WHAT IS WRONG WITH OUR NHS MENTAL HEALTH SERVICES?

WHAT IS WRONG WITH OUR NHS MENTAL HEALTH SERVICES?

UPDATED REPORT (January 2025)  ON A LISTENING PROJECT CONDUCTED BY

RABBI DR MICHAEL HILTON AND RABBI DAVID MITCHELL

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.

A few 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 reports themselves vary widely in their quality and there is no consistency in who the coroner decides to send them to.  The effect of this is that millions of pounds spent on the 109 coroner areas in England and Wales is being wasted because of an inadequate system of follow up.

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.’ [A and E consultant – compassion fatigue] It often emerges that the NHS undervalues its own staff, and they in turn sometimes undervalue the patients. One very experienced psychiatrist told us: ‘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.’ This does not in itself require 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.

But excellence is rarely rewarded and good staff so often leave. Mental health gets just  8% 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.’  The NHS 2023 ‘Long Term Workforce Plan’ with its motto ‘Train-Retain-Reform’ is an important start, but how is it to be fully implemented?  Importantly, the plan states that ‘we want staff to feel valued’ but does not spell out how that is to be achieved. At present, so many NHS staff feel unthanked and unappreciated, not by their patients, but by their employers, in part no doubt because many managers themselves feel undervalued.  The embedded poor culture will be difficult to shift, but this is the most vital change of all, because it leads to staff leaving and patients themselves feeling devalued by demoralised staff.

At present, very many services are overwhelmed. 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 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. There is no clear point of access to the system. Although the Suicide Prevention Strategy 2023 states ‘ there is no wrong door’, patients and carers too often feel that the door they have entered leads to a dead end. The recent changes to London policing mean police will no longer take a patient to hospital unless they are deemed to be at immediate risk.

 One interviewee, who felt in their own work they were achieving much that is useful, nevertheless told us that politicians are promoting the survival of the fittest. It is certainly a step forward that the long awaited new Mental Health Bill will be published soon. 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 some 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 Trust managers actively promote the use of risk assessment software,  even though some of England’s top psychiatrists tell us that it simply doesn’t work. Questionnaires and software are no substitute for building a good support system around the patient. We are aware that suicide is uncommon and always difficult to predict.  A caring and compassionate service should be able to build the personal relationships with patients which can lead to warning signs being spotted more easily. 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. This requires less suspicion about data sharing. 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. Nobody should not be permitted to veto decisions which are in the best interests of patients. Building patient-centred services is difficult but not impossible, and everything needs to be measured against how it effects patients.  In the past, change has come about because of public anxiety.

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:

  • 1. An immediate reduction in the fragmentation* of the service by allowing referrals from one clinic direct to another, and the building of linked up and efficient IT systems.
  • This will require a review of the workings of the multi-disciplinary teams with increased emphasis on continuity of care. The system introduced in 2005 which allowed various professions to make initial diagnoses has not been completely successful.
  • Direct referrals without having to go back to the GP will require a review of how the method of allocating funding disrupts continuity of care.
  • The 2023 DHSC policy paper, Suicide prevention in England: 5-year cross-sector strategy points out: ‘there is no wrong door – when people experiencing suicidal thoughts or feelings reach out, they [must] receive timely support, no matter what service the individual initially accesses. Systems and services are connected around individual’s needs.’   This requires a detailed review to make sure it happens. (https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england-2023-to-2028/suicide-prevention-in-england-5-year-cross-sector-strategy)
  • Those suffering from acute mental illness may lead disordered and chaotic lives. When they get help, they need to feel they are entering a system which is clear, punctual and orderly and yet very flexible. If they are referred from one member of staff to another, having to repeat their story every time, they may be quite unable to cope with that and despair of getting the help they need.
    • 2. Access to acute mental health services for everyone who needs them, with appropriate follow-up.
  • A good start was made on working with the street homeless during the lockdowns on 2020/1 but many of these initiatives have since been lost. Other groups who are left out include those without GPs, increasingly common among young adults, and those who try to enter the ‘system’ through A and E and are not followed up at the point of discharge, and longer term patients required to move on from their current level and place of support, be it hospital, hostel or simply a therapist.
  • In spite of the 2010 Equality Act and the 2010 Marmot review Fair Society, Health Lives,  health inequalities have also continued to grow.
  • By 2020 all NHS mental health trusts had opened 24/7 crisis lines, but access can still be difficult, responses can still be inappropriate, and follow-up can still be lacking.
    • 3.An NHS which shows that it values and appreciates its staff, and is willing to invest in their health, wellbeing and training.
  • It is difficult but not impossible to change a culture. Showing gratitude and courtesy costs nothing and makes a huge difference to how staff feel. If staff feel demoralised and unhappy, patients will feel even worse. Good therapeutic relationships can be measured, but not by most of the recent or current NHS targets. Occupational health provision for NHS staff widely varies in quality from place to place.
  • The Department of Health Document New Ways of Working for Psychiatrists, 2005 (https://core.ac.uk/download/97904.pdf),  talked about the importance of acknowledging continuing barriers to change at all levels. ‘These include medical responsibility; public, organisational and clinical perception of risk; professional boundaries; lack of time to reflect; uncertainty about process; assumptions about other professions; concerns about and credibility of new and changing service models; personal anxieties about the capacity and capability to do things differently; and finally, differing values, perspectives and formulations about the needs of people with mental health problems, and their carers, families and friends.’

New NHS policies tend to be up-beat and forward-looking but do not tend to refer to still unfulfilled promises from previous policies.