Nottingham's Mental Health Services Demoralised
To review of what is happening in the local mental health services is to write about growing and generalised demoralisation. This is the product of general (national and international) processes and more specifically local developments. The national processes include government driven changes in the health and social services generally, as well as issues more specific to psychiatry and mental health as distinct topic areas. The local include the shifting and unrelenting changes in institutional and managerial landscapes which has effected both health services and local government as well the changes going on in the neighbourhoods and communities of Nottingham which is leading to increasingly disturbed people coming onto the psychiatric wards.
Let's look briefly at each in turn. Twenty years ago Nottingham was widely considered a thriving centre of innovation in its mental health services. These were the heady days when Nottingham was seen as leading the way in the development of the user movement in psychiatry; days in which multi disciplinary mental health teams were being introduced and social workers were confident that they had something to say to their medical colleagues, and were not there meakly to follow the psychiatrists; a time when experiments were taking place with new organisations and new approaches - like the SPAN occupational therapy project. At that time participants of local mental health services – service users, carers, voluntary sector activists, psychologists, social workers, nurses, administrators - saw themselves as active “players” competing and co-operating in the creation of a new mental health service. At one point in this now distant era, at the end of the 1980s, as development worker at Nottingham MIND, I even wrote a draft alternative plan for the reorganisation of the whole local mental health service on psycho-social lines. I organised a conference at which about 30 mental health workers and users amended the plan, discussing the alternative principles, organisational framework and transitional arrangements and funding for a new mental health service.
I wouldn't bother doing anything like that nowadays. It would be unthinkable. The times have certainly changed.
Why?
For one thing, at a national level, central government now entirely hogs the mental health change agenda. Changes are driven by central government – for example implimenting the National Service Framework (NSF) for mental health. We are not minor players in our own drama any more – a role which allowed us to feel, in times past, that we were also influencing a national agenda when we explained what we were doing and dialogued with others at national level conferences – no, we are now extras in the government's dramas. But of course the government must get its ideas from somewhere – and in regard to mental health either they are the warmed over ideas of ten years ago picked up belatedly by civil servants or they are the stifling orthodoxy of the big vested interests, or they are the alarmed knee-jerk responses to Daily Mail headlines. Thus a “joint planning process” was replaced by a Local Implementation Team (implementing the standards and targets of the NSF).
Meanwhile management time has been devoted, mega scale, to a never ending series of 'improvements'. Nottingham Health Authority is replaced by Primary Care Trusts. Nottingham Mental Health Unit became Nottingham Healthcare NHS Trust, then it became Nottinghamshire NHS Trust. Nottinghamshire Social Services split into Nottingham Social Services and the residual Nottinghamshire Social Services. The addresses changed, the people in many cases remained the same. But they were so busy getting their headed notepaper changed, sorting out complicated arrangements in relation to the new geographical boundraries, moving offices backwards and forwards across Nottingham, redesigning their new management arrangements, getting used to working with the latest set of reshuffled colleagues, and, not but not least, attending to the government defined “must dos”, that life became one never ending series of meetings in which local practitioners own ideas about how patient care might be delivered or improved got lost, abandoned, forgotten. A few weeks ago a colleague in the statutory sector described to me the “highly fluid” character of mental health system management at the current time – in other words, after all this ceaseless reorganisation, with everything changing all at once and no fixed points of reference to hang onto, there is no mental health management worth talking about any more – although there may be plenty of managers, budgets overspent, PR newspapers and flashy internet sites.
There were, of course, “consultations”. |f you attended these consultation meetings you would listen endlessly to what had to happen, and what was going to be done – it was all about legitimising what was going to happen anyway. For example, apart from the managers themselves (who thought that their career paths would be made by it) very few people wanted Nottinghamshire Healthcare Trust as they thought that this large lumbering county wide organisation would not be responsive to more local interests. But we got it anyway. So people like myself stopped bothering with consultations processes.
Simultaneously, it has become more and more difficult for community and voluntary organisations outside the big NHS and local government to get any money – unless you could dress it up in some way as helping local services meet government targets there's none to be had any more. Innovation in the voluntary sector became starved through lack of funds and lack of any form of attention or interest. The role of the voluntary sector as source of experiment and innovation has all but dried up – that's government's job. Meanwhile well established watchdog arrangements like Community Health Councils were abolished.
At the same time that this is happening the government is playing up to the headlines. Mental Health service users are more liked to be on the receiving end of violence than doling it out, they are not more violent than “sane” people on average but 'Mad Murderers' sell newspapers, make money for the Northcliffes and pay for the editor's expense account lunches with city managers. So the government agenda is playing to the gallery, in response to the baiting of the papers like the Daily Mail and Sun. And this means leaning towards one side of the scale only - 'risk reduction' rather than therapy and social support. It means an emphasis on procedures that rely heavily on observation, surveillance and supervision, all of which tend to reduce mental health service users options, mark them out and stigmatise them – rather than leaning in the other direction - which would mean encouraging therapy and support to facilitate vulnerable people with chaotic and empty lives getting new experiences, finding new directions, forming new relationships, getting themselves lives and real futures.
You can see that on the psychiatric wards in Nottingham. Duncan MacMillan was famous as a psychiatrist in Nottingham who first unlocked the wards of Mapperley Hospital. Now the wards are being locked again. Highly trained nursing staff, who go through a lot of training, find that they are spending most of their time “on observation”. Patients are assigned into risk categories. The high risk ones are observed – to ensure that they do not run away, harm themselves or others – the others can sit all day long and no one can talk to them.
In recent debates at the Nottingham Mental Health Alliance, an occasional meeting of mental health workers and service users, much of the discussion has been about the paucity of meaningful therapeutic activity on psychiatric wards. Of course, people come in and then go out again eventually but usually their recovery is little to do with drugs and therapy. Rather what is happening is that their initial breakdowns were typically an outcome of isolation, a lack of meaningful purpose and routine. Admission to a psychiatric ward stabilises these again at the most basic level – instead of the erratic fantasies and day dreams of an empty, lonely and frightened life on one's own, without a future, there are other people to talk to again, there are regular meals, there are regular times to sleep. Users touch base - and pull together the shreds of coherent functioning minds. But the staff play little role in any long term change – either on the wards or afterwards. When people are discharged they commonly go back to the same conditions, the same lack of a life worth living, and in a short time they are back again.
You can't entirely blame national policy for this. Other places around the country, like Bradford, are trying out other approaches and have made progress. There are new models for working with service users, like the Tidal Model, developed by Professor Phil Barker and associates. Alas, Nottingham is no longer a centre of innovation. The CEO of Nottinghamshire Healthcare Trust has been to Mental Health Alliance meetings, as has some of his less senior managers. He said the right words about listening to service users and workers and encouraging debate. Months later he comes back and admitted virtually nothing has changed. You can tell, he only began to think about the meeting a half an hour before, probably when he got in his car.
Doubtless he's busy with trying to fulfill the government agendas. However, one should also remind about the fears of critics at the time that it was being “proposed” - namely that Nottinghamshire Healthcare Trust would become a great lumbering bureaucracy. That might also have something to do with. Nottinghamshire Healthcare claims that, when it was formed, it saved money in its management changes that have been invested in new services. But management preoccupations are obviously on more important things than sorting out the demoralised acute admission hospital wards.
Meanwhile these acute admission wards are importing the negative sides of Nottingham's economic and social development, the bits that don't get talked about, measured or considered in the rush to become a young, dynamic, competitive, high-tech, 24 hour, Euro City - Queen of the East Midlands, Shopping Paradise by Day and Mega Party by night.
As the statistics tell us Nottingham is a young city – with a particularly high number of young people in late adolescence and early adulthood. The transition from home to adult life is inevitably a time of instability and predictable life crises as young people struggle to invent and experiment with their own identity through work roles, through setting up home and the formation of independent relationships. There is so much going on, starting out with little experience, it is no wonder it is a time of high emotion , anxiety and instability. It is the time when the stereotypical “schizophrenic breakdowns” occur – particularly among young people who prove unable to make the transition out of the family nest to the frightening world where they must invent and discover their own future out of a fog of frightening uncertainties and unknowns.
In Nottingham, in areas like the New Deal for Communities zone of Radford and Hyson Green, there are large numbers of students in this young age group who are mostly upwardly mobile, mixing shoulders, in the same streets, shops, pubs and clubs, with those Nottingham young people who give Nottingham its poor educational attainment statistics – who at the moment have no reason to believe that the futuristic future of the Nottingham envisaged by their betters has a place for them, unless they button their lups, buckle down and try harder in school and college.
And if they don't make it? What's so important about Nottingham? The city elite tell us that it is to be the shopping city par excellence. The excitement is in how they are going to redevelop the Broad Marsh Centre. However, if you are going to have fun in a shopping city you need a bucket of money, otherwise it is a pretty miserable place. You are not wanted there – and certainly not begging. Without money how can you join the drunken orgy that takes place every weekend in the city centre? Will the flesh on display there ever be available to them, young men without money are bound to ask themselves.
Want to attract a young woman? You must have money, a car, you must offer excitement, you must be able to be able stride around John Lewis and get your bijouterie in one of the Arcades. No money? No prospects? Then sorry, you are not entitled to a life.
There are two responses to this situation - to sell drugs or to take them them to dull the pain– or often enough doing both. Afterwards you live with the paranoias and power moves inside the illegal drug economy.
As Nottingham becomes a manic city 24 hour city, speeding up, and with less sleep (is this one reason why there is such a high accident rate in Nottingham?), and as it becomes a more unequal city, the psychological casualties of the city of parties and shopping appear on the psychiatric wards. Over the last few years people on the psychiatric ward have tended to become much more disturbed and are more likely to be the suffering from what doctors label a dual diagnosis. That means that they've got a drug and/or alcohol problem on top of a mental health problem.
On the psychiatric wards it's a losing battle. At the moment the trend is running the wrong way because people can be restabilised to a minimal degree but without solutions to the fundamental problems in their lives – work, relationships, a satisfying and meaningful future that they can create for themselves - the people involved will be back, though what is called “the revolving door”. The staff aren't equipped to actually deal with these life problems after the psychiatric ward - and many of the staff there know it.
Most users understand this in their guts, but cannot always articulate it, nor do much about it. Many of the nurses and community nurses, the social workers, the occupational therapists and the psychologists understand it too. Unfortunately the people who usually understand this least of all are the people with the clinical leadership role, the medically trained psychiatrists. They work with a model of mental health problems which locates the problem primarily in the person's brain, rather than in their ideas and in their lives. The solution for them is tinkering with the brain, usually with drugs. In the 20 years that I have been involved in the local mental health services I have been to hundreds of multi agency and multi-disciplinary meetings about every subject under the sun. The ones who never turn up are the psychiatrists. And they hold the most of the power and take out the highest salaries. (The Medical Director Dr Richard Turner is apparently worth £130,000 a year, slightly more than Jeremy Taylor the CEO himself). They are the legal pushers, of drugs that are unpleasant to take, as opposed to the ones that create excitement or dull the pain.
It's been known for years the medical model is rarely helpful and often profoundly unhelpful. By privileging brain based explanations and interventions – it suggests that the user can do little about their problems without the guiding interventions of the doctor tinkering with their brain chemistry and neurological functioning – indeed it can be said to convey a harmful message about the usefulness of drugs in the management of life problems, encourages rebellious users to “self medicate” - with the alternative street drugs of their own choice. The hidden allies of the psychiatrists in this respect are the drug companies.
As is the case nationally many mental health workers and users in Nottingham are well read up on and aware of the damage that can be done by medication. While recognising it sometimes has a place, many workers and users are rendered cynical and demoralised when they notice innapropriate and over use, when they notice polypharmacy (multiple prescribing), when they notice the damage coming out immediately, or years later. They are rendered cynical and demoralised too when they become aware of the cynical way in which drug companies operate. Studies that have been presented at the Nottingham Mental Health Alliance have shown how the drug compaines manipulate doctors and their prescribing. Doctors will deny that they are influenced by the little presents, the lunches, and by the sponsorship, but the hard statistical evidence show that they clearly are. (Doctors are unable to form objective and accurate judgements on their own behaviours, it seems, when it comes to prescribing it appears. This is something that they really need to meditate upon as they judge persistent the 'thought disorders' of their patients.).
Many mental health workers and users are aware too how, in recent years, the drug companies have invented a host of chemicals as solutions for what are socially generated problems or everyday problems in living, thus making money out of human misery, causing untold long term neurological damage, and irresponsibly diverting the hard search for practical solutions to everyday difficulties (e.g drugs for childhood 'hyperactivity'). These things do not of course, get said in the PR newsletters of the Nottinghamshire Healthcare Trust or in government statements. The big money is in the bullshit, not in funding its critical examination. But there is widespread understanding of how much lying bullshit there is in the mental health services, how thoroughly and totally institutionally corrupt it is, and this does not do, of course, do much good for morale.
It is difficult to see how this this block of vested interest which absorbs and wastes such huge quantities of resources into an institutional black hole can be dismantled. It is ironic that medical psychiatry's theorisations about mental health are less credible now than they have ever been. They are rooted in a very 19th century idea that the mind is somehow like a secretion of brain processes and that faulty thinking is the result of faulty neurology. Yet it has been shown that by making conscious effort in therapy, for example using techniques from meditation that teach people to watch their own minds, observe the passage of their own thought processes, and re-evaluate those thought processes, that people can break free of compulsive behaviours. The conscious efforts of thinking rewires one's own brain - neurological connections inside the brain evolve in a process called “neuroplasticity”. In this case it is not the brain determining thought, but thought determining the brain. Medical psychiatry quite simply uses a wrong model – but it still has institutional power and has the big money.
The consequence is that the other ways of going about things – attempting to intervene at the crisis points in people's lives in various constructive ways - are starved of resources. There is not a lack of other promising approaches – there is a surfeit of them. But they are all stunted and underdeveloped or struggling to survive in niches, or on the fringes of other institutions, and in the voluntary sector – rather than being what they should be, the very core of an alternative mainstream.
For example there is a realisation in various places in Nottingham city council that there is a mental health agenda to be developed. A worker has been appointed, so far on a short term cotract, to advise how to support council employees suffering from stress at work, workers promoting a self esteem agenda in community and leisure services among young people. The city also supports my own work - trying to find responses to the high stress and low job satisfaction in the voluntary sector. In my job I've come across therapists developing promising new approaches from complimentary therapy. They are helping people cope with anxieties, stresses, life difficulties and crises without hard drugs, by promoting better self care and through the use of touch therapies that work directly on the muscles that become tense and jangly when one is on that jittery edge of serious psychological disturbance. These are real and preferable alternatives to Prozac.
Some officials in the city council realise too that the mental health promotion agenda, presently represented by a cinderella service, microscopically funded as part of the PCT, ought to be connected to an important process to be pursued in neighbourhood development. Area 6 in particular, St Anns and Sneinton, has a very high proportion of suicides and psychiatric hospital admissions and a working sub group has been set up there to look at how this can be addressed by local level initiatives. In this regard the important thing is to connect community care and community development in some joined up thinking. Community garden projects, food projects, arts projects, all these can give people meaningful enjoyable activities where they can overcome their isolation, make social contacts and friends, and in many cases develop life skills like growing and preparing food, that will improve their quality of life and enhance job prospects – projects that can act as bridges for people in difficult life transitions to new periods of stability.
Unfortunately these promises cannot be properly realised with tiny amounts of money. Setting targets for community level projects to bring down suicide rates and mental hospital admission rates in St Anns and Sneinton, and then giving them £50,000 (the current proposal before the City) isn't even giving them half the salary of the CEO of Notts Healthcare.
Setting the wrong kind of targets can damage also mental health projects and demoralise their participants. You don't start enjoying life to performance standards – unless you are a pretty neurotic person. And you set up projects to fail if you give them tiny resources to solve huge problems so that they inevitably undershoot unrealistic targets. You create miserable stressed projects that are no fun to be part of because the people running them are harrassed and demoralised. Too little money and what you are doing is barely keeping projects alive. This exploit those micro-projects like my own, Ecoworks, whose workers have got used to keeping a valuable community garden service going largely through the gift of their time. Everyone says they want to support Ecoworks. The money remains at the end of the rainbow.
This is why, seen from my point of view, and of course that's an important qualifier, a lot of people in Nottingham's mental health services are demoralised. Or some of the reasons anyway.....
© BRIAN DAVEY