The NHS, a suitable case for radical treatment

The main problem with the mental health system provided by the NHS is that the intelligent people are mostly in the wrong place. Go to any senior management meeting or similar get-together (the possible reasons for which are far too numerous to mention) in an NHS Trust and what you will find is the sharpest brains in the organisation picking over administrative or, on a good day, clinical minutiae well beyond the stage where there is any prospect of its being of any benefit to patients. And minor sparks, such as a complaint for example, get fanned by the oxygen of instant, mass organisational communication to the point where sometimes a dozen or more highly intelligent and articulate senior staff offer their increasingly prolix solutions to an inferno which they are unaware they are partly responsible for. Meanwhile, the slow-burn of under-treated patients edging towards unmanaged crises watched over by less able staff continues.

A primary reason for this is that careerism is rewarded in the NHS (and other State megaliths) at the expense of vocation. Crudely, the further removed you are from the patient, the higher your status, the greater the kudos and the heftier the rewards. This feels progressive to those who benefit from this culture, seeing themselves as expert enablers who can generate well-crafted policies and guidelines, and generously pass their wisdom and expertise down the line. In fact, the appetite for status and the search for demarcations which will magically conjure it up are highly primitive impulses which can be found at work in most, if not all, hierarchies.

You can see this dynamic enacted throughout mental health in the NHS. As soon as nurses have done their post-qualifying six months penance on the acute wards they begin to detach themselves psychologically and prepare to move out to specialist services in the community. Here, not only are pay and conditions much better, the psychological demands and skills required are much less. That is to say, being able to pad out the day with meetings and trips out to see people at home challenges one’s psychological and intellectual capacities much less than spending eight hours with eighteen very different and disturbed patients in the confined space of the average psychiatric ward.

It is not difficult to see that this exodus is self-perpetuating. Without the consistency, continuity and the knowledge of patients – of their backgrounds, patterns of illness and everyday foibles – provided by experienced staff, acute wards tend at best to be tense, tricky and counter-therapeutic places in which to work. At worst, they are lawless islands, distant from the mainstream, where assaults and threats go unpunished because of the powerful myth that if you happen to be crazy for a time you have some kind of fundamental moral deficit or are impaired to the point where you have no responsibility for your actions or duties towards others.

Attempts by senior escapees to reduce stress and improve performance among their embattled juniors will always fail because they are essentially insulting, the hidden message being “we were clever and agile enough to leave but you haven’t sussed how to do it or are not yet up to scratch”. Aware that a common complaint of patients is that staff tend to be holed up in the nursing office planning care rather than doing it, the generals have come up with the concept of “protected time”, meaning that the other ranks should guarantee they spend one-to-one time with those who psychologically – and through no fault of theirs – they experience as the enemy. That they are undertrained and underequipped to work with shifting and tricky boundaries – between us/them, patient/staff, crazy/not-crazy, and so on – and not yet skilled in combining empathy and intense listening with analytic observation (“the third ear”) is in a sense irrelevant because this has become the natural order of things: downward training and support simply strengthens the pillars of the status quo.

Not only does this culture ensure that senior staff are largely insulated from patients and patients themselves are denied the know-how and nous of senior staff, it also has instability and waste built into it. This is because, as staff graduate up through the levels of the towering hierarchy that symbolises and stimulates their ambitions, clinical imperatives gradually give way to administrative ones, and the importance of making your mark trumps the fading wish quietly to go about helping patients to move on in their lives.

There are two other currents which add impetus to the one-way traffic away from what should be the primary work of any mental health system. The first is the essentially paranoid belief, or strictly speaking feeling, that professionals can’t be trusted to act most of the time in the best interests of their clientele without relentless monitoring and instruction from the central machine. One consequence of this is that the morale of more experienced, creative staff on the ground is squeezed to the point where the only route to relieving their feelings of disappointment or despondency seems to be to graduate to a level where they can have a hand on the controls of the machine themselves.

The second current derives from the ability of the market to exploit uncertainty or anxiety among those at the centre who have responsibility for shaping policy and ultimately practice but have either never done the work themselves or long ago lost touch with its subtleties and complexities. Baffled that practice rarely seems to get better or safer in spite of all the systems and extra cash that are applied to it, they lever in new strata of management, populated with impressive motherhood and apple-pie titles, and pepper staff on the ground with branded initiatives, most of which are imported from the US. This approach is reinforced with expensive, time-consuming training, the actual effectiveness of which is not even considered, let alone demonstrated. Further public money is then creamed off through so-called quality assurance and accreditation, a process driven largely by vested interests manoeuvring and lobbying for mark-ups of one kind or another.

In fact, clinical practice, when it is allowed to, improves organically. It is no different in this respect from bricklaying, plastering, playing the trombone or acting. That is, people learn best and achieve the most through doing while being instructed. And instructors become better at instruction by being guided by those who have more or less mastered their art or craft. Organic change, however, takes time and can’t easily be distilled and packaged by salesmen gurus looking for an opportunity. The solution is simply to invert the hierarchy – while flattening it where possible because staff who work in a steep hierachy tend to have hierachical relationships with patients. Reward vocation and clinical longevity; make sure that status, if it can’t be eliminated, attaches to the hardest, most valuable work; see to it that administration is the servant of clinical practice, rather than the other way round; and, if there has to be clinical or organisational change, start the process of analysis, observation and planning from the day-to-day therapeutic experience and exchange.