MEMORANDUM BY THE ROYAL COLLEGE OF PSYCHIATRISTS
PROVISION OF NHS MENTAL HEALTH SERVICES (MH
36)
A. TRANSITIONS
If there is a theme to the examples you give
from the terms of reference, it is one of transition. Comprehensive
mental health services may need to manage the interfaces:
(i) across acute and longer-term, voluntary
and involuntary care;
(ii) in both hospital and community settings;
(iii) for different diagnostic groups, requiring
different treatment modalities as they pass between different
age groups;
(iv) at the hands of psychiatric and other
professional workers within multi-disciplinary teams or separate
organisational structures;
(v) with co-operation between professional
and users' and carers' groups;
(vi) in a pyramid of primary, secondary,
tertiary and quaternary level interventions of increasing specialisation;
(vii) often involving contributions from
both NHS and privately funded health care;
(viii) and, for some, across civil and criminal
jurisdictions
(ix) that might require low, medium or high
security provision.
It is at those interfaces that much of the most
innovative mental health work is carried out. But there are many
obstacles to its success.
B. PERSONNEL
ISSUES
(i) Morale
In some geographical areas, and in some sub-specialities,
morale is low. This is particularly true of inner-city, acute,
general psychiatric wards that remain an essential part of integrated
mental health care and without which community services would
be inappropriately exposed. In many wards it has become difficult
to recruit and retain good quality mental health nurses and the
number of consultant psychiatric vacancies is rising.
(ii) Revalidation
It is vital that all mental health professionals
are properly trained, kept up-to-date in their knowledge and have
their practice regularly evaluated. But this should be seen as
a constructive exercise accrediting the vast majority who work
well in difficult circumstances and helping those who could perform
better—not as a "witch hunt" that would further
erode personal and public confidence.
(iii) Clinical Governance
Pesonal evaluations should not be confused with
the clinical governance of services, the responsibility for which
lies in the hands of the Chief Executives of Trusts. It is possible
for mental health teams to be working to the maximum of their
capabilities, but yet not be able to fulfil all that the users
of services require because of a shortage of resources rather
than skills.
(iv) Personal Supports
However well resourced, mental health work remains
a stressful occupation that will occasionally undermine the mental
and physical well-being of its practitioners. It is in the interests
of everyone, including patients, that there are sympathetic support
systems that do not equate difficulties with weakness or incompetence.
"Casualties" would further denude services that are
already over-stretched.
C. SERVICE ISSUES
(i) Local Organisation
So bewildering has been the rate at which mental
health services have been passed backwards and forwards between
hospital, community and primary care trusts as they have merged
and un-merged over the last few years, that it has been difficult
for them to establish integrated patterns of care with outside,
Local Authority agencies or even within their own teams. Different
disciplines and sub-specialities have found themselves living
within different "parental" bodies. There is no evidence
that such reorganisation has led to better mental health care
or even that it has saved money. What services now need is a settled
period in which their work can be monitored and changes made according
to local circumstance rather than prescriptive national dogma.
(ii) Devolution
The Royal College of Psychiatrists covers all
parts of the United Kingdom and Southern Ireland. We welcome the
chance that devolution has offered for different countries to
develop their own systems of mental health care—not least
in their relationship to primary care trusts and frameworks of
mental health legislation. This is an opportunity for innovation
and for learning from each other. We should recognise, however,
that this may create problems for patients and staff as they move
across boundaries, and for the College as it struggles to co-ordinate
its members' training and practice at the centre.
(iii) Resources
Despite Ministers' admission that they have
been let down in the past by insufficient resources, mental health
services remain the "Cinderella" of the NHS. Money has
been promised to fund the implementation of the National Service
Framework, but we are anxious that this is genuinely "new"
and sufficient for the task. Many of the Government's own proposals
(including those for compulsory orders and personality disorders)
are expensive. The danger is that either they will drain off resources
from less politically pressing, but equally vital areas of mental
health services, or options will be chosen that have more to do
with economy than clinical need. In raw terms, the money received
by most health authorities from the modernisation fund would not
even cover the unmet portion of last year's pay-rise for nurses.
(iv) Information Technology
As patients move between hospital and community
services and partners, families and others become even more important
to their care, the collection and dissemination of good quality
information is vital; tragedies happen where communication is
poor. Information Technology systems will be the key to that process,
but a careful balance needs to be struck between the carers' need
to know and the patients' right to confidentiality.
D. PUBLIC ISSUES
(i) Stigma
The sub-title of the College's anti-stigma campaign
is "Every Family in the Land". It emphasises the fact
that no one will be untouched by mental health problems, either
in themselves or those close to them. And yet mental illness still
carries a stigma that prevents those suffering it from seeking
treatment and ostracises those in mental health care. The responsibility
for eroding that stigma lies with the public and its stereotypes,
with the media who feed on images that reinforce them and with
politicians who sometimes react too hastily to them.
(ii) Public Safety
We understand the need to balance individual
rights with public safety but the balance seems heavily weighted
one way. Contrary to the impression given by mandatory homicide
inquiries, the vast majority of the mentally ill are more at risk
from those around them than a danger to others. The proportion
of homicides committed by the mentally ill has been falling while
that committed by the non mentally ill has risen rapidly. The
College would welcome the chance to treat people with personality
disorder more effectively, but the Government should realise that
the overlap between severe personality disorder and dangerousness
is a tenuous one. The Home Secretary's recent proposals may be
both unethical and misguided.
(iii) Mental Health Legislation
Reform of the Mental Health Act is much needed
to reflect wholesale changes in mental health practice over the
last two decades. It is right that we should sever the link between
compulsory care and the hospital bed and many psychiatrists will
welcome the attempt to lift responsibility for imposing longer-term
orders from their shoulders and onto the new tribunals. However,
the Green Paper proposals, based on a broad definition of mental
disorder but without any restrictions based on capacity or treatability,
may cast the legislative net so wide as to overwhelm the hard-pressed
wards and community teams. Once again, this seems a misdirected
pursuit of safety that will not be achieved by mental health legislation,
however well it is couched.
(iv) Users' and Carers' Movement
Good mental health services should represent
a partnership between the multi-disciplinary teams and those in
their care. Most patients will be treated without compulsory order
and will have both a right and responsibility to decide issues
about their care for themselves. Services should be organised
around patients' particular needs and the experience of patients
fed back into the training of mental health professionals and
the assessment of services through clinical governance. All this
is reflected in the greater co-operation between professional
organisations like the College and the users' and carers' bodies
that play a prominent role within it.
E. SUB-SPECIALITY
ISSUES
(a) Child and Adolescent Psychiatry: the
transition to adult services may only be fully resolved by the
development of youth psychiatry services covering the period when
severe mental illness most commonly arises and the maximum continuity
is needed. In the meantime, there are resources for only 10 per
cent of children with significant mental health problems to be
seen and there is such a major shortage of in-patient units for
disturbed adolescents that they often find themselves inappropriately
placed on adult wards, with or without joint protocols. The origins
of many adult disorders lie in childhood, but most services are
so absorbed by "fire-brigade" treatment of established
illness that they cannot find time for preventative work.
(b) General Adult Psychiatry: much of this
submission rightly focuses on the needs of such services. In addition,
there are great anxieties about the rising rate of suicide amongst
young adult men; about the under-funding of facilities for the
treatment of eating disorders within the NHS; about the difficulty
of extending services to so-called "fringe groups" like
the homeless; and about ethnic minority issues. The College Research
Unit has shown that black people are six times more likely to
be sectioned under the Mental Health Act than white people. The
causes must be evaluated.
(c ) Psychiatry in Old Age: the Faculty
looks forward to the National Service Framework for Older People
and its interface with that for Mental Health. Demographic trends
will have major implications for mental health services as the
NHS comes to terms with the impact of dementia and its treatment
demands. Psychiatrists are concerned about the lack of recognition
of much potentially treatable depressive illness in older people.
We regret the lack of response to the Royal Commission on Long
Term Care.
(d) Psychiatry of Learning Disabilities:
people with learning disabilities have a higher prevalence of
mental health problems than the general population and the College
recognises this with a Faculty of psychiatrists with specific
training in their treatment; but many patients do not have access
to specialised services, what services there are tend to be poorly
resourced, and mainstream services are often unsuitable. Whatever
capacity legislation emerges from the Lord Chancellor's document,
"Making Decisions", will be particularly important for
this group.
(e) Psychotherapy: the National Service
Framework has responded to the call from users and carers for
more "talking treatments" in established mental disorder
and for the use of psychotherapeutic interventions in preventative
work. And yet the number of consultant posts funded in psychotherapy
is woefully small and services are provided "by post-code"
rather than need. In very few areas is psychotherapy for schizophrenia
or cognitive behaviour therapy for depression, both of proven
efficacy, readily available on the NHS. Any expansion through
specialised psychotherapists or general counsellors in primary
care will need to be based on proper training, registration and
monitoring of practice.
(f) Substance Misuse: there is a growing
recognition of the importance of substance misuse, as a disorder
in its own right and as a co-morbid factor in other mental illnesses.
There needs to be good liaison, therefore, between specific services
for drug and alcohol abusers and those for adolescents, for general
adult psychiatric care, and the prison health services. The danger
is that patients with so-called "dual diagnosis", especially
in late adolescence or early adulthood, may fall between services
to their own detriment and potential danger to others.
(g) Forensic Psychiatry: Government proposals
for Reform of the Mental Health Act and for the Management of
Dangerous People with Severe Personality Disorders will have major
implications for the work of forensic psychiatrists and the general
mental health teams with whom they interact. It remains to be
seen what proportion of their work will be spent within prisons,
within hospital settings, within secure facilities or within new
assessment and treatment centres. There will need to be safeguards
against the stripping of existing services, already over-stretched,
to man any more "attractive" facilities as they develop.
As in all mental health services, we would stress the need for
research into what does and does not work before changes are made
of debatable efficacy, dubious ethics and great financial implications.
Despite all of these difficulties, mental health
services continue to do exciting and effective work with very
vulnerable patients that have never been given the public, political
and professional attention that they deserve.
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