Copyright 2019 - Clinical Commissioning Groups Association

The Development of Psychiatric Care - Professor Wendy Burn, President of the Royal College of Psychiatrists

“The added disability from which our health system suffers is the isolation of mental health from the rest of the health services”

This doesn’t sound out of place today. Mental health services are still seen as the poor relation of the NHS and too often continue to be delivered on isolated sites in dilapidated buildings. My clinic room can be a windowless cupboard.

But this was said by Nye Bevan, founder of the NHS, in 1946, two years before the creation of now the world’s largest publicly funded health service. Fast forward to 2018 and we can wish a very happy 70th birthday to the NHS. Will there be cake?

Cake, of sorts, was promised to the NHS by the Prime Minister. Whether this will be enough to go around and, importantly, how it will be divvied up, is being picked over. There is no hyperbole that does justice to the achievements of the NHS. But unfortunately the isolation of mental health services that Bevan spoke of in the 1940s continued.

“As the NHS has grown mental health was not a service that was prioritised”. Prime Minister Theresa May recognised. This is exactly why mental health services are asking for a bigger slice of the cake; why mental health services need a bigger, fairer slice.

The much lauded “cradle to grave” NHS offer really is a source of national pride. The service has retained its founding principles, including “comprehensiveness within available resources”. But, frustratingly, the needs of people with mental illness weren’t truly considered part of a “comprehensive” healthcare offer. There has been progress over the decades. When I started work on NHS mental health wards thirty years ago there were still patients who had been incarcerated for life in an asylum for illnesses that they had long recovered from. This would now, thankfully, be unthinkable.

But some current experiences of patients with mental illness are still unthinkable for those with physical illnesses.

There’s no stronger indictment than the significantly stunted lives of people with serious mental illnesses - these reduce life expectancy by 10 to 20 years. Far too many missed birthdays.

People with mental illnesses use emergency health services far more than other people – 7% of the adult population make use of mental health services but 17% of AE attendances are for patients who also use mental health services. This is a sure sign that the right support really isn’t there.

And this is escalating even further into more people being detained under the Mental Health Act. A sobering irony at a time where we look back with pride on the huge transformation away from a model of institutionalisation that the mental health sector underwent decades ago. Ending this requires a truly comprehensive cradle to grave NHS, which takes mental and physical health fully into account.

What would this look like? Really, this starts before the cradle. A good start in life is inextricably linked with a mother’s health - their physical and their mental health. Until recently, support for the many mothers who suffer from mental illness during pregnancy and immediately after (the perinatal period) was scarce. This meant that not only did suffer without support but their untreated illnesses would often have had a severe impact on their child’s development.

One of the absolute best developments in the NHS in recent years is that 7000 more women now receiving specialist perinatal mental health support, their children benefitting in turn. This is world class stuff, but we can’t forget what a low base we have been working from.

The local investment into these amazing new services needs to be maintained so that their benefit does not fade. A future NHS should provide universal perinatal mental health support, with antenatal classes including mental health advice with support for fathers also available.

Now moving on to children and young people. It certainly doesn’t take a doctor to tell you that there is “something going on” with the mental health of young people. To be brutally honest we just don’t know the scale of mental illness within children or of the extent of unmet need. It’s been 14 years since any proper review of the extent of mental illness within our children.

Simon Stevens, chief executive of the NHS, says that the long awaited figures on children and young people’s mental health, due this year are “bound to show that the level of undiagnosed mental health problems and distress among young people is much higher than has officially previously been recorded.”

Recognition of this is certainly something. In the long term expectations and ambitions need to be raised. We need to aim to treat the majority of young people with a mental illness, rather than the minority, and for services to be commissioned accordingly. After all, is it any help for the Prime Minister herself to talk of prioritising something if your child isn’t getting support? It is essential that local spending on services for child and adolescent services is upheld, including for emerging new services such as Mental Health Support Teams in schools.

And then to adulthood. How does such a gaping void of up to two decades emerge between life expectancies of people with and without some types of serious mental illness? A large part of this answer lies within the care received, or not, during this expanse known as being an adult. Recent focus has been on quite specific areas, rather than on “general” services for people with long term serious mental illness and psychosis.

Services that support these people are being cut back and early intervention services are patchy. The whole country knows when A&E departments see 90% of patients within 4 hours rather than 95%. We have no idea how long people are waiting for mental health crisis treatment.

It’s no coincidence this comes at a time when increasing numbers of people are being detained under the Mental Health Act. “Those with the most severe forms of mental illness have the greatest needs, and continue to be the most neglected and discriminated against” the interim report of the Review of the Act investigating this rise says succinctly.

RCPsych wants to see all areas commission first response services to be able to direct 111 callers to support and for resourcing of community health services and rehabilitations teams to be prioritised in all areas so that fewer people go without support and hit crisis point.

And now to those older generations, who, like the NHS, are looking beyond their 70th Birthday. Whereas in 1948, women could expect to live to 70 and men to 66, today those figures are 83 and 79 respectively. Our ageing population is no secret. Again, no medical degree is needed to guess that this poses a challenge to the whole NHS.

Supply really has not geared up to meet rapidly growing demand on mental health services of a much larger group of older people. Old age mental health has not been prioritised in recent years, which shows through lack of services and staff. As this issue is not going to go away, and the tax payers purse will know all about it, the NHS must start to focus on ensuring that the specialist, complex mental health needs of older adults are catered for, including the implementation of the Dementia Care Pathway by all CCGs

I work with the elderly and our disjointed health and social care system is far from meeting their needs. No one wants to have to repeat their story endlessly or to attend different hospital appointments in separate places thinking about individual problems, especially not an 80 year old with many, interrelated problems.

The progress in recent years both in public attitudes towards mental illness and available services throughout the 70 years of the NHS is invaluable, particularly recent bounds forward. Momentum needs to keep up, a greater number of medical students need to be encouraged to choose psychiatry, and locally commissioners and providers need to work to ensure their own work places are mentally healthy to retain the staff they do have. Otherwise the opportunity to provide comprehensive care and change the lives of the millions in this country living with mental illness will be lost. The NHS and its patients will continue to suffer.

We can’t have our cake and eat it. Mental health services know that any new resources come with new responsibilities to modernise and become more efficient. We are up for that.

By the time the NHS reaches the big 8-0 I want “cradle to grave” to really mean something different. Another slice please.

Content provided by Professor Wendy Burn, President of the Royal College of Psychiatrists.

f t g m