The news media are overflowing with speculation about the cataclysmic implications of Brexit, which is fair enough. It is a huge event. Meantime, out in the world at large, we need to anticipate the likely consequences for our own work, which in my case means mental health services.
I was at a party in London on Saturday, twenty-four hours after the referendum result. A lot of people there did not know anyone who admitted to voting to leave. Up here in North Wales and the North West of England, quite a few of my friends and acquaintances voted out. We already have some post-referendum clichés. One of them is that people who voted for Brexit are either neglected estate dwellers with no GCSEs, no hope and a pit bull in their back yard, or old people who hope that Winston Churchill might return to be Prime Minister. The characterisation is ridiculous. In my experience, Brexit voters are certainly disaffected, but they represent a wide range of demography and opinion. Many have aligned themselves with people like Gove, Johnson and Farage despite disliking them. One of my friends mentioned on Facebook that he is looking forward to getting the old Kitemark back instead of the unreliable CE symbol. They are nostalgic for a nation where the red wire was live and the black wire was neutral, and they vote issue by issue, because they feel that professional politicians are unreliable and disdainful of ordinary people.
Of course, the migration and spending promises of the Leave campaign cannot be delivered. When problems develop over the next few years, Remain voters are likely to blame Leave voters, who in turn are likely blame migrants. There is a risk of anger all round and a huge polarisation. It looks a bit dangerous to me. Some people are making appeals for peace, love and understanding and others are starting to build the barricades. Historical precedence suggests that the former is ineffective and the latter heals no wounds. Predictably, some commentators are making analogies with Germany in the early 1930s. These are grossly misleading. The situation is serious, but it is entirely unprecedented. We need to stop thinking in terms of analogies and symbols, and start thinking about tangible practicalities.
This week, the Royal College of Psychiatrists holds its international congress in London. I will be attending. The entire medical profession and its organisations strongly advised that Brexit would be damaging to the NHS and to the health economy, so I expect that there will be a fair bit of apocalyptic prognostication in the bars. I doubt that I will be able to resist participating, but I think we need to try to focus on what is likely to happen to mental health services in the immediate future. It is grim that England and Wales have turned their backs on internationalism, but the decision is made and it cannot be reversed. The outcome for the economy and for communal tensions are uncertain, but there are some possible consequences in mental health services that need urgent attention.
The UK economy depends on markets and financial services. Both of these are adversely affected by uncertainty. Despite statements by politicians on both sides of the EU debate that there is no hurry to start negotiations to leave, Britain is likely to come under huge political and economic pressure to do exactly that. In the short run, the pound and the UK economy are very likely to weaken, in which case prices and unemployment will rise. Tax revenues will fall. Even if the extra £350 million per week for the NHS had been a truthful claim, it would take years for the money to become available. We are almost certainly going to see actual cash cuts to health spending in the short run, against the background of a pre-existing threat of imminent financial meltdown in NHS England. Mission control, we have a problem. Unfortunately, mission control is currently unmanned. The old regime has its head in its hands and the victorious adventurers do not necessarily like each other. A self-confident new regime seems a remote possibility.
So here is the main immediate risk as far as I can see: a serious shortfall in funding to mental health services that coincides with a sharp worsening of recruitment problems.
The NHS’s traditional sources of overseas recruitment are unlikely to provide sufficient staff, because UK Governments have treated overseas doctors rather badly of late. The UK is no longer trusted or esteemed in the international health education market, and has lost its market share. Young doctors prefer to go to the USA or Australasia. For now, EU doctors are free to come here and work, but they are likely to be increasingly reluctant. They will be uncertain over their ability to complete their training when Brexit is implemented. They will be worried over future reciprocal recognition of qualifications between countries.
There may well be sensible resolutions to problems like these in due course. In the meantime, it is probable that there will be a long period of uncertainty. The big problem all round is uncertainty.
A weak right wing Government, unable to put together a plausible economic strategy, and under political pressure over deteriorating NHS services, may be tempted to fully privatise some elements of health care. They may claim that a recruitment crisis is beyond their control, using this as a diversion from the funding problem. They may rely on the supposed vibrancy and innovation of private business to overcome the failure of central manpower planning and staff retention. They might, for example, chose to continue to fund emergency services but decide that those who want more than basic care will have to insure themselves. It is easy to see how the arguments would be marshalled.
Mental health would be very vulnerable if events unfold as I fear they might. For example, it might be proposed that talking treatments should be funded through private insurance (perhaps with an element of subsidy), and that responses to self-harm and behavioural disturbance should be dealt with through an integrated police and mental health emergency service. There are current initiatives that were entirely appropriate in The-World-Before-Thursday, but which could now be used to justify partial privatisation of core services. What would be lost would be the ability to deliver comprehensive services to those at greatest need, and the atomisation of care would be complete.
I hope that I have this completely wrong. The sun will continue to rise for the foreseeable future. I certainly do not want to catastrophise a difficult situation. I do strongly believe that we should prepare for realistic hazards such as the scenario that I have described.
We, the broad mental health community, need to come together. In any crisis, there will be various interest groups who see an opportunity to advance their cause. To succumb to this kind of factionalism in mental health would be self-indulgent and, in any case, it will not work. We need to form a functional alliance between service users, all of the mental health professions, carers and the third sector. The formation of a campaigning umbrella group would be good, though it is not essential. We need to have a common view about the necessary components of decent mental health services and about the need for services to be comprehensive and free at the point of delivery. We need to be assertive about the consequences of current and future ‘welfare reforms’ and about the critical importance of social infrastructure and intervention in improving the nation’s mental health.
We need to come together right now. There will be plenty of time to squabble when the dust settles, in about 15 years time. For now, we need to be smarter than the politicians who have inadvertently created a transnational political crisis on a similar scale to the banking crisis of 2008.
I am pleased to report that apart from that, everything is fine.