Today’s Guardian interview with Professor Simon Wessely, President of the Royal College of Psychiatrists, reveals how large the mental health care and treatment gap has become. Professor Wessely draws comparisons between mental health and cancer services, saying:
“People are still routinely waiting for – well, we don’t really know, but certainly more than 18 weeks, possibly up to two years, for their treatment and that is routine in some parts of the country. Some children aren’t getting any treatment at all – literally none. That’s what’s happening. So although we have the aspiration, the gap is now so big and yet there is no more money,” he said.
Wessely said there would be a public outcry if those who went without treatment were cancer patients rather than people with mental health problems. Imagine, he told the Guardian, the reaction if he gave a talk that began: “‘So, we have a problem in cancer service at the moment. Only 30% of people with cancer are getting treatment, so 70% of them don’t get any treatment for their cancer at all and it’s not even recognised.”
NHS England places considerable emphasis on ‘parity of esteem‘, with the Improving Access to Psychological Therapies (IAPT) programme intended to be a one, key, part of making this happen. Evidence like Simon Wessely’s, combined with (for example) BBC/Community Care investigatory evidence of cuts in services, points to a chasm between the stated intention and the frontline reality.
This lack of parity extends to research. Within the last week or so the Liberal Democrats made a promise to include in their general election manifesto a commitment to increase mental health research funding by £50m each year. It has often struck me how poorly funded mental health research is. Mental health researchers can apply for support to bodies like the NIHR and NISCHR, and many do with some success (see all my previous posts on this site relating to COCAPP, RiSC and Plan4Recovery, for example). But unlike most other areas of health care the mental health field has no large-scale, dedicated, charitable research funding. Mental Health Research UK was founded in 2008 as (it says on its website) the UK’s first charity devoted specifically to raising funds to support research into the causes and treatments of mental illness. And that’s about it, I think: unless someone is able to tell me differently?
For the second time in two months the BBC and Community Care have collaborated to establish the extent of funding cuts to mental health services in England. Freedom of Information requests were sent to 51 NHS trusts, of whom 43 responded. Summaries of this investigation, and headline findings, can be found on the BBC website here and on the Community Care website here. Community Care says:
Data returned by over two-thirds of the mental health trusts, obtained in two separate Freedom of Information requests, showed that:
- Overall trust budgets for 2013/14 had shrunk by 2.3% in real terms from 2011/12. Ten out of 13 trusts that provided forecast budgets for 2014/15 are projecting further cuts next year.
- Budgets for ‘crisis resolution teams’ fell 1.7% in real terms compared to 2011/12 while the average monthly referrals to these teams rose 16%. The teams provide intensive home treatment in a bid to prevent acutely unwell people being hospitalised.
- Budgets for community mental health teams flatlined in real terms but referrals rose 13.3%. These services provide ongoing support in a bid to prevent people’s mental health deteriorating to crisis point.
Community Care also lists 10 ways this underfunding is damaging care.
This is also the month that a special, free-to-download, ‘impact of austerity’ edition of Mental Health Nursing journal has appeared. In an email forwarded to all members of Mental Health Nurse Academics UK by Steve Hemingway (who is both an MHNA member and a member of the MHN editorial board), Dave Munday at Unite the Union (which publishes the journal) says:
This month the Mental Health Nursing journal is focused on austerity and mental health. I hope you’ll agree with me that this is a vitally important topic that not only every mental health nurse should know about, but every citizen. We hope that the journal will help to trigger some thoughts and debates that you can have locally in your workplaces but also outside of work. To this end we’re making the journal free to access even if you’re not a MHNA member or MHN subscriber.
Last week I drafted a short, commentary-type, paper for a special edition of Mental Health Nursing which will be focusing on practice and services during a time of austerity. Some years ago I was on the editorial board of MHN. I’m pleased to learn that having disappeared from the library shelves in favour of becoming an online journal (available only to members of Unite the Union) it has made a return in traditional paper form. I’ve been sent a stack of copies, which I’ll be distributing to students.
Anyway: no sooner had I completed my draft and sent it onwards than yesterday’s big health and social care story broke. Under the banner England’s mental health services ‘in crisis’ the BBC ran a report drawing on a joint investigation conducted with Community Care magazine. The headlines were sobering, suggesting over 1,500 mental health hospital beds being lost since April 2011. These bald figures were illustrated with personal stories, revealing people needing crisis admission being transferred to wherever beds could be found around the country, and wards running at over 100% occupancy.
This is very bad news, and suggests a shrinkage back to the way things last were in the early to mid 1990s. In writing my paper for MHN I fished out my copy of this article by David McDaid and Martin Knapp, in which the point is made that at times of economic hardship demand for mental health care increases. And yet, as we are finding, services are actually retracting as austerity bites.
Two interesting collections of papers have caught my eye in the last week or so. Davina Allen has edited an online volume of articles, all previously published in the journal Sociology of Health & Illness, addressing the sociology of care work. In her editorial Davina sets the scene with reference to the Francis Inquiries and concludes with this:
[…] in the wake of Francis the predominant response to raising the quality of care and compassion has been to focus on the attributes of individuals and wider regulatory arrangements. As we have seen, however, the kind of care that can be provided depends fundamentally on the social organisation of care work, which in turn hinges on what we (society) are prepared to pay for. Francis has called for national fundamental care standards, but this requires more careful attention to the models of care-giving practice that will sustain them, including care-giver roles, the inter-relationship of care work components and features of the organisational context. The papers in this collection reveal there are no easy answers to these questions, but the insights they yield make an important contribution to these debates. In bringing the papers together in this virtual special issue the aim is to both raise the profile of the individual contributions, but also their collective value to this critical issue of public and policy concern.
Meanwhile, Tim Tenbensel, Stephen Birch and Sarah Curtis have edited a special issue of Social Science & Medicine devoted to the study of complexity in health and health care systems. I have a personal interest here, as it is in this collection of new papers that my article Connections and consequences in complex systems: insights from a case study of the emergence and local impact of crisis resolution and home treatment services appears. Describing himself as ‘a sympathetic outsider to complexity theory’, Tim Tenbensel in his editorial closes with this:
[…] perhaps the most important conceptual issue for complexity theory seems to be the place of ‘top-down’ interventions in complex systems. Are they part of the landscape of complexity, or are they things that ‘impede’ the unfolding of self-organising, emergent phenomena? More sophisticated applications of complexity suggest the former answer, yet the will to control through linear, rational, prescriptive mechanisms remains an ever-present shadow – something that should be minimised – because it this a defining trope of complexity theory applied to the social sciences. This theoretical challenge is perhaps most pressing in contexts in which health services are directly funded from public sources.
My apologies to the doctoral students whose ‘complex systems’ module I taught a few weeks ago, who may erroneously have thought that I knew what I was talking about, but like Tim Tenbensel I regard myself as being a relative newcomer to this whole complexity approach. So I for one am looking forward to reading the other papers in this new collection, and to learning plenty that is new.
Further to my last post referring to Raymond Tallis’ staunch defence of the NHS, a second excellent health service-related talk at Hay was Andrew Edgar’s. Andrew is a philosopher at Cardiff University, and on Tuesday he gave a customarily considered account of (amongst other things) the principles underpinning the NHS and how these contrast with those associated with health care systems elsewhere in the world. I particularly appreciated Andrew’s view of the NHS as being more than a way of simply (simply?) funding and delivering health care. It is a unifying force, embodying the majority view that some things are best paid for and organised collectively. Insurance based systems, as Andrew observed, are abhorrent to many in the UK because they treat health care as a commodity and pay insufficient regard to need.
Beyond the principles, as Andrew also pointed out, lie some difficult day-to-day health service realities. These include the existence of rationing (which clearly exists, but is rarely talked about in an open way), and the fact that the system retains a capacity to grind down, and sometimes even brutalise, those who work within it. But opening the service up to market forces, along the lines happening in England with the passing of the Health and Social Care Act 2012, is no remedy. Note my reference to ‘England’ here. Quite correctly, in my view, Andrew was careful to talk of not one but four ‘NHSs’ reflecting the divergence in systems across the different countries.
Yesterday at the Hay Festival I heard Raymond Tallis deliver a strong attack on the coalition government’s ‘redisorganisation’ of the NHS in England. The Health and Social Care Act 2012 has opened the NHS to the market in unprecedented fashion. Tallis talked of the dominance of private providers on clinical commissioning groups, and gave examples of patients being cherrypicked by organisations more concerned with profit than with meeting need. He also contrasted the upheaval with pre-2010 general election promises by both the Conservatives and the LibDems not to unleash major top-down change on the health service.
Tallis was critical of his own profession (medicine) for having failed to coordinate opposition to the legislation as it worked its way through parliament. He did, though, pick out and praise Clare Gerada of the RCGP for leading the resistance. I’m aware that the RCN was against the proposed Act, but I’m not sure that nurses as a group were particularly visible during the debates.
The first question from the audience asked what needs to be done to prevent the Act infecting Wales. The balance of politics here is different than in England, but it was a good question nonetheless.
Since publishing my last post the Health and Social Care Act has come into force in England. For a frontline NHS worker’s views on what this means, check out this commentary by East London GP Dr Youssef El-Gingihy. Personally I’m glad to be living and working in Wales. I am pleased to say that here there is still government support for an NHS which is funded, planned and provided with the public good in mind.
Elsewhere, within my corner of nursing (the academic bit) an editorial by David Thompson and Philip Darbyshire which appeared in the January issue of the Journal of Advanced Nursing has provoked a series of robust, just-published, responses. These have variously been penned by Bryar et al, Gallagher, Ralph, Rolley, White and Cross and Williams. JAN also carries Thompson and Darbyshire’s rejoinder, through which the responses are responded to.
The debate has a number of elements. In their editorial Thompson and Darbyshire argued that the quality of academic nursing has declined, and that some nurses working in some universities occupy positions of seniority which their experiences and qualifications have not prepared them for. They also accused those they termed the ‘killer elite’ of running departments as managerial fiefdoms, without tolerance for critical enquiry or dissent. This month’s responses include pieces both for, and against, the Thompson and Darbyshire position. Interested readers can follow all this up for themselves through the links I’ve given above, and I won’t attempt to summarise the full range of views offered.
What I will say is that, for all sorts of historical and contextual reasons, it remains remarkably difficult to sustain a career as a nurse doing research. Funding streams for nursing and midwifery departments in UK universities are largely earmarked for teaching, and relatively few university-based nurses have had opportunities to study for research degrees. Amongst those who have completed doctorates many have found it hard to progress to become independent researchers. Large numbers appear to have returned to roles which do not include significant research components. Only a handful of departments have a critical mass of research-active nurses and midwives, leaving the majority vulnerable when key people leave or retire.
But we have to keep at it. What nurses do touches the lives of millions, every day of the year. Research has an important part to play in improving the nursing contribution: from finding out ‘what works’, to learning about the experience of people on the receiving end of nurses’ services, and onwards to establishing how care might best be organised. Taking a research idea and turning it into a proposal which stands a chance of securing funding through open competition is tough (ask a scientist or a historian: it’s just the same for them), but if we truly want a sound base for nursing practice then this is work which has to be done. And as I am currently learning all over again, actually doing research once funding has been obtained is never as straightforward as the textbooks would have us believe.
Yesterday the Health Secretary, Jeremy Hunt, declared that would-be nurses should spend a year doing hands-on care, working directly with health care assistants, in order to be eligible for funded nursing degrees. Today it occurs to me that large sections of the population may be labouring under the misapprehension that student nurses currently spend their whole three years sitting in classrooms. So let me join the queue of people who have already pointed out that, absolutely, they do not. In order to register, students are required to spend half of their time working directly in practice. This point, plus others, was very well-made by the University of Southampton student (whose name I cannot remember, unfortunately) who was interviewed on this matter on yesterday’s BBC News. Bearing in mind that nursing degrees are lengthy affairs (the terms are much longer than those followed by students of most other disciplines), the amount of time learners spend doing care work is already significant.