The mental health services in England peaked in the late 90’s: since then they have deteriorated with fewer beds, in-patient units closing, reduction of community services, loss of essential staff, often through low morale, the virtual disappearance of child psychiatric services, and isolation from general medical services. Funding is partly to blame, as it has been consistently less than indicated by the data for mental health service usage compared with general medical services. In-patient units , originally based around main population centres, have been closed or moved to other sites, often to those of the original mental hospitals that were closing in the 60’s.
However, the full reasons for the decline are historical and must be attributed to Margaret Thatcher’s ill-advised attack on the NHS in the early 90’s, of which the the results have only gradually become apparent. Three key factors were: the institution and growth of ‘general management’, changing a body of skilled administrators into managers with a financial and self-interest ethos, directing a service without professional knowledge; the ‘purchaser-provider’ split, artificially creating a market where none was needed; and the creation of Trusts, which for mental health meant isolation from the main body of medical services.
The New Labour government made no essential changes to this structure, although provided some improvements in the delivery of service. As we know, the present Tory government, is carrying out an ideological battle, which even Margaret Thatcher was reluctant to embark upon, of privatising the NHS.
The present state of the mental health services is thus an historical process rather than a crisis, but nevertheless services are uniformly damaged. Perhaps the worst aspects one observes are: patients forced into hospital hundreds of miles from where they live; services unable to take on the statutory demands of the Care Programme Approach; and everywhere clinical independence replaced by rule-dominated, self-protecting obsequiousness to management. The corrosive acid of the market has pervaded our NHS and eaten away some of our professional pride and standards. Sometimes it seems the NHS is run by a self-perpetuating cadre of managers without thought for what the service is for. And of course there have been scandals.
The Royal College of Psychiatrists appears to be changing its cautious political neutrality into welcome outright condemnation of the present state of affairs. Other academic bodies have joined them.
What is needed is: an increase in funding to give mental health services parity with the rest of general medical services. There should be an immediate cessation of mental health bed closures until local planning by clinicians has established the needs. In-patient units must be re-established around centres of population. Closure of mental health centres must immediately cease. A central drive is needed to raise number, the morale and the reputation of mental health staff
But changes should occur in the whole NHS, to re-establish the ethos and goals of 1945, when the National Health and Social Care Act 2012 is struck down. This need not be ‘another reconstruction’, as it would need only firm central guidelines to present management to change their role from direction to support.it could start in the mental health service and spread throughout the NHS. Consultants and other senior clinicians need to take the lead in developing their local service, with a skilled force of administrators to carry out the changes, subject to central budgetary control. The end of commissioning by GPs, who should be professionally employed, and its replacement by local joint planning by all relevant clinical specialities, supplemented by patients’ views, would inform central funding. Senior clinicians need to be encouraged to return to clinical independence and expertise, subject to medical and other scientific evidence. All specialities would make an effort to return to collegiality , to offer liaison and cooperation in patient treatment and care. Patient feedback is essential in all NHS services, with new powers to question developments and have access to services explained clearly.
We need to preserve the gains made in the last 25 years or so: services firmly based in the community, reaching in in to hospitals, geographically organised with multidisciplinary teams, based on a medical model. Low level mental distress should be firmly the province of the general practitioner, with ready access to consultation. The secondary services should concentrate on serious and disabling mental disorder. Treatments should be strictly evidence-based. There needs to be a commitment to ensuring that present advances in research are converted into practice.