MH services in the UK are shit for so many reasons, but top of the list has to be money-saving on a scale not even seen elsewhere in the NHS, year on year, decade on decade, whittling away at every part of provision, because of an assumption that nobody who really matters will notice too much if mental health services disappear.
Hospital/inpatient care is now all but nonexistent. Beds have been reduced repeatedly, for decades.
Even after the (necessary but bodged) "care in the community" de-institutionalisation programme of the early eighties, the number of psychiatric beds left by the late eighties was four times what it is now. And compared to the early 2000s, just twenty years ago, we have half the psychiatric beds we had then.
That's not because the need is less. We have some different drugs available now, but the old ones were pretty much as effective as the newer ones, just with different side effects. There have been no revolutions in therapy. People now get seriously unwell and impossible to keep safe or effectively treat at home, just like they did in 1988, or 2002. The difference is that there are only a quarter of the beds of 1988, or half of 2002.
There's an argument that people recover better in their own home than in hospital, but even back in the late eighties, people generally weren't having psychiatric inpatient treatment unless they really needed to. Home treatment teams visit people at home as a (cheaper) alternative to going into hospital, to check on them and give them drugs. But if you ask anyone who's either been seriously mentally unwell themselves or had a seriously mentally ill loved one, and who has experience of the HTT, it can feel frighteningly inadequate and unsafe, with extreme reluctance to escalate to hospital admission, and an eagerness to discharge from the service. It can also be intrusive and embarrassing having mental health workers visiting your home.
As well as a reduction in beds, there seems to be a reduction in staffing for those psychiatric inpatient beds that do still exist — often wards seem to be unable to find enough staff, though they might full spaces with bank or other temporary staff, who often don't know the ward or the patients. Even fully-staffed, there often don't seem to be enough of them to operate a ward safely or therapeutically (not least because the smoking ban meant patients often have to be individually escorted if they want a cigarette…). And this might come across badly, but because of attempts to plug shortages by recruiting abroad, many staff on some psychiatric wards were trained abroad, and some seem to face significant cultural barriers to interacting therapeutically with patients. Not that staff ward cultures were always particularly therapeutic anyway… and bad ward cultures seem to get passed on to new staff and perpetuated, especially in stressful, high-pressure environments created by current funding and staffing issues.
With so few beds available, every bed is always filled, so even a fully-staffed ward has staff working full-tilt, every day. And they're more difficult patients to look after than in the past, too — every patient in every filled bed is a patient who would have been one of the 25% most severely ill on a late-80s ward. This makes wards more stressful for staff, leading to burnout, and more stressful for patients, making it harder to get better.
Another effect of slashing bed numbers like this, meaning practically every bed is filled all the time, is that there's no slack in the system. As well as resulting in unacceptable numbers of out-of-area placements, having no slack in the system makes it nigh-on impossible to run single-sex wards even if there was the will to do so. (This will doesn't actually exist, with the main argument being that mixed-sex is better for socialising patients to society, as though we're discussing one of those historic mental hospitals that attempted to create a microcosm of society, with multiple-month stays as standard.) Even if you have two identical general adult wards for an area, you can't make one male and one female unless you always happen to have just the right number of extremely ill male and female patients, and a bed always opens up on the right ward for your patient's sex. With no slack, people have to go where they'll fit. (And no, the "single-sex accommodation" on psychiatric wards isn't remotely the same. It's barely worth the paper is written in IMO.)
An expectation that stays will be short, for crisis stabilisation only, results in what has felt to me like a dramatic reduction in psychological therapy, occupational therapy, meaningful activities, or any real therapeutic input at all. It also means that people are discharged when still extremely unwell — and we know that discharge from hospital is one of the highest-risk periods for mentally ill people.
So where do that other 75% go, who would've been on a psychiatric ward 35 years ago? They can't go to the day hospital, which used to provide a weekday programme of activities and therapy for people with serious mental illness who didn't need to be in hospital but would benefit from the routine, from the opportunities for social contact, and from the therapeutic input. Those have pretty much disappeared.
Maybe some will be under HTT, but only in extreme crisis.
The community mental health team will carry some of these cases, but they've been cut to the bone. 20 years ago, my CMHT had something like a consultant psychiatrist, two other psychiatrists, and a trainee psychiatrist, as well as at least a couple of psychologists, and of course psychiatric nurses, psychiatric social workers, and other staff members.
Last time I was under them, my CMHT had merged with a neighbouring one so probably double the catchment area, but still only had one consultant psychiatrist, and had other staff actually reduced — I think only one other psychiatrist, and as far as I'm aware other staff similarly cut back.
The CMHT will therefore try to discharge back to the GP at the first possible opportunity, even if you're still quite seriously unwell.
That's if you even managed to be successfully referred in the first place, which isn't easy. There's likely to be a barely-qualified staff member reading and rejecting most of the referrals from qualified and concerned general practitioners, who are aware that the patient's needs are beyond their expertise. Get past that, and the next gatekeeper is likely to be a nurse, who will chat to you and may well decide the GP can manage you just fine. If you're lucky you might get to see a psychiatrist, but probably not a long enough appointment for a proper psychiatric assessment. And good luck accessing psychology through a CMHT these days — the few that are left seem to spend much of their time doing assessments, maybe for specialist therapies run by another part of the Trust, which of course have their own gatekeepers, and their own lengthy waiting lists.
In the past, people might be kept under CMHT for many months or even years. Sometimes even if they were well and didn't need to see anyone they were kept on with the CMHT, just to keep them in the system and give them a softer landing into services if they became unwell again. This is now framed as a bad thing.
Now? If you're no longer actively and imminently suicidal, or no longer struggling with terrifying command hallucinations, or whatever your most extreme symptom was, you're likely to be discharged to the GP. They might give you a leaflet or two, or recommend you investigate local charities, drop-ins, or, in my area at least, the local Trust's laughable "recovery college" (a patronising "let's play pretend" mishmash of crappy groups, the very occasional useful psychoeducation course, and general fob-offery run in random rooms of random public buildings, aimed at those who in the past would've received actual treatment for their serious, chronic mental illness).
Some people in this position — still unwell, but discharged/refused by CMHT — will try and get help through IAPT (I think they're called NHS Talking Therapies now, but IAPT is quicker). They might be refused because IAPT assesses them as being too severe, too complex — essentially, that IAPT can't manage them and CMHT is more appropriate. This is one of the biggest cracks people seem to fall through.
Or they might be taken on by IAPT, and of course dealing with people who would've previously had help from the CMHT puts pressure on a service that was designed to provide psychological help for those with simpler mild-to-moderate problems (which, don't get me wrong, are still horrendous to live with, but have different treatment needs to things like bipolar disorder or cPTSD). At the same time, IAPT is experiencing intense pressure from the other side of things, with increased public awareness and various societal pressures resulting in huge numbers of people either self-referring or being referred by the GP.
And in the meantime, when people can't get IAPT treatment, can't get CMHT treatment, can't get day hospital services, can't get long-term specialist psychotherapy, can't get inpatient treatment, they have to fall back on the GP. Who is already drowning under all the other shit that gets dumped on GPs. Or go to A&E.
I haven't even talked about more specialist inpatient provision, ED services, neurodevelopmental disorder assessment (increased public awareness, strong gatekeeping, ludicrous waits) and support (pretty much absent) for adults and children, LD services, or other areas I don't have much personal experience of.
Basically, it's shit because
- successive governments have been taking bites out of it for decades and telling services to make do, because they know most people don't care and won't notice until it affects them
- we haven't worked to counter the decades-long "less is better" narrative about psychiatric beds and ongoing psychiatric care for those with mental illness
- many of those left working in services have nothing to offer people, have unhelpful attitudes, are totally exhausted, or all three