Should NHS mental health services fear the private sector? NoBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5385 (Published 04 October 2010) Cite this as: BMJ 2010;341:c5385
All rapid responses
Elaine Murphy and Philip Sugarman highlight that "almost all long
term care for dementia" is provided in the private sector. I hardly think
that this a good example of successful private mental health care.
Many nursing and residential homes are understaffed and the staff
working in them are often undertrained in dementia care. As a result
dementia patients are overprescribed antipsychotics and other
tranquillising medications. When homes are no longer able to manage
patients because of Behavioural and Psychological Symptoms of Dementia
(BPSD) the fall back is nearly always the NHS.
NHS Older Adult Community Mental Health Teams (OACMHTs) have begun to
develop inreach services into private nursing/ residential homes to
address these issues of care and training and we are now beginning to set
up proactive reviews of all patients in nursing and residential homes
prescribed antipsychotic drugs.
Although there are a few examples of exemplary care, by and large the
private sector has failed to provide a quality service for the long term
care of patients with dementia. Without the active input and support of
local NHS OACMHTs many long term dementia patients in the private sector
will continue to experience substandard care.
If the experience of long term dementia care in the private sector is
anything to go by, other mental health service users have much to fear
Competing interests: The author is a practising NHS Consultant Psychiatrist
With escalating 'human costs', the cost of mental illness in England
is 105.2 billion pounds.  The positive benefit from services that
improve overall mental 'wellbeing'  has yet to be estimated. Evidence
from Samaritans about NHS commissioning suggests the measures chosen in
the new 'Outcomes Framework' may shape mental wellbeing.  Clear
population goals for public mental health could orchestrate a Symphony of
service providers - without clear goals, competition driven by short term
profit and expediency will end in Discord. That atonal clash would hurt
patients, especially those with complex or long term needs.
Some claims in Head to Head (9 October) seem naive, e.g. private
providers are more 'innovative' and their 'new ideas flourish'. Most
stakeholders in mental health research, development and innovation report
these activities much more widespread in NHS trusts than in private
providers. In my own research area of child and family wellbeing (e.g.
resilience in relation to alcoholism, violence or disability) new ideas
may arise from the NHS or Local Government, not from private businesses
busy policing or warehousing children. Grafting mental health models from
the USA to England arouses concern. Compared to the UK, America has much
higher rates of suicide and homicide where 'there has been a near-total
breakdown in public psychiatric services'  especially services that can
respond proactively for childhood resilience in the face of trauma, abuse
or developmental problems.
"Strong political leadership" is even more critical to co-ordinate
children's services around clear Outcomes, during times of "financial
turbulence" and reluctance to take responsibility for "complex illness".
(quoting Sir Al Aynsley-Green, http://edition.pagesuite-
professional.co.uk/ August Public Servant digital edition,
accessed 9 October 2010).
 Centre for Mental Health. The economic and social costs of mental
health problems in 2009/10. London: CMH, 2010.
 Burstow P. Better mental health is key front in fight against
poverty. National Mental Health Development Unit (http://www.its-
services.org.uk/nmhdu/news/ accessed 2 September 2010).
 Samaritans. Submission to Health Select Committee inquiry on NHS
commissioning. London: Samaritans, 2010.
 Lewin-Fetter V. Self-harm on either side of the pond. Lancet
2010; 376: 1224.
Competing interests: Member of the National Public Mental Health Steering Group for the Department of Health.
Any commercial transaction involves a contract between two or more
parties, each of whom is able to make decisions and able to advance their
interests. In a world where the mental health care is provided by the 'for
profit' companies the stake holders will be the executives whose jobs and
bonuses depend on the profit margins, the share holders who want maximum
return for their investment, the commissioning agencies who want to get
the service for the lowest price and the patient who, due to the mental
illness, may lack the motivation and mental resources necessary to advance
his interests. Financial profitability trumps patient care in such a
A large proportion of patients in the mental health system are
detained under the Mental Health Act and their discharge is dependant on
the decisions made by employees of the detaining hospital. A conflict of
interest is apparent when your profit margins depend on your bed
occupancy. Any financial transaction where the seller decides what the
buyer buys cannot be fair and cannot represent the best interests of the
buyer. The potential for exploitation is even more when the buyer is a
vulnerable person. Any assertion that the 'good-will' of private companies
or the government regulation will protect the patients' interests will
have to ignore the recent banking crisis, the Enron scandal and the state
of mental health services in USA.
In this country the private sector has already started to get into
the more profitable parts of the mental health care, mostly in the form of
specialist inpatient units. Money has been diverted from generic services
(which in addition to providing inpatient care also provide care in
community, educational and research benefits) to private units with a very
limited role of inpatient care. The patients always come back to the NHS
for costly follow ups. There has been a mushrooming of private units with
USPs that range from non evidence based inpatient personality disorder
units to units more suitable for an apartheid mindset e.g. segregated
black and minority ethnic units. Such units are an example of the extremes
to which the independent sector can go to maximise their profits.
In a system where the private companies take over the mental health
care the main casualty, in addition to the care of the most vulnerable in
our society, will be education and research and the tax payer will end up
footing a separate bill for such endeavors.
Competing interests: The author is a NHS doctor