Growing Smaller: My Part in the Great Expansion of Mental Health

Keir Harding

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.

This is very accurate, working in a CMHT with caseloads of 50+ service users is not only reckless but it’s neglectful for those who use our service. Not to mention the detrimental impact it’s having on the physical and mental wellbeing of the NHS staff on the frontline trying to carry the load and the responsibility.

Until recently I worked as an OT IN A CMHT we were overwhelmed, I would try to do 6 or more home visits in a day and would rarely have time to eat lunch. As we were short staffed I had a high caseload (56), this was not a caseload of individuals who had a particular OT need I just picked up whoever needed allocating. Sadly it didn’t feel like what we provided was good enough despite the staff being very dedicated. Just over half of the care coordinator were b5 and there are few opportunities for career progression, good staff left to work outside the nhs for this reason.
I now work in an early intervention team which is much better resourced.
There is a good IAPT service but they are very selective about who they will take and service users are referred to CMHT because they are too high risk where they are assessed and then referred back to IAPT because they don’t meet CMHT criterea – it must feel very unhelpful and for some people a repetition of the experience of rejection that have suffered in their lives.
I work in a CMHT. Everyone is overstretched. B5 colleagues have had very complex clients allocated to them inappropriately due to lack of capacity amongst B6 staff. There isn’t enough time to care for people in the way we should. Before I worked as a Care Co-ordinator I used to be annoyed when CCOs “didn’t bother” to visit their clients when they’re in hospital, but now I can see the other side. Those clients are in a place of safety, so you know they’re being looked after. They have to slide down the scale of priorities while you’re fire fighting elsewhere. I regularly get home from work, put the kids to bed and then work for another 3-4 hours writing up notes on my laptop because I have to spend all day visiting people to ensure they’re seen as often as needed. I don’t have time to do all of the extra stuff that would benefit people’s wellbeing, only the essentials. It’s heartbreaking.
I have only been qualified for just over a year and have worked on an acute MH ward since then. There used to be one OT per ward and now there is 0.5 OTs per 16 patient ward (so one OT covers 2 wards). We have to prioritise – there is no way we can get to see all the people who need OT. There is constant pressure to discharge as there is always a massive waiting list for acute beds. People will be discharged to the community before they are ready or before they have adequate community support in place (because the community teams are so stretched).There is a high rate of readmission. Ideally we would treat more people in the community but there is no resource or lack of suitable supported housing (social care is a major problem). Also many of the voluntary organisations that used to bridge the gap or help people in the community have had their budgets cut reducing potential support networks further. I see no evidence of expansion of MH services or budgets at all!
 
I work in housing support services and am a newly qualified OT – what I find is that we now receive referrals from CMHT for people who have a housing need but I am most definitely managing the mental health as a priority over the housing need – my OT skills come in very well but it’s not my remit to work as an OT within that role but when I refer back to CMHT I can hear the stress in the workers voice – like they become unable to cope with their case load – what is the answer – clearly investment – I’ve seen nothing from the Tories – nothing – they continue to cut benefits to PIP and ESA (by the way in two years I can apply to be an assessor for DWP and my salary world be 34k?) it’s all unbalanced and it’s because those who represent these people cannot empathise with them – get labour back in – at least we will see more compassion – isn’t compassion more important than budgets anyway ?????? It’s sad that as a newly qualified professional I would rather set up a social enterprise supporting people grass roots than be in the NHS or CMHT because all I hear is stress and disparity 😩
I’ve worked in MH for 20 years and have never known it as bad as it is now. Under funded, cut back after cut back after cut back. Staff morale is awful because people’s hands are tied and cannot give the care they want and the service users need due to lack of resources and increasing pressures to do more and more with less and less
I completely agree with this post
I hear you loud and clear…. unfortunately its not just in CMHT its community wide. I myself will be leaving and heading towards grass roots community development services. It can’t continue the way it is.

 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

 
I agree wholeheartedly! 😔money seems to be directed towards assessment teams not treatment. So more people know they have a mental health issue but there is less clinicians to help them through it. Money allocated to iapt but for people with mild moderate anxiety and depression issues but who present with minimal risk. CMHT work with people at more severe and enduring end of MH spectrum with less care to co-ordinate then ever and fewer beds and the plethora of people in the middle fall through the ever expanding gap. They present in ever increasing numbers to ED. Certainly not a model of care to be proud of as the increasing numbers of people ending their lives would evidence. It’s only going to get worse with Tories in power. Selling of NHS assets for BOGOF!! 😡 Where will this end???
 It is sad to say but I have to agree with this post. 😞
sadly my experience in NI exactly mirrors yours. I have 22 years experience in MH and I have watched services being eroded to the extent that people are actually at risk of dying through lack of care. This used to be the exemption- now it appears to be the rule. I watch colleagues burn out and break down because of being blamed for losing someone to suicide because they simply couldn’t offer the level of security and safety the individual needed, often having been refused hospital admission or being discharged back to the community barely treated. But time after time the CMHT staff shoulder the blame rather than lack of service due to cuts being recognised. 
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!
A lot of what has been said here resonates with me. I am barely qualified; I worked in a cmhrs for a year and have been in inpatient​ forensics​ for 3 months. I would add to the revolving door those who are referred to the cmhrs but do not meet the threshold only to be referred repeatedly until they have deteriorated to the point of meeting it, too late for any preventative work. So people are now sicker and for longer than they perhaps have to be. How does this save money if that is the point? My caseload was thankfully protected where I worked, 15- 20, (still felt like a lot!) and there was always OT need, care coordination was minimal, and the team was cohesive. One of the main reasons was an excellent manager. I cannot say the same in my current position where it would be a stretch to say there was an OT service at all due to the ‘natural wastage’ described by another commenter and the politics that comes about when most people are inexperienced, underresourced and frustrated and different disciplines are fighting for the paltry resources that are available. 3 months in and I am considering leaving because there is no sign that it will improve. It can only get worse under the Tories.
Keir is a Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk

 

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)

10 thoughts on “Growing Smaller: My Part in the Great Expansion of Mental Health”

  1. We can talk about funding until the cows come home and whilst it plays a part I do not believe that money, or lack of it, is the biggest problem. I believe that much of the problem stems from how MHS are run and how little credence is given to the actual financial cost of poor quality care – not only to MHS themselves, but also society as a whole. Lack of good quality ongoing care and lack of early/timely/any intervention in a crisis makes no sense whatsoever, when it means that the service user has no chance of recovery; families/carers, etc. become ill because of the stress of caring and the police, ambulance service, A & E and GP’s are fundamentally doing the job of MHS.

    Yes there are cuts and staff not being replaced, but there are SO many staff that are SO disillusioned by management policies they leave; and of course fewer and fewer people will go into the profession – particularly those who genuinely care about the outcome for the service users.

    But no matter how poor the culture of senior management is – there is nothing to stop them because no one is truly analysing what is going on – presumably because no one in power really wants to know, because if they did they would have to address it. The CQC, the PHSO, etc. all talk about identifying ‘trends’ and ‘themes’ in complaints but in the real world they aren’t making any attempt to do this; suicides are under-reported by Coroners and the diagnoses of those people who die by suicide/suspected suicide aren’t even recorded, therefore any service user group that are routinely excluded from treatment, such as those with Personality Disorder, will never show up. This is happening every day in the UK and MHS are fully aware of it, therefore it is in their power to change it but those with a poor culture aren’t interested in changing it and as long as they believe in their own ‘spin’, they get off the hook and no one will be safe.

    And finally (although there is a lot more I could say) you mention ‘respite’ – I have known this work exceptionally well for people, but to a large extent any type of stay in a MH hospital seems to have demonized and treated a last resort by MHS. The alternative in so many cases is to leave the service user in the community at exceptionally high risk, often with no support and no MHS intervention however bad the situation gets. And however harsh this sounds (but I’ve witnessed it first hand with a vulnerable person in my community), it seems that MHS give far greater weight to suicide in hospital than they do to suicide in the community which they can distance themselves from far more easily.

    So I don’t think it matters how much money is thrown into MHS until CEO’s etc. are held to account for the 1000’s of unnecessary deaths that ultimately they are responsible for.

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    1. Well, I agree to some extent but…services do have to do more with less money so they have to think about what to cut. I suspect if services were awash with money there would be more beds, therapies, treatment and support. As it is managers have to prioritise and I notice that the most stigmatised group of the most stigmatised group in health are not at the front of the queue to be assisted. I desperately hope that can change.

      Thanks for taking the time to share your ideas with me.

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  2. Thank you for writing this blog. It is a refreshing change to read an accurate portrayal of M.H services which reflects my experience both as a Service User and as a Service User Consultant. I remember when care in the community first started. At that time (as a service user) I was actively encouraged to ask for help when I felt ‘unwell’ before reaching crisis point, this was part of my care plan and my responsibility In 1998 I had a change of psychiatrist & Key worker as well as new diagnosis Personality Disorder. With this new diagnosis came a whole new approach and a new care plan. Personality Disorder from then on was underlined on the top of any of my medical notes, both in Mental Health and Physical Health. At that time there was no remit for treating Personality Disorder. Having the diagnosis of Personality Disorder meant that all of the coping skills I had worked hard on with my previous psychiatrist and key worker around keeping myself safe, asking for help before reaching crisis point were now viewed very differently. Instead of asking for help, I was seen as seeking attention. Self harm was seen as a very manipulative way of ‘getting’ back into hospital. I was discharged from M.H services in 1998, not because I was ‘cured’ but because at that time in Wales CMHT’s did not engage with people with Personality Disorder.
    A few years ago I went back to work as a Service User Consultant, I worked as part of a mulit disciplinary team,in a Therapeutic Community. As a member of staff I experienced services being closed down as people retired and were not replaced. Waiting lists of 2-3 years for service users waiting to engage with psychological therapies. Staff sickness at an all time high, services barely managing with a minimum of staff and the responsibilities of staff increasing all the time. Staff that spoke up were left feeling unsupported by their line managers and were admonished for ‘acting out’ and causing ‘splits’ for voicing their concerns. In my opinion both service users and staff experiences mirrored each other in many ways. Well done Keir for highlighting these issues! I feel that this blog is a breath of fresh air and a very important read for everyone.

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  3. I can definitely see the argument for robbing Peter to pay Paul. Iapt does a lot of good, but not if you don’t meet their criteria.
    I don’t see Labour being willing or able to increase funding or allocate it according to need though. The conservatives have a solid plan, whereas Labour just says “tax the rich” with no insight into the long term devastation that will cause.

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    1. Just my observation but the Conservatives have been in power for SEVEN YEARS, and as Keir stated in his blog, I am yet to see any improvements in provision of mental health services. This is not to mention the increase in demand on MH services because of initiatives like the “bedroom tax” and Work Capablity Assessments putting people under immense additional pressure. I’m not confident things will change if the Conservatives get in again, I’m surprised you are! http://jeremycorbyn.org.uk/articles/jeremy-corbyn-theresa-mays-speech-on-mental-health/

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    3. Well, those MH plans have been ditched….Whoever is in power, I don’t see a market economy with a focus on profit being the best way to meet the needs of complex people. Some things we should do because its what makes us human. The irony is that funding residential treatment is extortionately expensive and the NHS could save millions by investing in community services…

      Thanks for taking the time to share your thoughts. Really appreciate it.

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  4. As a service user of some years now you paint a picture which rings true with me. A hospital stay is unhelpful now as it’s frightening and noisy on the ward. I come out worse than I go in. I feel guilty at taking up so much of services time and yes there’s been a lot of firefighting in my case but consistent low level care instead of a roller coaster ride of support, then discharge, getting unwell again etc is never cost effective but it’s all short term measures. I doubt whether m h services are achieving anything now – there might be the odd person who is a quick fix but those with serious mental health problems don’t stand a chance now – even if they can get referred in the first place.
    I might as well give up now and admit that I will not be able to get the right help – ever – unless I win the lottery.

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