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

Humbug and Hope


Thursday 18 December 2014


Apparently I am supposed to write a “Christmas Message” for the faithful.  This is a new one for me, not least because this is the time of year when I wish my first name was Ebenezer.  Has the right ring about it.  Not entirely sure what the form is -  am guessing that I tell you about my State visits to various parts of the world we used to own, the rapturous receptions I received there, and how delightful my grandchildren  (or is it great grandchildren?) are, before calling for World Peace.


So let’s take that as read, shall we?  What has actually been happening back on Planet Earth?  Let’s start with the College. We began the summer with an extended discussion at Council, to agree our top three priorities for the next three years:


1)    Recruitment and retention (workforce and training);

2)    Standards for individual practice and services;

3)    Communication and engagement.


The next step is to translate these in to action.


In relation to workforce, there is a unique opportunity offered by the expansion in numbers for foundation posts in psychiatry. Some 45% of all doctors undertaking the Foundation programme will complete a psychiatry placement. It is of critical importance that we get this right.  This could radically improve the understanding of mental health of doctors across all specialties.  Ensuring a good quality experience will be vital - if we fail on this, we have only ourselves to blame.  Every one of you matters in making this happen. As the Jesuits might have said: “Give the young trainees a good experience and they are ours for life.” 


So that’s the exciting stuff. More prosaically, but just as important, we will work with the Department of Health on getting the outcome measures, and the payment systems they inform, into a state where that are at least vaguely ‘fit for purpose’, as the cliché goes.  Probably the single most important step towards parity is to ensure that the funding systems for mental health are similar to those underpinning acute services – and agreeing outcome measures is a step towards that.


Within the College itself, the new Board of Trustees is up and running, with three independent expert lay members, representing the worlds of running large public bodies, law and finance.  I am very confident that this will improve the governance of the College, and we are already undertaking a number of initiatives to make this happen. It will also allow us to make Council more interesting and relevant, and as you know we are exploring if we can live stream the meetings in the future for added transparency.


One thing to watch out for in the New Year is the College’s Commission to review the provision of inpatient psychiatric care for adults, chaired by Lord Nigel Crisp, which will seek to understand the periodic merry-go-round of bed crises. Why do they keep happening here and how do some countries manage to avoid it? 


OK, what about in the wider world?  Mental health has seemingly continued to climb the political agenda, with much being promised by the government.  Senior politicians now speak about it frequently, and sometimes, as with Nick Clegg at the Lib Dems conference, even eloquently.  The new boss of NHS England, Simon Stevens, likewise often talks it up, and I have already had rather more meetings with him in the last six months than my predecessor did with his predecessor over her entire term.  No doubting the rhetoric, but ‘what the speeches giveth, too often the Treasury taketh away’.


To be fair, there have been some announcements of more funding for some key areas.  After several prominent negative news stories highlighting the highly stretched nature of Tier 4 CAMHS services, it is good to hear that more funding is in the pipeline.  Other services under severe pressure, which will stand to benefit from both extra funds and new waiting times and access standards, include eating disorders, early intervention in psychosis and liaison psychiatry services– these last two no doubt brought to attention because of the crisis over A and E pressures. 


Another piece of good news: for a while we have been keen on the concept of the “named clinician” - the person with whom the buck stops. This is part of the “name on the bed” initiative, which is being adopted now in both medicine and surgery.  On the principle of what is good enough for them is good enough for us (did anyone say parity?), but more importantly because we know it is what patients, carers and GPs want, we have been lobbying for this for mental health.  At the last minute it looked like this had been blocked by the Treasury, but I’m pleased that some very late lobbying indeed led to Jeremy Hunt announcing this at the launch of the second National Schizophrena Audit report in October.  Given that I had asked for this in my introduction for the Secretary of State, this felt like one of those times when one team scores straight after the kick off.


Despite these positive developments, the reality remains that there is no more money and the cuts are still with us.  Mental Health services could be subject to 1.5% cuts next year, on top of real terms cuts for the last three years.  While the latter is disputed, we and others are holding firm on this.  I suspect that most of you reading this would not find that hard to accept.  So we are faced with many unknowns. Will we really get the extra money every politician promises?  Will it really be new money?  Where will it come from?  Where will it go?   Will we really see a true shift in funding from the acute hospital based services to community services?   If so, that would be a first, and, of course, commended.


I don’t recommend reading most government reports – the ones with titles like: “Towards a shared vision:  Better care, better health, better safety, improving access, improving outcomes, improving quality, integrating services, crossing boundaries , a world class service for all”.


You know the type.  But there is one that you should read.  This is Simon Stevens’ Five Year Plan for the NHS (OK, it’s not actually called that – as someone who knows his history he probably would avoid that title). This one really matters, which is why for the first time I am including a link to it (   Simon is saying that the future of the NHS depends on how we integrate three fault lines - these three juxtapositions being: primary and secondary care; health and social care; and perhaps most crucially between physical and mental health care. This begs the question of whether this is achievable within the current structures of the NHS. Mercifully, there seems to be little appetite for further disruptive top-down reorganisation of the health service – after all, that worked so well last time, didn’t it?  This at least gives the bruised NHS some chance for recovery from Mr Lansley’s attentions.


Whatever happens after the election, mental health is now a well organised and increasingly influential lobby, with the College partnering with charities and patient groups to amplify our voice.  Even a cynic like me does believe that politicians are listening – but unfortunately the ear that we really need is the Chancellor’s, no matter who wins the election.


So, compliments of the season.   Enjoy it whilst it lasts. As they say in ‘NHS Speak’, next year will be “challenging”, we will need to have “conversations”, which may even be “difficult”, and to “consult”, which will naturally be “widespread”.  You get the message by now.  But let’s however continue to do our best to ensure that throughout this we remain visible, credible and useful.

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Re: Humbug and Hope
Happy Christmas Mr President.
Re: Humbug and Hope
Excellent read and entertaining tone, honest and to the point. Thanks for the work you are doing on our behalf.
Re: Humbug and Hope
For the sake of the patient , a humane and efficient mental health service needs to have CONTINUITY OF CARE as one of its guiding principles. This has been largely lost in the last few years, with changes based upon vote-catching and ideology rather than experience and evidence.
Re: Humbug and Hope
A wonderful commentary which should be read, really, by everyone working in the public service.
So often, when different or even conflicting needs in the same individual collide with each other, each separate specialism takes refuge in its own classification system and refuses to listen to anybody else's.
Perhaps the advent - if that ever comes about - of a separate and historically detailed health record for each citizen, held by him or her personally and PROPERLY EXPLAINED AND UNDERSTOOD, may eventually sort this out?
Educationalists, general practitioners, nurses, social workers and pharmacists would all need to become involved in such a process and legislation about commercial advertising would be needed too but still, perhaps, we can keep on hoping.
Re: Humbug and Hope
I echo John Cooper on continuity of care which is among other reasons the most efficient way of running a service. Unfortunately it requires spare capacity, a concept that is unacceptable to administrators despite its being the basis of a more efficient and humane service.
Re: Humbug and Hope
Excellent tone and content, thank you. Named responsible clinician very good idea, will someone tell the bed managers, please? The split of authority from responsibility is the single most damaging element of the NHS, in my opinion.

Re: Humbug and Hope
Another good column, keep up the excellent work on behalf of our patients and the pressure to make sure the politicians rhetoric becomes reality
Re: Humbug and Hope
Another very good column.

Please keep calling it the way you see it, avoiding all lapses into the bland officialese that trips off other tongues so easily and so meaninglessly.

As to continuity - I agree it is crucial, but it has been diminished or lost altogether in much of acute medicine and surgery, and for all I know in primary care too. It is going in mental health services, as teams multlply and fragment. Maintaining it requires a recognition of the longtitudinal view of most illness experience - rather than the acute, episodic. intervention-based model upon which so much health care planning and funding is based.
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Professor Sir Simon Wessely


Professor Sir Simon Wessely


Simon Wessely is Professor and Head of the Department of Psychological Medicine and Vice Dean for Academic Psychiatry at the Institute of Psychiatry (IoP), King’s College London. He is a clinical liaison psychiatrist, with a particular interest in unexplained symptoms and syndromes.

As Vice Dean he has overall responsibility for undergraduate and postgraduate psychiatry training, and is particularly committed to sharing his enthusiasm for clinical psychiatry with medical students. He also remains research active, continuing to publish on many areas of psychiatry, psychological treatments, epidemiology and military health.