Are our mental health services in crisis?

There is an increased demand for mental health services in Britain, but we are failing some of our most unwell and vulnerable people.

Last week, the Health and Social Care Information Centre published its annual report into the use of the Mental Health Act. In 2012/13, for the first time, the number of people detained under the Mental Health Act crossed 50,000 (a 4 per cent increase on 2011/12, continuing a rising trend).

The NHS bed crisis

And yet since 2008, bed numbers for the mentally ill have been cut by 36 per cent. In the last year alone, 1,700 beds were cut, representing a 10 per cent reduction in bed numbers.  This massive reduction in the capacity to care for our most unwell has led to the stories that have emerged in recent weeks of people having to be admitted 200 miles away from home and; tragically, those who have killed themselves while awaiting a bed.

In August 2013, the Health Select Committee reported that Approved Mental Health Practitioners were having to detain people under the Mental Health Act, illegally, in order to secure a bed as it was almost impossible to admit people who agreed to come into hospital.

In my own practice, I’ve heard of several days in the last few months when there has been no NHS bed left in the country. The system has been stretched beyond breaking and it’s perhaps no surprise that the average city inpatient ward is a place seething with anger, threats and chaos. Small wonder that in these environments, demoralised and overworked staff are reduced to focusing on immediate risk reduction with the unwell, rather than supporting their recovery in a therapeutic environment.

In October Dr Martin Baggaley, the medical director of the South London and Maudsley Trust and one of the leading psychiatrists in the country said that mental health services in England are in a state of crisis. The Care Minister, Norman Lamb, acknowledged that there are problems, but still there is a lack of action.

How did things get so bad for mental health services in Britain, and what underlies our inability to act?

Suicide rates and austerity

Suicide rates are an indicator of the strengths and weaknesses of the system. Falling year by year since 1997, they started to rise again after 2009. The Office for National Statistics reported that 2011 saw a further ‘significant’ rise in suicide numbers, 6045 people took their own lives that year.

The idea that a nation’s mental health will inevitably suffer as a consequence of the economic recession is flawed. Both Iceland and Greece suffered with the collapse of their economies. However, Iceland rejected bailouts – with austerity strings attached, invested in health and social care, and its population has not suffered a change in health status. On the other hand, Greece’s austerity drive has led to a worsening of a host of health indicators including a 30 per cent increase in suicides.

Based on some economic indicators, the Coalition is claiming success for austerity-based policies. But viewed from a health perspective, there is little to be joyous about.

A perfect storm

Within the health service, the conditions of the ‘Nicholson Challenge’ for the NHS to find £20 billion savings by 2015 and the first disinvestment in mental health services for working age adults since 2001 (according to the Department of Health’s National Survey of Mental Health Investment) have contributed to the current crisis. Other factors include cuts to Local Authority budgets that have led to social workers being ‘redeployed’ away from mental health teams into more traditional social worker roles and cuts to voluntary sector funding that has led to the closure of many of the programmes that supported severely unwell people to find purpose in their lives.

It’s within this ‘perfect storm’ that services are cutting, slicing and re-disorganising to meet cost improvement challenges.  Hidden behind politically correct jargon of ‘treatment at home’ and ‘care in the community’ beds are being cut to meet the financial pressures.

The Health Select Committee report raised the alarm that it was more than just anecdotal evidence that suggested illegal detentions. People are killing themselves while awaiting a bed. If this was happening to people with heart disease or cancer, there would be an outrage. Why is it taking so long for any action to be taken?

Private concerns

Perhaps the answer lies in the dramatic increase (32 per cent) in the number of admissions of the mentally ill to private sector beds, which is a consequence of the NHS bed crisis.

In October, the Health Service Journal reported that these admissions often cost £3000 a week in the private sector. A spokesperson for Cygnet Healthcare, a private provider, has even said in an interview reported in Community Care that the reduction in NHS beds has been one of the main drivers for a 30 per cent increase in the number of service users it had supported in 2011/2013.

These beds are often not local to the patient. At a time when someone is most unwell creating distances from family and friends is the opposite of what many people need. Similarly, the loss of the continuity of care between the NHS community team and the inpatient private provider will extend the duration of an admission and worsen therapeutic engagement.

This is the opposite of high-quality care. Whereas community mental health teams support patients as much as they can to try an avoid unnecessary admissions and there is often a discussion between the inpatient and community teams of the local NHS service about the need and expected outcome of an admission – what are the incentives that operate within the private sector and will this make clinical care better in the long term? Is this economically effective?

There are also concerns about transparency. The Health and Social Care Information Centre raises concerns that although the independent sector are now looking after a quarter of inpatients, some of the major providers are not providing required information (the mental health minimum data set) for monitoring.

We’ve been fighting a battle to keep the NHS public, and yet a portion of the NHS that supports the most vulnerable is being dismantled in this crisis. Conservative politician, Oliver Letwin, said in 2004, within 5 years of a Tory government there would be no NHS. I can’t help but wonder if the dramatic privatisation of the care of the mentally ill is more than an unintended consequence.

Stigma and discrimination

The stigma and discrimination that people with mental illness continue to face partly explains the lack of action. According to YouGov research in early October, the mentally ill are widely seen as the most discriminated group in Britain. Attitudes have hardened towards the mentally ill, and the narrative of deserving and undeserving poor has hit this group hard.

This is despite £21 million lottery and DH funded anti-stigma campaign led by leading mental health charities. Stigma can be a difficult concept to understand, but the fact that this is a group of people with relatively less power and that attracts little public sympathy has allowed this crisis to continue.

The road ahead

There is much that needs to be done. We must galvanise public support; research into the impact of privatisation on care pathways and audit the costs; and develop a workable plan to reverse or at least halt further bed closures until capacity for community support can be expanded and its safety and effectiveness demonstrated. And this needs strong leadership – both clinical and political.

Encouragingly, at Labour party conference this year Ed Miliband showed that he gets it. He described mental illness as a one nation problem – but one that we don’t talk about, that’s been swept under the carpet and how that needed to change.

In an excellent speech on mental health and illness to the Royal College of Psychiatrists last year, Miliband announced setting up a Labour Mental Health Taskforce. Now is the time for that taskforce to act.