Last Word


The rolling crisis in mental healthcare

Source: National Health Executive Jan/Feb 2015

Philip Barber FRCP, a consultant respiratory physician at University Hospital of South Manchester NHS FT and The Christie, discusses what he sees as the de-medicalisation of clinical psychiatry.

The news that Nick Clegg is to head up a taskforce looking to reform mental health services is welcome, but the attention being paid to the continuing crisis in mental health care is long overdue. Clegg certainly has a job on his hands, but to address it he needs to be aware where the deficiencies lie, and the reasons for them.

As a medical student I enjoyed psychiatry. Our teachers emphasised the prevalence of mental illness, but also its responsiveness to treatment, subject to accurate diagnosis, which included the exclusion of neurological or other physical illness as a prime responsibility. (Patients with brain tumours, metabolic disorders and organic dementias tend not to improve with psychotherapy).

As a respiratory physician, I have always been interested in the interaction between the psyche and the soma, which in lung disease is broad but complex. The act of breathing itself lies at the very interface between the conscious and the unconscious mind, and can be affected by a wide range of influences, both mental and physical. Accurate diagnosis is critical to outcome, and is often greatly assisted by expert psychological opinion – or used to be.

When I was a trainee, clinical psychiatry was frequently criticised for being ‘over-medicalised’, with comprehensive systems of classification linked to specific therapies, often pharmacological. But, there was free access to consultant opinion for referring physicians and GPs. My first inkling that things had changed was around 15 years ago, when I referred a patient to a local professor of psychology. I received a pleasant and courteous letter thanking me for my referral but regretfully informing me that I was no longer allowed to refer patients directly to him. Contact could now be made only through a mental health ‘team’, which included no qualified doctors. Since that alarming event, I have witnessed the virtual disappearance of clinical psychiatry, certainly at consultant level, from the secondary care sector. I no longer even attempt any direct professional contact with my fellow consultants (the few, that is, who remain).

GPs are in a similar situation, at least in Manchester. Even acutely ill patients are denied rapid access to expert medical psychiatry opinion and advice. They are assessed instead by community teams, which often do not include any medically qualified members, and who therefore have in some respects a lower skillset than the referrers (a curious process of ‘upward triage’, including the infamous ‘tier two’, which has led to delay and disaster in many other areas of clinical medicine).

The buck is often passed back to the GP who requested specialist help in the first place, often with no consultation scheduled with a qualified psychiatrist. Lengthy reports are compiled, but in a largely ‘diagnosis-free zone’ incapable of determining appropriate therapy. Lives are undoubtedly put at risk. The occasional catastrophic event that makes the headlines represents the extreme tip of a massive iceberg of deprivation and morbidity.

In case this should be seen as sensationalism, a psychiatrist colleague told me recently that he had been asked to assess a seriously disturbed man as an outpatient, but that the examination was delayed because it was considered ‘too dangerous’ until another expert healthcare professional could accompany him. When they finally made contact, it turned out the patient, though institutionalised, was allowed freely into the community, and was even using public transport! Such events represent a failure of governance, not to say common sense, and a threat to patient and professional safety.

So, what is needed? First, the recognition that clinical psychiatry, far from being ‘over-medicalised’, has been comprehensively and disastrously ‘de-medicalised’. The recruitment of consultant psychiatrists must be greatly augmented, and medical psychiatry returned to the heart of the diagnostic process, and to team leadership; without good diagnosis there can be no effective therapy.

It is not at all clear how, for example, a patient with psychiatric manifestations of a neurological or other physical illness would ever be diagnosed under the existing arrangements, particularly if the clinical issues were complex

or obscure, as they often can be. Second, the resources available to mental health need to be on a par with other clinical disciplines; that commitment was indeed made in an amendment to the Health and Social Care Act, proposed by Labour but courageously accepted by the Coalition. We are very far from that parity under the current administration, and no amount of team-based ‘motherhood and apple pie’ is likely to make a difference without real resources.

Third, the ability of GPs, and of senior clinicians in the secondary care sector, to refer patients directly for consultant psychiatric assessment needs to be restored.

Finally, it must be clearly acknowledged that ‘asylum’, in its true meaning, has been denied to many disturbed and needy citizens by the summary closure of institutions and the continuing and culpable reduction in psychiatric beds, requiring the most seriously disturbed patients to be transported many miles from their communities for treatment, and with often lengthy and risky delays.

So, Nick Clegg, there is a lot to do; and it will not be possible to make a difference simply by ‘changing attitudes’. Structural reform of the service is required, and a substantial increase in resources, together with a change of culture, especially the restoration of medical psychiatry to the heart of the process, assisted by close links with other core clinical disciplines. Mentally ill patients marooned in ‘the community’, often in extreme isolation, deserve a better deal.

Tell us what you think – have your say below or email


Donna   10/02/2016 at 21:12

society needs to take responsibility for apparently psychiatric conditions. There are very few conditions that need medication . We have commenced down a path of no return in psychiatry pathologising/medicalising behaviour, perceptions. Maybe if the world was less influenced by drug companies an alternative approach to human distress could be ? discovered ! /explored/managed

Add your comment


national health executive tv

more videos >

latest healthcare news

NHS England, DHSC rejects reports that patients’ 30-year right to choose where they are treated is under threat

22/02/2019NHS England, DHSC rejects reports that patients’ 30-year right to choose where they are treated is under threat

NHS England and the Department of Health and Social Care (DHSC) have rejected reports that the rights of patients to be able to choose where they... more >
NHS staff and families to be evicted under plans to close accommodation

22/02/2019NHS staff and families to be evicted under plans to close accommodation

Staff at University Hospitals of Leicester NHS Trust could be forced out of their homes as the trust’s plans to close the accommodation at ... more >
NHS staff to receive ‘fast-track’ mental health support as part of wellbeing plans

21/02/2019NHS staff to receive ‘fast-track’ mental health support as part of wellbeing plans

The government has pledged to provide better mental health and wellbeing support for NHS staff as part of its ‘workforce implementation pla... more >
NHS pays £35m in tax penalties for staff breaching pension limits

21/02/2019NHS pays £35m in tax penalties for staff breaching pension limits

Nearly £35m was paid by the NHS for thousands of staff members who broke limits on pensions savings, according to the Financial Times.... more >


How can winter pressures be dealt with? Introduce a National Social Care Service, RCP president suggests

24/10/2018How can winter pressures be dealt with? Introduce a National Social Care Service, RCP president suggests

A dedicated national social care service could be a potential solution to surging demand burdening acute health providers over the winter months,... more >
RCP president on new Liverpool college building: ‘This will be a hub for clinicians in the north’

24/10/2018RCP president on new Liverpool college building: ‘This will be a hub for clinicians in the north’

The president of the Royal College of Physicians (RCP) has told NHE that the college’s new headquarters based in Liverpool will become a hu... more >
Duncan Selbie: A step on the journey to population health

24/01/2018Duncan Selbie: A step on the journey to population health

The NHS plays a part in the country’s wellness – but it’s far from being all that matters. Duncan Selbie, chief executive of Pu... more >
Cutting through the fake news

22/11/2017Cutting through the fake news

In an era of so-called ‘fake news’ growing alongside a renewed focus on reducing stigma around mental health, Paul Farmer, chief exec... more >
Tackling infection prevention locally

04/10/2017Tackling infection prevention locally

Dr Emma Burnett, a lecturer and researcher in infection prevention at the University of Dundee’s School of Nursing and Midwifery and a boar... more >

last word

Hard to be optimistic

Hard to be optimistic

Rachel Power, chief executive of the Patients Association, warns that we must be realistic about the very real effects of continued underfunding across the health service. It’s now bey... more > more last word articles >


Maximising volunteer potential in hospitals

14/02/2019Maximising volunteer potential in hospitals

Sam Ward, director of commissioned services at the Royal Voluntary Service, argues that the right training can help harness the power of voluntee... more >
ICO: Cyber security and the NHS

14/02/2019ICO: Cyber security and the NHS

Peter Brown, acting head of technology policy at the Information Commissioner's Office (ICO), explains the importance of good practice in data pr... more >
Leading and managing experts

14/02/2019Leading and managing experts

A coaching conversation is likely to yield the best results. Managing experts in the health industry can be a challenging and varying responsibil... more >
Mesothelioma in the UK: a growing fight

14/02/2019Mesothelioma in the UK: a growing fight

The health impacts of asbestos in the UK can cast a much wider net than those in the construction and building sector. Liz Darlison, head of serv... more >

the scalpel's daily blog

Did Brexit drown out the NHS Long Term plan?

20/02/2019Did Brexit drown out the NHS Long Term plan?

In January the NHS released its much-anticipated Long Term plan, pledging to save 500,000 lives through new prevent strategies, and making a concerted effort to improve the general public’s health. But Simon Keen, media relations manager at NHS Providers, poses the question: Did Brexit drown out the NHS Long Term plan? Brexit. Bruss... more >
read more blog posts from 'the scalpel' >