NHS Mental Health Services: A problem-transfer system

1. 1.             A Tale of Two Patients

On a random day in late winter I visited a patient in a private hospital in south London to assess his suitability for a hostel in the community.  He had been there many months and his stay was funded at great expense by the state because there was a shortage of NHS beds for people with his profile. For ease, he could be called patient A.

He was a pleasant, interesting man who (this wasn’t mentioned in the reports I was sent in advance) had had a few hit singles around twenty years before. He’d been an anxious teenager with agoraphobic tendencies but, as often happens, these morphed into serious and qualitatively different difficulties as he went through his twenties. After many years of highly disturbed and risky behaviour, driven by all-enveloping paranoid beliefs, catastrophic changes to what had been a fairly conventional and productive life, and a series of medications which had minimal effect, he was now, finally, clinically pretty well.

This was down to a newish kind of drug which pushed his dangerous ideas to the periphery of his consciousness. In the space that was left behind he had rekindled some old interests, as well as his volition and motivation. He was extremely settled on the ward, with good relationships with staff who ensured he took his medication without fail at the prescribed times. His leave had gradually built up to the point where it was now almost unrestricted. He was back on good terms with his parents but couldn’t live with them.  The agreed aim was to find him exactly the right place to move into in the community and a specialist team was gearing up to supplement this once he was fully discharged. This was a man with a serious, lifelong illness who was getting just about the best care and treatment that could be devised for him.

After our long and stimulating discussion, I returned home to care for a close relative who after a very troubled decade had been admitted to hospital under a section of the Mental Health Act around six months before. We could call him patient B. He was well-looked after in hospital for four months. A perceptive and assertive consultant established him on a depot early on when it was clear that accepting and swallowing oral medication was too much of a challenge for him. While there was some softening of the hard edge of his beliefs, he remained profoundly troubled and depressed. The regime itself was, perhaps unusually, very inclusive and the main family members were formally slotted into weekly ward rounds.

Yet in a number of domains patient B seemed to his family to be getting more unwell. His ideas were now more exposed and new behaviours developed. Motivation, volition and spontaneous speech deserted him.  The undertow of his dangerous ideas became, if anything, stronger. He was less crazy, maybe, but more ill. While he paced the corridors, he had reached a kind of toxic stasis.

But at a moment when nothing much had changed, something changed significantly. A random seed seemed to germinate in the collective institutional mind. It was time for him to move on. The destination was far less important than the parting. No goal had been reached because there was no goal. The machine had run out of steam. A detached outsider might protest that, if anything, symptomatology had increased but the rule of optimism began to dominate the clinical discourse. Improvements were imagined where there were none. This process was the precursor which would legitimise discharge. A hidden momentum, owned by no-one because its spring was an institutional one, carried all parties to a perfunctory ritual one afternoon when the kind consultant was otherwise engaged. Patient B was discharged and this was duly recorded by a junior doctor on a keyboard in the corner.

This triggered the instantaneous collapse of support for Patient B and his family. 24-hour support and surveillance from a large multidisciplinary team were replaced, on the tapping of the keys, by 24-hour parental muddling through. Notionally, care was transferred to a different team with different priorities and personalities unguided by meaningful knowledge of the person, his history and illness. A locum was replaced by a locum. Another locum conducted what for the purposes of data-collection only was designated a review. Continuity, without which treatment and intervention are shots in the dark, was abandoned by default. A person, without a home, social network, income or constructive activities, was similarly abandoned to the goodwill of family.

1. 2.      Comment

 

Compare the fortunes of these two patients. Patient A, who had committed offences which seriously threatened the lives of others, received gold standard care. His treatment was more or less optimised; he had become well (for him); his move from hospital was to be gradual; parents were to be partners in his aftercare not providers. The threshold for discharge was a demanding one.

By contrast, patient B was the victim of the therapeutic U-turn.  This is sometimes seen in childcare where benign support turns into oppressive intervention almost, and sometimes actually, overnight, the overseeing institution being more capricious than the individual professional. In his case, more distant factors than mere clinical ones led to peremptory action which was imperative-driven rather than goal-driven.  Indeed, perversely, lack of progress by this stage was seen as a reason for discharge. 

Lurking in the middle of a ward notice-board spattered with out-of-date flyers was an impressive poster detailing how the number of bed-days patients were having on  wards had been reduced.  Implicit here was one of many misplaced anti-therapeutic assumptions that have unintentionally created  a sclerotic, maladaptive system for providing mental health care for people with serious illness; that spending a long time (the definition of this is shaped by many variables) in hospital is a bad thing and patients should be moved on as soon as the organisation can get away with it.

Such ideas infiltrate the whole system, becoming so normalised and invisible that they lie beyond routine interrogation. Again as in children’s services where there has been a guiding principle that work should be aimed at preventing the need for state care, admission to hospital is seen as a failure – and an irksome and disruptive one at that.  Over time, dense filters, often staffed by those with least experience of managing illness and risk outside hospital, have been levered in to maintain a structure predicated on this crude idea rather than on clinical need or wisdom. Professionals in the community wanting a bed, often for a patient the course of whose illness is well-understood, are confronted by a bed management (where it should be a patient management) system as impervious as the most sophisticated inter-continental ballistic missile shield.

Insider blindness prevents those who administer the process from seeing what is obvious to the uninitiated on the outside. Patients must become dangerously disturbed before navigation to what was clinically indicated often months before can be achieved.  Yet again, the consequences of this are actually known in a sense to insiders but the system requires that they are denied. Very ill people generally (acute, florid illness as in bipolar disorder being an exception sometimes) take far longer to get better than those who are becoming ill; there is clear evidence that if some forms of serious mental illness are allowed to continue untreated, patients will never reach the level of recovery that they would have if effective intervention had happened earlier; thirdly, risk to self and others increases – exponentially, once a certain level of disturbance is reached. 

Mostly, in the last area, there are narrow escapes, collusively and collectively smothered as the need to fend off the next crisis arrives. Patient C, she could be called, had an established history of mania and psychosis, their trajectory as familiar to her teenage son and his father as the seasons of the year. Routine appointment letters got no response. The second of a couple of home visits triggered verbal abuse through a closed kitchen window. Eventually, her son, sheltering elsewhere with his father, agreed to let staff in to see her.  As so often happens, she wasn’t thrown by the arrival of two complete strangers in her kitchen but demonstrated, sometimes with good humour, the extent and intensity of her mania with a wide-ranging splurge of grievance and rage.  

Years of ad hoc triage in similar circumstances told staff that intervention at the time beyond mere listening would be ineffective and risky. The therapeutic point of no return had unarguably arrived. After they left on reasonably affable terms, an hour or so was dutifully spent back in the office completing the forms for a formal Mental Health Act assessment. A decade or so before there would have been no forms and no delay but this was what was now needed to kickstart a process which could run for weeks, even months if there were abortive visits with police and ambulance.

The next day patient C was picked up by the police outside a nearby school gesticulating with a machete. By the evening she was in hospital under a section and on medication.  Later contact with son’s father revealed that they both had been worried about her around three months before but didn’t know what to do. He had his son mostly stay with him and eventually, having circumvented the practice manager, persuaded her GP to ask for a psychiatric assessment about six weeks before.

Patient C may have been moments away from causing serious or fatal harm.  Those who knew her knew where she was heading. Those who knew her professionally from the past had moved on, her case being closed for administrative rather than clinical reasons. Nothing would be or could be learned from this, a routine near miss, because it was felt to demonstrate, perversely, that the system to which everyone had become habituated was somehow working.  In other words, it fitted and was familiar.  If good fortune hadn’t intervened and she had gone on to kill, an internal inquiry would have deftly fudged the inherent systemic failings and a later external inquiry would have buried the truth of it in a clogging slurry of misplaced recommendations.

T did actually go on to kill – his mother, as recounted in “An Independent Investigation into the Care and Treatment of T., a Mental Health Service User in Camden” (Niche, July 2017). This makes all the usual errors of such reports, being far too lengthy, making a long list of irrelevant recommendations (which, if actually implemented, would have further weighed down a lumbering NHS bureaucracy), and tragically missing the key clinical lesson.

This was a classic case of undetected risk to a caregiver dropping into a convoluted, risk-promoting, over-layered system. T had what could be called form. Struggling with a toxic illness - paranoid schizophrenia for twenty years - he had threatened both parents with knives; he had assaulted his mother on a number of occasions and had expressed a worry some time before he actually did that he would kill her. Unable to stay in his own flat, he had moved back in with her and both reported fears that he would attack her.  She contacted services on two occasions as his untreated hallucinations and delusions grew. 

Uniquely for him, T wanted to be admitted. In the many phone conversations between the two and the relevant mental health team, well-worn, tangled assumptions and stereotypes blocked the way to a clear understanding of danger. She was described as “forceful, frantic, demanding and overly dramatic”. His “controlled manner, good concentration and logical thought processes” were deemed to be “incongruent to reports of his deteriorating mental state”. A number of mental health team staff, the “gatekeeping team”, different bed managers and a “Crisis Team” added confusion and complexity to an essentially simple manner. Somehow the fact that no bed was available became a systemic belief that no bed was needed. Further assessment was delayed with mother being advised to call the police or take her son to A+E if things became worse and T, now well into his episode of florid illness, being given a prescription for medication.

Staff from two different teams saw T in his mother’s flat at 11 am. He was clearly psychotic and asked several times if they were going to take him to hospital. Each time he was told he didn’t need to be in hospital, this being the institutional misapprehension which had crystallised.  His mother insisted that he did and that he hadn’t taken any medication, which he contradicted. T was asked to go to a team-base later that day for a medical review, which he failed to do. Around 5 am the next morning a voice told T to kill his mother, which he obeyed, stabbing her many times.

T told the external inquiry that during the 11 am assessment he was hearing voices telling him he had to kill his mother (symptoms which he found “embarrassing”) and that he “couldn’t believe how nuts [he] was and that they didn’t put [him] in hospital”. He said that in retrospect he realised he should have hit a member of staff because then he would have been sectioned.

This sad story is an uncanny echo of the stabbing by Raymond Sinclair of his elderly mother in Kent in November 1994 (having threatened his brother with a bread-knife two months before). Similarly, dangerous assumptions took staff away from the core risk, as did underlying prejudice about close, dependent relationships between older men and their mothers. And a key clinical question was suppressed by a myriad of non-clinical pressures, concerns and muddle: namely, “have you been having thoughts about harming your mother – I know it’s difficult for you but try to tell me what has been going on in your mind about her”. Generally, when the right question is asked in the right tone, patients do not dissemble.

Perversely, such inquiries are serial rather than cumulative.  Very straightforward, easily implemented clinical lessons are drowned in a heavy wash of bureaucratic care-speak.  Instead of an accretion of ideas (and stories, for that matter) leading to greater clinical safe practice over the years, succeeding generations of mental health professionals approach each crisis and challenge as if for the first time.

Mostly, patients such as T., Raymond Sinclair and the many sufferers acting on intense paranoid delusions or powerful imagined commands to kill recover quickly once detained and treated in the wake of their offences. But, as with patient A., building on that recovery and setting up a structure to sustain it after discharge is a slow and measured process.  In other words, in order to maximise your chances of getting optimal treatment, first commit a serious offence.

This absurdity is a function of a now deep-rooted culture of a high threshold for admission and a low threshold for discharge.  Waiting to admit, say, patients with cancer until their condition became much harder to treat and discharging them in a way that made it much more likely to flair up would be considered primitive and bizarre. It is easy to attribute the huge disparity between spending per capita on the treatment of and research into cancers and those of, say, paranoid schizophrenia to differing degrees of stigma or societal acceptability. While it is true that there is a collective unconscious wish for serious high-stigma conditions such as schizophrenia (less so with low-stigma ones such as anorexia or bi-polar disorder) to be invisible and therefore denied as far as possible, there are other institutional forces at play which are easier to turn round than these deeper currents.

Our mental health services are channelled, not through a treatment system so much as a problem-transfer system. Where once this was into the cul-de-sac of the long-term, monolithic institution, the increasing fragmentation of such services into functions and specialisms promotes the passing of responsibility and therefore any commitment which can be mustered to whichever part of it has the weakest barriers (and families generally have the weakest of all). Each element, subscribing to its own, local goal rather than an agreed, collective goal, will over time devise its own criteria for acceptance and, more important, organically acquire a mentality which instinctively looks for reasons for not taking on a patient rather considering how the organisation as a whole can best help the patient. Every person manning the gate, as it were, will necessarily ask themselves or those at nearby desks: “what detail can we discover which means we don’t have to take this patient on?” instead of “what should service should our Trust be providing this person with at this time?”

This approach will be found not just at intake on the boundary but throughout a service.  It is at its most obvious and absurd where mental illness and heavy use of drugs are concerned. Patients circulate through prison, the street, the family (briefly), psychiatric wards of various kinds and levels of security, a series of hostels, the street again and so on. They become heavily, if invisibly, tainted in a cycle which only concludes if or when a serious crime is committed.  The most egregious example of such a person is Paul Crossley, a man who was being treated for paranoid schizophrenia, who pushed a 91 year-old man onto the rails at Marble Arch tube station in April 2018 having consumed £600-worth of crack cocaine the day before.  Now serving a minimum of 12 years in prison (the judge was unsupportive of his claim that his mental illness was the primary reason for his offence), Mr Crossley, a Teflon patient to whom no service would stick, is almost certainly much improved now that he is medicated with prescribed rather than unprescribed drugs.

Community Treatment Orders (CTOs) have also been used by more strategically minded mental health teams to halt the cycle of waste and repetition. Though criticised in some unhelpful and misplaced research (CTOs for Patients with Psychosis (OCTET): a random controlled trial, March 2013), the power they give psychiatrists to recall patients to hospital if they default on their medication has enabled a very large cohort of patients to settle in the community, resume contact with their families and engage in constructive activities – often after decades of interrupted treatment and dangerous behaviour to themselves and others.

Institutional thinking is self-evidently a challenge to treat - serious mental illness much less so. There are now a wide range of drugs which are very effective in the treatment of both psychotic and affective (schizophrenia, bi-polar illness and depression essentially) disorders. It may necessarily take a while for patient and medication to be optimally matched in that the study of pharmacogenetics has revealed that reaction to drugs is genetically and therefore individually determined.

A number of other variables also contribute to this delay. For example, there is an over-reliance on newer drugs, promoted by pharmaceutical companies, at the expense of older, much cheaper ones which actually work very well for certain patients. Secondly, when patients become unwell again, there is an institutional bias in favour of trying a different drug and a failure to examine carefully what medication they were taking in periods of stability.  Thirdly, there is a similar, if understandable, bias in over-estimating a patient’s capacity to make decisions about medication and allowing depot medication to be replaced by oral forms. Fourthly, a high turnover of clinical staff (a relatively new phenomenon) and a structure which leads to patients moving around between many different segments militates against continuity and the development of the lasting and trusting therapeutic relationships which are necessary to help patients to take and remain on effective treatment.

These factors combine to promote chronicity and morbidity. Awareness that somehow something isn’t working leads not just to the barriers to prompt admission described above but to other intended solutions which compound the problem.  The levering in of other structural layers, such as funding panels and separate so-called “pathway” teams to oversee placement in hostels and other forms of residential care, means not only that key decisions are made by staff who do not know the patient but that there is always a proportion of patients on wards who do not need to be there, crucially reducing therapeutic investment in those who really do need to be there. The old Broadmoor joke – “a third of the patients don’t need to be there – it’s just a question of knowing which third” – could be a motto on just about any psychiatric ward currently.

Individual disasters, lazy stereotyping of mental health services as a whole, the lobbying of narrow vested interests and this implicit, generalised consensus that things are “not working” (whatever that means) inevitably lead to calls for more funding but pouring more cash (as New Labour did in the 1990s and beyond) into a flawed system will merely intensify the flaws.  If the essential problems of a dysfunctional system aren’t fully understood and owned, solutions become the problem.  Thus, New Labour money increased fragmentation and speeded up the flight of staff from wards into much better paid, more prestigious jobs in the community, rewarding careerism at the expense of experience and vocation.

In the area of mental health services, less policy is needed not more. Policy which leads to a further cycle of pointless change should be replaced by structural streamlining in the name of productive simplicity.  So:

• simplify and clarify the “objective goal” (NB one organisation, one goal)
• make sure all staff identify with the objective goal
• make sure all non-clinical work is subsidiary to lasting clinical improvement
• align incentives so that different parts don’t have conflicting ones
• eliminate counter-therapeutic thinking (e.g. “we must prevent the need for hospital care”)
• make sure the best and clinically most effective staff have the most contact with patients at critical moments (e.g. entry into the system, admission, in-patient treatment, discharge)
• end the institutionalised marginalisation of families
• have generic teams with specialists in them, not specialist teams (which inevitably become generic eventually)
• build in continuity of approach: knowing the patient is as important as knowing the illness
• eliminate the embargo on understanding

Resistance to such measures arise out of a primary anxiety about contamination by the craziness of others (see Covid-19 for a physical equivalent) and secondary concerns about being overwhelmed and therefore powerless. The avoidance and compartmental thinking and behaviour which derive from these are the motor of a problem-transfer system.  Defensive mental health services actually increase pressure from the outside, as do measures intended to mitigate such pressure. Ease of access, it must be understood, does not always mean inundation.