Robert Nisbet – Where will mental health services be one year from now?

“History admits no rules, only outcomes. What precipitates outcomes? Vicious acts and virtuous acts. What precipitates acts? Belief’.

David Mitchell. Cloud Atlas [2004]. Chapter: ‘The Pacific Journal of Adam Ewing’

The book ‘Cloud Atlas’ consists of six‘ interrelated’ stories that take the reader from the remote South Pacific in the nineteenth century to a distant, post-apocalyptic future. Eventually the reader ends where they started. Each story contains a document, movie or tradition that also appears in a previous story. It shows how history not only repeats itself, but also connects to people in all time periods and places.

On the 18^th February 2014, Norman Lamb, Care and Support Minister, launched the ‘Crisis Care Concordat’ (https://www.gov.uk/government/news/better-care-for-mental-health-crisis) – signed by more than 20 national organisations – in a bid to drive up the standards of care people should expect if they suffer a mental health crisis, specifying how emergency services ought to respond.

Norman Lamb proclaimed the concordat would ensure “Better care for people in mental health crises will not only help those living through their darkest hours to recover – it can also save lives’. 

The Confederation Mental Health Network chief executive, Stephen Dalton, applauded this statement, but emphasised the need for mental health to be treated on a par with physical, or “…all the will, awareness and training in the world won’t translate into real improvements.”

The concordat follows the policy directive launched in January 2014 by the Deputy Prime Minister, Nick Clegg, ‘Closing the Gap: Priorities for Essential Changes in Mental Health’.  Closing the Gap outlines 25 areas for health and care services to take action to make a difference to the lives of people with mental health conditions, and builds on the Government’s policy launched by Norman Lamb last March, which aims to make mental health services more effective and accessible, and to be funded and planned in an equal fashion to physical health services.  Seemingly we are not short of guidance, policy and ministerial commitment to the task of bringing our mental health services out of crisis, emphasising again the long-standing policy focus of delivering services in the community and of being responsive to individuals needs particularly at time of crisis.

News stories continue to provide insights as to how bad the situation has become in many parts of the country with:
– Bed shortages,
– People being held in police cells due to the lack of a bed or having to be placed in a hospital considerable distances from their home, friends and family
– The demise of multi-disciplinary teams, particularly noting the withdrawal of social workers, the ‘tearing up’ of joint working agreements between health and local authorities and in some areas cuts by local authorities in the number of social work, and support service posts and the closure of community mental health facilities

Last week’s blog by Dr. Nic Hendey ‘Realistic Recovery Model – Rhetoric or Reality’, questioned whether our mental, physical, and social care services are really integrated, operating in tandem and equal, and gave an insightful testimony that they are not!

With Local Authorities around the country announcing their budgets for 2014/15 meaning further cuts to welfare care, it’s all a bit gloomy.  Or is it?  Writing in the Guardian last Friday, Nigel Edwards, a Senior Fellow at the King’s Fund, argues that the quality of care for patients at home or in the community is becoming more of a reality.  Yet to achieve this requires an investment in staff and services.  He argues that government initiatives have failed, too concerned with structure and ownership than the actual operation of services.  Our most important task now, he states, is to ‘reduce the complexity of services’.  However, his call for services to ‘find ways to increase their reach’  seems hollow given the current reality for many Local Authorities and voluntary sector services.

Karl Marx commented that history repeats itself, firstly as ‘tragedy’ and secondly as ‘farce’.  Will history be kinder to our mental health services of today?  It is worth remembering that 2014 is the not the first time we have deemed our mental health services inadequate and outmoded.  In July, 1960 Enoch Powell became Health Minister in Harold McMillan’s conservative government.  He set about the immense task of reforming the nations then antiquated hospital services, including the ‘Mental Hospitals’ – or ‘Asylums’ as they were frequently referred to.  At the Conservative party conference in March 1961, Powell slammed these institutions. He spoke of the need for the transition to community based care, the horrors of the asylums, the implications of the changes due and the services and finances he envisaged were needed to facilitate this.  A ten year plan for change to mental health services was drawn up with a view to assessing the needs of the mid and long-term future, and the changes that would need to take place to accommodate those needs.  His speech set the wheels turning for ‘community care’.

Powell expressed the need for ruthlessness in preparing these provisions, and to reduce the number of mental health beds by 50%. This was related to the advances that had been made in the preceding years to his speech, not just in terms of treatment but also in the legislation that had been passed – the Mental Health Act 1959, much of which still remains evident in the Mental Health Act 1983, even after the amendments introduced in 2007.

Then, as now, a change of attitude was needed.   Services themselves were to form the identity of mental healthcare, rather than the buildings, and as such, the buildings and operational framework would be dismantled.  Still to this day we see much of the type of services that Powell envisaged being put in place as important.  The environment suitable for mental health treatment in the future would be in wings of general hospitals, which would assist in the deinstitutionalisation of mental healthcare.

Then, as now, there was a need to forget the money spent to improve institutionalised services, and to rather consider the benefits of the changes to be made in order to provide something ‘different and better’.  Local Authorities needed to work with medical staff in hospitals in order to develop community services, and that they must take responsibility for those in their care.  In essence, it was no longer acceptable to place somebody in a hospital and have no further involvement in his or her care; teamwork would be required.

The rest of the story, as they say, is history, and many readers of this blog will recall what happened in the years after Enoch Powell’s ‘Water Towers’ speech.  Part 2 of this blog will look at whether the development of ‘community care’ did subsequently become a tragedy of history and, if we take Marx’s analysis at face value, a farce is to follow?

Robert J. Nisbet.
He also blogs at http://donquixote.me/
Contact: Robert@donquixoteme.info
Tweet: @NisbetRock

Dr Nic Hendey – Realistic Recovery Model: Rhetoric or Reality?

Please welcome the inaugural post from our second new editor, Dr Nic Hendey

Are our mental, physical, and social care services really operating in tandem, integrated, and equal?  My experience is not.

Having just been discharged from a stay on a psychiatric ward I thought that a blog about some of my experiences would be of interest. I am both an academic and a mental health service user.  I have mobility problems as well as being registered blind and arrived on the ward with my guide dog Beels. My dog is unique in being dually qualified, as he is a dog for the disabled too, and helps me with tasks around the house.  Beels also supports me when I walk.

The day after admission I was horrified and devastated when Beels was removed as staff did not think that the ward was a suitable environment for him. I was astonished as Beels has accompanied me into other hospitals in London and stayed on surgical wards.  I have not seen Beels for six weeks now, a situation which is detrimental to both of us given that we work as a team and my reliance on him. He is currently with his breeder in Gloucestershire.

It seems as if my other problems, that are not directly mental health related, have been overlooked.  I am now back at home without my assistance dog and no care package in place. This is a serious omission given my mobility problems and degree of visual impairment. Normally I have personal assistants helping me but this has been suspended due to my recent hospitalisation.

Patients with multiple disabilities do present challenges that require fresh thinking and it is essential that staff are able to meet the needs of such patients.  The lesson to be learned here is that you cannot look at psychiatric conditions in isolation from any other disabilities that a patient may have, and that this is intrinsic to a holistic approach to patient care and a realistic recovery model.

Dr Tom Insel – Mental Health in Davos

In addition to the post by Dr Hendey, we wanted to draw your attention to this post by Dr Tom Insel, Director of the National Institute of Mental Health.  Dr Insel’s post follows his attendance at the Word Economic Forum in Davos, where global mental health was a hot topic.   As a taster, here is the first paragraph – for the full post, please visit the NIMH’s official blog here.

Just returning from the World Economic Forum (WEF) in Davos, Switzerland. While media reports covered speeches from some of the 40 heads of state attending or skewered the over-the-top parties of the rich and famous associated with this annual meeting, they missed a remarkable story: this was the year that mental health became a hot topic at the WEF. There were over 20 sessions on health, many of them focused on mental illness, dementia, or mindfulness. Philip Campbell, editor-in-chief of Nature, moderated a session on the “Mental Health Imperative.” An unprecedented health summit began with the Prime Minister of Norway declaring that mental health was her leading health care priority. And celebrities from Goldie Hawn to Arianna Huffington argued for the need to focus on mental health. One Davos regular compared mental health in 2014 to AIDS in 1994, when the WEF declared the need for a global focus on an emerging, heavily stigmatized, frequently misunderstood disorder…

Robert Nisbet – At a Drop of Another NHS Hat: The Health Clinician (and Patient) Cometh!

We are pleased to welcome a post by our newest editor, Robert Nisbet.

The Beryl Institute defines the patient experience ‘as the sum of all interactions, shaped by an organisations culture, that influence patient perceptions across the continuum of care’. Through a number of benchmarking reports and research projects the Institute demonstrates that actions by most organisations are primarily tactical, which pose challenges to achieving true systemic impact and lasting change. This highlights the need for organisations to think more strategically about their patient experience goals and to let this strategy influence their business objectives and decisions on how clinical care should be delivered.

Thinking through some of the challenges of effective patient engagement in their care and treatment, I quickly drifted into the memory banks of my childhood and in particular family Sunday lunch times. Silence was strictly observed at the table to ensure that the BBC’s Light Programme ‘Family Favourites’ (best remembered by its later name ‘Two-Way Family Favourites’) was not interrupted, as it crackled from a Bakelite wireless that sat like some shrine on the sideboard.

Silence, though, could be interrupted if a Flanders and Swann song was played, to enable us to accompany the well-acclaimed duo. Their songs of the ’60s were linked by contemporary social commentary; ‘a witty and educated diversion‘ as Kenneth Tynan, critic for the Observer, commented.  Flanders and Swann’s concerts toured first with ‘At a Drop of a Hat’ and, on return to the UK after their European and American tour, ‘At the Drop of Another Hat‘.

To prevent any further drift into my recall of the ’60s, the Flanders and Swann song ‘The Gas Man Cometh’ is a timeless piece of insightful commentary into the habits and culture of many organisations and services. Flanders (with Swann nodding his agreement), fresh back from across the pond, would press upon their audience their observations that ‘wandering around things have come to a pretty underpass here in England while we’ve been away. It’s small wonder to us that satire squats, hoof in mouth, under every bush‘. The purpose of satire is to strip of the veneer of comforting illusion and cosy half-truth, and as Flanders and Swann practiced ‘to put it back again’. Of their ‘respectable songs for responsible people’, ‘The Gas Man Cometh’ is best known for providing a ballad of unending domestic upheaval.

Recognising that my reworking of the songs lyrics are no match for the talents of Flanders and Swann, I hope that they still convey the same style of satire that duo applied to situations of everyday life; in this case the challenges faced by the NHS. Moreover, I hope that I do not offend any individual whose profession or ‘craft’ is referenced below. If you wish to sing or play along, click here.

The Health Professional Cometh
‘Twas on a Monday morning
The GP came to call;
The medication wasn’t working – I couldn’t go out at all.
He tore of all my clothes
To try and find a vein,
And I had to call a Nurse in to put them back again.
Oh, it all makes work for the NHS to do!
‘Twas on a Tuesday morning
The Nurse came ’round;
She pulled and she stretched and she said, “Look what I’ve found!
Your joints are far too tight but I’ll put it all to rights.” Then picking up a leg [pop] put my knee right out.
Oh it all makes work for the NHS to do!
‘Twas on a Wednesday morning, the osteopath came round.
He called me Mr. Nesbit, which isn’t quite my name.
He couldn’t reach the knee without sitting on by back, so I called the physio in.
Oh it all makes work for the NHS to do!
‘Twas on the Thursday morning the physio came along.
With her lotions and braces and her merry…phy-sio song,
She popped my knee back in…it took no time at all,
But I had to get a psychiatrist in to come and assess my needs.
Oh it all makes work for the NHS to do!
‘Twas on a Friday morning the psychiatrist made a start.
With questions and theories he covered all my past.
Every nook and every cranny,
But I found when he was gone.
He’d made so depressed that I lost the will to live.
Oh it all makes work for the NHS to do!
On Saturday and Sunday they do no work at all…but alas I sat in A&E.
So, ‘Twas on the Monday morning that the GP came to call.

If we are to engage the patient with a better experience of their healthcare this requires a radical transformation in the way healthcare institutions and professionals serve their patients. Likewise, we need to assist patients (if the circumstances permit) to recognise and take responsibility for being active participants in also changing their ‘role’. Noting that professionals, and their family members, are not immune at times from having to be ‘patients’ themselves.

The necessary change is being spurred by recent legislation coupled with an overwhelming entourage of policies, guidance, commissioning and payment models designed to reduce costs while improving outcomes. These efforts centre on the idea that improved communication and engagement equals a better patient experience and real cost savings. The work of the IMH alongside a wide and informed network of research and evidence-based practice is playing a crucial and influential part not only in the debate but in the ‘making it happen’ zone.

But!

Organisational cultures, professional comfort zones, the long tradition of patient ‘passivity’ and the ‘fairy tale’ belief that the NHS will always be there, sets an incredible challenge. Cuts, reconfigurations, mergers and acquisitions in health and social care services are providing, and will continue to provide for some time, regular items for the news media.  Is there sufficient time to achieve what we know can make vital difference to how we plan and deliver services or will the ‘Gasman still cometh‘ until there is no one to answer their knock on the door?

If by reading this article you have become a little disheartened – then cheer yourself by watching another rendition of the ‘The Gasman Cometh’ (new page)!

Robert J. Nisbet.
Robert is a member of the IMH and by ‘trade’ a social worker. He worked in post-sixties Britain in a variety of mental health services, and these days he provides programme management support for the East Midlands Adult Safeguarding Board.
He blogs at http://donquixote.me/
Contact: Robert@donquixoteme.info
Tweet: @NisbetRock

Helena Brice – A Step Towards Closing the Gap

In addition to Robert’s post above, we also have a re-blog from the Centre for Mental Health’s Policy Officer, Helena Brice.  The original post, and the rest of the Centre’s blog, can be found here.

Recently government published an action plan: ‘Closing the gap: Priorities for essential change in mental health’, building on the 2011 strategy paper ‘No Health without Mental Health’, which set out how to improve the mental health and wellbeing. The strategy aimed to put mental health on a par with physical health (parity of esteem) and to tackle negative outcomes. Lots of positive work has happened since the strategy was published, but there is a lot more still to do and hopefully this action plan will spur the relevant bodies back into action.There are key roles for all government departments as well as local authorities. The Health and Social Care Act 2012 enshrined parity of esteem in law and that esteem is now in the action plan. The Welfare Reform Act 2012 also has had major implications for people with mental health problems.

‘Closing the gap’ lists 25 areas where people can expect to see, and experience, the fastest changes. These fall under the following five headlines:

1. Increasing access to mental health services.
2. Improving the quality of mental health services.
3. Integrating physical and mental health care.
4. Starting early to promote mental wellbeing and prevent mental health problems.
5. Improving the quality of life of people with mental health problems.

1.   Increasing access to mental health services

People have to wait too long for treatment but access to services is a very important step towards recovery. We therefore fully support the commitment to introduce clear standards for access and waiting times by 2015 but they need to apply to children and young people as well as adults. To monitor that this is taking effect in child and adolescent mental health services (CAMHS), the government must collect the appropriate data.

As the Bradley Commission’s first briefing paper explored, Black and minority ethnic (BME) communities are still a group less likely to access mental health services and, when they do, it’s often through less mainstream routes, such as community organisations or liaison and diversion services. It is fantastic to see in the action plan that the government is committed to working with the Race Equality Foundation and other stakeholders to understand why BME communities find it so hard to access services.

2.   Improving the quality of mental health services

Quality of mental health services is a huge issue; unlike in physical health services the friends and family test has not been in place. This means that mental health services have not been under the same obligation as physical health services to improve. Information about public attitudes to the quality of services has not been collected and services can’t find out what works and what doesn’t work. We welcome that from the end of December 2014, the friends and family test will be used in all mental health care settings including for children and young people.

3. Integrating physical and mental health care

If the health care system is going to become more efficient, it is vital that mental health and physical health are integrated. Although there was a clear objective in the strategy that more people with mental health problems would have good physical health, this has still not been realised.

If mental health and physical health are better integrated it will have a number of positive outcomes, not only leading to better health but also to savings for the NHS. A great example of such integration is psychiatric liaison services. They provide mental health care to people being treated for physical health conditions in general hospitals and were found by the Centre to save an average hospital £5 million a year. Centre research has also calculated that between 12% and 18% of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – this equates to roughly £10 billion in England each year.

Accordingly, it is very good to see that the government has asked Health Education England to develop training programmes for healthcare employers on mental health problems and how they may affect their staff.

4.   Starting early to promote mental wellbeing and prevent mental health problems

The government has acknowledged that half of people with lifetime mental health problems first experience symptoms by the age of 14. One in ten children aged between 5 and 16 has a mental health problem, the most common of which is conduct disorder. At its most severe, conduct disorder affects 5% of children but many more will suffer from early behavioural problems that will have serious consequences. If these early behavioural problems are not dealt with, the children affected are twice as likely to leave school with no qualifications, three times more likely to become a teenage parent, six times more likely to die before age 30 and 20 times more likely to end up in prison.

The action plan commits to support schools to identify mental health problems sooner. This is very encouraging, but more needs to be done.

Too often teachers don’t know the symptoms of mental health problems in children and, if they do, are not sure where to refer them. The Centre recently published a series of tailored briefings aimed at different professionals that may come in to contact with children who have the signs of conduct disorder. One of them is specifically for those working in schools.

We know that targeted parenting programmes are effective and cost effective, for severe behavioural problems. The cost of these interventions is more than covered by subsequent savings in public spending. Parenting programmes need to be easily accessible to those parents who need it, but we know that this is not currently the case.

5.   Improving the quality of life of people with mental health problems

Mental health lags behind many other conditions on the information front. Cancer has a long established National Cancer Intelligence Network and there is also a Child and Maternal Health Intelligence Network. Public Health England and NHS England are currently establishing the Mental Health Intelligence Network (MHIN). This network will bring together comprehensive information about mental health and wellbeing to provide a greater insight into common mental health problems, how they vary with age, and what the make-up of different areas is in relation to mental health problems.

The information will help health and wellbeing boards and clinical commissioning groups commission the most appropriate services for their areas. It will also help better inform the government of what works. Practical and substantive change cannot be made without this information.

In recent years there has been a central government cut back on collection of data, hopefully the MHIN will help buck this trend. It is encouraging to see that the government is pushing for greater information sharing. Integration can only truly happen if the information is shared, however we must make sure that the correct information is shared. Information is vital to drive change and to influence policy.

Why this document is good

This paper re-asserts who in the health and social care world are responsible for what in mental health. It is brilliant news that the government is planning on measuring their progress against the priority activities described in the document and that they will report back next year. This means that we should be able to see where improvements are really being made and where work stills need to be done.

Helena Brice
Policy Officer, Centre for Mental Health

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David Smith ~ “Closing the Gap”

David Smith’s blog = “My take on the world, life, mental health and charity in the UK”.

David is Director of Development at The Retreat in York (http://www.theretreatyork.ork.uk @theretreatyork).

On January the 21st David posted a reflection re. “Closing the Gap”.

Please find below the link to this blog.

David has given us his permission to use this on our IMH blog.

http://davidsmith3012.wordpress.com/2014/01/21/36/