British psychiatry and its discontents

Summary

Psychiatry in the UK is currently faced with serious difficulties arising from failure in recruiting British doctors and a high rate of early retirement from the specialty. To diagnose the underlying causes, account must be taken of government policies affecting the NHS in general and mental health services in particular. The latter include an excessive run-down of acute hospital beds, as well as projects aimed at changing the clinical role of psychiatrists and promoting mass treatment of milder mental disorders by non-medical personnel.

Psychiatrists have reacted to these developments with anger and dismay, but have as yet reached no consensus with regard to either causal factors or appropriate response. Their uncertainty reflects the need for a firmer grasp of the historical background. Modern British psychiatry was effectively created and moulded as an integral part of the NHS. It flourished as long as the public service framework remained intact, but has suffered a decline since the whole structure began to buckle under the pressure of sustained political assaults. A clearer understanding of this vital connection would help to raise psychiatrists' morale and encourage them to establish common ground with medical colleagues and other healthcare professionals.

All is not well with British psychiatry. According to the Dean of the Royal College of Psychiatrists, the specialty is currently faced with a ‘catastrophic’ shortage of British practitioners and is overly dependent on foreign doctors, while in the National Health Service (NHS) posts for fully-trained and qualified specialists (in Britain called ‘consultants’) are going to candidates, many of whom the College regards as barely satisfactory.¹ In the 1990s, the number of UK medical graduates taking the membership exam ran at an average of around 200 annually, the increment of newly-trained specialists being supplemented each year by about one-third this number of overseas graduates.² Over the past decade, established posts in the specialty have increased by well over 50%, but the supply of UK graduates who completed training failed to keep pace. The number who sat the RCPsych exam fell from 338 in 2005 to 315 in 2006; thence to 257 in the following year; to 230 in 2008 and to 64 (or only 1 in 8 of all candidates) in the first half of 2009.¹ Despite a yearly average of 1000 overseas graduates who train in the UK, around 1 in 7 specialist posts remain vacant or are filled by locums. This decline in recruitment has coincided with a number of published articles and letters from British psychiatrists, expressing their unhappiness with the condition of the specialty.

To some extent, the British situation may be regarded as part of a global trend. Katschnig,³ in a recent international survey, noted a fall in recruitment in other high-income countries, accompanied by a ‘brain drain’ of psychiatrists from the developing world. He attributed the decline of psychiatry as a medical career choice, on the one hand to challenges originating within the specialty itself (loss of confidence in the knowledge base and lack of a unified theoretical foundation); on the other hand to those emanating from without (client discontent, negative public image and competition from other professional groups).

Katschnig's review excluded pressure due to interventions by the state or other cost-bearers, on the grounds that these mostly affect medical services as a whole. To understand the causes of the British problem one must, however, take account of state interventions, since for the past 60 years psychiatry in this country has been largely created and moulded by the state-controlled NHS, and mental-health care has been increasingly singled out for government intervention.

Emergence of the crisis

Three official policies in particular have contributed to the present situation. The first was an ongoing reduction in psychiatric bed numbers beyond the point at which this decrease could be compensated for by shorter inpatient stay and more community care. A decline from the peak level of 150,000 beds began in the mid-1950s, following on introduction of neuroleptic drugs and improved rehabilitation for long-stay patients, and continued steadily thereafter. From the late 1980s onwards, however, this reduction was effectively incorporated into government policy as a piecemeal closure of the large mental hospitals began.⁴ The number of NHS psychiatric beds in England fell steadily to around 47,000 by 1996 and 34,000 a decade later.⁵ Admission rates for mental disorders as a whole peaked in 1998 and then also began to fall. Those for psychotic disorders remained steady, however, while those for drug and alcohol problems actually increased. Meanwhile, the proportion of involuntary admissions was rising and so were bed-occupancy levels, causing overcrowding in some hospitals.⁶ These trends reflect a growing shortage of NHS bed provision and a resulting shift in character of the inpatient population: both changes that put an increased strain on hospital psychiatrists and trainees.

Second, the report of a national working group on service reform was published in 2005 under the title New Ways of Working for Psychiatrists (NWWP).⁷ This document, co-sponsored by the Royal College of Psychiatrists and published by the Department of Health, proposed that psychiatric consultants should surrender personal control over case referral, diagnosis, treatment and continuity of patient care, in favour of a system based on more widely distributed responsibility across a multidisciplinary team. As stated in the opening summary, ‘this will be a big culture change … not just tinkering at the edges of service improvement’.

Why the reform was judged necessary can be gleaned from early reports, included in the document, of a pilot project in a number of local areas. From these it would appear that psychiatrists in the areas concerned had found themselves overstretched between inpatient and community care, and unable to provide the levels of supervision and clinical leadership required for optimal functioning of their teams. The traditional ‘sector psychiatrist’ model was, therefore, replaced, under guidance from the local Health Trusts, by a more specialized system in which individual clinicians should be designated for either inpatient care or community mental health teams, but not for both.

According to the new policy, inpatient consultants would be restricted to hospital settings, where they would retain clinical responsibility, regardless of patients' place of residence. Continuity of patient care would be maintained, but by the care programme co-ordinator rather then by the individual consultant. Community consultants, in contrast, would each work in a multidisciplinary team with a defined catchment area. They would have fewer direct patient contacts and carry no individual case-loads, but instead would provide a consultative service to support other mental health professionals in their frontline tasks. Episodes of care would be defined by team rather then by individual specialist, and Primary Care Trusts would no longer commission direct GP-to-specialist referrals.

An intended feature of this new approach was to be increased collaboration and intermeshing with private healthcare. ‘Independent sector provision’, stated the document⁷ (p. 24), ‘is likely to continue to increase in the future, as will a growing movement of staff between the sectors. It is important, therefore, for the sector to be partners (sic) in the process of developing a modern mental health workforce.’

So far, no systematic audit or evaluation of the NWWP programme has been published. Two-thirds of psychiatrists in England and Wales and one-third in Scotland are said to have confirmed that its broad principles were being implemented by their local Health Trusts;⁸ but plans for a detailed survey of the College membership on this subject had to be dropped because of lack of funding and unresolved methodological problems.⁹

Third, another mental health project was launched by the Department of Health under the title Improving Access to Psychological Therapies (IAPT).¹⁰ Based in part on the utilitarian ideas of the economist Richard Layard,¹¹ the scheme is designed to train some 3600 non-medical professionals in cognitive behavioural therapy (CBT) and to deploy them in community-based treatment centres across England, from which they will treat persons referred by GPs or employment agencies, who suffer from depression, chronic anxiety or related neurotic disorders. Here again the contribution of the independent sector is emphasized. Commissioning guidelines make it clear that contracts for the new centres will be awarded subject to tender on the basis of ‘world-class commissioning’, which means, in practice, that private companies, whether based in Britain or elsewhere, will be eligible to submit bids.¹²

Official pronouncements assert that the new policies will mean improved care: for patients with severe and ‘complex’ mental disorders because inpatient consultants will have more time to concentrate on their treatment, and also for those with milder conditions (of whom only a fraction are referred to psychiatrists) because CBT is the most cost-effective therapy for their conditions. One should note, however, that the two projects outlined above are not co-ordinated with one another at the practice level; indeed, the two sets of pilot studies did not cover the same area services or populations.

Response by British consultants

Many psychiatrists have reacted to these developments with anger and dismay, but it has taken time for anything like a consensus of opinion to form and find expression. In 2008 a statement by 37 British clinical specialists was published,¹³ which probably represents the views of a great many more.

‘British psychiatry’, it declared, ‘faces an identity crisis. A major contributory factor has been the recent trend to downgrade the importance of the core aspects of medical care. In many instances, this has resulted in services that are better suited to delivering non-specific psychosocial support rather than … thorough, broad-based diagnostic assessment with formulation of aetiology, diagnosis and prognosis … For those with severe mental illness, to avoid medicalisation is at best confusing and at worst damaging, or even life-threatening.’ Within the new model of distributed responsibility and leadership, it continues, referred patients may never see a psychiatrist or see one only at the discretion of other team members, which means that many will not get a skilled diagnostic assessment before commencing treatment.

This statement clearly identifies the threat to clinical autonomy and hence to the quality of patient care, but fails to make a closer analysis of the underlying problem. The retrogressive move to divide specialists into hospital inpatient and community consultants respectively is not challenged. A false antithesis between biomedical and psychosocial aspects of care is postulated. Moreover, responsibility for the crisis is attributed in part to ‘active collusion and passive acquiescence by psychiatrists themselves’, suggesting a deep schism within the British specialty for which no evidence is given.

A more cogent explanation has since been offered by a second group.¹⁴ Since the 1990s, they write, ‘… the NHS has been in a state of perpetual reform. Emphasis has shifted from meeting the needs of patients as assessed by clinicians to achieving centrally set targets … Business models … and a specific focus on private sector providers have been introduced … The new market economy requires a common currency for comparing wholly different services. New “measures” are introduced to facilitate auditing, but these often distort clinical practice and destabilise services.’

New Ways of Working, the article continues, is now being used as an excuse to cut medical staff numbers and reduce the psychiatric component in services: policies that are likely to prove counter-productive for mental-health care. We do well to remember that it was psychiatrists not managers who led the moves to empty the asylums and balanced the competing biological and social theories of schizophrenia; and that in recent years psychiatrists have played a major part in fighting the threat to civil liberties posed by illiberal mental health legislation. This declaration,¹⁴ in short, places the blame for psychiatry's current predicament squarely on the political pressures to which the NHS as a whole and mental health services in particular have been subjected over the past two decades. In doing so, it emphasizes the need for a clearer overview of British psychiatry's recent history.

Mental-health care in the NHS

The first 30 years

The close connection between psychiatric care and health service infrastructure becomes apparent as soon as one adopts such a perspective. From its inception in 1948 the NHS was, in the words of Charles Webster,¹⁵ ‘an enormous improvement on the ramshackle assemblage of health services that it superseded’. Healthcare became a right of citizenship, free at the point of delivery. Despite the legacy of outmoded hospital buildings, under-funding, staff shortages and a backlog of unmet medical needs, a more equitable distribution of resources was achieved and the founding principle of universal care maintained. Moreover, improvements in population health compared well with those of other industrialized countries. Decrease in infant mortality and rise in life expectancy curves in the UK, for example, were more favourable than those for the USA, for Europe as a whole, or for all OECD countries combined, though annual expenditure per capita on health was significantly lower.¹⁶

The influence of the NHS on British psychiatry over the past 60 years has been ably reviewed by Freeman¹⁷ and Boardman.¹⁸ Improvements in mental-health care made slow progress at first because of financial constraints and the low priority accorded to this part of the service. At the outset a great deal of specialist work was being undertaken by poorly-qualified and -trained staff and there were many vacant posts for which no suitable candidates could be found. The wages of mental nurses were derisory in an age when better pay could be earned almost anywhere else. In the early years, moreover, a flood of patients into the mental hospitals gave rise to severe problems of overcrowding and understaffing.

By the mid 1950s, however, improvements in staff quality and service structures, combined with therapeutic progress, were transforming the situation. Official reports now began to stress alternative approaches to care and to forecast that fewer mental hospitals would be needed in future. The term ‘community care’ appeared and began to denote a reality. Innovations and developments in those years included open wards, group therapy and rehabilitation units in mental hospitals; general hospital psychiatric departments; day hospitals and day centres; home visiting by mental health professionals; halfway hostels and sheltered employment for the chronically mentally-ill. In large measure these were ‘bottom-up’ developments that grew out of innovations made by clinicians in their own hospitals and local communities.^14,17 The Royal Commission Report of 1957 was largely embodied in a new Mental Health Act two years later. The concept of the District General Hospital (DGH), with psychiatry as one of its core specialties, became embodied from 1962 on.

In a synergistic development, psychiatry was advancing as a teaching specialty. Academic departments were established in medical schools up and down the country, started training courses and attracted able young doctors. Research units in clinical, social and epidemiological psychiatry were set up by the Medical Research Council. In 1971, after a prolonged gestation, the Royal College of Psychiatrists was born. Throughout these years British psychiatrists, working mainly in the NHS, remained a unified profession and engaged in few ideological disputes. The various ‘anti-psychiatry’ factions associated with the names of Szasz, Foucault, RD Laing and others gained wide media coverage and stimulated debate within the specialty, but exercised little influence on either service structures or the treatment of patients.¹⁹

An integrated structure for health and social care was proposed in the 1975 government White Paper, Better Services for the Mentally Ill, the main components being provision of facilities locally, expansion of community nursing, closer coordination between medical and welfare agencies, and increased staff–patient ratios. Mental hospitals were to be sectorized as a step to their replacement by DGH psychiatric units, which would become the new base for the specialist teams, supplying both inpatient and community treatment. Ironically, however, these plans were announced just before the 1975–1976 economic recession hit the UK, so that many proposed changes were delayed or never fully implemented.

The 1980s and after

Despite some political retrenchment, the NHS thus survived its first 30 years essentially intact. From 1979 onward, however, its core values came increasingly under threat as government policy shifted to promotion of an internal market in healthcare. In the mental-health field new legislation placed growing emphasis on risk avoidance through restrictive measures. The 1983 Mental Health Act concentrated on detention of inpatients and paid little regard to questions of community care. A few years later, piecemeal closure of the large mental hospitals commenced in accordance with government policy,¹⁸ and numbers of long-stay beds in the NHS more generally began to fall as residential care for the chronically-disabled was transferred to independent, mostly for-profit, care homes.

In 1991, a Care Programme Approach (CPA) was introduced to systematize priorities for specialist care in the community. The CPA was intended to ensure that each patient should have a care plan covering assessment of treatment needs, social background and possible risks, together with a named care coordinator to follow the programme through. A 1998 Department of Health publication took bureaucracy a stage further, asserting that ‘community care has failed’ and setting out new proposals to augment investment in community provision while at the same time increasing managerial control over both patients and services ‘to ensure compliance with appropriate treatment’.²⁰ These proposals met with strong opposition, principally because they failed to resolve the disparity between shortage of trained staff and increasing government requirements of the service. From the early 1990s, in the words of one critic,²¹ psychiatric teams had been caught between the demands of a primary-care led NHS for open access and those of the Department for concentration on the severely mentally-ill. Instead of resolving this problem, the new strategy had compounded it.

Despite or because of official policies, meanwhile, the pressure on psychiatric acute beds increased and led to a growth in private sector provision, especially of forensic facilities. This trend towards re-institutionalization, present in a number of European countries, has been ascribed to a culture of risk management, preoccupation with public safety and the difficulties in coping with ‘revolving door’ psychotic patients.⁴

As clinical staffing increased with the expansion of mental health services, problems of medical recruitment and retention, never easy for psychiatry, grew more acute. Statistics from the 1990s onward show a growing shortfall in British graduates and a heavy reliance on overseas doctors. With vacancies in senior positions running at 14% or higher, the services have become overstretched and in some areas dependent on locum appointments. To make matters worse, qualified, experienced specialists are giving up too soon. Only a minority of psychiatrists now carry on until 65, and many are choosing to retire before they reach 60. The chief grounds named for early retirement are high case-loads, excessive bureaucracy, lack of resources and problems with management – including the existence of a ‘blame culture’.²²

Discussion

Only 10 years ago two professors of psychiatry in England could still contend that ‘The comprehensive approach of sectorised care in the UK (having the same team responsible for inpatient and outpatient care), provides a remarkably flexible response to the needs of [the severely mentally ill] … we take it for granted and seem unaware of what an asset it is … By international standards our services are extraordinarily straightforward and well co-ordinated.’²³ The contrast with recent assessments (see above) reflects how much things have deteriorated over the past decade.

To those old enough to have witnessed its early impact on health – and in particular on psychiatric – care, it seems a truism that the NHS provided the essential conditions on which a modern, equitable, single-tier health service could be built. Upon this foundation, major improvements in mental-health care provision were achieved: partly by direct government action, but at least as much by the seminal effect on professional recruitment, training and conditions of service. Erosion of the national consensus on healthcare started in earnest in the 1980s, as part of the rolling back of welfare state provision and the move away from collectivist ideas. Government policy came to rely increasingly on market solutions and the commissioning of private agencies for provision of public services.¹⁶

Although evaluation of any national service is intrinsically difficult,²³ some broad inferences may be drawn from this story. British psychiatry, it appears, flourished as long as the NHS remained secure and in good hands, but then, despite ongoing scientific progress, has gone into decline since the national service infrastructure began to disintegrate under sustained political pressures. The same misguided policies that led to re-institutionalization, shortage of acute beds and an assault on patients' civil liberties are now undermining professional practice and recruitment to psychiatry. A clear understanding of this connection and the underlying dynamics might greatly benefit the morale of clinical psychiatrists, encouraging them to close ranks and establish common ground with medical colleagues as well as with other healthcare professionals. Improvement in morale could at the same time release fresh energy and hence, as in early years of the NHS, generate new ways of working that would answer clinical and public health needs far more effectively than the ‘top-down’ scenarios of an over-centralized managerial system.

What changes such a groundswell of opinion would bring about in local practice cannot be nicely predicted, but likely trends include a drive for better conditions on many acute mental health wards; closer integration rather than separation of inpatient and community teams; renewal and strengthening of liaison and primary care psychiatry, and increased cooperation with serious campaign groups who are working on behalf of the mentally-ill and their family caregivers.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor BC

Contributorship BC is the sole contributor