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EDITORIALS: Max Marshall Modernising mental health services BMJ 1999; 318: 3-4 [Full text]

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Neurosis in Primary Care

John Canning   (4 January 1999)

defining the boundaries

Leslie Burton   (4 January 1999)

A Fresh Start in Community Psychiatric Nursing Service

Peter Gilbert   (4 January 1999)

Personality disorders: arbitrary and subjective medicalisation of human variation

John Sharkey   (5 January 1999)

Consultant Psychiatrists - an endangered species

Alison Abraham   (5 January 1999)

Community Care: the government has "failed"

Tim Johnston   (6 January 1999)

No evidence for modernising mental health services

P Johnstone   (12 January 1999)

Have psychiatrists failed community care?

D B Double   (15 January 1999)

Untitled

Victoria Hawkins   (20 January 1999)

Psychiatrists should oppose community treatment orders

Joanna Moncrieff   (25 January 1999)

In what sense has community care failed?

D B Double   (27 January 1999)

Untitled

Janet A Butler   (17 February 1999)

Re: Neurosis in Primary Care

Max Marshall   (21 February 1999)

Neurosis in Primary Care 4 January 1999
John Canning, GP and LMC Secretary Middlesbrough Send response to journal: Re: Neurosis in Primary Care	I am surprised and disgusted at the allegation that a primary care led NHS demmands an instant acces to Psychiatric teams for "all neurotic patients". primary care manages most neurotic psychological problems unaided, and is increasingly having to manage psychotic patients as well. Integration and co-operation, if that is what the NHS and government want, will never occur with such attitudes from colleagues.
defining the boundaries 4 January 1999
Leslie Burton, Consultant Psychiatrist Darlington Memorial Send response to journal: Re: defining the boundaries	This excellent editorial should be read by Frank Dobson,all M.P's,Chief Executives of Trusts,and Chairmen of Primary Care Groups.
A Fresh Start in Community Psychiatric Nursing Service 4 January 1999
Peter Gilbert, General Practitioner 1 Oxford Terrace , Gateshead Tyne & Wear Send response to journal: Re: A Fresh Start in Community Psychiatric Nursing Service	The failure of Care in the Community is in small part due to an inadequately funded CPN service. We in inner city General Practice recognise the strains placed on the psychiatric nursing service and their increasing workloads. A zealous approach to CPA has also placed a burden on their time I propose a new role of Practice Nurse in Mental Health who would work attached to GP practices and liaise with the Crisis Teams and Psychiatric Nurses attached to consultant teams. Every major psychiatric illness and crisis usually presents in the early stages to members of the Primary Care Team. I would hope that every practice would have its own team of Practice Nurses in Mental Health just as it has District Nursing.
Personality disorders: arbitrary and subjective medicalisation of human variation 5 January 1999
John Sharkey Send response to journal: Re: Personality disorders: arbitrary and subjective medicalisation of human variation	EDITOR Over the past few months the issue of personality disorder has come up several times, most recently in the BMJ editorial ‘Modernising mental health services' (1). The reporting of the Michael Stone case was such as to fuel the madness/badness argument to the point that the Home Secretary chose, in the usual populist rhetoric, to take a pop at psychiatrists. The difficulty with personality disorders is that, by their very nature, they are an arbitrary and subjective medicalisation of human variation. It is hardly surprising that they are frequently not amenable to treatment. A supervising Consultant Psychiatrist once asked me to name any psychiatrist I knew that did not have a personality disorder. When I considered this poisoned chalice and declined a reply, he said a person without a personality disorder is a person without a personality. If personality disorder is sufficient legal grounds to detain someone, several questions need answered: when should he/she be released, does the ‘tariff' of duration of detention fit with crimes committed or is it a value call for the psychiatrist in question. We find ourselves in difficult ideological times if society cannot cope with the less savoury aspects of human variation. The profession should be bigger than to fall for the tabloid headline driven myth of a safe society. John Sharkey Consultant Psychiatrist General Hospital, Jersey, Channel Islands, JE2 3QS 1. Marshall M. Modernising mental health services: Time to define the boundaries of psychiatric care. BMJ 1999;318:3-4
Consultant Psychiatrists - an endangered species 5 January 1999
Alison Abraham Send response to journal: Re: Consultant Psychiatrists - an endangered species	EDITOR - I would refer to Max Marshall's Editorial ‘Modernising Mental Health Services'1 in which he discusses the government's new national mental health strategy for England. He rightly points out ‘two fundamental flaws' on which I would like to focus this letter. The first is the proposal to ‘modernise' mental health act legislation to allow the detention indefinitely of people who have committed no crime but will not be detained for the purposes of treatment; and the second is the shortage of consultants in general psychiatry (amongst a general shortage of trained staff). Max Marshall does not emphasise strongly enough however the fact firstly, that the present shortage of consultants is due to a large extent, to a previous government's earlier flawed strategy, and that secondly, if this current, proposed, flawed strategy is pushed through, the shortage of consultants will become dramatically greater. The previous government forced the care programme approach on psychiatrists, and it's time-wasting bureaucracy, now shown also to be ineffective2, has driven consultants out of the NHS and into early retirement, and trainees into sub-specialties. As a consultant psychiatrist, I have learnt a lesson from this, and am determined to be pro-active this time round. I therefore propose to make it clear that I will not use any mental health legislation to detain anyone for any purpose other than treatment which cannot be provided in any other way. I also wish to make it clear that community treatment has not failed, and that everyone, patients and society alike, would benefit from less control and more support for mental health service users' autonomy. Mental health legislation needs to be modernised towards more specific targetting of mental incapacity related to need for treatment, not towards social control. If the government, and society, wish to move in that direction they should be reviewing Criminal Justice legislation and looking at all citizens who pose a serious risk of violence to others. It is not only in psychiatry that doctors' views appear to be ignored, or not sought by the government in formulating policies, who are increasingly imposing controls on clinical practice, which have none of the proven effectiveness which they, rightly, expect from medically driven practice. Should not doctors, unitedly, be urgently tackling this situation? Yours sincerely ALISON ABRAHAM Consultant Psychiatrist 1 Max Marshall, Modernising mental health services: BMJ 1999;318:3-4 (2nd January) 2 Marshal M, Gray A, Lockwood A, Green R. Case management for people with severe mental disorders. The Cochrane Library. Cochrane Collabora-tion. Oxford: Update Software, l998.
Community Care: the government has "failed" 6 January 1999
Tim Johnston, Specialist Registrar in General Adult Psychiatry/Research fellow Belfast City Hospital Send response to journal: Re: Community Care: the government has "failed"	Maxwell's commentary on the new mental health strategy "Modernising Mental Health Services"(1) is to be commended. However it fails to challenge the most fundamental flaw of the document-that "community care has failed"(1-2). Indeed for the majority of patients community care has provided them with the freedom denied to their predecessors. The fact that it has not been able to "deal effectively with the most severe cases" is more likely to be since "it has not been properly tried" as declared by Graham Thornicroft, chairman of the national committee set up to advise on mental health policy (3). Indeed it is ironic when you consider that the substitute for community care will probably be community care in a more punitive guise. I agree with Maxwell's analysis on the balance of staffing levels with that of bureaucracy. Indeed in Northern Ireland where I work, there are no consultant vacancies. This, I believe is reflected by the lack of bureaucracy in the province-namely there is no formal Care Programme Approach. The document insists that there is an outdated legal framework. There are not many that would disagree-but not for the reasons the government suggests! The attempt to "ensure compliance with appropriate treatment" is a framework for social control, which will do little for recruitment levels and I suspect actually decrease compliance in the long term. Likewise, the "detention for those with a severe personality disorder" is not for any therapeutic reasons whatever. Therefore why should psychiatrists provide their scarce time and beds to act as prison officers. Prison would seem the more appropriate setting. Maxwell is right to highlight the discrepancy in priorities between a primary care led service and those of the department of health. This appears to be indicative of the government's policy in general and their attempt to please all men but only succeed in pleasing none. However the difficulties it has caused cannot be underestimated. In conclusion, the government's strategy for modernisation has been to increase bureaucracy, blur the boundaries of psychiatric care and exert greater social control over psychiatric patients. Far from modernising the service, such an approach is likely to reverse the progress that has already been made. No matter what spin the government puts on this document, I suggest that it indicates the government has failed and not community care. 1.Maxwell M Modernising mental health services. BMJ 1998; 318: 3- 4. 2.Department of Health. Modernising mental health. London. Department of Health 1998. 3 Dean M. Mental care versus public safety in the UK. Lancet 1998;352: 1995.
No evidence for modernising mental health services 12 January 1999
P Johnstone Send response to journal: Re: No evidence for modernising mental health services	In addition to Marshall's editorial (1), we were a little surprised to see that the Government's plans for modernising the NHS Mental Health services are not based on any of the findings from its own R&D Programme (2). Although we appreciate these are 'emerging findings' and many of the recommendations are based on examples of good practice, not a single systematic review nor barely a randomised controlled trial was quoted. The Cochrane Library for example provides readily available evidence for mental health policy on case management(3), assertive outreach (4), use of hospital beds (5) and effective Community Mental Health Teams (6). Surely at a time when the Government itself is encouraging all clinicians to use evidence-based medicine (through the National Institute for Clinical Excellence, and the Commission for Health Improvement), there should be a clear link between committing £700M on new policies and evidence of effectiveness. Paul Johnstone, Consultant in Public Health Medicine Berkshire, and Honorary Clinical Senior Lecturer. University of Oxford. Chrissy Allot, Librarian Berkshire Health Authority References 1. Marshall M. Modernising mental health services: time to define the boundaries of psychiatric care, BMJ 1999;318:3-4 2. Department of Health. Modernising mental health services: safe, sound and supportive. London: Department of Health, 1998 3. Marshall, M, Gray, A, Lockwood, A, Green, R. Case management for people with severe mental disorders, Cochrane Review. In:The Cochrane Library, Issue 3. Oxford:Update Software;1998. Updated quarterly. 4. Marshall, M, Lockwood, A. Assertive community treatment for people with severe mental disorders. Cochrane Review. In:The Cochrane Library, Issue 3. Oxford:Update Software;1998. Updated quarterly. 5. Johnstone P Zolese G. Long versus short term hospitalization for serious mental illness. Cochrane Review. In:The Cochrane Library, Issue 3. Oxford:Update Software;1998. Updated quarterly. 6.Tyrer, P, Coid, J, Simmonds, S, Joseph, P, Marriott, S. Community mental health team management for those with severe mental illnesses and disordered personality. Cochrane Review. In:The Cochrane Library. Issue 3. Oxford:Update Software, 1998. Updated quarterly. Dr P Johnstone Berkshire Health Authority 57-59 Bath Road Reading Berkshire RG30 2BA
Have psychiatrists failed community care? 15 January 1999
D B Double, Consultant Psychiatrist Norfolk Mental Health Care, Norwich NR6 5BE Send response to journal: Re: Have psychiatrists failed community care?	EDITOR-The editorial by Marshall is a useful contribution to the debate about mental health policy (1), apart from, as noted by Canning (2), the betrayal of an apparent lack of understanding about the need for integration of primary and mental health services (3). Debate about mental health strategy continues at the Mental Health Policy website (http://www.uea.ac.uk/~wp276/mental%20health%20policy.htm). Campaigning organisations opposed to the rundown of the traditional psychiatric hospital, such as SANE (http://sest.mkn.co.uk/help/extra/charity/sane/index) have deliberately exploited public anxieties. Initially this was the concern that homelessness is being increased among the mentally ill, but their tack changed when evidence accumulated against this view (4), to concern about public safety due to homicides by psychiatric patients. The tragic killing of Jonathan Zito on the London Underground led to the formation of the Zito Trust, and Jayne Zito's motivation to improve mental health services is understandable, as she has been unable to pursue a negligence claim in relation to her husband's death, because courts are loth to rule that public bodies, such as mental health services, owe a duty of care to third parties. Campaigners against community care will presumably have to change their theme again now that it has become clear that the proportion of homicides due to mentally disordered people has decreased over the period of deinstitutionalisation (5). Unfortunately, SANE has already convinced the government that community care has failed. The appointment of Graham Thornicroft as Chair of the External Reference Group of the National Service Framework for mental health, however, seems inconsistent with this conclusion, as he thinks that community care has not failed because it has not yet been fully tried (6). It is important to recognise the reactionary influences which have brought the government to its position, not least many psychiatrists themselves, who are opposed to community care, because of their loss of power in the traditional psychiatric hospital. Psychiatrists' attitudes to community care need to change before it can be said to have been properly implemented. The review of the Mental Health Act should provide further safeguards against the potential abuse of medical power, reinforcing the motivation for the 1983 reforms (7). 1. Marshall M. Modernising mental health services. BMJ 1999;318:3-4 2. Canning J. Neurosis in primary care. eBMJ, 2 Jan 1999 http://www.bmj.com/cgi/eletters/318/7175/3#EL1 3. Double DB. Staff in mental health services need clearer guidelines. BMJ 1996;313:1208 [http://www.bmj.com/cgi/content/full/313/7066/1208/b] 4. Leff J. All the homeless people - where do they all come from? BMJ 1993;306:669-670 5. Taylor PJ, Gunn J. Homicides by people with mental illness: myth and reality. British Journal of Psychiatry 1999;174:9-14 6. Thornicroft G, Goldberg D. Has community care failed? Maudsley discussion paper 5. London: Institute of Psychiatry, 1998 7. Gostin LO. A human condition. London: MIND, 1977
Untitled 20 January 1999
Victoria Hawkins Send response to journal: Re: this article	EDITOR - I write to support the views expressed by Marshall in a recent editorial on the government's strategy document, "Modernising Mental Health Services". He highlights many important criticisms of this publication, including the worrying nature of the proposed changes to the law. These changes would allow indefinite detention of patients who have committed no crime, but whose untreatable personality disorder is considered to make them a danger to themselves or others. This is a policy plagued with contradictions. The government states its commitment to a modern, decent and inclusive society, but in the very same document is outlining legislation which will forcibly remove unwanted people from such a society.2 The document contains a lengthy explanation of the stigma which surrounds mental illness, which, it says, is derived from ignorance and inaccurate, sensationalist media coverage. However, rather than heeding its own information, it proposes knee-jerk policies which threaten to return the practice of psychiatry to the custodial times of the Victorian asylum. Furthermore, the government appears to be blissfully ignorant of the apparent dichotomy between a restrictive proposal such as this, and several of its own well-publicised priorities. The recent social services white paper stated that promoting independence was one of their top priorities. Marshall highlights the tension between this proposal and the government's policies on social exclusion and user participation.1 This proposed change in legislation raises some important ethical considerations, which do not appear to have been properly addressed. For example, to what extent is public safety deemed more important than individual liberty? Extrapolated further, the argument that public safety is more important than individual liberty would result in measures such as the banning of road vehicles to prevent road traffic accidents, or compulsory blunting of all sharp objects. There is also an important therapeutic consideration; increasing the custodial role of health care professionals could further increase the strain on the clinical relationship. There is an additional irony in that, despite Mr Dobson's statement that care in the community has failed in, amongst other things, its duty to protect the public, 2 a recent study showed that the proportion of homicides committed by mentally ill people has actually fallen significantly during the time of care in the community. It would appear that this policy is being driven by the weight of public opinion and the need for tabloid approval, rather than responsible decision making on behalf of everyone, including society's most vulnerable members. The government has ordered its proposed alterations to current mental health law to be scrutinised by a review panel, who are to report back in April of this year. The medical profession must be ready to speak out against these policies if they are as unjust and ill thought out as they appear to be. Victoria Hawkins Third year medical student University of Newcastle upon Tyne 1 Marshall M. Modernising mental health services. BMJ 1999; 318: 3- 4. (2 January.) 2 Department of Health. Modernising mental health services. London: Department of Health, 1998. 3 Department of Health. Modernising social services. London: Department of Health, 1998. 4 Taylor P, Gunn J. British Journal of Psychiatry 1999; 174: 9-14. Quoted in; Woodman R. Community care does not increase homicide risk in UK. BMJ 1999; 318: 77. (9th January.)
Psychiatrists should oppose community treatment orders 25 January 1999
Joanna Moncrieff, specialist registrar in psychiatry Chelsea and Westminster Hospital, London SW10 9NG Send response to journal: Re: Psychiatrists should oppose community treatment orders	Dear Sir, At a meeting in Bradford on January 8th a group of senior psychiatrists set out their objections to the measures proposed by the government for increased control of psychiatric patients. We welcome the reservations expressed in Marshall's editorial(1) but we would like to outline why we feel there are good grounds to oppose proposals for commmunity treatment orders (CTO), as well as the more obviously controversial idea of preventive detention for people with personality disorders. The introduction of CTOs will mean that people who have been psychiatric patients will not enjoy the same human rights as the rest of the population, even when they are functionning well and have committed no crime. They will not have the basic right to determine what happens to their own bodies, in particluar whether top contiue taking powerful drugs that are well known to have severe and unpleasant side effects. CTOs, as well as preventive detention of people with personality disorders, are fundamentally measures of social control. Rather than improving the quality of care, they are likely to further estrange challenging patients from mental health services. By reducing the rights of people who suffer from mental disorder they will add to the stigma such people experience. We believe there are many other psychiatrists who are uneasy about these issues and the preceeding correspondence testifies that this is so. We invite these psychiatrists to join us in a campaign we will be mounting, alongside the campaigns of some mental health user groups, to oppose the introduction of these coercive measures. Yours etc. Authors: Joanna Moncrieff (address above) Dr Philip Thomas, Consultant Psychiatrist, Bradford Community Health Care, Bradford. Dr Mike Crawford, Specialist Registrar, Institute of Psychiatry, London Dr Claire Henderson, Research Fellow, Institute of Psychiatry, London 1) Marshall M Modernising mental health services, BMJ, 1999, 318, 3- 4.
In what sense has community care failed? 27 January 1999
D B Double, Consultant Psychiatrist Norfolk Mental Health Care NHS Trust Send response to journal: Re: In what sense has community care failed?	The Government has now confirmed that it will not apologise for its emphasis on public safety in mental health policy (1). Its stance is unsurprising as it has no wish to concede that it has been duped by campaigning organisations such as SANE (2), and Frank Dobson has given mental health services his personal priority as Health Secretary. Public relations are central for this government and its position could at least lead to reconciliation of sterile disputes about community care. In this context, it does seem important to establish in what sense community care can be said to have failed. There will be general agreement with the statement in the government's strategy document, Modernising Mental Health Services, that the policy of community care has brought many benefits and that the failures have been caused by underfunding, inadequate care and poor management (3). The issue is, therefore, about standards of care, which makes the work of the External Reference Group crucial. However, it is not easy to create consensus. For example, most psychiatrists are still based in psychiatric hospitals and probably should be based in community mental health centres, but they will tend to resist such change. Public outcry may have been counterproductive by encouraging defensive rather than therapeutic practice. Over recent years, more people have been locked up in secure beds as numbers of other adult mental health beds have reduced (see figure at http://www.uea.ac.uk/~wp276/beds.htm) and numbers of people detained under the Mental Health Act have increased. Justifiable motivation for the revision of the Mental Health Act is because of the changed circumstances of deinstitutionalisation (1). Ideological issues cannot be avoided. The Government's view could reinforce a simplistic model of mental illness, viewing it as caused by biological deficits that can be corrected by medication. There are consequences of treating people as though they are objects (4). The efficacy of psychotropic medication and the methodology of clinical trials are not certain (5). Attempts by psychiatrists to justify their authority by biological approaches to mental illness, rather than attempts to understand people's problems, have undermined community care (2). Although the Government may need to be educated about the complexities of mental health care, its intention to improve the quality of care should be supported. 1. Department of Health. Radical changes needed to mental health services, says minister. Press release 1999/0036, 21 January 1999. [http://www.coi.gov.uk/coi/depts/GDH/coi1262f.ok] 2. Double DB. Have psychiatrists failed community care? eBMJ http://www.bmj.com/cgi/eletters/318/7175/3#EL8 (15 January 1999) 3. Department of Health. Modernising mental health services: safe, sound and supportive. London: Department of Health, 1998 4. Kaiser D. Against biologic psychiatry. Psychiatric Times. http://www.mhsource.com/edu/psytimes/p961242.html (December 1996) 5. Fisher S, Greenberg RP. (eds) From placebo to panacea. Putting psychiatric drugs to the test. New York: John Wiley, 1997
Untitled 17 February 1999
Janet A Butler Send response to journal: Re: this article	Dear Sir, Marshall highlighted the increasing burden placed on general psychiatrists due to expanding and competing referral priorities1. One solution, as he suggests, would be to define the boundaries of general psychiatry. However surely the aim should be to treat all those suffering from psychological ill-health. Both the "neurotic patients" referred by primary care and the "severely mentally ill" noted by the government have psychological difficulties impairing their functioning. Furthermore established treatments have been shown to benefit both neurotic and psychotic conditions. Current practise not only overburdens psychiatrists but also fails to deliver optimal care to many and limits training opportunities. The recent recommendation for more liaison2 services recognises that patients can have treatable psychological difficulties that are neither in established psychiatric specialities nor easily integrated into current community general psychiatry. Also such difficulties make up the majority of psychological distress seen by most non-psychiatric clinicians yet current general psychiatry is poorly placed to teach medical students how to manage them3. An alternative way to limit the workload of individual psychiatrists yet continue to treat the range of psychological illnesses would be to reconsider the expectations of a general psychiatry service. Models can be sought from medical and surgical firms. Many general physicians and surgeons have an area of specialist knowledge that complements their colleagues within the same hospital. Furthermore there is an increasing recognition that expertise is gained by seeing larger numbers of patients with particular conditions4. Maybe the time has come for some specialisation within general psychiatry teams working within a defined geographical area. They could then build complementary areas of multidisciplinary expertise covering all psychological conditions. A similar model has already proved successful within a child psychiatry service5. Yours sincerely, Dr Janet A Butler Senior House Officer in Psychiatry Maudsley Hospital Denmark Hill London SE5 8AZ 1. Marshall M. Modernising mental health services. BMJ 1998;318:3-4. 2. Royal Colleges of Physicians and Psychiatrists. Joint Working Party Report:The psychological care of medical patients. Recognition of need and service provision. Royal College of Physicians and Psychiatrists, London.1995. 3. Sharpe M, Guthrie E, Peveler R, Feldman E. The psychological care of medical patients: a challenge for undergraduate medical education. Journal of the Royal College of Physicians 1996;30(3):202-204. 4. Mahadeva R, Webb K, Westerbeek RC, Carroll NR, Dodd ME, Bilton D. Clinical outcome in relation to care in centres specialising in cystic fibrosis: cross sectional study. British Medical Journal 1998;316:1771- 1774. 5. Roberts S, Foxton T, Partridge I, Richardson G. Establishing a specialist eating disorder team. Psychiatric Bulletin 1998;22:214-216.
Re: Neurosis in Primary Care 21 February 1999
Max Marshall, Senior Lecturer and Honorary Consultant University of Manchester Send response to journal: Re: Re: Neurosis in Primary Care	Dr.Canning's comment on my editorial is quite justified. I am aware of the contribution that primary care makes to the management of neurotic disorders, but re-reading the offending part of my article I can see that this does not come across. Since electonic publication offers the unusual opportunity to correct mistakes let me say that what I should have said was not "instant access to psychiatric care for all neurotic patients" but "improved and more rapid access to psychiatric care for patients with neurotic disorders".