Society of Clinical Psychiatrists Chairman’s AGM Address 2011

The signature of estate agents in our time is “Location, Location, Location”. That of the NHS might reasonably be “Outcomes, Outcomes,Outcomes”. By this I mean that whereas the noble aspiration of those early post WW2 years - and since - of the NHS continues to mesmerise public discourse on healthcare government policy. No matter what shortcomings, outrages even, in care and treatment of patients, outcomes in public fact, of this most aspirational healthcare system there appears a disconnect between such as the Mid Staffordshire NHS Foundation Trust Hospital massive patient neglect and associated avoidable deaths;  the devotion of the populace to “our NHS” emerges unscathed.

At one level this is understandable. When any criticism of this NHS institution is reported widely there are inevitably individual voices writing in the popular press extolling their recent 100% satisfaction when they were treated in their local hospital or GP surgery by dedicated, effective and courteous professional staff. However, patient neglect and death statistics across the country which reveal the inadequacies and horrors somehow fail significantly to stifle these public plaudits for “our NHS”. Therein lies political failure to responsibly educate the public about the patently failed system. Politicians tend to concentrate comfortably on the single patient story of satisfaction and really would prefer if the massive systemic failings didn’t register too strongly on the public radar. And when unavoidable media attention insists on politician response this tends to be an “Inquiry” as a tut-tut eventually followed by a Committee shibboleth “Lessons have been learned”. More truly lessons have been lost and/or ignored. Oddly, when individuals are named and blamed they are usually doctors, even when the failings have been nursing which recently seems to rebrand itself as “medical’, when convenient.     

This phenomenon has not been confined to our specialty. But psychiatry has proved an attractively soft target for cost cutting mediated through staffed bed, whole ward and hospital closures. Unlike older general hospitals deemed to be in that popular phrase no longer ‘fit for purpose’, closed and replaced with modern hospitals and equipment, psychiatry has been repeatedly told (by those who seem to know least) that “care in the community”, formally adopted by government in 1962, is of itself an adequate and sufficient replacement for hospital treatment and care. This has too frequently meant, especially in metropolitan areas, bed-occupancy levels of say 120%, something which other specialties have some difficulty in understanding but is all too clear to psychiatrists.

In October this year (D Telegraph, November 11, 2011) Andrew Porter highlighted think tank Centre for Social Justice (CSJ), founded by Work and Pensions Secretary Ian Duncan Smith, declaration that “community care had failed” the mentally ill and indeed attacked it both financially and in terms of family breakdown as “completely unsustainable”. In some detail It further echoed the views long held by this Society and as such was hardly ‘breaking news’; but refreshing honesty. It  was certainly not an unexpected consequence of the reduction of mental illness hospital beds from 150 000 in 1960 to 32 000 in 2003 (Mental Health Act Commission Eleventh Biennial Report IN PLACE OF FEAR 2003-2005 hmso). After 2003 numbers of inpatient psychiatric bed numbers have been difficult to establish.

The Royal College of Psychiatrists, already all to well aware of community care inadequacies, had as far back as 1975 agreed bed numbers per thousand of the population (Better Services for the mentally ill.DHSS,Cmnd, 6233,London). Although its recommendations were never formally repudiated, the DH decided unilaterally to disregard them and indeed the  recommendation made by the College  c1987 in relation to acute admission wards bed occupancy rate was c74% to allow for peaks and troughs as virtually 100% of psychiatric admissions are emergencies (whether voluntary or section). This agreement also was unceremoniously banished by the DH.

Astonishingly,that happened a very short time after publication of an All Party House of Commons Select Committee Report Community Care (with special reference to adult mentally ill and mentally handicapped people) 1985,hmso.  That condemnatory report unleashed a coruscating criticism on the failings of care in the community and of the thousands of patients who had suffered as a result. In unusually forthright language (for a government publication) it stated...”any fool can close a longstay hospital: it takes more time to do it properly and compassionately”. There was a powerful quote from one Mrs Major (no relation of John Major) of the National Schizophrenia Fellowship....”Patients should not be removed until the alternative facilities exist in the community. It seems to me it is like asking a passenger to jump off an elderly ship with the assurance that the lifeboat will be along in a few months time”.  It regarded the proposition that “community care would be cost neutral a untenable”   

Why did we allow this Hogarthian rakes progress to so diminish our psychiatric service (and ineluctably psychiatrists as well) over so many decades. Unfortunately the BMA (the doctors’ trade union as media proclaim), which will ably assist you purchase a car, secure a home insurance policy for you, advise on a pension plan - all useful stuff - but on major issues of healthcare policy it remains it remains formally conjoined to  government defined NHS and its inevitably political cost saving rather than best patient care standards which notionally is the medical profession’s ethical aim. If this seems harsh just remember the record described so far.

The Royal College of Psychiatrists under a number of recent years presidencies prior to Professor Dinesh Bhugra has been disappointing. Those who disappointed defended their patient services omertà as perhaps leading to conflict with its appointed royal college status as a recognised medical teaching body. Such consideration did not inhibit earlier presidents from exerting stronger influence in defending service standards more robustly. Professor Bhugra stands out as a president of recent years in, shortly after  commencement of his presidency, declaring that he would not be happy to have a member of his family treated in a number of NHS psychiatric units. And as his presidency term ended (June 2011) he gave a long and courageous interview to the Guardian newspaper journalist Amelia Hill (20 June 2011) in a no-punches -pulled comments on “a damning assessment of Britain’s mental health services and the deleterious impact on patient care: British doctors not training as psychiatrists; 554 consultant posts (14% of total) either unfilled or filled by locums...”a massive problem”. A much fuller account is available on the internet (http://www.guardian.co.uk/society/2011/jun/20/mental-health-services-in-crisis-over-staff-shortages) . I am not aware of any other such comprehensive condemnatory comment on the state of England mental health services.

Max Pemberton, a young doctor and talented medical coumnist on The Daily Telegraph penned a strong endorsement of Professor Bhugra’s comments in a piece, The hospitals that do more harm than good . However, his comment, “In recent years, there has been a drive to move mental health service provision from the hospital to the community...” brings a smile to older eyes. That drive is older than years, older even than decades. it started half a century ago with then Health Secretary Enoch Powell declaiming in his famous 1961 Water-Tower speech..

“There they [the Victoria mental hospitals] stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined rising unmistakable and daunting out of the countryside - the asylums which our forefathers built with such solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault.”          

This adumbrated his 1962 10 year Hospital Plan for England and Wales aimed at wholesale closure of hospitals. Mental hospitals were especially targeted because already a bed reduction had occurred thanks to the mid 1950’s introduction of chlorpromazine as a successful treatment for some, by no means all,in heretofore quite refractory patient illnesses. Psychiatrists had already begun the process of patient-bespoke care in the community with medically-paced, individualised after-discharge care programmes.

It was the end of a properly medically managed hopeful beginning.

It remains a pleasure for me on behalf he Society’s to thank our Honorary Secretary and Treasurer Dr Mike Haslam, Dr John Harding-Price, our Press Officer, Dr MS Elameer, our Webmaster and Dr Peter Tomlin, President of The Doctors Support Group for all their thought and work on the Society’s behalf.   

Dr Dermot J Ward

Chairman