mental health

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?

*this was never followed up, so in retrospect it seems it was just platitudes to shut me up

Talking about depression and seeking help

Someone I know emailed me this week, saying he was feeling depressed. He was very self-critical about it because objectively his life was the best it had ever been (after a lot of difficult experiences in his childhood and early adult life he is now employed, in a relationship, with a nice home) and therefore it felt ungrateful to complain about anything (like social anxiety, work stress, sleep disturbance, niggles in the relationship, having to care for a dependent parent) as he should be happy. He felt perpetually exhausted and like therapy and medication was for people with ‘real problems’ and talked about wishing he didn’t exist. This was my answer:

There is no ‘should’ with feelings. They just are what they are. We can learn to challenge our thoughts or change our behaviours, which can have a positive knock on effect, but feelings we have little control over. So just be mindful of them, and try to deal with the stuff that underlies them when you are feeling well-resourced and supported.

I read a rather naff explanation on facebook today, but it has a germ of wisdom in it:

I held up an orange and asked a boy in the audience “If I were to squeeze this orange as hard as I could, what would come out?”

He looked at me like I was a little crazy and said, “Juice, of course.”

“Do you think apple juice could come out of it?”

“No!” he laughed.

“What about grapefruit juice?”

“No!”

“What would come out of it?”

“Orange juice, of course.”

“Why? Why when you squeeze an orange does orange juice come out?”

He may have been getting a little exasperated with me at this point.

“Well, it’s an orange and that’s what’s inside.”

I nodded. “Let’s assume that this orange isn’t an orange, but it’s you. And someone squeezes you, puts pressure on you, says something you don’t like, offends you. And out of you comes anger, hatred, bitterness, fear. Why? The answer, as our young friend has told us, is because that’s what’s inside.”

It’s one of the great lessons of life. What comes out when life squeezes you? When someone hurts or offends you? If anger, pain and fear come out of you, it’s because that’s what’s inside. It doesn’t matter who does the squeezing—your mother, your brother, your children, your boss, the government. If someone says something about you that you don’t like, what comes out of you is what’s inside. And what’s inside is up to you, it’s your choice.

When someone puts the pressure on you and out of you comes anything other than love, it’s because that’s what you’ve allowed to be inside. Once you take away all those negative things you don’t want in your life and replace them with love, you’ll find yourself living a highly functioning life.

Now, I’m not totally on board with filling yourself exclusively with love and light (because I think negative feelings are pretty normal and have their value too), and I’m not sure that anyone can ever respond only positively to life’s pressures, but he is right with one thing – your response under stress reflects what you have learnt and experienced in your life up to that point. If you are filled with the poison of being bullied at school or denigrated by your parents, with the wounds of failed relationships, with traumas and losses, then that becomes your norm. It will tarnish your view of yourself, the world and others, and it has the potential to leak out in unhelpful ways. When you carry that baggage and aren’t buoyed up by positive experiences and relationships it becomes much harder to be resilient to the day to day stressors of life. It becomes harder to feel you deserve a better life and to seek out positive experiences for yourself, and you can instead end up avoiding or sabotaging them.

Therapy is there to help you recognise that skew, and to separate the result of negative experiences from your innate worth as an individual. It can help you to challenge your thinking, to change your behaviour, to give yourself opportunities to test and refine your beliefs about yourself, the world and others. It can help you reflect on the patterns in your relationships, why you keep replaying the ones that are not helpful and how you can begin to change this. And sometimes when you are feeling so hopeless and worn out that even the idea of therapy is too much to manage, medication can help to give you the energy and optimism back to allow change to be possible.

The biggest problem of depression is that people can see it compassionately in others, but we are very critical of ourselves for feeling that way, and unable to recognise that the stuckness and self criticism is part of the depression and – importantly – eminently treatable. If you read back your email to me and imagine someone else made it, I think you’d be a lot more compassionate to that person than you are being to yourself. The problem is that you are trying to measure the objective situation with a subjective (and in fact distorted) tool – yourself. And that distortion increases when you are depressed. So be kind to yourself, and allow others to help you. You don’t have to be stuck with feeling sad just because you can’t pin a reason for it on something specific or because there are other people who have bigger problems in their lives.

You said that you sometimes wish you didn’t exist, but I am very glad you do, and I am sure that there are lots of other people who value you and would miss you if you weren’t around. When you are depressed it is hard (if not impossible) to imagine that life can get better. But it can get better. Not only that, but it does get better for most people with depression. Most people who are depressed or even suicidal go on to happier times and to be glad they didn’t act on those thoughts. So please, seek help and don’t give up. Call the Samaritans if you feel like you might harm yourself, and speak to your GP about medication and/or a referral for psychological therapy. After all, 90% of people who turn up to therapy start to feel better, and you can too.

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

Challenging times

Time for another update, but sadly not a positive one.

On the good side, I got new accountants who sorted out the mess and applied for my tax rebate (though it is still to materialise), and moved to a new online system for keeping my financial records which is great. My AP got onto training and left in September. The diabetes project was Highly Commended in the FSJ Efficiency awards. We had lots of positive interest in what we were doing and put in 3 substantial bids. I’ve been invited to speak at a range of exiting national conferences, and I’ve been involved with quite a lot of national committees. The book has sold about 1000 copies and has received some lovely reviews.

The bad news is that none of the bids were successful, and none of the interest has translated into a contract for our services (yet). Legal aid fees for court work have come down another 20% and the maximum hours per case are also being squeezed. A high proportion of invoices are being queried, which generates extra work, and quite a few are not being paid at all (due to solicitors going out of business, or problems between them and the LAA, or disputes about who is responsible for the fee) as well as loads taking 12-36 months to pay. Although we have a few therapy cases, half of them are at our subsidised rate that barely covers costs. The diabetes project may be commissioned by the CCG or hospital trust at some point in the future, but there are no guarantees, and any contract definitely won’t be in place before the new financial year. Our finances were already tight, and I don’t really believe there will be a contract until it is signed off, and I can’t afford to keep the team employed until it comes through.

The CCG say that our service is too small to separate from the diabetes contract. The NHS trust made positive noises in public, but in private it was a different story. An NHS finance director told me that the trust would not consider subcontracting our service because it reduces crisis presentations that are income generating for them. That’s horrific to my thinking – that they have perverse incentives to want people to end up in diabetic comas, or with blindness, amputations or suicidality if it makes them money as an organisation. So I have to count on the service closing.

The reduction in work would mean that staffing costs will exceed our income quite substantially from January (about £5k/month) so it looks like the business has to shrink from me plus 4.5 whole time equivalent to me plus 1.6 whole time equivalent as quickly as possible, with the potential of me returning to work as a sole trader or taking up employment elsewhere in 3-4 months time if we don’t secure more work.

This is obviously gutting, and makes me feel horrendously guilty and stressed. I’ve been so upset about it that I’ve pretty much wanted to hide under my duvet and cry, rather than try to continue working. Its just horrible to feel I’ve let people down (even though I know logically that it isn’t my fault, and that I’ve always been clear with people that it is a small business and doesn’t have the safety net of the NHS, and that many of the staff were on fixed term contracts related to specific projects anyway). Of course, being self-employed I can’t just sign off sick with stress, and have to see through the court work I’m doing, but I can’t wait for some time off at xmas…

Basically, I’m having a bit of a ‘why am I doing this?’ moment, and I don’t really feel like I know what my goals are any more.

Finding my own way forward

It feels like so much has changed even over the last five months since I last posted.

We moved into the new offices, furnished them and got fibre-optic broadband and unlimited phone calls. We’ve got a lovely therapy room, a reception, a kitchenette, a loo, an office where most of the team sit, and my office which can be used for consultations and appointments when the other room is busy. This suits us so much better than being in a giant serviced office building as the space is ours alone. There is something quite remarkable about being able to do things immediately and autonomously when compared to how long each process would take in the NHS.

The team now consists of me, a part-time operational manager, a full time nearly-CP (just needs to get thesis corrections signed off and HCPC registration), an AP, an AP(R), a general assistant (psychology graduate), a part-time admin (the full-time one didn’t work out), and a part-time CBT therapist who contributes to one project. We are recruiting again, as demand still exceeds supply, and hope to get someone (or two) to join us from a clinical course as they qualify in September. It feels like we are on a path of steady growth, but it is actually quite tricky to ensure that we balance workforce and work. I’m learning a lot more about running a business, and also learning to delegate to my team. We have set up a social enterprise company* to split off the provision of therapy and certain other projects from the court-work focused limited company. We have a new local accountant helping us get our more complex books in order.

The research aspect has also really taken off. We have won a Health Foundation Shine award, which gives us £75k to offer and evaluate a psychological therapy service to aid treatment adherence for diabetes patients at the local hospital and a small parish council grant to run and evaluate a group for expectant mothers and a perinatal group. There is potential to expand the hospital pilot to other areas over the next year. We are also going to apply for an ESRC grant in collaboration with a local university. We’ve formed connections with lots of the voluntary and community organisations in our local area, and have put in some small grant applications for various projects. We’ve also got talks going on with various social care and health organisations about delivering consultancy, assessment and therapy services, and enquiries about many other things we have mentioned. We’ve had a few therapy referrals from various different sources, including some self-funded private clients, and are (frustratingly slowly) becoming registered as a provider for one of the major health insurers. The court work continues to flow in as our main income too, with ever more complex and interesting cases, so it feels like I need to be careful we don’t grow in too many directions at once, and focus on the interface between our passion, our expertise and what is marketable.

Meanwhile I’ve got my book coming out next month which hardly feels real! We are planning to have a launch event of the new social enterprise coupled with a book launch on 1st March and do some free talks for various groups of professionals at a local venue, which should be fun. The publishers are keen for this to be the first of a series, but I need to carefully consider what (if anything) to write next. I’m toying with the idea of writing up some papers and a book (and perhaps even a phd) on an area of research that’s been particularly interesting to me, but it rests on getting another grant and/or some paid academic sessions and deciding this is worth the time commitment compared to other projects. I’ve also joined the committee of the BPS faculty for children, young people and their families, and the FJC/BPS reference group for psychologists as expert witnesses as well as my on-going role with CPLAAC. Its probably a bit much all at once whilst running two companies, but I value each role for different reasons. It has also brought me into contact with a new peer supervisor, which is great.

Most important of all, I’m still enjoying it! I’ve built a fantastic team of people who I enjoy working with each day, and I’m working with the issues that are of most interest to me, and I’m keeping a balance of activities but all with a focus on quality. It turns out that CP skills are quite marketable, if you are creative about it and have a good reputation and network. Although I’m still weak at the financial side (invoicing, chasing late payments, keeping good records of expenses to put on tax returns, etc) I hope this will be a mountain I conquer this month, with a one-off blitz and then keep under control by devising ways to delegate aspects of this to others in the team. We still seem to be ticking over though.

My other aim for this year is to get a clearer vision of our destination, or at least our direction of travel, and then think about the company structure that will be necessary to achieve that vision. I’m quite obsessional about the business to the point of being a bit of a control freak, and so I find it hard to delegate and not to be involved with everything, but this will be necessary as we grow. I think this will get easier as the experience of the team grows and I test out what other people can do well without me. Hopefully this will allow me to have a better work life balance, where I can fit in more time for leisure, exercise, relaxation and sleep – not just work and the kids!


*A social enterprise is a company that is run for the purposes of doing good. So either it can be a normal business that donates the majority of its profits to a good cause, or it can be a business that does something worthwhile where the majority of the profit is reinvested in delivering that work.

Into uncertainty…

Well, we are now in a fog of low morale and lack of information, in which the rumours suggest that many CP posts will be down-banded and the current post-holders given only limited pay protection. We’ve got an initial meeting next week to hear what is planned, but I really don’t expect we will hear the truth until our posts have transferred over. It seems inevitable that there will either be redundancies or an attempt to avoid paying out by hoping that with down-banding people will seek jobs elsewhere, so everyone I know is considering their options (and regularly checking the job pages).

Personally, even though I am one of the people with least commitments to hold me here (as I don’t have kids in a local school, or a partner who wouldn’t be willing to move, or a house in negative equity) I’ve felt much more impact than I expected. I’ve lost motivation towards my work – I’m reluctant to get up in the morning, I’ve let my admin get behind, and I’m not doing the extra hours I normally do. In work I feel like I can’t make long term plans, so its really hard to think about the scoping exercise I’m supposed to be doing as part of the induction for my new post.

However, its also opened up a whole set of new ideas – if I’m not anchored to this job in this location then my husband could look for a job that he might like better than the one he is doing at present, or we could build a house on a Scottish Island, or I could have a career break and have babies, or I could turn my private court work into a proper business. This means it is harder to refuse requests for private work, in case this becomes my main source of income over the next year.

My mind is constantly wandering away from my NHS work and considering other possibilities, like whether it is worth finding a way to appeal the decision, or whether we should be working together to create another option like contracting directly with social services. It feels like as an individual I’ve lost my focus, but also that I’m in an organisation that has lost its focus. How can this be good for the NHS compared to the dedicated focused team we were a couple of months ago?