“Community Psychiatry: was it all a ghastly mistake?” Or, “Defragging Psychiatry – it’s time has come”
Evidence is a tricky word. In the mental health part of the NHS these days nothing much can be done if it’s not, as they say, “evidenced-based”. In practice, it tends to be a slogan used by powerful guilds or vested interests which, when un-picked, actually means “a few iffy facts which demonstrate that we are indispensable and deserving of further investment”. Emerging information which threatens clinical wisdoms and caucuses generally fails to penetrate their protective shield. A recent meta-analysis of research into CBT which clearly demonstrates it is becoming less effective (one explanation being that the placebo effect is now wearing off) so far has the status of heresy and it remains to be seen when, if ever, the ubiquitous dominance of this approach will be reined in.
The introduction and expansion of so-called “assertive outreach treatment” (AOT), a concept imported from the USA, is a reasonable example of this phenomenon. Promoted by converts-with-status, it led to mental health nurses – and other professions – being creamed off standard, well-established teams, paid a premium and given caseloads less than half the size of their previous ones. Initially, staff in standard teams were relieved that there was a new service primed to take their most recalcitrant, contrary patients – a sentiment which fairly quickly morphed into envy that their better-paid, more prestigious colleagues were able to schmooze with them in coffee-shops or the gym.
Developing doubt about the cost-effectiveness of the new approach was countered with faint insinuation that the doubters were old-timers and therefore resistant to progress, and with the assertion that this was proper, scientific, evidence-based psychiatry – as opposed to doing your best and muddling through. As it happened, multi-centre evaluation of AOT subsequently revealed that, as far as hospital bed-days were concerned, some standard teams did better than the specialist ones with similar patients. Yet even while fessing up to this inconvenient truth and the reasonable expectation that if you’ve got a third of the average caseload you should do maybe 25% better than your peers elsewhere, promoters of AOT continued to champion it and argue for more investment.
Numerous other organisational or clinical changes are introduced in such a way and with such a tone that to question or disagree with them automatically becomes a kind of diehard, regressive folly. Who could possibly challenge the validity of specialist alcohol or eating disorder services, which are now so much part of the clinical landscape that a return to a purely generic approach is unimaginable? The fact that this created a kind of hierarchy of disorder, largely in step with the hierarchy of class, and a therapeutic apartheid in which ordinary acute psychiatric wards, as they became the default zone for patients with unpleasant, frightening psychotic illnesses, turned into lawless, counter-therapeutic, control-based places, remains an inconvenient or worthless truth. Equally, the argument that people with non-psychotic disorders could learn and benefit psychologically from being treated on an ordinary, generic ward, where feelings of being special or different or even superior would quickly fade, can’t even get out of the blocks. If it did, it would quickly be eased off the tracks by committed separatists who, as the saying goes, cannot think their thought is wrong.
More recently triage wards were similarly promoted, as a way of reducing serious pressure on beds by sharpening the focus on early discharge. They were introduced because when enough people with status say a measure or change is “a good thing” it becomes a good thing. In practice, the essential triage function and staff whom it instinctively suited disappeared from the second line of acute wards which rapidly filled with patients well beyond their discharge-by date. Around the same time, the idea, prematurely imported from physical health, that mental health services should be divided up according to diagnosis gathered enough momentum to tip it into actual implementation. This move quickly came up against some inconvenient truths: namely, that disorders of the mind rarely fit neatly into such a classification and that the opportunity costs of moving patients between smaller, embattled services as a different diagnosis came to the fore and of the inevitable disagreements that go with this would be excessive. The objections of those who had to contend with the fallout of yet another non-organic bright idea were portrayed as regressive and resistant, and thereby easily dispensed with.
The closure of beds, the squeeze on outpatient clinics and the setting up of large, multidisciplinary teams in the community around the beginning of the 1990s, working to a brief of promoting recovery, inclusion, partnership and personalisation, are derivatives of lazy ideology and the hazy liberal notion that institutions are most of the time “a bad thing”. Much of what went on in the asylums of the last two centuries, given their death sentence by health minister Enoch Powell in 1961, was repressive and cruel, if largely well-intentioned, but at the same time they provided a sense of belonging and of space (an important commodity for troubled or over-active minds), employment with supervision, diversion, entertainment, a spiritual dimension (albeit in the form of a basic choice between two Western religions) and even the chance to play organised team sports. The gamut of the needs of patients were at least partly met on a single site whereas now they are devolved to numerous agencies around the community, a logistical nightmare which amplifies risk.
The marriage of ideology and money, predicated on a primitive belief that hospital takes away freedoms and opportunities while the “community” (NB hospitals are actually part of the community) confers them, continues to lead to the widespread closure of hospital beds. Sadly, the response to the extreme pressure on existing beds leads to an intensification of the focus on so-called gate-keeping and potentially risky attempts to prevent admission and to speed up discharge. In fact, having the prevention of admission as an organisational goal increases risk (as it does with child protection) because there will be many cases where at times admission itself should be the goal.
The problem with change generally is that it takes out the good along with the bad. Staff are often resistant to change because it sweeps up elements of previous systems and practice which were both useful and congenial. The move to community psychiatry, especially its later form in which services have been chopped, according to function, diagnosis and length of treatment, into increasingly smallpieces, coupled with huge changes in prescribing under the influence of relentless pressure from pharmaceutical companies and the magic of the brand, has in this way taken out much which may not have been ideal but which worked.
The outpatient clinic was certainly conservative – in the sense that its aim was largely maintenance of the status quo – but it was also highly cost-effective. It catered for very large numbers of patients who were seen regularly and with a frequency informed by clinical need and the supportive capacity of the patient’s network. Paradoxically perhaps, it also avoided the promotion of chronicity and dependence which is a common flaw of the intensive services which have replaced it. For many patients with serious mental illness, knowing that they would see a trusted expert on a particular date in two, three or six months time provided both the incentive and the containment necessary to manage the interval, invariably by taking a consistent dose of an unchanging medication.
The current practice, encouraged if not enforced by commissioners and policy-makers, of discharging patients from community caseloads early with a promise to GPs that they will be taken back into secondary care if the need arises mainly suits those with difficulties in their personality. It is mostly contra-indicated where there is serious mental illness partly because it jeopardises continuity of clinician and treatment and also because problems are often not picked up until well after the stage where they can be handled easily and informally. In fact, many psychiatric emergencies, often needing powers conferred by the Mental Health Act, are created by the prevailing system and practice.
Continuity of clinician is now no longer understood as an essential part of effective mental health care because staff have become to be seen as interchangeable and therefore dispensable conduits for a prescriptive, algorithmic approach to treatment. The personal is seen as capricious and unreliable, and must therefore be rinsed out of the machine of delivery wherever possible. However, discontinuity of clinician inevitably leads in practice, if not in theory, to discontinuity of treatment – especially that of pharmacotherapy – as previous medication is disparaged and new, often heavily promoted, alternatives are speculatively tried.
Managerial whim and the ebb and flow of clinical fashion also reversed the system of having the same consultant and other professionals responsible for the care of patients both in hospital (and for admissions to hospital) and in the community. This compounded discontinuity but also removed any real incentive for clinical staff in the community to work to reduce the need for admission and to speed up discharge. And an absence of incentive, which is genuine and felt as opposed to the distant negative threat of paymaster punishment, inevitably leads to services becoming stagnant and self-serving.
The extreme bias in favour of new, so-called atypical antipsychotic drugs and anti-depressants (SSRIs and SNRIs) has almost certainly contributed to an increase in chronicity, symptomatology, admissions and even deaths. This is because the effectiveness of newer - and therefore more costly - drugs and the drugs themselves are over-promoted by vested interests and a convenient blind eye is turned to the risks of stopping or changing drugs which the brain has permanently adapted to and so can no longer re-normalise.
Drugs with names such as aripiprazole, clozapine, risperidone and quetiapine have a compelling currency which many doctors find hard to resist while the use of faded, veteran drugs, often those given by injection, is felt to be regressive and to indicate a failure to move with the pharmacological times. In fact, the developing science of pharmacogenetics suggests that the instinct of old-timer nurses and even social workers that somehow drug A seemed in a strange way to suit patient B was on the right objective, scientific track. The side-effects which accompanied traditional medications were reasonably well-treated with another medication, a practice common in physical medicine, rather than by stopping and swapping the primary drug.
The motherhood of recovery and the apple-pie of self-directed care have shifted focus and finance away from the detection and treatment of illness. What used to be an illness service with narrow and limited but therefore achievable and pragmatic aims has morphed into a grandiose, idealised project with a seam of inefficiency and disappointment running right through it: the NHS as good doctor has become the NHS as good parent.
Fantasy shuts out the empirically obvious: that if you optimise treatment, you minimise risk and maximise opportunity. Patients, the public and overburdened - at times desperate - staff are the casualties of the passive surveillance of much community psychiatry, laced with wishful optimism and constricted by the deadweight of bureaucracy which necessarily grows as it chases the fantasy. Psychiatry needs to go back to its basic settings, and re-develop organically, simply and non-hierarchically behind a firewall which protects it against cyclical fashion and the grandiose excesses of policy-makers and vested interests. There are times when to be rudimentary is to be radical.