Modernising mental health services

Time to define the boundaries of psychiatric care

In Modernising Mental Health Services, the new national mental health strategy for England announced in December, 1 2 the government lays out detailed plans for reforming general psychiatric services, and places them in the context of its wider NHS reforms. The document asserts that “community care has failed” and blames underfunding, inadequate services, overburdening of families, problems in recruiting and retaining staff, and an outdated legal framework. It then describes a strategy for providing a service “in which patients, carers and the public are safe and where security and support is provided to all.” This strategy has two key elements: increased investment and increased control (over patients and clinicians).

The increased investment consists of =A3700m spread over three years. These extra funds will provide more beds (in hostels and secure units); outreach teams and 24 hour access; new treatments, including atypical neuroleptics; and staff training. Increased control of patients will be achieved by “modernising” mental health act legislation to “ensure compliance with appropriate treatment” (in the community) and to permit “a new form of reviewable detention for those people with a severe personality disorder.” Control of clinicians will be achieved using the mechanisms set up under the overall NHS reforms: the National Institute for Clinical Excellence (to set standards) and the Commission for Health Improvement (to inspect them).

To some extent the strategy has merit. Increased funding, improved standards, and regular inspection could make psychiatric care more efficient and effective. However, the strategy has two fundamental flaws. The obvious flaw is that detaining indefinitely people who have committed no crime sits uneasily with the government's policies on social exclusion and user participation, not to mention its international treaty obligations. The less obvious flaw is that, despite lip service to recruitment problems, the Government has not faced up to its fundamental predicament—the disparity between the supply of clinicians and the demand for psychiatric services.3 Underlying this disparity are three inter-related problems: the failure of successive governments to establish priorities for general psychiatry,4 failure to stem the bureaucratic processes encroaching on clinical time,5 and the worrying shortage of trained staff. 6 7 How far will the government's strategy affect these problems?

Establishing priorities —Since the reforms of the early 1990s psychiatric teams have been caught between the demands of a primary care led NHS (instant access to psychiatric care for all neurotic patients) and those of the Department of Health (concentration on the severely mentally ill).4 By trying to please everyone psychiatric services have succeeded in pleasing no one and have failed to develop the tightly defined, highly staffed, and narrowly targeted approaches that are known to be effective.8 Rather than relieve the competing pressures, Modernising Mental Health Services has increased them by guaranteeing 24 hour open access while insisting that resources should be concentrated on those with greatest need. Moreover, it has added a new pressure—responsibility for those with untreatable personality disorders.

Bureaucracy —Psychiatrists, like other doctors, have experienced the unfettered growth of non-clinical demands, but they also have their own special bureaucracy—the care programme approach. Described (by one of its creators) as “overwhelming,” the care programme approach is a bureaucratic nightmare of dubious effectiveness that must be applied to all patients in contact with psychiatric services. 9 10 Care programmes emerge unscathed from the proposed reforms, their survival reflecting the government's singleminded pursuit of the unobtainable—totally safe community care. The unpalatable fact is that since homicide is rare, attempts to prevent it are subject to the low positive predictive values inherent in predicting any rare phenomenon. Thus procedures designed to reduce the risk of homicide must involve high costs relative to their returns (even if effective). For patients these costs are a drastic curtailment of civil liberties and a custodial relationship with their therapists. For clinicians the cost is time wasted in the empty rituals of universal care programming and risk assessment. Thus the whole process of providing effective care is distorted and degraded while the rates of homicide remain unchanged.

Shortage of staff —Psychiatric services in several parts of Britain are becoming exsanguinated.11 Fourteen per cent of consultant posts in general psychiatry are vacant, and similar shortages exist among other key staff. The shortfall reflects high rates of early retirement and low rates of recruitment (as specialist registrars seek accreditation in other subspecialties).6 In a survey by the Royal College of Psychiatrists the commonest reason for early retirement was not lack of resources or workload but bureaucracy.11

Thus the government, by underestimating and exacerbating the disparity between supply and demand, risks undermining its own strategy. It is time to cut bureaucracy and define the boundaries of psychiatric care.