The flame still flickers

I have had a good idea. Let’s acknowledge that the functionalised system of care in mental health was never a clearly articulated policy, that it was never based on proper evidence, that most patients and professionals dislike it and that it does not work. Let’s abandon it. All we have to do is to agree what we should replace it with.

As a general rule, it is impossible to restore the status quo ante, no matter how attractive that state of affairs may appear in retrospect. There can be no return to an imagined golden age. We need to find ways to establish continuity of care, strategic treatment planning and sustained therapeutic relationships in modern treatment settings, provided that we can agree that these things are important.

Functionalisation seems to have proliferated for two main reasons:

Firstly, it was congruent with a substantial ideological shift in mental health service management that developed under the Blair Government, which I have described as Fordism in healthcare.

Secondly, it addressed real and serious problems that were prevalent in inpatient services. Unfortunately, it has generated problems that are worse than the problems it solved.

There are major problems in mental health services across the UK. These are due a wide variety of factors, but functionalised care frequently exacerbates other difficulties. In my opinion, it is particularly disastrous that it was introduce immediately prior to major cuts, because two of its flaws are inflexibility and lack of resilience. The whole system has to be in good order for it to work. No one could accuse the NHS of being in good order right now.

In January 2017, the British Journal of Psychiatry published a debate entitled “Splitting in-patient and out-patient responsibility does not improve patient care”. The case was made by Tom Burns, recently retired as Professor of Social Psychiatry at Oxford University, and countered by Martin Baggaley, former Medical Director of South London and Maudsley NHS Foundation Trust. The current (March 2017) edition includes a letter from Luiz Dratcu, who was an early advocate of functionalised care, and a riposte from Tom Burns.

I strongly disagree with Martin Baggaley and Luiz Dratcu. I have sometimes disagreed with Tom Burns too, but on this matter I am in complete agreement with him. He has set out the arguments with his usual rigour, fidelity to evidence and rhetorical elegance. To my mind he makes an entirely convincing case, but then he has been making these arguments for some time.

I am not going to re-run the debate here, but I have a few additional points:

  • No one wants to go back to the model of inpatient care prevalent in my youth. In particular, old-fashioned ward rounds were anti-therapeutic and unnecessary. I worked in community teams in Liverpool and North Wales that were led by nurses and social workers. We gradually developed our multidisciplinary reviews until ward rounds disappeared altogether. The choice is not between the current model and the distant past, it is between a dysfunctional model and something new and better
  • It is suggested that we need inpatient-only consultants because of high levels of violence and legal compulsion in modern inpatient settings, necessitating special expertise in rapid tranquillisation. To me, this reflects an appalling therapeutic nihilism. Toxteth in Liverpool is one of the most deprived inner city areas in the UK. Our team worked hard at developing relationships with patients, their families and the local community. Eventually, this avoided many detentions and minimised inpatient aggression. Good knowledge of our patients allowed us to anticipate disturbed behaviour and take early action that avoided physical restraint and forced tranquillisation. We had no psychiatric intensive care unit, no seclusion facilities, we made very few out of area referrals, and the patch had a low rate of referral to the regional forensic psychiatry service. I left in 2004, not because the approach did not work, but because a new managerial regime made it increasingly difficult to work that way. Could it be that functionalised care is a factor in high levels of aggression and compulsion, rather than being part of the solution?
  • It is said that inpatient services are too expensive, and that money is better spent on community services. I agree with this. In our book Clinical Skills In Psychiatric TreatmentRobert Higgo and I argued that if the political will existed it would be possible to safely abolish institutional psychiatry altogether and replace it with well-staffed, high-quality local community services. What Martin Baggaley describes as a “gradual reduction in the number of inpatient beds (17% in the past three years)” has been precipitate and in many places accompanied by repeated reorganisation and demoralisation of community teams. There is no evidence whatsoever that functionalisation of care has led to a general transfer of funds from inpatient to community services

Not so long ago, service user experience was said to be paramount. Now it is rarely mentioned. The limited evidence suggests that service users and families do not like functionalised care. Professor Tony Pelosi (another long-term critic) and his colleagues have published a study of patient’s views. They concluded:

Our survey suggests that most patients prefer the traditional model where they see a single consultant throughout their journey of care. The views of patients should be sought as much as possible and should be taken into account when considering the best way to organize psychiatric services.”

It is hard to disagree with that. It is hardly surprising that service users do not like functionalised care, as it is predicated on moving them through a depersonalised system as quickly as possible. Our book addressed the question “what is inpatient admission for?” Admission is necessary when no other measure will render the total situation acceptably safe. There is no mental state threshold for admission or discharge, and if admission decisions are made without reference to the situation in the community, the intervention is likely to be ineffective and traumatic for the patient and their family. Getting people out of hospital quickly is not necessarily the most important objective.

I do not suggest that functionalised care cannot work. I am sure it does in some locations, but it is inappropriate as a national model. Where it is not working, it should be abandoned.

What offsets all of this is the fact that most mental health professionals try to do the best for their patients, despite systemic efforts to thwart them. Tom Burns has spent his career convincingly demonstrating that things that he has advocated, such as assertive community treatment and community treatment orders, are no better than standard care when rigorously tested. In his riposte to Luiz Dratcu he strikes a hopeful note that is in contradiction to his main argument. His OCTET trial of CTOs showed that community teams were surprisingly good at continuity of care:

“They provided regular, about fortnightly, follow-up over the 3 years, and only 19 out of more than 300 patients (6%) were lost to care. They achieved this despite the functional split and the endless Maoist reorganisations that were imposed on their services. The flame still flickers.”