On the Today program at 8.34 on May 31st, Jeremy Hunt the health minister announced that the conservative party had presided over the greatest expansion of mental health services in Europe. The statement went unchallenged on the program but it was so different to my experience that it’s bounced around my head for the past 2 days, asking other people if they heard it and finally going on iPlayer to make sure that he actually said what I thought he did. And he did. Said it loud and proud as a fact that couldn’t be disputed. I’m going to dispute it.
I’ve worked solidly in mental health in England, Scotland, Wales and a brief stint in New Zealand since 1999. That is a fair few years of experience and I was trying to think of a time when it felt like things were expanding. I started my first community mental health job around 2002. This was a time of major change as the 1999 National Service Framework for Mental Health had directed trusts to put together a number specialist teams. A Home Treatment Team to keep people out of hospital, an Assertive Outreach Team for those with severe mental illness who were in danger of dropping out of services, and an Early Intervention Team to work with those who had had their first psychotic episode. While some staff from the community mental health team (CMHT) went off to staff these new services, I remember it as a time of expansion, as a time when we were doing more with more, a time when there was time to spend with people and options when things got tough. This period might have lasted about 5 years. After that talk became less about how we expand, but how we could contract. It was probably around this time that that the “doing more with less” paradox began to float around the NHS.
Since the heady days of the early millennium I’ve heard a lot more talk of trust deficits, balancing books and saving money. This has played out in a number of ways. The obvious ones that I’ve seen are not replacing staff who leave. In a team of 10, this means cutting the staffing by 10% and watching the rest of the team get on with it while the savings are counted up. Where that is unsustainable, experienced staff who move on are replaced by less experienced staff. A band 7 nurse becomes a band 6, who becomes a band 5. For me, this left teams short staffed, staffed by those with less experience or with vacancies that were only available for new graduates in teams that were already struggling.
So why are teams struggling? As well as the staffing issues above, it certainly feels like demand has increased. When I first joined a CMHT there was time. There was time to build a relationship, time to do things that felt useful and time to think about the quality of what you were doing. CMHTs now feel like they’re under siege. There is a mound of referrals flying in each week, the caseloads are so large you can barely spend any time with people and instead of building relationships and making plans, you spend your time putting out fires. And there are many fires. There is someone sat on a duty desk and daily they’re receiving calls from those who are acutely psychotic, desperately suicidal, wildly elated or all of the above. Their choice is often not how to put out the fires but which fires to put out. Overwhelmed, the CMHT referral meeting is less about who to accept but how to refuse. With no disrespect to those who work in CMHTs now, it feels like the standard of care people get has fallen. Weekly visits were common when I was working in CMHTs. Now they seem like a luxury reserved only for the most acutely ill.
If CMHTs have become overwhelmed let us consider the wards. The Telegraph tells us that 15,000 beds (in all areas) have been cut over the past 6 years. This year 2037 people were given mental health beds ‘out of area’ in 4 months. This says something about the demand on hospital beds. It also says something about how acutely unwell you need to be to get onto an acute ward. These wards are populated by the most disturbed, disinhibited and dangerous (to themselves and others) people in the mental health system. People used to come to mental health wards for respite. The restraints, alarms and noise of the ward mean that there is little respite to be had. They feel chaotic. They don’t feel safe. And places that don’t feel safe cannot be therapeutic.
The recent Panorama program on mental health gave me an account of mental health services that I was a lot more able to relate to than the health ministers. Instead of a confident service expanding, the program focused on a trust that opted to save money by reducing inpatient mental health services. “Very Sensible!” we might think. “Care in the community! Lets keep people in their own homes!”. Laudable sentiments. Alas the trust made the egalitarian decision to cut community service too. The results were a disaster.
For a few more personal examples (as if any of this isn’t just the thoughts at the top of my head) I walked past my friend who was sat in his police car the other night. He told me people were sleeping in the corridor at the local mental health unit and the nearest bed was 150 miles away. Even closer to home, my friend had 3 assessments in 3 days from a variety of mental health services. Each agreed they required an admission. There wasn’t a bed to be had. Not in their area, not in the next. “What do I have to do to get a bed?” they asked. “Something potentially lethal to yourself or someone else” I thought. To quote a very wise service user consultant I once worked with – “Don’t think this message doesn’t seep into the subconscious of those looking for help”.
Since returning to work in England I have noticed some significant changes. Services being put out to tender means that companies can bid to replace the NHS services. If you are in the NHS and your service is going out to tender in 2 years, why invest in it? Why invest in your staff? Do you focus on improving patient health or demonstrating change so that you win the next tender bid it takes months to prepare for. If you are a private company you look at how you can undercut the NHS. The easiest way to do this is to hire less experienced staff and spend nothing on developing them. After all, you might not be running the service in 2 years time.
It’s worth saying at this point that I work with people who would be classed as having significant mental health problems. The Improving Access to Psychological Therapies program has certainly provided much to people with mild to moderate problems, even though I hear a lot of criticism about how time limited the interventions are. That aspect of mental health services may well have expanded but I will argue that services for those I work with have not. It feels like they have contracted and even the most charitable part of me could only say that services have robbed Peter to pay Paul, expanded one area at the cost of another. But I may be wrong. I hear the government is putting £1.4 billion into mental health. I haven’t seen it. I have heard of CCGs spending their extra money on other things. I have heard much talk about how to do more with less. If there are mental health professionals rubbing their hands together at a loss as to how to spend all the extra cash that is rolling in, I have yet to meet them.
If all of the above is the expansion, I would hate to be relying on the mental health system when it starts to shrink.
After I wrote all the above I shared it with some fellow mental health professionals to check that my experience wasn’t unique to me. The comments they made below suggest not. To keep this apolitical, I first saw services contracting under a labour government. I haven’t seen them expand in many, many years.
To be clear, all of this is a general impression rather than reflecting any particular team I’ve worked with or been a part of.
I now work in an early intervention team which is much better resourced.
Also, under resourced Crisis Services struggling to safely support people in the community because there are no hospital beds. People presenting to A&E due to deterioration in their mental state and having to spend hours (sometimes days) in medical bed
Neither service users nor staff win in the current climate and the voluntary sector can’t plug the gaps.
I’m one of the lucky ones – I work in forensic mental health with a protected caseload- but who knows how long that will last.
It’s hard to stay positive when the future looks so bleak. And as for Jeremy Hunt, I think he’s firmly embraced ‘post-truth politics’ and sadly his agenda seems to be to dismantle the NHS in favour of some sort of private health care
Thanks for sharing this Keir, it’s good to know that others are seeing this too!
Those who feel that they’ve been part of the greatest expansion of mental health services are quoted below:
(You may wish to read those quotes twice)