Authors:
Rabbi Michael Hilton
Rabbi David Mitchell
Executive Summary
Spiritual guidance and practical help are the two foundations of Jewish pastoral care. As rabbis, we help mourners hold the darkness of grief, but need much more help with acute mental illness. To educate ourselves, we conducted a listening project with 21 participants (professionals, patients and carers) to learn about the state of the NHS services. We identified six key themes: workforce crisis, communication failures, lack of access to the services, inadequate resources, bureaucratic barriers and patient safety concerns. We conclude that the NHS needs not only more resources, but also values-driven care that prioritises building relationships and the quality of patients’ lives over more easily measurable targets.
A LAST RESORT
Ministers of religion are often approached as a last resort when all else fails. When family and friends are in despair, and nobody else has anything to offer, it is the priest, the imam, or the rabbi who will be there. We are two rabbis who have learned the hard way what acute mental illness is: we have sat with congregants, friends and family at the darkest times of their lives, to offer spiritual guidance and practical help — the two foundations of Jewish pastoral care.[i] We know what it is like to lead a funeral for someone who has taken their own life, and we know too the very difficult bereavements which family and friends go through, with a mixture of raw emotions which can continue for many years afterwards.
YEARS OF SERVICE DECLINE
Michael remembers from thirty years ago a woman who arrived with a large box of papers, saying: ‘Please store my evidence: there are people out to get me, and you need to keep this safe.’ She had left her husband and children and was sleeping in her car, at different places, neglecting herself and at risk. It took a lot of co-ordinated work from and with excellent NHS services to find her and get her to a place of safety.
Services are not providing that standard today. From time to time, David has taken late night phone calls expressing despair and desperation from suicidal congregants. He has been the last resort when the ambulance does not come, when hospitals cannot access the records they need, when there no named GPs, and when the crisis team does not respond. ‘I came to realise why mentally unwell people just give up. I knew I had to continue to advocate. As a rabbi you endeavour to follow best practice, to put in place strict time boundaries – but unlike other practitioners, your deepest fear is that you may all too soon be conducting the funeral.’
When rabbis explore the Bible, we look at the wording to see where it speaks and where it keeps silent.[ii] Jewish pastoral care has been described as‘spiritual accompaniment.’[iii] We notice how congregants describe their feelings, what they say and what they choose not to say, where they speak and where they remain silent.
The pastoral scenario we encounter most often is death. We help mourners to hold the darkness of grief, not fully entering that darkness with them, but offering companionship along the journey. Through our training and experience, we learn how to assist in many of life’s crises. But with acute mental illness, there are aspects that we cannot comprehend. Though we may ease the burden, we cannot grasp the totality of someone’s experience nor envisage their path ahead. We are not trained clinicians, and rely on the right professionals to be there. We stand at the door, unable to enter the room. If the darkness or the confusion is not too great, we may be able to offer spiritual comfort and support. But in an acute crisis, that is not enough. What do we do when someone urgently needs a place of safety and ambulance does not arrive? Rabbinic pastoral work demands action as well as words.
A LISTENING PROJECT
In our own pastoral work, we have seen the voluntary sector increasingly struggling because of very poor NHS mental health services. Together, we decided to discover what has gone wrong. Inspired by the huge Listening Project of South London Citizens leading to action on mental health recovery,[iv] we talked to twenty-one people between 2023-2026—patients, carers, GPs, psychiatrists at different stages of their career, senior managers, nurses and a coroner. We concentrated on acute services for mentally ill adults in England. We found examples of improvements in practice, including the increased provision of talking therapies, the ‘no wrong door’ approach in Somerset, and suicide prevention training available for everyone in London: but we felt quite overwhelmed by the stories of inadequate and even dangerous provision, with the number one problem being a severe workforce crisis. A psychiatric nurse educator told us ‘It is all fire fighting…. The system is overloaded.’ Psychiatrists said:
- ‘Staffing shortage is the biggest problem, especially shortage of care co-ordinators and staff on in-patient wards’
- ‘The better supported the staff feel, the greater the degree of morale and cohesion, the better the patient care and the better the outcomes. I have sometimes said the best way to improve care is to put the staff “at the heart of everything we do”, because if we do that, patient care will automatically and invariably improve without you having to do anything else.’
And yet staff morale is knocked back by communication failures. Representative comments included: ‘None of the NHS computer systems talk to each other… this doubles up on the work. (Nurse Educator). ‘The lack of communication between GPs and the Team is very poor. (Carer). Nurse educators told us of the pressures to keep up with the admin for every patient without support staff.
These failures both cause and are caused in part by the fragmentation of the service. We heard from a GP that the loss of individual named GPs, plus referrals to a mental health team, means it is a system where nobody takes responsibility. A carer told us that her son had seven different care coordinators in the course of a year.
Psychiatrists criticised ‘meaningless targets.’ ‘It is a tick box culture… The targets only measure the speed and number of the letters, not the quality… Getting to know patients is not valued.’ Carers stressed the need for more humane approaches which they saw as the opposite of the ‘target’ culture. A carer told us their feeling that doctors and staff lacked compassion, and made assumptions rather than asking questions.
Patients and carers mentioned alarming instances of clinical negligence. One carer told us about ‘negligence and sloppiness on an industrial scale in the monitoring and use of clozapine for my son… it took nine months to get the correct dosage put on the computer, and then only after I wrote to the Mental Health Trust…at one point when trying to get a GP visit we were told “I only ever come out to a suicide attempt.”’
The Suicide Prevention Strategy 2023 states ‘there is no wrong door .. [they must] receive timely support, no matter what service the individual initially accesses.’[v] But we heard that changes in London mean that police can no longer take a patient to hospital unless they are deemed to be at immediate risk,[vi] and will not even make the necessary referral to a crisis team. The patient’s friend told us that the point of entry needs fixing, because nowhere should lead to a dead end.
OUR CONCLUSIONS
In their book Inclusive Judaism: The Changing Face of an Ancient Faith, Rabbis Jonathan Romain and David Mitchell wrote about the importance of welcoming people with poor mental health into caring, diverse, inclusive and non-judgemental communities.[vii] Other British rabbis, such as Helen Freeman, have written about respect and inclusion for those dealing with physical and mental health challenges.[viii] But unfortunately our own work and that of everyone in the voluntary sector is undermined when the NHS fails us. Our Listening Project has taught us that patients, carers and staff are well aware of what the problems are. When things go wrong, they are shocked but not surprised. And that leads us to ask: if everyone is aware of the fault lines, how come nothing seems to change? How do you change a culture?
Our conclusions are that there are many good services and many excellent and compassionate staff. But when services fail so badly that patients are left despairing or untreated, then staff morale plummets, and the service enters a spiral of decline which feeds on itself. One of our psychiatrist participants recalled better times twenty years ago. ‘We never had waiting lists. If urgent, a patient was seen the same day. If you run a good service in your local area, you don’t have many emergencies.’ Such memories are a motivator for change — things do not have to be the way they are now.
But today, NHS staff often feel overwhelmed, and some of them leave, placing increasing pressure on those who remain. For staff and patients much would be eased by higher budgets, better primary care and preventative strategies. But for us in the voluntary sector there is something more fundamental that needs addressing. What is the NHS for? What counts as success? The service is constantly undergoing ‘redesign’ or ‘transformation’ but fails to improve.[ix] The fundamentals get lost in the details. Good care builds not only health, but hope. Patients who recover, or take a few steps forward, improve the morale of the whole team. Why not have values driven targets, such as staff getting to know patients, even though they cannot easily be measured? Perhaps NHS practitioners have something to learn from pastors: ‘wonder at the depths of human suffering and the extraordinary capabilities troubled people have for resilience and growth.’[x]
NEXT STEPS … COMING SOON
[i] For practical help as part of Jewish pastoral care see Ozarowski JS Bikur Cholim: Paradigm for Pastoral Caring. In Jewish Pastoral Care: A Practical Handbook, ed. D. Friedman, Jewish Lights Publishing, 2005, 56-73 (65-6).
[ii] Cooper H. Reflections on Jacob’s Dream. European Judaism 25/1, Spring 2025,94-101 (95).
[iii] Friedman, D. PaRDeS: A Model for Presence in Livui Ruchani. In Jewish Pastoral Care: A Practical Handbook, ed. D. Friedman, Jewish Lights Publishing, 2005, 42-55.
[iv] South London Citizens, South London Listens, 2022. (https://www.citizensuk.org/chapters/south-london/south-london-listens).
[v] https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy; also Samaritans, Suicide Prevention Principles: From Policy to Practice, Suicide Prevention Consortium, March 2025. (https://media.samaritans.org/documents/Samaritans_SPS_Suicide-prevention-principles-from-policy-to-2.pdf)
[vi] NHS. Mental Health Crisis Care for Londoners: London’s section 136 pathway and Health Based Place of Safety specification. May 2024 ,25 (https://www.england.nhs.uk/london/wp-content/uploads/sites/8/2024/05/Londons-Section-136-Pathway-and-Health-Based-Place-of-Safety-Specification_May_2024.pdf ); also NHS England. Guidance on implementing the National Partnership Agreement: Right Care, Right Person’. 18 November 2024 (https://www.england.nhs.uk/long-read/guidance-on-implementing-the-national-partnership-agreement-right-care-right-person)
[vii] Romain J, Mitchell D. Inclusive Judaism: The Changing Face of an Ancient Faith, Jessica Kingsley 2020, 202-206.
[viii] Freeman H. The Lack of Inclusivity for Those with Physical or Mental Health Problems in the Jewish Community. In What Makes Me Angry: Howls of Rabbinic Rage.. and Solutions, edited by J Romain, Movement for Reform Judaism, 2022, 45-51.
[ix] Hilton M. How We Treat the Homeless and the Sick. In What Makes Me Angry: Howls of Rabbinic Rage.. and Solutions, edited by J Romain, Movement for Reform Judaism, 2022, 81-91 (89).
[x] Friedman M, Yehuda R. The Art of Jewish Pastoral Counselling: A Guide for All Faiths, Routledge 2017, 204.