BMJ 2014;348:g1907 doi: 10.1136/bmj.g1907 (Published 5 March 2014)
Page 1 of 2
Editorials
EDITORIALS Improving mental health services in England Their current fragmentation points up the oxymoronic nature of government’s latest initiative Trevor Turner consultant psychiatrist Keats House, London SE1 9RS, UK
Documents on mental health policy tend to be diffuse and careful. They are aspirational rather than rational, tiptoe around the snags of stigma and different interest groups, and they do not commit funds.
Once it was simple. There were some 120 asylums (mental hospitals), and local authorities and ratepayers paid for them. Since the closure of these hospitals in the 1970s and 1980s we have had community care (dubbed “other people, somewhere else” by a leading academic). It was a policy that was stumbled into as humane and embraced “normalisation,” a watch word akin to the “recovery model” that adorns all modern documentation. Struggling under the steady cannonade of homicide inquiries (20-30 a year since the mid-1990s), initiated by the Clunis report of 1994,1 mental health services have had to endure the care programme approach, risk management (a phrase unseen in psychiatric textbooks until the mid-noughties), and fragmentation. Thus the NHS plan of 2002 introduced packaged new teams, such as “crisis intervention” and “assertive outreach,” apparent additions to the standard (and rather effective) community mental health teams that served each locality. With the other hand, the Department of Health reduced acute bed numbers (who needs beds with home treatment so active?), thereby creating the 120% bed occupancies that keep defying improbability. Yet re-institutionalisation is on the rise,2 as the Home Office agenda demands more secure units.
Now we have Closing the Gap: Priorities for Essential Change in Mental Health, written by the Social Care, Local Government and Care Partnership Directorate.3 4 It sets out 25 areas as priorities for action and where it thinks the 2011 strategy is “coming to life.”5 There are eight areas under “Increasing access to mental health services,” three under “Integrating physical and mental health care,” three under “Starting early to promote mental wellbeing,” and seven under “Improving the quality of life of people with mental health problems.” Much of this is perfectly reasonable, although area number 25—“We will stamp out discrimination”—should have been a common thread throughout.
We should cheer the promotion of access to psychological therapies, support for new mums and for children in school, quicker pathways to “the mental health services they need,” and
enabling people to live in homes that “support recovery.” But the document has no references or evidence base at all, it has 46 “further information” resources of varying provenance (for example, “Lethal discrimination” by the charity Rethink Mental Illness,6 but “Implementing recovery through organisational change” seems a little far fetched7), and it is bedevilled by management language. We are told that therapy works (as if it were a panacea) but are not told that social services cuts mean that people who recover are kicked out to “independent living” because the hostel bed is needed for someone else. If we look for practical approaches, such as having psychiatric units in all general hospitals or pricing alcohol per unit, as the relevant royal colleges have vigorously demanded, or clearer legislation against stigma in employers’ attitudes (the NHS often being the worst), we find very little. Instead, we read that they will ensure that commissioners have access to the relevant National Institute for Health and Care Excellence guidelines—what a brainwave. We are also told that NHS England “is developing a range of clinical commissioning tools to support commissioners, including tools that will support integration of physical and mental healthcare.”
Despite agencies and working groups galore we are to be given a new national Mental Health Intelligence Network (MHIN). The Department of Health has also developed a “mental health dashboard” to track key measures and highlight “the priority outcomes from the outcome frameworks” to ensure that “everyone can see what is happening.” The fragmentation of things may not be apparent to naive readers. But the notion of Public Health England alcohol and drug teams working with NHS England area teams, local authorities, and clinical commissioning groups to “promote and support the commissioning of joined up mental health and substance misuse provision” should open their eyes to the intrinsically oxymoronic nature of this enterprise. Amidst all of this well intentioned stuff—helping victims of crime and armed forces veterans, easing children’s transit to adult services, and trying to reduce inequalities of access—there are several hidden minefields. The friends and family test is a must for the easily exploited, such as those with mental illnesses, but is it the most important measure of quality what “people who use mental health services think”? Detention under the
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Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1907 doi: 10.1136/bmj.g1907 (Published 5 March 2014)
Page 2 of 2
EDITORIALS
Mental Health Act normally over-rides a patient’s wishes, so it would seem more relevant to strengthen the powers of mental health review tribunals and the inspectorate process. Similarly, there is only brief mention of giving adults the right to choose which provider and consultant or mental health professional will be in charge of their care.
This goes against the whole notion of defined catchment areas for mental health, a policy based on clarifying local responsibility (often contentious enough for cash strapped local authorities) and the simple practicalities of receiving care from the community mental health team that works in your community. It is not like consulting a London specialist for a hernia repair because the continuing (perhaps twice weekly) social support, access to the local day centre, and treatment inputs cannot be done at a distance. Psychiatrists embedded within these teams are the essence of continuity of care and true accessibility. But what your local frontline psychiatric team thinks and does would not seem relevant to the acronymous bureaucrats of the NHS,8 who should be redistributed to talking to patients rather than each other.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3
4 5 6 7 8
Ritchie JH, Dick D, Lingham R. The report of the inquiry into the care and treatment of Christopher Clunis. Stationery Office, 1994. Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, et al. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ 2005;330:123. Social Care, Local Government and Care Partnership Directorate. Closing the gap: priorities for essential change in mental health. Department of Health, 2014. www.gov. uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_ V2_-_17_Feb_2014.pdf. Iacobucci G. UK government vows to monitor waiting times for mental health services in new strategy. BMJ 2014;348:g410. Richardson A, Cotton R. No health without mental health: developing an outcomes based approach. NHS, 2011. www.londonprogrammes.nhs.uk/wp-content/uploads/2012/04/ MHN-Mental-Health-Outcomes-Report.pdf. Rethink mental illness. Lethal discrimination. 2013. www.rethink.org/media/810988/ Rethink%20Mental%20Illness%20-%20Lethal%20Discrimination.pdf. Centre for Mental Health. Implementing recovery through organisational change. 2010. www.centreformentalhealth.org.uk/recovery/publications.aspx. Salter M, Turner T. Community mental health care. A practical guide to outdoor psychiatry. Churchill Livingstone, 2008.
Cite this as: BMJ 2014;348:g1907 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Improving mental health services in England Their current fragmentation points up the oxymoronic nature of government’s latest initiative Trevor Turner consultant psychiatrist Keats House, London SE1 9RS, UK
Documents on mental health policy tend to be diffuse and careful. They are aspirational rather than rational, tiptoe around the snags of stigma and different interest groups, and they do not commit funds.
Once it was simple. There were some 120 asylums (mental hospitals), and local authorities and ratepayers paid for them. Since the closure of these hospitals in the 1970s and 1980s we have had community care (dubbed “other people, somewhere else” by a leading academic). It was a policy that was stumbled into as humane and embraced “normalisation,” a watch word akin to the “recovery model” that adorns all modern documentation. Struggling under the steady cannonade of homicide inquiries (20-30 a year since the mid-1990s), initiated by the Clunis report of 1994,1 mental health services have had to endure the care programme approach, risk management (a phrase unseen in psychiatric textbooks until the mid-noughties), and fragmentation. Thus the NHS plan of 2002 introduced packaged new teams, such as “crisis intervention” and “assertive outreach,” apparent additions to the standard (and rather effective) community mental health teams that served each locality. With the other hand, the Department of Health reduced acute bed numbers (who needs beds with home treatment so active?), thereby creating the 120% bed occupancies that keep defying improbability. Yet re-institutionalisation is on the rise,2 as the Home Office agenda demands more secure units.
Now we have Closing the Gap: Priorities for Essential Change in Mental Health, written by the Social Care, Local Government and Care Partnership Directorate.3 4 It sets out 25 areas as priorities for action and where it thinks the 2011 strategy is “coming to life.”5 There are eight areas under “Increasing access to mental health services,” three under “Integrating physical and mental health care,” three under “Starting early to promote mental wellbeing,” and seven under “Improving the quality of life of people with mental health problems.” Much of this is perfectly reasonable, although area number 25—“We will stamp out discrimination”—should have been a common thread throughout.
We should cheer the promotion of access to psychological therapies, support for new mums and for children in school, quicker pathways to “the mental health services they need,” and
enabling people to live in homes that “support recovery.” But the document has no references or evidence base at all, it has 46 “further information” resources of varying provenance (for example, “Lethal discrimination” by the charity Rethink Mental Illness,6 but “Implementing recovery through organisational change” seems a little far fetched7), and it is bedevilled by management language. We are told that therapy works (as if it were a panacea) but are not told that social services cuts mean that people who recover are kicked out to “independent living” because the hostel bed is needed for someone else. If we look for practical approaches, such as having psychiatric units in all general hospitals or pricing alcohol per unit, as the relevant royal colleges have vigorously demanded, or clearer legislation against stigma in employers’ attitudes (the NHS often being the worst), we find very little. Instead, we read that they will ensure that commissioners have access to the relevant National Institute for Health and Care Excellence guidelines—what a brainwave. We are also told that NHS England “is developing a range of clinical commissioning tools to support commissioners, including tools that will support integration of physical and mental healthcare.”
Despite agencies and working groups galore we are to be given a new national Mental Health Intelligence Network (MHIN). The Department of Health has also developed a “mental health dashboard” to track key measures and highlight “the priority outcomes from the outcome frameworks” to ensure that “everyone can see what is happening.” The fragmentation of things may not be apparent to naive readers. But the notion of Public Health England alcohol and drug teams working with NHS England area teams, local authorities, and clinical commissioning groups to “promote and support the commissioning of joined up mental health and substance misuse provision” should open their eyes to the intrinsically oxymoronic nature of this enterprise. Amidst all of this well intentioned stuff—helping victims of crime and armed forces veterans, easing children’s transit to adult services, and trying to reduce inequalities of access—there are several hidden minefields. The friends and family test is a must for the easily exploited, such as those with mental illnesses, but is it the most important measure of quality what “people who use mental health services think”? Detention under the
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1907 doi: 10.1136/bmj.g1907 (Published 5 March 2014)
Page 2 of 2
EDITORIALS
Mental Health Act normally over-rides a patient’s wishes, so it would seem more relevant to strengthen the powers of mental health review tribunals and the inspectorate process. Similarly, there is only brief mention of giving adults the right to choose which provider and consultant or mental health professional will be in charge of their care.
This goes against the whole notion of defined catchment areas for mental health, a policy based on clarifying local responsibility (often contentious enough for cash strapped local authorities) and the simple practicalities of receiving care from the community mental health team that works in your community. It is not like consulting a London specialist for a hernia repair because the continuing (perhaps twice weekly) social support, access to the local day centre, and treatment inputs cannot be done at a distance. Psychiatrists embedded within these teams are the essence of continuity of care and true accessibility. But what your local frontline psychiatric team thinks and does would not seem relevant to the acronymous bureaucrats of the NHS,8 who should be redistributed to talking to patients rather than each other.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3
4 5 6 7 8
Ritchie JH, Dick D, Lingham R. The report of the inquiry into the care and treatment of Christopher Clunis. Stationery Office, 1994. Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, et al. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ 2005;330:123. Social Care, Local Government and Care Partnership Directorate. Closing the gap: priorities for essential change in mental health. Department of Health, 2014. www.gov. uk/government/uploads/system/uploads/attachment_data/file/281250/Closing_the_gap_ V2_-_17_Feb_2014.pdf. Iacobucci G. UK government vows to monitor waiting times for mental health services in new strategy. BMJ 2014;348:g410. Richardson A, Cotton R. No health without mental health: developing an outcomes based approach. NHS, 2011. www.londonprogrammes.nhs.uk/wp-content/uploads/2012/04/ MHN-Mental-Health-Outcomes-Report.pdf. Rethink mental illness. Lethal discrimination. 2013. www.rethink.org/media/810988/ Rethink%20Mental%20Illness%20-%20Lethal%20Discrimination.pdf. Centre for Mental Health. Implementing recovery through organisational change. 2010. www.centreformentalhealth.org.uk/recovery/publications.aspx. Salter M, Turner T. Community mental health care. A practical guide to outdoor psychiatry. Churchill Livingstone, 2008.
Cite this as: BMJ 2014;348:g1907 © BMJ Publishing Group Ltd 2014
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
