Short Notes from a Muddled Island (with apologies to Bill Bryson)

Hugh Middleton, MD
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There has been quite a bit going on in the UK mental health world of late, and MiA already shares some of this in the form of open letters from Kinderman, et al. and Richard Bentall. Both are responses to a series of BBC programmes. In their letter Kinderman, et al., also make reference to a recently published report; The Five Year Forward View for Mental Health. This has been published by a so-called independent body; The Mental Health Taskforce to the NHS in England. We still have the NHS, just about, and documents like this which have been commissioned by the great and the good are expected to influence how it is funded and what it does. This one begins with a rounded criticism of NHS mental health services:

“The NHS needs a far more proactive and preventative approach to reduce the long term impact for people experiencing mental health problems and for their families, and to reduce costs for the NHS and emergency services.”

It goes on to develop this criticism and make a whole series of recommendations. As Kinderman, et al. point out, on the face of it this should make encouraging reading for UK readers of MiA. The problem is we have heard it all before …

In 2009 the UK Department of Health published New Horizons. A Shared Vision for Mental Health which was endorsed by the then Prime Minister Gordon Brown and his Secretary of State for Health, Andy Burnham. New Horizons described itself as

a cross government programme of action with the twin aims to: improve the mental health and well-being of the population and improve the quality and accessibility of services for people with poor mental health.

Readers would find it encouraging; it refers to a need for closer attention to early intervention, to the need to address stigma, for a focus upon life’s transitions, and innovations that could support recovery, personal autonomy and well-being; defined not as symptom control but as “A positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.” You might have thought that the officials who compiled the report were familiar with MiA and similar sources of comment about mental health services.

What happened? Nothing! We had a change of government and none of these recommendations saw the light of day.  Over the last seven years mental health services have become more coercive, with a steadily rising proportion of inpatients on a detention order. We have a bed crisis as a result of which individuals might find themselves hospitalised miles from their homes and loved ones. We are seeing more and more suicides. The rate of pointless prescriptions for antidepressants, antipsychotics and so-called mood stabilisers has continued to rise and once again we have falling levels of morale amongst the NHS mental health workforce with consequent difficulties over recruitment and retention. Are we about to repeat the cycle?

The [2016] Five Year Forward View for Mental Health makes absolutely no reference to its 2009 predecessor, but it does make very much the same recommendations. It openly acknowledges that current NHS mental health services are unsatisfactory and firmly recommends enhanced crisis care, easier access to psychological therapies and preventive work, especially amongst young people. It encourages attempting to achieve “recovery,” as in; enabling people to lead better lives as equal citizens, and the building of healthy communities through the provision of suitable housing and the reduction of stigma. It has been lauded by the Royal College of Psychiatrists, who were party to its authorship and have produced their own briefing paper outlining its implications for the profession. Again there is little here about medication or symptom reduction and much about even better access to psychological therapies, vulnerable minorities and “recovery.” The central role of services user experiences is respected:

“Co-production with clinicians and experts-by-experience will be at the heart of commissioning and service design, and involve working in partnership with voluntary and community sector organisations…” (page 5) 

These are establishment publications. It is fascinating that the same views have eventually come through following a change of government. 2009 was the dying year of the Labour government and 2015 saw the election of a majority Conservative government after a period of transition. Despite these changes at the top, on the face of it, the UK health policy establishment has remained faithful to a vision of NHS mental health services that gives more weight to talking therapies than medicines, appears to understand “recovery,” recognises that well-being is dependent upon opportunities of employment, appropriate housing and acceptance, and that all of this can’t be provided for free. It will be even more fascinating to see what the fate of a renewed commitment to these aims turns out to be. Not only is it a welcome vision for those of us who would like to see change and improvement in mental health services, it is also a blueprint for a more caring and accepting society.

On the other hand I do wonder whether the establishment figures who have responded to the blindingly obvious in relation to NHS mental health services are really joined up with those who are charged with realising a neo-liberal ideology in other government departments. The medical focus the BBC has followed and which Kinderman and Bentall have commented upon suggests not, but perhaps the debate is becoming louder and more public. As Kinderman and Bentall have hinted, where are the celebrities and other opinion leaders who can lend their voices in support of a less medical approach? It seems they should have the backing of the UK establishment!

1 COMMENT

  1. Dear Dr Middleton

    What about the Big Society.

    People talk about the NHS as a provider:-

    I was a ‘Care in the Community recipient’ for about 4 years while I cooperated with the Psychiatric System (in Ireland).

    My longterm recovery came about as a result of me leaving the Mental Health System (and my recovery cost the country nothing).

    Regardless of how the NHS Mental Health System might improve itself I think we might be better off without it or with a lot less of it. I believe that at least 60% of it is white collar sponging.

    (What worked for me CBT/Meditation/Peer support – was either self supporting or for free).