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The Royal College of Psychiatrists Improving the lives of people with mental illness

A Christmas Tree Zone

Apparently there is a tradition that the President sends a Christmas message to all our members. No one knows why, nor what it is supposed to contain. And neither do I. So this year the blog will be a Christmas free zone. Actually when I first typed this, predictive spelling made it a Christmas tree, rather than free, zone. That seems a suitably whimsical title, so I stick with it. If you only clicked on the blog to find out what on earth it meant, now you know and can go back to doing something more productive.

On the subject of predictive text, one of my colleagues who shall remain nameless but has one of those names in which you can reverse first and second name without any difficulty, like Henry James, once wrote a letter to a GP in which he said the patient had a “dull normal IQ”, except he was using voice recognition software and it came out as “dull normal like you”. He didn’t notice, but the GP most certainly did.

OK, that’s enough levity, and what better way is there to lower the spirits than talk of the state of NHS finances. Which are dire. You know that. If you work for a Trust, as most of you do, it is more likely than not that it will be in deficit. Everything is going down, except of course waiting lists, the burden of regulation, column inches in the Daily Mail saying how rubbish doctors are, the age of the population and the demands of politicians and expectations of patients. And despite stoking up expectations and increasing demand (NHS 111, 24 hour NHS, “cancer test” results in days and so on), we are also told “there is no more money”. All of this means an increasing financial crisis, not made any easier by the sudden appearance of a new disorder, one which even the DSM has not yet catalogued I am talking about DAD, or Deficit Amnesia Disorder as it will no doubt appear in DSM-6. This is a disorder that seems to afflict political leaders of all colours when they take to the stage at party conferences and forget to mention money and its absence.

All of this comes to a climax in what is called the Spending Review, which is when the government announces its spending plans. It is always preceded by an avalanche of lobbying, leaks, claims counter claims and general mayhem. And this time was no exception. Only a few weeks ago those in the business of economic forecasting (a profession which, according to the great JK Galbraith, only exists to make astrology respectable) were confidently predicting cuts to the police that would leave terrorists in control of the streets, slashes to the science budget that would leave us with little more than a child’s chemistry state to conduct future research, but most alarming to all of us, no more money for the NHS. And there were many who would have welcomed this. I lost count of the number of MPs who told me that what else could we expect – we are all ungrateful so and sos, never acknowledging how lucky we were to have been ring fenced in previous spending reviews, always demanding more and more and never saying thank you. I was told that those days were well and truly over – and it was time now to tighten our belts and be grateful for what we had received. No more NHS Santa. I would plaintively wail “well, we never got any of that extra funding anyway, rather the opposite, so please can we moan a little”, but it seemed to be falling on deaf ears.

In fact not quite. Simon Stevens, the NHS Chief Executive, often nicknamed Tarzan by the sketch writers, seems to have cast some sort of last minute spell over the Chancellor, and secured an extra £8 billion for the NHS. Well, at least enough to keep the show on the road over the winter, which at one time didn’t seem likely. And following a concerted effort by mental health organisations and professionals including myself, we were all pleased to see £600m pledged additional funding for mental health as part of that. No, not enough to make up the gap that still exists between mental and physical health, but at one time it looked like there would be nothing at all. This too will help stabilise current pressures, and also some of it will go to those areas of mental health that politicians do “get”, namely babies, children and talking therapies. So stand by for at least some extra money for perinatal services, some of the promised investment in CAMHS, and more for IAPTS. Access and waiting times also appeals to politicians, and so we also hope that some of this cash will assist there, not least because it has already been pledged earlier by Government, albeit “subject to funding”.

A word about IAPTS. As a verb, improving access to psychological treatments is something we stand four squarely behind. When it comes to depression and anxiety, there are treatments out there that work reasonably well, and are not getting to those in need. But I also know that as a noun, Improving Access to Psychological Treatments (IAPTS) causes some mixed feelings, especially when as now the extra funding is going to allow IAPTS to extend into long term conditions (LTCs) and medically unexplained symptoms (MUS). I share the concern that IAPTS as a noun, i.e. as the existing stand alone service model, may not be the right service model to deliver what we all want, which is extending access to psychological treatments to those with chronic illness, be it diabetes or schizophrenia, or with unexplained physical symptoms for which also good psychologically informed treatments exist. We have been working hard to ensure that the expansion in these two areas is going to be based on existing service models and teams, whether in primary or secondary care. We believe that these can best be delivered by integrating psychological treatments and professionals within the diabetes team, CMHT or liaison service, and not as a stand alone service. I will be co-chairing a committee with David Clark, who has been a game changer in this area, with the express intention of ensuring proper integration and not fragmentation.

So far I have been talking mainly about what are so often called “front line services”, a phrase which is I think unfortunate, since it suggests that those outside A and E, acute wards and so on, are somehow less important, which is manifestly absurd. But whatever we use, we know that “front line services”, and indeed the NHS in its entirety, is only part of a much wider picture. We need to look more widely at the impact of budget cuts, and believe me they are cuts, to social care, workforce education and public health, all of which are critical in the delivery of mental health services and care for patients.

Now it’s time for a Tale of Two Reports. I have written before about the Mental Health Taskforce, set up at the end of the last administration by NHS-England, ably chaired by Paul Farmer, and which is tasked as the new five year strategy for mental health for England. I promised you in my last blog that I would be able to share with you the recommendations of the Taskforce in my next blog, but guess what, I lied. Not intentionally, but the Spending Review announcements have meant that some revisions are needed, and it looks like this will not now be published in January. January 2017. No, that’s a joke, and I do hope that finally I will be able to talk more about that next time. Certainly I can tell you that we have played a key role as part of the mental health taskforce, and will seek to play a key role in the implementation of its recommendations.

Then in early February, we have the launch of the The Independent Commission on Acute Adult Psychiatric Care, which we definitely don’t call the “Beds Commission”, because it’s not just about beds. We set this up , and support it. It is however independent of us. It is being chaired by Lord Crisp, who was the last but one version of Simon Stevens – i.e. the boss of the NHS. The Commission is reviewing the provision of acute inpatient psychiatric care for adults and the scandal of the current bed crisis, where currently many patients have to be treated out-of-area. This time I really don’t know what the recommendations are going to be, but I am confident it will be a quality product.

The Minister that we spend most time with, Alastair Burt, Minister of State for Community and Social Care (those of you at the last International Congress will remember that he gave his first speech on assuming office at the Congress) mentioned both reports during a government debate this month on out of area treatments. “ ...I intend to go further and put in place a national ambition to address out-of-area treatments. I will do this in consideration of the Crisp Commission and the taskforce report, and I will communicate details of this ambition by the end of March 2016 - that is, by the start of the next financial year...I want to wait and see what Lord Crisp and the Mental Health Taskforce say and then consider exactly what the ambition should be. Should it be an ambition for complete elimination? Should it provide a much tighter variation? I want to see those reports before I set the ambition, but I will set it, and the targets...".

Well, it’s better to be talked about than not talked about. Let’s see.

I cannot of course finish this blog without a reference to the current state of play with our junior doctors. Independently, and also as part of the Academy of Royal Medical Colleges, in the run up to the proposed strike days, we were urging both sides in the current dispute to step back from the brink and re-enter negotiations in good faith so that an agreement can be reached – if necessary be through third party conciliation and arbitration. Whether this played any part in what happened – that the Government and BMA did indeed go to ACAS, the arbitration and conciliation service, I don’t know, but I think it did have some influence. So now we have a period where one hopes proper negotiations will take place, and I think we all hope that a deal that is satisfactory to our juniors, and by implication all of us, can be reached.

But whatever happens, the deeper issues surrounding junior doctors - about feeling valued and supported - still need to be addressed. This is something that greatly concerns me, and I will use my position wherever possible to draw attention to this and look at how it can be remedied, working to influence the issues within the health sector and government, and also through the media.

Finally, I think one good thing has come out of this dispute. I have been travelling up and down the land, and talked to lots of different groups of junior and senior doctors in psychiatry. The degree of solidarity and support from the consultant body wherever I went was remarkable. Likewise, I also noticed that solidarity between the junior doctors irrespective of what speciality they were pursuing, or what grade they were, was also tangible and, dare I say it, moving. I doubt that neither the BMA nor Jeremy Hunt had that in mind when this dispute started, but it may prove to be one of the more enduring and welcome outcomes.

I promised this would be a Christmas tree zone, so no best wishes I am afraid for Xmas. But I can at least wish everyone a Happy New Year.

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Re: A Christmas Tree Zone
Ebenezer Scrooge?
Re: A Christmas Tree Zone
I was wondering if David Tony might be the nameless colleague? Thank you for a little entertainment on a dull Friday afternoon.
Re: A Christmas Tree Zone
Hi Simon, Have you or the council done some thinking about the college responses on confidentiality regards PREVENT, MAPPA and MARAC? There is a GMC consultation underway.
Best wishes
Happy Hanukah!
Re: A Christmas Tree Zone
No it wasn't me!
Re: A Christmas Tree Zone
Keep up the good work. We support you and hopefully things will get better! The service is in poor shape- I only do tribunals.
Re: A Christmas Tree Zone
and a holly yew fir...
Re: A Christmas Tree Zone
Forgive me for writing to your good self – but I know none other.
I have always been an admirer of Sir Simon, but such, I fear, falls short at his attempts at somewhat misplaced humour translating as frank cynicism in his recent Christmas blog. Whilst I would entirely accept the Wilde definition of a cynic being a romantic who has failed, indeed I would perhaps plead guilty of that myself, I fear that the Presidents recent attempt at supposed witticism may well turn out to be something of an “own goal”. Sir Simon would do well to recall that for many Members and Fellows, Christmas is a very special time of the year, indeed to some it is actually sacred, and to ride roughshod over that which many hold dear might well be regarded as an error in judgement – perhaps worthy of explaination, even for apology ? As an afterthought, I am left wondering if Sir Simon would have expressed similar feelings about the great festivals of any of any other of our planets great religions ? Christians are too often considered to be “fair game” because of their unfortunate habit of staying silent – I do not subscribe to such a habit; I regret what may well be representative of Sir Simons early childhood experiences but...perhaps my Grandmother was right in saying that If you have nothing good to say it may well be wiser to say nothing at all ?
Nonetheless, may I wish all who work so hard at RCPsych, including its President a very genuine and a Very Happy Christmas.

Re: A Christmas Tree Zone
Greetings Julian, sorry if I upset you, but I don't think my comment implied any disrespect. Christmas trees are not actually part of any theological tradition, liturgy or mentioned in any sacred or canonical texts. In fact I think they are a relatively recent addition to the seasonal celebration - starting Germany and then popularised in this country by Prince Albert if memory serves me rightly. Anyway, no disrespect intended, and should you follow my wife on Twitter (which I don't recommend but many do) you will note that our family also has since last week a large example of the genus Christmas Tree dominating our living room .
Re: A Christmas Tree Zone
I would like to agree with the thoughts and sentiments that Dr Boulnois has expressed in the comments. For the President to say "no best wishes I am afraid for Xmas" was rather insensitive and uncalled for.
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