Reforms

Since the 1990s, the National Health Service (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 as in the National Service Framework for Mental Health. ¹ Business models administered by an expanded NHS management ^{Reference Goldberg2} and a specific focus on private sector providers ^{Reference Dobson3} have been introduced. Each reform has moved mental healthcare away from the priorities of psychiatrists, such as the clinical perspective and providing a reactive service to the most unwell, to those of politicians. Instead of openly debating the rationing and funding of healthcare, political decisions about funding are reformulated as local service efficiency and resource management problems to be resolved by further political reforms. Services are changed without evidence that the changes improve care. Reformers talk about ‘prevention’ to justify introducing new services, initiatives and strategies, without providing adequate evidence that they prevent anything. Unfortunately, to establish these new services, existing services that aim to satisfy clinical needs are cut. The introduction of assertive outreach teams was one such initiative. ^{Reference Burns, Creed, Fahy, Thompson, Tyrer and White4}

Audit

The new NHS market economy requires a common currency for comparing wholly different services. New ‘measures’ are created to facilitate auditing but these often distort clinical practice and destabilise services. ^{Reference Oyebode5} Attempts to render organisations auditable result in ‘decoupling’, whereby the auditable outcomes become separated from the actual work of the organisation, which then produces irrelevant figures for central consumption rather than as part of an audit cycle aimed at learning and improving services. Another effect is ‘colonisation’ whereby the audit world spills over into the clinical and provides a dominant reference point for organisational activity, so that things are done because they are audited rather than because they are beneficial or necessary. In higher education the introduction of audit to allocate resources had a ‘fatal’ impact on research culture. ^{Reference Power6} Similar effects are appearing in the NHS, for example Goodhart's law ^{Reference Goodhart7} - the paradox that when a surrogate measure is made a target for conducting policy, it loses the information content that would qualify it to play such a role, making the measures of doubtful value even to those who require them. The government recognises that top-down targets stop the police from policing but does not recognise a similar process in healthcare. ⁸

Changes in medical regulation

Politicians use medical scandals to limit the professional independence of doctors and to bring them more directly under state control. ‘The individual orientation that doctors are trained for does not fit with the demands of current healthcare systems’. ^{Reference Smith9,Reference Edwards, Kornacki and Silverstein10} Renegotiating the compact (sic) between the medical profession and society ^{Reference Ham and Alberti11} and revising medical and psychiatric professionalism ^{Reference Williams and Cormac12,Reference Bhugra13} are overdue. We welcome the appropriate development of accountability that comes with medical professionalism; indeed this is why we believe professionalism is important. However, excessive and intrusive regulation wastes resources, deflects from clinical work, stifles creativity, and displaces time-tested methods of professional self-regulation. ^{Reference O'Neill14} This is not unique to psychiatry, but psychiatrists are more vulnerable to this because psychiatric practice involves risk taking and managing uncertainty.

Spin

The new rhetoric of healthcare seeks to achieve hegemony by the appropriation of language in a way that makes opposition or even debate, however principled and evidence-based, sound narrow or ridiculous. How can anyone question or debate ‘politically correct’ catchphrases like Vision, Empowerment, Recovery, Best Practice, Clinical Excellence, High Quality, Accelerating Change, Personalised Services, Choice, Partnership, and Continuous Improvement?

New Ways of Working

New Ways of Working was a practical response to the shortage of consultant psychiatrists and the demoralisation of psychiatrists caused by excessive workload in the late 1990s. ^{Reference Kendell and Pearce15,Reference Pidd16} In 2004, a national working group with high-level representation from many interested groups reviewed the roles and responsibilities of psychiatrists; this included the Royal College of Psychiatrists. The group suggested that consultant psychiatrists should move from their traditional roles of taking referrals, diagnosing, treating, allocating and overseeing clinical work, providing continuity of care over time and across settings and holding clinical responsibility, to becoming ‘truly consultative with multidisciplinary teams taking responsibility for patient care.’ The concept of distributed responsibility within multidisciplinary teams was introduced, which meant that every team member was seen as accountable for what they did. ¹⁷ The College agreed these changes after consultation with its membership. ¹⁸ This was intended not as a way of cutting medical staff, but a way of using consultants and all other members of the multidisciplinary team to do what they do best. Also planned was a training package that would allow non-medical members of each team to assume their new extended roles. ¹⁹ If well implemented, this could improve services for patients and job satisfaction for all staff. However, New Ways of Working can and has become shorthand in trust boards for cutting the numbers of medical staff and for reducing the psychiatric orientation of the service. This has led to the removal of consultant psychiatrists from assessment, diagnosis and treatment planning, but non-medical staff have often not been able to take over this role because they are not adequately trained. This has resulted in services that are not capable of offering psychiatric assessments and treatment. ^{Reference Craddock, Antebi, Attenburrow, Bailey, Carson and Cowen20} In our experience this results, at times, in clinically unacceptable low standards.

Functional teams

Functional teams have been introduced alongside New Ways of Working. This meant splitting sector-based psychiatry teams into community mental health teams (CMHTs), primary care mental health teams, crisis resolution teams, home treatment teams, recovery teams, in-patient teams, complex enhanced care programme approach teams, assertive outreach teams, early intervention teams, etc. This means that patients may see three or four consultants during a single episode of acute illness. There are some advantages in this. Specialist teams are more focused and can be more efficient, and the implementation of specialist in-patient teams has greatly improved in-patient care. The creation of home treatment teams, which operate round the clock, has significantly reduced bed usage and improved the capacity to provide home treatment to those who are acutely ill. However, this has often reduced community care for those with the more complex psychiatric disorders because these changes were implemented without expanding overall resources and because staff recruited to new teams came from the same recruitment pool and has not been replaced. This will get worse with the national implementation of the Improving Access to Psychological Therapies programme, ²¹ because their staff also will come from the same pool. The introduction of functional teams fragmented services and created new problems.

1. • There are many boundary disputes about who should look after individual patients, which distracts from patient care.

2. • There are communication problems between teams - most serious untoward incident inquiries highlight communication difficulties as a major factor in suicides and homicides.

3. • Patients miss long-term relationships with their doctors or nurses on whom they rely at times of difficulty; such relationships have important effects on outcome even in drug treatments. ^{Reference Krupnick, Sotsky, Elkin, Simmens, Moyer and Watkins22}

4. • Dealing with many different professionals along complex care pathways through a fragmented functional service activates some patients’attachment difficulties and may cause iatrogenic harm. ^{Reference Fonagy and Bateman23}

Many of these problems can be overcome; there are examples of functional services that work well and provide high-quality and safe services which are more effective than the sector-based services that they have replaced. However, this requires careful planning and effective management. Unfortunately, this has not always happened, particularly when CMHTs become depleted of staff. On balance, our experience leads us to believe the haphazard implementation of functional teams has resulted in poorer services.

Changes in training

Along with the fragmentation of care, a similar fragmentation of knowledge has come in the form of competency-based training. Competency in a profession is of paramount importance but the spotlight on competency-based assessments takes the focus away from the competencies that are difficult to measure and that allow an understanding of the patient's narrative. This is akin to the age-old question, ‘Is medicine art or science?’ Psychiatry is clearly both. It is important that we do not end up measuring things purely because they are measurable and ignoring those that are difficult to measure. Complex professional skills and qualities that take years of training and apprenticeship to master must not be reduced to isolated competencies that become part of a box-ticking exercise. Learning to fill in forms is not sufficient professional education. Sennett explained that craftsmanship requires interplay between tacit knowledge and self-conscious awareness: ‘When an institution like the NHS, in churning reform, doesn't allow the tacit anchor to develop, then the motor of judgement stalls. People have no experience to judge, just a set of abstract propositions about good-quality work.’ ^{Reference Sennett24} This is even more acute for non-medical colleagues who may be expected to perform new tasks outside of their core professional role after minimal training.

The new reductionism

Reductionist developments have impoverished the mental health services. Providing high-quality psychiatric care is reduced to meeting targets; professionalism is reduced to competences; diagnostic assessment is reduced to assessing needs and risk; clinician-patient relationships are reduced to an assembly line model where functional teams provide ‘client-centred’ but fragmented and impersonal care. The current emphasis on ‘mental health’ rather than psychiatric illness, ‘health centres’ rather than hospitals or clinics and ‘recovery’ rather than treatments represent ‘magical thinking’ in attempts to deny the existence of ‘madness’. ^{Reference Evans25} These manoeuvres also help to tidy away the suffering and emotional pain of the mentally ill person.

Comparing the current state of mental healthcare with the government rhetoric about services at times recalls the Orwellian satire ^{Reference Orwell26} on the command economy of the former Soviet Union, where the Party proclaims ever more grandiose plans, exhortations, targets and self-congratulations; everyone knows, and doesn't know at the same time that the targets are absurd and often irrelevant, their results are unreliable and the goods are, all too often, shoddy. Work then becomes a game of survival to produce figures to fulfil the impossible targets. For example, the ‘NHS strategic plan’ or Darzi report ²⁷ refers to ‘change fatigue’ and states ‘that NHS staff is tired of upheaval - when change is driven top down,’ yet it proposes another 40 changes while promising ‘no new national targets’.

Incredibly, there has been no systematic sustained data collection by the Department of Health to monitor the impact of the ‘market-style’ NHS reforms ²⁸ following the ‘NHS plan’. ²⁹ Evidence that commissioners add value or are cost-effective is not demonstrated.

What patients want

When asked about aspects of care, patients rank their contacts with doctors as among the most important issues (Box 1).

Harm done through managerial and political wasted resources should be given equal status to the harm done by side-effects of drugs and rogue doctors. Reorganisations, structural changes, new systems of audit, analysis, and revalidation, all should be subject to the same level of testing and proof before they are introduced as applies currently to medical treatments. We recognise that most middle-grade and senior managers appreciate the fallacy of what is going on, but they are under immense pressure from the centre to meet the targets, and under threat of not getting foundation status or losing funding.

Given how bad things actually are, it is surprising that the profession seems to have had difficulty in speaking up for patients and for psychiatric care. Perhaps it is fear of being envied that prompts psychiatrists to deny their own training, skills and authority, ^{Reference Main and Kreeger31} or perhaps it is because of change fatigue and the conviction that nothing they can do would affect the outcome (learnt helplessness). Stung by these criticisms (Box 2) and at times failing to find immediate responses to them, psychiatrists have either retreated into the safety of clinical practice (‘I don't do politics’) or embraced changes which sober reflection would have revealed are not in the best interests of patients.

What psychiatry is and what it should be

Psychiatry requires expert medical practitioners to do the complex task of assessing physical and mental aspects of illnesses, and providing appropriate pharmacological and psychological treatments. ^{Reference Marneros36} Extensive and complex training is required to equip psychiatrists with a wide range of knowledge (medical, psychiatric and social sciences), skills (in assessment, and pharmacological and psychotherapeutic treatments) and professional attributes (ethical, managerial, maintaining appropriate relations, honesty, justice, and commitments to patient care and service quality).

The ideal psychiatrist, in Jaspers’ view, is one who combines ‘scientific attitudes of the sceptic with a powerful impressive personality and a profound existential faith.’ He is someone with a solid foundation in medicine, the biological and behavioural sciences and is able to cope with the intellectual isolation implicit in such a critical eclecticism. The intervening years since Jaspers made his observation have not diminished the need for such a rare combination of abilities. ^{Reference Clare37}

What the intervening years have done is to increase dramatically the relevant knowledge base and set of skills that practitioners need to bring to the task. Thus, the capacity for change and for responding to changes in knowledge, culture, politics and health service organisation is a key attribute. For this reason psychiatrists should not be slow to encourage reform or weak in self-criticism. Nor have they been. It was psychiatrists who led the moves to empty asylums. It was psychiatrists who balanced the competing biological and social theories of schizophrenia into a subtle biopsychosocial understanding of the illness. Psychiatrists strongly advocated the specialist training of all professionals in multidisciplinary teams. It has been psychiatrists who, despite doing themselves no favours with the government, have joined with others in leading the resistance to the illiberal features of the proposed changes to the Mental Health Act. It was a psychiatrist (Aaron T. Beck) who started and first developed cognitive–behavioural therapy.

Conclusion and recommendations

Psychiatry is facing multiple challenges. Endless changes and reorganisations are imposed from the centre without being piloted or assessed. New centralised models of public services administration have displaced clinical thinking and professionalism. Priorities are determined by politicians and implemented by managers with insufficient understanding of the complexities of psychiatry. Complex tasks are devolved to generic mental health workers. Increasingly, psychiatric care is provided without a proper diagnostic assessment. Instead, it is being reduced to assessing risk and needs, and providing generic psychosocial support. Services are fragmented into functional teams providing ‘person-centred services’ that are none the less impersonal. High-value aspects of psychiatric care, such as diagnostic assessment, tailored treatment and the therapeutic relationship, ^{Reference Krupnick, Sotsky, Elkin, Simmens, Moyer and Watkins22} are not subject to targets or audited and therefore are devalued and sacrificed in the pursuit of administrative targets. Left unchallenged these will lead to further erosion of the quality of psychiatric care. Patients’ needs fall into different categories – the ‘one-size/plan-fits-all’ approach is inappropriate, and consumer models must be modified. We recognise that all the problems we identified are not happening everywhere and/or always.

High-quality psychiatric care requires a range of professional skills: psychiatrists, psychiatric nurses, occupational therapists, psychiatric social workers, clinical psychologists, and psychotherapists, all have specific areas of professional expertise that are required, at the appropriate time, in the care of different patients.

Psychiatrists with their unique skills in diagnostic assessment and management of psychiatric illnesses are essential. High-quality psychiatric care requires more than assessment of risk and needs, and general psychosocial support. Psychosocial assessment and care is necessary but not sufficient to deliver quality psychiatric care.

Most politicians, commissioners, guideline writers or business managers, if faced with psychiatric illness in their family, would want an expert assessment by an experienced psychiatrist for their loved one, rather than assessment by a generic mental health worker using proforma tools and guidelines. We suspect that private psychiatric care will be a beneficiary of poorly implemented New Ways of Working, as those that can afford to seek the doctor–patient relationship and continuity of care that increasingly are available only in the private sector.

It is understood that ambiguity and uncertainty abound despite guidelines and that psychiatrists are trained specifically, and at great length and cost, to exercise clinical judgement to make difficult decisions under circumstances of great complexity.

What should be done? We welcome the Royal College of Psychiatrists’ Fair Deal campaign ³⁸ that addresses many issues relating to providing high-quality services to psychiatric patients. We hope the College will begin to recognise that there can be no fair deal for patients if we as a profession do not value our own role in providing high-quality care. The College needs to recognise that NHS resources are limited and that care needs to be prioritised. Consultant psychiatrists who are clinical team leaders are ideally placed to do this working with others. We urge the College to educate further the government, clinical colleagues and the community (Box 3) on the central importance of the psychiatrist and the broad medical model ^{Reference Shah and Mountain39} in a comprehensive biopsychosocial assessment of patients suffering from a broad range of mental illnesses, some moderate, some severe, some acute, some long-term.

Declaration of interest

None.