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 18th February 2014, Norman Lamb, Care and Support Minister, launched the ‘Crisis Care Concordat’ ( – 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
Tweet: @NisbetRock



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2 responses to “Robert Nisbet – Where will mental health services be one year from now?

  1. Pingback: Robert Nisbet – Where will mental health services be one year from now? | donquixotedotme

  2. In welcoming the speculation as to where mental health is going, I venture a suggestion that change will be growing apace, as psychiatry seeks to address how better approaches and treatments are eclipsing pharmacology and funding dilemmas with more fundamental ground-breaking challenges to the current order of conventional wisdom. To help us all, Daniel Mackler’s exploration of the Open Dialogue Approach is now available in full, so here it is for your thorough appraisal:

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