Histrionics and quantum politics

Last week started with a somewhat anti-climactic announcement from the Prime Minister about mental health services. Her speech ended with a statement that “parity means parity”. If this was intended as a triumphant conclusion to a stirring performance, it fell rather flat. The phrase echoed her hollow “Brexit means Brexit” catechism. The Prime Minister seems to be deploying the circulus-in-probando logical fallacy as a catchphrase. This leaves me wondering whether grammar schools of the 1970s were really as good at educating their pupils as Theresa May sometimes claims.

Any hope of a warm glow from the announcement of £15 million for English community mental health services was lost when Mike Adamson, CEO of the British Red Cross, described the situation in the English NHS as a humanitarian crisis. This incensed Mrs May and other senior Conservatives, who responded by accusing Mr Adamson of hyperbole, citing statistics on staff employed and money spent and stating that there is always winter seasonal pressure. A few days later, Mrs May followed this up by suggesting that GPs are responsible for the excess pressure on A&E because they have failed to offer daily 12-hour opening. She went on to make an aggressive threat over funding. We are caught, it seems between histrionics and indifference: unprecedented disaster or business as usual?

Looking back, I notice that I blogged that a crisis in the NHS was in the news back in August, long before any winter seasonal pressures were felt. In fact, senior figures in the NHS and its regulatory bodies have been warning that 2016-17 would bring unprecedented financial pressure for a long time. I am sure that someone, possibly Jeremy Hunt, must have mentioned this to Theresa May when she became Prime Minister. Angry responses to Mrs May have gone far beyond the usual statements from the Labour Party and the BMA, who are obliged to be outraged at more or less everything she says. Medical Royal Colleges, Dr Sarah Wollaston MP (Conservative chair of the Parliamentary Health Select Committee) and even Simon Stevens, Chief Executive of NHS England have made unusually forthright statements about problems with NHS resources. They have contradicted the idea that current problems might be due to the indolence of GPs.

Crises in the NHS have been part of the annual news cycle ever since the “winter of discontent” that helped Margaret Thatcher to power in 1979. These crises are hard for people outside of the NHS to understand because they are not tales of uniform catastrophe. Even in a single hospital, some departments face terrible problems in offering adequate care while other departments carry on much as usual. I attended hospital as an anonymous out-patient this week. The department was calm, I was not kept waiting very long, and I had an unhurried and entirely satisfactory consultation. At exactly the same time, the local A&E departments were crowded with sick people because there were more patients than they could assess within a safe time frame, beds could not be found and patients could not be moved out of A&E to make space for new arrivals. Everyone, staff and patients alike, was stressed, irritable and distressed. It is like this most days.

Mental health services have experienced disproportionate reductions in funding and psychiatric emergencies make up part of the unremitting pressure on A&E departments. Inadequate financial resource, destruction of social care infrastructure, massive reorganisation and recruitment problems create problems that converge in A&E departments. It is important to have a mental health presence, but A&E is an exceptionally poor environment for urgent psychiatric assessment. People in crisis are best assessed calmly in their own home. This allows a better understanding of their circumstances; better access to the people around them; and it keeps open options other than admitting them to hospital or sending them away. Better quality of assessment is one of the many strengths of community psychiatry.

In England, Community Mental Health Teams, Crisis Teams and Home Treatment Teams have been stripped down and they are understaffed. They are frequently “at capacity”. This means that they are unable to respond to emergencies. GP recruitment is a serious problem everywhere. Far from wilfully refusing to extend opening hours, all the GPs I know are working flat out to maintain a safe service. It is often difficult to get to see a GP promptly because there are too few doctors. Non-statutory services to support people with mental health problems have lost funding. They have shrunk or disappeared. When other types of help are hard to access, there is little choice but to go to A&E, where the presence of increasing numbers of people with mental health problems exacerbates the effect of all the other pressures.

Against this backdrop, medical practitioners have conflicting duties. It is important not to spread unnecessary alarm and consternation amongst the general public, because not everything is at the point of collapse. Nevertheless, we have a duty to warn that many parts of the health system are in really deep trouble. Any fix will involve providing more money for health and social care. Although some people believe that the crisis has been contrived to facilitate full privatisation of the NHS, business has no solutions to the current situation. It is highly unlikely that anyone would want to buy NHS emergency services at present. They are about as marketable as a knackered used car. The private sector is disinvesting from residential social care. In my opinion, we are here due to political ineptitude, not intention.

You can tell that this NHS crisis is unusually severe from the voices that are speaking out. Simon Stevens has put his job on the line by contradicting the Prime Minister. Medical Royal Colleges are cautious bodies that do not indulge in hyperbole. The only voices that claim that the situation is due to normal seasonal pressures come from within the Government, whose record on evidence and reasoning are questionable.

“Parity means parity”. When Mrs May said this, she referred to the peculiarly named principle “parity of esteem”. This became legally binding with the Health and Social Care Act 2012. It means that mental health must be given equal priority to physical health. “Parity” has been law for five years, but mental health spending is falling as a proportion of all health spending in England. Most dictionaries say that “parity” means “equal”. Mrs May seems to have intended to say that parity of esteem means equality. If she is seriously suggesting that inequality is the same as equality then she has passed through Schrödinger’s cat-flap. She has invented quantum politics.

Mike Adamson’s use of the term “humanitarian crisis” was probably ill advised, not because he is wrong but because it gave the government the opportunity make irrelevant comparisons with Aleppo and to suggest that its critics are guilty of hyperbole. They are not. The crisis is real and it is going to take a lot more than a few million pounds to sort it out. Substantial areas of health and social care policy will have to change to get out of this mess.

In the background, I have another concern. In recent times, the mental health community, including the Royal College of Psychiatrists and the third sector, have been successful in getting mental health high up the political agenda. My worry is that it has made little difference on the ground. Services are deteriorating in many places. I hope that in 2017 the mental health interest groups will come more closely together to campaign. At present, there is still a reasonably straightforward route out of the mess. With further neglect, the problem may become irreversible.