Foreign nurses hold the NHS together – ignore the Daily Mail

The Daily Mail has a lot in common with genital herpes. It’s seemingly permanent, an unacceptable topic in polite conversation, can go several months without causing annoyance but occasionally flares up in repulsive and virulent fashion. And so it did today. Following the (entirely justified) conviction of Victorino Chua, who poisoned at least 22 patients, the Mail saw fit to effectively brand all Filipinos as potential murderers:

Daily_Mail_20_5_2015

Why not just ‘Did The Nurse Murder 11 More?’

In the article itself, the linking of which to my blog makes me physically nauseous, the Mail gives details of their undercover investigation into the hiring practices of NHS organisations in the Philippines. It was possible to cheat on some entrance exams, they say. Forged copies of qualifications can be obtained in Manila, they say (though they found no proof this had happened – but their reporter did get some certificates made and stood outside the shop looking shifty for effect). The insinuations are clear – that the nurses aren’t any good but are gaming the system to steal UK taxpayer’s money and also have sinister intentions.

What a load of crap.

If some entrance exams are too easy, allowing a slim minority of underqualified nurses to gain employment in the UK then fine, look into that. Do make sure you don’t forget about the series of other rigorous process that nurses have to undergo to start and remain in work in the UK when you cast judgement.

But don’t anyone dare conflate this with foreign staff being of generally poor quality with criminal intent. I have worked in the NHS for many years, and met many foreign nurses. I’ve met so many because there are so many. One in seven trained abroad. The vast majority have been hardworking, well trained, caring and kind people who came to the UK not in pursuit of a fortune or an easy ride – who the hell would call £25,000 a year for the ridiculous hours our nurses work that – but because they felt the NHS offered them a chance to be able to care for people without having to live in poverty. Victorino Chua would not have been caught by a more demanding entrance exam or tougher document checks, just like Harold Shipman wouldn’t have been caught by compassion testing. And his crime has nothing to do with his nationality. One bad apple is no excuse to tarnish a whole culture.

Far from taking advantage of our system, foreign nurses actually make the UK money. We didn’t pay for their school or university education, and because they’re able to work they won’t be needing to claim benefits. They help return sick people to work, where they can resume paying tax. Morevoer, they pay income tax themselves.

Without foreign staff the NHS would collapse – almost literally – in a matter of minutes. Stupidly we’ve neglected our own nurse training schemes for years, leaving vast numbers of posts empty and relying on overseas staff to cover for our mistakes, leaving their own countries worse off for it. And trust me, whatever the Daily Mail says, when the inevitable day comes when you feel that twinge of chest pain, your left side going weak, or a loved one collapses, and you reach for the phone to call 999, you’ll be bloody glad they’re still here.

Where does ‘Choosing Wisely’ fit into mental health services?

Last week the Academy of Medical Royal Colleges announced that it would be bringing ‘Choosing Wisely’ to the UK. The US initiative, which has spread to more than 12 countries worldwide, encourages leading medical organisations to list tests, procedures and medications with little evidence behind them and advise doctors to think twice before using them.

This is a good thing. In many areas, medical intervention has expanded way beyond the point of usefulness, resulting in extra risk to patients for little gain.

Though the Patients Association reacted cautiously, fearing it might mark the beginning of ‘rationing’ of interventions, the reception was overwhelmingly positive. No one really buys the ‘rationing’ worry – the ethos of the campaign is openly directed at empowering choice not withholding, and you have to wonder what the harm would be in rationing ineffective treatments in any case. Atul Gawande hit the nail on the head in his utterly readable New Yorker piece ‘Overkill’, saying that these types of intervention aren’t just ‘low-value care’ but no value care.

I’ve been thinking about how this all applies to mental health services in the UK.

The Royal College of Psychiatrists has signed up for Choosing Wisely, as is right and laudable. And there definitely are interventions in psychiatry which could potentially be cut down on. Antidepressants for mild depression, for example, are next to useless but prescriptions continue to rise suspiciously. Antipsychotics for behavioural disturbance in dementia are only temporarily helpful (if at all) but result in a significantly increased risk of stroke. Antipsychotic polypharmacy for schizophrenia is poorly supported by research, associated with increased side-effect burden, but not rare.

However, we need to keep things in perspective. Unlike most other medical specialties, psychiatry faces the paradox that though we can prune a few treatments back as unhelpful, our main problem is that we’re vastly undertreating most people.

A lot of the time this is fairly convincingly not our fault, due to there not actually being a service in existence to do the treating. Only half of women in the UK have access to perinatal mental health services. Liaison psychiatry provision is so patchy that no official statistics exist, but a recent survey found that even in London only 50% of hospitals have a 24 hour service. Only 25% of people with depression or anxiety access help; the proportion of children with a mental illness in treatment is similar.

But even patients who are lucky enough to find their way to a psychiatrist can somehow avoid being offered effective treatment. Clozapine, the antipsychotic which works significantly better than all others, is meant to be offered after two failed trials of different antipsychotics lasting 6 weeks each. But recent research suggested that the average time to be offered clozapine – which is associated with vastly improved functional and symptomatic outcomes – was 4 years. Similarly, despite the fact that it probably works better than anything else for prophylaxis and suicidal prevention in bipolar disorder, lithium prescribing rates have dropped. Most likely due to the the lack of pharma interest (you can’t patent an ion) and the need for annoying blood test monitoring, patients aren’t getting the best treatment. Moreover, antidepressants aren’t increased to effective doses and aren’t switched in a timely enough fashion if they don’t work. Using an algorithm can help.

And it’s not just medications that are underprovided. According to the National Audit of Schizophrenia less than half of people with schizophrenia who aren’t in remission are offered CBT, just 59% of smokers get offered advice and a measly 25% get counseled on their high blood pressure. Doubtless this is frequently due to clinicians being pressured for time, but the facts remain.

In short, though cutting out pointless and potentially risky interventions is always desirable, in mental health it can hardly be our main focus. We’re way behind the luxurious curve that other specialties find themselves on. Managing to identify and reduce ineffective decisions while introducing effective ones will demand considerable mental dexterity and vigilance of psychiatrists. And of course, they’ll only be able to make those calls if services for them to work in are commissioned in the first place. Choosing wisely is great, but it requires having a choice to start with.

An open letter to Alistair Burt, the new Minister of State for Health

Dear Mr Burt,

Congratulations on your recent appointment as Minister of State for Health and for holding your seat as an MP in North East Bedfordshire.  I must admit, the majority your party obtained last week in the General Election was not the result I had personally wished for, but the result of a fair democratic election is not something to be sniffed at.

Forgive me if I’m wrong here, but a quick trawl of the internet suggests that this is the first time your brief has included mental health. In fact, it seems to be the first time you’ve been tasked with managing health policy of any kind. I was hoping, as a member of the mental health community that includes inordinate numbers of patients, carers and professionals who have spent their lives immersed in this complex area, that I might be able to offer you some advice.

As it turns out, you have big shoes to fill. Norman Lamb was well liked as a politician, which I am sure you’ll recognise as a rare attribute. As one of only a handful of Lib Dem MPs to survive the recent cull, the positive impact of his work over the last 5 years is beyond doubt.

How did he achieve this respect? By having the integrity and compassion to admit that the mental health system he was in charge of was critically inadequate, leading to the needless suffering of countless thousands. His Crisis Care Concordat and the Liberal Democrat’s Closing the Gap report were ample evidence of their commitment to make positive changes in mental health, and they were the only party to give a concrete funding promise (of £3.5bn over 5 years) in their manifesto.

And oh, how we needed that money. Though your colleague Mr Hunt has claimed that mental health funding went up in real terms over the last parliament, no figures in the public domain support that assertion. When corrected for inflation, official figures seem to show a minute fall. But these numbers don’t match our experience of services on the ground – Trusts have recently reported an 8% drop in funding over the last 5 years. Moreover, they expect their funding to keep on falling, by an additional 8% over the next 5 years.

The sad thing is, our services were on the ropes even before these cuts. Mental health problems account for 23% of the illness burden in the UK, but receive only 13% of the funding, an approximate annual shortfall from CCGs of £6.5bn. And during the cuts of the last 5 years, referrals to community teams actually rose by 17%, stretching us further. This pressure had to tell, and the result was agonising. We lost over 2,100 inpatient psychiatric beds. Community teams, the development of which is usually touted as an excuse for reductions in bed numbers, were cut too. Patients continue to be shipped up and down the country, away from their friends and family, just for the sake of finding a bed. Sometimes, even worse, they are sent home when a bed cannot be found or admitted to a ward but without a bed (!). At least seven patients have ended their lives by suicide as a result, just the tip of an iceberg shrouded by confidentiality and incomplete reporting. Those who somehow manage to stay alive receive a grossly and shamefully lower standard of care than their counterparts with physical health disorders. Despite the touting of increased overall nursing numbers in the pre-election period, here in mental health we’ve actually lost 3,300 nurses over the last 5 years.

As if this wasn’t hard enough to bear, the deep cuts to social care have hit people with mental health problems harder than any other group, with a staggering 48% fewer people claiming help in 2013 than they did in 2006. Because recovery in terms of mental health encompasses the whole person, this only serves to heighten the risk of needing more intensive input from mental health services, wasting money in one area by pinching pennies in another.

I could go on, detailing the desperate state of our services in detail. But that wouldn’t be as productive as telling you how to help. You see, you may have inherited nothing short of a national human rights issue, but it is a national human rights issue that you can go a seriously long way to fixing. Our services aren’t that complicated and they’re not even expensive in comparison to interventions in the rest of medicine – but the results can be incredible. Early intervention services, for example, were recently shown to be capable of saving £15 for every £1 invested. Similarly, though perinatal mental health problems costs society £8bn a year, over half the women in the UK don’t have access to a specialist perinatal mental health service. Providing cost-effective care consistent with NICE guidelines to the whole UK would set you back just £337m a year in comparison. I believe economists call this ‘low hanging fruit’. Instead of cutting your outgoings now, cut them in the future by funding these services, and save some lives to boot.

Here’s another tip. Listen to people who have lived experience of using the services that you are in charge of. Listen to them more than you listen to statistics or advisors. When they say that there is a problem, then trust me, there’s a problem. Mental health is fascinatingly complex and learning all its nuances takes years – I still learn something new every day. Genuinely hearing what these people have to say will win you supporters for life, but assumption and hubris will turn this crowd against you like no other.

As well as individuals, listen to the major organisations. They talk a lot of sense and are driven solely by wanting the best for people with mental health problems. Mind, Rethink and the Mental Health Foundation are just about as informed and influential as charities get. My own affiliation, the Royal College of Psychiatrists, regularly turns out lucid documents on topics like Parity of Esteem. They also asked for 6 things from the incoming government, including investment in (again, unbelievably cost-effective) parenting interventions and liaison psychiatry services.

As an additional note, could I implore you to bring a halt to the government’s flirtations both with putting online CBT into Job Centres and sanctioning people who refuse treatment for long term conditions. Both policies are in direct contradiction to the most basic principles of medical ethics (i.e. free consent), underestimate how difficult recovery is for people with these difficulties, discriminate against people with mental health problems and risk a dangerous conflation of unemployment with illness. The goal of recovering from a mental illness should be recovery itself, not employment. To be honest, in a general sense, I do not feel that the further fragmentation of our health services through privatisation, which brings with it the added clash of ideologies between profit and care, and a cumbersome and expensive tendering process, has any place in the NHS. But this is an issue for another day.

In summary, your new job may have more in store for you than you may have expected. You quite literally have the power to do more good, and to win more plaudits, than any other politician in the UK today. We will help you in any way we can, but only if you are eager to listen. I genuinely look forward to working with you in future.

Yours in collaboration,

Alex

CBT in Job Centres: Five Objections

In March, Nick Clegg announced his plan to improve access to mental health care for people who are out of work. It started off so well, but had a bizarre twist.

He said that he’d found an extra £25 million for mental health, to be invested over the next three years. So far so good.

And that this money might end up helping 40,000 people. Great.

And that this money would fund ‘specialists in mental health support’ to provide talking therapy in 350 Job Centres across the UK. Sorry, what?

On the face of it, you might mistake this for a good idea. Unemployed people are statistically more likely than average to have a mental health problem, and CBT can be pretty effective.

But there are at least 5 reasons why this is a disastrous plan:

  • It feeds into the belief that people with physical health problems should get better but people with mental health problems should get back to work. You won’t be seeing 350 new physiotherapists in Job Centres trying to get people with back pain back to work, even though back pain is a hugely significant cause of sickness absence. This is because we know that recovery comes first, is the primary goal, and happens in a recovery-focused setting, not a Job Centre, where the intentions of those doing the ‘treating’ become murkier.
  • There were already brewing concerns that people with mental health problems would feel coerced into accepting such treatments when the Tories simply came out and said it in their manifesto – some people will lose their benefits if they say no. This baulks against the very fundamentals of medical ethics, of being able to make an uninfluenced decision about what treatment to accept. Furthermore, doing therapy with people who simply don’t want to be there is at best a waste of money and at worst downright harmful.
  • It targets help at people who have something to offer in return, i.e. getting back to work and paying some tax. This is firmly against the principles of the NHS, which state that a person’s means (including, if you have any common sense, their potential) should have no say in their access to treatment. People with equally troublesome mental health problems but no likelihood of ever working again won’t see a penny of this £25 million.
  • What on earth are ‘specialists in mental health support’? According to these contracts for over 80% of the £25 million they appear to be online CBT assistants. These types of resources can be valuable and effective, but working in isolation, as I presume these guys will be, could be unsafe and result in downright quackery. Mental health conditions are complex and require a commensurate amount of assessment – not a quick meeting with someone who is barely qualified. Is there a chance that sub-standard assessments could diagnose problems where there are none, or worse, conclude that not being able to get back into work is a CBT-suitable problem in itself? This is a hair’s breadth from seeing unemployment as illness.
  • Despite it being sold in some articles as ‘co-location’ (i.e. multiple services working closely together in the same place), I can only see this project fragmenting services even further. It will simply add another layer of complexity and miscommunication to pathways which are already needlessly arcane and soul-destroying. Put it this way – the ‘specialist in mental health support’ isn’t going to be ringing the GP or psychiatrist with a thorough summary of treatment and progress, are they? If you want joined up services, put more employment advisors in mental health settings. Fund OT and social work better.

Clegg has been a positive figure for mental health in recent years, so I can’t be too harsh on him. But if he wants people with mental health conditions to recover and get back to work, my suggestion is simple. Fund mental health services better. Don’t create a coercive, work-orientated, untried, discriminatory and disconnected treatment model staffed by isolated and weakly trained staff.

Mental health in the manifestos: what are the parties promising?

The general election is nearly upon us.  After five years of fierce discussion, debate and dispute, we finally get a concrete chance to influence the political landscape of this country. And for the first time, mental health has been acknowledged as a key issue. Last year The Mental Health Policy Group, a collection of six leading mental health charities and organisations, published it’s own ‘Manifesto for Better Mental Health’, outlining where they felt the main political parties needed to commit their energies following this election. In summary, they lobbied for:

  • fair funding for mental health services
  • giving children a good start in life (including perinatal care and education on MH at school)
  • improving physical health care for people with mental health problems
  • improving the lives of people with mental health problems (anti-stigma and pro-employment)
  • enabling better access to mental health services

The Royal College of Psychiatrists published their own ‘6 months, 6 asks’ manifesto around the same time, detailing what they felt should be priorities for the next government:

  • tackling the mental health bed crisis
  • introducing maximum waiting times
  • improving crisis care
  • improving liaison psychiatry services
  • introducing a minimum unit price for alcohol
  • investing in parenting programmes

So let’s see how well each of the main three parties lives up to these expectations in their manifestos.

The Conservatives

The Tory manifesto is light on references to mental health. The first mention it gets is in the scandalous segment on how people with long-term but treatable conditions will be ‘helped back to work’ by having their benefits cuts if they refuse a treatment. The same segment does also offer the following rather nebulous promise, again tied in closely to being able to get back to work:

“We will also provide significant new support for mental health, benefiting thousands of people claiming out-of-work benefits or being supported by Fit for Work”

Later on in the manifesto, there are marginally more specific pledges, namely that that the Tories will ensure…

“…that there are therapists in every part of the country providing treatment for those who need it. We are increasing funding for mental health care. We will enforce the new access and waiting time standards for people experiencing mental ill-health, including children and young people. Building on our success in training thousands of nurses and midwives to become health visitors, we will ensure that women have access to mental health support during and after pregnancy, while strengthening the health visiting programme for new mothers.”
 
It should be noted that mental health nursing numbers have dropped like a rock rock over the last 5 years, and mental health funding has probably fallen too, so this passage felt a little trite. But although the promises are vague and the pledge to increase funding is unquantified, the commitments are there.
 
Finally, there is an acknowledgement of the vital need for improvement in care for people who come to the attention of the police:
 
“We will ensure proper provision of health and community-based places of safety for people suffering mental health crises – saving police time and stopping vulnerable people being detained in police custody”
 
 
 
Labour
 
In their manifesto, Labour are keen to push the fact that we need more joined-up, integrated services:
 
 
“Our health reforms will focus on prevention and early intervention, and joining up services from home to hospital. When people cannot get to see their GP, many go to A&E instead. When mental health problems are not spotted early, people can deteriorate and need more intensive support”
 
 
“The current system is too fragmented. It was not designed for the growing numbers of people living with chronic conditions or multiple needs. Rather than having three separate systems for dealing with physical, mental and social care, we will create a whole person approach: a single service to meet all of a person’s health and care needs”
 
 
And they go on to briefly mention parity and improving access to services, with a particular focus on children:
 
 
“Mental health will be given the same priority as physical health. People will have the same right to psychological therapies as they currently have to drugs and medical treatments. To help address the problem of undiagnosed mental illness, NHS staff training will include mental health. We will increase the proportion of the mental health budget that is spent on children, and make sure that teachers have training so they can identify problems early and link children up with support. To support young people’s health and wellbeing, we will encourage the development of social and emotional skills, for example through the use of mindfulness to build resilience. And we will set out a strategy with the goal of ensuring that the great majority of patients can access talking therapies within 28 days, and that all children who need it can access school- based counselling”
 
 
This, I felt, was slightly more encouraging than the Tory effort. Still no hard figures, but Labour at least seem sympathetic to the plight of people with mental illness, and aware of the inefficiency and turmoil of having such fragmented care. The nod towards funding ‘wellbeing’ interventions, which the Chief Medical Officer warned against last year due to a limited evidence base, was probably included to make the manifesto’s commitment to mental health resonate with the public at large. I also note that Labour only promise to increase the proportion of the mental health budget spent on child services, effectively committing to cuts elsewhere unless funding is increased overall. This is cheeky.
 
 
 
Liberal Democrats
 
As promised by Nick Clegg there is a pledge to ‘guarantee equal care for mental health’ on the front cover of the Lib Dem manifesto. There is also a more intentful mention of mental health in their introductory paragraph than in any of their competitor’s opening statements:
 
 
“Those facing anxiety and depression will be seen swiftly, people struggling not to harm themselves will find emergency help at A&E and teenagers suffering from eating disorders will get the help they need close to home”
 
Indeed, mental health is alluded to more frequently in this manifesto than in the others. Apprenticeships are to be tailored better for people with mental health problems, and foster carers are to be better educated on the topic. Later, in the health section, they become the only major party to offer an exact figure for investment:
 
 
“…£500m [extra per year by 2016/17] to transform mental health care with waiting time standards to match those in physical health care”
 
 
When added to previous pledges, as reported this week, that that would add up to £3.5bn extra for mental health over the next five years, to be partially paid for through changes to capital gains tax.
 
This promise is part of a solid two pages of text on mental health. Assurances given in this generous space include:
 
  • “a waiting time standard from referral of no more than six weeks for therapy for depression or anxiety and a two-week wait standard for all young people experiencing a first episode of psychosis”
  • “increased access to clinically and cost-effective talking therapies”
  • “transforming care for pregnant women, new mothers and those who have experienced miscarriage or stillbirth, and help them get the early care they need”
  • implementing the proposals outlined in the report of the Government’s Children’s Mental Health Taskforce. For example, “building better links with schools, ensuring all children develop mental resilience, and getting support and care quickly to those who are struggling”.
  • “ensure no one in crisis is turned away, with…better crisis care in A&E, in the community and via phone lines. This will enable us to end the use of police cells for people facing a mental health crisis”.
  • “extending the use of personal budgets, integrating care more fully with the rest of the NHS, introducing rigorous inspection and high-quality standards, comprehensive collection of data to monitor outcomes and waiting times and changing the way services are funded so they do not lose out in funding decisions in future”
  • “introduce care navigators so people get help finding their way around the system, and set stretching standards to improve the physical health of people with mental health problems”
  • “publish a national wellbeing strategy”, with a “public health campaign promoting the steps people can take to
    improve their own mental resilience” and “ensuring people with mental health problems get the help they need to stay in or find work”
  • “establish a world-leading mental health research fund, investing £50m to further our understanding of mental illness and develop more effective treatments”
  • “continue to support the Time to Change programme to tackle stigma against mental health”
  • “ensure all frontline public service professionals, including in schools and universities, get better training in mental health”

There’s also a vow to offer more “support for personnel and veterans with mental health problems”.

It doesn’t take a PhD in politics to work out that the Lib Dem manifesto is head and shoulders above the Conservatives and Labour in terms of engagement with the issue and promises made. They have ticked pretty much every one of the Mental Health Policy Group’s boxes for suggested improvements. Again, there is an infatuation with wellbeing, but the groundwork done by Norman Lamb with his Crisis Care Concordat has gone some way to engendering trust in the party when it comes to tackling more weighty issues. The real question is, will they have any power to implement these changes on May the 8th?
 
 

The Green Party

The Greens dedicate a generous proportion of their  to mental health, not least because one of their main focus points – equality – is tied in with it so closely. They state clearly, and in a way that no other party does, that their policies are all intertwined, for example that reducing mental ill health will have a positive knock-on effect on the economy, crime and drug use.

They pledge to ‘increase investment in mental health care’ as part of a general £12bn increase in NHS funding per year, but don’t say exactly how much of that £12bn mental health will get.

They highlight the huge disparity between the proportion of illness that is due to mental health problems (28%) in UK society and the amount of NHS funding dedicated to mental health services (23%), before going on to make a series of promises:

 

  • Ensure that no one waits more than 28 days for access to talking therapies.
  • Ensure that everyone experiencing a mental health crisis, including children and young people, should have safe and speedy access to quality care, 24 hours a day, 7 days a week.
  • The use of police cells as ‘places of safety’ for children should be eliminated by 2016, and by the end of the next Parliament should only occur for adults in exceptional circumstances.
  • Ensure that everyone who requires a mental health bed should be able to access one in their local NHS Trust area, unless they need specialist care and treatment. If specialist care is required, then this should be provided within a reasonable distance of where the patient lives.
  • Implement a campaign to end the discrimination and stigma associated with mental health through supporting the Time for Change programme and offering employment support to those with mental health problems.
  • Invest in dementia services, ensuring that support is available for all affected by this debilitating disease, including families and carers.
  • Pay special attention to any mental health issues of mothers during and after pregnancy, children and adolescents, Black and Minority Ethnic people, refugees, the LGBTIQ communities and ex-service people and their families.
  • Improve access to addiction services, including both drugs and alcohol addiction.
  • Give higher priority to the physical healthcare of those with mental health problems.

 

These are ambitious pledges, but rather unembellished ones. Such changes would take huge about of reinvestment and substantial reorganisation of services, but I haven’t seen any finer detail from the party on how this would happen. On the plus side, the manifesto has a lengthy but understandable appendix which lists every revenue and expenditure the party would implement, evidencing their financial plans.

 UKIP

To be fair to UKIP, there is a promise to ‘invest £1.5 billion into mental health and dementia services’ in the introduction to their manifesto and they do mention the need for parity. They also acknowledge how important liaison services are, pledging to end the ‘postcode lottery’ in that respect. To continue being fair to UKIP, the rest of their commitments to mental health are very dilute and feel like token statements. For example, they promise:

  • Directing patients diagnosed with a debilitating long-term condition or terminal illnesses to mental health professionals when appropriate
  • Recognising there is often a link between addiction and mental illness and offering appropriate treatment where this is the case
  • Offering direct access to specialist mental health treatment for pregnant women and mothers of children under 12 months of age
  • Fighting the stigma around mental illness and supporting those seeking to get back into work.

Hardly groundbreaking – they sound more like standard expectations of the current service.

In a bizarre move, they also pledge to bring in a ‘veteran card’ so that ex-serviceman and women can be ‘fast-tracked’ into NHS services, including when they need mental health care. There is no need for such a two-tiered system – it would surely be a better aim to make services accessible to all in a timely manner.

 
The SNP
 
The SNP manifesto notes that they would pledge and additional £100m over 5 years for mental health (in Scotland), mainly to be directed at primary care and children’s services, but doesn’t have a dedicated section on mental health. In fact, that’s pretty much the only mention of it at all. 
 
So ladies and gentlemen, if mental health is the issue dearest to your hearts, then there are your contenders. Vote for whoever you choose, but please, please, do vote.

Starving you back to work: Why Tory policy of cutting benefits if you refuse treatment is vile

The Tory manifesto it out. Like many others I was immediately drawn to page 28, where David Cameron explains how he will ‘help you back into work if you have a long-term yet treatable condition‘. But their spellchecker must be on the blink because they obviously don’t mean ‘help’, they mean ‘threaten’.

‘We will review how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back into work. People who might benefit from treatment should get the medical help they need so they can return to work. If they refuse a recommended treatment, we will review whether their benefits should be reduced’

The idea of starving sick people back to work was first raised by the Tories last year, but despite the fact that it went down like a sack of lead crap, they’ve stuck with it.

I viscerally object to this policy in so many ways it’s hard to know where to begin.

Firstly, it only seems to target people who have an illness or condition that they can (mistakenly) be blamed for. Cameron won’t be threatening poorly-controlled diabetics with benefit cuts if they don’t take their insulin, and he won’t be nagging people to attend their physiotherapy following a stroke. He’ll only be threatening people who he thinks, from his ivory tower, chose to become ill. This shows just how ignorant the Tories are when it comes to difficulties like addiction, obesity and mental health problems. People with these problems hardly ever choose to be that way. The causes of their suffering are often as external to them as any ‘physical health’ problem – poor housing, employment, lack of affordable healthy food. But Cameron thinks their difficulties are a lifestyle choice, and this is sheer discrimination. He wants people with physical health problems to return to health, but people with mental health problems to return to work.

Secondly, it is hideously naive of the Tories to assume that change is easy for people with these conditions. It isn’t, and there are good reasons for that. Therapy for a mental health problem can be an emotional pressure cooker, and medications all have side effects. I assume that losing weight when you can afford only the cheapest, most unhealthy foods is pretty difficult too. Any kind of help for these problems requires insight and motivation, which can take years of careful mental and social preparation. To force someone into treatment too soon using the threat of financial penalties actually risks wasting money and might actually make people worse. As an aside, I’ve never done therapy with or prescribed a tablet to someone who had to accept it or they’d lose their benefits, and I wouldn’t want to. It’s not a great place to start a therapeutic relationship and sits in stark opposition to good medical ethics.

Finally, the fundamental ethos of this policy sickens me. A caring government, who want a ‘brighter, more secure future’ and a ‘good life for all’, would create a society in which people wanted to take up treatment of their own accord. They would provide adequate services to provide that treatment and explore the reasons why people might be struggling to accept it, instead of cutting services to the bone then denying it). They would fix the root causes of social problems like obesity and addiction. But instead, we have a government who delight in the use of the stick over the carrot, placing unfortunate individuals as solely to blame for complex conditions then punishing them for not taking up treatment for which they probably aren’t ready.

The incentive for recovering from a mental health problem or addiction should be recovery itself, not starvation from benefit cuts. This policy needs to be scrapped, and quickly.

Open Dialogue: reflections on the model and the evidence

You can’t work in mental health services for too long without hearing about Open Dialogue.

There certainly aren’t a shortage of bold claims about the model of care used to treat psychosis in a small pocket of Finland, for example, as the Open Dialogue UK website states:

‘They have the best documented outcomes in the Western World. For example, around 75% of those experiencing psychosis have returned to work or study within 2 years and only around 20% are still taking antipsychotic medication at 2 year follow-up’.

And as a well-publicised play inspired by the model suggests, there is a rumour that they have actually eradicated schizophrenia in Western Lapland. These are substantial claims – so substantial that a seriously hard objective look at both their model and the evidence for its success is required to verify them. I wasn’t able to find such an interrogative assessment online, so I thought I’d write one myself.

My aim is to contribute to a transparent, honest discussion about what the effective parts of Open Dialogue might be, and how confident we can be of that. There has been a lot of fervour about this approach, but we also need an impartial examination of the facts. Please do leave comments underneath the post.

I want to make a disclaimer straight away: Yes, I am a psychiatrist, but no, I am neither a particular fan of medication nor a particular hater of talking therapy. I try to appraise the evidence for both objectively. What I am not a fan of is a treatment of any kind being pushed harder than the evidence base should permit. Our patients deserve treatments that have been rigorously proven to work, whatever they may be.

The model

Open Dialogue has been the standard psychiatric model in Western Lapland since the mid-1990s. In short, it sounds very much like a cross between a crisis team and intensive family therapy. When a referral comes in, whoever answers the phone is responsible for organising the subsequent care for that patient. The care involves a series of meetings at the patient’s home, at which 2 or 3 therapists as well as anyone else who is important in the patient’s life come together to share their experience of the crisis, develop an understanding of it and work out a plan. The team try to leave their assumptions and professional models at the door, and there is an added focus on avoiding ‘neuroleptic’ medication (antipsychotics) for as long as possible.

 

Their practice has 7 tenets:

1) On receiving a referral the first meeting with the patient should take place within 24 hours.
2) The social network of the patient should be invited to take part in the meetings from the outset and for as long as necessary.
3) The treatment should be adapted to the needs of the individual patient and their family, using the most suitable methods.
4) Mental health services will guarantee that certain people will take responsibility for the patient and organise a team that will make decisions with the patient and family about all aspects of treatment.
5) Psychological continuity is guaranteed; staff from different teams will be invited to participate as required.
6) A sense of security should be promoted by tolerating uncertainty, which mobilises the resources of the patient and family.
7) The team should focus on creating a dialogue between everyone in the meetings to create a new language for experiences previously unspoken.

 

There’s no denying it – all these principles are laudable. However, the most interesting thing that struck me about them is that we already value most of them in NHS mental health services, but struggle due to poor resourcing. They aren’t exclusive to the Open Dialogue model.

Seeing every patient in crisis within 24 hours? We’d love to do that. But in reality the more likely scene is of a nurse quietly holding back the tears of frustration as the duty phone won’t stop ringing. The NICE quality standards instruct that newly psychotic patients should be seen within 14 days and even’s that’s difficult to achieve. The Open Dialogue team clearly have enough staff and resources to be able to see people quickly, which may be an important part of why they do so well, but there’s nothing novel about the idea of early intervention.

Likewise, tailoring the treatment to the specific needs of the patient, taking their wishes and the wishes of their family into account, is also something we try hard to do, and would do better if we were simply properly resourced. Again, the NICE quality standards highlight family interventions, employment, education and support for carers and CBTp (as well as medication) as a range of choices which should add up to patient-centred care.

Similarly, continuity of care as a patient progresses through the system is a well-recognised aim for mental health professionals the world over. Sadly, the fragmentation of NHS mental health services has made this noticeably harder to achieve.

So, many facets of the Open Dialogue model are general qualities of a good service, qualities which could be achieved by improving the current systems we have rather than bringing in a whole new way of working.

However, some of the other facets of Open Dialogue are quite unique to their model. I think the aim to maintain a non-judgmental approach and foster a shared language between the patient and their family has great merit. I’m not keen on forcing people to take a certain narrative for their distress, and if they can find a way of understanding themselves that keeps them safe and well, then great. However, I do have reservations that this is suitable for all patients. Especially where I work in London, perhaps more so than in Lapland, we see an awful lot of extremely psychotic people. People whose mental states are an acute and serious risk to themselves or others, people whose experiences are plainly so extreme that to deny their pathological nature and take immediate action would be irresponsible.

This all links into the related discussion on whether psychosis is something we should be mainly trying to find meaning in, or remove. It’s not at all unusual to see a patient improve from their psychosis and come to the opinion that their psychotic beliefs were all absolute nonsense and they’re relieved to have had them medicated away instead of mused over. I wonder how Open Dialogue would address those patients.

Another issue would be that we see a lot of people who are so psychotic that they cannot engage in a series of meetings, either because they are unable or unwilling to talk, often with marked hostility or confusion. Also, many of our patients either lack any semblance of social network or possess one that actually contributes to their illness. Many would simply refuse to consent to the process, valuing their confidentiality, because they are individualists. The question mark over the cultural generalisability of Open Dialogue is huge.

Finally, I do find it hard to accept a model whose prior aim is to avoid antipsychotic medication for as long as possible. Whether you personally love them or hate them, there is a huge amount of evidence that especially in the early stages of psychosis antipsychotics are tremendously helpful for reducing symptoms and therefore distress. Their research papers (see below for links) note that at least historically they have tried to use only benzodiazepines for the first 3 weeks of treatment. This is a curious plan, as benzodiazepines expose patients to all kinds of side effects (oversedation, falls, paradoxical reactions) without any of the positives of antipsychotics.

The evidence

As I said earlier, some huge claims have been made about Open Dialogue. They are essentially stating that schizophrenia, an illness that for hundreds of years no treatment (including many other talking therapies) has failed to adequately improve has been eradicated simply by a different method of talking. We owe it to our patients to examine these claims carefully.

I chose only to read the quantitative research into Open Dialogue, for the simple reason that only quantitative research could provide evidence for these claims. Furthermore, if we’re going to spend public money on Open Dialogue, quantitative research is the only thing that will prove that it works better than alternative options.

I need to say from the outset, I found the evidence base to be thin. Very, very thin. Whereas a single drug needs to be tested on hundred if not thousands of people to get anywhere near the marketplace, the amount of patients that Open Dialogue has been given to in quantitative studies appears to total 64, and the studies are of poor methodological quality.

The first study of interest is Seikkula et al. (2011a), which compares outcomes of Open Dialogue psychosis patients during two periods (1994-97 and 2003-05) with outcomes for psychosis patients seen by the team before they used the Open Dialogue model (1992-93). During this pre-Open Dialogue period the team still had a non-medication focus and the system of treatment had already been reorganised towards a needs-focused approach, but the specific Open Dialogue model had not been fully implemented. Seikkula et al. (2006) uses identical data but uses only the earlier Open Dialogue group.

The number of patients in each group was low – 46, 18 and 36 respectively – limited further by exclusions, including 9 from the Open Dialogue group that ended up with 18 patients, because patients refused to participate, could not be reached or follow-up or had died. There was no significant difference between the groups over the 2 year follow up period concerning:
• The number of patients given antipsychotics (26-50% started them across groups)
• The number of relapses (less than 30% in all groups)
• Employment status (62-78% studying or working across groups)
The mean Brief Psychiatric Rating Scale (BPRS) scores of patients in the 1994-97 group were significantly lower after 2 years than those in the 1992-3 group (30 vs 24), but this effect had disappeared by 5 years and the 2003-05 group showed no significant difference to the control at either point. More than 80% of patients in each group were free of psychotic symptoms at 2 year follow-up, but again, there was no significant difference between the Open Dialogue groups and the control. The amount of days patients spent in hospital was different between groups, with the control group (25 days) being worse than the 1994-97 group (9 days) and 2003-05 group (14 days).

So this study is the source of the statistics in the introductory quote, but overall, what these results make clear is that Open Dialogue is actually no better than the model that went before it, the simple needs-focused approach. The unusually good outcomes reported in the area must be due to factors other than the switch in model. Could it be that the team, who are dedicated, cohesive and not burnt out, get good results whatever the specifics of their model? Could it be that the area, a highly atypical one compared to the UK, has less of the stressors associated with emerging psychosis? Could it possibly be that all the patients who are going to do badly simply don’t seek out the local service or don’t engage with it, biasing their sample? And lets’ not forget that a third of the 2003-05 sample were excluded – are they very unwell?

Another paper which seems to be the source of so many large claims about Open Dialogue is Seikkula et al. (2003). As far as I can tell, this is the only time that the results of an Open Dialogue team have been compared to those of a different team. The paper uses the same Open Dialogue group from 1994-97 and the same pre-Open Dialogue comparison group from 1992-93 but adds in another comparison group – one from a neighbouring Finnish community that weren’t using Open Dialogue. They investigate the outcomes of only the patients in each group with schizophrenia, not other psychotic disorders, as only that subgroup of patients was comparable in demographics across treatment arms. This raises immediate questions – are the neighbouring community’s patients older, more unemployed, less married? In any case, the resultant groups are absolutely tiny – just 14 patients in the neighbouring community control, versus a barely better 22 and 23 in the Open Dialogue groups.

The results show that the Open Dialogue patients were in a much better state that the control group after 2 years. Only 6 out of 23 patients had relapsed compared to 10 out of 14 in the control group, 15 out of 23 were working or studying versus 3 out of 14 in the control group, and 8 of 23 had needed antipsychotics at some point compared to all 14 in the control group. Days spent in hospital were fewer in the Open Dialogue group, but interestingly BPRS scores weren’t significantly different between the groups (25 vs 27).

The limitation of this study are eye-popping. Anything as minor as the psychiatrist in the control group having a very paternal style of practice (i.e. favouring medication and longer stays in hospital) could have biased the whole thing. Heck, there could be a crack den or a genetically unfortunate family in the control area that skewed the results. The sample sizes are tiny and a group of 14 people is in no way an adequate representation of ‘treatment as usual’ in the rest of mental health services. The Open Dialogue team seemed to keep their patients off medication, out of hospital and in work but their actual levels of psychosis – the BPRS scores – weren’t any different, so are they treating psychosis or just providing awesome social support?

The final study of note is Seikkula et al (2011b). In this study, the notes of every patient aged 15-44 who presented to mental health services in Western Lapland between 1984 and 1994 are examined, the patients are retrospectively diagnosed based on those notes, and the relative rates of diagnoses between two groups (1985-89 and 1989-94) are compared to see if the rates of schizophrenia dropped after Open Dialogue was brought in. The paper states that a comparison between pre- and post-1990 was chosen as family therapy programmes began in the area in 1989. This seems to reconcile poorly with the previous papers that used the 1992-3 group as the ‘pre Open Dialogue’ group, effectively admitting that the 1992-93 group is very similar to Open Dialogue proper.

The authors found that the mean annual incidence of schizophrenia fell from 25 to 10 between the 1985-89 and 1990-94 groups. The fewest cases diagnosed in any one year was 3, in 1994. Brief reactive psychoses rose from 1 to 7 cases per year. The paper also notes that there were no patients staying longer than a year in hospital after 1992. It is from this paper, it seems, that the claim that schizophrenia has been eradicated has emerged. The authors hypothesise that so many of the local population must have been involved with their family meetings that the beneficial psychological effects may have spread, actually preventing new cases of schizophrenia emerging in the first place.

Sadly, there are several more mundane possibilities. The local economic climate may have picked up, or illicit drugs might have been better controlled. The professionals who originally saw the patients, working for a service that is so enthusiastic about reducing psychosis, may have been selective in their note taking at the time, leaving out or not fully exploring key psychotic symptoms. After all, the difference between a ‘psychotic episode’ and ‘schizophrenia’ is only a clinician’s judgement of how soon the psychosis ended. Furthermore, retrospectively diagnosing patients from their notes isn’t exactly accurate and using old notes to establish a regional incidence rate isn’t close to watertight. The claim that the Open Dialogue model has disseminated amongst the local populus, creating a psychosis-resilient social environment, is a huge one and there is no reason to believe it without intense further study. There’s not even a lot of evidence that individual interventions like medication and CBT work for people at ultra-high risk of psychosis, so it’s a real long shot hypothesis.

 

Summary

My thoughts on Open Dialogue can be summed up in two themes:

Firstly, their model is admirable, but many facets of it, like continuity of care and timeliness in intervention, have been recognised as key components of good care for many decades. The reason we struggle to achieve them in the NHS is because we’re so short on resources, not because we lack the Open Dialogue model. Other facets of the model are more unique but there are huge issues around their generalisablity on social, cultural and individual levels.

Secondly, the evidence which suggests that Open Dialogue works better than any other treatment is slim to none. We have no idea if it’s the general facets of the model that cause improvements (if there are any), or more specific aspects of the dialogical approach. If we’re going to make significant investments in the model in this country, using public money, we need to have more convincing data. A multi-centre UK trial is in the offing and I look forward to the results with an objective eye.

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