No more money – please! Or “The NHS and the Concorde Fallacy”
Never being surprised is an essential attribute for personal psychological well-being for those who work in public sector mental health services. In its benign and progressive version this state of mind is very different from the anxious embattled pessimism which infects most if not all health and social care institutions, and leads staff to imagine themselves to be hunkered down on the “front line” fending off catastrophe from ahead and dismissal from behind.
In clinical work with patients, too, the capacity to receive and witness in a neutral and open-minded way the disturbing material that the unbounded unconscious can throw up is an essential component of honest and trusting engagement. Again, this is qualitatively very different from the jaundiced indifference or tired complacency which impede the development of a therapeutic relationship between equals and which allows risk to thrive.
Thus, no relatively sane (sanity being relative not absolute, at least in this context) or psychologically healthy NHS employee should be surprised by the fact that the its deficit of £930m for 2017-2018 was £435m more than expected and that this is largely the result of having 100k vacancies, almost all of which will be filled by an expensive cadre of locums doing the rounds of teams whose permanent staff come and go. Similarly, this employee - and there remains a quorum, if a dwindling one, of them still hunched over their computers – would not be taken aback by the Parliamentary and Health Service Ombudsman’s (PHSO) recent report that five common systemic failings persist in the care of patients who at times pose a serious risk to themselves or others.
These failings are symptomatic not substantive. Skim any so-called serious untoward incident (usually homicide or suicide) and you find exactly the phenomena which the PHSO identifies: a misreading of risk, important information about risk being scattered around the nexus of care and the person’s wider social network, and a poor flow of that information between the various parties in contact with the person. There are many others woven into the web of failure, in particular the under-treatment of the main triumvirate of mental illnesses, namely psychotic, bi-polar and depressive disorders; what is sometimes called “the rule of optimism” (unrealistic but reassuring surface expectations about what can be achieved with individuals or families) against a backdrop of ingrained pessimism (“in truth there’s little we can do to prevent serious harm”); insider blindness (an inability of those on the inside to see what is easily visible to those on the outside); dangerous assumptions (e.g. “the more failed past attempts, the less serious the patient is about committing suicide”); the diluting of risk over time, and so on.
A permutation of these was almost certainly at work in the context surrounding the suicide of Teresa Colvin in Woodhaven Hospital in Hampshire in 2012 which led to Southern Health NHS Foundation Trust being fined £2m earlier this year. Reading between the lines of Justice Stuart-Smith’s pained remarks before sentencing, the defining clinical approach to Ms Colvin may well have been that two very recent attempts to suffocate herself with a plastic bag (the second of these on the morning of her death), cutting her body in several places and escaping the ward to go to a motorway bridge were interpreted as evidence of a histrionic or unstable personality disorder rather than of a pressing determination to die. A previous misuse of alcohol and prescription drugs may have added weight to this formulation of her difficulties. In the event she used the cord of a telephone out of view of the nurses’ station to achieve the end which her troubled mental state craved.
However, Michael Holder, a health and safety pundit commissioned by the Trust to do a review of risk not long before her death, was onto something more systemic than dereliction of clinical duty when he bailed out of his gig with the forlorn observation that “the Trust didn’t see the safety of patients as part of its core business”. The Trust no doubt countered that the year before it had done an assessment of potential ligature points throughout its buildings and had carefully rated each one on a scale of 0 – 500, and above 500 where “urgent consideration” of removal was needed. The telephone cord, in contrast to the judge’s personal rating of it as 1000, scored 300 which was at the lower end of “medium risk”. Thus it was that an instrument which would have cost £55 to remove was available to Ms Colvin on the evening of 22nd April in 2012.
Otto Fenichel, a premier league psychoanalytic theorist, wrote that those who misunderstand the objective task are doomed to inefficiency and disappointment. Another way of couching this is to say that paranoia, the fearful anxiety which ironically is the motor of mental health services, and efficiency are mutually exclusive. What Mr Holder had cottoned on to was that simple, straightforward institutional and clinical goals such as minimising risk and the management and treatment of mental illness have been extruded from the nest of patient care by the cuckoo of bloated administrative excess.
Southern Health’s scouring of its estate for ligature points no doubt felt purposeful and a good use of the many staff hours it must have taken. Giving each danger a numerical score would have added to the feeling that its approach was thoughtful and objective. It may even have notified its paymasters and inspectors that it had carried out a rigorous review of risk comfortable in its overlooking of the fact that the suicidal mind is inventive and resourceful, and that a quick memo to ward managers, backed up by a modest budget, to neutralise all such points by the end of the month would have been a much better way of attending to “its core business”. However, it is in the nature of things that the organisation which takes its institutional eye off the ball will inevitably be hit by it.
Public sector mental health services now measure everything except whether the patient got better. Although this is what most patients and almost all relatives desire, mental illness being an unpleasant, debilitating and sometimes destructive condition, thinking has become so distorted that, the tokenistic recording of diagnosis apart, there is increasing pressure on staff to dispense with the concepts of illness and patienthood altogether. The chronic failure to be true to the essence of a good clinical service, underpinned by two or at most three simple, achievable goals, and to instil them in staff to the extent that they easily and durably identify with them, has created a vacuum in which the virus of bureaucracy, competing vested interests and idealisation thrive.
As more convoluted and prolix protocols and information-gathering (information being mistaken for knowledge) requirements are levered into the relatively straightforward business of mental health work, compliant or dependent staff gradually succumb to learned helplessness (see Seligman’s theory of depression as a response to random stimuli) while the renegades move on in the hope of eventually finding a home for their creativity and sense of purpose. Leaderlessness, feelings of impotence, cascading then rising up and down a stiff, vertical hierarchy, and a pathological inability to prioritise which leaves the system open to political whim and pressure-group demands, destroy efficiency and sap initiative. Indeed, using ones initiative, as ward staff whose primary duty was to keep Ms Colvin safe and alive might have done but didn’t, is an option resisted by staff through fear of being seen as letting the side down in some way and of being exposed to disciplinary retribution.
When clinical imperatives are elbowed out by administrative ones – because goals have become primarily administrative rather than clinical – incentives become perversely counterproductive or disappear altogether. In the area of risk the dominant culture is now hyper-prescriptive but hypo-protective: if staff feel motivated at all, it is to keep feeding the expanding risk domain in the patient’s swollen electronic notes rather than to think, engage, empathise, enlist his or her self-protective instincts - and think again.
Indeed, any organisation which lays on no or perverse incentives for staff will quickly become sclerotic, static and maladaptive. In mental health services there are numerous examples of the incentive crisis. For example, the bureaucratic load involved in any patient contact leads staff to retreat to the typing-pool which their offices have become or to the nurses’ station (often well-fortified by shatter-proof glass rendered crazed and opaque through years of assault in the hope of getting at least some attention), such abdication from assertive intervention increasing risk and devolving responsibility to struggling relatives and agencies which can’t say no.
Measures, usually in the form of funding panels, which were intended to reduce expenditure on residential and nursing placements, actually have had the opposite effect because, having lost control and therefore responsibility for such budgets, clinical and social care staff have also lost any incentive to move their patients on, especially where they are clinically stable, into less expensive placements or even into those funded entirely by housing benefit. Indeed, residents themselves will often have a hefty investment in the status quo because they feel settled and at home, as will their relatives and, even more so perhaps, the owners of such places who can rely on a secure, long-term income from individuals who stay put.
Further, there is an absence of any incentive for community staff to help move their patients on from acute wards – in fact, the incentive lies the other way because they can relax and switch their attention elsewhere when a tricky or worrying patient is in the (usually) relative safety of hospital. Where once they were closely involved with the ward and its senior staff and had admitting rights for patients who were becoming unwell and perhaps risky (and to facilitate this would free a bed by taking an improving patient home for some leave), filtering teams and systems have been levered in, with the perverse result that, albeit unintentionally or unconsciously, community staff wait for their patients to become unwell enough to convince the filtering staff that admission is unavoidable. A system which is mostly only spurred into decisive action through created emergency not only promotes risk but also increases morbidity in that the longer that many forms of mental illness go untreated (or under-treated), the more intense and intractable symptoms tend to become.
Where incentives are weak, perverse or non-existent, where the clinical gaze is mostly in the direction of specious or sterile targets, and where there is no unifying goal but disparate, conflicting goals spread around small, rivalrous sub-systems, you will get a mental health service in an inexorable decline which is shored up by goodwill and masked by the distraction of misplaced change – that is, change which introduces solutions without first knowing what the problem is.
There is a warning-bell from recent history, its sound now faint in the relentless winds of ideology, fashion, short-termism and myopic conviction. Concorde was a thing of great beauty to onlookers and tapped into a seam of nationalistic pride. But the idea of it carried far more weight for many years than the truth of it – which was that it was ruinously expensive to run and maintain, cramped and uncomfortable, and had an absurdly voracious thirst for fuel. It was an emblematic signifier of British greatness, its survival maintained by co-delusion (the French had an imperial investment in it as well) and the so-called Concorde fallacy.
Powering the symbol of Concorde and its survival way beyond its ideal life-span was an emotional-economic failure to heed the so-called sunk costs lesson. This is that “the viability of an enterprise should not be based on what has already been spent”. This failure would be voiced along the lines of: “because we have already spent and invested so much in this project, we must continue with it so we don’t throw away that investment”. As a result, it continues to be defended when the cost of defence is a great deal more than calling it a day and creating a better alternative.
The death of more than 100 people when Concorde crashed outside Paris in July 2000 gave a pretext for calling it a day and a diversion away from the years of flawed reasoning and collective denial which had kept the project going beyond the point where it was viable, if indeed it ever was. The NHS is kept in the air by absurd levels of misapplied spending but the crash which would enforce a return to basic principles, pragmatically re-drawn, will never be allowed to happen. However, when the revolution will never arrive, revisionism becomes the only answer. In the case of its mental health services this must be, first, deconstruction down to their essence – the partnered clinical exchange between patient and professional – with ruthless administrative gatekeeping which allows in only those measures which facilitate and optimise it; and, secondly, the unbending alignment of incentives, imperatives and institutional goals.