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?

Thinking about vulnerability and risk

Sometimes you pull on the littlest of threads and the biggest of issues appear at the other end.

Today I have been training in quite a remote location in the Welsh borders. It is the first time in quite some time that I’ve been in a location with no mobile signal. And no mobile signal meant no satnav to find my location last night, and no means to let my husband know I had arrived. I soon found there was no working phone box, and given the late hour there was nobody around to ask directions. And all of a sudden I realised that I was lost, alone and that nobody knew where I was! For those few minutes before I found the hotel, I realised how much I have grown to rely on technology to feel safe and oriented in my day-to-day life. And then I wondered if I felt less fearless before those technologies were so ubiquitous, or whether it is just the absence of a crutch I have grown to rely on that made me feel more vulnerable. After all, what was the real risk?

I started to think about about how we are trained to over emphasise certain sorts of risk (like stranger-danger, or the risk of immigrants on unemployment rates), and to under-recognise others (like the risks to children from exposure to domestic violence, or the risks that so many families face from poverty and discrimination). It seems that the media trains us to be most afraid of the things we have least control over. A cynic might think they want us to have an external locus of control and a certain degree about learnt helplessness when it comes to social issues. Whatever the motivation, the result is that many people go about their lives with little awareness of the risks that I see as the most important in society today – how vulnerable many children and adults are to abuse and exploitation, how maltreatment is normative in certain families and communities, and how interpersonal violence, trauma and abuse can change the path of people’s lives.

One example of risk and vulnerability that has been prominent in the media recently is how the press has turned once again to discrediting victims of abuse who speak up. This has taken several strands. First the media narrative has changed from “survivors of child abuse” to “alleged survivors of child abuse”, sowing the seed of doubt about every person who makes a disclosure. Second politicians are telling their colleagues to withdraw allegations due to loyalty to their party, and trying to shame the brave few who spoke up and asked for multiple disclosures and allegations to be investigated into apologising for maligning a powerful public figure. And third we are repeatedly hearing that those with allegations against them which are dropped by the police or CPS have been “proven innocent” or that victims have “lied” or “fabricated” rather than the more accurate truth of the matter, in which there is insufficient evidence to have a high enough chance of successful prosecution to merit public funds to proceed. The climate of being willing to look into abuse allegations against the rich and powerful, which gained such momentum from the public disgust about how Jimmy Savile got away with such extensive crimes for so long, has turned once again into a climate in which victims feel that the authorities are biased towards powerful and they are not going to be believed. This blog is an eloquent example of that.

Whilst I firmly believe in the principle of innocent until proven guilty, and the need for exceptional reasons to name someone against whom allegations have been made before the case has sufficient evidence to come to trial, we are dealing with a system far more weighted towards false negatives than false positives. Let us not forget that as many as 1 in 5 children are sexually abused, and yet only 15% are able to disclose in a way that leads to a police investigation. That’s the scandal here, not the impact on the reputation of a dead politician.

We need to remember that the victims of abuse are human beings like us who have been failed by society. If all politicians see is demographics and price tags, or characters and plots in which the goody is the one who becomes rich and powerful, then they don’t treat people like people. Recognising human beings and their ability to suffer is necessary to form policy, to offer justice and to be objective in investigations. In fact, that recognition of our common humanity and how people are shaped by their experiences makes you more able to consider that the perpetrators who are too often written off as incurable and evil are mostly people who have been victims themselves and never had the positive learning experiences children need to develop healthily in their own lives.

I think tackling child maltreatment is the primary social problem in the world today. To address this problem we need a multifaceted approach. I believe that if we can prevent child abuse and help people to have secure attachment relationships they will learn to be more resilient, empathic and socially skilled. In time this will have immeasurable positive impact on society. It will reduce crime, addiction, conflict, mental health problems, and even reduce the incidence and severity of many major physical health problems such as heart disease, diabetes and cancer. And interventions to help reduce maltreatment, improve attachment relationships and support children to make an optimal recovery from abuse or poor care are highly cost effective. Every pound spent in addressing childhood adversity through evidence-based interventions is repaid tenfold to the state in savings before adulthood (for example, we know that mental health interventions in childhood can save £83 more per pound spent where issues are prevented or treated in childhood rather than remaining into adulthood). But it doesn’t stop there. These changes continue to make ripples that save costs in health, social care, criminal justice, employment, benefit, and tax spheres for the rest of the person’s lifetime, and then for their partners, children and future generations.

We just need to stop blaming the vulnerable, and imagining risks where they don’t exist, and start trying to solve the systemic problems that make them vulnerable in the first place.