1999 - Mental Health Care Failure In England - Myth And Reality

EDITORIAL

Mental health care failure in England flyth andreality T O f l B U R N Sa n d S T E F A NP R I E B E

The pa$ fN yca6 have seennentd hcdkh scdces in En8land lnore sorhan in the Ul( scnc.ally) subjectcd ro an unpreceJented batr4c of criticisn. Ihc ronc has &en ser by tabloid newspapersl London\ ntntal heatth seniccs . shambleJ !,.,t s stdndarrl, 16 .la\Mrr 1996\ "We rc mad to trusr shrnrks" Dd'l! Mnn\ 9 tebruary 19961.Fucllcdby enquiri€sintohish profile homi.nks br rhc mentally ill, and by concems over tft numbersof Jistrubed individuals livins rough on the capital\ {reers. theserepons hav. h.d I profound effcct on public confidcnccii menialhealth scruiccs. 11h.slittle im!,actro poiit ourih.iihe homi cidc r.te by peoplc wirh menr.l illnesshas been stublErrily unaflectcd br community care policics lBennen, 1996) and thir vio lelce obsercd in a saiery is morc cotret.red qnh unrcsolvedscial problcms rhan wirh rhc fiactice oflsycbiarry, and in pafiiculaf the propoftion of patients trearcd in com nuniry based scrvlces.It rpFars simillrly turilc to denon$rare drar closlres ofnentil hospitah ,rc nor linked ro homele$r$s (L€ff, l99li Crais, 1998)- lhc curienr. p€r vasiveopi.ion is fiar Indnh ncntal health serices {€sp€cirllyin cides)areunacccptabl! poor (DeaI &Turner,1997). Tle S€cretary ot Stdtefor Heahh, Frant Dobson, h.s re ccndy pronounced rhat "communiry care has failed", aid hi! lredece$or .xp.e$ed then lack of confidenceby imposinsa succession of incrcasinglr rest.i.rive legshtive .equrenent! rhc Care Programre r\p proa.h (Departmenrof Hc![h, 1990), th€ supernior resister(Derartmcnt of r lealth, 1994) and sufcrviseddisclnrselDepartrient To nake a meani.stul overull asess m€nt or periormance, a compariror is necesry. Such a comprnon could be eithd wirh English senices in rh. pdsr or with senics in other equivalentcounrics. Anothd posibnny is ro compare wcll fu.dcd with loorlr tundcd EnglishseNics in r€rmsoi codprehensivcnc$of pro\ision. lnterprcting su.h internd comparisons is,

howevcr, friught wirh difficulties, ds ihe differencesin fundn,g are unlikel_vro hrve flsen arbitmrily. (lonparisons wirb orhcr countnes are vcry conFlicar€d! becausc culrucs, political and scial rraditions and he.lrh cdrc vsrens .re nr diffcrcit. Sinple llke wiih likc mcrsues arc ha.d io obtain. (iontext nust be ackrowhdsed (in rartl cular thc los UK spcnd). .nd conpler judsencnrs m.de (Burns & P.iebe, 1996). Both of us have worked in .ouisies ihar spend .onsidetublr turc on mental health carethan rhc uK. 5.1.recendr movedto e.$ Lon&n aftcr p(ciisins nr B..lin, anJ T.B. worked for rhreevearsin Swcdcn-Throush our.c.denic !fld re*arch intereeswc borh rcsuhrly visit and work wirh colleasus ,n tbesc ,nd other luopcrn coudr.ies. Our pdsoml experienceof cvffydiy pracii.e in other countr'.s has nade us s..ptical of the sweeping cfuicsms oI English m.nhl helkh c.re. Ou. expcncn.esare, how€ver, subjecrirc, ,nd ioi based on empnical rce.rch. Data rhar link learuresof Dcnral kalth care systemsro ollcone arc hardly rrailable, ind funhcr inrcisive re*arch w,ll be ncededio overcom. rhe conceptualand meth.dolosicrl problens lsmi.red with such studicswhen ther are co.dDcted. There arc undoubiedly serious shon .omlngs in the English services.llcsc includc the eacessive prcoccupdrlonwnh risk. th€ hnncd rheraleutic involvemeniof con sultanB ,nd ihe shonasc ot servicesfor patienB wirh le$ rvero merral ill.es$, ro rame just a f€w. ()n rhe other hand. rhcrc arc aspecisof our carc which. despneour low hcahh spetul,we would suRsesicompare favourablywirh nuch in ljuopc dnd Nofth AnEica. Coordirurio. and continuiq of crc, prfticularlr fo. rhosesiih severcmcntal illie$, are.€rainll, befter.The conprc hensivc dpproa.h of scctorisedcarc in rhe tX (havins the same reanr rcspo.sible lor in paiienr and out p.tient .are) provtd* a .emarkably flexible responsero rhc nccds ot ths grou!. Becaus. it is so wid€sFcad rnd so lons estrblishcd(Johnson& 'l hom i-

.tufr, 1991),wc rdke jr for grantedand *cm umwar. otwhat an asserit is. Mentalh.ahh care n, wnh fcw exceptions, wnhin rhc lublic doDain. and servi.e llalnins n not so1€lydriven by rhe economic intercstsof se.viceprovidersand insuranceconpanies. Althousb the pa$ decadc hrs cxFerien.ed i@ nrany servicechmgcs. rh.s. ch.nges ai leis dcmorsr.ie the nexibilitr of rhc sys ren. Senicc dclivcryls senerallvtransparcnt .nd subi€.t to .l,niol audit and a wide sprcadconsideration.f clin,c!l cf fcdiven€ssEngl$h pstchiatrists,cor.ectlt trctrcupied wirh rhe Foblc'ns senerard by rhe splir bdween herhb lnd scial care, sem mr.ly to rcflef on rhc dcsree to vhich senns rrc fr.emented elsewhc.c.By inteharional stlDdlrds our servicesarc ctrrmrdliarily straishtiotr rd .nd well coordimred. In the absenccofclear objeciire.riteria ror succes!or f.ilurc of.ommlniN nenral hcakh c.r. and siven rhc (ar l..st panlr) favourable conparison *irh orher coun tics, we can lind no jusifi.atioi lor rhe swccpins starnen har n has failed.

o R t G t N so F c R t T t c t s M The esonsfor ch a hcavilyiiiical siance !rc prob. bly seve.al.Thc c!.rent eappraisal ofaU prori$ionals meansthar ps_vchiairists, jLr$like othd dcto6. a.e subjed i(, incrcdr iig que$ionilg. lr hasl)rob.bly beenmargir allr mo.e pronoun ed io. us, as ou.p.acti.e h.s movcd fiori the obscuriN of iehted nental hospirals to sre.ter openn€ssand accountabilitvin the connuniries we sene. Theseexiemal prcssur.sare ln,poft.nt, but much ol rhe -iiicism lris.s riom wirhin. l', thc UK, where rhc Narionil lleahh senicc (NHs) 6 a sinsle fudins sour.e and has a lons hniory ol un.ler re$ucins, throud Navins has bNome aLaepredbe hallour ior dmhrs. Insistineon hos dire rh,nss rre is ihe rdoBii*d negotiatins position - one ihar would hav. d6asfous corsequenccsIn a nrarketeconomy!or cven in a mi{ed economy wirh adeqMre provi sion.Ior erample,rhc inpresslonleli by sd eralr(cnr public.tions 1e.9.MILMIS P.o,ec.t Croup,199i; Dc.hl & Turner, 1997;King s Furd, 1997) is rhar rryi.es are udfornly p@r a.ross l-ondon wirh .o arailable beds rnd .i .bkn.€ of .ffcclive i.ter.sency workl.g. Yet both of uswork n, servi.esthat alwlts have empty beds r. dmn acutepa iiens, lnd both enjoyeflectivecolbboration wnh l(ul itiatscrvrces. we notalonein rhis, and ir n.v benorefruirtul

ro invstisatc and undcKtand the* va.ia rions than tocontinuclo rc$atc the gcn.ral ig. Making thcsc poin6 is almost cmbarmssnrg for us- It sccns like lening th€ sid€ dosn, blunns the force of the pn,fes sion'sca*, rarherthan (asit really is) cnsu ing dut the licu€ lresnted accurately reflec$ servic€ vdiarions in tbe capit.l. Another imponant difference berween rhe UK and mo{ of Europe is the .elarive shorta8e of dmtors. Not only does this tuke ihe job difficult, bur the security it affords may iead rs to bishlight serviceinadequaciesrathcr rhar rcsolveth€m. 'lqhile rhe UK may havc few docton conpared with other Eu.opean .ounti€s, it is cer tainlr not shori of acad€micsor rexarch into community nenial heahh. We ha'e sx adive .€sc.r.h p.ofcssorsof.omDuniw psychiatry in l-ondon alone, and a srrons r.dnion of hishly resarded, prasmatic mental healih servicesre*arch. Such re r.rch is bound io identify gaps in provi sion and makc recomendations for change.This can give the impre$ion that our servicesare inlerior to those in coun lnes rhar do not collect such derailedslaris tics or conduct rigo.ous studies. The $ronsst voices in th€ d€bate are often from the teaching hospirals, who may he les qualified to speak for the proles sion on this natter than on otheB. Driven by tbc lcArimare dema'& of tc,ch'.s ard rerarch, they hav€ s€neraly been slower to invest in lcal senice developfredt de spnc confronting greaterihan avcraecchallengcsin inncrcity arc,s. Thcn cxpcr'c.ces havc pr.bdbly bccn scn.raliscd cxccslvcly.

IMPACT OF CRITICISMS we ,re concerned th.t eyasseratcd rnd undiffereltiatcd crnicism is *rbusly damasins ou sniccs and thc m.rllc .f ou staf| Continuously enphasisins h.{ awful things are will deter brighr saiuates from choosingpsychi.fy as a profe$ion jNt as hlpPened in senerdl p.acticc wh.n those lmcdtbncrs were so vGiiercusly critlcalofiheirlor (Je.lins & Scott, 1998). Bla.kct c.iticism will obeu€ real and import".t differenceswithin se'vice proll sion and thcrcby prcv.nt nnpomnt lessons be,nslernt fron, what thc bc{ sN,ccs havc bteach. lhcs lcsonsrrc importanrboth at homc and ah)ad. lf the stensths of sdd *r vicesgo utu(osni*l, national policr mkcrs ar deniedthe opFottlritv of bulidiig upon th.m and fosrering evolution.rr improve

t92

loraURN5FRcPsy.h,Deprimenrorf\/.hrar.t5tceorge!rlospr.rMenGS.hoo Lon.lon STFFANPR FgE MqSrBafrhoromew!ann Royatoid.n5.hoo ofMed.,neA.aaem(UnntanHrm f'1.moraHospir LDidoi Coffesponden.e ProresofTom BLrns DeparlmenlofP!r.h alry lenief W ng StC..rB.s H.!pia M c d t r a S . h o . C r a n m . r l e r f a . e l . n d . n S W r r 0 R L a n d P a i h l ' n d . rN H S T r u n T . l 0 S 7 2 5 5 5 4 2 .

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n€ns in care.Th€.csult is that tbcy will in port servicenodels fron abro.d which €irh€r nay be inappropriate to th€ Enslish context (c.s. by neslectinsthe role ofsell-developed primary carc) o. whos cli.ical adv.ntases have bccr dcnoNtrated asainst uncenain control situtioN k.s. Solomon, 1992). Shroud wayins is unlikel] to achieve its pD.pos ol generatingindeased inve$neit in menial hcahh scdccs unlc$ a .l.ar, a.iicdated model in which io inr$t accon panies it. V/e have to convince the Gov€m€nt that we k.ow how to lead ou sedc€s and inve$ then money wiselr. Vithour a $rons clini.al lead, ih€n r€ sponse to the hishlishtd risk is likely eith€r to be burcaucratic (e.s. rhe Care Pro sr.one Approach, supervisio. regi$ert or ro rurn to altematile sourcesof advice. The gap Icft by thc profc$io. in planning the shapeof scr'ccs w,llbc f'llcd by oficn, ofteo much less experienc€d. There is no shonage of adyice about how to reford the mcntal hcalih sdccs b.ins rroffered by pressuresroups and volunrary bodies. In many ca*s their conyiction may far ex cccd cviden.e for rhe feasibiliry or value of then proposak. Bur if thens is ihe only posnivc advicc the (;olcmrnent ls getting, we shodd nor b. too surpriscdif it takcs n. Nenher one of us donbB rhe rcal rro blems thar tace nodem menr.l beahh se. vices.The rules of rh€ g.m€ .re ch.nsins!rnrily rnd sh..i!l chinses n.ke coprngwnh problescvc.c m.ndl ii!n.s infe.sigly n!n.. Public c{pcctationsrrc rising, rfd in our.Drrent, very visiblc Fsnion, balarcing theij py wiih scial co.trol is highly delicate. [.ngL.nd has a]ways un
morhcr is not casy (Burns& Prnb€, 1996), but est.blishins sone anchor points is an ev sential first step to nakns sensiblejudge ments about chanse.The sam. is rruc fo. variations within the NHs scniccs. which havetob€describedandaoaly$d,ccuratclv. Th€ second pre.equisite i to take respotri bilitr for what is eoorl in what we do khere isa lot) butalsofor*hat*e shoulddo differ endy. Thismighr involvc a mor.prc{riprin and consistent approach wirhin the profes sion than we ar€ curendy usd to. lf we do noi do sonethins about it, the €nemy wirhin mry prove as deadly as th€ enenies wnhout.

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