental health issues as a creative boon, she says there is something intrinsic to the arts that can make artists and workers particularly at risk.

“To be [an artist] we have to be vulnerable, we have to give of ourselves, hugely, we have to allow ourselves to feel an array of emotions – some of them good, some of them really difficult,” she says. That’s why it’s particularly important that arts workers can access resources and support tailored to their industry – a gap the Arts Wellbeing Collective is hoping to fill.

“What we do [as arts workers] is so bound up with who we are. This is not necessarily a good or bad thing, it’s just a way that a lot of us identify,” Bradman says. “We have to negotiate what that means, so that in the quieter times – in those times when there’s not as much work – we don’t equate a lack of achievement with a lack of self-worth, or an uncertainty about our direction.”

‘I’d spun out of control’

For Simon J Green, it started with scratching. He had been running an independent film company for eight years – a creative investment with huge financial strain, long hours and high responsibility – when his wife noticed him absent-mindedly digging paths across his forearms. “As soon as she mentioned it, I realised I’d been scratching my legs, too. I pulled up my pant legs and we both gasped at the ragged, bloody strips I’d torn in myself.”

Simon J Green experienced ‘extreme levels of stress and depression’ while managing a film production company in Melbourne for eight years

Green, who is based in Melbourne, was experiencing “extreme levels of stress and depression” combined with long working hours and a lack of sleep, which meant every small problem took on extreme proportions. It’s a spiralling feeling that many performing arts workers identify with.

“Taking on staff, and the pressure of keeping them both paid and creatively satisfied, weighed on me more than I realised,” he said. “Combined with managing [my] cystic fibrosis, and trying but failing to meet my own creative needs, I’d spun out of control to the point I was literally tearing myself up.”

There was another factor too, Green says: a lack of perceived value. “People don’t think our work is worth much, which puts pressure on us to make more for less.”

This is an issue Bradman raises too, which she is looking into with a new, broader survey which soft-launched in January. “Culturally, and particularly in the current climate, [there are questions] over the perceived value of the arts, not only within the performing arts community but the broader community.”

In 2015, the Abbott government slashed funding from the Australia Council – cuts which were handed down, for the most part, to the small-to-medium arts sector. In May 2016, the artistic directors of major theatre companies penned an open letter calling it an “unprecedented assault” on the arts, and individual artists were among the biggest losers.

“When funding is shifting and changing, and there is so much uncertainty, that can really play into one’s sense of where one is going in life, and one’s sense of self-worth,” Bradman says.

The issue of worth came up in the Entertainment Assist report too. “Performers working for free is a huge issue in our industry. It devalues our skills and puts us out of work,” said one participant. “[We need] more government support and to realise the importance of the arts,” said another.

In the film industry, Green says, that devaluation has specific repercussions. “There’s a real scarcity mindset that seems to undermine collaboration – a sense of a zero-sum game of work available, which isn’t true. I think it comes from that feeling that we aren’t really valued by society at large; from all of us being told at school, ‘Don’t be an artist, you’ll never make a living, be something else’, to the tired joke (that we perpetuate) that an arts degree is useless.

I pulled up my pant legs and we both gasped at the ragged, bloody strips I’d torn in myself.

Simon J Green, film producer and writer

“Performing artists are twice as likely to attempt suicide, and depression is five times higher than the general population. That’s a horrifying statistic,” he says. “Clearly there’s a problem, but no one really cares. If it were a different industry – say, manufacturing – there’d be a national discussion.”

Green remembers when the report came out, alongside an article on how little money is made by actors who are considered famous in Australia. “The comments sections were full of people saying, ‘Boo hoo, get a real job, they chose that life.’ With all this, how can the arts not be fatiguing our mental health?”

Beyond the performing arts

Although the report, and the Arts Wellbeing Collective which has sprung from it, are focused on the performing side, mental health issues in the arts are by no means confined to that. Mental suffering has a long and storied history with visual art, for instance, and a recent callout for arts workers who had experienced mental health flare-ups drew mostly anecdotes from writers, who spoke of anxiety, depression, bipolar disorder, eating disorders and recent, heartbreaking suicides among their community.

Developed by a performing arts company, the focus of the Arts Wellbeing Collective reflects its origins. Upcoming workshops are titled “the Green Room”, “Centre Stage” and “the Show Must Go On”. But Bradman hopes the resources made available will be of use across the industry and beyond, and has aspirations for expansion.

“There is absolutely nothing to preclude it from being broadened out, if it’s successful,” she says. “I think it’s really important to be slowly, slowly about it, to let it build up and evolve, to let this year really inform the shape that it takes in the next.”

Above all, she hopes it achieves a top-down recognition of mental health issues, removing stigma, generating conversation and increasing support: “A real sense of committing, on the part of the organisations, to a nonjudgmental, open and supportive relationship when it comes to mental health in the arts,” she says.

• Find out more about the Arts Wellbeing Collective

‘I was literally tearing myself up’: can the performing arts solve its mental health crisis?