WHAT IS WRONG WITH OUR NHS MENTAL HEALTH SERVICES?

FIRST REPORT ON A LISTENING PROJECT CONDUCTED

BY

RABBI DR MICHAEL HILTON AND RABBI DAVID MITCHELL 

MAY 2024

We began our listening project because we have both seen for ourselves, in our congregations and in our own lives, too many examples of negligent or incorrect treatment of seriously mentally ill people, causing unwarranted distress, a worsening of their illness, or occasionally even their deaths. We wanted to find out what is going wrong in NHS services for mentally ill people. Over the past year, we have interviewed 17 people, including patients, carers, GPs, psychiatrists at different stages of their career, voluntary sector executives, and nurses. We have been fortunate to be able to include administrators and researchers at the very top of the NHS tree or the Royal College of Psychiatrists.

Some of our interviewees are broadly happy with the NHS services, but  even they gave us sharply critical comments. The vast majority, however, told us about alarming faults and gaps in the system. We interviewed them under the Chatham House Rule which enables us to publish what they said without restriction, but without mentioning any of their names.

What follows is a brief summary of what we heard. There are two caveats. Firstly, to pick out quotable phrases is necessarily subjective. To achieve complete objectivity is impossible. Secondly, it has become clear to us that the solutions are by no means simple. The National Health Service is very complex and there are many very different faults which need remedy.

Shortage of staff and resources is everywhere apparent, but we also heard of many systemic failures which would not be remedied by more funds. The unintended consequence of specialised mental health teams has been multiple teams of different kinds with poor cross-referrals and people being excluded from the system.  Patients are frequently discharged into the care of their GP while still needing additional help, which means new referrals are needed.* What was once a joined up system has become very fragmented. Too often, nobody takes responsibility. This is sometimes because hospital and community teams can be too large.

Fragmentation happens in the broader health services, but the consequences for those with an acute or long term severe mental illness can be much more devastating. People whose lives are dysfunctional because of their illness cannot cope with a health system which can sometimes be thought of as dysfunctional as they are. The huge change which means that inpatients and outpatients are seen by different teams has not benefited everyone. Furthermore, we urgently need to restore the ability of one specialist team to refer a patient to another team without having to go through the GP. Public interest disclosures within the NHS need to be listened to more attentively and action taken.

Patients who desperately need the reassurance that they and their problems are being understood and acted on do not always find it. We heard from one patient who has been taking clozapine for years, but seen the essential monitoring get worse and worse, with ‘negligence and sloppiness on an industrial scale.’ For that patient the local mental health team has lost 66% of its staff. The patient’s carer has looked at ‘Prevention of Future Deaths’ (PFD) reports from coroners where clozapine is mentioned. Each year, 450 PFD reports are sent to institutions, including government ministers, by coroners in England and Wales, but only a minority are acted upon. The law requires recipients of such reports to respond with a proposed course of action within 56 days. But, we heard, no one enforces that legislation, no one follows up if the response is late, and nothing happens if there is no response. There is no independent body, no system for monitoring PFDs — no one is responsible. The effect of this is that millions of pounds spent on the 109 coroner areas in England and Wales is being wasted because the lessons are not being learned.

A very articulate older carer told us how she has a detailed knowledge of the system and is very active in complaining, including attending Trust meetings. Her relative who is a long term patient had seven different care co-ordinators in a twelve month period. Only constant nagging and lobbying of the NHS Trust CEO in person led to an adequate level of care. Asked what is the most important improvement that could be made, she said that ‘staff should be more compassionate in their actions.’ It often emerges that the NHS undervalues its own staff, and they in turn sometimes undervalue the patients. This is not a problem which requires a higher budget. We frequently noted that patients and carers flounder around in the system until by chance they meet one wonderful person with the compassion and the position to organise the correct care.

However, such excellence is rarely rewarded and good staff so often leave. Mental health only gets 3% of the NHS budget which is too low to meet the demand. One interviewee told us that there is too much reliance on agency nurses who don’t have the training.  Because the general adult mental health provision is so poor, people are not being followed up and they are getting unwell again. They end up in hospital and then they are discharged too early. If they had proper treatment in the first place they wouldn’t need the rehabilitation unit. Many are unable to advocate for themselves. There is too much pressure on beds, leading to the ‘revolving door’ effect (patients get discharged but get ill again and have to be readmitted).  Hospital and primary care staff feel that too much time has to be used for doing their own administration and record keeping. ‘We need earlier intervention and better staff training.’  ‘In the whole NHS, not enough staff are arriving and too many are leaving.’  

Services are overwhelmed and patients devalued. This means that more preventative medicine is vital, accompanied by early intervention and better training for staff and the voluntary sector. ‘Professionals need more give into the system so that staff have head space and don’t feel their hands are tied.’ ‘Patients are being left to handle more of their own health care. There are high levels of anxiety in the population about trying to get through the door.’

But even this analysis is not simple. We heard that services have been expanding since 2016 but demand has increased even faster. ‘One third get seen by professionals, one third get community help, and one third have nothing.’

The failure of the primary care service to provide a reasonable degree of access to one named GP who knows the patient is a huge disaster for mental health services, where understanding of a patient’s needs requires much patience and more time. At the same time, there is an explosion of demand, particularly for services for young people, so much so that the system is becoming paralysed. Professionals and other have successfully opposed stigma about young people’s mental health and now young people talk all the time about their mental health. But we didn’t prepare for the inevitable consequences of a huge rise in referrals, leading to a demand crisis.

This is exacerbated by the overall numbers of GPS going down and access to them deteriorating. Two thirds of students say they have mental health issues, which means some problems are being over-medicalised. What protects us from life’s adversity, including major life events? We do it by activating our social networks (96%).  The main causes of mental illness in children and young people are bullying, poverty, being abused and drugs.  A very senior psychiatrist told us that £40 billion should be transferred from secondary to primary care, including provision of counselling nursing and therapy services which can deal with problems before they become a serious mental illness. Primary care sees 82% of patients (1.4 million a day) but has only 8% of the budget.

 What is more, we know that there are people who, because of the nature of their lives, are excluded from NHS care altogether. One interviewee, who felt in her own work they were achieving much that is useful, nevertheless told us that politicians are promoting the survival of the fittest. It certainly does not help that the new Mental Health Bill has been postponed for an indefinite period. Although there is much more sympathy and awareness in the wider community of mental illness, services have not adapted to meet the increasing needs. And change takes far too long.

The expansion of primary care would help a lot. So many people suffer from mental illness that it would be impossible for all of them to access specialist services. Mental health needs to form a larger proportion of medical training. We ourselves have witnessed situations where even an experienced GP feels unable to prescribe or to reduce medication because they do not have the training.

Exacerbating all these problems is a frequent lack of understanding by NHS managers. Too many tend to treat mental health as simply another branch of physical health. This leads to the setting of inappropriate aims and targets. The frequent statistics about the numbers of patients diagnosed with a particular condition tells us nothing about their wellbeing and happiness. Having a diagnosis is useless when the support and treatment does not materialise. One interviewee put it like this: ‘the problem is that built into our notion of people being unwell is the idea that they will get better — but sometimes they don’t. This wrong thinking can lead to risks being downgraded. Good decision making takes time, and staff can become desensitised.’  Another interviewee told us: ‘Working holistically has in effect been banned by misguided management efforts to improve productivity. Discharge from hospital or from a community team should not mean discharge from care.’

A particular concern of ours is the prevention of suicide. We have seen too many lives turned upside down by the anguish of losing a loved one to suicide. NHS managers actively promote the use of risk assessment software, which is no substitute for building a good support system around the patient. We are aware that suicide is a low frequency outcome and always difficult to predict. But there is much more that could be done. IT systems need to be joined up across all trusts and surgeries so that notes on previous episodes can be easily accessed, especially when episodes happen in quick succession. Care needs much more continuity ,and non-medical support needs a huge boost for vulnerable people at risk.

There are also problems within the charity sector. Well trained professional staff in a voluntary organisation too often find that they are not treated as professionals by NHS staff, and this can mean, for example, that patients they take to Accident and Emergency departments are required to wait for a further triage which will be the same as the charity has already done and recorded. Volunteer groups in faith organisations and in other community groups find their efforts impeded by red tape and sometimes over-zealous regulatory and compliance requirements. These should not be so arduous that they inhibit the recruitment of much needed volunteers.

We also need better trained GPs with bigger budgets, better qualifications in mental health and longer time slots for appointments, and compassionate care co-ordinators who can offer good continuity of care. One junior doctor told us that in hospitals, pressure to discharge means making overly complex decisions under time pressure. There is not enough support to discharge people to and this leads to defensive medicine. GPs have the primary responsibility for that patient from the moment of discharge. But at all levels relational models have been replaced by transactional ones. Getting to know patients is not valued and does not appear in the targets, because targets must be clearly quantifiable. People’s happiness and quality of life are not easily measured, though there are indications which could be used. Professional autonomy for everyone needs to be restored and valued. Managers should not be permitted to veto decisions which are in the best interests of patients. Above all, we need to start putting patients first and services need to have an outward focus.

Conclusion:

We have discovered that all mental health services are in crisis because of inadequate budgets and staffing, and rising demand. Access has deteriorated and relationship building between patients and professionals is poor. Services are not joined up, and primary care from GPs, for so long the backbone of the system, is very inadequate and sometimes at the point of failure.

 We recommend as first steps:

1. An immediate reduction in the fragmentation* of the service by allowing referrals from one clinic direct to another.

2. in the medium term, linked up and efficient IT systems.

3. Investment in staff and training for the longer term.

In time, better services will lead to healthier patients and save costs. Above all, patients need to be put first.  Good therapeutic relationships cannot be measured by NHS targets. In the past, change has come about because of public anxiety. Therefore, much lobbying needs to be done.

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