This was first published in the NHS Consultants Association Newsletter
While I realise the tendency of the retired to bemoan all developments since they left the stage, nevertheless I have felt for some time that the mental health services, in England and Wales at least, peaked in efficiency and effectiveness sometime in the mid 1990s, and have started to decline in many aspects. This is based on my observations of the mental health services from the underside, as it were, in carrying out the duties of a medical member of the Tribunals Service, in the south-east. (I am speaking mainly of the mental health service for the adult age range.)
History
Britain has a long history of tolerance and care for the mentally ill. Fifteenth century England made specific state provisions, as a duty of the sovereign, to care for the mentally handicapped and mentally ill. While the prevalence of the major psychoses has probably remained the same for centuries if not millennia, the population explosion of the industrial revolution made the absolute numbers of psychotics apparent and spurred the state to provide services – or containment. After the 1601 Poor Law, services for the mentally disordered were largely provided by the developing municipalities, apart from the few famous asylums and ‘mad-houses’ for the mentally disordered rich. The county councils provided and ran the asylums of the mid to late 19th century. The National Health Service of 1948 at a stroke, incorporated the municipal and county provision and made change from poor law containment to a medical service. The increasing number of doctors evolved into genuine physicians for mental disorder, rather than the pejorative ‘alienists’. This process culminated in the 1959 Mental Health Act, the most humane and advanced mental health legislation in the world at the time.
Even in the early 19th century asylums, some patients made spontaneous recoveries and were discharged. By the 1960s, however, these institutions, now ‘mental hospitals’, were containing up to four times the number for which they were originally provisioned. Fortuitously, at this point, came the beginning of the true psychiatric treatments, the anti-psychotics and electro-convulsive therapy, which dramatically reduced bed numbers, only to be re-filled by the same patients months later, later known as the ‘revolving door’. It was clear that extra-mural services were required, leading to the development of out-patient clinics in general hospitals, Day Hospitals, and later the full panoply of ‘care in the community’. The asylums needed to be closed: they were foul and disgusting places in which to treat our citizens and many of them were literally falling down with age. Scandals in the ill-treatment of patients in the mental hospitals hastened their closure. The Conservative government of the day, with a shrewd eye for the potential of large asylum sites, let them go for pittances to private developers, without re-directing the profit to community services.
Labour’s 1975 document ‘Better Services for the Mentally Ill’, demonstrated a comprehensive multi-disciplinary service, based on general hospitals. In the philosophical zeitgeist well-meaning US and UK writers of the libertarian left tried to prove a connection between society’s structure and serious mental illness, which to this day is what much of the media understands by causes of mental illness. Sadly, this led to the rubbishing of mental health professionals and the families of the mentally ill, and to opposition to the improvements in pharmacological treatments. The improving ‘mental health teams’, now often operating from community bases, were also influenced to ‘treat’ much less severe mental disorders and even social disorders, manifestly because they believed it would be preventative, latently because these patients were easier, transient and usually grateful. The same process in the USA and in other European countries, realised ‘Care Management’, the identification of the severely mentally ill who were to be the highest priority for care, and the necessary planning to do this. In 1991, the UK Departments of Health and Social Services , put out twin papers on the ‘Care Programme Approach’ (CPA) a simple, pragmatic and operational guideline for operating a system of dispersed psychiatric multi-professional care and treatment.
Three other important concepts developed in the NHS, mainly in medical professionals: scientifically-based medical evidence as the basis for treatments; the systematic clinical audit of services; and particularly in the mental health services, the assessment of risk. As with the scandals in the hospitals, so publicity given to a small number of prominent homicides by the mentally disordered, led to the high-lighting of security and safety, resulting from patients perceived to be improperly in the community and not in hospital.
In the wider NHS, by this time, all was not well, general organisational and political developments having been set in motion that would include the mental health services. The first of these was the 1985 Griffiths Report, which produced a corporate management system ending the felicitous collaboration of health professional and NHS administrators in running the service. Quasi-industrial ‘managers’, rapidly assumed the role not just of running but directing the NHS, without much clinical input. Secondly, NHS Trusts were imposed as the units for governance of the NHS, with the wholly artificial model of the ‘purchaser-provider split’, in which some elements of the service played at buying and others at selling. Sadly the New Labour government had little intention of putting the service back where it belonged.
Mental Health Services, the Zenith
By the mid-90s, most of the mental hospitals had closed and the normal place of treatment was the new psychiatric unit in or attached to the general Hospital. The long-stay patients of the mental hospitals had been discharged to a variety of residential care facilities, some entirely NHS and highly staffed. Psychiatric consultants in the new units were simply consultant colleagues in the medical and surgical body and a few became chairs of medical staff committees. The focus of psychiatric attention switched to the mental health multidisciplinary team often working from a community mental health centre as team base into hospitals rather than from hospitals to the community. Mental health services became localised and accessible. The consultant was the recipient of GP referrals, responsible for deciding who would assess the patient. Teams, including the consultant, would meet weekly , both in the ward and in the community to deal with problems. The service was geographically ‘sectorised’ , meaning that a consultant-led multidisciplinary team would adopt a wedge of the catchment population, and thus be fully cognisant of the social and economic characteristics of their area and this started to lead to an epidemiological approach to mental disorders. It also encouraged continuity, so that the patients with the typically long-standing problems could feel supported and be thoroughly planned for under the CPA. Training for psychiatrists was led by the Royal College, and was the envy of other medical disciplines, with keen clinical tutors organising weekly teaching sessions. The Mental Health Act guaranteed legal safeguards for those who needed involuntary detention.
The Labour government introduced 3 measures of importance to mental health: the Human Rights Act (a mental health patient was its first cited case); NICE, the National Institute for Clinical Excellence, which took a properly scientific attitude to the proliferation of psychotropic drugs; and the National Service Frameworks, of which mental health was the first. Computerised case registers were devised. Clinical Audit was carried out into local services, and nationally into suicides and homicides by mentally ill people. For the first time for decades morale in the service was high.
The down
An insidious deterioration has followed this peak and I believe resulted from Thatcher’s reforms. By the new millennium the managerial revolution in the NHS could be recognised. Highly trained clinical staff mutated into untrained ‘managers’, with a net loss to the service. Endless manuals , directives and guidelines were generated . With little evidence base, they changed a professional and clinically led intelligent approach to our work into the bureaucratic following of procedures. Meaningless woffley ‘management speak’ became the norm. The championing of individualism over collective approaches made ‘choice’ the prime concern for management, but least relevant for the mentally ill. The attack on professionalism, begun by Thatcher, denigrated all professionals, particularly consultants. The need for units of the NHS to bill and pay each other led to financial bureaucracy and waste of resources to accounting, rather than saving (recently confirmed by a Commons Select Committee). The concern with cutting at all costs, to meet an entirely artificial internal NHS tax, has led to disruption of well-functioning services. Thousands of acute in-patient beds have been sliced away across the country, so that in-patient units are only for those who must be admitted at all costs, usually because they are both psychotic and homicidal: in-patient wards have once again become scary places. Beds are again extremely scarce in the cities. In Kent the three asylums of the 19th century, replaced by seven local units, are now about to be replaced by three hospitals, each on the site of the old asylum. The Mental Health Act has been misused by some county councils so that they will not have to pick up the bill for after-care, and inevitably the proportion of detained patients on wards, previously 15%, has risen to an average of 50% .
Tertiary care is often essential for the long-term mentally ill. No longer is it possible for one consultant to refer to any other. Valuable resources are now wasted in funding-panels who rarely accept the expertise of the local team, and fund the cheapest rather than the correct option.
The process whereby everyone knew better what was needed for mentally ill people than trained clinical specialists, reached its acme when the New Labour Government began to ‘badge’ services which it fancied, thus shattering the carefully built up mental health teams, into a cloud of acronyms, but with no increase in staff. Without national consultation or evidence, managers concerned about in-patient standards, once again divided psychiatric hospital wards from their community by appointing separate consultants to each.
Electronic case records, which could have offered so much as the nervous system of a dispersed service, collapsed nationally, and locally are less available than the written case records and seem to function only defensively.
The early NHS Trusts concentrated on surgery at the expense of disciplines like psychiatry, with the result that mental health Trusts were created to reserve resources, once more separating psychiatrists from their medical colleagues. Mental Health Trusts then merged into giant bureaucracies, which seemed peculiarly susceptible to managerial authoritarianism, with the consequence that consultants are often cowed, passive and defensive. Practice has become more slovenly, clinical case notes poorly written, GPs forced to refer to nebulous teams, rather than to a doctor. The CPA is observed in word only. After falling for decades, the UK suicide rate is now rising, following the 2008 bank collapse. Diane Abbott recently noted: “for the first time in a decade we have seen a cut in the total spending on mental health… what we’re seeing is a staff shortage crisis, vulnerable people not getting the help, respect and dignity they need and crucial care services are withering away”. Morale is low and exhaustion high, at least in the acute mental health services.
The Health and Social Care Act 2012 is widely seen as the beginning of the end for the NHS: if we let it. It is particularly irrelevant to the mental health services, which historically have always been publicly provided. GPs are supposed to commission, but in reality will give over this task to Clinical Commissioning Groups which themselves will use commercial companies for implementation. The commissioning process is particularly difficult to specify for mental health services and individuals, and it will get bogged down in further bureaucracy. Individual GPs will disregard mental health patients, who are notoriously unassertive. The ‘Any Qualified Provider’ clause will push more patients seeking fewer beds into private institutions, whose standards are already cause for concern. Inexpert voluntary and private community services will be used because they are cheaper, ‘qualified’ will be widely interpreted, with the patient care and safety imperilled. Risky patients may be diverted to Forensic Psychiatric beds, and find it difficult to return to the mainstream service. Liaison with Local Authority provided services will become more difficult. The gap with other medical disciplines will widen. The Act’s ‘payment by results’, has been endorsed by The Royal College of Psychiatrists, but there are many reasons to distrust this system, mainly because of the difficulty of specifying, and even less measuring, outcomes in mental health.
Ed Milliband recently made a speech to the Royal College of Psychiatrists in which he pointed out that mental ill health costs the nation at least £26Bn annually, yet, he said, politicians almost ignore it. Benefits to general medical services would result from improved mental health service funding.
What is needed
Many of today’s problems in England’s mental health services, could be solved by the NHS returning to the status quo ante 1985. ‘National’ would once again mean all-UK. The NHS would be the provider for all health, with rare exceptions. This envisages a simpler localised service, with funding dispensed from the centre, without an internal market, run on an operational basis by professional clinicians with NHS administrators for its implementation. The NHS would assert its enormous purchasing power to drive down prices of drugs, equipment and services from without. Commissioning would be swept away and revert to strategic clinical planning, for which every consultant would be contractually obliged to assist to a specified limit(no more incessant ‘meetings’!). A robust and democratic patient feedback, with delegates representing users on all NHS bodies and liaising with local government would be the third limb.
The useful aspects of what has been learnt since 1985 would be kept: that community and hospital services need to be seamless, planning should follow medical evidence, clinical audit, multiprofessional equality and NICE.
There is possibly less scope in mental health for primary prevention, but there is some. Consultants should be expected to respond to requests for education from schools, places of work , the Police and other institutions of society. Alcohol reduction, improvement of diet and increase in exercise would impact on alcoholism, depression and vascular dementia. This would demand far more of the NHS than that envisaged by the last government, one in which it would be able to intervene against commercial power, in, for example, the supermarkets. There is more scope in secondary and tertiary prevention, for example in schizophrenia, with the development once again of sheltered work programmes funded partly by appropriate benefit; and the routine use of of investigative measures in order to plan remediation, taking place in rehabilitation units.
National mental health strategy must be set by expert mental health professionals working with government, not by political whim. We need a ‘Good Practice loop’, where innovation locally is tested centrally and then implemented. Local mental health needs should be assessed within the remit of each service, principally by the clinicians and lead naturally to local strategy. If we could return to planning bed numbers and team sizes using known indices and a geographically based service, we could improve ward standards, continuity of care and the consequent efficiency of the management of serious mental illness. With calmer wards, more therapeutic milieux could be developed, based on clinical, psychological and educational evidence.
Nowhere is medical evidence more needed than in mental health services, potentially a large black hole for funding, particularly at the milder end of the spectrum. Psychological treatments particularly should be strictly limited to diagnostically defined conditions, time limited and automated where appropriate.
The CPA should be applied more conscientiously. All new patients should be referred to the consultant and his team, diagnoses made, treatment plans drawn up and recorded in a clinical case register of the service. Longer -term and more severe patients should have care coordinators allocated by the NHS (not by the local authority) and the full care plans adhered to, with internal audit to ensure its proper operation.
Professionals need to re-assert their status. Management should ring fence clinical procedures into which they will not intrude, thus allowing clinicians to return to intelligent professional thinking – what used to be called ‘clinical freedom’. The Royal College should reassert its domination over local clinical teaching and maintenance of clinical medical standards, with the assistance of local administration.
There needs to be a much more thorough monitoring of legal aspects of the service, to ensure that patients and their relatives are being given all their legal rights and that doubtful practices are identified and questioned. Patients need more free legal assistance than that granted for the Tribunals as many are too ill or demoralised to fight for their rights. There should be a national guideline on the relation between the Police and the mental health services.
Mental health staff must not separate themselves from general health services, as human illness takes no such account. Mental health services need to return to the easy clinical contact with all medical specialities, and this can be assisted by the removal of the commercial barriers that started the present separation.
Psychiatric patients are among the poorest in the land. Benefits are essential to those who cannot work and should be dispensed, using a proven instrument, by a statutory authority and not a commercial company, to a patient assisted where necessary by an advocate.
I have spoken about only a tranche of the mental health services: those of England and not the UK, where those in Scotland appear to have so far maintained their standards; and the general adult range, ignoring child psychiatry, the elderly service, learning disability and the forensic services, yet many of the criticisms I have made, will apply in these specialities also.