As austerity puts the squeeze on the most vulnerable, many more people are lurching into mental health crisis. At the same time, services are stretched to breaking point. The mentally unwell are having to fend for themselves. Todd Hamer looks at the issues.
Between 2002-3 and 2007-8 there was a 17% reduction in mental health inpatient beds from 32,753 to 26,928. A Panorama investigation found that there had been a further reduction of 17% since 2008. We have lost a third of inpatient capacity in just 10 years1.
At the same time the people needing inpatient services is increasing. From 2008/9 to 2011/12 there was a 33% increase in the number of people detained under the MHA at the same time as the number of inpatient beds has decreased. In 2008/9, 32,649 people were detained under the Mental Health Act2. This rose to 48,631 in 2011/123.
A CQC report found that 15% of wards were operating above 100% capacity (which means patients are either sleeping on sofas in the day areas or being shipped out to B&Bs during the night and brought back to the ward during the day.)
The number of informal (or voluntary) admissions has decreased over this time but not enough to compensate for the increased number of sectioned patients. In 2006/7 one third of patients were detained under the MHA.
By 2011 this figure rose to around 40% and it is suspected there will be further increases when the Department of Health releases new data in October. A recent Health Select Committee was told that in some areas “being detained is simply a ticket to getting a bed”.
However, this increase in the use of the Mental Health Act also tells us something about the type of patients who are being admitted. Whilst the Mental Health Act can be abused there are good clinical reasons why it is necessary.
If a person breaks their leg then they will suffer pain and seek help. Similarly, if a person is depressed or anxious they will suffer mental distress and seek help. But a person in psychotic crises does not experience this subjective feeling of pain or suffering.
The person who believes that their friend is possessed by demonic spirits may seek help from a priest but is unlikely to present at A&E. The Mental Health Act exists to contain such people whilst they go through these experiences. Such containment can be therapeutic. In any case, it seems better than the alternatives.
The increase in the use of the Mental Health Act suggests that more people are entering psychotic crisis and this in turn is a reflection of broader failure of community services.
Increasingly Community Mental Health Teams (CMHTs) are discharging patients to their GPs due to pressure from new referrals.
The GPs do not have the time or specialist knowledge to meet the needs of this client group. In 2009/10 there were 1.25 million users of mental health services. In 2011/12 this number rose to 1.6 million. The CMHTs have not grown to meet this growing demand — if anything they have shrunk.
Many people who have already been through an episode of psychosis will notice relapse indicators (loss of sleep, high/low mood, increased paranoia etc.) several weeks before they enter crisis. It is at this point that they are most likely to seek help. Intervention at this stage can avert a full-blown crisis. The increase in emergency admissions suggests that this intervention is not happening because people cannot access the services they need. Increasingly a person’s psychotic crisis is allowed to develop until that person comes to the attention of the police.
The Association of Chief Police Officers claim that 20% of police time is now taken up with dealing with people in mental health crisis. In 2011/12 there were 23,569 uses of section 136 (the police authority to detain people pending a MHA assessment). 37% (8,667) of these people were assessed in a police cell rather than a hospital.
In addition to these problems, specialist mental health services are being cut. For example, almost all NHS drug and alcohol services have been cut and outsourced to the voluntary and private sector. The government has imposed a reactionary abstinence focus on drug services, with a funding regime that pays services for getting people off drugs and discharged back to their GPs.
The tried and tested harm-reduction approach that the NHS championed for decades has been sidelined along with the skilled NHS workforce. Gary Sutton, from the drugs charity Release, told the Guardian: “A major social experiment is underway, the results of which we cannot predict”.
But Sutton underestimates the extent of the social experiment. Unlike the rest of the NHS, where cuts and lack of resources are part of the history, this situation is entirely new for the mental health sector. Before 1948 there were no physical health services for the majority of the population and ill health was treated with prayers and quackery. But “services” for the mentally unwell are much older than the NHS.
The imprisonment and containment of the mentally unwell started in earnest in the 17th century. At that time the emerging industrial capitalist class were pushing the rural poor into the factories and trying to impose some basic capitalist work discipline (e.g. turning up for work on time, working through the winter months etc.). There were many people who did not comply with this new way of working and the authorities responded by imprisoning anyone who did not fit the mould.
Michel Foucault claims that by the mid-17th century over one per cent of the population of Paris were imprisoned. Workhouses and asylums were built and filled with a motley assortment of vagabonds, misfits, prostitutes, drunkards, learning-disabled, and mentally-ill people.
Over time, and in a fairly arbitrary way, the mentally ill were separated out from the rest and the modern asylum system was born.
Much torture and abuse took place in these institutions. This history may also lead us to question the social purpose of psychiatry for a modern capitalist society. However, these institutions are the ancestors of the modern psychiatric establishment. In 1955, when the asylums were being closed down, there were over 150,000 mental health beds in Britain (compared with just over 20,000 today).
The closure of the asylums was made possible by advances in medical science and by the then-Tory government’s desire to cut costs. Initially the closures were complemented by an expansion of community provision. Care in the community was never well resourced, but generally it was a progressive step forward and it did grow to meet the growing demand.
For many years now there has been no growth in services. All services are being cut to levels unseen before in modern history. We are approaching a dangerous crisis point.
For four centuries the mad have either been contained and shackled to live out their madness away from society or, in recent years, for the lucky few, have been aided on journeys of recovery. The best mental health practice combines therapeutic containment in crisis with a hopeful facilitation of recovery for less stormy times.
Increasingly mental health services are not equipped to provide either service. Unless we get organised and fight to reopen the wards and expand the community teams, we face a brave new world where the mentally ill are left to their own devices, live out their madness amongst us, and emergency containment is provided by police truncheons and CS spray.
While the crisis in the NHS rages, the private sector is experiencing boom times. With more people needing hospital admission for mental health crisis, the NHS is having to ship out patients to the private sector. The number of patients detained in private hospitals (paid for by the NHS) has risen by 21% in 2011/12 alone.
The bed crisis is so grave that it has extended into the private sector. Sometimes finding a private bed is near impossible. In London, there is a growing trend for Trusts to seek cheaper private beds outside of the capital. Solidarity has received reports that South Londoners experiencing acute psychotic crisis have found themselves shipped many hundreds of miles to private beds as far afield as Newcastle and Wales.
Cygnet Healthcare, a major provider of private mental health beds in London, has seen a 30% increase in the number of NHS patients on its wards in the last year alone.
Some NHS Trusts now have teams dedicated to policing these private sector “partners” to make sure they aren’t detaining patients unnecessarily or bumping up their profits with excessive treatments. You don’t need to be paranoid to be suspicious of the intentions of a for-profit mental health hospital!
By filling its wards with NHS patients, the private sector is accumulating the cash to expand into other areas of mental health care. Forensic services for people with mental health problems in the criminal justice system offers a promising site for investment. The patients are long-stay and move through the system at a snail’s pace. There is also a large potential market.
A 2011 report by the Sainsbury’s Centre for Mental Health found that 90% of the 84,000 prisoners had mental health problems and 23% could do with specialist treatment. From 2007/8 to 2011/12 the number of forensic inpatients rose from 1,917 to 2,130.
The private sector absorbed almost all of these new patients. That leaves around 20,000 potential patients in the prisons which are also in the process of being privatised. Companies like Serco, who run prisons and will be looking to run medium-secure psychiatric units, could make a fortune out of this captive market.
Mental health services are generally funded by block grants, which makes them easy to cut. For this reason many NHS bosses want to move to the Payment by Results where you get paid per patient.
The problem is how to attack a price tag onto a mental health problem. Diagnosis in mental health is notoriously difficult. Treatment is also quite hit and miss. And what exactly are the “results”?
Brushing these problems aside, NHS bosses have insisted that frontline clinicians use the Orwellian titled “Health of the Nation Outcome Scale” (HoNOS) to provide them with data that they hope they can later translate into cash sums.
Unsurprisingly, the HoNOS data doesn’t make much sense. PbR was supposed to be implemented in April 2013 but has been delayed into the distant future. The advocates of PbR believe that they just need “better” data.
But psychiatrist Emma Stanton identified the fundamental problem: “real life is not connected to what the data shows”. While it is obvious to most of us that people’s experience of mental distress cannot be measured in pounds and pence, this delusion continues to dominate in the minds of NHS bosses.
PbR is the agenda of city accountants who wish to introduce cash payments to every part of human existence.
Mental health workers should stop wasting their time filling out the clinically useless HoNOS assessments, and demand they are given the resources they need to do their jobs.