Feature

Caught in a contradiction

The conflicting pressures of national policies and local fundholders have created a ‘double bind’ for mental health care services, says Frank Ledwith

Notwithstanding the distortions of the mass media which seem only able to deal in bad news, there is ample evidence that the NHS really is in crisis. Surveys suggest that staff morale is deteriorating, the public service ethic which ‘oils the mechanism’ is being eroded by the operations of that blind mechanism ‘the market’, and there are indications that waiting lists are rising again.

There is one service where this scenario is certainly true and which is particularly instructive to examine since it arises from a policy contradiction which is fundamental and will have to be resolved sooner or later, whichever party wins the general election. The service is that for mental illness, which finds itself caught between two conflicting policies.

The first is the directive from central government, which most people would support, to give more attention to the needs of severely mentally ill people. Sadly this policy is not motivated by altruism towards a neglected and marginalised group but by the wish of ministers to avoid tabloid-driven campaigns about spectacular homicides or suicides by ex-mental hospital patients. Sadly, as is usually the case, there is no new money for this new priority.

The other policy is probably the decade’s ‘big idea’ in health policy: that the NHS should be primary care-led. This is an admirable idea which fits with the World Health Organisation prescription of Health for All, but the organisational reality is complex. As a result of this policy, plus new GP contracts and other factors such as increased social fragmentation and deprivation, GP workloads have increased dramatically over the last five years. Specifically with regard to mental health, GPs are becoming increasingly averse to repeat prescribing of tranquillisers and anti-depressants. They are turning instead to counselling as a means of coping with the ever-increasing volume of human distress and misery they see in their work. They give a lower priority to the needs of seriously mentally ill people since they see so few of them (and can, as a last resort, have them admitted to psychiatric inpatient facilities).¹

What brings these policies into collision is the increased power of GPs, actual in the case of GP fundholders who have the money to demand more counselling and psychiatric nursing support, and potential in the case of other GPs who can threaten to become fundholders, thereby decreasing the health authority budget still further.

The consequence of these two policies is what could be called the ‘two-way stretch’ for community mental illness services. The staff of community mental health teams (CMHTs), consisting of psychologists, social workers, community psychiatric nurses, psychiatrists and sometimes occupational therapists are first required to devote more time to the most vulnerable patients, especially those being discharged from hospital under the Care Programme Approach and, second, to provide more counselling within general practice. CMHTs have been slow to evolve in Britain with some patchy beginnings. Joint working between health and social services is not easily achieved and is helped by long-term stability in staffing which has allowed time for staff to learn to work together.² But the two-way stretch is rapidly fragmenting such joint working, with staff increasingly working in isolation from one another.

There appears to be a policy conundrum for the NHS, which is simply being writ large and early with regard to mental health services: how can there be central direction to massive shifts in staff work patterns, yet a fostering of local direction from primary care-led services? Perhaps the problems are more sharply drawn in mental health services, where the central direction concerns a relatively small group of very vulnerable people, and yet GPs concentrate on the needs of the many who attend their surgeries. But the issue goes far wider than mental health.

The Tory government has been spectacularly centralist in its actions (if not its rhetoric) since 1979, driven primarily by the wish to contain public spending. The massive organisational changes in health and social services demanded by government since 1991 have been delivered by hundreds of senior managers (who have been roundly denigrated by ministers for their pains).

To allow the future to be determined by 25,000 GPs running what are essentially small businesses is something which no national government can sustain in the long term. Allowing so many individuals to make decisions based on their own, local and partial needs, presents the looming threat of the ‘tragedy of the commons’ where facilities for everyone are destroyed by individuals seeking maximum benefit for themselves.³ Maintaining or developing district-wide teams (particularly for small groups of patients) is likely to be increasingly difficult if policies are made by the average 250 GPs per district, who can also spend their money as they see fit.

But for community mental health services, the question is: what is to be done to resolve the contradictions between these two, individually sensible sounding policies? GPs and their patients will continue to demand more counselling services. It would be very sad if central government gave up on its commitment to those who are severely mentally ill and it is unlikely given public disquiet about the process of closing the large Victorian mental hospitals (which by now have huge costs per patient). ‘More money’ is not a likely solution: no government will substantially increase the funds for ‘Cinderella’ mental illness services or relax their strenuous efforts to control public expenditure.

Other solutions will have to be found. Some staff, particularly psychiatrists, have suggested that the NHS should deal only with severely mentally ill people and leave counselling and other talking support to other agencies. Though drastic and partial, there is the germ of a good idea here, of allowing organisations to play to their strengths. The NHS tends to be a very top heavy, professionally-led service which, as a result, is relatively expensive but may be more appropriate for those with severe mental health problems where medical, psychological and nursing skills are needed.

Social services could complement such provision by providing a supportive social infrastructure in the community. They could provide ‘bottom-heavy’ services, with care assistants supervised to befriend and support such clients. Such community support teams have been introduced in areas such as Blackburn and Preston with very positive reactions from users.

There is however a ‘third force’ in this provision, namely the voluntary sector which is well suited to meeting the wide-ranging and various needs of those with less severe and enduring problems, and which could play a bigger part in providing counselling and other support services. The advantages of the voluntary sector are that it is relatively cheaper to run, using less highly qualified and paid staff; has a shorter span from workers to senior management and thus can be more responsive to individual client needs; can innovate more quickly and easily, due to leaner organisations with lower overheads for start-up; and can provide more appropriately for the needs of minority groups by flexibility and by employing of members of these groups to provide services.

No doubt older socialists who cut their teeth in the post-war consensus which gave us the NHS will be suspicious of the privatisation of provision, with the savings to be found partly in poor wages. Another objection is that such a solution will fragment the working of the CMHTs, but such fragmentation is already occurring and will continue with the internal drive of the two-way stretch. Certainly there would need to be more equal district-wide partnerships between health and social services than is found at present. Social services are very much the junior partners in leadership of teams, yet have more expertise and experience in funding the voluntary sector, using grants and, more latterly, contracts.

The realistic solution is to deal with such pressures in a constructive way, partly funded by savings which can be achieved in medication budgets by using counsellors,⁴ rather than hoping, ostrich-like, that if we do not look the problems will go away.