Earlier this month (mid-December 2012) I was drawn to two headlines/articles appearing on the Guardian and on Mental Health Today. The Guardian headline read ‘Mental health patients to be given new rights- Patients to be allowed to choose consultants, a move that will give them parity with those with physical health problems’ (Campbell, 2012). In a similar vein, the Mental Health Today headline announced ‘Mental health service users to get greater choice in care’ (Mental Health Today, 2012).
The article on the Guardian continued:
‘Patients with mental health problems are to be given new rights over which consultant psychiatrist they see under new plans to end institutional bias against them in the NHS. The move, to be announced on Thursday by the Department of Health, will allow people with conditions such as depression [and anxiety] to choose which specialist they go to for treatment from 2014.
Nick Clegg, the deputy prime minister, who has been instrumental in securing the change, said that giving patients with mental health conditions more choice and control over their treatment would increase the chances of their making a good recovery and help to give them parity with those with physical health problems.
“It does not make any sense that some of the most vulnerable members of our society have little control about how their condition is treated. If any group of patients could benefit from being empowered by taking control of their own care, it is people with mental illness”, Clegg said’.
The article on Mental Health Today conveyed similar messages:
‘Mental health service users will get more choice about where and how they get their condition treated by the NHS, the Government has announced. The Government’s response to the ‘Liberating the NHS: No decision about me, without me’ consultation outlines how patients will be able to choose from any provider [NHS or private provider] in England when they are first referred to see a specialist in secondary care. In addition, the response outlines plans more broadly to increase patient involvement in decisions about their care and treatment and to increase patient choice. It sets out the next steps to be taken to make ‘no decision about me, without me’ a reality in the NHS, including:
i) A proposed pledge for the NHS Constitution to promote individual care plans, which will act as a written agreement between patients and their GP on what decisions were made about their care. Patients will be able to hold their doctor to account if they don’t receive the care they agreed to; and
ii) Introduction of an NHS Choice Framework, which sets out for patients the choices they have around their care, including choosing GP practice, where to go for first appointment as an outpatient and which consultant to be in charge of their treatment.
Care Minister Norman Lamb said: ‘Today’s announcement is a further step to make sure people with mental illness have more choice, more control and more information about their care […] By giving patients more choice in their care, we are making sure they get the right type of high quality mental health care at the right time, which suits them and their needs’.
These two articles paint a very hopeful and empowering picture of the future of mental health care in England given that mental health service users presumably will soon (by 2014) have new (extended) rights, more information, more choice and more control when it comes to their own care and treatment; hence, mental health service users will presumably be more involved in shared (democratic) decision making about their care, will experience a sense of empowerment, and will benefit from an optimal and highly personalised approach to mental health care, which in turn is bound to maximise their chances of making a good recovery.
Whilst reading the above mentioned articles I felt as if I was being transported to the equivalent of Alice’s fantasy world of Wonderland, that is to a future promised utopia of mental health care…I even caught myself thinking nostalgically of a dream or rather of a deep longing that I have come to nurture…a longing for humane and emancipatory psychiatric services that would refrain from coercion and injustice and have the potential to truly heal…
But then suddenly I felt I was shaken out of my daydream and pulled right back to the harsh reality of mental health care in England at the end of the year 2012…a reality that contradicts strongly the optimistic and empowering picture of the future of mental health care in England …an undoubtedly disempowering and frightening – almost dystopian– reality that appears so paradoxical when juxtaposed with the future promised utopia of mental health care…
And I recalled a number of media headlines and articles from 2011 and 2012 concerning users of mental health services in England that provide a vivid portrayal of this harsh and disempowering reality:
‘Mental health services in crisis over staff shortages’ (Hill, 2011, The Guardian)- ‘Overcrowded and understaffed psychiatric wards are leaving patients fearful for their safety and unable to make proper recoveries, according to a damning assessment of Britain’s mental health service by its lead professional body (ie the Royal College of Psychiatrists).
Professor Dinesh Bhugra, the outgoing president of the Royal College of Psychiatrists, told the Guardian that widespread failures in inpatient care for mentally ill people meant many hospital wards did not meet acceptable standards and discharged back into society sick people who remained a risk to themselves and others […]
The Royal College, in a report published in 2011, describes how about half of patients – mostly women – report feeling unsafe in many of worst-performing hospital trusts. The report also says:
- Average bed occupancy rates in English inpatient units are much higher than the 85% standard, with some wards running at 120% occupancy;
- Access to psychological therapies falls far short of acceptable standards recommended by the National Institute for Health and Clinical Excellence and other health bodies;
- Daily one-to-one contact with nursing staff is less than that accepted as being conducive to recovery.[…]
Several dozen psychiatric patients take their own lives while in NHS care every year. Mental health charities such as Rethink claim this shows that care needs to be improved and staffing levels boosted. Rethink spokeswoman Rachel Whitehead said: “Psychiatric wards are not a therapeutic environment. Many people tell us they don’t feel safe there and they are not getting access to the support and therapy they need. Supervision is also a problem, largely due to overstretched staff and wards which are over their occupancy levels.” […]
Wards are also failing to provide structured therapeutic activities, the Royal College report finds, with 35% of patients complaining of too little to do during weekdays, rising to 54% in the evenings and at weekends. Bhugra said: “The value [of this] cannot be overestimated. A lack of regular activities can lead to boredom, frustration and inactivity, which not only impede recovery but also can instigate unsafe, violent and erratic behaviour. Inpatients may be experiencing paranoia, be easily over-stimulated and sometimes frightened and disorientated.” […]
Finally, the Royal College report found just 52% of patients claimed to have “supportive”, one-to-one meetings with staff for at least 15 minutes every day. In 20% of the worst-performing trusts, as few as 50% of patients felt they were given enough time with a psychiatrist and even fewer said they were given enough time with a nurse. Bhugra said every patient should have a one-to-one session with a relevant staff member once a day’.
‘Mental Health Act detentions hit record levels’ (Community Care, 2012)- ‘The number of people detained under the Mental Health Act by social workers and other professionals has hit its highest level, official figures show. Data from the health and social care information centre reveals that 48,600 people in England were detained under the Mental Health Act in 2011-12, an increase of 5% from 2010-11. The number of detentions is now at its highest level since monitoring of the Mental Health Act 2007 was introduced in 2007-08.
The number of people discharged from hospital under community treatment orders (CTOs) also rose to 4,200 in 2011-12, an increase of 10% on the previous year. CTOs place people on compulsory supervised community treatment with strict conditions. The College of Social Work’s approved mental health professional (AMHP) network is currently investigating social workers’ experiences of CTOs amid concerns that some doctors may be using them “coercively”. […] Simon Lawton-Smith, Head of Policy at the Mental Health Foundation, said the rise in detentions was ‘extremely worrying’.
‘Mental health patients complain of ‘zombification’ – Excessive use of forced detention and coerced treatment by the NHS means patients have little control over their treatment’ (Gould, 2011, The Guardian) – “I became ‘zombified’ for nearly 12 months when I was forced to take mood stabilisers and antipsychotic medication,” says Reka Krieg, forcibly detained and treated in hospital in 2009. Krieg’s case exemplifies the crisis in NHS psychiatric care, which is resulting in excessive use of coercive detention and treatment of people with mental illness.
Latest statistics released in January show a 17.5% rise in the number of people being “sectioned” – under the Mental Health Act (MHA) – from 32,649 in 2008‑09 to 38,369 in 2009-10. This means that nearly 40% of patients in NHS psychiatric units are there under legal duress. […] The use of community treatment orders (CTOs) has also rocketed. Since they were introduced in 2008, more than 6,200 have been served – 10 times the expected number. Under a CTO, patients are released from detention, but can be forcibly returned to hospital if they fail to take their medication or other treatment. However, patients complain that once given a CTO, it takes them too long to get it removed, obliging them to stick with medication they believe they no longer need […] ‘
When they decided to impose the CTO, I felt I had no control over my human rights’, says Krieg […] Tony Zigmond, the Royal College of Psychiatrists’ lead on mental health law, says the situation (in psychiatric services) is “a disgrace”. He fears some mental health services are becoming so focused on the risk of patients harming themselves or others that they make excessive use of compulsion and coercion.He describes detention under mental health law as “a lobster pot – easy to get into but hard to get out”. His College and the Mental Health Alliance, an umbrella group of charities, civil liberties organisations and lawyers, are lobbying MPs to amend the health and social care bill to make it harder to impose CTOs.
Otherwise, he fears the use of CTOs could spiral out of control. “The top line is that CTOs have increased the number of detentions,” he says. “In effect, they are prisons without walls so the numbers on them could be limitless.” […] Zigmond wants a more consensual approach to treatment, and more space set aside in hospitals for patients to use as sanctuaries in times of crisis. […] Marjorie Wallace, chief executive and founder of mental health charity Sane, says … ‘our experience is that psychiatric wards offer very little sanctuary, with overworked staff and few therapeutic services.”
‘People with mental illness will be hit by benefit changes, charities warn’ (Mental Health Today, 2012) – ‘Leading mental health charities have claimed that people with mental illness will be adversely affected by changes to welfare benefits outlined in Chancellor George Osborne’s Autumn Statement and have called on the Government to reconsider the move. In his Autumn Statement, Osborne said that a 1% cap will be put on the rates of certain benefits, including employment and support allowance (ESA), which helps those who are unable to, or need support back into, work for the next 3 years.
However, Mind and Rethink Mental Illness have both condemned the move saying it will have adverse effects on people with mental illness who claim ESA. Vicki Nash, Mind’s head of policy and campaigns, said: “This cap will hit people hard, many of whom have mental health problems and already live on the breadline. When you combine this with the on-going inadequacies of the work capability assessment to assess whether people are fit for work, it’s easy to see why we are seeing more and more people needing support as a result of the distress caused by these welfare reforms.“Any savings achieved from the welfare bill will undoubtedly have a knock-on effect on our health service as people’s health may deteriorate. We urge the Government to reconsider this short sighted move”.
Paul Jenkins, chief executive of Rethink Mental Illness, agreed: ‘[…] “This comes at a time when people with serious mental illnesses are already being attacked from all sides as cuts to social care, the NHS and benefits all begin to bite at once. We urge the Government to think again about ESA – it really could be the difference between life and death for some of the most vulnerable people in society.”
‘Incapacity Benefit reviews can result in suicides say mental health campaigners’ (Recruitment International, 2012) – ‘Mental health campaigners including Mind, Centre for Mental Health, Royal College of Psychiatrists and the Scottish Association for Mental Health have signed a letter warning the government that their Incapacity Benefit review scheme is unfit for purpose and can result in suicides. The letter says: “We’ve found that the prospect of incapacity benefit reassessment is causing huge amounts of distress, and tragically there have already been cases where people have taken their own life following problems with changes to their benefits.”
I too use mental health services – I have been doing so in Manchester since 2008…as a result, the harsh, disempowering and frightening reality of mental health care in England at the end of the year 2012 that the media headlines and articles above capture so effectively, is where I have to live and operate as well…
When this reality hits me hard, I often catch myself dreaming of escaping down the White Rabbit Hole and into Alice’s fantasy world of Wonderland…
 A dystopia is a community or society, usually fictional, that is in some important way undesirable or frightening. It is the opposite of a utopia. Dystopias are often characterized by dehumanization, political repression and totalitarianism (www.en.wikipedia.org).
- Campbell, D. (2012) ‘Mental health patients to be given new rights’, 13 December. (www.guardian.co.uk)
- Community Care (2012) ‘Mental Health Act detentions hit record levels’, 24 October. (www.communitycare.co.uk)
- Gould, M. (2011) ‘Mental health patients complain of ‘zombification’, 15 March. (www.guardian.co.uk)
- Hill, A. (2011) ‘Mental health services in crisis over staff shortages’, 20 June. (www.guardian.co.uk)
- Mental Health Today (2012) ‘Mental health service users to get greater choice in care’, December. (www.mentalhealthtoday.co.uk)
- Mental Health Today (2012) ‘People with mental illness will be hit by benefit changes, charities warn’, December. (www.mentalhealthtoday.co.uk)
- Recruitment International (2012) ‘Incapacity Benefit reviews can result in suicides say mental health campaigners’, December (www.recruitment-international.co.uk).