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The rolling crisis in mental healthcare

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.

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