It is often difficult to comprehend just how much of the current mainstream indoctrination has worked its way into various systems unchecked and unopposed, since Labour came to power even though it’s only been a few weeks.
Having been on holiday, I sat at my NHS desk, ready to spend two days replying to the hundreds of emails I had received despite the out of office sign being on. The first things I saw made me sit back in amazement!
There was a generic email from NHS England saying that if anyone had suffered anxiety due to the riots, they could seek help from the staff support system. And there was another one saying that all minority staff who felt threatened by what had happened were being given permission to work solely from home. There was also a person posting on the local blog asking people to join him in cancelling their X accounts due to, in his opinion, Elon Musk being an irresponsible bigot and trying to cause riots and promote fascism.
It made me wonder what the purpose of encouraging minority staff in particular to think that they were likely to be set upon in the street by far-right fascists if they left home was. As for other violent protests in the past, there had been barely a flicker of interest from the government or the press, let alone announcements from the NHS, except to say they were mostly peaceful. Perhaps I am being unkind, and the present government really does worry about violent protest of all types, but somehow, I don’t think so.
I deleted all three and was hopeful of something more clinical to get my teeth into. The first thing I saw was that a post-training support plan for psychologists and therapists that a colleague and I had written eighteen months ago, still had “one last committee” to go through before we could release it to staff and patients. I will probably have retired by the time it gets the go ahead.
Nowadays, any correspondence that could be constituted as giving advice or information has to be approved by NHS England and its various committees before publishing, even if it is only for local staff use. This new rule occurred because another clinician had written some helpful pointers on a topic they were well qualified to opine on last year and an ex-patient objected to it. As a result, all correspondence has to be vetted before release by several important quangos; whoops committees, and a focus group of ex-service users.
Clinical judgement and experience on its own is no longer enough and your thoughts and abilities have to be judged by people who know nothing about your profession or how it works, to decide if you’ve got it right or not. They rely more on the views of the focus groups, or experts by experience as they like to be called, to decide what modifications should be made which always makes me smile. I have my own views on the usefulness of focus groups in mental health and the sort of people who join them, but that is for another article.
Using this approach with say a physical health service, you would get training protocols for operations being decided by focus groups who had undergone the treatment and had a definite view on how it was conducted. The implications are horrible to say the least.
People often say that the NHS is in a mess, and I would be hard pushed to disagree. However, if you can get yourself into a position where you are working under the radar so to speak and your department is not “in focus” for comment, small groups of clinicians can and do very good work.
Mental health was one of these departments, until the covid debacle triggered a series of supposed mental health crises leading the powers that be to call for expansion. In order to monitor the expansion, people were collectively divided up by age, area and ethnicity so that the stats would make sure that the service treated the right amount of each group per head of population to ensure equality. Those of you who are familiar with statistics, will know that this is ridiculous, but from the management point of view, it makes perfect sense as it tells them where they are going to allocate funds from the overall mental health budget.
In times gone by, the mental health budget was ring fenced for mental health purposes, but since the community transformation process, some of this money has been “repurposed” away from direct NHS psychological and psychiatric services to shore up the community support programme.
This is a very big issue which I hope to talk more about in the future. In this article, I am trying to give you a flavour of what it’s like to face this day after day and not get anywhere.
Now, all is directed from the centre and our managers are a bit like the government. It is their job as area managers to cascade the wisdom from the elites to the front line and tell them to make it happen. The result is that anything that someone with local knowledge or who works with local patients has to say about change is passed up for consideration and it takes forever to get a decision.
Mental health services are currently in a hybrid position where management protocols often conflict with clinical protocols and the result is either stalemate, until something gives, or the threat of funding reallocation if it goes on for too long.
For instance, there are a significant number of Asian women in certain parts of the country who have severe recurring depression due to the cultural family set up. Services are asked to treat the depression whilst respecting the culture that spawned it. It is impossible of course but no one is listening. I often think that the answer to the Islamists is to empower their females to act as free agents. Some of them have a bigger axe to grind than the indigenous population.
At the moment everyone is having hours of management meetings to decide on the response to the tragedy in Nottingham, where a clearly very unwell man was able to attack and kill people without anyone from services knowing what he was doing.
Management loves protocols. They have them for everything and as long as everyone follows them, there is no danger of any recently qualified clinician learning anything else from practise except how to follow them as a form of CYA. No doubt the agreed protocols were followed in Nottingham but unfortunately, they weren’t the right kind of protocols for this kind of problem. I’m sure many focus group members with paranoid schizophrenia who were consulted fed a lot into the making of these protocols, but anyone with schizophrenia, no matter how well controlled is hardly likely to suggest more monitoring in the community to make sure that they take their meds as it would be seen as contrary to their human rights.
The tendency of management to let small groups of past patients design services for themselves and others is not a good idea in my opinion, but a great way to show that said mangers are inclusive and care about the needs of their populations. It’s a bit like the audience on question time, but with more sinister outcomes.
Management on the whole supports this as it means they can spend less money on services and the reliance on third sector increases. Unfortunately, the third sector are often charities and their funding is not stable from year to year.
When I first started practising many moons ago, I was, by dint of my qualifications to practise, solely responsible for my patients and I would treat them according not only to their mental health needs, but what fitted their personality type and life circumstances as I was able to get to know them well.
Over the years, services have begun to operate a just in time model of patient intervention, as though they were being processed through a system designed for them to come out at the other end repaired. People now expect this. But what does “repair” look like, I hear you say.
Well, from what I can gather, it means “living your best life”, whatever that is, or if you can’t because of other factors, being able to live in a state of calm neutral feelings so that you are not plagued with either sadness or anxiety about your condition.
This all started in the early 2000’s when management decided to adopt “lean thinking” and quality improvement training from America. Oh, how we laughed when it was first proposed.
I mean great for factories, but humans are not broken widgets, it’ll never catch on.
Oh, how we now realise how stupid we were, agreeing to targets and set numbers of sessions per patient etc., and numbers recovered to hit ever increasing targets to “fix” more widgets/people.
On the management side, success is measured by numbers statistically; amount of patients seen and for how long.
On the clinician side, it is more qualitative, with numbers playing a very minor part with regards to waiting times and experience and Clinical judgement taking centre stage. Many experienced colleagues are very unhappy about what is happening and do speak out. However, they do not control the budgets anymore and their opinion is clearly seen to be optional.
And why is clinical judgement important? Well, in most cases, assessment for mental health services is done on the basis of patient self-report, even when completing symptom forms and this does not always capture what is really going on. An experienced clinician can spot the signs of whether something needs a bit more attention, or even if the person does not have a mental health problem, but their symptoms are a result of their current lifestyle.
What I find most sinister is the idea that you can therapy your way out of hopelessness even if you are in an impossible situation, and live a calm life. Rogers tried this with prison inmates when he was proposing person centred counselling. When he asked what the biggest factor affecting the person’s current mental state was, they said being in prison!
I sometimes think in my darker moments that mental health is being used to get the population to accept the unacceptable as normal and not make too much fuss about it.
With regard to serious mental health problems, that is a different thing altogether and often very costly. The idea of a wraparound package of care in the community for seriously ill people is that it better keeps them in contact with reality and their friends and family and may offer a chance to work. We don’t have nearly enough resources going in for this to be anywhere near effective and so Nottingham will happen again in the not-too-distant future, I fear.
Xandra is an NHS Consultant Psychologist