Mental Health First Aid in the UK: how important is First Aid when Professional Mental Health Services are in dire straits?

Mental Health First Aid (MHFA) has become a trend that is taking over the medical and mental health world. While there are several manuscripts that are exemplifying the benefits of MHFA, the implications for people who undergo the MHFA training, for mental health services and medical and non-medical professions devoted to mental healthcare, have been ignored. In this short communication, we are arguing against MHFA not because we believe that the scheme is not beneficial, but more as a critical reflection as to where MHFA should stand in the mental health world, and how it should serve the people as a community investment company.

Jorm et al. [1] recently reported a worldwide impact of Mental Health First Aid (MHFA) referring to the very successful dissemination of this programme. Personal views and a conviction that MHFA could be useful for society [2][3][4] notwithstanding, the picture drawn by the developers of MHFA negates important facts about mental health provision, with implications for the effectiveness of MHFA itself and for the overall care for people with mental health difficulties, with potential worldwide implications for public healthcare.
MHFA is a tool for trained volunteers to support and signpost individuals with mental health difficulties and to provide first aid until professional help is received or until the crisis is resolved. There are two problems here that need to be noted. First, any professional who supports people with mental health difficulties (e.g. psychiatrists, psychologists, and/or psychotherapists) has a predetermined outlet to receive support (e.g. a colleague, a local support network of therapists, supervision), but this is not de facto for Mental Health First Aiders (MHFAers), who are certainly exposed to similar distressing situations (e.g. suicidal ideation). While it is usual and perhaps expected for those who provide first aid to experience some trauma (depending on the severity of the case), the lack of appropriate support and professional care for MHFAers is problematic. In addition, there are significant issues around the lack of clarity with boundaries and potential safety concerns for the trained volunteer. Provisions and a clear support network with guidelines for roles, boundaries and safeguarding procedures are urgently needed for those individuals who volunteer their time to become MHFAers in their community or workplace. MHFA needs to become more accountable in their 'duty of care' for MHFAers to reduce the risk of harmful outcomes for volunteers and the associated personal and economic healthcare costs outcomes. There is an ethical imperative to take care of volunteers and ensure that ongoing support is made available by MHFA to those whom it has trained. It should not be incumbent on volunteers to ensure their own safeguarding, and this needs to form part of the employer responsibility and be overseen by MHFA as part of the programme responsibilities.
Second, people with mental health difficulties are frequently referred by MHFAers to professional services in the UK, only to return to the MHFAer as there are long waiting lists or unavailable specialist care in their area. This leads to an unintentional deficient 'cycle of care', where MHFAers become the first point of contact and recurrently provide help and support to people who are in need; this is outside of the intended jurisdiction of the role. In other words, without appropriate and adequate mental health professionals, the true purpose of MHFA is redundant, and the description by original developers as being a 'first aid model' is false, essentially putting both the trained volunteers and those who seek support at risk.
The plans for the expansion of MHFA training in the public sector have crucially made no references to the shortage of professionals in mental health. While MHFA is aiming to increase its position as a business for profit, it inevitability and uncomfortably finds advantage in the current crisis of insufficient mental health staff in the UK in the National Healthcare System (NHS) and the increase in ill mental health globally. While the intentions of developers of MHFA are undoubtedly good and ethical, if the political motivation and intent behind supporting MHFA is aligned with using MHFA to meet increasing need alongside reductions in investment in professional mental health care, it creates a scenario that is both short-sighted and unethical. In the UK, mental healthcare continues to be a challenging issue. The rise in uptake of MHFA occurs in a climate where there is little motivation for medical doctors to train in psychiatry, the government is actively reducing barriers for migrants specialising in mental health, the British Psychological Society is podcasting the shortage of psychologists, and the Five Year Forward View for Mental Health [5][6][7][8] published by the NHS in 2016 appears a utopia prior to Brexit negotiations. Altogether, the facts about mental healthcare present a bleak reality and future for mental health professions and care. When uncritical enthusiasm and political motivations become the foundations of policymaking to improve mental health and inform how MHFA is implemented-without including mental health professionals in this process-the value of MHFA to society is reduced. The danger of perceiving MHFA as a panacea to the current crisis is manifold, not least of which that it becomes a divider in services, an unwelcome addition to the health care community and a further push to the privatisation of mental health care. MHFA has a social responsibility as a Community Interest Company (CIC) to guard mental healthcare for all, over and above the intended purposes of MHFA.
MHFA training is useful for raising awareness around mental health issues. However, it is not simply a community interest endeavour without any consequences to societies if it fails to serve its intended purpose. MHFA is branded to enhance (a) mental health (although critical perspectives are missing), (b) social capital (which is left to the discretion of employers and governments), and (c) public perceptions (change that can occur through media and leadership by Public Health England). The evidence base for positive outcomes for those who have received the support by MHFA volunteers do not yet exist, and the potential consequences for the millions of people who have been trained to provide a safe passage to mental health professionals are unknown. MHFA has indeed had successful dissemination [1], but such success should not deter researchers and clinicians from asking difficult questions to ensure that mental health care for all is not compromised by indiscriminate implementation of MHFA as a volunteer mental health service to replace mental health professionals and well-appointed public healthcare to timely respond to mental health crises. A consensus of implementation for enhancing public health is urgently needed to ensure a harmonious coexistence with publicly funded healthcare systems.

Compliance with Ethical Standards
The manuscript did not study any humans or animals and did not require approval by an Ethical Review Board.

Conflict of Interest
The authors declare that they have no conflict of interest.
Informed Consent Informed consent was not required for this manuscript.
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