Mental Health Services Today and Tomorrow

Pt. 2

Charles Kaye, Michael Howlett

• Publisher: CRC Press
• Year: 2018
• eBook ISBN:
  9781315346830
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This work traces and anticipates past, present and future changes in mental health services to assess the impact both of developments in care, and of the implications of new organisational change. It includes contributions and perspectives of those involved in services at all levels, including service users, to draw upon their experience to give a fuller picture of today and help sketch in tomorrow. It balances academic scrutiny with personal involvement, to reflect both national trends and local initiatives.Overall this work is in two volumes, each of which can stand alone: the companion book Part 1 focuses on the realities of offering and receiving care at a practical and local level; this Part 2 reviews policy and practice from national and international perspectives. Together these books provide essential information and views on mental health services for professionals throughout health and social care, managers, policy planners and policy shapers including those in the third sector and patient groups, academics and the media.

CHAPTER 1

Harnessing the Flow

CHARLES KAYE and MICHAEL HOWLETT

The Current

Across the landscape of English public services flows the Amazon that is the National Health Service (NHS): its tributaries reach into every area and influence domestic and political life on a daily basis. It stretches from fertility to finality, sweeping along colds and cancer, phobias and psychopathy: its availability dominates local debates and its organisation, and reorganisation, is the enduring preoccupation of politicians of all hues. Despite 60 years of turbulence about funding, about clashes between politicians and the medical establishment and about central diktat versus local clamour, it remains in full spate, nationally accepted as an essential feature of today’s, and tomorrow’s, society.

Clearly it has changed continuously since 1948 and that change, as elsewhere in society, has accelerated in pace. While the carapace and the supportive rhetoric surrounding it has a gnarled and almost totemic presence, new forms are emerging which presage change on a scale not previously imagined. Curiously this public process of change has been visible and widely advertised but hardly recognised. Generations of politicians have struggled with the need to control and direct a service that swells by social osmosis, sucking in the needs of a population that increasingly looks for medical solutions to relieve difficulties – with doctors and a pharmaceutical industry that are just as eager and dedicated to providing those solutions. The resulting monolith – 8.2% of gross domestic product,¹ 1.3 million employees (in 2004)² – seems nationally unmanageable, spilling over in a thousand places, uneven and erratic.

Over the last 20 years a new national philosophy has developed – in an unspoken and, of course, unacknowledged alliance between different governments during that time.

This could be said to have started with Roy Griffiths³ and his recommendation of general management, to have moved through the purchaser/provider split, and to have come to full fruition in the current description⁴ of public service reforms which seek to:

• ➤ combine top-down approaches of inspection, regulation and targets
• ➤ with horizontal pressure from competition and contestability
• ➤ and bottom-up incentives of choice and voice
• ➤ supported by improvements in capability and capacity
• ➤ … to create a “self improving system”’.

In practical terms for the NHS, this means the overt separation of all those elements that provide healthcare (progressively to become Foundation Trusts), the heavily fertilised introduction of competition from independent healthcare providers and the creation of a national network of commissioners who will buy the best value healthcare according to nationally set standards. Or as the same document⁵ describes it (in hospital terms):

FIGURE 1.1 Policy review: public services, January 2007. © Crown copyright. Reproduced with permission from Cabinet Office, Prime Minister’s Strategy Unit.

So the monolith is deconstructed by separating the planning, buying and monitoring powers from the responsibility for providing. The former remains the task of government (representing the taxpayers) while the latter becomes a devolved plurality where market forces will come into play sorting out the weak and the inefficient. (Interestingly the Scottish model cleaves to 14 Health Boards responsible for planning and delivery of all healthcare.)

‘ … we are likely to see the NHS evolving into a network rather than an institution: more “ecosystem” than “army”.’

Stevens S. Crosscurrents. 50th Anniversary Edition. London: NHS Institute for Innovation and Improvement; 2006.

This is the clear and unambiguous goal of the political leaders supported by their praetorian guard, the managers who obediently lead their cohorts onto the next target. However, all the indications suggest that the vision (rapidly becoming a reality as the first group of Foundation Trusts – including several mental healthcare providers – rather carefully flex their competitive muscles) has yet to be recognised or accepted by the NHS staff groups – who will have to make it work – or by the general public whose focus remains not the national philosophy but the local provision. Further it needs to be appreciated that this new model is essentially geared to the provision of acute healthcare and acute illness: note that the diagram above refers explicitly to ‘hospitals’, the behemoths of the NHS. The questions we want to ask are simple. Firstly, in practical terms how does this new analysis apply to mental healthcare? And secondly, what evidence is there that it will improve the nation’s mental health?

Turbulence

Before we can respond to these questions, we need to describe key elements of change and conflict in the world of mental healthcare which have a major influence on that service and national opinion.

In one area, mental health has been a pioneer, setting a trend which politicians hope that acute care will follow (even if with a great deal of kicking and screaming). The exodus from the Victorian institutional model of mental healthcare has been dramatic (not just in England but throughout western Europe): the number of inpatient psychiatric beds in England has reduced from 131 825 in 1978, to 77 628 in 1988–89, to 33 000 in 2001–02.⁶ In 2005–06, the figure was 29 802.⁷ The new Care in the Community approach quickly ran into considerable problems and has been extensively revamped. But the institutions themselves are now literally being built over, becoming in many places the location for new housing estates.

FIGURE 1.2 Park Prewett Hospital, Hampshire. Constructed between 1913 and 1916 to accommodate 1300 patients. The water tower is between the ward block and main entrance and new housing is being constructed on the left of the picture.

This de-institutionalisation, however, has exceptions: significantly the provision of secure psychiatry beds has nearly doubled in a decade, from 1557 in 1996 to 2807 in 2006.⁸ Over that period secure psychiatric beds have risen from 4% of the total available to 9.4%. In the same period the prison population has risen from 45 000 (1993) to 80 000 (2006)⁹ and is still rising. And while transcarceration may not be explicitly established, the dramatically high incidence of mental illness and mental disorder in the prison population has been.¹⁰ Similar trends have been noted in several other European countries – particularly The Netherlands, Germany, Sweden and Spain.¹¹

Running alongside this massive reorientation of mental health services – and literally of many of its recipients – has been an awkward, conflicting and contentious public debate. The stigma attached to any form of mental illness has long been evident and is well illustrated elsewhere in our companion volume, Mental Health Services Today and Tomorrow Part 1: experiences of providing and receiving care (cf. chapters by Hegarty and O’Brien, Campbell, and Pelendrides). Much laudable effort has been invested nationally and locally to inform and educate and to counter this prejudice. Some ground has been gained by hard work and persistence, although almost daily the negative is expressed.

‘Microchips for mentally ill planned in crime shake-up’

Daily Telegraph, 17 January 2007

A survey by the Scottish Executive, however, in 2005,¹² showed an encouraging trend of better understanding and greater tolerance. This ambivalence is repeated in the 2007 survey on Attitudes to Mental Illness where positive responses on questions of mental illness declined compared to earlier surveys.

Nevertheless, the painstaking work of sharing and explaining is often eclipsed by the surge of fear that the reporting of a violent incident involving mental illness can release. A random stabbing on the underground or in Richmond Park speaks with greater volume and more authority than an appeal to understanding and humanity. And the Government’s determined fierceness in confronting and punishing crime in many respects amplifies the volume and confirms the authority. Thus, not unusually, government’s public pronouncements and attitudes – in all sincerity – broadcast different messages which compete and conflict. It may be understandable for Walt Whitman to say:

‘Do I contradict myself?

Very well then I contradict myself.

(I am large, I contain multitudes.)’

From: ‘Song of Myself’

But governments work on a national canvas with greater impact – and con tradictions at the centre breed greater confusion!

Essentially we still live in a society which is antipathetic, frightened, suspicious and even contemptuous of mental illness, and ever ready to condemn, anathematise and even criminalise it. The experience of mental illness does not in the wider context carry with it the sympathy (or the funding) accorded to cancer sufferers or sick children and recovery does not generate the feel-good factor that, say, a successful transplant offers.

So, as we survey the turbid stream, these are our key observations:

• ➤ carried along with the rest of the NHS, mental healthcare is being reshaped – providers segregated and competition anticipated
• ➤ a highly regulated, centrally driven pattern of service has established uniform and multifarious targets with a new standard service provision to achieve them
• ➤ in the public arena, stigma and fear still dominate the spectators’ view of mental illness; despite – or perhaps because of – its high incidence, mental illness remains ostracised
• ➤ mental health services have not yet fully internalised/digested the move from institution to community.

Shooting The Rapids

The NHS has rarely enjoyed tranquillity; controversy has been both midwife and godfather. But the present time seems particularly tumultuous and as always in the public health debate when the going gets tough, it gets even tougher for mental health services. Our survey in 2005¹³ revealed real concerns about finance and the availability of funds to further improvements. This note is becoming more dominant: as has always historically been the case, when the acute services go into deficit, one pocket to raid is the mental health budget. Mental Health Trusts as far apart as Nottinghamshire and Hampshire recorded in 2005–06 substantial levies they had to return to Primary Care Trusts (PCTs) to meet acute sector deficits. Public service finances are amazingly complicated, as Michael Maher describes them elsewhere in this book:

Financial and managerial processes in the NHS are famously Byzantine in their obscurity and cumbersomeness; those of local authorities aspire to match them in these qualities.

A recent monthly financial report to a Mental Health Partnership Trust ran to 30 pages of text and charts! In addition current discussions about ‘disinvestment’ between newly aggregated PCTs and Mental Health Trusts anticipate cuts, however they are presented. Surveys^14,15 by Rethink in 2006 suggested that £30 million had been cut from Trusts’ mental health budgets in 2005–06 with the prospect of a further £37 million to follow. The Sainsbury Centre Review¹⁶ painted a similar picture. However, targets and expectations remain unchanged, thus generatin...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• List of contributors
• Acknowledgements
• Introduction
• 1 Harnessing the Flow
• 2 The social and economic impact of mental health: meeting the challenge
• 3 Central control and local freedom: a new balance
• 4 New ways of working in mental health services
• 5 More than black and white: mental health services provided to people from black and minority ethnic communities
• 6 Race and mental health: there is more to race than racism
• 7 Child and adolescent mental health services in England
• 8 Third age mental health services: all our tomorrows?
• 9 Services for depression, anxiety and post-traumatic stress disorder
• 10 Mental health, employment and housing
• 11 Devolving mental health social care: policy outcomes in Sweden and England
• 12 Mental health in Europe: the Green Paper
• 13 Mental health in Europe: the wider challenge
• Index