Left to right: Dr Justin Wilson, Professor Sir Simon Wessely,
Melanie de Smith, Holly Taggart, Peter Spilsbury, Stephen Firn, Ben
Dyson, Richard Murray
In my last blog I told you all about RCPsych’s calls to the next
Five Steps to Fairness, on the need for a
bigger mental health workforce. By the end of today we should have
seen the manifestos from all the main parties, but in the meantime
we already know that Theresa May already is pledging to increase
the mental health workforce by 10,000.
Nothing wrong with that. We are calling for more mental health
staff. Naturally, rumours persist that this 10,000 won’t really be
ten thousand, after staff changes in recent years are accounted for
and the possibility that some of these numbers may be voluntary
roles. And who is going to pay for this?
We need to make sure that the posts of some of the most
skilful members of the workforce are not mortgaged off to swiftly
train up people who with the best will in world will not be able,
or indeed allowed, to help the most severely ill, and the most
complex. We will fight our corner on this one. As I’ve
said before, when it comes to helping people with mental ill
health, it isn’t about expensive kit, it’s about staff, highly
trained, in the right numbers, how they work, where they work, the
teams they work in and how they feel.
And those teams are beginning to change right across the NHS.
Our report, published today,
Mental health and new models of care: Lessons from the
Vanguards examines new ways of doing things that
aim to move care out of hospitals and into the community, reducing
traditional divides to deliver care that treats mental, physical
and social needs together.
In what has been a leitmotif of these blogs, at least when they
are about the NHS, your knowledge of these developments may be
sketchy. Mine is. This is not helped by the fact that as ever
they are disguised by a complex system of codes that would have
baffled the people who broke the Enigma codes - NCM, MCP, PAC
etc. I sometimes think there is a computer in the basement of
NHS England that produces random three letter sequences, and then
it is the task of the officials to produce plans to fit the
acronyms, rather than the other way round.
But when it comes to transforming care, we are not just in the
vanguard, but we are the vanguard of the vanguards.i We
have done a lot of this. More than any other part of the NHS.
Deinstitutionalising services, moving care out of hospitals into
the community through the care programme approach, care
coordination and investing in crisis care home resolution treatment
teams. We did the lot. We transformed ourselves from an
almost entirely hospital based service to one that is now the
opposite. No one else has achieved anything remotely similar.
It wasn’t without its problems, but we got there. So we know
of what we speak.
And so common sense would dictate that as the rest of the NHS
seeks to transform, they would look to us, the vanguard of
vanguards, for a tip or two. But have they?ii
Through our work, jointly with the King’s Fund, we’ve found that
some areas have made great advances to include mental health but
have been disappointed that some others barely considered the
sector at all. The bulk of mental health plans within new models of
care revolve around enhanced models of primary care, with mental
health expertise directly embedded into primary and community
health teams. For this we can see a common and distinct move of
specialists, including psychiatrists, out of hospitals and into the
community, and teams of mental health nurses and allied health
professionals with them. It's not new – indeed, one
Geraldine Strathdee, soon to be our latest Honorary Fellow, started
her career doing just that.
Nothing radical in this. It’s what we believe – adhering
to a biopsychosocial approach based on multidisciplinary
working. So it’s nice to see new exemplars in action. In West
Cheshire Way, an older people’s consultant psychiatrist post has
been created to provide educational input into the integrated care
teams and primary care. This supports RCPsych’s manifesto ask
that not only do we need more psychiatrists but we need a greater
understanding of mental health across the wider NHS workforce. In
Tower Hamlets, mental health nurses in the integrated community
health team have protected time to provide training to primary care
as well as community health teams.
Putting mental health expertise in places where most people
access services is likewise bread and butter to us. That’s
exactly why I went into Liaison Psychiatry many years ago.
Now in Tower Hamlets and elsewhere mental health nurses are working
within integrated teams, as opposed to community or acute mental
health services. Many of the vanguards sites are starting with
older people’s health services. Quite right too –
says someone who has just got their bus pass (BUT NOT
But despite these positive steps, our overall assessment is that
opportunities to integrate mental health into new models of care
have not been fully realised. The level of priority given to mental
health has just not been high enough. Sometimes we are an
afterthought, picked up after checking in the rear view mirror,
other times we don’t even make it on to the pitch.
Does this matter? Very much so. Because if the vanguards are at
the front of the line, what is coming behind is the main force.
These are the
sustainability and transformation plans
or “STPs”, which I have droned on about
before. And we need to make sure that the omissions by the
vanguards are not repeated when the main army takes the field.
Ah, I hear you say, surely these new things have been
evaluated. Everything is evaluated these days. Indeed so, but
there are evaluations and…er…evaluations. And in the
evaluations of the vanguard sites mental health is conspicuous by
its absence. Plenty of good things being measured, but none are
specific to mental health.
So we are asking that future evaluation includes the impact of
this latest New Model Army of new care models on people with mental
health problems. And continuing the Cromwellian analogy, leaders
must not be cavalier with mental health – and need to be seen to
take account of good practice where the gold standard (with mental
health support successfully embedded in integrated care teams,
enhanced models of general practice, and urgent and emergency care
pathways) has been achieved. Until then, we will follow another
acronym, this time introduced by Ronald Reagan when he was
negotiating the end of the Cold War with Mikhail Gorbachev.
TBV. Trust But Verify.
[i] Pedanticus, in what may be his last message to you, notes
that “vanguard” is actually a French word, derived from avant
garde, meaning the front of the line. Once a military term, it is
now more often used in art and culture. But as the Pub Landlord
would point out, either way it is French, and now that Brexit means
Brexit, surely we should find a good Anglo Saxon word instead.
Arrow Fodder perhaps?
[ii] Pedanticus reminds me that is a rhetorical question. And as
Pedanticus takes his final bow, a round of applause please. I would
be lost without his belief that getting the facts right, no matter
how trivial, matters.
Professor Sir Simon Wessely
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