Most fair-minded people would agree that there have been recent improvements in NHS services for those with physical illnesses. Sadly, this is not so for those with psychiatric problems. Mental health is supposedly one of the NHS priorities, and the government began well with the first National Service Framework for mental health which contained spending promises in excess of £1 billion. However, few of the service targets have been reached, and nobody has been able to trace where the extra funds went. All agree they didn’t reach the patients.
Furthermore, psychiatric services came out very badly in recent assessments by the Healthcare Commission. More than one third of mental heath trusts received a rating of one star or less – a performance much worse than acute trusts.
In particular, the standard of in-patient care for people with serious mental illness – schizophrenia and manic-depression – has been in freefall. Inner city units have become frightening places with endemic drug abuse and violence. Women have been especially at risk – one of my patients described her previous ward as “Sodom and Gomorrah” with disturbed and disturbing men propositioning her for drugs or sex. Last year, half the respondents to a MIND survey reported sexual harassment, abuse or even rape on wards. The Sainsbury Centre for Mental Health found that 40 per cent of inpatients did not take part in any social or recreational therapy during their stay.
A picture emerged “of an inefficient, atherapeutic and poorly co-ordinated service, profoundly demoralising to patients and staff, and unable to cope with the growing pressures.”
Inevitably, patients are reluctant to be admitted to such wards, which are often in a deplorable physical state, so the proportion that have to be admitted under compulsion has steadily increased – to over half of all patients in inner London. Professionals are fleeing from the wards too. One survey showed that 50 per cent of night staff were agency or bank staff. There are 400 vacancies for consultant psychiatrists, so patients endure a succession of disinterested locum doctors. One man suffering from schizophrenia told me that he had had 18 consultants in three years. To my shame, I initially suspected that this might be part of his delusional system until his claim was smartly verified by the social worker who accompanied him.
The shortage of beds means that only the very severely ill can be admitted, which results in a toxic concentration of very disturbed people. It also means that there are no places available for many who would benefit. A young woman went to her GP saying she recognised the warning signs that she was about to relapse into frank psychosis and asked for admission. However, the duty psychiatrist refused hospitalisation because she still had insight into her condition and there were far worse cases without a bed. As she predicted, two weeks later she was hallucinating and deluded and everybody wanted her admitted. However, by then she had lost insight, denied that she was ill and had to be admitted under compulsion.
To compensate for the shortage of beds, a thriving market place has developed in the provision of private places for NHS patients, offering poor quality care at huge costs. Over a third of places for patients in need of security are within privately owned institutions. They are often hundreds of miles from the patient’s home and, of course, there is no incentive for such institutions to discharge their patients, since it would decrease their income. As an editorial in the British Medical Journal pointed out, the annual cost to the NHS exceeds £100 million, but no mechanism is in place to monitor value for money or the standards of these private madhouses.
How did things get so bad?
As part of a switch to community care, the number of NHS beds for the mentally ill declined from 148,000 in 1954 to 33,000 in 2002. This was planned, but in retrospect it is clear that policymakers overestimated the ability of community services to keep people well. Furthermore, as part of the same policy, any additional funds for mental health services were channelled into developing community outreach services, thus starving inpatient units of resources.
Secondly, the frequency of psychosis in cities has risen. The use of drugs such as amphetamines, cocaine and cannabis increases the risk of schizophrenia. The fact that many don’t stop taking the drugs which caused their illness in the first place, means that instead of recovering, they repeatedly cycle through the wards. In addition, migrants are well known to be at increased risk of schizophrenia, and black people in the UK have rates six times higher than the rest of the population. So the combination of more people with drug-induced psychosis and more migrants means that services in many inner cities have far more patients than they budgeted for.
Thirdly, although the proportion of murders caused by the mentally ill has been steadily declining for decades, government ministers and tabloid headlines endlessly emphasise the risk of violence from these people.
Psychiatrists react to this pressure by concluding that they will not lose their job by locking up too many patients, but they might well do so by being too liberal. Consequently they admit more patients to hospital under compulsion and are more reluctant to discharge them.
What can be done?
The potential for helping the mentally ill has never been greater. The ideological wars that used to divide mental health professionals and users are now a thing of the past and all are agreed on the importance of making available the best in medical, psychological and social treatments. Over the last ten years there have been dramatic advances in these treatments. There are better antipsychotics, such as clozapine, and new drugs for those with manic depression. Patients and their doctors have a better chance of jointly choosing a drug with maximum benefit and minimum side-effects, but although recommended by NICE, the new drugs are not sufficiently prescribed. Talking treatments are also necessary and over the last decade UK universities have demonstrated that cognitive behaviour therapy is also valuable. What is holding us back, is the shortage of psychologists trained to administer it.
Some of our services have been improving. For example, home treatment is now more available, as is treatment for heroin addicts and care for disturbed young people. However, European-wide surveys have shown that our neighbours are much better at providing high-quality care. What determines the quality of care? Not surprisingly, the amount of resources available. Holland, Switzerland and the Scandinavian countries invest the most and have the best psychiatric services. Here in the UK it is vital to reverse the trend whereby mental health services receive a steadily diminishing proportion of the NHS budget.
Furthermore, we need to stop diverting resources from inpatient units in order to fund other new initiatives.
Instead we must provide accommodation that patients can appreciate. New hospitals for the physically ill are springing up in many cities; surely the mentally ill have a right to similar quality of accommodation. New units can have a tremendous effect. When the Hackney psychiatric unit moved from an old Victorian hospital into purpose-built accommodation, the compulsory admission rate was halved! Modern units can also help to renew the enthusiasm of nurses and prevent the haemorrhage of experienced staff. Not only are permanent staff less expensive than agency or locum staff, but admissions are likely to be shorter, more fruitful and less distressing if patients and staff know each other.
Finding the right social niche for patients is also important, and here government initiatives on social exclusion have much to offer the mentally ill. In addition, reintroducing the hospital social worker would facilitate appropriate and speedy transitions between hospital and community. Despite the enormous pressure, and at times greater than 100 per cent occupancy of acute psychiatric beds, some patients remain in hospital for months because of bureaucratic wrangles over who should fund their placement outside. Dealing with this would free up capacity and save much-needed funds.
Finally, we need to address the rising trend of drug abuse, otherwise services will be flooded with an increasing number of patients with drug-induced psychoses. While few care about the exact legal classification of cannabis, it is important that users know that heavy and persistent use of it increases the risk of schizophrenia.
