Falling through the cracks – the current state of NHS mental health services

Recently I spent sixteen hours trying to get an acute mental health assessment for a someone. The details of the case are not what matter here, but I want to talk about what I learnt from the process, and to do that I’ll need to give some context. It is necessarily vague and some information has also been changed to protect confidentiality.

However, as a pen picture it is fair to say that there was a combination of a severe deterioration in mental health with risk to others (the person had bizarre beliefs that led them to want to injure/kill people within particular demographics). The person did not want any mental health input, but I felt that the risk issues were so acute that it was necessary to override the lack of consent and request that an urgent mental health act assessment be undertaken. The other members of the household were keen for this to happen, as were various professionals who were already involved from the health, social care and criminal justice sectors. The person was open to a locality mental health service, but after the initial assessment identified various needs nobody had been allocated to undertake the work, so although it was an open case there had been no service for several months.

So, I rang the local service to ask for a psychiatric assessment. It wasn’t an area where I have worked before or a service that I had any prior experience with so I rang the number on their website. I explained I felt that there was acute risk coupled with obvious decline in mental health, but a lack of consent to treatment, so I enquired what kind of urgent services could be triggered, suggesting that the person involved would be difficult to approach and it would almost certainly be necessary to undertake a mental health act assessment and an admission against the person’s will might be necessary to safeguard others. And that is where I hit a brick wall.

The local service told me they were not commissioned to have a crisis service, and that unless the person involved had self-harmed they did not meet the urgent criteria. No amount of risk to others, or deterioration in mental health would qualify for their service, unless there was self-harm, or the person presented at A&E themselves, or we waited the timescales of their routine service (which had no capacity to allocate a worker). Pointing out the NICE guidance required a same-day response didn’t shift their position. Highlighting the risk to others or the individual likewise seemed to go unheard. The Approved Mental Health Professionals team said that the person met their criteria, but they could not get involved unless there was a psychiatrist from the locality team who had seen the person and would identify the bed if it was necessary to use a section. The psychiatrists said they were not resourced to go out and see people, and that they were not prepared to put themselves at risk by attending a person who presented a risk to others, even though I had arranged for the police to be present. They said the only way they would see the person was if the police used section 136 to bring them to the hospital as a place of safety, where they could then provide an assessment. They suggested that we call 999 to ask for ambulance and police assistance. The ambulance and police said they were not there to provide transport, and if the person was calm and inside the house, they did not present an imminent threat that required removing them using section 136.

Deadlock.

The next day I phoned the local mental health team again and asked to speak to someone senior to raise my concerns about the case. The duty clinician called me back several hours later. I got asked “what do you expect us to do on a Friday afternoon?” and “why is this our problem?” and then got talked over loudly again and again as I tried to explain the issues with risk and mental health. I asked politely four times for the person to stop talking over me, without effect and then asked her name. She refused to tell me and ultimately hung up on me. Her service wouldn’t tell me who I had spoken to, or give me any information about the complaints procedure beyond telling me to write a letter to their postal address. I asked to speak to a service manager. Unavailable. To a psychiatrist. Unavailable. I asked for someone to call me back. at 4.45 I got a return call with the same content as the previous conversations. No crisis service. Doesn’t meet their urgent criteria. A&E, the police bringing in under a 136 or nothing. I wrote a report giving all of my concerns to the whole network in writing.

In supervision I talked about my anxiety about a serious incident, and my fear that nothing would be done, and everyone would pass the buck. I was supported that my concerns were legitimate, and made the decision to try to take it up the chain of command. I called the department again. Then I called the directors of the trust involved, and the complaints department. I made calls all morning with no response, having already had no response for over a fortnight to concerns I felt were so acute they needed a same day response. So I called the CQC.

The CQC were very helpful, and made me feel that it was the right place to raise my concerns. I feel that the systemic issues will eventually be addressed because of the CQC having sufficient power to influence commissioning decisions, but that doesn’t help in the timescale of the individual. Likewise someone near the top of the trust concerned did get back to me the next day, and want to learn from the process (perhaps motivated by awareness of the CQC being involved). Hopefully we’ll look at the pathway, and address the various issues that my experience flagged up. But again, that’s fixing the stable door after the horse has bolted. At the individual level, the outcome was disappointing. The person is moving to a different area within the next few weeks, and the service have decided that means that they don’t have to do anything, whilst the new area will only act if concerns are raised once the person arrives.

So the story doesn’t have an ending yet. There wasn’t a happily ever after, because the service I felt was required within a matter of hours hasn’t been provided, despite several weeks having passed. However, there hasn’t been a serious incident either. I’m keeping my fingers crossed the former happens before the latter.

But it was a pretty weird experience for me. Normally, if I raise a concern people take that pretty seriously. I’m a fairly senior clinician with the titles Dr and Consultant by my signature. I’ve been an expert witness in 200+ court cases. And I’ve had 20 years of experience against which to judge risk and after 16 years in the NHS I also think I have realistic expectations of services. I’ve never made a complaint about an NHS service before, and I hope I never have to again, but I didn’t feel like I had any other option. I was genuinely horrified to see defensive service specifications being used to deny a person with clear acute mental health needs a service. I felt like my concerns were ignored and dismissed because they were inconvenient and didn’t fit within existing pathways.

I’m not sure that my involvement did any good at all for the person in the end, despite spending hours and hours on the phone and writing emails and letters. But it made me wonder, what if I wasn’t there? What if there wasn’t someone with a title and qualifications and NICE guidelines to cite to try and agitate for the services to do the right thing? What if a family member or friend of the individual rather than a professional was trying to express their concerns? Why are the barriers so high when it comes to accessing mental health services? Why have services got specifications that exclude people in serious need? Why are the processes to raise concerns so opaque and so slow? Why don’t services join up better? Why are services always reactive and so rarely proactive? Are age, gender, race or other demographic characteristics a barrier to accessing treatment? Why are we still so far from parity between mental and physical health services? Why does mental health still not have the kind of services there are for acute physical health needs? Most of all, why does common sense and compassion get lost in pointless bureaucracy when it comes to referral pathways and criteria?

I used to be so proud to be part of the NHS. Now I wonder about what it has become. Is this just what is left after decades of cuts and reorganisations, or was I always a roll of the dice away from hitting a dead end?

All change!

Someone once said to me that, if you can manage the stress, change can be an opportunity. They argued that a time of confusion is a good time to put forward ideas that could be seen as potential solutions, as nothing is set in stone yet. Derren Brown (the skilled TV hypnotist, cold-reader, sleight of hand maestro and showman) said something similar when he talked about how confused and stressed people are at their most suggestible. I think he said it whilst persuading bookies at the races that he had won on losing tickets, which was not something I felt was ethical to replicate (even if I had his skill-set) but I do have some anecdotal experiences of this being true. I remember a few years ago going shopping in early December and queuing up to pay in a very busy clothes store. I had a loyalty card which gave a discount for the event at the store, but when I got to the till I couldn’t find it. The poor cashier was on hold to the accounts department to see if they could find my details when, whilst making small-talk, I asked if the discount was the same as the student discount. The cashier then decided it would be easier to put my purchase through as a student discount (which did not require a card number), so that she could deal with me more quickly. Thus I got the discount without the card, and she was able to move on to the next customer. I could see that my comment had unintentionally introduced the potential for an easy win into her mind. Of course as soon as I left the crowded store I was able to find the card, but it made me think about the attractiveness of offering an easy option when the demands are overwhelming. I find this a reassuring concept to think about when the public sector organisations seem to be constantly in a state of organisational change, demands that exceed resources to meet the need, and a pervasive level of uncertainty and confusion! This idea that sometimes a suggestion with serendipitous timing could influence change in a positive direction offered an interesting alternative perspective to my pessimism about how difficult it can be to get even solid, evidence-based, cost-saving ideas accepted into practise (see previous blogs).

I’ve also been talking about the need for change in how I work in my personal development coaching sessions. I’ve previously blogged about feeling a bit burnt out by the emotionally harrowing content of some of my work, the need for me to get better at prioritising and how I am trying to get a better work-life balance. One of my motivations to start the coaching was my sense that I have so many plates spinning I have almost lost track of why I am spinning them and what my goal is. I wanted to re-evaluate what my goals were, and to find the joy in my work again. As I have begun to clear space in my life to reflect on this, I have recognised that my beliefs about what my career would look like have not really kept pace with changes in the public sector and in my own interests and ways of working.

At some level, my template for a good career in psychology was based on my Mum. She worked in child psychology and CAMHS, and was Head of Child Psychology for a county at the point she retired a couple of years ago. I had always assumed that was pretty much how my professional life would pan out. I had qualified in 2000, worked my way up the bands to make Consultant Grade and be part of the CAMHS management team in 2008, and expected to end up as Head of a Child Psychology service somewhere. In metaphorical terms, that was the train journey I bought a ticket for. But something changed when I had kids and went through a lot of stress related to the organisational changes when the CAMHS contract was won by a competing trust and we were TUPEd over. In the end I left the NHS and did something different. In the metaphor, I got off the train. My early plans for my company were very much based on wanting to replicate what I was doing within the NHS, but without the systemic problems I experienced in the NHS trust that I left. So in the metaphor I caught the bus, but I was still headed for the same destination. At various points I meandered, detoured to explore things I had heard about, joined groups to see the local sights, even hiked across country with my own compass, but underneath it all my destination was still the same.

Of course once you are going off the beaten track, sightseeing, hiking and choosing your own route, the journey becomes a bit more scary but much more interesting. In turn, the destination becomes less fixed and also less important, because it can continue to change and there may be steps beyond each destination to another. You can also grow in confidence and tackle bigger challenges and find new things inspiring, so you end up setting goals you had not considered at the beginning of the journey. Once I was off the train, I didn’t need to follow the tracks, or try to make my way by other means to where they led. I didn’t need to replicate CAMHS or to try to set up a LAC service outside the NHS, and I didn’t need to be Head of a Child Psychology service. Indeed I was offered an NHS post with this title last year, which was my expected destination, but I declined the offer. I learnt things about the post that made me concerned that I’d be jumping back into a train on a route where everything was running late and all the passengers were unhappy, whilst I was no longer afraid of being off the rail network and doing my own thing – in fact I had remembered how much I could enjoy the journey if my focus was in the here and now and not about trying to get to the destination ASAP. I started to think of myself as being a much more adventurous person and put my skills to use in much more flexible ways.

Sadly, the kind of NHS I envisaged spending the next 25 years in isn’t there any more, and the jobs at 8C and above bear a lot of the brunt of the change by having to take on the new political and financial pressures, whilst the lower banded staff continue to do much the same work (albeit with increased pressures of throughput and whilst hot-desking). There are good services remaining, and some people will still think that is the best career option for them, and I’m glad about that as I love the NHS and want to see it survive and hopefully thrive in the future with more investment. But for me it isn’t the only option any more. There are other opportunities for adventures outside of the NHS that hang on to my core ethics and values, and put my clinical psychology skills and experiences to good use, but without some of the constraints of the NHS. I can write my own job description, choose my own working pattern and be paid for what I do, rather than on a fixed set of salary points for a set number of hours. Perhaps surprisingly to me, I’ve learnt I’ve got competencies and ideas that are useful and marketable in lots of places. Despite the austerity in the NHS, I continue to have more opportunities and offers of work than I can accept, and some of these are quite well paid. In short, I have learnt that I can actually think much more creatively about what options for my professional life will make me happy if I let go of the template of how I expected my career to be.

With that insight, I’ve got a growing desire to start afresh and do the things that have most impact and bring me most joy. That means I need to look hard at all the options in front of me, and all the plates I have been spinning, and figure out which of those I want to focus on, and which I want to pass on to other people or drop. There may also be entirely new projects that I can develop because they are interesting to me, but I can recognise a future market or source of funding for.

There is big change ahead. But my business is small and agile, I’ve got an entrepreneurial attitude, and I’m lucky enough to have some interesting offers on the horizon. I’m in a position where I can embrace the change, so I am seeing it as an opportunity.

How much do you have to prove? A tale of the modern NHS marketplace

I took a voluntary redundancy from the NHS in 2011. Since then I have run a small company providing clinical psychology services. I mainly do expert witness work for the family courts, which I have blogged about before, but we also offer therapy, consultancy, training, research and other services.

In 2012 we bid for a grant from The Health Foundation to offer brief psychological interventions into the diabetes service for people of all ages at the local hospital. We wanted the bid to be innovative, and so we were determined to think differently about how we structured the service and hoped for it to be commissioned. We decided we would use the grant to set up a Social Enterprise to deliver psychological services, and that we would aim to get commissioners to agree to fund the service in retrospect according to the outcomes we achieved. You read that right – we planned to deliver a service for no cost in return for an agreement to pay for the outcomes we achieved. No more “spend-to-save deadlock” in which the NHS can’t invest in the things that will save money; we were providing the service for no cost to the NHS during the project period and offering to continue to do so, based on retrospective returns dependent upon whether we improved people’s lives and saved costs for their medical treatment. We also agreed to survey the level of mental health need amongst the population using the diabetes service at the hospital, and look at whether this related to their blood test results (which are the best indicator of adherence to medication regimes and lifestyle advice, and of physical health prognosis).

Diabetes is a hot topic because it is predicted to “bankrupt the NHS” due to the rising incidence and cost of treatment. It already costs the NHS £10 billion to treat nearly 4 million people with diabetes in the UK, and this is set to rise to £17 billion by 2035 as the incidence increases to 6.25 million diabetics. Once the loss of working days, early death and informal care costs are factored in, these costs more than double. Even more shocking is the fact that 79% of this expenditure is preventable, if patients followed the lifestyle advice and medication regimes recommended. Studies consistently show that around 40% of people with diabetes have mental health problems, and around 14% of this cost is prevented if there are services to support the psychological health of patients. That is £2.4 billion pounds of avoidable NHS expenditure per year, and around £3.2 billion more in the wider economy. Yet psychological services for people with diabetes are far from universally available.

The Health Foundation loved our proposal and gave us a £75,000 Shine Award to deliver it.

We set up our Social Enterprise which we called Evolving Families. The name is designed to reflect the fact that people change in their thinking, behaviour, learning and roles over their lifespan (and a fair chunk of our work is with adults reflecting on childhood, with parents or with young people whose family circumstances have changed). A Social Enterprise is a business that is run for the benefit of a community, society or environment, and invests the majority of their profits towards that good cause. Our Social Enterprise was designed to invest in delivering psychological services that might not be otherwise funded, like doing research or subsidising people who could not afford to pay for therapy but were not eligible to get what they needed on the NHS.

We used our agility as a small company to employ staff very quickly, and we were up and running for the project to start on 1st Jan 2013. We accepted 65 referrals in the following year (52 adults and 13 children), and closed the project at the end of December 2013. Of those 48 (36 adults, 12 children) attended for psychological therapy and completed pre and post therapy measures, with an average of 6 therapy appointments each. We were able to see people at their homes, at schools, in the community and in our offices. We saw people in the evening if this was more convenient. We went to multi-agency meetings about some of the young people. And most importantly we didn’t have defensive service boundaries – if we felt we could improve psychological wellbeing then we offered services that didn’t directly relate to their diabetes or mental health, for example cognitive assessments, advice about employment, exploration of the impact of neuro-developmental difficulties or sensory impairments.

We screened 750 adults and 100 children who attended the clinics, using the PHQ-SADS (a measure of depression, anxiety and stress used in the IAPT scheme) and the Problem Areas in Diabetes questionnaire. This showed a highly significant relationship between all areas of mental health and HbA1c (the blood glucose score that is the best indicator of how well controlled the diabetes is). There was a very high rate of mental health problems, including a very worrying level of suicidal ideation in both age groups. There was also a very poor level of diabetes control; only 20% had an HbA1c score in the range considered to be optimal (<7) whilst 60% had dangerously elevated levels (>7.5), indicating that this hospital clinic serves a very complex and risky population group.

After the year was complete, we had clear evidence that our service was helpful and cost effective. We made a significant change to participants lives – not bad for 48 people getting  an average of 6 sessions of psychological therapy. Their mental health improved markedly. Fifteen people who were having frequent suicidal thoughts were no longer suicidal, 19 A&E visits in the months before therapy were reduced to 1 in the same number of months after therapy, 30 ward admissions in the same period were down to 5. The cost saved by this reduction in physical treatments was greater than the project cost to deliver. All in all we had pretty impressive results for providing psychological interventions at a cost per head that was lower than IAPT. We were Highly Commended in the HSJ Efficiency Awards.

But did commissioners bite our hand off to take up the offer of paying for the service based on the results it achieved? No. We couldn’t even get to talk to commissioners in person. The hospital told us to talk to the CCG, the CCG told us to talk to the hospital. They told us they need fixed cost contracts to put in their budget, not this outcome based stuff. The contract value is too small to be separately commissioned, and we are outside providers. The service closed to referrals a year ago, and although our service users are passionate about the need for the project and the impact it made on their lives, nobody seems to be listening. So we’ve written a business case and given it to the various service managers at the hospital, and we’ve presented our results locally and we wait, with dwindling hope that it will be picked up at some point in the future. Maybe in the next financial year. Maybe when they reconfigure the diabetes provision.

So I ask: how much do you have to prove in the modern NHS marketplace? If we can deliver a highly effective, life-changing service, and save the NHS more than it costs within the financial year, and we are prepared to accept payment in arrears based on the outcomes we achieve, what more can we do?

Video flash of powerpoint showing outcome data for the project is here: https://www.youtube.com/watch?v=sdyVfGOkdD0

Service user comments about the project are here: https://www.youtube.com/watch?v=KsQDgs-yDq4